治疗女性压力性尿失禁_1课件

TVTTVT尿道中段悬吊术尿道中段悬吊术 微创伤手术微创伤手术 1.1. 减少手术时间减少手术时间 Reduce surgical timeReduce surgical time 2.2. 减少住院时间减少住院时间 Reduce length of hospitalization Reduce length of hospitalization 3.3. 减少并发症减少并发症 Reduce complication rates/risksReduce complication rates/risks 4.4. 复原快复原快 Allow quicker return to normal, daily activitiesAllow quicker return to normal, daily activities 5.5. 减少费用减少费用 Lower costsLower costs GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVTTVT尿失禁的无张力支撑尿失禁的无张力支撑 TVTTVT尿失禁的无张力支撑是一种创新的微创伤尿失禁的无张力支撑是一种创新的微创伤 手术方法手术方法, , 它对压力性尿失禁治疗的有效性它对压力性尿失禁治疗的有效性 已得到了充分的临床证明已得到了充分的临床证明 GYNECARE TVT Tension-free Support for Incontinence is an GYNECARE TVT Tension-free Support for Incontinence is an innovative minimally invasive surgical alternative for the innovative minimally invasive surgical alternative for the effective treatment of stress urinary incontinence, with effective treatment of stress urinary incontinence, with proven results.proven results. GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 使用使用ProleneProlene网带进行无张力尿道中段悬吊术网带进行无张力尿道中段悬吊术 The placement of a piece of PROLENE mesh (45 cm x 1.1 cm x The placement of a piece of PROLENE mesh (45 cm x 1.1 cm x 0.7 mm) without tension, at the mid urethra0.7 mm) without tension, at the mid urethra GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 局麻局麻, , 阻滞阻滞/ /硬膜外硬膜外Local anesthesia, sedation/regionalLocal anesthesia, sedation/regional 切口小切口小, , 分离少分离少 Minimal incisions and dissectionMinimal incisions and dissection 网带无张力地置于尿道中段下网带无张力地置于尿道中段下Tape placed at mid Tape placed at mid urethra without tensionurethra without tension 术中使用膀胱镜术中使用膀胱镜 Cystoscopy performedCystoscopy performed 术后插尿管时间短术后插尿管时间短 Infrequent use of post-op cathetersInfrequent use of post-op catheters 当天出院当天出院 Discharge home the same dayDischarge home the same day Goal of SurgeryGoal of Surgery 手术目的手术目的 1. 1. 修复和修复和/ /或加强阴道尿道韧带或加强阴道尿道韧带 Restore and/or Restore and/or reinforce the pubourethral ligaments.reinforce the pubourethral ligaments. 2.2.修复和修复和/ /或加强尿道下阴道吊筋膜或加强尿道下阴道吊筋膜 Restore and/or Restore and/or reinforce the suburethral vaginal hammockreinforce the suburethral vaginal hammock 3.3.加强尿道旁结缔组织加强尿道旁结缔组织 Reinforce the paraurethral Reinforce the paraurethral connective tissueconnective tissue GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 普理灵聚丙烯网带普理灵聚丙烯网带 PROLENE* polypropylene mesh tapePROLENE* polypropylene mesh tape 无需和任何组织固定无需和任何组织固定 No fixationNo fixation 经阴道进路经阴道进路 Trans-vaginal approachTrans-vaginal approach 组织分离少组织分离少 Minimal tissue dissectionMinimal tissue dissection GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 局麻局麻 Local anestheticLocal anesthetic 导尿管使用时间短导尿管使用时间短 Minimal catheter useMinimal catheter use 可在门诊进行可在门诊进行 Out-patientOut-patient GYNECARE TVT Tension-free Support for Incontinence IndicationsGYNECARE TVT Tension-free Support for Incontinence Indications TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 适应症适应症 适应于以下原因引起的女性张力性尿失禁适应于以下原因引起的女性张力性尿失禁 Intended to be used for treatment of Female Stress Intended to be used for treatment of Female Stress Urinary Incontinence resulting fromUrinary Incontinence resulting from 尿道过度活动尿道过度活动 urethral hypermobilityurethral hypermobility 内源性内源性尿道括约肌功能障碍尿道括约肌功能障碍intrinsic intrinsic sphincter deficiencysphincter deficiency GYNECARE TVT Tension-free Support for Incontinence GYNECARE TVT Tension-free Support for Incontinence ContraindicationsContraindications TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑 禁忌征禁忌征 怀孕病人怀孕病人 Pregnant patientsPregnant patients 未完成发育的病人未完成发育的病人 Patients withPatients with future growth potentialfuture growth potential 计划要怀孕的病人计划要怀孕的病人 Women with plans for future pregnancyWomen with plans for future pregnancy Warnings and PrecautionsWarnings and Precautions 注意事项注意事项 不要进行抗凝治疗不要进行抗凝治疗 No anticoagulation therapyNo anticoagulation therapy No UTINo UTI 要有一定膀胱颈悬吊术的经验要有一定膀胱颈悬吊术的经验 Familiar with bladder neck suspension surgeryFamiliar with bladder neck suspension surgery 用最小的张力在尿道中段下放置用最小的张力在尿道中段下放置TVTTVT网带网带 TVT placed with minimal tension at mid urethraTVT placed with minimal tension at mid urethra 使用膀胱镜观察确保膀胱完好使用膀胱镜观察确保膀胱完好 Cystoscopy to confirm bladder integrityCystoscopy to confirm bladder integrity 注意盆腔结构注意盆腔结构, , 避免组织损伤避免组织损伤 Attention to pelvic anatomy to avoid injuries to structuresAttention to pelvic anatomy to avoid injuries to structures 出院前观察是否有耻骨后血肿出院前观察是否有耻骨后血肿 Observe for retropubic hematoma before dischargeObserve for retropubic hematoma before discharge GYNECARE TVT Tension-Free Support for Incontinence SystemGYNECARE TVT Tension-Free Support for Incontinence System TVT TVT产品系列产品系列 TVT TVT 网带网带 GYNECARE TVT DeviceGYNECARE TVT Device GYNECARE TVT Introducer GYNECARE TVT Introducer GYNECARE TVT Rigid Catheter Guide GYNECARE TVT Rigid Catheter Guide GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence Description: PROLENE*polypropylene mesh covered by a plastic sheath Prolene*网 带: 网 状 钩 形 编 织 , 外 面 套 有 塑 料 膜 Prolene*网 带 Prolene Prolene 普理灵普理灵 特点特点 惰性强惰性强 组织相容性强组织相容性强/ /组织反应小组织反应小 有延展性有延展性 表面光滑表面光滑 易于操作易于操作 心血管吻合的专用缝线心血管吻合的专用缝线, ,在缝合材料中有在缝合材料中有“ “缝缝 线之王线之王” ”的称号的称号 GYNECARE TVT IntroducerGYNECARE TVT Introducer 推针器推针器 GYNECARE TVT Rigid Catheter GuideGYNECARE TVT Rigid Catheter Guide 导引杆导引杆 GYNECARE TVT - Preoperative EvaluationGYNECARE TVT - Preoperative Evaluation 术前评估术前评估 确诊确诊为压力性尿失禁为压力性尿失禁 进行排尿分析进行排尿分析 GYNECARE TVT Patient InformationGYNECARE TVT Patient Information 病人情况病人情况 手术介绍手术介绍 Procedure overviewProcedure overview 病人手术风险病人手术风险Potential risksPotential risks 血肿血肿 B Bleeding-hematoma formationleeding-hematoma formation 感染感染 InfectionInfection 膀胱穿孔膀胱穿孔 Bladder perforationBladder perforation 尿潴留尿潴留 Urinary retentionUrinary retention 排斥反应排斥反应 Mesh erosion or rejectionMesh erosion or rejection 复原复原 RecoveryRecovery 期望期望 ExpectationsExpectations GYNECARE TVT - Pre OpGYNECARE TVT - Pre Op TVT TVT 术前术前 术前抗菌素术前抗菌素 Peri-operative antibioticsPeri-operative antibiotics 停止使用抗凝剂停止使用抗凝剂 Cessation of anti-coagulants Cessation of anti-coagulants Postmenopausal patient should have estrogenized vaginal Postmenopausal patient should have estrogenized vaginal wall tissue.wall tissue. Instrument RequirementsInstrument Requirements 手术需要的器械手术需要的器械 阴道重锤阴道重锤/ /拉钩拉钩 弯剪弯剪- -组织分离组织分离 蚊式钳蚊式钳 - - 钳住塑料套钳住塑料套, , 抽出抽出. . 长的硬膜外针头长的硬膜外针头- -局麻局麻 5050cccc注射器注射器 - - 向膀胱内注生理盐水向膀胱内注生理盐水 7070度膀胱镜度膀胱镜 - - 观察膀胱情况观察膀胱情况 1818号号( (单枪单枪/ /双枪双枪) )导尿管导尿管 GYNECARE TVT - ProcedureGYNECARE TVT - Procedure 手术过程手术过程 病人准备病人准备 Patient preparation Patient preparation 切口切口 IncisionsIncisions Dissection, needle passage and tape Dissection, needle passage and tape placement placement Tension adjustment Tension adjustment Completing the procedure Completing the procedure Patient PositionPatient Position 病人体位病人体位 Insert 18 fr catheter and empty bladder Insert 18 fr catheter and empty bladder 插插1818号导尿管号导尿管, , 排空膀胱排空膀胱 Anesthetic Anesthetic 麻醉麻醉 局麻局麻 + +静脉加强静脉加强 Local Anesthesia with IV sedation, Local Anesthesia with IV sedation, recommendedrecommended 骶麻或全麻骶麻或全麻 Regional or General anesthesia possible.Regional or General anesthesia possible. AnesthesiaAnesthesia Abdominal InjectionsAbdominal Injections Anesthesia Anesthesia 麻醉麻醉 Abdomen Abdomen 腹部腹部 AnesthesiaAnesthesia Vaginal WallVaginal Wall Anesthesia Anesthesia 麻醉麻醉 Vaginal Wall Vaginal Wall 阴道前壁阴道前壁 Incisions Incisions 切口切口 阴道前壁阴道前壁 VaginalVaginal 在离尿道外口在离尿道外口1 1cmcm处作处作1.5 1.5 cm cm 纵向切口纵向切口 腹部腹部 AbdominalAbdominal 在耻骨联合上方，腹中线两侧各作一个在耻骨联合上方，腹中线两侧各作一个0.5 0.5 cm - cm - 1.0 cm1.0 cm切口切口 2 2 incisions each side of midline incisions each side of midline 两切口相距最宽两切口相距最宽4-54-5公分公分 just above symphysis just above symphysis 4 - 5 4 - 5 cm cm apart max. apart max. Vaginal Wall IncisionVaginal Wall Incision 阴道前壁切口阴道前壁切口 IncisionsIncisions Vaginal WallVaginal Wall DissectionDissection Blunt dissection of anterior wall sub and paraurethrallyBlunt dissection of anterior wall sub and paraurethrally Abdominal Incisions Abdominal Incisions 腹部切口腹部切口 GYNECARE TVT - ProcedureGYNECARE TVT - Procedure 手术过程手术过程 PreparationPreparation IncisionsIncisions Dissection, needle passage and tape Dissection, needle passage and tape placement placement 组织分离组织分离, , 穿针和放置网带穿针和放置网带 Tension adjustmentTension adjustment Completing the procedureCompleting the procedure Dissection of Anterior WallDissection of Anterior Wall 阴道前壁分离阴道前壁分离 Blunt Dissection sub and paraurethrallyBlunt Dissection sub and paraurethrally 在尿道旁和尿道下进行钝性分离在尿道旁和尿道下进行钝性分离 Insert TVT Rigid Catheter GuideInsert TVT Rigid Catheter Guide 插入插入TVTTVT导引杆导引杆 Introduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT Device 推入推入TVTTVT网带网带 通过阴道切口推入通过阴道切口推入 Introduce through vaginal incision Introduce through vaginal incision 针头指向髂骨针头指向髂骨 Aim toward ipsilateral shoulder Aim toward ipsilateral shoulder 绕过耻骨绕过耻骨 Hug the pubic bone (do not scrapHug the pubic bone (do not scrap 从腹壁切口出从腹壁切口出 Exit at abdominal incisionExit at abdominal incision Introducer/needle pointed toward ipsilateral shoulderIntroducer/needle pointed toward ipsilateral shoulder 针尖指向同侧肩膀针尖指向同侧肩膀 Finger in vagina guides needle Finger in vagina guides needle 食指经阴道导引针的放行食指经阴道导引针的放行 Needle hugs the pubic bone during insertion Needle hugs the pubic bone during insertion 穿针时针紧贴着耻骨穿针时针紧贴着耻骨 Abdominal incisions act as a guide Abdominal incisions act as a guide 腹部切口可作为方向引导腹部切口可作为方向引导 Cystoscopy performed after each needle passage Cystoscopy performed after each needle passage 穿针后进行膀胱镜检查穿针后进行膀胱镜检查 Bladder is drained again and needle is passed on other Bladder is drained again and needle is passed on other sideside 再次排空膀胱，在另一侧穿针再次排空膀胱，在另一侧穿针 After confirming bladder integrity, needles are passed After confirming bladder integrity, needles are passed through abdominal incisionsthrough abdominal incisions 确认膀胱完好，将针拉出腹壁 Needle Passage and Tape PlacementNeedle Passage and Tape Placement Introduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT Device 推入推入TVTTVT网带网带 Guide the Needle Tip to the Abdominal IncisionGuide the Needle Tip to the Abdominal Incision 将针头导向腹壁切口将针头导向腹壁切口 针头不要拔出针头不要拔出 Cystoscopy Cystoscopy 膀胱镜膀胱镜 针穿过后针穿过后, , 使用膀胱镜确保膀胱完好使用膀胱镜确保膀胱完好 After each After each passage of the needle, cystoscopy should be completed to passage of the needle, cystoscopy should be completed to verify bladder integrityverify bladder integrity 将膀胱注液后使用膀胱镜将膀胱注液后使用膀胱镜 Cystoscopy should be done Cystoscopy should be done with bladder half-fullwith bladder half-full Bladder Perforation Bladder Perforation 膀胱穿孔膀胱穿孔 Bladder Perforation Bladder Perforation 膀胱穿孔膀胱穿孔 Second Passage of the GYNECARE TVT DeviceSecond Passage of the GYNECARE TVT Device 第二根针的穿入第二根针的穿入 重新插导尿管重新插导尿管, , 排空膀胱排空膀胱 Re-insert the catheter and Re-insert the catheter and drain the bladderdrain the bladder 重复第一次穿针的步骤重复第一次穿针的步骤 The opposite side is The opposite side is completed in the same manner as the firstcompleted in the same manner as the first 确保网带没有扭转确保网带没有扭转 Ensure that the tape does not Ensure that the tape does not twist twist 再次使用膀胱镜再次使用膀胱镜 Cystoscopy after the second pass of Cystoscopy after the second pass of the TVT needlethe TVT needle 针从腹壁切口拉出针从腹壁切口拉出 Pull TVT needle through the Pull TVT needle through the abdomen incisionabdomen incision Tape AdjustmentTape Adjustment 调整网带调整网带 在网带和尿道间放置一把剪刀或止血钳在网带和尿道间放置一把剪刀或止血钳 Place Place scissors or hemostat between the tape and the urethrascissors or hemostat between the tape and the urethra 拉腹壁端的网带拉腹壁端的网带, , 直到网带贴住剪刀直到网带贴住剪刀 Pull the Pull the abdominal ends of the tape until there is contact between tape abdominal ends of the tape until there is contact between tape and instrumentand instrument 将针剪去将针剪去 Separate needles from the tapeSeparate needles from the tape 先不要拉出塑料薄膜先不要拉出塑料薄膜 Do not remove the plastic sheathDo not remove the plastic sheath Cough Test Cough Test 腹压测试腹压测试 膀胱注液膀胱注液250250毫升毫升 Fill bladder with 250 ml of saline Fill bladder with 250 ml of saline 取出尿道下的剪刀取出尿道下的剪刀/ /或止血钳或止血钳 Remove instrument under the Remove instrument under the urethraurethra 取下阴道重锤取下阴道重锤 Remove vaginal speculumRemove vaginal speculum 要病人用力咳嗽要病人用力咳嗽 Ask patient to coughAsk patient to cough 调整网带松紧度调整网带松紧度 Adjust TVT tapeAdjust TVT tape 调整松紧度时调整松紧度时, , 剪刀要置于网带和尿道之间剪刀要置于网带和尿道之间 Instrument should be placed between the tape and the urethra Instrument should be placed between the tape and the urethra during adjustmentduring adjustment Initial Cough Test Initial Cough Test 初步腹压测试初步腹压测试 Adjust Tape with Instrument in PlaceAdjust Tape with Instrument in Place 器械放置在网带和尿道间器械放置在网带和尿道间, , 调整网带调整网带 Completing the ProcedureCompleting the Procedure 完成手术完成手术 抽出塑料薄膜抽出塑料薄膜 Remove plastic sheathRemove plastic sheath 剪去腹壁上多余的网带剪去腹壁上多余的网带 Cut Prolene MeshCut Prolene Mesh 缝合皮肤和阴道粘膜切口缝合皮肤和阴道粘膜切口 Close skin and vaginal Close skin and vaginal epithelium epithelium 排空膀胱排空膀胱 Empty bladderEmpty bladder 取出导尿管取出导尿管 Remove catheterRemove catheter Completing the ProcedureCompleting the Procedure 完成手术完成手术 removing plastic sheathremoving plastic sheath取出塑料薄膜取出塑料薄膜 Completing the ProcedureCompleting the Procedure完成手术完成手术 Trimming the meshTrimming the mesh剪去多余的网带剪去多余的网带 GYNECARE TVT Postoperative Assessment Before DischargeGYNECARE TVT Postoperative Assessment Before Discharge 出院前的术后评估出院前的术后评估 出血出血/ /血肿血肿 Bleeding/hematomaBleeding/hematoma 餐饮餐饮 Eating and drinkingEating and drinking 排尿排尿 VoidingVoiding GYNECARE TVT Postoperative InstructionsGYNECARE TVT Postoperative Instructions 术后要求术后要求 术后排尿残留术后排尿残留 Post void residual Post void residual 3-43-4天抗菌素天抗菌素 Antibiotics 3-4 Days Antibiotics 3-4 Days 限制活动限制活动 Activity limitationsActivity limitations - -驾驶驾驶 - -锻炼锻炼 - -性生活性生活 - -工作工作 GYNECARE TVT Postoperative CareGYNECARE TVT Postoperative Care Follow-up appointmentsFollow-up appointments 随访随访 3 3 weeksweeks 6 months6 months YearlyYearly GYNECARE TVT Complications 3 5 prior 11 2 prior operations; 3 5 prior operationsoperations 82% (28/34) cured82% (28/34) cured Neg SST, 90%Neg SST, 90% 9% (3/34) significantly improved9% (3/34) significantly improved Neg SST, QOL 75% 75% 90%, 90%, 90% 90% 70 yrs, MUCP 70 yrs, MUCP 10cm H2O, fixed urethra Rezapour M, Falconer C, Ulmsten U. Int Urogynecol J (2001) (suppl 2):S12-14. Concomitant Vaginal Surgery with TVT for Treatment of Concomitant Vaginal Surgery with TVT for Treatment of Female SUI and Pelvic Support DefectsFemale SUI and Pelvic Support Defects TVTTVT合并手术治疗女性合并手术治疗女性SUISUI和盆底支持缺损和盆底支持缺损 Retrospective reviewRetrospective review 回顾性研究回顾性研究 133 pts TVT vs. 47 TVT +133 pts TVT vs. 47 TVT + Demographics similar except ageDemographics similar except age 除了年龄病人统计学上相似除了年龄病人统计学上相似 Concomitant surgeryConcomitant surgery 1 SSLVS1 SSLVS- 8 - 8 前壁修补前壁修补 1 1 阴式子宫阴式子宫- 13 - 13 post colporrhaphypost colporrhaphy后壁修后壁修 补补 4 enterocele rep4 enterocele rep直肠膨出修补直肠膨出修补- 14 - 14 LeFort colpocleisisLeFort colpocleisis 15 perineorrhaphy 15 perineorrhaphy 会阴修补会阴修补 Horton TR, Druckenmiller J, Lucente V. Poster Presentation, SGS Annual Mtg, March, 2001 Concomitant Study ResultsConcomitant Study Results 合并研究结果合并研究结果 相近的治愈率相近的治愈率 TVT 98%, TVT + 100%TVT 98%, TVT + 100% 24 hr 24 hr 排尿率接近排尿率接近 膀胱穿孔率接近膀胱穿孔率接近 没有伤口感染和排异没有伤口感染和排异 TVT + associated with expected TVT + associated with expected in: in: OR time (p 0.001)OR time (p 0.001) EBL ( p 0.03)EBL ( p 0.03) Length of hospital stay ( p 0.0003)Length of hospital stay ( p 0.0003) 麻醉麻醉 TVT 95% local, 4% regional, 0.8% GETTVT 95% local, 4% regional, 0.8% GET TVT + 41% local, 55% regional, 4% GETTVT + 41% local, 55% regional, 4% GET A Randomized Control Trial of Colposuspension and TVT for A Randomized Control Trial of Colposuspension and TVT for Primary Genuine Stress Incontinence Primary Genuine Stress Incontinence 3 Year Follow-up 3 Year Follow-up BurchBurch手术和手术和TVTTVT手术对比的手术对比的3 3年随访年随访 在英国和爱尔兰的在英国和爱尔兰的1414个医院个医院 包括妇产科、泌尿科和女性泌尿大夫包括妇产科、泌尿科和女性泌尿大夫 344344个病人随机分成个病人随机分成TVTTVT和和BurchBurch两组两组 结果结果 6 6个月时个月时, , 需要自主导尿的病人需要自主导尿的病人BurchBurch组比组比TVTTVT组多组多 BurchBurch的病人有更多并发症的病人有更多并发症 BurchBurch组比组比TVTTVT组更多排尿问题组更多排尿问题 Ward,Hilton, et.al, Intl Urogyn Journal 2002 结论结论 女性尿失禁的发生逐年增长女性尿失禁的发生逐年增长 GYNECARE TVT GYNECARE TVT 是一种有效和微创的手术方是一种有效和微创的手术方 式。式。 独特的独特的GYNECARE TVT PROLENE GYNECARE TVT PROLENE 材料使得手材料使得手 术并发症比使用合成材料少术并发症比使用合成材料少 长期随访数据很优秀长期随访数据很优秀 合并阴道手术并发症少，而且有效合并阴道手术并发症少，而且有效