第五课TVTO治疗女性压力性尿失禁规范课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,TVT-O,治疗女性压力性尿失禁,* Trademark,TVT-O治疗女性压力性尿失禁* Trademark,GYNECARE TVT* Tension-free Support for Incontinence TVT,尿失禁无张力支持,TVT,的尿道中段悬吊已经成为“金标准”,Long-term, seven year follow-up data presented at 2003 IUGA reported,+,Cure rate of 81%,Significantly improved rate of 16%,Comparable to 5 year data of 85% / 11% respectively,Very low rates of reported major complications in over 500,000 patients,Reported bowel injury less than 6 / 100,000 procedures,Reported major vascular injury less than 9 / 100,000 procedures,+,Nilsson, et. al,7 Year Follow-up of the Tension-free Vaginal Tape (TVT) Procedure,;,International Urogynecology Journal, IUGA Abstract # 116 (89); October, 2003.,GYNECARE TVT* Tension-free Sup,Complications Statement,Complication US Ex-US Total %,血管损伤 7 37 44 0.009,尿道磨损20 0 20 0.004,肠损伤16 12 28 0.006,神经损伤 3 1 4 0.0008,血肿 4 16 20 0.004,Most Significant Reported Complications,+,Based on over 500,000 patients treated worldwide,+ As of September 26, 2003, seven deaths are associated with GYNECARE TVT. Six cases were for bowel perforation. Five were associated with undiagnosed bowel perforations at the time of surgery. In the sixth case of bowel perforation, no additional information could be obtained. The seventh case was associated with a woman who had a bleeding disorder who died from uncontrolled postoperative bleeding in the retropubic space.,Complications StatementComplic,Concept Development of GYNECARE TVT Obturator,Professor Jean de Leval, Chairman of Urology at the University of Liege, Belgium,Concept Development of GYNECAR,为什么经闭孔?,避开耻骨后空间可能带来的好处,减少膀胱穿孔，尤其对有手术史的病人,避免耻骨后血肿,避免肠穿孔,减少大血管的损伤,悬吊带方向的改变可能带来的好处,减少术后尿潴留的发生率,手术时间更短,为什么经闭孔?避开耻骨后空间可能带来的好处,Retropubic Slings,(“U” shaped),F,1,F,1,F,2,F,2,Obturator Slings,(Hammock Shaped),“U” Shape vs. Hammock Shape,Hammock shape of sling may result in less obstructive symptoms and/or de novo urgency, since it is harder to overcompress the urethra,悬吊带方向的改变减少梗阻的发生和术后急迫症状,However, this may also make it more difficult to correct certain patients, such as those with ISD,但是，对于,ISD,的病人可能不能完全纠治,Retropubic Slings F1F1F2F2 Obt,GYNECARE TVT Obturator System,Consists of three major components,GYNECARE TVT,经闭孔吊带,GYNECARE TVT,螺旋穿刺针,GYNECARE TVT,蝶型导引器,Blister package,Shown with Tyvek,Lid removed,GYNECARE TVT Obturator SystemC,GYNECARE TVT Obturator System,吊带,锥形头的塑料管连于带,塑料外套的蓝色,普理灵网带,塑料管和组件的材料,-,聚乙烯,-,聚亚安酯,塑料管直径4.2-4.8毫米,(,从尖锥部到底部),螺旋穿刺针,预先放置于塑料套内,固定在塑料套内,材料,聚碳酸酯的手柄,-,不锈钢穿刺针,GYNECARE TVT Obturator System吊,Bendable Tabs,6 cm,7 cm,GYNECARE TVT Obturator System,蝶型导引器有助于螺旋穿刺针准确一致地穿过组织,6,公分长, 可以延长至7公分.,Bendable Tabs6 cm7 cmGYNECARE,Workstation Design,With left hand, grab,Helical Passer for,patients right side,Winged Guide slides,out of workstation in,this direction,With right hand, grab,Helical Passer for,patients left side,After grasping both,handles and,removing, rotate,handles outward,Holds Helical Passer, Device, and Winged Guide,Allows for dumping or aseptic transfer from Tyvek Blister,Patient orientation,symbol,Workstation DesignWith left ha,Product Ordering Information,Product Code: 810081,Product Ordering InformationPr,Review of Procedural Steps& Anatomy,Review of Procedural Steps& A,病人体位和准备,截石位, 臀部和床边齐.,这样床的边缘不会干扰医生穿针的过程.,病人的大腿和腹部尽量保持垂直.,术前排空膀胱,病人体位和准备截石位, 臀部和床边齐.,麻醉,手术可以在局麻, 硬膜外或全麻下进行.,如进行局麻, 术者必须:,使用经稀释的,长效麻醉剂(同,TVT),在尿道中段处注射5-10毫升,在皮肤出针点注射5-10毫升,用硬膜外针,在螺旋穿刺针的路径注射10-20毫升,从阴道切口,和,皮肤出针点分别注射, 都朝向耻骨联合和耻骨降支处.,Note: The above technique is from Vincent Lucente M.D. - GYNECARE does not recommend any particular anesthesia protocol.,麻醉 手术可以在局麻, 硬膜外或全麻下进行.Note: Th,-,沿尿道口画一水平线, 第二条线为第一条线上两公分, 出针点为第二条线的大腿皱褶外两公分处. 可以现在就作皮肤切口.,Mark the exit points by tracing a horizontal line at the level of the urethral meatus, and a second line parallel and 2cm above the first line. - Locate the exit points on this second line, 2cm lateral to the folds of the thigh . Optionally, skin incisions may be made at this time.,-,用,Allis,钳牵夹, 在尿道口下一公分作一个一公分的切口.,Using Allis clamps for traction, make a 1cm midline vaginal incision starting 1cm proximal to the urethral meatus,STEP #1:,标记大腿根部的出针点和阴道正中切口,- 沿尿道口画一水平线, 第二条线为第一条线上两公分, 出,锐性分离,Sharply dissect, using blade or sharp scissors (tenotomy or Metzenbaums not Mayo)-,钝性分离, 使用前推-撑开技术向耻骨和耻骨降支的联合处分离, 剪刀为水平略向上方向, 角度为45度角.,Bluntly dissect, using a push-spread technique toward the junction between the body of the pubic bone and the inferiorpubic ramus, orienting scissors horizontally or pointed slightly upward, and at approx 45 degree angle (toward palpable junction) -,突破闭孔膜,Perforate the obturator membrane-,略微将剪刀撑大,Spread scissors slightly apart,STEP #2:,组织分离至闭孔膜并突破,锐性分离Sharply dissect, using b,准备,准备,STEP #3:,插入蝶型导引棒和螺旋穿刺针, 然后取走蝶型导引棒,在剪刀的路径中插入蝶型导引棒,Insert Winged Guide, into tract at same angle as scissors,如果蝶型导引棒没有突破闭孔膜, 取出蝶型导引棒, 用剪刀重新分离.,If Winged Guide does not “pop” through obturator membrane,Remove and reestablish tract using scissors,蝶型导引棒放置好后, 插入螺旋穿刺针, 针尖贴着蝶型导引棒的凹槽.,With Winged Guide in place, insert Helical Passer, keeping tip in line with the channel of the Winged Guide,压住螺旋穿刺针穿过闭孔膜, 感觉突破感.,Press Helical Passer through obturator membrane, feeling “pop”,取走蝶型导引棒,Remove Winged Guide,STEP #3:插入蝶型导引棒和螺旋穿刺针, 然后取走蝶型导,一边旋转穿刺针, 手柄部位同时移至中线位置.,Simultaneous,rotation and centering of Helical Passer handle-,在到达中间位置前不要转到手柄, 和将手柄在水平位置移动.因为这样容易使穿刺针误入耻骨后空间.,Do NOT rotate handle,prior,to centering or orient handle in the horizontal plane, as either of these motions may increase the potential for the Helical Passer to enter the retropubic space(remember.POP, DROP & ROTATE),STEP #4:,旋转螺旋穿刺针直至手柄转到中间位置,一边旋转穿刺针, 手柄部位同时移至中线位置.Simulta,螺旋穿刺针在靠近前面设定的出针点附近穿出.,Helical Passer should exit near the previously determined exit points.-,可能需要拉一下皮肤,Slight skin manipulation may be required.-,如果手术开始时没有作皮肤切口, 那么应该在此刻作皮肤切口,If skin incisions were not created at start of procedure, they should be created now.,STEP #5:,针尖传出皮肤切口,螺旋穿刺针在靠近前面设定的出针点附近穿出. Helic,-,针尖穿出皮肤后, 钳夹塑料管顶端- 稳住尿道处的塑料管,Stabilize the plastic tube near the urethra- Remove the Helical Passer by a reverse rotation of the handle, overcoming the detent holding the Plastic Tube to the Helical Passer.,STEP #6:,钳夹塑料管-反向转出穿刺针,- 针尖穿出皮肤后, 钳夹塑料管顶端- 稳住尿道处的塑料,使用器械,使用器械,After clamping plastic tip with hemostat (not shown), place thumb at base of Plastic Tube (as shown below) and rotate Helical Passer out of Device,用止血钳夹住塑料管顶端, 用拇指握住塑料管的底部, 然后将螺旋穿刺针转出塑料管.,After clamping plastic tip wit,-,将塑料管和网带完整拉出皮肤直到网带露出, 而且塑料外套的靠近阴道切口.,STEP #7:,将塑料管和网带完整拉出皮肤,-将塑料管和网带完整拉出皮肤直到网带露出, 而且塑料外套的靠,-,完成另一侧步骤后, 确保网带平放在尿道下,STEP #8:,在另一侧完成步骤2-7,- 完成另一侧步骤后, 确保网带平放在尿道下STEP #8:,-,使用规范方式调整网带, 比如使用一个钝性器械,Use the standard method for tape adjustment, such as placing a blunt instrument between the tape and urethra- Close the vaginal incision. - Cut the tape ends at the exit points just below the skin of the inner thigh. Close the skin incisions with suture or DERMABOND* Topical Skin Adhesive,STEP #9:,调整网带, 抽出塑料套, 缝合切口,* Trademark,-使用规范方式调整网带, 比如使用一个钝性器械Use the,完成手术,完成手术,TVT-O,的组织分离路径,分离尿道旁组织,进入耻尾肌起始端后和闭孔内肌处的提肛肌弓状腱下的坐骨直肠窝的前凹处,Enter the anterior recess of the ischioanal fossa inferior to the origin of the pubococcygeus muscle and below the arcus tendineus levator ani on the obturator internus muscle,绕过与耻骨连接的耻骨降支,从侧面穿过闭孔内肌的边缘, 然后在侧前方穿过闭孔膜, 闭孔外肌, 内长肌的上方, 和内短肌.,从皮下组织和皮肤出针,TVT-O的组织分离路径分离尿道旁组织,需要做膀胱镜吗?,可根据术者的判断,决定是否要进行膀胱镜检查,-,我们鼓励良好手术规范,鼓励术者进行膀胱镜检查,需要做膀胱镜吗?可根据术者的判断,决定是否要进行膀胱镜检查,Summary of Inside-Out Obturator Clinical Experience,由内而外的经闭孔手术的临床经验总结,Novel Surgical Technique for the Treatment of Female Stress Urinary Incontinence: Transobturator Vaginal Tape Inside-Out,;,de Leval, Jean.;,European Urology,2003; 44(6), 724-730.,107 consecutive patients (mean age=62 years),Mean operative time of 14 minutes (range=7-20 min),No bladder or urethral injury,No vascular or neurological complications,Surgery was carried out under spinal, general, and local anesthesia in 82, 24, and 1 case(s), respectively,Summary of Inside-Out Obturato,