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Urogynecology & Pelvic
Floor Reconstruction
吳銘斌 醫師/博士
(Ming-Ping Wu, M.D.,Ph.D.)
奇美醫學中心 婦產部婦女泌尿暨骨盆醫學科主任
台北醫學大學醫學院 婦產學科 副教授
成功大學醫學院臨床醫學研究所 博士
教學二版2011.07-10
尿 失 禁 種 類
尿動力學檢查 (Urodynamic study)
• 奇美B2婦女影像尿動力檢查室
Solar with video system
Urodynamic Study (UDS)
A. 21004C尿流速圖 (Uroflowmetry, UFR)
B. 21005C尿道壓力測量檢查
(Urethral pressure profile studies, UPP)
21012B應力尿道壓力測量檢查
(Stress urethral pressure profile, Stress UPP)
C. 21007C膀胱壓檢查(Cystometry, CMG)
D. 21011C壓力尿流速圖(Pressure-flow study)
E. 21003C外括約肌肌電圖
(External sphincter electromyogram, EMG
F. 21006B錄影尿流動力學檢查
( Video-urodynamic study)
UDS
UDS machine
Keyboard
Monitor /
Display
Computer (PC)
Printer
Mouse
Patient unit Cable
Puller /
Profilometer
Patient Unit
UroPump
Infusion
Medium
EMG
Remote Control
Life Tech Co.
Pressure Transducers
and Tubing
UDS machine
Life Tech Co.
Procedure of UDS in Urogyn Clinic
1. 500ml water 1 hour before test
2. Do Pad test
3. Do Uroflowmetry
4. Insert infusion & pressure transducer
Check postvoid residual (PVR) .
5. UPP
stress UPP
6. CMG
Infusion 80ml/min;
FD: cough (c)x1, cx1, cx6, running water
Max Capacity, cx1, cx1, cx6, (Standing, cx1, cx1, cx6)
6. VLPP
7. Pressure flow study
Recording Flow
Flow Transducer
Vura
Qura
Urodynamic Equipment
Uroflowmetry (UFR)
Abnormal Uroflowmetry
(A) Superflow pattern with poor urethral resistance; (B) intermittent multiple peak pattern;
e.g. DSD, abd. straining
(C) intermittent interrupted pattern; (D) obstructive pattern with increased
outlet resistance or poor propulsive force.
Uroflowmetry:
normal
Uroflowmetry: intermittent, low
flow
Uroflowmetry (before reduction)
Uroflowmetry (after reduction)
Rectum Bladder
30°
Bladder filled with 200 ml, I'm Straining
with Increased Force up to Leak !
Pabd
Pves
Qura
60 80 100 120
Leak
尿動力學檢查
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf 0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
Cough
ND
UIDC
RH
Cough
UU
SD
Cough
Leak
Urodynamic study: Cystometry
Urodynamic stress incontinence (USI)
Urodynamic stress incontinence
(USI)
Nygaard & Heit 2004 Obstet Gynecol
Pdet
Pves
Pabd
Cystometry: DO without incontinence
Cystometry: DO with incontinence
Urodynamics in OAB
Detrusor overactivity incontinence
Nygaard & Heit 2004 Obstet Gynecol
Pdet
Pves
Pabd
Resting UPP Stress UPP
Urethral pressure profile (UPP)
Urethral pressure profile
Stress urethral pressure profile
Stress urethral pressure profile
Solar Video Urodynamics
+
Laborie Dorado™
Video-urodynamic study
28
OAB Definition in 2002
• In 2002, ICS : Overactive bladder (OAB)
“symptom syndrome“ suggestive of lower
urinary tract dysfunction.”
• Definition :
“Urgency, with or without urge incontinence, usually with
frequency and nocturia, if there is no proven infection or other obvious pathology.”
• Synonyms : Urge syndrome
Urgency-frequency syndrome
29
3 distinctive OAB subtypes :
1. OAB dry
2. OAB wet
3. OAB with voiding difficulty
Hung MJ: 2006 J Urol 176:636-40
Core symptom
30
Hung MJ J Urol 2006;176:636-40
Hung MJ J Urol 2006;176:636-40
Impact on female adaptation by
OAB subtypes
32
During normal cycle,
desire to void (urge) is
intermittent and
increase with bladder
volume.
During an urgency
episode, the desire
to void increases
abruptly, resulting in
a void, shortening
the intervoid interval,
reducing the volume
voided
Chapple et al. BJU Int 2005
33
Refractory period: interval between voiding and the next urgency
episode, can be measured and may be affected by therapy.
Warning time: can also be measured as the time from the onset of
urgency to voiding
Chapple et al. BJU Int 2005
選擇治療方式
•物理治療
•藥物治療
•手術治療
Nonsurgical Management of
Urinary Incontinence
Nonsurgical Management of UI:
Nonpharmacologic Treatments
• First-line therapy for both stress and
urge incontinence
• Can reduce episodes of stress and/or
urge incontinence by 50% to 80%1,2,3,4
• Can lead to almost full continence for
25% to 50% of women treated1,2,3
• Does not have to be aggressive or time-
intensive to be effective3
1Fantl, JA, et al. JAMA. 1991:609-613.
2Burgio KL, et al. JAMA. 1998:1995-2000.
3Subak LL, et al. Obstet Gynecol. 2002:72-78.
4Burgio KL, et al. Obstet Gynecol. 2003:940-947.
Nonsurgical Management of UI:
Lifestyle Modifications
• Increase or decrease in fluid intake
• Reduction of dietary irritants
• Increase in dietary fiber
• Weight reduction
Nonsurgical Management of UI:
Behavioral Therapy行為治療
Bladder Training/ Scheduled Voiding
• Goal: Increase functional capacity of
bladder
• Methods
– Deferred voiding (most commonly
used method)
– Desensitization training
– Timed voiding
Nonsurgical Management of UI:
Vaginal Cones
• 2002 Cochrane review*
– Better than no active treatment for stress incontinence
– As effective as PFMT and pelvic floor stimulation
*Herbison P, et al. The Cochrane Database of Syst Rev. 2002:CD002114.
(Colgate Medical, Berkshire)
物理治療
•骨盆底運動(凱格爾運動)
•生理回饋治療
•電刺激療法
•體外磁波治療
骨盆底肌
Nonsurgical Management of UI:
Physical Therapy: Pelvic Floor Muscle Training (PFMT)
• Teaches women to identify pelvic floor
muscles and to control their contraction
• Helps with all types of urinary incontinence,
but especially with stress incontinence
• Rates of successful outcomes: 36% to 71%*
* Dannecker C, et al. Arch Gynecol Obstet. 2005:93-97.
Nonsurgical Management of UI:
Physical Therapy
Pelvic Floor Muscle Training (PFMT)
• Typical prescribed protocol
– 2 to 5 times per day
– 10 to 15 sets of contraction cycles
• Length of contractions: from as long as
possible, gradually increasing to 10 seconds
• Process takes at least 4 to 6 weeks and
sometimes as long as 6 months
凱格爾運動
生理回饋治療
Demo
Case-
pre
Case-
post
Nonsurgical Management of UI:
Pelvic Floor Stimulation
• Electrical or magnetic stimulation
• Found to improve symptoms in 60%-90% of
patients, with a 10%-30% cure rate1
• Other studies: No more effective than PFMT
alone2,3
1Iselin CE, Webster GD. Urol Clin North Am. 1998:625-645. 2Goode PS, et al. JAMA. 2003:345-352. 3Spruijt J, et al. Acta Obstet Gynecol Scand. 2003:1043-1048.
Extracorporeal Magnetic
Innervation (ExMI)
藥物治療
• 年紀大或較輕度應力性尿失禁
• 膀胱過動症 (頻尿﹑急尿﹑急迫性尿失禁)
• 嚴重頻尿﹑膀胱容積縮小
• 混合型尿失禁
• 無法開刀處理的尿失禁患者
Nonsurgical Management of UI:
Tricyclic Antidepressants (TCAs)
• Imipramine only agent in this class widely studied
• Used when more effective medications have failed
• Serious side effects possible
Level Grade
Antimuscarinics
Tolterodine 1 A (highly recommended)
Trospium 1 A (highly recommended)
Darifenacin 1 A (highly recommended)
Solifenacin 1 A (highly recommended)
Propantheline 2 B (Recommended)
Atropine, hyoscyamine 3 C (optional)
Mixed Action Drugs
Oxybutynin (muscle
relaxant effect)
1 A (highly recommended)
Propiverine (CC blocker) 1 A (highly recommended)
Dicyclomine 3 C (Optional)
Flavoxate 2 D ( possible)
Hormone
Level of evidence Grade of
recommendation
Estrogen 2 C
Desmopressin * 1 A
*Nocturia
Peripheral Action of neurotransmitters in the
micturition cycle
The storage phase is mediated
peripherally by Ach and NA
The voiding phase is peripherally
mediated primarily by ACh
藥物治療
Botulinum toxin • Neurotoxin produced by G(+) anaerobic organism
Clostridium botulinum.
• Inhibit release of acetylcholine at neuromuscular junction
=> causes muscle relaxations
=>chemodenervation
• Not yet licensed for use in bladder symptoms.
• 2nd line treatment in pts refractory to
conventional antimuscarinic therapy
Kelly plication
Tradition bladder-neck sling
1st generation: Retro-pubic (RP)
TVT, SPARC, IVS
2nd generation: Trans-obturator (TO)
TVT-O, Monarc
The evolution of anti-incontinence surgeries
3rd generation: Single-incision
TVT-secure, MiniArc
IVS: intravaginal sling
TVT: tension-free vaginal tape
TVT-O: tension-free vaginal
tape -obturator
SPARC: suprapubic arc
Endoscopic bladder neck suspension (EBNS)
Retropubic urethropexy: MMK, Burch
Laparoscopic Burch colposuspension
anti-incontinence surgery
Retropubic urethropexy (RPU)
traditional sling Minimally invasive synthetic
suburethral sling (MISS)
The trend of different surgical
0
200
400
600
800
1000
1200
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 year
n
RPU 59.5
Sling 59.4
TVTs 59.79
Kelly 59.3
Needle 59.6
59.71
Injection 59.72
The changing trend of different surgical types
Wu MP 2008 Int Urogyn J
• Department of Health. Hospital Episode Statistics. Department of
Health [online] 2006 URL:http://www.hesonline.nhs.uk
第三代 TVT-Secure, MiniArc迷你手術
Pelvic organ prolapse- quantitation
(POP-Q)
Bump RC 1996 AJOG
PCF
B
U
PVR
Burch
VOS
Sacrocolpopexy, USS
High McCall’s
Op
MISS
Cx. V.
Sling
Laparoscopic approaches to PFR
MISS: minimal invasive suburethral sling; PVR= para-vaginal repair; SSVS : sacral
spinous vaginal suspension ; USS: utero-sacral suspension; VOS: vaginal obturator
shelf;
Cardinal ligament
arcus tendineus
fasciae pelvis
Rectovaginal fascia
Pubocervical ligaments
Pelvic suppport structures
6 Ligaments, 2 Fascia, 1 Ring
TeLinde’s Operative Gynecology
Pericervical ring
Surgery for POP
Surgery for POP
骨盆重建手術 (pelvic reconstructive surgery)
• 使骨盆腔內的臟器 回復到原來的位置
• 骨盆重整手術 經陰道進行手術
使用人工網膜支撐骨盆肌肉韌帶
• 骨盆重整手術合併尿失禁手術
The changing trends of surgical types for
POP in Taiwan
2917
31242983 3002 2991 2987
25192660 2679
25342642
2642
28412719 2735 2740 2752
23252405 2377
2297 2284
275 283 264 267 251 235 194 255 302 237358
0
500
1000
1500
2000
2500
3000
3500
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
N
Year
Total hysterectomy uterine suspension
Table II The patients’ age and associated procedure
were the determinants for the choices of surgical types.
Surgical types
Total ChiSQ P uterine suspension hysterectomy
no. % no. % Total 2921
9.4 28117 80.6 31038
Patient Age <50 2056 25.1 6128 74.9 8184 3288.3 <.0001
50-59 397 6.4 5770 93.6 6167
60-69 263 2.9 8669 97.1 8932
<69 205 2.6 7550 97.4 7755
with
anti-incontinence no 2507 8.8 25923 91.2 28430 139.5 <.0001
yes 414 15.9 2194 84.1 2608
Wu, MP, Liang, CC, Tang, CH
Surgery equipment OR
• Cystoscopy – 0o, 70o
– 28019C (1,800)
• Cystostomy – suprapubic
catheterization (Bard)
– Cystofix (B Braun)
– 8-12 Fr
– Trocar method
– 78003C (3,285)
• Foley catheterization
Gynecare Prolift Pelvic Floor Repair System
(GPS)
Gynecare Prolift Pelvic Floor Repair System
(GPS)
The Perigee™ System
American Medical System (AMS)
American Medical System (AMS).
The Apogee™
Vault Suspension System
Tension-free vaginal mesh (TVM)
Single incision TVM迷你人工網膜
Elevate, AMS
Prosima, J & J:
Post-OP care
• Foley catheterization
– Day 1 for TVM w/w’t TVT-O
– Day 1 for TVT-O only
• Timing of removing catheterization
– VV (voided volume)> 200 ml,
– PVR (postvoidal residual) < 100ml
• Suprapubic cystostomy
– Discharge day
Quiz: where are the camels?
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