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

MiniArc

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?