Introduction to urogynecology

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1 婦女泌尿暨骨盆醫學介紹 1. What relationship between the group 1 and group 2 questions in the following questionnaire? (A) irrelevant; (B) group 1 voiding, group 2 storage; (C) group 1 storage, group 2 voiding, (D) quality of life. 吳銘斌醫師 (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 Symptoms Chapple CR 2005 Nat Clin Practice Urol Bladder & Urethra Normal micturition cycle Normal Storage Voiding Bladder Relaxed Contracted Urethra contracted relaxed Abnormal Storage Voiding Bladder Overactive Underactive Acontractile Urethra Incompetent under stress Inappropriate relaxaed Functional or anatomic obstruction Stanton SL,Tanagho EA 1986 Springer-Verlag 1

2 有多少婦女有尿失禁的問題? 歲婦女 26% 60 以上婦女 38% 住安養機構的婦女 48% 造成尿失禁的原因 : 女性先天尿道較短泌尿道感染先天因素如人種 : 亞洲人比黑人骨盆腔肌力較弱, 白種人肌力更弱懷孕與生產 : 陰道生產, 產程延遲者發生率高第一胎影響最大造成尿失禁的原因 : 停經後女性荷爾蒙缺乏年齡 : 更年期缺乏女性荷爾蒙腹部壓力增加 : 肥胖肺部病變粗重工作者長期咳嗽或便秘吸煙骨盆腔手術過後 : 子宮頸癌根除術後癌症放射療法後 Evaluation 2. In a patient with a history consistent with an overactive bladder (OAB), which of the following study is the most useful? (A) Valsalva leak point pressure, (B) frequency/volume bladder chart over 48 hours, (C) pelvic ultrasound, (D) pressure-flow study. 2

3 尿失禁頻尿急尿治療流程婦女泌尿專科門診內診檢查尿動力學檢查鑑別診斷尿失禁種類棉墊試驗漏尿嚴重度膀胱日誌每週 ( 日 ) 喝水解尿漏尿的自我紀錄頻尿 (frequency) 與夜尿 (nocturia) 白天小便次數多 ( 等 ) 於八次每晚起床小便超過 ( 等於 ) 二次急尿 (urgency) 急迫性尿失禁 (urge incontinence) 膀胱過動症 (overactive bladder, OAB) 急尿頻尿急迫性尿失禁膀胱過動症 Medication 3. The most common side effect of oxybutynin which lead poor medical compliance is: (A) blurred vision, (B) dry mouth, (C) drowsiness, (D) nausea, (E) constipation. (Ref Clin Obs Gyn 2004). 3

應力性尿失禁 (stress urinary incontinence,sui) 為什麼我運動時都會漏尿? 我咳嗽也會漏尿!

vaginal weights, (C)electronic stimulation, (D) hypnosis, (E) bladder training. (Ref Clin Obs Gyn 2004).

4 應力性尿失禁 (stress urinary incontinence,sui) 為什麼我運動時都會漏尿? 我咳嗽也會漏尿! 尿失禁種類應力性尿失禁 40% 膀胱頸支撐組織變弱尿道過動尿道括約肌缺損急迫性尿失禁 25% 逼尿肌不穩定混合型尿失禁 25% 其他類型 10% 暫時性尿失禁泌尿道感染瞻妄滿溢性尿失禁脊髓損傷瘻管 Conservative treatment 4. The most effective non-surgical treatment of stress urinary incontinence is: (A) pelvic muscle training, (B) vaginal weights, (C)electronic stimulation, (D) hypnosis, (E) bladder training. (Ref Clin Obs Gyn 2004). 選擇治療方式保守性療法 --- 針對輕度尿失禁患者藥物治療 - 行為療法 - 骨盆肌運動 - 凱格爾運動 (Kegel s exercise) 強化骨盆肌肉強度, 使下墜的骨盆器官回復到原來的生理位置生理迴饋物理療法 - 將病人的骨盆肌肉生理現象, 轉換成可用聽覺或視覺的方式, 讓病人感覺其中的變化, 以便明瞭如何收縮骨盆肌肉電刺激物理療法 - 用電流刺激功能異常的骨盆肌肉恢復正常婦女尿失禁物理療法婦女尿失禁物理療法 ( 含生理回饋電刺激 ) 已重新恢復作業, 地點於第二醫療大樓 B1 ( 感謝復健科提供地點與時間分享 ) 4

5 Demo 生理回饋 - 幫妳做對骨盆運動 Casepre Casepost Extracorporeal Magnetic Innervation (ExMI) 尿流動力學檢查 Solar 功能說明 n 中文 Windows 作業系統 n 紅外線遙控操作 n 週邊 Plug & Play 功能 n 可擴充藍芽 (Blue- Tooth) 功能 n 具自我診斷及校正軟體 n 任一 PC 可作判讀工作站 n 可擴充 24H 動態檢查儀影像尿動力學檢查 (Videourodyanmic study 已規劃並施工完成之影像尿動力學檢查室, 提昇婦女泌尿的發展深度地點 : 第一醫療大樓 B2 碎石中心暨婦女影像尿流動力檢查室 5

Video-urodynamic study Video-urodynamic study Laborie

Equipment Recording Flow Flow Transducer Urodynamics 5.

overactivity incontinence, (C) low compliance bladder,

(From: Nygaard & Heit 2004 Obstet Gynecol).

6 Video-urodynamic study Video-urodynamic study Laborie Dorado 32 Apr 2004 Uroflometry (UFR) Vura Qura Urodynamic Equipment Recording Flow Flow Transducer Urodynamics 5. What is your diagnosis for the urodynamic study (arrow indicates urine leakage)? (A) urodynamic stress incontinence, (B) detrusor overactivity incontinence, (C) low compliance bladder, (D) sensory urgency, (E) detrusor sphincter dyssynergia (From: Nygaard & Heit 2004 Obstet Gynecol). A 儲尿期 B 解尿期 CMG (Filling Pressure flow) Pdet = Pves Pabd P 膀胱壓 P APIS Pabd RPC-9 Abdominal Pressure Catheter P 尿道壓 P Pabd 6

20 ml FD ND SD Electromyography (EMG) Urodynamic study: Cystometry EMG EMG Pura UU H : 9 H : 3 Pves Speaking Cough Cough RH Cough Pabd UIDC Pdet Leak H0959A Surface Electrodes 1512F Wire Electrodes

7 20 ml FD ND SD Electromyography (EMG) Urodynamic study: Cystometry EMG EMG Pura UU H : 9 H : 3 Pves Speaking Cough Cough RH Cough Pabd UIDC Pdet Leak H0959A Surface Electrodes 1512F Wire Electrodes Qura Time 1 min/div Vinf ml Urodynamic stress incontinence Detrusor overactivity incontinence Nygaard & Heit 2004 Obstet Gynecol Nygaard & Heit 2004 Obstet Gynecol Mechanism of urinary incontinence Surgery 6. Which treatment option for stress urinary incontinence consistently results in significant improvement? A. Anterior colporrhaphy; B. Kelly plication ; C. Retropubic urethropexy; e.g. MMK, Burch D. Needle urethropexy. a: normal voiding or DO; b: DSD; c: impair bladder compliance; Stanton S L,Tanagho E A 1986 Springer-Verlag d: urethral instability; e: UDSI 7

8 手術治療當藥物物理療法等保守療法都無法控制病情時傳統膀胱懸吊術 - 恥骨後陰道懸吊術 (sling operation) 膀胱頸吊帶術 (Burch colposuspension) 需開腹或損失自身的腹直肌肌膜或側股骨筋膜做為吊帶手術無張力陰道吊帶手術 - 目前最新手術方法傷口小恢復快治癒率高術後膀胱訓練時間短病人接受程度高 Hammock theory --Abdominal pressure on urethra and pelvic floor DeLancey JOL Am J Obstet Gynecol: Pubo-vaginal sling Burch colposuspension Stanton SL,Tanagho EA 1986 Springer-Verlag Stanton SL,Tanagho EA 1986 Springer-Verlag Burch colposuspension Open retropubic colposuspension 開腹式膀胱頸懸吊 8

9 Laparoscopic colposuspension- 腹腔鏡膀胱頸懸吊台灣地區近十年來尿失禁手術改變驅勢 n 1200 The trend of different surgical RPU 59.5 Sling 59.4 TVTs MUS Kelly 59.3 Needle LS Injection year Wu MP, Tang CH, et. al 2008 Int Urogyn J 手術理論基礎 (Umsten Integral Theory) PUL: pubo-urethral lig. 經陰道無張力吊帶手術超迷你吊帶經閉孔平時用力時經恥骨後 9

10 第一代 Retropubic 經恥骨後系統第二代 :Transobturator 經閉孔膜系統第二代 Monarc, TVT-O Monarc (TOT) 經閉孔膜系統 TVT-O American Medical System SPARC 經恥骨後系統 TVT 無張力尿道中段吊帶術膀胱中段尿道第三代 : 超迷你吊帶術 (Miniarc) 無切口 10

11 第三代 : 超迷你吊帶手術 TVT-S (J&J 傳統膀胱懸吊術無張力陰道吊帶超迷你吊帶吊帶住院天數術後 3-5 天術後隔天出院術後隔天出院手術時間稍長 ( 約分 ) 短 ( 約分 ) 非常短 ( 約分 ) 麻醉方式插管全身麻醉可用靜脈或局部麻醉可用靜脈或局部麻醉手術侵襲性大小超小手術成功率 % % % 術中可確定是否已達到良好效果否是是手術傷口腹部 10cm 傷口 2 個皮膚小切口無皮膚傷口 Mini-Arc (AMS) Ajust (Bard) 術後放置導尿管時間 3-4 天隔夜即可拔導尿管或不用術後併發症少少有傷到膀胱可能性術後疼痛程度中等輕微大腿內側疼痛隔夜即可拔導尿管或不用極少無傷到膀胱可能性幾乎無疼痛無大腿內側疼痛 The evolution of midurethral sling (MUS) 3rd generation: Single-incision TVT-secure, MiniArc 2nd generation: Trans-obturator TVT-O, Monarc 聖路易美國 1st generation: Supra-pubic TVT, SPARC, IVS Endoscopic bladder neck suspension (EBNS) Tradition bladder-neck sling Kelly plication TVT: tension-free vaginal tape TVT-O: tension-free vaginal tape -obturator SPARC: suprapubic arc 台南台灣 Tainan: snacks, historic resorts and?? Chi Mei Museum, Tainan, Taiwan Ole Bull Giuseppe Guarneri del Gesù 1744 Italy-Cremona 11

12 Apical (uterine and vaginal vault) prolapse Normal vaginal axis in nulli-parous woman in the standing position Walters MD, Karram MM 1999 Mosby Pelvic bony structure Pelvic Floor Support DeLancey JOL 1994 Am J Obstet Gynecol Level I: suspension Cardinal ligament Utero-sacral ligament Level II: attachment Ant: pubo-cervical fascia Post: recto-vaginal septum Level III: fusion perineum Pelvic suppport structures 6 Ligaments, 2 Fascia, 1 Ring Vaginal wall assessment Pericervical ring Cardinal ligament arcus tendineus fasciae pelvis Rectovaginal fascia Pubocervical ligaments TeLinde s Operative Gynecology Liu CY Chattanooga Women s Laser Center 12

Pelvic organ prolapsequantitation (POP-Q) POP-Q 7.

(POP-Q) system, point C is: (A) anterior vagina,

fornix, (E) introitus. Bump RC 1996 AJOG POP-Q 8.

(C) apical defect, (D) anterior and posterior

Prolapse of the apical segment of the vagina -3-3

13 Pelvic organ prolapsequantitation (POP-Q) POP-Q 7. Using the Pelvic Organ Prolapse Quantification (POP-Q) system, point C is: (A) anterior vagina, (B) posterior vagina, (C) cervix, (D) posterior fornix, (E) introitus. Bump RC 1996 AJOG POP-Q 8. Which predominant support defect does the below line diagram depict? (A) anterior wall defect, (B) post wall defect, (C) apical defect, (D) anterior and posterior defect. Prolapse of the apical segment of the vagina Miklos JR 2002 Curr Opin Obstet Gynecol 子宮托 (2-5 號 ) Sacral colpopexy with mesh (Option) 77 Apr

14 Sacral colpopexy 子宮薦骨懸吊術 (Sacro-hysteropexy) Sacral promontory Walters MD & Karram MM: 1999 Mosby Inc. Uterosacral vaginal vault suspension Vaginal stump U-S Lig Rectum Walters MD & Karram MM: 1999 Mosby Inc. Uterosacral ligament suspension high McCall colpopexy Sacrospinous vaginal suspension (SSVS) Wu MP: Int J Gynecol Obstet 1997 Walters MD, Karram MM 1999 Mosby 14

Sacrospinous vaginal suspension (SSVS) Enterocele: peritoneum in direct contact with vaginal epithelium with no intervening fascia Deschamps ligature carrier Miya Hook Walters MD, Karram MM 1999

Posterior vaginal wall prolapse The Evolution of Pelvic Reconstructive Surgeries Single incision mesh: Prosima (J&J);Elevate (AMS) Tension-free biologic mesh TVM: post.

suspension Miklos JR 2002 Curr Opin Obstet Gynecol Abdominal sacro-colpopexy VTH+ A-P colporrhaphy Manchester; LeFort TVM: tension-free vaginal mesh; SIS (Cook); Pelvicol (Bard) Surgery-POP Which

15 Sacrospinous vaginal suspension (SSVS) Enterocele: peritoneum in direct contact with vaginal epithelium with no intervening fascia Deschamps ligature carrier Miya Hook Walters MD, Karram MM 1999 Mosby Miklos JR 2002 Curr Opin Obstet Gynecol Benson JT 2000 McGraw-Hill Co. Posterior vaginal wall prolapse The Evolution of Pelvic Reconstructive Surgeries Single incision mesh: Prosima (J&J);Elevate (AMS) Tension-free biologic mesh TVM: post. IVS (Tyco); Prolift (J&J); Perigee+Apogee (AMS); Avaulta (Bard) Surgeon-tailored 4-corner mesh fixation ( bilateral S-S lig. suspension) Uterosacral lig. suspension Sacro-spinous lig. suspension Miklos JR 2002 Curr Opin Obstet Gynecol Abdominal sacro-colpopexy VTH+ A-P colporrhaphy Manchester; LeFort TVM: tension-free vaginal mesh; SIS (Cook); Pelvicol (Bard) Surgery-POP Which LSC surgery is not recommended in the treatment of uterine prolapse with uterine preservation? (A) High McCall hysteropexy, (B) U-S ligament hysteropexy, (C) sacral hysteropexy, (D) Sacral spinous ligament uterine fixation, (E) Gilliam round ligament hysteropexy. 陰道人工網膜植入術 (Transvaginal mesh, TVM) 經閉孔人工網膜 Transobturator TVM 無切口陰道工網膜 Single incision TVM 15

16 無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM) 無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM) Gynecare Prolift Pelvic Floor Repair System (GPS) Trans-vaginal Mesh (TVM) Technique Gynecare Prolift Pelvic Floor Repair System 陰道人工網膜植入術 Tension-free Vaginal Mesh (TVM) 經閉孔人工網膜陰道前壁 Perigee AMS 16

17 經閉孔人工網膜陰道前壁 Perigee The Apogee Vault Suspension System American Medical System (AMS) American Medical System (AMS). 無切口人工網膜 ( 無會陰切口 ) A 經閉孔人工網膜 (4-6 會陰小切口 ) (+ 無張力尿道中段吊帶術 ) B Monarc or TVT-O Perigee ( 前片 ) Apogee ( 後片 ) 保留子宮切除子宮 C 無切口人工網膜 ( 無會陰切口 ) (+ 無張力尿道中段吊帶術 ) D Monarc TVT-O Mini-Arc Elevate ( 前片 ) Elevate ( 後片 ) Surgery-POP 9. What is the major concern to use mesh in pelvic floor reconstruction? (A) surgical failure, (B) post-operative recurrence, (C) the technical difficulty, (D) erosion. 保留子宮切除子宮 17

18 合併症 : 網膜暴露 Mesh erosion or migration da Vinci Robotic surgery Robotic sacro-colpopexy 達文西子宮薦骨懸吊術 (sacro-hysteropexy) 18

10. A 58 y/o patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy

She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria.

Urinary tract infection; C. Vesicovaginal fistula; D. Detrusor instability; E. Diabetic neuropathy. 11.

cervix. A suprapubic catheter was placed at the time of surgery.

She is also leaking urine with activity, coughing, and sneezing.

19 10. A 58 y/o patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy with anterior colporrhaphy and Burch procedure for uterine prolapse and stress urinary incontinence. She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria. Which of the following is the most likely explanation for this complaint? A. Failure of the procedure; B. Urinary tract infection; C. Vesicovaginal fistula; D. Detrusor instability; E. Diabetic neuropathy. 11. A 49-year-old woman had a radical hysterectomy and lymph node sampling for stage 1B squamous cell cancer of the cervix. A suprapubic catheter was placed at the time of surgery. She is now 8 weeks postoperative and has not been able to void. She is also leaking urine with activity, coughing, and sneezing. What is the most likely reason for voiding difficulty? A. spasm of the pelvic floor muscles; B. outflow obstruction; C. postoperative swelling around the bladder; D. innervation to the lower urinary tract was transected; E. overdistention of the bladder. 夢想不該隨著年紀愈大而縮水 Thank you for your attention! 19

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投影片 1 婦女尿失禁 (Female urinary incontinence) 吳銘斌醫師 (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婦女常見生殖泌尿道問題泌尿道感染生殖道感染生殖道萎縮月經週期異常婦女泌尿疾病尿失禁頻尿急尿骨盆鬆弛子宮脫垂膀胱直腸脫垂男女大不同