经阴道无张力尿道中段吊带术-TVT术

经阴道无张力尿道中段吊带术TVT术上海第二医科大学附属仁济医院泌尿外科TVT微创伤手术1.减少手术时间Reducesurgicaltime2.减少住院时间Reducelengthofhospitalization3.减少并发症Reducecomplicationrates/risks4.复原快Allowquickerreturntonormal,dailyactivities5.减少费用LowercostsGYNECARETVTTension-freeSupportforIncontinenceTVT尿失禁的无张力支撑简介I•TVT尿失禁的无张力支撑是一种创新的微创伤手术方法,它对张力性尿失禁治疗的有效性已得到了充分的临床证明GYNECARETVTTension-freeSupportforIncontinenceisaninnovativeminimallyinvasivesurgicalalternativefortheeffectivetreatmentofstressurinaryincontinence,withprovenresults•使用Prolene网带进行无张力尿道中段悬吊术TheplacementofapieceofPROLENEmesh(45cmx1.1cmx0.7mm)withouttension,atthemidurethraGYNECARETVTTension-freeSupportforIncontinenceTVT尿失禁的无张力支撑简介II•局麻,阻滞/硬膜外Localanesthesia,sedation/regional•经阴道进路，切口小,分离少Minimalincisionsanddissection•网带无张力地置于尿道中段下Tapeplacedatmidurethrawithouttension•普理灵聚丙烯网带无需和任何组织固定Nofixation•术中使用膀胱镜Cystoscopyperformed•术后插尿管时间短Infrequentuseofpost-opcatheters•可在门诊进行，当天出院DischargehomethesamedayGoalofSurgery手术目的1.修复和/或加强阴道尿道韧带Restoreand/orreinforcethepubourethralligaments.2.修复和/或加强尿道下阴道吊筋膜Restoreand/orreinforcethesuburethralvaginalhammock3.加强尿道旁结缔组织ReinforcetheparaurethralconnectivetissueGYNECARETVTTension-freeSupportforIncontinenceIndicationsTVT尿失禁的无张力支撑适应症•适应于以下原因引起的女性张力性尿失禁IntendedtobeusedfortreatmentofFemaleStressUrinaryIncontinenceresultingfrom–尿道过度活动urethralhypermobility–尿道括约肌损伤intrinsicsphincterdeficiencyGYNECARETVTContraindicationsTVT尿失禁的无张力支撑禁忌征•怀孕病人Pregnantpatients•未完成发育的病人Patientswithfuturegrowthpotential•计划要怀孕的病人WomenwithplansforfuturepregnancyGYNECARETVTTension-FreeSupportforIncontinenceSystemTVT产品系列•TVT网带GYNECARETVTDevice•推针器GYNECARETVTIntroducer•导引杆GYNECARETVTRigidCatheterGuideGYNECARETVTTension-freeSupportforIncontinenceDescription:PROLENE*polypropylenemeshcoveredbyaplasticsheathProlene*网带:网状钩形编织,外面套有塑料膜Prolene*网带TVT网带•长45公分,宽一公分的网带,成分为聚丙烯•网带的两侧边有特意编制的毛刺,增加其在腹壁中的摩擦力,将带子固定在腹壁中•外面包有一层塑料套,塑料套在中间分开•网带的两头分别为长30公分,直径为5毫米的针.手术中,针通过阴道前壁切口,带着网带穿过腹壁,使其置于尿道中段下•网带的网眼大小适中,术后结缔组织会长在网眼中,加强盆底的组织Prolene普理灵•特点–惰性强–组织相容性强/组织反应小–有延展性–表面光滑–易于操作•心血管吻合的专用缝线,在缝合材料中有“缝线之王”的称号GYNECARETVTIntroducer推针器推针器•推针器的方形头部结在真的方形尾部,手术中,术者的手握住推针器的T形手柄,帮助针顺利穿过腹壁GYNECARETVTRigidCatheterGuide导引杆导引杆•导引杆在手术中的作用主要是推开膀胱,防止穿针过程中产生膀胱穿孔•它从18号导尿杆进入膀胱,从左侧穿针,就将膀胱推向右侧,反之亦然GYNECARETVTPatientInformation病人情况•手术介绍Procedureoverview•病人手术风险Potentialrisks–血肿Bleeding-hematomaformation–感染Infection–膀胱穿孔Bladderperforation–尿潴留Urinaryretention–排斥反应Mesherosionorrejection•复原Recovery•期望ExpectationsGYNECARETVT-PreOpTVT术前•术前抗菌素Peri-operativeantibiotics•停止使用抗凝剂Cessationofanti-coagulantsInstrumentRequirements手术需要的器械•阴道重锤/拉钩•弯剪-分•蚊式钳-钳住塑料套,抽出.•长的硬膜外针头-局麻•70度膀胱镜-观察膀胱情况•18号(单枪/双枪)导尿管GYNECARETVT-Procedure手术过程•病人准备Patientpreparation•切口Incisions•分离，穿针，放置网带Dissection,needlepassageandtapeplacement•网带松紧度调整Tensionadjustment•结束手术CompletingtheprocedurePatientPosition病人体位•截石位，膝盖与耻骨联合平行•插18号导尿管,排空膀胱Insert18frcatheterandemptybladderAnesthetic麻醉•局麻+静脉加强LocalAnesthesiawithIVsedation,recommended•骶麻或全麻RegionalorGeneralanesthesiapossible.Anesthesia麻醉Abdomen腹部Anesthesia麻醉VaginalWall阴道前壁Incisions切口•阴道前壁Vaginal–在离尿道外口1cm处作1.5cm纵向切口•腹部Abdominal–在耻骨联合上方，腹中线两侧各作一个0.5cm-1.0cm切口2incisionseachsideofmidline•两切口相距最宽4-5公分justabovesymphysis4-5cmapartmax.VaginalWallIncision阴道前壁切口•在离尿道外口1cm处作1.5cm纵向切口AbdominalIncisions腹部切口–在耻骨联合上方，腹中线两侧各作一个0.5cm-1.0cm切口，两切口相距最宽4-5公分DissectionofAnteriorWall阴道前壁分离BluntDissectionsubandparaurethrally在尿道旁和尿道下进行钝性分离InsertTVTRigidCatheterGuide插入TVT导引杆IntroductionoftheGYNECARETVTDevice推入TVT网带•通过阴道切口推入Introducethroughvaginalincision•针头指向髂骨Aimtowardipsilateralshoulder•绕过耻骨Hugthepubicbone(donotscrap•从腹壁切口出ExitatabdominalincisionIntroductionoftheGYNECARETVTDevice推入TVT网带GuidetheNeedleTiptotheAbdominalIncision将针头导向腹壁切口针不要拔出Cystoscopy膀胱镜•针穿过后,使用膀胱镜确保膀胱完好Aftereachpassageoftheneedle,cystoscopyshouldbecompletedtoverifybladderintegrity•将膀胱注液后使用膀胱镜Cystoscopyshouldbedonewithbladderhalf-fullBladderPerforation膀胱穿孔BladderPerforation膀胱穿孔SecondPassageoftheGYNECARETVTDevice第二根针的穿入•重新插导尿管,排空膀胱Re-insertthecatheteranddrainthebladder•重复第一次穿针的步骤Theoppositesideiscompletedinthesamemannerasthefirst•确保网带没有扭转Ensurethatthetapedoesnottwist•再次使用膀胱镜CystoscopyafterthesecondpassoftheTVTneedle•针从腹壁切口拉出PullTVTneedlethroughtheabdomenincisionTapeAdjustment调整网带•在网带和尿道间放置一把剪刀或止血钳Placescissorsorhemostatbetweenthetapeandtheurethra•拉腹壁端的网带,直到网带贴住剪刀Pulltheabdominalendsofthetapeuntilthereiscontactbetweentapeandinstrument•将针剪去Separateneedlesfromthetape•先不要拉出塑料薄膜DonotremovetheplasticsheathCoughTest腹压测试•膀胱注液250毫升Fillbladderwith250mlofsaline•取出尿道下的剪刀/或止血钳Removeinstrumentundertheurethra•取下阴道重锤Removevaginalspeculum•要病人用力咳嗽Askpatienttocough•调整网带松紧度AdjustTVTtape–调整松紧度时,剪刀要置于网带和尿道之间InstrumentshouldbeplacedbetweenthetapeandtheurethraduringadjustmentInitialCoughTest初步腹压测试AdjustTapewithInstrumentinPlace器械放置在网带和尿道间,调整网带CompletingtheProcedure完成手术•抽出塑料薄膜Removeplasticsheath•剪去腹壁上多余的网带CutProleneMesh•缝合皮肤和阴道粘膜切口Closeskinandvaginalepithelium•排空膀胱Emptybladder•取出导尿管RemovecatheterCompletingtheProcedure完成手术removingplasticsheath取出塑料薄膜CompletingtheProcedure完成手术Trimmingthemesh剪去多余的网带GYNECARETVTPostoperativeAssessmentBeforeDischarge出院前的术后评