TVTO治疗女性压力性尿失禁

TVT-O治疗女性压力性尿失禁*TrademarkGYNECARETVT*Tension-freeSupportforIncontinenceTVT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,sevenyearfollow-updatapresentedat2003IUGAreported+•Curerateof81%•Significantlyimprovedrateof16%•Comparableto5yeardataof85%/11%respectivelyVerylowratesofreportedmajorcomplicationsinover500,000patients•Reportedbowelinjurylessthan6/100,000procedures•Reportedmajorvascularinjurylessthan9/100,000procedures+Nilsson,et.al,7YearFollow-upoftheTension-freeVaginalTape(TVT)Procedure;InternationalUrogynecologyJournal,IUGAAbstract#116(89);October,2003.ComplicationsStatementComplicationUSEx-USTotal%血管损伤737440.009尿道磨损200200.004肠损伤1612280.006神经损伤3140.0008血肿416200.004MostSignificantReportedComplications++Basedonover500,000patientstreatedworldwide++AsofSeptember26,2003,sevendeathsareassociatedwithGYNECARETVT.Sixcaseswereforbowelperforation.Fivewereassociatedwithundiagnosedbowelperforationsatthetimeofsurgery.Inthesixthcaseofbowelperforation,noadditionalinformationcouldbeobtained.Theseventhcasewasassociatedwithawomanwhohadableedingdisorderwhodiedfromuncontrolledpostoperativebleedingintheretropubicspace.ConceptDevelopmentofGYNECARETVTObturator•ProfessorJeandeLeval,ChairmanofUrologyattheUniversityofLiege,Belgium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RetropubicSlings(“U”shaped)F1F1F2F2ObturatorSlings(HammockShaped)“U”Shapevs.HammockShape-Hammockshapeofslingmayresultinlessobstructivesymptomsand/ordenovourgency,sinceitishardertoovercompresstheurethra悬吊带方向的改变减少梗阻的发生和术后急迫症状-However,thismayalsomakeitmoredifficulttocorrectcertainpatients,suchasthosewithISD但是，对于ISD的病人可能不能完全纠治GYNECARETVTObturatorSystem•ConsistsofthreemajorcomponentsGYNECARETVT经闭孔吊带GYNECARETVT螺旋穿刺针GYNECARETVT蝶型导引器•BlisterpackageShownwithTyvekLidremovedGYNECARETVTObturatorSystem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BendableTabs6cm7cmGYNECARETVTObturatorSystem•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.WorkstationDesignWithlefthand,grabHelicalPasserforpatient’srightsideWingedGuideslidesoutofworkstationinthisdirectionWithrighthand,grabHelicalPasserforpatient’sleftsideAftergraspingbothhandlesandremoving,rotatehandlesoutward•HoldsHelicalPasser,Device,andWingedGuide•AllowsfordumpingoraseptictransferfromTyvekBlisterPatientorientationsymbolProductOrderingInformation•ProductCode:810081ReviewofProceduralSteps&Anatomy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:TheabovetechniqueisfromVincentLucenteM.D.-GYNECAREdoesnotrecommendanyparticularanesthesiaprotocol.•-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.•Marktheexitpointsbytracingahorizontallineattheleveloftheurethralmeatus,andasecondlineparalleland2cmabovethefirstline.-Locatetheexitpointsonthissecondline,2cmlateraltothefoldsofthethigh.Optionally,skinincisionsmaybemadeatthistime.•-用Allis钳牵夹,在尿道口下一公分作一个一公分的切口.•UsingAllisclampsfortraction,makea1cmmidlinevaginalincisionstarting1cmproximaltotheurethralmeatusSTEP#1:标记大腿根部的出针点和阴道正中切口-锐性分离Sharplydissect,usingbladeorsharpscissors(tenotomyorMetzenbaums–notMayo)-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.Bluntlydissect,usingapush-spreadtechniquetowardthe‘junction’betweenthebodyofthepubicboneandtheinferiorpubicramus,orientingscissorshorizontallyorpointedslightlyupward,andatapprox45degreeangle(towardpalpablejunction)-突破闭孔膜Perforatetheobturatormembrane-略微将剪刀撑大SpreadscissorsslightlyapartSTEP#2:组织分离至闭孔膜并突破准备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InsertWingedGuide,intotractatsameangleasscissors-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.IfWingedGuidedoesnot“pop”throughobturatormembrane,Removeandreestablishtractusingscissors-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.WithWingedGuideinplace,insertHelicalPasser,keepingtipinlinewiththechanneloftheWingedGuide-压住螺旋穿刺针穿过闭孔膜,感觉突破感.PressHelicalPasserthroughobturatormembrane,feeling“pop”-取走蝶型导引棒RemoveWingedGuide-一边旋转穿刺针,手柄部位同时移至中线位置.SimultaneousrotationandcenteringofHelicalPasserhandle-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.DoNOTrotatehandlepriortocenteringororienthandleinthehorizontalplane,aseitherofthesemotionsmayincreasethepotentialfortheHelicalPassertoentertheretropubicspace(remember…..POP,DROP&ROTATE)STEP#4:旋转螺旋穿刺针直至手柄转到中间位置-螺旋穿刺针在靠近前面设定的出针点附近穿出.HelicalPassershouldexitnearthepreviouslydeterminedexitpoints.-可能需要拉一下皮肤Slightskinmanipulationmayberequired.-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Ifskinincisionswerenotcreatedatstartofprocedure,theyshouldbecreatednow.STEP#5:针尖传出皮肤切口-针尖穿出皮肤后,钳夹塑料管顶端-稳住尿道处的塑料管Stabilizetheplastictubeneartheurethra-RemovetheHelicalPasserbyareverserotationofthehandle,overcomingthedetentholdingthePlasticTubetotheHelicalPasser.STEP#6:钳夹塑料管-反向转出穿刺针使用器械Afterclampingplastictipwithhemostat(notshown),placethumbatbaseofPlasticTube(asshownbelow)androtateHelicalPasseroutofDevice…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.-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