TVTtraining

TVT尿道中段悬吊术,微创伤手术,1.减少手术时间 Reduce surgical time 2.减少住院时间 Reduce length of hospitalization 3.减少并发症 Reduce complication rates/risks 4.复原快 Allow quicker return to normal, daily activities5.减少费用 Lower costs,GYNECARE TVT Tension-free Support for IncontinenceTVT尿失禁的无张力支撑,TVT尿失禁的无张力支撑是一种创新的微创伤手术方法, 它对压力性尿失禁治疗的有效性已得到了充分的临床证明GYNECARE TVT Tension-free Support for Incontinence is an innovative minimally invasive surgical alternative for the effective treatment of stress urinary incontinence, with proven results.,GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑,使用Prolene网带进行无张力尿道中段悬吊术The placement of a piece of PROLENE mesh (45 cm x 1.1 cm x 0.7 mm) without tension, at the mid urethra,GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑,局麻, 阻滞/硬膜外Local anesthesia, sedation/regional切口小, 分离少 Minimal incisions and dissection 网带无张力地置于尿道中段下Tape placed at mid urethra without tension 术中使用膀胱镜 Cystoscopy performed 术后插尿管时间短 Infrequent use of post-op catheters 当天出院 Discharge home the same day,Goal of Surgery手术目的,1. 修复和/或加强阴道尿道韧带 Restore and/or reinforce the pubourethral ligaments.2.修复和/或加强尿道下阴道吊筋膜 Restore and/or reinforce the suburethral vaginal hammock3.加强尿道旁结缔组织 Reinforce the paraurethral connective tissue,GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑,普理灵聚丙烯网带 PROLENE* polypropylene mesh tape 无需和任何组织固定 No fixation经阴道进路 Trans-vaginal approach 组织分离少 Minimal tissue dissection,GYNECARE TVT Tension-free Support for Incontinence TVT尿失禁的无张力支撑,局麻 Local anesthetic 导尿管使用时间短 Minimal catheter use 可在门诊进行 Out-patient,GYNECARE TVT Tension-free Support for Incontinence Indications TVT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Intended to be used for treatment of Female Stress Urinary Incontinence resulting from 尿道过度活动 urethral hypermobility内源性尿道括约肌功能障碍intrinsic sphincter deficiency,GYNECARE TVT Tension-free Support for Incontinence Contraindications TVT尿失禁的无张力支撑禁忌征,怀孕病人 Pregnant patients 未完成发育的病人 Patients with future growth potential计划要怀孕的病人 Women with plans for future pregnancy,Warnings and Precautions 注意事项,不要进行抗凝治疗 No anticoagulation therapyNo UTI要有一定膀胱颈悬吊术的经验 Familiar with bladder neck suspension surgery用最小的张力在尿道中段下放置TVT网带 TVT placed with minimal tension at mid urethra使用膀胱镜观察确保膀胱完好 Cystoscopy to confirm bladder integrity注意盆腔结构, 避免组织损伤Attention to pelvic anatomy to avoid injuries to structures 出院前观察是否有耻骨后血肿Observe for retropubic hematoma before discharge,GYNECARE TVT Tension-Free Support for Incontinence System TVT产品系列,TVT 网带 GYNECARE TVT Device GYNECARE TVT Introducer GYNECARE TVT Rigid Catheter Guide,GYNECARE TVT Tension-free Support for Incontinence,Description: PROLENE*polypropylene mesh covered by a plastic sheathProlene*网 带: 网 状 钩 形 编 织 , 外 面 套 有 塑 料 膜,Prolene*网 带,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,GYNECARE TVT Introducer 推针器,GYNECARE TVT Rigid Catheter Guide 导引杆,GYNECARE TVT - Preoperative Evaluation术前评估,确诊为压力性尿失禁进行排尿分析,GYNECARE TVT Patient Information病人情况,手术介绍 Procedure overview病人手术风险Potential risks血肿 Bleeding-hematoma formation感染 Infection 膀胱穿孔 Bladder perforation尿潴留 Urinary retention排斥反应 Mesh erosion or rejection复原 Recovery期望 Expectations,GYNECARE TVT - Pre OpTVT 术前,术前抗菌素 Peri-operative antibiotics停止使用抗凝剂 Cessation of anti-coagulants Postmenopausal patient should have estrogenized vaginal wall tissue.,Instrument Requirements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50cc注射器 - 向膀胱内注生理盐水70度膀胱镜 - 观察膀胱情况18号(单枪/双枪)导尿管,GYNECARE TVT - Procedure手术过程,病人准备 Patient preparation 切口 IncisionsDissection, needle passage and tape placement Tension adjustment Completing the procedure,Patient Position病人体位Insert 18 fr catheter and empty bladder 插18号导尿管, 排空膀胱,Anesthetic 麻醉,局麻 +静脉加强 Local Anesthesia with IV sedation, recommended骶麻或全麻 Regional or General anesthesia possible.,Anesthesia,Abdominal Injections,Anesthesia 麻醉Abdomen 腹部,Anesthesia,Vaginal Wall,Anesthesia 麻醉Vaginal Wall 阴道前壁,Incisions 切口,阴道前壁 Vaginal在离尿道外口1cm处作1.5 cm 纵向切口腹部 Abdominal 在耻骨联合上方，腹中线两侧各作一个0.5 cm - 1.0 cm切口 2 incisions each side of midline 两切口相距最宽4-5公分 just above symphysis 4 - 5 cm apart max.,Vaginal Wall Incision 阴道前壁切口,Incisions,Vaginal Wall,Dissection,Blunt dissection of anterior wall sub and paraurethrally,Abdominal Incisions 腹部切口,GYNECARE TVT - Procedure手术过程,PreparationIncisionsDissection, needle passage and tape placement 组织分离, 穿针和放置网带Tension adjustmentCompleting the procedure,Dissection of Anterior Wall 阴道前壁分离Blunt Dissection sub and paraurethrally在尿道旁和尿道下进行钝性分离,Insert TVT Rigid Catheter Guide 插入TVT导引杆,Introduction of the GYNECARE TVT Device推入TVT网带,通过阴道切口推入 Introduce through vaginal incision 针头指向髂骨 Aim toward ipsilateral shoulder 绕过耻骨 Hug the pubic bone (do not scrap从腹壁切口出 Exit at abdominal incision,Introducer/needle pointed toward ipsilateral shoulder 针尖指向同侧肩膀 Finger in vagina guides needle 食指经阴道导引针的放行 Needle hugs the pubic bone during insertion 穿针时针紧贴着耻骨 Abdominal incisions act as a guide 腹部切口可作为方向引导 Cystoscopy performed after each needle passage 穿针后进行膀胱镜检查 Bladder is drained again and needle is passed on other side 再次排空膀胱，在另一侧穿针 After confirming bladder integrity, needles are passed through abdominal incisions 确认膀胱完好，将针拉出腹壁,Needle Passage and Tape Placement,Introduction of the GYNECARE TVT Device推入TVT网带,Guide the Needle Tip to the Abdominal Incision将针头导向腹壁切口,针头不要拔出,Cystoscopy 膀胱镜,针穿过后, 使用膀胱镜确保膀胱完好 After each passage of the needle, cystoscopy should be completed to verify bladder integrity将膀胱注液后使用膀胱镜 Cystoscopy should be done with bladder half-full,Bladder Perforation 膀胱穿孔,Bladder Perforation 膀胱穿孔,Second Passage of the GYNECARE TVT Device第二根针的穿入,重新插导尿管, 排空膀胱 Re-insert the catheter and drain the bladder重复第一次穿针的步骤 The opposite side is completed in the same manner as the first 确保网带没有扭转 Ensure that the tape does not twist 再次使用膀胱镜 Cystoscopy after the second pass of the TVT needle针从腹壁切口拉出 Pull TVT needle through the abdomen incision,Tape Adjustment 调整网带,在网带和尿道间放置一把剪刀或止血钳 Place scissors or hemostat between the tape and the urethra拉腹壁端的网带, 直到网带贴住剪刀 Pull the abdominal ends of the tape until there is contact between tape and instrument将针剪去 Separate needles from the tape先不要拉出塑料薄膜 Do not remove the plastic sheath,Cough Test 腹压测试,膀胱注液250毫升 Fill bladder with 250 ml of saline 取出尿道下的剪刀/或止血钳 Remove instrument under the urethra取下阴道重锤 Remove vaginal speculum要病人用力咳嗽 Ask patient to cough调整网带松紧度 Adjust TVT tape调整松紧度时, 剪刀要置于网带和尿道之间 Instrument should be placed between the tape and the urethra during adjustment,Initial Cough Test 初步腹压测试,Adjust Tape with Instrument in Place器械放置在网带和尿道间, 调整网带,Completing the Procedure完成手术,抽出塑料薄膜 Remove plastic sheath 剪去腹壁上多余的网带 Cut Prolene Mesh缝合皮肤和阴道粘膜切口 Close skin and vaginal epithelium 排空膀胱 Empty bladder取出导尿管 Remove catheter,Completing the Procedure 完成手术removing plastic sheath取出塑料薄膜,Completing the Procedure完成手术Trimming the mesh剪去多余的网带,GYNECARE TVT Postoperative Assessment Before Discharge出院前的术后评估,出血/血肿 Bleeding/hematoma 餐饮 Eating and drinking排尿 Voiding,GYNECARE TVT Postoperative Instructions术后要求,术后排尿残留 Post void residual 3-4天抗菌素 Antibiotics 3-4 Days 限制活动 Activity limitations 驾驶 锻炼 性生活工作,GYNECARE TVT Postoperative CareFollow-up appointments随访,3 weeks6 monthsYearly,GYNECARE TVT Complications & Treatment并发症及其治疗方法,尿潴留 Urinary retention,GYNECARE TVT Complications & Treatment并发症及其治疗方法,膀胱穿孔 Perforation of the bladder使用膀胱镜确认 Cystoscopic identification 取出针,重新穿 Remove needle and reposition 导尿管留置1-2天 Indwelling catheter x 1-2 days,GYNECARE TVT Complications & Treatment并发症及其治疗方法,阴道出血/后腹膜血肿 Vaginal bleeding / Retropubic hematoma 保守治疗 Manage conservatively 压迫 如必要，进行引流,GYNECARE TVT Complications & Treatment并发症及其治疗方法,Infection 感染抗菌素- 口服/静脉用药 Oral / IV antibiotics,History of GYNECARE TVT:Clinical ResultsTVT的历史临床报告,TVT的历史,由Dr. Ulf Ulmsten在1995年首次使用Prolene网带进行尿道中段悬吊术。到2004年全球已超过50万例。每年都发表TVT临床随访报告 （7年）,Pubo Vaginal Sling - Prolene TapeSubjective Cure,1 - 2 year follow-up2 - follow-up 12 months3 - 3-18 months follow-up4 - 3 Year follow up,Pubo Vaginal Sling - Prolene TapeIntraoperative Results,Pubo Vaginal Sling - Prolene TapePostoperative Complications,Pubo Vaginal Sling - Prolene TapeOutcome of Surgery,GYNECARE TVT Tension-free Support for Incontinence使用TVT治疗尿失禁GYNECARE TVT Clinical Results 临床结果,了解这5个临床报告,Long Term Study(Nilsson et. al. Study 2001)长期报告Recurrent SUI Study (Rezapour Study 2001)复发尿失禁治疗研究ISD Study (Rezapour/Falconer Study 2001)ISD 研究Concomitant Study (Horton Study 2001)合并手术研究TVT versus Burch Study(Ward Hilton Study 2002)比较TVT和Burch手术,Long Term Results of the TVT Procedure for Surgical Treatment of Female Stress Urinary Incontinence女性压力性尿失禁的TVT手术的长期临床结果,Prospective, study of 90 patients前瞻性的，90个病人的研究Follow-up of 48-70 mo. (mean approx 5-year)随访4870个月Three study sites三个研究中心Patients with ISD excludedISD病人除外84.7% (72/85) curedNeg SST, Neg 24hr pad, QOL 90% 10.6% (9/85) significantly improved 50% or 2 prior operations; 3 5 prior operations82% (28/34) curedNeg SST, 90%9% (3/34) significantly improvedNeg SST, QOL 75% 90%发生推迟排尿比“简单”的SUI病人要高,Rezapour M, Ulmsten U. Int Urogynecol J (2001) (suppl 2):S9-11.,何时使用这个临床报告？,当你要说服手术技术纯熟的泌尿科医生进行复杂病例的治疗时目标客户首选TVT的泌尿科医生使用Burch的医生妇产科和泌尿科,Rezapour M, Ulmsten U. Int Urogynecol J (2001) (suppl 2):S9-11.,TVT in Stress Incontinent Women with Intrinsic Sphincter Deficiency-A Long-term Follow-up使用TVT治疗ISD的长期随访结果,Prospective study of 49 women49名妇女的前瞻性研究平均随访4 yrs (range 3-5 yrs）ISD 定义为 MUCP 90%, 90% 70 yrs, MUCP 10cm H2O, fixed urethra,Rezapour M, Falconer C, Ulmsten U. Int Urogynecol J (2001) (suppl 2):S12-14.,何时使用这个临床报告？?,当你要说服医生使用TVT进行GSI+ISD的治疗目标客户有经验的泌尿科/妇产科医生尿动力做得好的医生妇产/泌尿,Rezapour M, Falconer C, Ulmsten U. Int Urogynecol J (2001) (suppl 2):S12-14.,Concomitant Vaginal Surgery with TVT for Treatment of Female SUI and Pelvic Support DefectsTVT合并手术治疗女性SUI和盆底支持缺损,Retrospective review回顾性研究133 pts TVT vs. 47 TVT +Demographics similar except age除了年龄病人统计学上相似Concomitant surgery1 SSLVS- 8 前壁修补1 阴式子宫- 13 post colporrhaphy后壁修补4 enterocele rep直肠膨出修补- 14 LeFort colpocleisis15 perineorrhaphy 会阴修补,Horton TR, Druckenmiller J, Lucente V. Poster Presentation, SGS Annual Mtg, March, 2001,Concomitant Study Results合并研究结果,相近的治愈率TVT 98%, TVT +