经阴道无张力尿道中段吊带术TVT术.ppt

1、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 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 IncontinenceTV

2、T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使用Prolene网带进行无张力尿道中段悬吊术 The placement of a pie

3、ce 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简介 II,局麻, 阻滞/硬膜外Local anesthesia,sedation/regional经阴道进路，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 普理

4、灵聚丙烯网带无需和任何组织固定 No fixation术中使用膀胱镜 Cystoscopy performed 术后插尿管时间短 Infrequent use of post-op catheters 可在门诊进行，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 ham

5、mock3.加强尿道旁结缔组织 Reinforce the paraurethral connective tissue,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尿道括约肌损伤intrinsic sphincter

6、 deficiency,GYNECARE TVT 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,GYNECARE TVT Tension-Free Support for Incontinence System TVT产品系列,TVT 网带 GYNECARE TVT Device 推针器 GYNECARE TVT Introducer 导引杆

7、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,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

8、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,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,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,GYNECARE TVT Rigid Catheter Guide 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

9、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,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-o

10、perative antibiotics停止使用抗凝剂 Cessation of anti-coagulants,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 Incisions分离，穿针，放置网带 Dissection, needle passage and tape placement 网带松紧度调整 Tension adjustm

11、ent 结束手术 Completing the procedure,Patient Position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Insert 18 fr catheter and empty bladder,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 麻醉Abdomen 腹部,Anesthesia 麻醉Vaginal Wall 阴道前壁,Incision

12、s 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,在离尿道外口1cm处作1.5 cm 纵向切口,Abdominal Incisions 腹部切口,在耻骨联合上方，腹中线两侧各作一个0.5 cm - 1.0 cm切口，两切口相距最宽4-5公分,D

13、issection 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

14、出 Exit at abdominal incision,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

15、 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

16、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 a

17、nd 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

18、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 Em

19、pty 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 Instruct

20、ions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

21、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 阴道填塞 Vaginal packing引流 Percutaneo

22、us drainage if necessary,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,Clinical Results临床报告总结,尿失禁是严重的健康问题，但一般病人不知道可以用手术方法治愈 Incontinence is an enormous health care problemTVT手术是一种有效而微创的手术 An ideal treatment is effective and noninvasiveTVT 手术有一定的技术难度，建

23、议在独立操作手术以前先协助有经验的医生做几例,Warnings and Precautions 注意事项,不要进行抗凝治疗 No anticoagulation therapy没有尿路感染 NO 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,谢谢,