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1、经阴道无张力尿道中段吊带术经阴道无张力尿道中段吊带术 TVTTVT术术上上 海海 第第 二二 医医 科科 大大 学学 附附 属属仁仁 济济 医医 院院 泌泌 尿尿 外外 科科TVTTVT微微创伤手术创伤手术1.1. 减少手术时间减少手术时间 Reduce surgical timeReduce surgical time 2.2. 减少住院时间减少住院时间 Reduce length of hospitalization Reduce length of hospitalization 3.3. 减少并发症减少并发症 Reduce complication rates/risksReduce
2、complication rates/risks 4.4. 复原快复原快 Allow quicker return to normal, daily activitiesAllow quicker return to normal, daily activities5.5. 减少费用减少费用 Lower costsLower costs GYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Supp
3、ort for IncontinenceGYNECARE TVT Tension-free Support for IncontinenceTVTTVT尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑简介简介 I ITVTTVT尿失禁的无张力支撑是一种创新的微创伤手尿失禁的无张力支撑是一种创新的微创伤手术方法术方法, , 它对张力性尿失禁治疗的有效性已得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到了充分的临床证明GYNECARE TVT Tension-free Support for Incontinence is an GYNECARE TVT Tensio
4、n-free Support for Incontinence is an innovative minimally invasive surgical alternative for the innovative minimally invasive surgical alternative for the effective treatment of stress urinary incontinence, with proven effective treatment of stress urinary incontinence, with proven resultsresults使用
5、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 The placement of a piece of PROLENE mesh (45 cm x 1.1 cm x 0.7 mm) without tension, at the mid urethracm x 0.7 mm) without tension, at the mid urethraGYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-fre
6、e Support for IncontinenceGYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑简介简介 IIII局麻局麻, , 阻滞阻滞/ /硬膜外硬膜外Local anesthesia,sedation/regionalLocal anesthesia,sedation/regional经阴道进路，切口小切口小, , 分离少分离少 Minimal i
7、ncisions Minimal incisions and dissectionand dissection 网带无张力地置于尿道中段下网带无张力地置于尿道中段下Tape placed at mid Tape placed at mid urethra without tensionurethra without tension 普理灵聚丙烯网带无需和任何组织固定 No No fixationfixation术中使用膀胱镜术中使用膀胱镜 CystoscopyCystoscopy performed performed 术后插尿管时间短术后插尿管时间短 Infrequent use of po
8、st-op cathetersInfrequent use of post-op catheters 可在门诊进行，当天出院可在门诊进行，当天出院 Discharge home the same Discharge home the same dayday Goal of SurgeryGoal of SurgeryGoal of SurgeryGoal of Surgery手术目的手术目的1. 1. 修复和修复和/ /或加强阴道尿道韧带或加强阴道尿道韧带 Restore and/or Restore and/or reinforce the pubourethral ligaments.re
9、inforce the pubourethral ligaments. 2.2.修复和修复和/ /或加强尿道下阴道吊筋膜或加强尿道下阴道吊筋膜 Restore and/or Restore and/or reinforce the suburethral vaginal hammockreinforce the suburethral vaginal hammock3.3.加强尿道旁结缔组织加强尿道旁结缔组织 Reinforce the paraurethral Reinforce the paraurethral connective tissueconnective tissue GYNE
10、CARE TVT Tension-free Support for Incontinence IndicationsGYNECARE TVT Tension-free Support for Incontinence IndicationsGYNECARE TVT Tension-free Support for Incontinence IndicationsGYNECARE TVT Tension-free Support for Incontinence Indications TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑适应症适应症适应于以下原
11、因引起的女性张力性尿失禁Intended to be used for treatment of Female Stress Intended to be used for treatment of Female Stress Urinary Incontinence resulting fromUrinary Incontinence resulting from 尿道过度活动尿道过度活动 urethral urethral hypermobilityhypermobility尿道括约肌损伤尿道括约肌损伤intrinsic sphincter deficiencyintrinsic sphi
12、ncter deficiencyGYNECARE TVT ContraindicationsGYNECARE TVT ContraindicationsGYNECARE TVT ContraindicationsGYNECARE TVT Contraindications TVT TVT尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑尿失禁的无张力支撑禁忌征禁忌征怀孕病人 Pregnant patientsPregnant patients 未完成发育的病人 Patients withPatients with future growth potentialfuture growth p
13、otential计划要怀孕的病人 Women with plans for future pregnancyWomen with plans for future pregnancyGYNECARE TVT Tension-Free Support for Incontinence SystemGYNECARE TVT Tension-Free Support for Incontinence SystemGYNECARE TVT Tension-Free Support for Incontinence SystemGYNECARE TVT Tension-Free Support for
14、Incontinence System TVT TVT产品系列产品系列TVT TVT 网带网带 GYNECARE TVT DeviceGYNECARE TVT DeviceGYNECARE TVT DeviceGYNECARE TVT Device 推针器 GYNECARE TVT IntroducerGYNECARE TVT Introducer 导引杆 GYNECARE TVT Rigid Catheter Guide GYNECARE TVT Rigid Catheter Guide GYNECARE TVT Tension-free Support for IncontinenceGY
15、NECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for IncontinenceGYNECARE TVT Tension-free Support for Incontinence Description: PROLENE*polypropylene mesh covered by a plastic sheathProlene*网网 带带: 网网 状状 钩钩 形形 编编 织织 , 外外 面面 套套 有有 塑塑 料料 膜膜 Prolene*网网 带带TVT网带 长45公分, 宽一
16、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 Prolene 普理灵普理灵特点惰性强惰性强组织相容性强组织相容性强/ /组织反应小组织反应小有延展性有延展性表面光滑表面光滑易于操作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 IntroducerGYNECA
17、RE 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 GuideGYNECARE 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 InformationGYNECARE TVT Patient InformationGYNECARE TVT Patient
18、 InformationGYNECARE TVT Patient Information病人情况病人情况手术介绍 Procedure overviewProcedure overview病人手术风险Potential risksPotential risks血肿血肿 B Bleeding-hematoma formationleeding-hematoma formation感染感染 InfectionInfection 膀胱穿孔膀胱穿孔 Bladder perforationBladder perforation尿潴留尿潴留 Urinary retentionUrinary retentio
19、n排斥反应排斥反应 Mesh erosion or rejectionMesh erosion or rejection复原 RecoveryRecovery期望 ExpectationsExpectationsGYNECARE TVT - Pre OpGYNECARE TVT - Pre OpGYNECARE TVT - Pre OpGYNECARE TVT - Pre OpTVT TVT 术前术前 术前抗菌素 PeriPeri-operative antibiotics-operative antibiotics停止使用抗凝剂 Cessation of anti-coagulants Ce
20、ssation of anti-coagulants Instrument RequirementsInstrument RequirementsInstrument RequirementsInstrument Requirements手术需要的器械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 - ProcedureGYNECARE TVT - ProcedureGYNECARE TVT - ProcedureGYNECARE TVT - Procedure手术过程手术
21、过程病人准备 Patient preparationPatient preparation 切口 IncisionsIncisions分离，穿针，放置网带 Dissection, needle Dissection, needle passage and tape placementpassage and tape placement 网带松紧度调整 Tension adjustmentTension adjustment 结束手术 Completing the procedureCompleting the procedure Patient PositionPatient Position
22、Patient PositionPatient Position病人体位截石位，膝盖与耻骨截石位，膝盖与耻骨截石位，膝盖与耻骨截石位，膝盖与耻骨联合平行联合平行联合平行联合平行插插插插18181818号导尿管号导尿管号导尿管号导尿管, , , , 排空排空排空排空膀胱膀胱膀胱膀胱Insert 18 Insert 18 Insert 18 Insert 18 frfrfrfr catheter and empty catheter and empty catheter and empty catheter and empty bladderbladderbladderbladder Anesth
23、eticAnestheticAnestheticAnesthetic 麻醉麻醉局麻 +静脉加强 Local Anesthesia with IV sedation, Local Anesthesia with IV sedation, recommendedrecommended骶麻或全麻 Regional or General anesthesia possible.Regional or General anesthesia possible. AnesthesiaAnesthesia 麻醉麻醉Abdomen Abdomen Abdomen Abdomen 腹部腹部腹部腹部Anesthes
24、iaAnesthesia 麻醉麻醉Vaginal Wall Vaginal Wall Vaginal Wall Vaginal Wall 阴道前壁阴道前壁阴道前壁阴道前壁Incisions Incisions 切口切口阴道前壁阴道前壁 VaginalVaginalVaginalVaginal在在离尿道外口离尿道外口1 1cmcm处作处作1.5 1.5 cm cm 纵向切口纵向切口腹部腹部 AbdominalAbdominalAbdominalAbdominal 在耻骨联合上方，腹中线两侧各作一个在耻骨联合上方，腹中线两侧各作一个0.5 0.5 cm - cm - 1.0 cm1.0 cm切口切
25、口 2 2 incisions each side of midline incisions each side of midline 两切口相距最宽两切口相距最宽4-54-5公分公分 just above just above symphysissymphysis 4 - 5 4 - 5 cm cm apart max. apart max. Vaginal Wall IncisionVaginal Wall IncisionVaginal Wall IncisionVaginal Wall Incision 阴道前壁切口阴道前壁切口在离尿道外口1cm处作1.5 cm 纵向切口Abdomin
26、al IncisionsAbdominal Incisions 腹部切口腹部切口在耻骨联合上方，在耻骨联合上方，在耻骨联合上方，在耻骨联合上方，腹中线两侧各作一腹中线两侧各作一腹中线两侧各作一腹中线两侧各作一个个个个0.5 0.5 0.5 0.5 cm - 1.0 cm - 1.0 cm - 1.0 cm - 1.0 cmcmcmcm切口，切口，切口，切口，两切口两切口相距最宽相距最宽4-54-5公公分分Dissection of Anterior WallDissection of Anterior WallDissection of Anterior WallDissection of A
27、nterior Wall 阴道前壁分离阴道前壁分离Blunt Dissection sub and Blunt Dissection sub and paraurethrallyparaurethrally在尿道旁和尿道下进行钝性分离在尿道旁和尿道下进行钝性分离在尿道旁和尿道下进行钝性分离在尿道旁和尿道下进行钝性分离Insert TVT Rigid Catheter GuideInsert TVT Rigid Catheter GuideInsert TVT Rigid Catheter GuideInsert TVT Rigid Catheter Guide 插入插入TVTTVT导引杆导引杆
28、Introduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT Device推入推入TVTTVT网带网带通过阴道切口推入 Introduce through vaginal incision Introduce through vaginal incision 针头指向髂骨 Aim toward Aim toward ipsilateralipsilateral
29、 shoulder shoulder 绕过耻骨 Hug the pubic bone (do not scrapHug the pubic bone (do not scrap从腹壁切口出 Exit at abdominal incisionExit at abdominal incisionIntroduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT DeviceIntroduction of the GYNECARE TVT Dev
30、ice推入推入TVTTVT网带网带Guide the Needle Tip to the Abdominal IncisionGuide the Needle Tip to the Abdominal IncisionGuide the Needle Tip to the Abdominal IncisionGuide the Needle Tip to the Abdominal Incision将针头导向腹壁切口将针头导向腹壁切口针不要拔出针不要拔出CystoscopyCystoscopyCystoscopyCystoscopy 膀胱镜膀胱镜针穿过后针穿过后, , 使用膀胱镜确保膀胱完好使
31、用膀胱镜确保膀胱完好 After each After each passage of the needle, passage of the needle, cystoscopycystoscopy should be completed to should be completed to verify bladder integrityverify bladder integrity 将膀胱注液后使用膀胱镜将膀胱注液后使用膀胱镜 CystoscopyCystoscopy should be done should be done with bladder half-fullwith blad
32、der half-fullBladder Perforation Bladder Perforation 膀胱穿孔膀胱穿孔Bladder Perforation Bladder Perforation 膀胱穿孔膀胱穿孔Second Passage of the GYNECARE TVT DeviceSecond Passage of the GYNECARE TVT DeviceSecond Passage of the GYNECARE TVT DeviceSecond Passage of the GYNECARE TVT Device第二根针的穿入第二根针的穿入重新插导尿管重新插导尿管,
33、 , 排空膀胱排空膀胱 Re-insert the catheter and Re-insert the catheter and drain the bladderdrain the bladder重复第一次穿针的步骤重复第一次穿针的步骤 The opposite side is The opposite side is completed in the same manner as the firstcompleted in the same manner as the first 确保网带没有扭转确保网带没有扭转 Ensure that the tape does not Ensure
34、that the tape does not twist twist 再次使用膀胱镜再次使用膀胱镜 CystoscopyCystoscopy after the second pass of after the second pass of the TVT needlethe TVT needle针从腹壁切口拉出针从腹壁切口拉出 Pull TVT needle through the Pull TVT needle through the abdomen incisionabdomen incisionTape AdjustmentTape AdjustmentTape AdjustmentT
35、ape Adjustment 调整网带调整网带在网带和尿道间放置一把剪刀或止血钳 Place Place scissors or hemostat between the tape and the urethrascissors 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 Pull the abdominal ends of the tape until there is contact between tape abdominal ends of the tape until there is
36、contact between tape and instrumentand instrument将针剪去 Separate needles from the tapeSeparate needles from the tape先不要拉出塑料薄膜 Do not remove the plastic sheathDo not remove the plastic sheathCough TestCough Test 腹压测试腹压测试膀胱注液250毫升 Fill bladder with 250 ml of saline Fill bladder with 250 ml of saline 取出尿
37、道下的剪刀/或止血钳 Remove instrument under the Remove instrument under the urethraurethra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调整松紧度时调整松紧度时, , 剪刀要置于网带和尿道之间剪刀要置于网带和尿道之间 Instrument should be placed between the tape and the urethra Instrument should be placed between
38、the tape and the urethra during adjustmentduring adjustmentInitial Cough Test Initial Cough Test 初步腹压测试初步腹压测试Adjust Tape with Instrument in PlaceAdjust Tape with Instrument in PlaceAdjust Tape with Instrument in PlaceAdjust Tape with Instrument in Place器械放置在网带和尿道间器械放置在网带和尿道间, , 调整网带调整网带Completing th
39、e ProcedureCompleting the ProcedureCompleting the ProcedureCompleting the Procedure完成手术完成手术抽出塑料薄膜 Remove plastic sheathRemove plastic sheath 剪去腹壁上多余的网带 Cut Prolene MeshCut Prolene Mesh缝合皮肤和阴道粘膜切口 Close skin and vaginal Close skin and vaginal epithelium epithelium 排空膀胱 Empty bladderEmpty bladder取出导尿管
40、 Remove catheterRemove catheterCompleting the ProcedureCompleting the ProcedureCompleting the ProcedureCompleting the Procedure 完成手术完成手术removing plastic sheathremoving plastic sheathremoving plastic sheathremoving plastic sheath取出塑料薄膜取出塑料薄膜Completing the ProcedureCompleting the ProcedureCompleting t
41、he ProcedureCompleting the Procedure完成手术完成手术Trimming the meshTrimming the meshTrimming the meshTrimming the mesh剪去多余的网带剪去多余的网带GYNECARE TVT Postoperative Assessment Before DischargeGYNECARE TVT Postoperative Assessment Before DischargeGYNECARE TVT Postoperative Assessment Before DischargeGYNECARE TVT
42、 Postoperative Assessment Before Discharge出院前的术后评估出院前的术后评估出血/血肿 Bleeding/Bleeding/hematomahematoma 餐饮 Eating and drinkingEating and drinking排尿 VoidingVoidingGYNECARE TVT Postoperative InstructionsGYNECARE TVT Postoperative InstructionsGYNECARE TVT Postoperative InstructionsGYNECARE TVT Postoperative
43、 Instructions术后要求术后要求术后排尿残留 Post void residual Post void residual 3-4天抗菌素 Antibiotics 3-4 Days Antibiotics 3-4 Days 限制活动 Activity limitationsActivity limitations -驾驶驾驶 -锻炼锻炼 -性生活性生活-工作工作GYNECARE TVT Postoperative CareGYNECARE TVT Postoperative CareGYNECARE TVT Postoperative CareGYNECARE TVT Postoper
44、ative CareFollow-up appointmentsFollow-up appointmentsFollow-up appointmentsFollow-up appointments随访随访3 weeks6 monthsYearlyGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & Treatment并发症及其治疗方法并发症及其治疗方法尿潴留 Uri
45、nary retentionGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & Treatment并发症及其治疗方法并发症及其治疗方法膀胱穿孔 Perforation of the bladderPerforation of the bladder-使用膀胱镜确认 CystoscopicCystoscopic identification identificati
46、on -取出针,重新穿 Remove needle and reposition Remove needle and reposition -导尿管留置1-2天 Indwelling catheter x 1-2 days Indwelling catheter x 1-2 days GYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & Treatment并发症及其
47、治疗方法并发症及其治疗方法阴道出血/后腹膜血肿 Vaginal bleeding / Vaginal bleeding / RetropubicRetropubic hematomahematoma -保守治疗 Manage conservativelyManage conservatively -阴道填塞 Vaginal packingVaginal packing-引流引流 PercutaneousPercutaneous drainage if drainage if necessarynecessaryGYNECARE TVT Complications & TreatmentGYNE
48、CARE TVT Complications & TreatmentGYNECARE TVT Complications & TreatmentGYNECARE TVT Complications & Treatment并发症及其治疗方法并发症及其治疗方法Infection 感染-抗菌素- 口服/静脉用药 Oral / IV Oral / IV antibiotics antibiotics Clinical Results临床报告总结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可以用手术方法治愈 Incontinence is
49、 an enormous Incontinence is an enormous health care problemhealth care problemTVTTVT手术是一种有效而微创的手术手术是一种有效而微创的手术 An ideal An ideal treatment is effective treatment is effective andand noninvasive noninvasiveTVT TVT 手术有一定的技术难度，建议在独立操作手术有一定的技术难度，建议在独立操作手术以前先协助有经验的医生做几例手术以前先协助有经验的医生做几例 Warnings and Prec
50、autionsWarnings and PrecautionsWarnings and PrecautionsWarnings and Precautions 注意事项注意事项不要进行抗凝治疗不要进行抗凝治疗 No anticoagulation therapyNo anticoagulation therapy没有尿路感染没有尿路感染 NO UTINO UTI要有一定膀胱颈悬吊术的经验要有一定膀胱颈悬吊术的经验 Familiar with bladder neck suspension surgeryFamiliar with bladder neck suspension surgery用
51、最小的张力在尿道中段下放置用最小的张力在尿道中段下放置TVTTVT网带网带 TVT placed with minimal tension at mid urethraTVT placed with minimal tension at mid urethra使用膀胱镜观察确保膀胱完好使用膀胱镜观察确保膀胱完好 CystoscopyCystoscopy to confirm bladder integrity to confirm bladder integrity注意盆腔结构注意盆腔结构, , 避免组织损伤避免组织损伤 Attention to pelvic anatomy to avoid injuries to Attention to pelvic anatomy to avoid injuries to structuresstructures 出院前观察是否有耻骨后血肿出院前观察是否有耻骨后血肿 Observe for Observe for retropubicretropubic hematoma before discharge hematoma before discharge
