Urogynecology & Pelvic Floor Reconstruction

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1 教學二版 Urogynecology & Pelvic Floor Reconstruction 吳銘斌醫師 / 博士 (Ming-Ping Wu, M.D.,Ph.D.) 奇美醫學中心婦產部婦女泌尿暨骨盆醫學科主任台北醫學大學醫學院婦產學科副教授成功大學醫學院臨床醫學研究所博士

2 尿失禁種類

3 尿動力學檢查 (Urodynamic study) Solar with video system 奇美 B2 婦女影像尿動力檢查室

UDS Urodynamic Study (UDS) A. 21004C 尿流速圖 (Uroflowmetry, UFR) B.

4 UDS Urodynamic Study (UDS) A C 尿流速圖 (Uroflowmetry, UFR) B C 尿道壓力測量檢查 (Urethral pressure profile studies, UPP) 21012B 應力尿道壓力測量檢查 (Stress urethral pressure profile, Stress UPP) C C 膀胱壓檢查 (Cystometry, CMG) D C 壓力尿流速圖 (Pressure-flow study) E C 外括約肌肌電圖 (External sphincter electromyogram, EMG F B 錄影尿流動力學檢查 ( Video-urodynamic study)

5 UDS machine Monitor / Display Mouse Keyboard Infusion Medium Puller / Profilometer EMG Patient unit Cable Computer (PC) Patient Unit Remote Control Printer UroPump Life Tech Co.

6 UDS machine Pressure Transducers and Tubing Life Tech Co.

Procedure of UDS in Urogyn Clinic 1. 500ml water 1 hour before test 2. Do Pad test 3. Do Uroflowmetry 4.

7 Procedure of UDS in Urogyn Clinic ml water 1 hour before test 2. Do Pad test 3. Do Uroflowmetry 4. Insert infusion & pressure transducer Check postvoid residual (PVR). 5. UPP stress UPP 6. CMG Infusion 80ml/min; FD: cough (c)x1, cx1, cx6, running water Max Capacity, cx1, cx1, cx6, (Standing, cx1, cx1, cx6) 6. VLPP 7. Pressure flow study

8 Uroflowmetry (UFR) Vura Qura Urodynamic Equipment Recording Flow Flow Transducer

9 Abnormal Uroflowmetry A) Superflow pattern with poor urethral resistance; (B) intermittent multiple peak pattern; e.g. DSD, abd. straining (C) intermittent interrupted pattern; (D) obstructive pattern with increased

10 Uroflowmetry: normal

11 Uroflowmetry: intermittent, low flow

12 Uroflowmetry (before reduction)

13 Uroflowmetry (after reduction)

14 尿動力學檢查 Bladder filled with 200 ml, I'm Straining with Increased Force up to Leak! Pves Pabd Leak Qura 30 Rectum Bladder

15 20 ml FD ND SD Urodynamic study: Cystometry EMG Pura UU Pves Speaking Cough Cough RH Cough Pabd UIDC Pdet Leak Qura Vinf Time 1 min/div ml

16 Urodynamic stress incontinence (USI)

17 Urodynamic stress incontinence (USI) Pdet Pves Pabd Nygaard & Heit 2004 Obstet Gynecol

18 Cystometry: DO without incontinence

19 Cystometry: DO with incontinence

20 Urodynamics in OAB

21 Detrusor overactivity incontinence Pdet Pves Pabd Nygaard & Heit 2004 Obstet Gynecol

22 Urethral pressure profile (UPP) Resting UPP Stress UPP

23 Urethral pressure profile

24 Stress urethral pressure profile

25 Stress urethral pressure profile

26 Solar Video Urodynamics +

27 Video-urodynamic study Laborie Dorado

28 OAB Definition in 2002 In 2002, ICS : Overactive bladder (OAB) symptom syndrome suggestive of lower urinary tract dysfunction. Definition : Urgency, with or without urge incontinence, usually with frequency and nocturia, if there is no proven infection or other obvious pathology. Synonyms : Urge syndrome Urgency-frequency syndrome 28

29 Core symptom 3 distinctive OAB subtypes : 1. OAB dry 2. OAB wet 3. OAB with voiding difficulty 29 Hung MJ: 2006 J Urol 176:636-40

30 Hung MJ J Urol 2006;176:

31 Impact on female adaptation by OAB subtypes Hung MJ J Urol 2006;176:636-40

32 During normal cycle, desire to void (urge) is intermittent and increase with bladder volume. During an urgency episode, the desire to void increases abruptly, resulting in a void, shortening the intervoid interval, reducing the volume voided 32 Chapple et al. BJU Int 2005

33 Refractory period: interval between voiding and the next urgency episode, can be measured and may be affected by therapy. Warning time: can also be measured as the time from the onset of urgency to voiding 33 Chapple et al. BJU Int 2005

34 選擇治療方式物理治療藥物治療手術治療

35 Nonsurgical Management of Urinary Incontinence

Nonsurgical Management of UI: Nonpharmacologic Treatments First-line therapy for both stress and urge incontinence Can reduce episodes of stress and/or urge incontinence by 50% to 80% 1,2,3,4 Can

36 Nonsurgical Management of UI: Nonpharmacologic Treatments First-line therapy for both stress and urge incontinence Can reduce episodes of stress and/or urge incontinence by 50% to 80% 1,2,3,4 Can lead to almost full continence for 25% to 50% of women treated 1,2,3 Does not have to be aggressive or timeintensive to be effective 3 1 Fantl, JA, et al. JAMA. 1991: Burgio KL, et al. JAMA. 1998: Subak LL, et al. Obstet Gynecol. 2002: Burgio KL, et al. Obstet Gynecol. 2003:

37 Nonsurgical Management of UI: Lifestyle Modifications Increase or decrease in fluid intake Reduction of dietary irritants Increase in dietary fiber Weight reduction

functional capacity of bladder Methods Deferred voiding

38 Nonsurgical Management of UI: Behavioral Therapy 行為治療 Bladder Training/ Scheduled Voiding Goal: Increase functional capacity of bladder Methods Deferred voiding (most commonly used method) Desensitization training Timed voiding

39 Nonsurgical Management of UI: Vaginal Cones 2002 Cochrane review * Better than no active treatment for stress incontinence As effective as PFMT and pelvic floor stimulation (Colgate Medical, Berkshire) *Herbison P, et al. The Cochrane Database of Syst Rev. 2002:CD

40 物理治療骨盆底運動 ( 凱格爾運動 ) 生理回饋治療電刺激療法體外磁波治療骨盆底肌

41 Nonsurgical Management of UI: Physical Therapy: Pelvic Floor Muscle Training (PFMT) Teaches women to identify pelvic floor muscles and to control their contraction Helps with all types of urinary incontinence, but especially with stress incontinence Rates of successful outcomes: 36% to 71%* * Dannecker C, et al. Arch Gynecol Obstet. 2005:93-97.

42 Nonsurgical Management of UI: Physical Therapy Pelvic Floor Muscle Training (PFMT) Typical prescribed protocol 2 to 5 times per day 10 to 15 sets of contraction cycles Length of contractions: from as long as possible, gradually increasing to 10 seconds Process takes at least 4 to 6 weeks and sometimes as long as 6 months

43 凱格爾運動生理回饋治療

44 Demo Casepre Casepost

45 Nonsurgical Management of UI: Pelvic Floor Stimulation Electrical or magnetic stimulation Found to improve symptoms in 60%-90% of patients, with a 10%-30% cure rate 1 Other studies: No more effective than PFMT alone 2,3 1 Iselin CE, Webster GD. Urol Clin North Am. 1998: Goode PS, et al. JAMA. 2003: Spruijt J, et al. Acta Obstet Gynecol Scand. 2003:

47 Extracorporeal Magnetic Innervation (ExMI)

48 藥物治療年紀大或較輕度應力性尿失禁膀胱過動症 ( 頻尿急尿急迫性尿失禁 ) 嚴重頻尿膀胱容積縮小混合型尿失禁無法開刀處理的尿失禁患者

49 Nonsurgical Management of UI: Tricyclic Antidepressants (TCAs) Imipramine only agent in this class widely studied Used when more effective medications have failed Serious side effects possible

50 Antimuscarinics Level Grade Tolterodine 1 A (highly recommended) Trospium 1 A (highly recommended) Darifenacin 1 A (highly recommended) Solifenacin 1 A (highly recommended) Propantheline 2 B (Recommended) Atropine, hyoscyamine 3 C (optional) Mixed Action Drugs Oxybutynin (muscle relaxant effect) 1 A (highly recommended) Propiverine (CC blocker) 1 A (highly recommended) Dicyclomine 3 C (Optional) Flavoxate 2 D ( possible)

51 Hormone Level of evidence Grade of recommendation Estrogen 2 C Desmopressin * 1 A *Nocturia

52 藥物治療 Peripheral Action of neurotransmitters in the micturition cycle The storage phase is mediated peripherally by Ach and NA The voiding phase is peripherally mediated primarily by ACh

53 Botulinum toxin Neurotoxin produced by G(+) anaerobic organism Clostridium botulinum. Inhibit release of acetylcholine at neuromuscular junction => causes muscle relaxations =>chemodenervation Not yet licensed for use in bladder symptoms. 2 nd line treatment in pts refractory to conventional antimuscarinic therapy

54 The evolution of anti-incontinence surgeries 2nd generation: Trans-obturator (TO) TVT-O, Monarc 1st generation: Retro-pubic (RP) TVT, SPARC, IVS Laparoscopic Burch colposuspension Retropubic urethropexy: MMK, Burch Endoscopic bladder neck suspension (EBNS) 3rd generation: Single-incision TVT-secure, MiniArc Tradition bladder-neck sling Kelly plication IVS: intravaginal sling TVT: tension-free vaginal tape TVT-O: tension-free vaginal tape -obturator SPARC: suprapubic arc

55 anti-incontinence surgery Retropubic urethropexy (RPU) traditional sling Minimally invasive synthetic suburethral sling (MISS)

56 The changing trend of different surgical types n 1200 The trend of different surgical RPU 59.5 Sling 59.4 TVTs Kelly 59.3 Needle Injection year Wu MP 2008 Int Urogyn J

57 Department of Health. Hospital Episode Statistics. Department of Health [online] 2006 URL:

58 第三代 TVT-Secure, MiniArc 迷你手術

59 MiniArc

61 Pelvic organ prolapse- quantitation (POP-Q) Bump RC 1996 AJOG

Laparoscopic approaches to PFR MISS Sling U

para-vaginal repair; SSVS : sacral spinous

62 Laparoscopic approaches to PFR MISS Sling U PCF High McCall s Op B Cx. V. VOS Burch PVR Sacrocolpopexy, USS MISS: minimal invasive suburethral sling; PVR= para-vaginal repair; SSVS : sacral spinous vaginal suspension ; USS: utero-sacral suspension; VOS: vaginal obturator shelf;

63 Pelvic suppport structures 6 Ligaments, 2 Fascia, 1 Ring Pericervical ring Cardinal ligament arcus tendineus fasciae pelvis Rectovaginal fascia Pubocervical ligaments TeLinde s Operative Gynecology

64 Surgery for POP

65 Surgery for POP

66 骨盆重建手術 (pelvic reconstructive surgery) 使骨盆腔內的臟器回復到原來的位置骨盆重整手術經陰道進行手術使用人工網膜支撐骨盆肌肉韌帶骨盆重整手術合併尿失禁手術

67 The changing trends of surgical types for POP in Taiwan N Total hysterectomy uterine suspension Year

68 Table II The patients age and associated procedure were the determinants for the choices of surgical types. uterine suspension Surgical types hysterectomy no. % no. % Total Total ChiSQ P Patient Age < < < with anti-incontinence no <.0001 yes Wu, MP, Liang, CC, Tang, CH

69 Surgery equipment OR Cystoscopy 0 o, 70 o 28019C (1,800) Cystostomy suprapubic catheterization (Bard) Cystofix (B Braun) 8-12 Fr Trocar method 78003C (3,285)

70 Gynecare Prolift Pelvic Floor Repair System (GPS)

71 Gynecare Prolift Pelvic Floor Repair System (GPS)

72 The Perigee System American Medical System (AMS)

73 The Apogee Vault Suspension System American Medical System (AMS).

74 Tension-free vaginal mesh (TVM)

75 Single incision TVM 迷你人工網膜 Elevate, AMS Prosima, J & J:

76 Post-OP care Foley catheterization Day 1 for TVM w/w t TVT-O Day 1 for TVT-O only Timing of removing catheterization VV (voided volume)> 200 ml, PVR (postvoidal residual) < 100ml Suprapubic cystostomy Discharge day

77 Quiz: where are the camels?

Current trend in anti-incontinence surgery

Current trend in anti-incontinence surgery 吳銘斌醫師 (Ming-Ping Wu, M.D., Ph.D.) 奇美醫院婦產部婦女泌尿暨骨盆醫學科主任台北醫學大學醫學院婦產學科副教授成功大學醫學院臨床醫學所博士 Anti-incontinence surgery Bladder buttress operation: Kelly plication Needle