1

吳銘斌 醫師 (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

婦女泌尿暨骨盆醫學介紹 1. What relationship between the group 1 and group 2

questions in the following questionnaire? (A) irrelevant;

(B) group 1 voiding, group 2 storage; (C) group 1

storage, group 2 voiding, (D) quality of life.

Symptoms

Chapple CR 2005 Nat Clin Practice Urol

Bladder & Urethra

Normal Storage Voiding

Bladder Relaxed Contracted

Urethra contracted relaxed

Abnormal Storage Voiding

Bladder Overactive Underactive

Acontractile

Urethra

Incompetent under stress

Functional or anatomic obstruction Inappropriate

relaxaed Stanton SL,Tanagho EA 1986 Springer-Verlag

Normal micturition cycle

2

有多少婦女有尿失禁的問題?

• 30--60歲婦女

– 26%

• 60以上婦女

– 38%

• 住安養機構的婦女

– 48%

造成尿失禁的原因：

• 女性先天尿道較短

• 泌尿道感染

• 先天因素如人種： – 亞洲人比黑人骨盆腔肌力較弱，白種人肌力更弱 。

• 懷孕與生產： – 陰道生產，產程延遲者發生率高。第一胎影響最大。

造成尿失禁的原因：

• 停經後女性荷爾蒙缺乏

• 年齡： – 更年期缺乏女性荷爾蒙

• 腹部壓力增加： – 肥胖、肺部病變、

– 粗重工作者、長期咳嗽或便秘。

• 吸煙

• 骨盆腔手術過後： – 子宮頸癌根除術後。

• 癌症放射療法後。

Evaluation

2. In a patient with a history consistent with an

overactive bladder (OAB), which of the

following study is the most useful?

(A) Valsalva leak point pressure,

(B) frequency/volume bladder chart over 48

hours,

(C) pelvic ultrasound,

(D) pressure-flow study.

3

尿失禁﹑頻尿﹑急尿治療流程

• 婦女泌尿專科門診

• 內診檢查

• 尿動力學檢查

– 鑑別診斷尿失禁種類

• 棉墊試驗

– 漏尿嚴重度

• 膀胱日誌 – 每週(日)喝水、解尿

、漏尿的自我紀錄

頻尿(frequency)與夜尿(nocturia)

白天小便次數多(等)於八次 每晚起床小便超過(等於)二次

急 尿 (urgency) 急迫性尿失禁(urge incontinence)

膀 胱 過 動 症(overactive bladder, OAB)

頻尿

膀胱過動症

急尿

急迫性尿失禁

Medication

3. The most common side effect of oxybutynin

which lead poor medical compliance is:

(A) blurred vision,

(B) dry mouth,

(C) drowsiness,

(D) nausea,

(E) constipation.

(Ref Clin Obs Gyn 2004).

4

為什麼我運動時都會漏尿?

我咳嗽也會漏尿!

應 力 性 尿 失 禁(stress urinary

incontinence,SUI)

尿 失 禁 種 類

• 應力性尿失禁 40%

– 膀胱頸支撐組織變弱

– 尿道過動

– 尿道括約肌缺損

• 急迫性尿失禁 25%

– 逼尿肌不穩定

• 混合型尿失禁 25%

• 其他類型 10%

– 暫時性尿失禁

• 泌尿道感染

• 瞻妄

– 滿溢性尿失禁

• 脊髓損傷

– 瘻管

Conservative treatment

4. The most effective non-surgical treatment of

stress urinary incontinence is:

(A) pelvic muscle training,

(B) vaginal weights,

(C)electronic stimulation,

(D) hypnosis,

(E) bladder training.

(Ref Clin Obs Gyn 2004).

選擇治療方式 保守性療法 ---針對輕度尿失禁患者

• 藥物治療-

• 行為療法-

• 骨盆肌運動-凱格爾運動(Kegel’s exercise)

• 強化骨盆肌肉強度，使下墜的骨盆器官回復到原來的生理位置

• 生理迴饋物理療法-

• 將病人的骨盆肌肉生理現象，轉換成可用聽覺或視覺的方式，讓病人感覺其中的變化，以便明瞭如何收縮骨盆肌肉

• 電刺激物理療法-

• 用電流刺激功能異常的骨盆肌肉恢復正常

婦女尿失禁物理療法

• 婦女尿失禁物理療法（含生理回饋、電刺激）已重新恢復作業，地點於第二醫療大樓B1

– （感謝復健科提供地點與時間分享）

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Demo

Case-

pre

Case-

post

生理回饋-幫妳做對骨盆運動

Extracorporeal Magnetic Innervation (ExMI)

尿流動力學檢查Solar功能說明

n 中文Windows作業系統

n 紅外線遙控操作

n 週邊Plug & Play功能

n 可擴充藍芽(Blue- Tooth)功能

n 具自我診斷及校正軟體

n 任一PC可作判讀工作站

n 可擴充24H動態檢查儀

影像尿動力學檢查(Video-

urodyanmic study • 已規劃並施工完成之影像尿動力學檢查室， 提昇

婦女泌尿的發展深度。

• 地點:第一醫療大樓B2碎石中心暨婦女影像尿流動力檢查室 。

6

Laborie Dorado™

Video-urodynamic study

Apr 2004 32

Video-urodynamic study

Recording Flow

Flow Transducer

Vura

Qura

Urodynamic Equipment

Uroflometry (UFR) Urodynamics

5. What is your diagnosis for the urodynamic

study (arrow indicates urine leakage)?

(A) urodynamic stress incontinence,

(B) detrusor overactivity incontinence,

(C) low compliance bladder,

(D) sensory urgency,

(E) detrusor sphincter dyssynergia

(From: Nygaard & Heit 2004 Obstet Gynecol).

P

P P

P 膀胱壓

尿道壓

儲尿期 解尿期

A B

APIS

RPC-9 Abdominal Pressure Catheter

Pabd

Pabd

Pdet = Pves – Pabd

CMG (Filling Pressure flow)

7

H

:

9

H

:

3

EMG

1512F Wire Electrodes H0959A Surface Electrodes

Electromyography (EMG)

EMG

Pura

Pves

Pabd

Pdet

Qura

Vinf 0 100 200 300 400 500 600 ml

20 m

l

Time 1 min/Div

Speaking

FD

Cough

ND

UIDC

RH

Cough

UU

SD

Cough

Leak

Urodynamic study: Cystometry

Nygaard & Heit

2004 Obstet Gynecol

Urodynamic stress incontinence Detrusor overactivity incontinence

Nygaard & Heit 2004 Obstet Gynecol

Stanton S L,Tanagho E A 1986 Springer-Verlag

Mechanism of urinary incontinence

a: normal voiding or DO; b: DSD; c: impair bladder compliance;

d: urethral instability; e: UDSI

Surgery

6. Which treatment option for stress urinary

incontinence consistently results in significant

improvement?

A. Anterior colporrhaphy;

B. Kelly plication ;

C. Retropubic urethropexy; e.g. MMK, Burch

D. Needle urethropexy.

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手 術 治 療 • 當藥物、物理療法等保守療法都無法控制病情時

• 傳統膀胱懸吊術－

– 恥骨後陰道懸吊術(sling operation)

– 膀胱頸吊帶術(Burch colposuspension)

– 需開腹或損失自身的腹直肌肌膜或側股骨筋膜做為吊帶手術

• 無張力陰道吊帶手術－

– 目前最新手術方法

– 傷口小、恢復快、治癒率高

– 術後膀胱訓練時間短、病人接受程度高

Hammock theory --Abdominal pressure on urethra

and pelvic floor

DeLancey JOL 19994 Am J Obstet Gynecol:

Pubo-vaginal sling

Stanton SL,Tanagho EA 1986 Springer-Verlag Stanton SL,Tanagho EA 1986 Springer-Verlag

Burch colposuspension

Burch colposuspension Open retropubic colposuspension

開腹式膀胱頸懸吊

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Laparoscopic colposuspension- 腹腔鏡膀胱頸懸吊

The trend of different surgical

0

200

400

600

800

1000

1200

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 year

n

RPU 59.5

Sling 59.4

TVTs 59.79

Kelly 59.3

Needle 59.6

59.71

Injection 59.72

RPU

Sling

MUS

Kelly

Needle

LS

Injection

台灣地區近十年來尿失禁手術改變驅勢

Wu MP, Tang CH, et. al 2008 Int Urogyn J

手術理論基礎 (Umsten Integral Theory)

PUL: pubo-urethral lig.

平 時 用力時

經陰道無張力吊帶手術

經閉孔

超迷你吊帶

經恥骨後

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第一代 Retropubic經恥骨後系統

第二代:Transobturator經閉孔膜系統

第二代 Monarc, TVT-O

American Medical System

Monarc (TOT) TVT-O

SPARC TVT

經閉孔膜系統

經恥骨後系統

無張力尿道中段吊帶術

膀胱

中段尿道

第三代:超迷你吊帶術(Mini-

arc)無切口

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第三代:超迷你吊帶手術

Ajust (Bard) Mini-Arc (AMS)

TVT-S (J&J 傳統膀胱懸吊術 無張力陰道吊帶 超迷你吊帶 吊帶

住院天數 術後3-5天 術後隔天出院 術後隔天出院

手術時間 稍長(約45-90分) 短(約15-20分) 非常短(約10-15分)

麻醉方式 插管全身麻醉 可用靜脈或局部麻醉 可用靜脈或局部麻醉

手術侵襲性 大 小 超小

手術成功率 80-90﹪ 85-95﹪ 85-95﹪

術中可確定是否 已達到良好效果

否 是 是

手術傷口 腹部10cm 傷口 2個皮膚小切口

無皮膚傷口

術後放置導尿管時間 3-4天 隔夜即可拔導尿管 或不用

隔夜即可拔導尿管 或不用

術後併發症 少 少 有傷到膀胱可能性

極少 無傷到膀胱可能性

術後疼痛程度 中等 輕微 大腿內側疼痛

幾乎無疼痛 無大腿內側疼痛

Kelly plication

Tradition bladder-neck sling

1st generation: Supra-pubic

TVT, SPARC, IVS

2nd generation: Trans-obturator

TVT-O, Monarc

The evolution of midurethral sling (MUS)

3rd generation: Single-incision

TVT-secure, MiniArc

TVT: tension-free vaginal tape

TVT-O: tension-free vaginal

tape -obturator

SPARC: suprapubic arc

Endoscopic bladder neck

suspension (EBNS)

台南 台灣

聖路易 美國

Tainan: snacks, historic resorts and ??

Ole Bull Giuseppe Guarneri del Gesù 1744

Italy-Cremona

Chi Mei Museum,

Tainan, Taiwan

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Apical (uterine and vaginal vault) prolapse

Walters MD, Karram MM 1999 Mosby

Normal vaginal axis in nulli-parous woman in the standing position

Pelvic bony structure

Pelvic Floor Support

• DeLancey JOL 1994 Am J Obstet Gynecol

• Level I: suspension

– Cardinal ligament

– Utero-sacral ligament

• Level II: attachment

– Ant: pubo-cervical fascia

– Post: recto-vaginal septum

• Level III: fusion

– perineum

Cardinal ligament

arcus tendineus

fasciae pelvis

Rectovaginal fascia

Pubocervical ligaments

Pelvic suppport structures

6 Ligaments, 2 Fascia, 1 Ring

TeLinde’s Operative Gynecology

Pericervical ring

Vaginal wall assessment

Liu CY Chattanooga Women’s Laser Center

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Pelvic organ prolapse- quantitation (POP-Q)

Bump RC 1996 AJOG

POP-Q

7. Using the Pelvic Organ Prolapse Quantification

(POP-Q) system, point C is:

(A) anterior vagina,

(B) posterior vagina,

(C) cervix,

(D) posterior fornix,

(E) introitus.

POP-Q

8. Which predominant support defect does the

below line diagram depict? (A) anterior wall

defect, (B) post wall defect, (C) apical defect, (D)

anterior and posterior defect.

-3 -3 -2

4.5 1 8

+2 +5 --

Prolapse of the apical segment of the vagina

Miklos JR 2002 Curr Opin Obstet Gynecol

Apr 2004 77

子宮托(2 - 5號)

(Option)

Sacral colpopexy with mesh

14

Sacral colpopexy

Sacral promontory

Walters MD & Karram MM: 1999 Mosby Inc.

子宮薦骨懸吊術(Sacro-hysteropexy)

Vaginal stump

Rectum

Uterosacral vaginal vault suspension

Walters MD & Karram MM: 1999 Mosby Inc.

U-S Lig

Wu MP: Int J Gynecol Obstet 1997

Uterosacral ligament suspension high McCall colpopexy

Walters MD, Karram MM 1999 Mosby

Sacrospinous vaginal suspension (SSVS)

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Walters MD, Karram MM 1999 Mosby

Deschamps ligature carrier Miya Hook

Sacrospinous vaginal suspension (SSVS)

Enterocele: peritoneum in direct contact with vaginal epithelium with no intervening fascia

Miklos JR 2002 Curr Opin Obstet Gynecol Benson JT 2000 McGraw-Hill Co.

Posterior vaginal wall prolapse

Miklos JR 2002 Curr Opin Obstet Gynecol

The Evolution of Pelvic Reconstructive Surgeries

VTH+ A-P colporrhaphy

Manchester; LeFort

Sacro-spinous lig. suspension

Surgeon-tailored 4-corner mesh fixation

( bilateral S-S lig. suspension)

Abdominal sacro-colpopexy

TVM: post. IVS (Tyco); Prolift (J&J);

Perigee+Apogee (AMS); Avaulta (Bard)

Single incision mesh:

Prosima (J&J);Elevate (AMS)

TVM: tension-free vaginal mesh;

SIS (Cook); Pelvicol (Bard)

Tension-free biologic mesh

Uterosacral lig. suspension

Surgery-POP

• Which LSC surgery is not recommended in the treatment of uterine prolapse with uterine preservation?

• (A) High McCall hysteropexy,

• (B) U-S ligament hysteropexy, (C) sacral hysteropexy,

• (D) Sacral spinous ligament uterine fixation,

• (E) Gilliam round ligament hysteropexy.

• 經閉孔人工網膜

• Transobturator TVM

• 無切口陰道工網膜

• Single incision TVM

陰道人工網膜植入術

(Transvaginal mesh, TVM)

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無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM)

無張力人工網膜植入術 Tension-free Vaginal Mesh (TVM)

Gynecare Prolift Pelvic Floor Repair System (GPS)

Trans-vaginal Mesh (TVM) Technique

Gynecare Prolift Pelvic Floor Repair System

陰道人工網膜植入術 Tension-free Vaginal Mesh (TVM)

AMS

經閉孔人工網膜

陰道前壁Perigee

17

經閉孔人工網膜 陰道前壁Perigee

American Medical System (AMS) American Medical System (AMS).

The Apogee™ Vault Suspension System

無切口人工網膜(無會陰切口)

Monarc or

TVT-O

A B

保留子宮

經閉孔人工網膜 (4-6會陰小切口)

(+無張力尿道中段吊帶術)

切除子宮

Perigee (前片)

Apogee (後片)

無切口人工網膜(無會陰切口)

(+無張力尿道中段吊帶術)

保留子宮 切除子宮

C D

Monarc

TVT-O

Mini-Arc

Elevate (前片)

Elevate (後片)

Surgery-POP

9. What is the major concern to use mesh in

pelvic floor reconstruction?

(A) surgical failure,

(B) post-operative recurrence,

(C) the technical difficulty,

(D) erosion.

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合併症: 網膜暴露

Mesh erosion or migration

da Vinci Robotic surgery

Robotic sacro-colpopexy

達文西子宮薦骨懸吊術(sacro-hysteropexy)

19

10. A 58 y/o patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy with anterior colporrhaphy and Burch procedure for uterine prolapse and stress urinary incontinence. She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria.

• Which of the following is the most likely explanation for this complaint?

A. Failure of the procedure;

B. Urinary tract infection;

C. Vesicovaginal fistula;

D. Detrusor instability;

E. Diabetic neuropathy.

11. A 49-year-old woman had a radical hysterectomy

and lymph node sampling for stage 1B squamous

cell cancer of the cervix. A suprapubic catheter was

placed at the time of surgery. She is now 8 weeks

postoperative and has not been able to void. She is

also leaking urine with activity, coughing, and

sneezing.

• What is the most likely reason for voiding difficulty?

A. spasm of the pelvic floor muscles;

B. outflow obstruction;

C. postoperative swelling around the bladder;

D. innervation to the lower urinary tract was transected;

E. overdistention of the bladder.

夢想不該隨著年紀愈大而縮水

Thank you for your attention!