奇美醫學中心 40 週年院慶系列活動

婦女骨盆重建醫學研討會

日期：2008 年 06 月 22 日（星期日）下午 1330-1730

地點：財團法人奇美醫學中心(永康院區)

急診大樓十二樓第一會議室

主辦: 奇美醫學中心 婦產部

協辦: 英商壯生和壯生股份有限公司

廣百實業有限公司

奇美醫學中心 40 週年院慶系列活動

婦女骨盆重建醫學研討會

日期：2008 年 06 月 22 日（星期日）下午 1330-1730

地點：財團法人奇美醫學中心(永康院區) 急診大樓十二樓第一會議室

時間 題目 講者 座長

13:30～13:45 Welcome remarks 致歡迎詞 黃國峯部主任

13:45～14:10 The roles of urogynecologists in modern women health care 婦女泌尿醫師在現代婦女健康照護的角色

高雄榮總 余堅忍教授

14:10～14:35

The epidemiology of lower urinary tract dysfunction (LUTD) and its impact to quality of life (QoL) 下泌尿道障礙的盛行率及對生活品質的影響

台中榮總 洪滿榮秘書長

14:35～15:00 Urodynamic study & pathophysiology of female urinary incontinence 婦女尿失禁的生理病學及尿動力學檢查

林口長庚 盧佳序主任

TUGA 蘇聰賢理事長

TAMIG 林武周理事長

15:00～15:20 討論及座長評論 座 長

15:20～15:50 中場休息 Coffee break

15:50～16:15 The use of tension-free midurethral sling (MUS) in female stress urinary incontinence無張力中段尿道吊帶術在婦女尿失禁之應用

高雄小港 龍震宇主任

16:15～16:40 The use tension-free vaginal mesh (TVM) in pelvic reconstructive surgery 無張力人工網膜在骨盆底重建之應用

高雄長庚 黃寛慧主任

16:40～17:05 The advantages and risks of prostheses in gynecologic surgery 在婦科手術中使用人工植入物之優缺點及疑慮

奇美 吳銘斌主任

台大 林鶴雄教授 台中中山 陳進典教授

17:05～17:25 討論及座長評論 座 長

17:25～17:30 Closing remarks 致結束詞 黃國峯部主任

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各位醫界先進同仁:

婦女泌尿暨骨盆重建醫學醫學(urogynecology & pelvic floor reconstruction)已經成為

一門完整而獨立的專科。此專科在提供婦女有關婦女尿失禁、頻尿、急尿、解尿困難、膀胱

過動(overactive bladder)，以及骨盆鬆弛疾病，包括膀胱脫垂(cystocele)、直腸脫垂

rectocele、子宮脫垂(uterine prolapse)及子宮切除後陰道穹窿脫垂(vaginal vault prolapse)方

面的醫療訊息及醫療服務--完整的評估與保守療法以及手術療法等更精緻治療方法。奇美醫

學中心婦產部承蒙各位醫界前輩及同行的支持，在此領域已有累積初步的經驗。於 2007 年

11 月成立婦女泌尿暨骨盆重建醫學次專科後，更承蒙您們的關心、指導、並轉介病患，已有

穩定的成長。婦產部婦女泌尿暨骨盆重建醫學科邀請到國內這領域的權威專家醫師 集會於一

堂，讓國內各大醫院有興趣的同好醫師及雲嘉南高屏地區基層醫師能分享這方面的新知與發

展。

在此邀請您蒞臨參加這場學術的盛宴。

奇美醫學中心

婦產部主任 黃國峯

婦女泌尿暨骨盆重建醫學科主任 吳銘斌 敬邀

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The Roles of Urogynecologists in Modern Women Health Care

Dr. Ken-Jen YU M.D., Ph.D.

Department of Obstetrics and Gynecology,

Veterans General Hospital, KaohSiung

Aging of the population is a global big problem. In our practice, we found more and more

patients have the diseases related to pelvic floor insufficiency, such voiding dysfunction, urinary/

stool incontinence, pelvic organ prolapse, chronic pelvic pain, and sexual dysfunction, et al.

Urogynecologists, in modern era, have the responsibility to handle all problems that related to the

pelvic floor dysfunction.

There are many precious event came out in the period of past 10 years. New concepts of

pathophysiology emerged from literature including pelvic organ prolapse, stress urinary

incontinence, interstitial cystitis, etc. New techniques had been developed in treatment of prolapse,

frequency, pelvic pain, and incontinence. A bunch of new medicine had been presented to release

miseries result from urogynecological diseases or dysfunction. Research in medical device, medical

material, stem cell application, and genetic medicine are blooming and bring us to a new frontier.

The modern urogynecologists should be reminded that disease prevention and public health

education are important other than to make a guideline in urogynecological practice or to apply

your best skills to treat a patient.

To improve the life quality of a patient is the responsibility of a physician and we should keep

it in mind always. Therefore, the quality of life should be considered when we treat a patient with

pelvic floor dysfunction, which may results from anatomic distortion or disease itself. Using the

surgery of nerve sparing radical hysterectomy to preserve the bladder function in a patient suffering

from a cervical cancer as an example. Urogynecologist should encourage an oncologist to use the

modern operation to treat his/her patients suffering from an early stage of cervical cancer.

To carry a friendly atmosphere with different field physicians and corporate each other is the

most important step to provide a modern health care to our patients.

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Urinary incontinent mechanism & Urodynamics

盧佳序

Tsia-Shu Lo, M.D.,

長庚大學/ 林口長庚醫院 婦產部 婦女泌尿科

Division of Urogynecology, Department of Obstetrics and Gynecology, Chang Gung Memorial

Hospital, Linkou Medical Center/ Chang Gung University, Taiwan.

Abstract

Urinary incontinence (UI) is any involuntary leakage of urine. It is a common and distressing

problem, which may have a profound impact on quality of life. Urinary incontinence almost always

results from an underlying treatable medical condition.

Urinary incontinence is defined by symptom and by sign. Stress urinary incontinence and the

detrusor overactive incontinence are the two main types. Stress incontinence is an involuntary loss

of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise.

Overactive bladder (OAB) is a urological condition defined by a set of symptoms: "urgency, with or

without urge incontinence, usually with frequency and nocturia." Detrusor overactive incontinence

is a subset of OAB that the incontinence is due to an involuntary detrusor contraction. The

International Continence Society(ICS) is responsible for both definition.

Symptoms reported by the patient are often an unreliable guide to the underlying dysfunction of the

lower urinary tract. Urodynamic investigations are the only way to evaluate bladder and urethral

functions. Urodynamic investigations allow characterisation of the pathophysiological aspects of

the different symptoms, give some elements to determine accurately the prognosis and help for the

choice of the therapeutic strategy.

Urodynamics is a set of urodynamic tests are conducted in sequence. The complexity of tests used

depending on the indication: 9

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• Free uroflowmetry measures how fast the patient can empty their bladder.

• A residual volume, measured either with ultrasound or by passing a catheter, measures how

empty the patient's bladder is after voiding.

• Multichannel cystometry measures the pressure in the rectum and in the bladder, using two

pressure catheters, to deduce the presence of contractions of the bladder wall, during bladder

filling, or during other provocative manouevres.

• Pressure uroflowmetry again measures the rate of voiding, but with simulatenous

assessment of bladder and rectal pressures. It helps demonstrate the reasons for difficulty in

voiding.

These common tests is augmented by EMG measurement of electrical activity in the bladder neck,

urethral pressure profilometry, assessing the "tightness" along the length of the urethra, and

fluoroscopy (moving video x-rays) of the bladder and bladder neck during voiding.

Urinary incontinence (UI) is a major clinical problem and a significant cause of disability in women.

Stress incontinence and urge urinary incontinence (a severe form of OAB)are two main causes of

UI in women. Many factors can determine UI and a complete evaluation is necessary to understand

the pathophysiology of symptoms. Urodynamic investigations can help to determine the exact

mechanisms of leakage. A specific treatment can therfore be proposed to the patient.

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The advantages and risks of midurethral sling in stress urinary incontinence 龍震宇

高雄醫學大學醫學系 副教授

高雄醫學大學小港醫院婦產科 主任

中華民國婦女泌尿暨骨盆鬆弛醫學會 副秘書長

In 1995, Petros and Ulmsten (1) introduced a new, minimally invasive surgery for the treatment of

female stress urinary incontinence (SUI), namely the tension-free vaginal tape (TVT) procedure.

Based on the integral theory, continence can be achieved by placing a vaginal tape underneath the

midurethra without tension to reinforce the weakened pubourethral ligament (2). It has become one

of the most popular procedures for female SUI because of its excellent results (1, 3). However, the

common use of the TVT has been associated with various operative complications, including

bladder perforation (4), major blood vessel injuries (5), and postoperative voiding difficulties (6).

In an attempt to reduce the morbidity of retropubic needle passage, an alternative approach with

transobturator route of the prolene tape (TOT) has been developed by Delorme (7). Subsequently,

De Leval designed a TOT inside-out procedure (TVT-O) (8) in 2003. In theory, the TOT sling lies in

midurethra at less of an acute angle compared to the TVT, and it is not likely to obstruct urine flow

during voiding. However, this transobturator procedure does not completely eliminate the risks of

bladder perforation or tape erosion (9).

With comparable objective cure rates, TVT-O had the advantages over TVT with shorter

operative time and relatively lower complication rate. However, TVT-O tape was at less of an acute

angle and localized to a more distal part of urethra, resulting in less urethral compression and a

lower rate of urethral kinking. Therefore, urethral dynamic kinking appeared to play an important

role in the mechanism of postoperative continence.

References

1. Nilsson CG, Kuuva N, Falconer C, Rezapour M, Ulmsten U. Long-term results of the

tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary

incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12 Suppl 2:S5-8.

2. Petros PE, Ulmsten UI. An integral theory and its method for the diagnosis and management of

female urinary incontinence. Scand J Urol Nephrol Suppl. 1993; 153:1-93.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Nilsson+CG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Kuuva+N%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Falconer+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Rezapour+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Ulmsten+U%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Int%20Urogynecol%20J%20Pelvic%20Floor%20Dysfunct.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Petros+PE%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Ulmsten+UI%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Scand%20J%20Urol%20Nephrol%20Suppl.');

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3. Nilsson CG, Falconer C, Rezapour M. Seven-year follow-up of the tension-free vaginal tape

procedure for treatment of urinary incontinence. Obstet Gynecol. 2004; 104:1259-62.

4. Meschia M, Pifarotti P, Bernasconi F, Guercio E, Maffiolini M, Magatti F, et al. Tension-Free

vaginal tape: analysis of outcomes and complications in 404 stress incontinent women. Int

Urogynecol J Pelvic Floor Dysfunct. 2001;12 Suppl 2: S24-7.

5. Kuuva N, Nilsson CG. A nationwide analysis of complications associated with the tension-free

vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand. 2002;81: 72-7.

6. Long CY, Lo TS, Liu CM, Hsu SC, Chang Y, Tsai EM. Lateral excision of

tension-free vaginal tape for the treatment of iatrogenic urethral obstruction. Obstet Gynecol.

2004;104:1270-4.

7. Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress

urinary incontinence in women. Prog Urol. 2001;11:1306-13.

8. de Leval J. Novel surgical technique for the treatment of female stress urinary incontinence:

transobturator vaginal tape inside-out. Eur Urol. 2003;44:724-30.

9. Abdel-Fattah M, Sivanesan K, Ramsay I, Pringle S, Bjornsson S. How common are tape erosions?

A comparison of two versions of the transobturator tension-free vaginal tape procedure. BJU Int.

2006;98:594-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Nilsson+CG%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Falconer+C%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Rezapour+M%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Obstet%20Gynecol.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Meschia+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Pifarotti+P%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Bernasconi+F%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Guercio+E%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Maffiolini+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Magatti+F%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Int%20Urogynecol%20J%20Pelvic%20Floor%20Dysfunct.');javascript:AL_get(this,%20'jour',%20'Int%20Urogynecol%20J%20Pelvic%20Floor%20Dysfunct.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Kuuva+N%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Nilsson+CG%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Acta%20Obstet%20Gynecol%20Scand.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Long+CY%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Lo+TS%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Liu+CM%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Hsu+SC%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Chang+Y%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Tsai+EM%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Obstet%20Gynecol.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Delorme+E%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Prog%20Urol.');http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22de+Leval+J%22%5BAuthor%5Djavascript:AL_get(this,%20'jour',%20'Eur%20Urol.');

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The use tension-free vaginal mesh (TVM) in pelvic reconstructive surgery

高雄長庚醫院 婦產部 黃寬慧 醫師

Abstract:

The pelvic organ prolapse (POP) comprises of anterior, posterior and middle(transverse)

vaginal wall prolapse and always combined multiple compartments prolapses. For example, the

total uterine prolapse often combined with cystocele (anterior vaginal defect) and rectocele

(posterior vaginal defect) or enterocele. According to the classifications of Dr. De Lancey in 1992,

the attachment of the vagina to the pelvic side walls can be divided three levels. The level I defect

(upper vagina) is the detachment of vaginal wall to ischial spine and sacrospinous ligament. The

level II defect (middle vagina) is the detachment of tendineus arch of the pelvic fascia. The level III

defect (distal vagina) is the detachment of puobocervical fascia and rectovaginal fascia.

From late 1960s to 1990s, Drs. Baden and Walker developed and referred a site-specific

classification for pelvic organ prolapse that addresses all potential sites of support loss. The original

classification was perceived to be too difficult for general use. After review of their original

classification by a committee of the American College of Obstetricians and Gynecologists, Baden

and Walker create a simplified version known as the halfway system. In September 1993, a

subcommittee of the ICS met in Rome to draft a system to enable accurate quantitative description

of pelvic support findings. This quantification system, the POP-Q system, was formally adopted by

the ICS in October 1995, the AUGS in January 1996, and the SGS in March 1996. The system is an

adaptation of Baden and Walker’s site-specific system that requires measuring eight sites to create a

tandem vaginal profile before assessing site-specific ordinal stages.

Pelvic organ prolapse and SUI are common problems. The coexisting of POP and SUI is 15

to 80% reported in the literature. The lifetime risk of undergoing prolapse or continence surgery is

11.1% in USA. Unfortunately, the pelvic organ prolapse surgery has high recurrent rate and the

re-operation was common in 30% cases, but the pathogenesis of POP remains unclear. Tracing the

history of pelvic organ prolapse surgery included traditional transvaginal hysterectomy add

anterior-posterior colporrhaphy, transabdominal colposacropexy, transvaginal sacrospinous

ligament fixation and mesh reinforcement methods. There is no golden standard procedure for POP,

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because the endopelvic fascia is time-dependent and slowly attenuated postoperatively.

The new advancement of synthetic prostheses is developed to appropriate for pelvic organ

prolapse and can reinforces the endopelvic fascia. The most common adopted mesh is

polypropylene mesh. The advantage of polypropylene are monofilament and macropore (size more

than 75 µm). This texture can decrease the infection rate and enhance the strength of endopelvic

fascia. Although the new developing absorbable symphasis pelvic graft is absorbable, the long-term

strength is still waiting for reports. The modern pelvic reconstructive methods are using 4 slings or

6 slings to fixation the mesh to the pelvic side walls and completely repair all the vaginal defects.

There are many manufacture kits for POP. All the products have the same methods to reinforce the

intravaginal mesh. From the anterior vaginal wall repair, the mesh were fixed to anterior pelvic side

wall with 4 slings passing through superficial and deep obturator membrane bilaterally. The

posterior and apical vaginal prolapse was suspended to bilateral sacrospinous ligaments with s sling

and a piece of mesh to augment the posterior vaginal wall. If the patient combined with stress

incontinence or occult stress incontinence, concomitant intravaginal midurethral sling was

performed.

Although the polypropylene mesh have been extensively used in pop reconstructive surgeries

to prevent higher recurrence. There is still many complications needed to overcome. A long-term

follow-up for more patients should be carried out before being an accepted opinion.

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The advantages and risks of prostheses in gynecologic surgery 吳銘斌 Ming-Ping Wu, M.D., Ph.D.

Director, Division of Urogynecology and Pelvic Floor Reconstruction, Department of Obstetrics

and Gynecology, Chi Mei Foundation Hospital, Tainan, Taiwan;

The high recurrence rate (up to 30%) after pelvic reconstructive surgery makes the more refined

surgery imperative, as well as the need for either biologic or synthetic prostheses as enforcement

adjuvant. Patients with recurrence risks may benefit from the adjuvant 1). to substitute the lacking

supportive tissue; 2) to reinforce inadequate tissue; 3) to induce new supportive tissue; 4). to

consolidate and complement the insufficient surgical techniques. However, some debatable issues

in the prostheses remain. Prostheses can make the simultaneous repair all vaginal defects of pelvic

organ prolapse (POP) and concomitant anti-incontinence surgery faster, easier and more precise.

Nevertheless, great care should be devoted to actual and theoretical short- and long-term risks,

many of which have not been fully elucidated. Despite lacking various ideal characters, type I,

monofilament, macroporous polypropylene is suggested the lowest incidence of infection and

erosion among the non-absorbable prostheses.

There is good evidence to support the use of non-absorbable synthetic mesh for abdominal

sacro-colpopexy; while prostheses for repairing isolated anterior and posterior compartment defects

remain controversial. No long-term studies with sufficient patient numbers can prove whether

synthetic or biological prostheses are superior in vaginal surgery. Tension-free vaginal mesh (TVM)

techniques with procedural kits are increasingly adopted, despite the paucity of data. Although

short-term follow-up showed a safe and effective technique to correct POP, however, anatomical

and functional results of a long-term follow-up has not yet to confirm the effectiveness and safety.

The mesh erosion remains a concern, with variable rates according to different materials, and

approaches. Newly developed prostheses offer an alternative option for pelvic reconstructive

surgery. However, some questions stay: Should prostheses be considered for primary repairs,

secondary repairs, or solely in patients with risk factors for recurrence? Which prostheses are the

better biomaterials, synthetic or biologic, absorbable or non-absorbable? Do the benefits of

prostheses for pelvic reconstructive surgery outweigh their risk of complications?

Reference: Ming-Ping Wu: The use of prostheses for pelvic reconstructive surgery: joy or toy?

Taiwan J Obstet Gynecol 2008;47(2):151–156

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座 長Closing remarks致結束詞黃國峯部主任