婦女應力性尿失禁手術治療新知

Update of Surgery for Female Stress Urinary Incontinence

目前尿失禁吊帶手術較偏向使用以無張力吊帶放置於中段尿道的微創手術方法，後來在相同的理論依據下，發展出以經閉鎖孔的手術與單一陰道傷口的吊帶術式，更使中段尿道吊帶手術的安全性跨出一大步，帶來更少的手術不適，實已進入尿失禁手術的新境界。陰道無張力懸吊術（TVT）最早由Ulmsten 及Petros在1995年提出，使用polypropylene tape放置於中段尿道來處理婦女的應力性尿失禁。目前最長 期追蹤的研究是Nilsson近20年的治癒率加改善率超過9成，十分另人滿意。經閉孔吊帶懸吊術（TOT）最早在2001年由法國的Delorme醫師所提出，為何要經閉孔來做此術式呢？原因有二：第一就是要避開 retropubic space。來減少膀胱，腸道及大血管受傷的機會。第二就是此術式將形成‘'V”形的吊帶懸吊，相對 於TVT 'U”形吊帶而官較水平，可能比較不會有尿道阻塞或原發性尿急（de novo urgency）的情形。單一傷口施行的尿道帶手術是目前尿失禁手術的最新的發展，故名思義，此類型的手術只需要一個位於陰道前壁的小傷口。目前上市的尿道帶產品有Solyx(R)(Boston scientific) 、OphiraO (Promedon) ; Ajust (Bard)。 若使用Solyx的術式，就以偏離中線左與右各45度角，用組織剪分離陰道壁下層組織與筋膜之空問。而 後，將裝有倒勾矛的尿道帶套上導引針，左右分別順著已劃開之隧道穿刺至恥骨後壁之內閉孔肌與筋膜上。這類單一傷口施行的尿道帶手術，輔自推出至目前都不超過5年的時問，短期一年的手術成功率， 大都不會高過其它術式的手術成功率，同時欠缺長期的研究數據，因此大部分醫師普遍都存著觀望的態度，較不會大量或常規地使用此術式。

Tension-free sling insertion at mid-urethra has currently been the most popular minimally invasive surgical method for female stress urinary incontinence (SUI). Based on similar mechanisms, transobturator surgeries and single-site vaginal tapes are developed to enhance even better patient safety and less discomfort. These innovations have taken urogynecological surgeries to a new horizon. Tension-free vaginal tape (TVT) was first introduced by Ulmsten and Petros in 1995, using polypropylene tape at mid-urethra to treat stress urinary incontinence in females. The longest follow up study was conducted by Nilsson, lasting almost 20 years, which showed satisfying treatment success rate that exceeded 90%. In 2001, Dr. Delorme from France later modified the device into transobturator tape (TOT), which was advanced in two ways. Firstly, it spared retropubic space and reduced injuries to the urinary bladder, bowels and great vessels. Secondly, the tape was assembled into a “U” configuration, creating less pressure to the mid-urethra as opposed to the “V” configuration in TVT. This design effectively reduced incidences of post-operative de novo urgency and urinary bladder outlet obstruction. Better yet, single-incision sling systems (e.g. Solyx® Boston scientific, Ophira® Promedon, Ajust® Bard) are now available to achieve the same aim with only one single small incision at the anterior vaginal wall. Taking Solyx as an example, dissection is first made between the vaginal subcutaneous tissue and fascia 45 degrees bilaterally to the midline incision using tissue scissors until reaching the obturator muscles. Solyx tape is then assembled at the tip of its specially designed mesh delivery device, which is driven to the bilateral tunnels created earlier sequentially and fixed at the retropubic obturator muscle and fascia. Because these single-incision tapes are so new (less than 3 years), long-term efficacy studies are lacking. Short-term studies with one-year follow up showed non-superior performance to the precedent TVTs or TOTs. Most practitioners are conservative and reluctant to use the new modality regularly or in large numbers. Surgical techniques and modalities for female SUI are flourishing, each with its own mechanisms, strengths and weakness. Although single-incision sling systems are tiny in size, short-term success rate are equally satisfying if more tension is exerted during its implantation. More and long-term studies are needed to test its safety and performance. Urogynecologists should work together and keep advancing in surgical techniques that are safe, effective, easy and long-lasting, to help our patients suffering from SUI.