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UrodynamicUrodynamic Study (UDS) in Study (UDS) in UrogynecologyUrogynecology
吳銘斌吳銘斌1,2 1,2 (Ming(Ming--Ping Wu)Ping Wu)
奇美醫院奇美醫院 婦產部婦產部 婦女泌尿科婦女泌尿科1 1
台北醫學大學醫學院台北醫學大學醫學院 婦產學科副教授婦產學科副教授22
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Bladder & Urethra function Bladder & Urethra function during storage and voidingduring storage and voiding
Normal Normal StorageStorage VoidingVoidingBladderBladder RelaxedRelaxed ConstrictedConstricted
UrethraUrethra ConstrictedConstricted RelaxedRelaxed
Abnormal Abnormal StorageStorage VoidingVoidingBladderBladder OveractiveOveractive UnderactiveUnderactive
AcontractileAcontractile
UrethraUrethra Incompetent under Incompetent under stressstress
Functional or Functional or anatomic obstructionanatomic obstruction
Inappropriate Inappropriate relaxationrelaxation
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URODYNAMIC (UDS) ICS Abbreviations
URODYNAMIC (UDS) URODYNAMIC (UDS) ICS AbbreviationsICS Abbreviations
Pura
Pdet
Pabd
QuraEMG
Pves
Pves Vesical Pressure Pabd Abdominal PressurePdet Detrusor PressurePura Urethral PressureQura Urinary Flow rateEMG Electromyography
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Stanton SL,Tanagho EA 1986 Springer-Verlag
Normal Normal micturitionmicturition cyclecycle
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Stanton S L,Tanagho E A 1986 Springer-Verlag
Mechanism of urinary incontinenceMechanism of urinary incontinence
a: normal voiding or DO; b: DSD; c: impair bladder compliance; d: urethral instability; e: USI
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ICS TerminologyICS Terminology
Chapple CR 2005 Nat Clin Practice UrolAbrams P 2002 Neurourol Urodyn
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Urodynamics (UDS)
Life Tech Co.
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Look inside the UDS machineLook inside the UDS machine
Keyboard
Monitor /Display
Computer (PC)
Printer
Mouse
Patient unit Cable
Puller /Profilometer
Patient Unit
UroPump
Infusion Medium
EMG
Remote Control
Life Tech Co.
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Pressure Transducers and Tubing
UDS- components
Life Tech Co.
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Select InvestigationUrodynamic investigations
Electromyography (EMG)Electromyography (EMG)
(UPP)
(UFM)(CMG)
(PFS)
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Recording Flow
Flow Transducer
Vura
Qura
Urodynamic Equipment
Uroflometry (UFR)UroflometryUroflometry (UFR)(UFR)
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UROFLOWMETRY ParametersUROFLOWMETRY ParametersUROFLOWMETRY Parameters
Time s
Quraml/s
Vuraml
100(Qmax) Maximum Flow Rate
Flow TimeVoiding Time
(TQmax) Time to Max. Flow
Voided Volume
Voided Volume
(Qave) Average Flow RateVoided Volume / Flow Time
Time to 100 ml
(Peak Flow)
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UroflowmetryUroflowmetry (UFM)(UFM)at least 200 ml needs to be voided to at least 200 ml needs to be voided to calculate reliable values. calculate reliable values. parameters are obtained: parameters are obtained: 1) flow rate (Q), ml/ sec1) flow rate (Q), ml/ sec2) maximum flow rate (2) maximum flow rate (QmaxQmax); );
> 15 ml/ sec > 15 ml/ sec
3) total flow time (3) total flow time (QtimeQtime); ); 4) average flow rate (4) average flow rate (QavgQavg); ); 5) total volume voided; 5) total volume voided; 6) 6) postvoidpostvoid residual urine volume (PVR)residual urine volume (PVR)
Cutoff: 50Cutoff: 50--100ml100ml< 20% total voids < 20% total voids
Kohli N 1998 Clin Obstet Gynecol
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Abnormal Abnormal UroflowmetryUroflowmetry
(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 outlet resistance or poor propulsive force
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Single channel Single channel cystomterycystomtery (CMG)(CMG)
Kohli N 1998 Clin Obstet Gynecol
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Normal Normal cystometrycystometry (CMG)(CMG)
Kohli N 1998 Clin Obstet Gynecol
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(A)(A) Normal filling Normal filling cystometrycystometry; ;
Kohli N 1998 Clin Obstet Gynecol(B) phasic contractions (detrusor instability);
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(C) phasic contractions with gradual rise in Pdet
Kohli N 1998 Clin Obstet Gynecol(D) (D) steady rise in rise in PdetPdet(low compliance bladder)(low compliance bladder)
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Multichannel Multichannel cystometrycystometry (CMG)(CMG)
Kohli N 1998 Clin Obstet Gynecol
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APIS
3-way
Pves
IPTS-DC-LT1
DLUPP-7D Dual Lumen CMG/UPP Catheter
Pdet = Pves – Pabd
Pves
UPDC
UPT
IV
CMG (Filling Pressure Flow Study)
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APIS
RPC-9 Abdominal Pressure Catheter
Pabd
Pabd
Pdet = Pves – Pabd
CMG (Filling Pressure flow)
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Indications for multichannel Indications for multichannel subtracted subtracted cystometrycystometry
Kohli N 1998 Clin Obstet Gynecol
TABLE
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Kohli N 1998 Clin Obstet Gynecol
Pabd
Pves
Pura
Pdet
Pucp
Flow rate
Storagephase
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H:9
H:3
EMG
1512F Wire ElectrodesH0959A Surface Electrodes
Electromyography (EMG)Electromyography (EMG)
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EMG recordingEMG recording
Activity of the pelvic floor• External spincter• Detect Detrusor sphicter dys-synergia (DSD)
Filling of the bladder VoidingFilling of the bladder Voiding
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CMG Basic PressureCMG Basic PressureCMG Basic Pressure
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
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CMG First Desire (FD)CMGCMG First Desire (FD)First Desire (FD)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
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CMG Cough (C)CMG Cough (C)CMG Cough (C)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FDCough
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CMG Normal Desire (ND)CMG CMG Normal Desire (ND)Normal Desire (ND)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FDCough
ND
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Uninhibited Detrusor Contraction (UIDC)Uninhibited Uninhibited DetrusorDetrusor Contraction (UIDC)Contraction (UIDC)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
Cough
ND
> 15 cmH2O
UIDC
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CMG Rectal Hyperactivity (RH)CMG Rectal Hyperactivity (RH)CMG Rectal Hyperactivity (RH)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FDCough
ND
UIDC
RHCough
Slow WavesAmplitude > 10 cmH2O
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CMG Unstable Urethra (UU)CMG Unstable Urethra (UU)CMG Unstable Urethra (UU)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
Cough
ND
UIDC
RHCough
> 30 cmH2O
UU
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CMG Strong Desire (SD)CMG Strong Desire (SD)CMG Strong Desire (SD)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FDCough
ND
UIDC
RHCough
UU
SD
Voiding:Voluntary Contraction
Autonomic Control
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CMG Leak Point (LP)CMG Leak Point (LP)CMG Leak Point (LP)
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FDCough
ND
UIDC
RHCough
UU
SD
Cough
Leak
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Urgency & Maximum CapacityUrgency & Maximum CapacityUrgency & Maximum Capacity
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
Cough
ND
UIDC
RHCough
UU
SD
Cough
Leak
UR
MC
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CMG ComplianceCMG ComplianceCMG Compliance
EMG
Pura
Pves
Pabd
Pdet
Qura
Vinf0 100 200 300 400 500 600 ml
20 m
l
Time 1 min/Div
Speaking
FD
Cough
ND
UIDC
RHCough
UU
SD
Cough
Leak
UR
MC
P1
P2
Compliance =V2 - V1P2 - P1
V1V2
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Two most common incontinenceTwo most common incontinenceUrodynamic stress incontinence (USI)
Detrusor overactivity (DOI)
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UrodynamicUrodynamic stress incontinence (USI) stress incontinence (USI) DetrusorDetrusor overactivityoveractivity (DO) (DO)
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UrodynamicUrodynamic stress incontinencestress incontinence
Nygaard & Heit2004 Obstet Gynecol
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DetrusorDetrusor overactivityoveractivity incontinenceincontinence
Nygaard & Heit 2004 Obstet Gynecol
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PressurePressure--flow studyflow study
Storage phaseStorage phaseVoiding phaseVoiding phase
Kohli N 1998 Clin Obstet Gynecol
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Filling phase Voiding phase
PressurePressure--Flow StudyFlow Study
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Kohli N 1998 Clin Obstet Gynecol
Pabd
Pves
Pura
Pdet
Pucp
Flow rate
Voiding phase
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Voiding Mechanisms in Voiding Mechanisms in Neurologically Intact Women Neurologically Intact Women
Depending on Depending on •• age, menopausal status, age, menopausal status, •• total voided volume, total voided volume, •• the presence of lower urinary tract dysfunction, the presence of lower urinary tract dysfunction,
the patient may void the patient may void •• detrusordetrusor contraction, contraction, •• abdominal straining, abdominal straining, •• urethral relaxation, urethral relaxation, •• combination of three combination of three
Kohli N 1998 Clin Obstet Gynecol
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Voiding Mechanisms in Voiding Mechanisms in Neurologically Intact Women Neurologically Intact Women
Kohli N 1998 Clin Obstet Gynecol
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Pressure flow studyPressure flow study
1. low 1. low PdetPdet, high , high QmaxQmax•• unobstrucedunobstruced
2. high 2. high PdetPdet, low , low QmaxQmax•• obstrucedobstruced
3. low 3. low PdetPdet, low , low QmaxQmax•• Poor Poor detrusordetrusor contractilitycontractility
PdetPdet > 15 cm H> 15 cm H22OO•• Shorter postShorter post--op bladder drainageop bladder drainage
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Definition for female bladder outlet Definition for female bladder outlet obstruction (BOO)obstruction (BOO)
GroutzGroutz A. A. BlaivasBlaivas JG, et al. 2000 JG, et al. 2000 NeurourolNeurourolUrodynUrodynMaximum flow rate (Maximum flow rate (QmaxQmax) < 12ml/s ) < 12ml/s DetrusorDetrusor pressure at peak flow pressure at peak flow ((PdetPdet at at QmaxQmax)> 20 cmH)> 20 cmH22O. O.
Massey JA & Abrams PH 1988 BJU Massey JA & Abrams PH 1988 BJU Maximum flow rate (Maximum flow rate (QmaxQmax) < 12 ml/s ) < 12 ml/s Maximum Maximum detrusordetrusor pressure (pressure (PdetPdet, max) > 50 , max) > 50 cmHcmH22O. O. PVR> 100mLPVR> 100mL
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APIS
3-way
UPDC
UPT
IV
Pves
Urethral pressure profile (UPP)Urethral pressure profile (UPP)
IPTS-DC-LT1
DLUPP-7D Dual Lumen CMG/UPP Catheter
Pclo = Pura – Pves
PuraPves Pura
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Urethral pressure profile (UPP)Urethral pressure profile (UPP)
Kohli N 1998 Clin Obstet Gynecol
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Urethral pressure profile (UPP)Urethral pressure profile (UPP)
Max urethral pressure (MUP)Max urethral pressure (MUP)Max urethral closure pressure (MUCP)Max urethral closure pressure (MUCP)•• 64 y/oy/oMean 65 cmHMean 65 cmH22OO
•• Cutoff: 20 cmHCutoff: 20 cmH22O for ISDO for ISD
Functional urethral length (FUL)Functional urethral length (FUL)•• 2.42.4-- 2.8 cm (< 50 2.8 cm (< 50 y/oy/o))
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UPPUPP
Kohli N 1998 Clin Obstet Gynecol
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Resting UPPResting UPP
Life Tech Co.
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Stress UPPStress UPP
Life Tech Co.
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Resting UPP Stress UPP
Urethral pressure profile (UPP)Urethral pressure profile (UPP)
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Rectum Bladder
30°
Bladder filled with 200 ml, I'm Straining
with Increased Force up to Leak !
RecordingPabd & Pves
and Leaks withLeak Detectorand Flowmeter
Pabd
Pves
Qura
60 80 100 120
Leak
Vasalva Leak Point Pressure (VLPP)
VasalvaVasalva Leak Point Pressure Leak Point Pressure (VLPP)(VLPP)
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VLPP and CLPPVLPP and CLPPPosition patient in almost upright Position patient in almost upright position for position for visual detectionvisual detection of of leakage. Use the remote control leakage. Use the remote control to mark the leakage.to mark the leakage.
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VLPP and CLPPVLPP and CLPPAutomatic detectionAutomatic detectionLeakage detection via Leakage detection via conductance ringsconductance rings on a water on a water cathetercatheter
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Leak point pressure (LPP)Leak point pressure (LPP)
Kohli N 1998 Clin Obstet GynecolVLPP: ValsalvaCLPP: Cough
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Leak point pressure (LPP)Leak point pressure (LPP)
McGuire EJ 1993 J McGuire EJ 1993 J UrolUrolVLPP < 60cmHVLPP < 60cmH22OO•• Type III incontinenceType III incontinence•• Intrinsic sphincter deficiency (ISD)Intrinsic sphincter deficiency (ISD)
VLPP > 90cmHVLPP > 90cmH22OO•• Type I, II incontinenceType I, II incontinence•• Urethral Urethral hypermobilityhypermobility
Kohli N 1998 Clin Obstet GynecolVLPP: ValsalvaCLPP: Cough
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Pressure transmission ratio Pressure transmission ratio (PTR) & Hammock theory (PTR) & Hammock theory
DeLancey JOL 19994 Am J Obstet Gynecol:
Abdominal pressure on urethra & pelvic floor
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Pressure Pressure transmission ratio transmission ratio
(PTR)(PTR)
100%100%•• Equal pressure Equal pressure
transmission to transmission to urethra & bladderurethra & bladder
Kohli N 1998 Clin Obstet Gynecol
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UrodynamicUrodynamic investigationsinvestigations Filling Pressure &
EMG recordig
Voiding Puller
Uroflow X
Cystometry X X
Pressure flow X X X
UPP X X
Gynaecology X X X X
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Procedure of UDS in Procedure of UDS in UrogynUrogyn ClinicClinic1. 500ml water 1 hour before test1. 500ml water 1 hour before test2. Do Pad test2. Do Pad test3. Do 3. Do UroflowmetryUroflowmetry4. Insert infusion & pressure transducer 4. Insert infusion & pressure transducer
•• Check Check postvoidpostvoid residual (PVR)residual (PVR)5. Infusion 80ml/min5. Infusion 80ml/min6. CMG6. CMG
•• FS, cough (c)FS, cough (c)**1, c1, c**1, c1, c**6, running water6, running water•• Max Capacity, cMax Capacity, c**1, c1, c**1, c1, c**6, 6, •• Standing, cStanding, c**1, c1, c**1, c1, c**6, 6,
7. VLPP 7. VLPP 8. Voiding pressure flow study8. Voiding pressure flow study9. UPP 9. UPP
•• Static UPPStatic UPP•• stress UPP stress UPP
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Interpretation of UDS in Interpretation of UDS in UrogynUrogyn ClinicClinicAbnormal storageAbnormal storage•• DetrusorDetrusor overactivityoveractivity (DO)(DO)•• Low complianceLow compliance•• Low capacityLow capacity•• Hypersensitivity bladderHypersensitivity bladder
•• DetectionDetection•• Low MUCPLow MUCP•• Short FULShort FUL•• Low Low PcloPclo•• Low PTRLow PTR
Abnormal voidingAbnormal voiding•• Low flowLow flow•• Abdominal strainingAbdominal straining•• Abnormal PVRAbnormal PVR
UrodynamicUrodynamic stress incontinence (USI)stress incontinence (USI)
•Visual or conductance ring
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Interpretation of UDS in Interpretation of UDS in UrogynUrogyn ClinicClinic
Description• UFR• CMG + EMG• Pressure flow study• UPP
Impression• Urodynamic stress incontinence (USI)• Detrusor overactivity (DO)• with/ without incontinence• Mixed type (USI + DO)• Detrusor sphincter dyssynergia
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影像尿動力學診斷系統影像尿動力學診斷系統
Where
? Who?
How?
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Apr 2004Apr 2004 6868
VideoVideo--urodynamicurodynamic studystudy
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尿動力學檢查尿動力學檢查SolarSolar功能說明功能說明
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
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遠端遙控功能遠端遙控功能
透過醫院網路直接遙控尿動力檢查儀
Hospital Network
院內網路
辦公室
病房
尿路動力檢查儀
☆瀏覽患者檢查資料
☆直接遙控操作機器
☆Monitor監視
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Apr Apr 2004200471
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檢測軟體檢測軟體
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Apr 2004Apr 2004 7272
影像尿動力學系統影像尿動力學系統X光機影像擷取X光機影像擷取
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Apr 2004Apr 2004 7373
影像尿動力學系統影像尿動力學系統X光機單張影像擷取X光機單張影像擷取
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Apr 2004Apr 2004 7474
影像尿動力學系統影像尿動力學系統
動態影像擷取動態影像擷取
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Urodynamic Study (UDS)UrodynamicUrodynamic Study (UDS)Study (UDS)
• A. 21004C尿流速圖 (Uroflowmetry, UFR) …….…..….……• B. 21005C尿道壓力測量檢查
(Urethral pressure profile studies, UPP) .…………....1,254點21012B應力尿道壓力測量檢查
(Stress urethral pressure profile, Stress UPP) …….….• C. 21007C膀胱壓檢查(Cystometry, CMG) … ……………….
21011C壓力尿流速圖(Pressure-flow study) …….………• D. 21003C外括約肌肌電圖
(External sphincter electromyogram, EMG)
• E. 21006B錄影尿流動力學檢查( Video-urodynamic study)
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VIDEO SPLIT
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Thank you for your attention
2006. 02 Tainan