[醫如往常] Senior Clerkship Day 18: Ob/Gyn SSCT; Urogynecology

Grand Round PGY
SSCT; Spermatogonial stem cell autotransplantqtion
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Subfertility (prevalence: 15%)
Subfertility generally describes any form of reduced fertility with prolonged time of unwanted non-conception.
來自 <http://humrep.oxfordjournals.org/content/20/5/1144.full>


• 17% male factor
• Drug, cancer
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Testis biopsy→Cryo-sperm→Propagation→
Rete testis, efferent ductules injection
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Crisper/Cas9 gene editing
Clustered regularly interspaced short palindromic repeats
NGG, NCC PAM(protospacer adjacent motif)
CRISPR/Cas (Clustered regularly interspaced short palindromic repeats and CRISPR-associated systems) 是將來自於化膿性鏈球菌(Streptococcus pyogenes)的Cas9蛋白與guide RNA形成一個複合體，由guide RNA上的Protospacer序列(17~20nt)辨識DNA，緊接在Protospacer序列之後的三個核苷酸(NGG)稱為Protospacer adjacent motif(PAM)，Cas9即辨識PAM並切割緊鄰的雙股DNA。其後又發展出只切割單股DNA的CAS9 Nickase以降低脫靶效應(off target effect)。
來自 <http://rd.mc.ntu.edu.tw/bomrd/hd/cell-2.asp>
Protospacer adjacent motif (PAM) is a 2-6 base pair DNA sequence immediately following the DNA sequence targeted by the Cas9 nuclease in the CRISPR bacterial adaptive immune system.
https://en.wikipedia.org/wiki/Protospacer_adjacent_motif
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GeCKO; Genome scale CRISPR-Cas9 knockout
Lentivirus
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41% azoospermia 仍可做TESE; Testicular sperm extraction
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Urogynecology 蕭醫師

Level I
Cardinal lig.


Level II, cystocele
Arcus tendineus (fasciae pelvis),white line


Level III
Perineum
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Radical hystectomy
C1 nerve-sparring
C2 non-nerve-sparring
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Sup hypogastric n.: Sympathetic
Inf. Hypogastric plexus: mixed
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Obturator n.
Adductor
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POP-Q system
D: omit when no cervix
Valsalva maneuver才準
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-3,-3,-8,-10,-3,-3,11,4,3
n Aa, Ba, C, D, Ap, Bp, total vaginal length,
genital hiatus, perineal body




Simplified POP-Q
n Ba
n Bp
n C
n D
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SUI
Sphincter defect
Urethral hypermobility. Q Tip test
1. Resting angle>30°
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Functional capacity >300 cc
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20 min pad test
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Voiding cystometry
Detrusor pressure=bladder-abd
Normal 10-25 mmH2O
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UPP
Maximal urethral closure pressure


SUPP
壓力傳導能力
Urethral hypermobility
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Correlation of LUTD before and after UDS


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VLPP(Valsalva Leak Point Pressure)<60
200 cc leak pressure
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Pharmacologic Treatment of SUI
n Duloxetine : serotonin-norepinephrine reuptake inhibitor (SNRI)
n Imipramine : Anticholinergic agents and α-adrenergic agonist
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MMK: cause Pelvic bone osteolysis
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TVT for ISD, Intrinsic sphincter defect
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先排除UTI
OAB


Solifenacin antimuscarinic for 3 months
Mirabegron beta-3 agonist


Sacral neuromodulation
Botox
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Uterus prolapse
Venous stasis may be related


Ip Vaginal sacrospinous colpopexy
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