经尿道内括约肌切除术在神经源性膀胱患者中的应用及长期随访研究

曹明欣; 张俊隆; 丘少鹏; 梁月有

doi:10.13201/j.issn.1001-1420.2021.01.007

经尿道内括约肌切除术在神经源性膀胱患者中的应用及长期随访研究

- 中山大学附属第一医院泌尿外科(广州, 510080)

详细信息

通讯作者: 梁月有,E-mail:shutongxuan@126.com

中图分类号: R694

收稿日期: 2020-04-13

Application and long-term follow-up of transurethral internal sphincter resection in patients with neurogenic bladder

- Department of Urology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, 510080, China

More Information

Corresponding author: LIANG Yueyou, E-mail: shutongxuan@126.com

Received Date: 13 April 2020

摘要

摘要: 目的：治疗神经源性膀胱的首要两大目的即保护上尿路功能，获得或保持最恰当的尿控能力，但目前缺乏完美的治疗方法。为评价经尿道内括约肌切除术在神经源性膀胱患者中的应用及长期效果，行本研究。方法：回顾性分析2010年6月—2019年6月在我院接受经尿道内括约肌切除术治疗的17例神经源性膀胱患者的临床资料，其中男9例，女8例，年龄14~88岁，平均57岁；病程2个月~47年，病程中位数24个月；隐性脊柱裂4例，神经根鞘囊肿1例，子宫全切除术后1例，脑血管意外3例，脊髓脊膜膨出术后2例，脊髓外伤3例，腰椎间盘突出2例，病因不详1例。临床表现有排尿困难11例、尿失禁9例。17例患者中留置导尿4例，其余患者残余尿（PVR）5~1000 mL，平均374 mL；影像学提示有双肾积水者9例；10例患者曾行膀胱造影，有明确反流者4例。观察手术后患者肾积水的变化情况，比较治疗前后PVR及血肌酐（Scr）水平。结果：男性患者平均手术时间61（30~140） min，女性患者平均手术时间35（29~45） min；男性患者平均出血量23（2~50） mL，女性患者平均出血量9（5~25） mL。随访时间6个月~7年，失访1例。术前留置导尿的4例患者，3例拔管后均可自行排尿，PVR 14~221 mL，1例患者拔管后因PVR多而再次持续留置尿管治疗至今。9例术前存在双肾积水患者，5例术后肾积水消失，3例肾积水较术前程度减轻，1例失访。9例术前有尿失禁患者术后仍有不同程度尿失禁，其中1例加重。患者术后Scr水平无明显增长[术前（91±41）μmol/L vs.术后（103±54）μmol/L，P>0.05]，PVR较术前明显降低[术前（372±253） mL vs.术后（134±127） mL，P<0.05]。结论：经尿道内括约肌切除术可作为神经源性膀胱的一种有效治疗方法，该术式可降低患者的PVR，改善或减轻肾积水，同时能维持原有的尿控功能，且手术简单、安全，值得临床进一步观察研究。
- 神经源性膀胱 /
- 经尿道微创治疗 /
- 内括约肌切开 /
- 治疗效果
Abstract: Objective: The two primary goals in the urologic management of neurogenic bladder dysfunction include protecting the patient's upper urinary tract and allowing the patient to maintain optimal urinary control. There's no perfect therapy treatment. We conducted the study to evaluate the long-term efficacy of transurethral internal sphincter resection in patients with neurogenic bladder.Methods: Between June 2010 and June 2019, a total of 17(male 9, female 8) neurogenic bladder patients with mean age 57(14-88) years and the duration of the condition for median 24 months(range:2 months to 47 years) were treated using transurethral internal sphincter resection in our center. The neurogenic causes were spinal bifida occulta in 4 cases, Tarlov cyst in 1 case, hysterectomy in 1 case, cerebrovascular accidents in 3 cases, meningomyeloceles in 2 cases, spinal cord injury in 3 cases, lumbar disc herniation in 2 cases, unknown cause in 1 case. There were 11 cases of dysuria and 9 cases of incontinence. Among the 17 patients, 4 had indwelling catheterization, other 13 cases were found postvoid residual volume 374(5-1000) mL. Imaging showed 9 cases with hydronephrosis. Cystography was performed in 10 patients, 4 of whom had definite vesicoureteral reflux. The changes of hydronephrosis in patients after surgery were observed. Postvoid residual volume and serum creatinine(Scr) level before and after treatment were compared.Results: The average operation time of male patients was 61(30-140) min, female patients 35(29-45) min. The average blood loss was 23(2-50) mL in male patients and 9(5-25) mL in female patients. The follow-up time ranged from 6 months to 7 years, and 1 case was lost. Of the 4 patients who had indwelling catheterization before surgery, 3 patients were able to urinate after surgery, and the residual urine volume was 14-221 mL. One patient continued to be indwelt the catheter after being extubated due to the large residual urine volume. Of 9 patients who had bilateral hydronephrosis before operation, 5 patients had no hydronephrosis. Three patients relieved compared with preoperative symptom. One was lost to follow-up. Nine patients with incontinence before operation still had varying degrees of urinary incontinence after operation, one of which exacerbated. The postoperative Scr did not increase significantly[preoperative(91±41) μmol/L vs. postoperative(103±54) μmol/L, P>0.05], and the PVR was significantly lower than that before surgery[preoperative(372±253) mL vs. postoperative(134±127) mL, P<0.05].Conclusion: Transurethral internal sphincter resection is an effective treatment for neurogenic bladder. This procedure reduces postvoid residual volume, improves or reduces hydronephrosis, avoids deterioration of renal function and maintains optimal urinary control. The operation is simple, safe and worthy of further clinical observation and research.
- neurogenic bladder /
- minimally invasive transurethral surgical procedure /
- internal sphincter resection /
- treatment outcome

HTML全文

参考文献(12)

[1]	陈忠, 刘继红, 叶章群, 等.铥激光膀胱内切开治疗高张力性神经源性膀胱早期报道[J].临床泌尿外科杂志, 2016, 31(12):1068-1070.
[2]	Blok B, Castro-Diaz D, DelPopolo G, et al.EAU GuidelinesEdn[M].Arnhem:EAU Guidelines Office, 2020.
[3]	Vainrib M, Reyblat P, Ginsberg DA.Long-term efficacy of repeat incisions of bladder neck/external sphincter in patients with spinal cord injury[J].Urology, 2014, 84(4):940-945.
[4]	Emmett JL.Further observations in the management of cord bladder by transurethral resection[J].J Urol, 1947, 57(1), 29-41.
[5]	O'Flynn JD.Early and late management of the neuropathic bladder in spinal cord injury patients[J].J Urol, 1978, 120(6):726-728.
[6]	仝墨泽, 陈成, 乔九玉.经尿道内括约肌切断术治疗高顺应性神经源性膀胱的疗效分析[J].安徽医学, 2014, 35(8):1069-1071.
[7]	张依利, 谢辉, 刘联承, 等.经尿道内括约肌切断术及尿流动力学联合治疗逼尿肌无反射神经源性膀胱功能障碍[J].中国伤残医学, 2015, 23(24):73-74.
[8]	Santiago JA.Sphincterotomy failure[J].J Am Paraplegia Soc, 1993, 16(3):164-168.
[9]	Yang CC, Mayo ME.External urethral sphincterotomy:long-term follow-up[J].Neurourol Urodyn, 1995, 14(1):25-31.
[10]	Derry F, al-Rubeyi S.Audit of bladder neck resection in spinal cord injured patients[J].Spinal Cord, 1998, 36(5):345-348.
[11]	Jung J, Ahn HK, Huh Y.Clinical and functional anatomy of the urethral sphincter[J].Int Neurourol J, 2012, 16(3):102-106.
[12]	Amarenco G, Sheikh Ismaël S, Chesnel C, et al.Diagnosis and clinical evaluation of neurogenic bladder[J].Eur J Phys Rehabil Med, 2017, 53(6):975-980.