经超声逼尿肌厚度测定在可疑膀胱出口梗阻患者中的应用

目的 分析可疑膀胱出口梗阻患者术前逼尿肌厚度,探讨逼尿肌厚度测定对可疑膀胱出口梗阻患者术后疗效的预测作用.方法 对可疑膀胱出口梗阻并行手术治疗的86例患者在行压力流率测定过程中,当膀胱容量为250 ml或灌注量为膀胱最大容量的50%时,应用7.5 MHz高频线纵超声探头行膀胱前壁逼尿肌厚度测定.术后3个月复查,将患者分为疗效显著组与疗效非显著组,比较2组患者年龄、前列腺体积及逼尿肌厚度.结果 疗效显著组(37例)与疗效非显著组(49例)患者年龄及前列腺体积差异无统计学意义(P＞0.05).逼尿肌厚度差异有统计学意义[(2.5±0.3)和(2.2±0.3)mm,P＜0.01].应用受试者工作特性曲线,当逼尿肌厚度≥2.8 mm时,逼尿肌厚度测定作为预测工作特异性和阳性预测值均为100%,而敏感性为19%,阴性预测值为62%.其曲线下面积为0.84±0.04.结论 逼尿肌测定预测可疑膀胱出口梗阻患者术后疗效可靠,但仍需要多中心、大样本的试验进一步确定临界值.

Abstract：

Objective To estimate the application of ultrasound measurement of detrusor wall thickness (DWT) in the assessment of curative effect after operation. Methods Detrusor thickness was measured by linear ultrasound (7. 5 MHz) either at a filling volume of 50% of cystometric capacity or at 250 ml filling in 86 patients, who were diagnosed equivocal BOO, during a pressure-flow study. All patients accepted transurethral resection of the prostate. At 3 months post-surgery, the patients were divided into two groups according to curative effect after operation. The volume of the prostate, age and DWT were compared between the two groups. Results There was no difference in either age or volume of the prostate between the two groups. DWT was significantly higher (P＜0.01) in the more curative effect group (37 cases, DWT 2. 5±0.3 mm) compared to the less curative effect group (49 cases, 2.2±0. 3 mm). As a predictor of curative effect, DWT of 2. 8 mm or greater had a positive predictive value of 100%, a negative predictive value of 62%, specificity of 100% and sensitivity of 19%. Receiver operating characteristic analysis (ROC) revealed that DWT had a high predictive value for curative effect post-surgery with an AUC of 0. 84±0. 04. Conclusions In patients with equivocal BOO, ultrasonographically assessed detrusor thickness may have a predictive value for curative effect post-surgery. However, this cutoff value needs to be validated in a larger study population.     

Possible use of ultrasonically-estimated bladder weight in patients with neurogenic bladder dysfunction

In 25 patients with detrusor areflexia, ultrasonically-estimated bladder weight (UEBW) was compared with bladder capacity and compliance obtained by cystometry, and UEBW was also compared with grade of bladder deformity as evaluated by cystography. UEBW correlated significantly with compliance (P < 0.01) and degree of bladder deformity (P < 0.01). Taking a cutoff value of 40 g, UEBW revealed diagnostic accuracy as high as 96% and 80% for low-compliance (< 10 ml/cm H₂O) and high-grade deformity (grade II/III), respectively. UEBW could be a new urodynamic parameter capable of evaluating functional as well as morphological changes of the bladder. © 1996 Wiley-Liss, Inc.     

Transabdominal ultrasonography of detrusor wall thickness in women with overactive bladder

Study Type – Diagnostic (case series)
Level of Evidence 4

OBJECTIVE

To determine the clinical usefulness of measuring detrusor wall thickness (DWT) as a noninvasive test in women with overactive bladder (OAB).

PATIENTS, SUBJECTS AND METHODS

We prospectively enrolled 122 women with dry OAB, wet OAB, and women with no OAB symptoms (control group). A 3‐day voiding diary was used to differentiate between wet and dry OAB. Transabdominal ultrasonography (TAUS) measurements of DWT were taken at bladder volumes of 250–300 mL and the maximal bladder capacity by both catheter‐ and natural‐filling. Video‐urodynamic studies (VUDS) were used to classify bladder dysfunction in 88 of the women.

RESULTS

The mean (range) age of the women was 58 (20–94) years. There were 39 ‘normal’ controls, 44 women had dry OAB, and 39 had wet OAB. Of the 88 women who had VUDS, 28 had a ‘normal’ test, 30 had increased bladder sensation (IBS), and 30 had detrusor overactivity (DO). The mean DWT at 250–300 mL among three symptomatic subgroups or urodynamic subgroups showed no significant difference by either catheter‐ or natural‐filling methods. The women with wet OAB had significantly greater DWTs than the controls at maximal bladder volume. The maximal bladder capacity was significantly greater in ‘normal’ women than in those with OAB. If we corrected maximal bladder volume to 250 mL, DWT at corrected 250 mL showed no significant difference among three symptomatic subgroups.

CONCLUSIONS

DWT measured by TAUS in women with OAB and without OAB was not different and did not differ with urodynamic status. Thus, TAUS measurement of DWT is not recommended as a useful diagnostic test for DO in women with OAB.     

经超声逼尿肌厚度测定在无创诊断女性膀胱出口梗阻中的应用

目的 探讨经超声逼尿肌厚度测定在女性膀胱出口梗阻诊断中的应用价值.方法 93例伴有LUTS的女性患者,行压力流率测定过程中,当膀胱容量为250 ml或最大膀胱容量的50％时,应用7.5 MHz高频线纵超声探头测定膀胱前壁逼尿肌厚度.以Qmax≤12 ml/s以及最大尿流率时逼尿肌压力≥25 cm H2O(1 cm H2O =0.098 kPa)作为诊断女性膀胱出口梗阻的标准,将患者分为梗阻及非梗阻两组,比较两组年龄、尿动力学参数及逼尿肌厚度的差异.应用相对工作特征曲线评价逼尿肌厚度测定作为诊断工具的价值. 结果 梗阻组42例,非梗阻组51例.两组年龄分别为(61.2±8.3)、(59.9±7.7)岁(P=0.44),最大膀胱灌注容量分别为(292.2±82.3)、(308.1±87.5)ml(P =0.37),组间比较差异均无统计学意义;两组最大逼尿肌压力[(43.1±11.2)、(16.2±7.1)cm H2O,P=0.00]、最大尿流率时逼尿肌压力[(34.3±8.2)、(13.1±7.8)cm H2O,P=0.00]、Qmax[(7.4±3.2)、(17.4±4.1)ml/s,P=0.00]、排尿量[(157.1±63.7)、(251.2±77.4)ml,P=0.00]、残余尿量[(117.5±71.3)、(37.7±18.1)ml,P=0.00]及逼尿肌厚度[(1.8±0.3)、(1.4±0.2)mm,P =0.00]比较差异均有统计学意义.当临界值≥1.9 mm时,特异性和阳性预测值均为100％,敏感性为38％,阴性预测值为62％.其曲线下面积为0.88±0.06. 结论 经超声逼尿肌厚度测定诊断女性膀胱出口梗阻具有无创、方便、可靠的特点.当临界值≥1.9 mm时,具有较高的特异度和阳性预测值,在一定程度上可取代压力流率测定.     

Transvaginal ultrasound measurement of bladder wall thickness: a more reliable approach than transperineal and transabdominal approaches

Study Type – Diagnosis (exploratory cohort)
Level of Evidence 2b OBJECTIVES To validate transperineal, transabdominal and transvaginal ultrasound (US) techniques to measure bladder wall thickness (BWT). SUBJECTS AND METHODS Women underwent US measurement of BWT at three different anatomical sites: anterior wall, dome and trigone of the bladder by two ‘blinded’ operators using transabdominal, transperineal and transvaginal approaches at separate visits and by a single operator using transabdominal and transperineal techniques. Bland–Altman analysis was used to determine interobserver reliability for all three techniques and intraobserver reliability for transabdominal and transperineal methods. RESULTS In all, 25 women were scanned. The transperineal US had a high interobserver mean difference when measuring the anterior BWT (?0.34) and a high intraobserver mean difference when measuring the anterior (0.54) and dome BWT (0.33). Transabdominal US had a high interobserver mean difference for all measurements of BWT, and a high intraobserver mean difference when measuring the trigonal thickness (0.56). Transvaginal US had a consistent interobserver mean difference for all three measurements. The transperineal and transabominal approaches had the widest intraobserver and interobserver 95% confidence intervals of the mean difference when compared with the transvaginal approach. CONCLUSIONS Transabdominal and transperineal US for measuring BWT did not have good intraobserver and interobserver reliability for measurement of the three anatomical sites to determine mean BWT. Transvaginal US had good interobserver reliability, thus mean BWT is best measured using the transvaginal approach.     

Location of spina bifida occulta and ultrasonographic bladder abnormalities predict the outcome of treatment for primary nocturnal enuresis in children

OBJECTIVE: We examined whether the existence of spina bifida occulta or ultrasonographic bladder abnormalities was related to the outcome of treatment for primary nocturnal enuresis in children. METHODS: Between April 1996 and September 2005, a total of 77 subjects (53 boys and 24 girls, aged 5-18 years; mean age, 9.9 years) with primary nocturnal enuresis were studied. Plain X-ray films of the spine and ultrasonographic bladder measurements (bladder wall thickness, bladder neck descent and bladder neck opening) were obtained and the correlations with the outcome of treatment using imipramine hydrochloride were assessed. RESULTS: On plain X-ray films of the spine, spina bifida occulta (lumbar vertebrae in three, lumbosacral vertebrae in 19 and sacral vertebrae in 31) was recognized in 53 children (69%). Ultrasonographic bladder abnormalities were recognized in 40 children (52%). Children with lumbar and lumbosacral spina bifida occulta showed a higher rate of concomitant ultrasonographic bladder abnormalities (P = 0.006) and had a poorer response to treatment (P = 0.041) compared with the children who had sacral spina bifida occulta. Children with ultrasonographic bladder abnormalities had a worse response to treatment (P = 0.005) compared to the children without bladder abnormalities. CONCLUSIONS: The presence of lumbar spina bifida occulta and ultrasonographic bladder abnormalities was related to the outcome of treatment for primary nocturnal enuresis in children, suggesting that spinal radiography and vesical ultrasonography may be useful predictive tests.     

A simple and reliable continent bladder stoma constructed from bladder wall

Patients presenting with recurrent bladder neck strictures or severe incontinence refractory to all forms of infravesical treatment usually require chronic catheterization or supravesical urinary diversion. As an alternative, we use a simple continent bladder stoma made from the bladder wall. After extraperitoneal bladder mobilization, a Lapides-like 4×8 cm U-shaped bladder flap is excised and sutured to a tube. Depending on the location of the stoma, the base of the flap can be chosen and/or the length of the flap can be adapted. After bladder neck closure the tube is reflected and, after incision and dissection of the detrusor in the middle of the base of the flap, embedded in Lich-Gregoir's technique. The distal end of the tube is then sutured to the stoma site. Five of our patients now have a minimum follow-up of 11 months (mean 17 months) . All are continent with a bladder capacity between 250 and 560 ml. In two, stomal stenosis at the skin level required epifascial stomal revision.     

Cystometric evaluation of bladder function in non-anesthetized mice with and without bladder outlet obstruction

PURPOSE: To develop a model for cystometric study of bladder function in the awake mouse, and to characterize urodynamically and immunohistochemically the non-obstructed and infravesically obstructed mouse bladder. MATERIALS AND METHODS: Non-obstructed Balb/CJ mice, and mice with bladder outlet obstruction after surgical, partial ligation of the urethra underwent continuous cystometry as previously described for rats. Bladders were also investigated by immunohistochemistry. RESULTS: During the period of cystometry, reproducible micturition patterns were obtained. Marked differences in the urodynamic parameters between non-obstructed and obstructed mice were revealed. In mice subjected to urethral obstruction, micturition pressure (p <0.05), threshold pressure (p <0.05), bladder capacity (p <0.001), micturition volume (p <0.001), and residual volume (p <0.05) increased significantly. There was no difference in basal pressure or compliance between non-obstructed and obstructed mice. Non-voiding bladder activity was consistently recorded in obstructed mice; both frequency and amplitude increased significantly (p <0.01). Compared with non-obstructed bladders, obstructed bladders showed hypertrophy of the bladder wall and various degrees of "patchy denervation" of the detrusor. When tested in non-obstructed mice capsaicin, prostaglandin E2 (intravesical administration) and apomorphine (subcutaneous administration) induced bladder overactivity. CONCLUSIONS: Continuous cystometry can be reproducibly performed in awake, freely moving non-obstructed mice and mice with bladder outflow obstruction. The changes induced by infravesical obstruction in mice were similar to those previously found in rats. This model may be useful for investigations of genetically modified mice.     

Increased bladder wall thickness is associated with severe symptoms and reduced bladder capacity in patients with bladder pain syndrome

ObjectivePatients with interstitial cystitis (IC) and ketamine cystitis (KC) usually have similar symptoms, such as frequency, urgency, and bladder pain. In patients with IC, ulcer type and nonulcer type may have different cystoscopic features. This study investigated the clinical characteristics and bladder wall thickness (BWT) measured using computed tomography (CT) in patients with nonulcer IC, ulcer IC, and KC.Materials and methodsThe detailed history and bladder condition of patients with a clinical diagnosis of IC and KC were retrospectively analyzed. An abdominal to pelvis CT scan with/without contrast was performed in every patient. Ulcer type IC was noted in nine patients, nonulcer IC in seven patients, and KC in 13 patients. The bladder mass volume and BWT were measured. Bladder CT images of 10 patients with nonmetastatic renal cancer served as controls.ResultsThe bladder wall was significantly thicker in all patients with ulcer type IC (8.91 ± 2.67 mm) and KC (10.7 ± 3.44 mm) than in those with nonulcer IC (2.89 ± 0.73 mm) or controls (2.65 ± 0.97 mm). Among KC patients, eight patients received augmentation enterocystoplasty. Moreover, the bladder wall was significantly thicker in patients who underwent augmentation enterocystoplasty (11.50 ± 3.21 mm) than those who did not (9.50 ± 3.81 mm). The bladder mass volume was increased in patients with KC who received augmentation enterocystoplasty (35.67 ± 11.19 mL) compared with those who did not (21.24 ± 7.25 mL). BWT significantly correlated with visual analogue scores for pain (R² = 0.484, p < 0.001), functional bladder capacity (R² = 0.31, p = 0.002), and maximum bladder capacity (R² = 0.469, p < 0.001) in overall patients.ConclusionThere are obvious differences in bladder CT scans of patients with symptoms of bladder pain due to different etiology. Increased BWT was associated with increased pain scores and decreased bladder capacity in patients with KC and IC. BWT on a CT scan might be considered a marker for the severity of bladder inflammation.     

Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 1: Nonurodynamic approach

PURPOSE: Many methods have been suggested for diagnosing bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature of the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison. MATERIALS AND METHODS: A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods used to diagnose bladder outlet obstruction. A direct comparison of all different methods was made using the sensitivity and specificity, positive predictive value and likelihood ratio of each test. For many of the techniques these values were calculated from the data presented in the article. RESULTS: A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods include symptoms, biochemical tests such as prostate specific antigen, ultrasound derived measurements such as post-void residual urine, bladder weight, prostate configuration and size, intravesical prostatic protrusion and the Doppler resistive index. Part 1 of the review explores and discusses the relative merits of the nonurodynamic based methods. CONCLUSIONS: Ultrasound derived measures such as bladder wall thickness and bladder weight offer a promising possibility of diagnosing bladder outlet obstruction noninvasively. However, further reproducibility and large accuracy studies with better methodological standards are required before they can replace pressure flow studies.     

Lower urinary tract symptoms,prostate volume,uroflowmetry, residual urine volume and bladder wall thickness in Turkish men: a comparative analysis

Aim To evaluate the association between lower urinary tract symptoms (LUTS) severity and bladder wall thickness (BWT). Materials and methods The study included 155 patients referred to outpatient clinics for LUTS. Patients were divided into three groups due to their IPSS. Group A included the patients with mild symptoms, group B included patients with moderate symptoms and group C included patients with severe symptoms. The patients were again divided into two groups due to their uroflowmetry results. Group 1 included the patients whose Q _max ≤ 10 ml/s and group 2 included the patients whose Q _max > 10 ml/s. Results The mean BWT was 4.14 + 1.03 mm (from 3 to 9 mm). Although there was no difference between the IPSS groups in BWT (P = 0.325), it was statistically significant between uroflowmetry study groups (P < 0.01). Conclusions BWT seems to be significantly increased in men who have Q _max values smaller than 10 ml/s.     

Body wall thickness in adults and children—Relevance to penetrating trauma

Aim

Although uncommon in children, penetrating trauma may be associated with considerable risk of morbidity and mortality. In part this reflects the child's thinner body wall. No data exists on the difference in body wall thickness in children as compared to adults.

Method

Computer tomography (CT) scans (23 adults and 17 children) selected at random were reviewed. Measurements of the thickness of the skin and subcutaneous tissue were taken from anatomically defined regions on the thoracic and abdominal wall. The differences between adults and children were compared and analysed statistically.

Results

The mean ages were 51.3 years for an adult and 8.9 years for a child. Indications for the CT scans included malignancy, inflammatory conditions and blunt trauma. Statistically significant differences in the median thicknesses of adult and paediatric thoraco-abdominal wall were found in all of the regions measured. This difference ranged from 7 mm at the xiphisternum to 14 mm in the right and left axillary lines at the level of the iliac crests.

Conclusions

The demonstrated difference in thickness of the thoraco-abdominal wall of an adult as compared to a child means that for a penetrating injury of equal depth, the body wall will be more easily breached and more organs potentially damaged in a child, particularly if the injury is sustained in the flanks. This supports the principle that all penetrating thoraco-abdominal wounds in children should be explored in the operating theatre under general anaesthesia to reduce the risk of a missed injury.     

Noninvasive methods of diagnosing bladder outlet obstruction in men. Part 2: Noninvasive urodynamics and combination of measures

PURPOSE: Many methods have been suggested to diagnose bladder outlet obstruction, as defined by the gold standard of pressure flow studies. Difficulty arises when comparing completely different methods of diagnosing bladder outlet obstruction. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by noninvasive means was performed with a view to allow such a comparison. MATERIALS AND METHODS: A MEDLINE search was done of the published literature covering until the end of 2004 on noninvasive methods, including single measure and combinations of measures, to diagnose bladder outlet obstruction. A direct comparison of all of the different methods was made using the sensitivity, specificity, likelihood ratio, and pretest and posttest probability of diagnosing bladder outlet obstruction for each test. For many techniques these values were calculated from the data presented in the article. RESULTS: A multitude of methods has been applied to diagnose bladder outlet obstruction. Broadly the methods were divided into nonurodynamic and noninvasive urodynamic methods. Nonurodynamic methods were considered in part 1 of the review. Part 2 considered noninvasive urodynamic techniques, such as uroflowmetry, the penile cuff, the condom method and Doppler urodynamics. A combination of single measures was also considered and the relative merits of these approaches were discussed. CONCLUSIONS: A combination of noninvasive urodynamics and ultrasound derived measures provide promising methods of diagnosing bladder outlet obstruction. However, pressure flow studies still remain the gold standard for assessing bladder outlet obstruction.     

逼尿肌厚度评估神经源性膀胱患者下尿路功能障碍

目的通过超声检测逼尿肌厚度(DWT)在评估神经源性膀胱(NB)患者下尿路功能障碍的临床价值。方法选取本院2015年7月至2018年7月诊治的78例因脊髓损伤引起的成年NB患者为病例组,以40例正常成年人群为对照组。超声测量DWT、尿动力学检测最大膀胱容量(MCC)、膀胱顺应性(BC)、残余尿量(PVR)及逼尿肌漏尿点压(ALPP)等指标。统计学分析比较DWT与MCC、BC、PVR及ALPP各指标的关系。结果病例组患者膀胱容量分别在50、100、150、200、250、300、400、500 mL时测得的DWT均明显大于对照组人群(P<0.05)。与低DWT组相比,高DWT组BC明显较低,而DLPP明显较高(P<0.05),组间PVR、MCC差异无统计学意义(P>0.05)。Pearson线性相关分析结果表明,DWT与BC呈明显负相关(r=0.635,P=0.001),与DLPP呈明显正相关(r=0.621,P=0.003),而与PVR、MCC无相关性(r=0.422、0.331,P=0.158、0.341)。结论NB患者DWT增加,DWT与膀胱顺应性呈负相关,而与DLPP呈正相关。应用超声评估NB患者DWT有助于反映NB下尿路功能障碍。     

Mycobacterial cell wall extract for treatment of carcinoma in situ of the bladder

PURPOSE: Bacillus Calmette-Guerin (BCG) established immunotherapy as an effective modality for carcinoma in situ of the bladder and remains the most effective agent for treatment. However, as a live organism it has the potential for undesirable side effects and toxicity. This result has led to the search for other active and safer biological response modifiers. We investigated the efficacy of a mycobacterial cell wall extract (MCWE) from Mycobacterium phlei, which does not contain live bacteria, for management of carcinoma in situ of the bladder in humans. MATERIALS AND METHODS: The requirement for an emulsified preparation was investigated with photon correlation spectroscopy to determine the stability of the bacterial fragments. A total of 61 patients with histologically documented carcinoma in situ completed the study. Cell wall extract from M. phlei suspended in oil droplets to form an emulsion were instilled into the bladder at a dose of 4 mg. once weekly for 6 weeks and then monthly for 1 year. Response assessment was performed at 3-month intervals. Complete response to treatment indicated the absence of endoscopic and histological evidence of carcinoma in situ. Partial responders were those cases in which cystoscopy and biopsies were negative but cytology was suspicious for malignant cells. All other cases were considered failures. RESULTS: The need for an emulsified suspension of the cell wall extract was confirmed by the demonstration that the cell wall extract alone in urine aggregated, whereas the MCWE emulsion had remained stable. Kaplan-Meier estimates showed negative cystoscopy and biopsies in 62.5% at 12, 49.3% at 24 and 41.1% of patients at 60 weeks after therapy. After this point the number of responders had remained stable. Excellent tolerance with minimal toxicity was observed. CONCLUSIONS: Our study demonstrates clinical activity of low doses of MCWE against human bladder cancer. The results observed at the dosage used in our trial are less than those observed with live BCG. However, MCWE has a better toxicity profile and can be instilled in the presence of a disrupted urothelium. It also appears to exhibit activity in patients in whom BCG has failed.     

Solitary abdominal wall metastasis from a urothelial carcinoma of the urinary bladder

Few cases of abdominal wall metastasis from a urothelial carcinoma were reported in the literature, and those were mostly attributed to iatrogenic implantation after laparoscopic surgery or a percutaneous nephrostomy. An 85-year-old man presented with an infraumbilical mass 6 months after transurethral resection of a bladder tumor (TURBt) for a T4 urinary bladder urothelial carcinoma. Abdominal sonography disclosed a 1.6 cm × 1.5 cm subcutaneous hypoechoic lesion. Wide excision of the mass was performed, and skin flaps were used for skin coverage. A combination of the patient's clinical history, tumor morphology, and immunostaining results were compatible with the pathologic characteristic of his previous bladder urothelial carcinoma. We present this rare case of solitary abdominal wall mass metastasis from a urothelial carcinoma of the urinary bladder.