生物反馈电刺激在膀胱排尿功能障碍治疗中的进展

膀胱排尿功能障碍主要表现为以尿频、尿急等下尿路症状,膀胱过度活动症,尿失禁,排尿困难,尿潴留等［1］。在临床实践过程中,由尿路结石、肿瘤、前列腺增生等引起的机械性梗阻可通过手术治疗取得较好的疗效,但神经源性下尿道功能障碍采用传统保守治疗不能取得很好的疗效,手术治愈率低且并发症较多［2］。近年来,随着生物反馈电刺激疗法在临床上的应用,在尿失禁、膀胱过度活动症的治疗及下尿路症状的缓解中取得了较好的疗效,为泌尿科医生提供了一种有效的新方法。目前,已被临床证实有效的治疗方法有膀胱内、骶神经、阴部神经、生殖器背神经、胫后神经电刺激等［3］。虽然膀胱内和骶神经电刺激在神经源性排尿功能障碍方面有较好的疗效,但二者需要有创操作或植入永久电极,费用昂贵且并发症较多,非侵入性电刺激：阴部神经、生殖器背神经、胫后神经电刺激具有无创、可调、易操作等优点,同时电刺激联合生物反馈治疗能够取得更好的疗效。现就非侵入性电刺激及生物反馈联合电刺激对排尿功能障碍治疗的研究进展综述如下。     

骶神经刺激治疗膀胱排尿功能障碍

目的：观察骶神经刺激治疗膀胱排尿功能障碍的疗效。方法：采用经皮穿刺刺激骶3神经治疗4例排尿功能障碍患者,其中1例接受永久性神经刺激器植入治疗。通过排尿日记及患者症状评价疗效。结果：3例难治性尿频尿急综合征的患者症状有显著改善,且排尿次数显著减少,平均排尿量增加,尿急程度减轻;另1例膀胱收缩无力患者无效。结论：骶神经刺激可以显著地改善部分患者膀胱排尿功能障碍。     

神经源性膀胱的诊断和治疗原则同样适用于非神经源性膀胱吗？

正常排尿活动是由脊髓、脊髓上反射中枢及交感、副交感、体神经共同参与完成。任何与排尿有关的中枢和周围神经受到损伤引起的膀胱功能障碍,即为神经源性膀胱（neurogenic bladder,NB）。其病因包括：①外周神经病变：糖尿病和感染性疾病;②中枢神经病变：神经脱髓鞘病变（多发性硬化症）、老年性痴呆、基底节病变、脑血管病变、额叶脑肿瘤和椎间盘疾病压迫脊髓,等;     

膀胱次全切除回肠扩大膀胱术治疗神经源性膀胱尿道功能障碍

目的：探讨肠道扩大膀胱成形术治疗神经源性膀胱尿道功能障碍的价值。方法：采用膀胱次全切除、回肠扩大膀胱成形术治疗7例神经源性膀胱尿道功能障碍患者。结果：2例术后排尿通畅，剩余尿消失；3例术后曾有排尿困难，经尿道膀胱颈电切后排尿通畅，无尿失禁，最大尿流率分别为27、16和18ml/s；1例术前曾采用经尿道膀胱颈电切术无效，行本手术后剩余尿消失，但仍有尿失禁，后在超声引导下于尿道周围注射硅酮后，尿失禁症状明显改善；余1例术后仍有排尿困难。结论：该手术方法对神经源性膀胱尿道功能障碍是一种可行的治疗方法。     

神经源性膀胱的治疗进展

正常的排尿活动由脊髓反射中枢及脊髓上反射中枢和交感、副交感、体神经共同参与完成。任何与排尿有关的神经受到损伤,引起的排尿功能障碍,即为神经源性膀胱。随着影像学诊断和尿动力学检查技术的进步,神经源性膀胱的诊断已无困难,但临床治疗仍无一个比较完美的方法。神经源性膀胱的分类很多,有Nesbit法、Bors法、Herschom法、Wein法等。无论哪一种分类方法,对于治疗的指导目的,都是正确评估危险因素,确定恰当的治疗策略,因为对神经源性膀胱的正确诊断是准确治疗的基础。治疗的根本目的是保护肾功能,其次是改善排尿症状以提高生活质量。其…     

糖尿病神经源性膀胱尿道功能障碍的研究及治疗

糖尿病神经源性膀胱尿道功能障碍 (neuro-pathic vesicourethal dysfunction of diabetic,NVUDD)是糖尿病引起的泌尿系统并发症 ,又称糖尿病膀胱病 (diabetic cystopathy) ,40 %～ 80 %的糖尿病患者可并发此症 ,即使经治疗控制了高血糖症 ,仍有 2 5%的发生率。NVUDD的发生率与性别和年龄无关 ,与病程和周围神经病变的发生率和程度有关 ,但由于其病因并不十分清楚 ,且症状具易变性及非致命性 ,故而在糖尿病的临床治疗中经常被忽视。然而 NVUDD不但给患者的日常工作、生活造成严重的影响 ,还可诱发泌尿系逆行感染及肾病并发症〔1〕。随…     

回肠膀胱术治疗神经源性膀胱功能障碍

目的 回顾分析回肠膀胱术治疗神经源性膀胱功能障碍的疗效和安全性。方法 2004年6月～2006年10月，对 7例神经源性膀胱功能障碍患者实施回肠膀胱术治疗。其中男5例，女2例，平均年龄27岁（17～56岁）。平均随访15个月（2～30个月），随访内容包括有无并发症和生活质量。结果 随访期内，患者未出现严重的并发症，生活质量较术前提高。结论 回肠膀胱术是治疗神经源性膀胱功能障碍患者的安全、有效、可接受的治疗措施。     

乙状结肠膀胱扩大术治疗神经源性低顺应性膀胱6例疗效观察

目的：探讨乙状结肠膀胱扩大术治疗神经源性低顺应性膀胱的疗效。方法：6例神经源性低顺应性膀胱患者行乙状结肠膀胱扩大术及双侧输尿管膀胱再植术。男5例,女1例。年龄16-40岁,病程5～20年。其中3例脊髓损伤,3例脊髓栓系。术后均自行间歇清洁导尿。结果：6例患者均随诊,术后B超示肾积水,较术前缓解或消失,血清肌酐水平较术前明显降低,尿动力学示膀胱容量为（458．6±37．2）ml,充盈期末膀胱内平均压为（17．8±4．6）cmH2O,无膀胱输尿管返流,2例出现泌尿系感染,1例出现肠粘液堵管,经对症治疗后缓解。结论：乙状结肠膀胱扩大术可有效地扩大膀胱容量,降低充盈期末膀胱压力,使患者有一个安全的储尿环境,是治疗神经源性低顺应性膀胱的最佳选择,提高了患者的生存质量。     

神经源性膀胱诊断与治疗

正常排尿活动由脊髓反射中枢及脊髓上反射中枢和交感、副交感、体神经共同参与完成.控制排尿的中枢或周围神经系统受到损害所引起的下尿路储尿及排尿功能障碍称为神经源性膀胱.所有可能累及有关储尿和/或排尿生理调节过程的神经系统病变,都有可能影响膀胱和/或尿道功能.诊断神经源性膀胱必须有明确的相关神经系统病史.     

Electrical stimulation of sacral nerves and roots for control of the neurogenic bladder and bowel

After damage to the spinal cord, some of the most frequent and severe complications are due to the neurogenic bladder and bowel, in spite of a variety of methods of management.Bladder and bowel emptying is usually impaired, but electrical stimulation of nerves surviving after spinal cord injury can produce controlled contraction of muscle, including the smooth muscle of the bladder and lower bowel, and this can be used to produce safe and effective bladder emptying on demand without catheters. It can also aid emptying of the bowel and reduce constipation. Hyper-reflexia of the bladder and lower bowel after spinal cord injury can produce reflex incontinence of urine and stool, and while this can sometimes be reduced by neuromodulation, it can be more predictably reduced by rhizotomy of the sacral sensory roots, while preserving the motor roots for stimulation. This combination of electrical stimulation and rhizotomy has restored bladder and bowel emptying and continence to several thousand patients, with reduced complications and improved quality of life over many years.     

膀胱自扩大术治疗高反射性神经原性膀胱

目的探讨膀胱自扩大手术治疗高反射性神经原性膀胱的方法及疗效。方法6例患者,男5例,女1例,年龄5～36岁,平均28岁。尿动力学检查显示6例均为膀胱反射亢进,逼尿肌括约肌协同失调。病程5～10年,平均6年。对6例患者的手术方法,手术前后膀胱容量,肾功能以及临床症状进行回顾分析。结果手术时间100～180min,平均120min。安全膀胱容量术前(182±52)ml,术后3个月(315±65)ml,术后10个月(420±105)ml,手术前后比较差异有统计学意义(P<0.01)。术后导尿间歇平均4h(3～5h),术前5例尿失禁患者尿失禁消失4例,1例经口服抗胆碱药物后症状明显改善。术前4例肾功能异常者3例恢复正常,1例改善。结论膀胱自扩大术结合清洁间歇自家导尿治疗高反射性小容量膀胱是一种简便,可靠的方法。     

骶神经根功能性磁刺激对脊髓损伤后神经源性膀胱过度活动症的作用

目的:观察骶神经根功能性磁刺激(functional magnetic stimulation,FMS)对脊髓损伤患者神经源性膀胱过度活动症(overactive bladder,OAB)治疗的效果。方法:将40例脊髓损伤后OAB患者按随机数字表法分为治疗组(20例)和对照组(20例)。两组患者均给予常规的膀胱功能干预,治疗组在此基础上给予骶神经根FMS(强度为70%～100%最大输出强度,频率15Hz,每分钟刺激5s,共刺激30min,每日1次,每周5次,共治疗8周),对照组则给予相同参数FMS(刺激线圈与治疗部位垂直,无刺激作用)。两组患者均于治疗前和8周后比较尿流动力学指标(初尿意时膀胱容量、最大膀胱测压容量、残余尿量)、排尿日记指标(单次尿量、排尿次数和最大排尿量)及因排尿不良而引起生活质量评分变化。结果:治疗8周后,两组患者尿流动力学及排尿日记指标较术前均显著改善。初尿意时膀胱容量(对照组65.25±6.41ml、治疗组78.44±9.52ml)增加(P0.05),最大膀胱测压容量(对照组339.55±36.75ml、治疗组394.46±36.68ml)显著增加(P0.05),残余尿量(对照组120.22±40.35ml、治疗组88.25±33.61ml)明显减少(P0.05);日均单次排尿量(对照组120.06±23.23ml、治疗组150.28±24.24ml)增加(P0.05),24h平均排尿次数(对照组12.28±3.31、治疗组9.44±3.95)减少(P0.05),最大排尿量(对照组233.58±47.14ml、治疗组274.51±30.18ml)显著改善(P0.05);因排尿症状而引起生活质量评分均明显降低;与组内治疗前比较,差异均有统计学意义(P0.05),且治疗组改善情况均显著优于对照组(P0.05)。结论:FMS可改善神经源性膀胱过度活动症患者的膀胱功能和提高患者的生存质量。     

神经根刺激器在治疗脊髓损伤所致神经原性膀胱功能障碍的应用价值

【摘要】〓目的〓探讨神经根刺激器在治疗脊髓损伤所致神经原性膀胱功能障碍(NBD)的应用价值。方法〓选取2009年3月至2013年5月期间我院确诊治疗的脊髓损伤所致NBD患者72例,分刺激组和对照组,两组患者均给予每天2次口服托特罗定(2 mg/次)治疗,刺激组患者在此基础上给予神经根刺激治疗,其中刺激组依据治疗方法又分为骶神经电刺激(SNS)治疗组和神经肌肉电刺激(NES)治疗组,对所有患者进行为期3个月的随访,观察患者尿流动力学、尿道压力和日均排尿次数。结果〓在尿流动力学方面,NES组残余尿量和最大膀胱容量明显优于SNS组(P<0.017),而SNS组残余尿量与最大膀胱容量明显优于对照组(P<0.017);在逼尿肌压力水平与日均排尿次数方面,治疗后60 d,NES组明显优于对照组(P<0.017);治疗后120 d,NES组明显优于SNS组与对照组,SNS组明显优于对照组(P<0.017)。结论〓神经根刺激治疗有利于改善脊髓损伤所致NBD患者膀胱功能。     

The effectiveness of ureteric reimplantation during bladder augmentation for high-grade vesicoureteric reflux in patients with neurogenic bladder: long-term outcome

Purpose

The outcome of ureteric reimplantation (UR) during bladder augmentation (BA) for high-grade vesicoureteric reflux (HVUR) in patients with neurogenic bladder was assessed to determine the effectiveness of UR. A literature review of HVUR and BA was also performed.

Methods

Twenty-two consecutive sigmoidocolocystoplasty patients were reviewed retrospectively; 10 had unilateral HVUR only, 3 had bilateral HVUR, and 9 had unilateral HVUR associated with low-grade VUR in the contralateral renal unit (RU). Preoperatively, VUR was grade V in 3 RU, grade IV in 22 RU, grade III in 5 RU, and grade II in 4 RU. Ureteric reimplantation was performed in the native bladder in 24 RU (16 patients) and in the colon cap in 10 RU (6 patients).

Results

Mean age at sigmoidocolocystoplasty/UR was 8.5 years (range, 2-15 years). Mean follow-up was 12.8 years (range, 2-22 years). Postoperatively, cystourethrography showed residual VUR (grade IV to grade III) in only 1 RU (3%); diethylenetriamine pentaacetic acid scintigraphy showed no obstruction in all RU; ^99mTc-dimercaptosuccinic acid was improved in 13 RU, unchanged in 18 RU, and worsened in 3 RU; and serum creatinine remained normal in 20 patients and worsened in 2. Urinary tract infection, universal preoperatively, was seen postoperatively in only 2 patients. In the literature, 0% to 16.7% of HVUR persisted after BA alone, and no long-term data were available.

Conclusions

Ureteric reimplantation during BA is safe and effective for treating HVUR in patients with neurogenic bladder.     

Neuromodulation in neurogenic bladder

While neuromodulation is a well-established treatment option for patients with non-neurogenic overactive bladder and urinary retention, its applicability to the neurogenic bladder population has only recently been examined more in depth. In this article we will discuss the outcomes, contraindications, and special considerations of sacral and percutaneous tibial nerve stimulation (PTNS) in patients with neurogenic lower urinary tract dysfunction.     

Epidural spinal cord stimulation for the treatment of neurogenic bladder

Summary The effect of percutaneous epidural spinal cord stimulation on neurogenic bladder has been evaluated on the basis of objective clinical and urodynamic criteria. Seven patients suffering from stable bladder and sphincter dysfunction due to spinal cord diseases of different causes of non-evolutive nature were examined. In some of them chronic pain or spasticity, or both, were also present.Spinal cord stimulation substantially improved micturition in six out of seven patients. Complete or almost complete relief of bladder spasticity, marked increase of bladder capacity, and reduction or abolition of residual urine were recorded. The beneficial effect on bladder and sphincter function is strictly dependent on the stimulation, though it can outlast it. It requires some weeks to reach its maximum. It is still obtained after 22 months of treatment (longest present follow-up).No changes of striatal activity and detrusor reflex were produced by spinal cord stimulation in two additional patients, treated for chronic pain but having intact bladder function.Partially supported by Ministry of Public Instruction.     

Aggressive bladder carcinoma in an HIV-positive man with tetraplegia and neurogenic bladder

Background/objective

Patients with neurogenic bladder secondary to spinal cord injury who are managed long term with an indwelling catheter are known to be at increased risk for transitional cell carcinoma of the bladder. Immunosuppression is a known risk factor for malignancies that often are more aggressive than those seen in normal populations.

Method

Case report and discussion of management recommendations.

Results

We summarize the case of a 44-year-old HIV-positive C5–C6 incomplete tetraplegic male (date of injury 1980), who was diagnosed with transitional cell carcinoma of the bladder and succumbed to disease within 6 months of diagnosis. The patient was a non-smoker who was never managed with an indwelling catheter. There has been no such case reported in the literature.

Conclusions

HIV infection in the presence of a neurogenic bladder may carry an increased risk of aggressive bladder malignancy. More studies are warranted to determine whether routine annual screening with cystoscopy in all patients with HIV and neurogenic bladder is indicated.