儿童反射亢进型神经原性尿失禁的手术治疗及术后排尿训练

背景脊柱裂引起的脊髓发育不良是儿童最常见的神经系统发育畸形之一,由此而引起的神经原性尿失禁可严重影响患儿的生活质量.目的观察反射亢进型神经源性尿失禁的手术治疗及术后排尿训练效果.设计前后对照,随访观察.单位郑州大学第一附属医院的小儿外科.对象于1992-01/2000-10治疗81例反射亢进型神经原性尿失禁患儿,男54例,女27例,年龄4～14岁,术前检查均证实盆底肌松弛,膀胱容量小.所有患者均为神经原性尿失禁患者并经尿流动力学结果证实为反射亢进型神经原性膀胱.方法对81例患者采用双侧髂腰肌加强盆底肌,回肠去黏膜带血管蒂浆肌层补片的基础上,行膀胱扩大术进行治疗,其中5例行锥状肌膀胱颈悬吊.术后3周,伤口愈合良好后,进行康复协调训练.随访患者术后尿失禁症状改善情况.结果81例术后2周拔除尿管后,40例患儿尿前有尿意,尿流呈线状,两次排尿间隔在60 min以上,膀胱最大容量、残余尿量、膀胱压力接近正常或正常,视为明显改善.23例患儿有尿意,尿流呈线状,两次排尿间隔时间在40 min左右,膀胱最大容量、残余尿量较术前减少,膀胱压力增大,视为改善.18例无效,经过正规排尿训练后较前有改善.对9例进行膀胱尿道测压,膀胱压平均1.2 kPa,尿道压平均1.15 kPa,剩余尿30～50 mL,最大容量300～600 mL.81例患儿有63例得到严格随访,完整随访期6个月,其余部分随访资料不完整.63例被随访者中56例控尿明显改善,5例改善,2例无效,总有效率达到97%.结论双侧髂腰肌加强盆底肌,回肠去黏膜带血管蒂浆肌层补片加强膀胱逼尿肌基础上行膀胱扩大术是治疗小儿反射亢进型神经原性尿失禁的较好方法,配合术后排尿反射及控制训练对治疗效果影响明显.

Surgical therapy and rehabilitation training for children with hyper-reflexic neuropathic urinary incontinence

BACKGROUND: Myelodysplasia induced by spina bifida is one of the common developmental malformations of the nervous system in children, and neurogenic urinary incontinence induced by it can affect the children' s quality of life.OBJECTIVE: To observe the effects of surgical therapy and rehabilitation training for children with hyper-reflexic neuropathic urinary incontinence.DESIGN: A controlled follow-up observation.SETTING: Department of Pediatric Surgery, First Hospital Affiliated to Zhengzhou University.PARTICIPANTS: A total of 81 children(54 males and 27 females), aged 4 to 14 years treated for hyper-reflexic neuropathic urinary incontinence between January 1992 and October 2000 were selected. All the cases were confirmed loose pelvic floor muscle and smaller bladder capaeity before operation. Moreover, all cases with neuropathic urinary incontinence were proved to be hyper-reflexic neurogenic bladder by urodynamic examination.METHODS: Pelvic muscles of the 81 patients were strengthened with bilateral iliopsoas and the bladder was augmented on the basis of ileocystoplasty. Five patients had an additional bladder neck suspension. Wound healing was satisfactory after 3 weeks; therefore, rehabilitative exercise for coordination was performed. The improvements in symptoms and urodynamic results were followed up.RESULTS: Urinary catheters were removed in the 81 patients 2 weeks after operation. Forty patients had voiding desire before micturition, with linear urine current, more than 60 minutes' interval between micturitions, and almost normal or normal maximal bladder capacity and pressure and residual urine volume, which was regarded as significantly improved. Twenty-three patients had voiding desire before micturition, with linear urine current, more than 40 minutes' interval between micturitions, and reduced maximal bladder capacity and residual urine volume, but increased bladder pressure, which was regarded as improved. However, 18 patients were improved after regular bladder training. The postoperative urodynamic results in 9 patients showed that the average bladder pressure, average urethra pressure, residual urine volume and maximal bladder capacity were 1.2 kPa, 1.15 kPa, 30 - 50 mL and 300 -600 mL, respectively. Of the 81 cases, 63 cases were followed up completely for 6 months whereas the others had no complete follow-up data. The follow-up results showed significant outcomes in 56 cases, improvement in 5 and no effect in 2, with the total effective rate of 97%.CONCLUSION: Satisfactory results can be obtained by combined augmentative ileocystoplasty with strengthening of pelvic floor by iliopsoas for children with hyer-reflexic neuropathic urinary incontinence. The combination of micturition reflex and control training after operation produces obvious therapeutic effects.