小儿膀胱输尿管反流87例相关尿动力学因素研究

目的 探讨小儿膀胱输尿管反流(vesicoureteric reflux,VUR)的尿动力学表现特点,为小儿VUR的诊断和治疗提供临床参考.方法 选取在郑州大学第一附属医院小儿尿动力学中心就诊的VUR患儿87例(男58例,女29例);年龄4～12岁,平均6岁.另选取因下尿路症状就诊而尿动力学检查无异常且无VUR小儿60例(男38例,女22例)作为对照组;年龄4～12岁,平均6岁.将VUR患儿依据反流的程度分为轻度(Ⅰ度,15例)、中度(Ⅱ度和Ⅲ度,33例)、重度(Ⅳ度和Ⅴ度,39例).尿动力观察参数包括:最大尿流率、残余尿量、最大逼尿肌收缩压力、最大膀胱容量和膀胱顺应性.结果 VUR组的最大尿流率和最大膀胱容量分别为(6.8±6.3)ml/s和(138.5±73.9)ml,均明显低于对照组(16.1±6.7)ml/s和(285.5±107.5)ml,组间比较,差异有统计学意义(P＜0.05).VUR组残余尿量为(95.9±103.4)ml明显高于对照组(9.6±13.9)ml,差异有统计学意义(P＜0.05).VUR组最大逼尿肌压力为(41.6±22.2)cmH2O与对照组(35.1±13.0) cmH2O比较,差异无统计学意义(P-0.229).VUR组男、女童尿动力学参数差异无统计学意义(P＞0.05).VUR组轻度反流(15例)、中度反流(33例)和重度反流(39例)的最大膀胱容量分别为(121.83±69.94) ml、(163.73±80.81)ml和(123.58±68.70) ml,组间比较,差异无统计学意义(P＞0.05).轻度反流组顺应性正常12例(80％),中度反流组12例(36.4％),重度反流组9例(23.1％),三组间差异有统计学意义(P＜0.05).结论 最大尿流率降低、最大膀胱容量减少、残余尿量增多和膀胱顺应性差可能是VUR发生的相关因素.     

小儿神经源性膀胱伴膀胱输尿管反流临床特点分析

目的 探讨神经源性膀胱(NB)患儿伴膀胱输尿管反流(VUR)的临床特征,为其临床早期诊断及治疗提供参考依据.方法 收集2014年1月至2019年12月于儿童肾内科收治并诊断为NB伴尿路感染的26例患儿的临床资料,根据有无VUR分为反流组(11例)与无反流组(15例),分析比较两组的临床特点.结果 相比无反流组,反流组患...     

尿动力学检查对小儿神经源性膀胱手术方式选择的意义

目的 探讨尿动力学检查对小儿神经源性膀胱手术方式选择的意义.方法 回顾性分析我院手术治疗的神经源性膀胱患儿的资料41例.所有患儿术前完成B型超声、排尿性膀胱尿道造影(voiding cystourethrogram,VCUG)、99mTc-DTPA肾动态显像(DTPA)、尿动力学检查.其中34例行储尿期+排尿期膀胱压力描记.结果 尿动力学检查提示逼尿肌过度活动23例,活动低下11例;括约肌过度活动21例,活动低下13例.根据患儿不同的临床症状,参考尿动力学检查结果,选用不同的手术方式.具体术式包括:回肠代膀胱扩大+阑尾代可控性膀胱流出道(Mitrofanoff)+阑尾代顺行结肠灌洗造瘘(Malone)+膀胱颈悬吊(Sling)2例,回肠代膀胱扩大+Mitrofanoff+ Sling 5例,回肠代膀胱扩大+输尿管再植+ Mitrofanoff+ Sling 7例,回肠代膀胱扩大+Mitrofanoff+右肾切除+Sling 1例,回肠代膀胱扩大+输尿管再植+ Mitrofanoff 18例,回肠代膀胱扩大+Mitrofanoff 2例,输尿管再植+Mitrofanoff 3例,膀胱颈封闭+回肠代膀胱扩大+Malone+回肠卷管代可控性膀胱流出道(Monti)1例,Mitrofanoff 2例.术后39例患儿获得随访,随访时限3个月～5年,7例出现术后并发症,大部分患儿术后恢复满意.结论 小儿神经源性膀胱的手术方式选择主要依据其临床症状以及超声、影像、同位素检查结果,尿动力学检查可明确膀胱尿道功能障碍的类型,对于手术的方案制定也有重要参考意义.     

神经性膀胱输尿管反流治疗对策的探讨

目的探讨神经性膀胱患儿输尿管反流的治疗措施。方法脊膜修补术后神经性膀胱并输尿管反流患儿45例,男29例,女16例,年龄4～14岁。排泄性膀胱尿道造影(VCUG)示膀胱输尿管反流左侧19例,右侧11例．双侧15例,其中Ⅰ°-Ⅲ°12例(15条),Ⅲ°-Ⅴ°33例(45条)。Ⅰ°-Ⅱ°中,5例(7条)仅行清洁间歇导尿,7例(8条)行保留膀胱黏膜肠浆肌层膀胱扩大术；Ⅲ°-Ⅴ°中,9例(12条)仅行间歇导尿。24例(33条)行保留膀胱黏膜肠浆肌层膀胱扩大术,其中19例(28条)同时行Lich-Gregoir手术,术后配合间歇导尿。结果6个月后随访,Ⅰ°-Ⅱ°15条中,7条行清洁间歇导尿,3条反流消失(42．9%),8条行保留膀胱黏膜肠浆肌层膀胱扩大术者,6条反流减轻或消失(75．0%)；Ⅲ°-Ⅴ°45条中,12条行间歇导尿者,10条反流程度进一步加重,5条单纯行膀胱扩大术者,2条反流减轻或消失(40．0%),28条同时行Lich-Gregoir手术者,23条反流减轻或消失(82．1%)。结论神经性膀胱输尿管反流的治疗方法取决于输尿管反流的程度。Ⅰ°-Ⅱ°单纯行膀胱扩大术,也可考虑只行清洁间歇导尿；Ⅲ°-Ⅴ°反流须在行膀胱扩大术的同时行输尿管抗反流术,术后配合间歇导尿。     

改良Lich-Gregoir手术治疗神经性膀胱输尿管反流的评价

目的　探讨改良Lich Gregoir手术在治疗神经性膀胱输尿管反流中的应用。方法　神经性膀胱并输尿管反流患儿 12例 ,男 8例 ,女 4例 ,年龄 4～ 14岁 ,均为脊膜膨出修补术后。排泄性膀胱尿道造影 (VCUG)示膀胱输尿管反流左侧 5例 ,右侧 3例 ,双侧 4例 ,其中Ⅲ° 4条 ,Ⅳ° 10条 ,Ⅴ°2条。全部行改良Lich Gregoir输尿管抗反流术 ,同时行保留膀胱黏膜肠浆肌层膀胱扩大术。结果　术后 6个月随访 ,VCUG显示 16条反流的输尿管中 ,Ⅲ° 4条反流完全消失 ,Ⅳ°10条中 3条变为Ⅰ°,3条变为Ⅱ° ,1条变为Ⅲ°,3条无明显变化 ,Ⅴ°2条变为Ⅲ°。结论　神经性膀胱逼尿肌压增高 ,导致膀胱输尿管连接部功能失调 ,同时逼尿肌纤维化、膀胱挛缩 ,使得输尿管膀胱壁内段缩短 ,是输尿管反流的重要原因。行改良Lich Gregoir输尿管抗反流术的同时 ,须行膀胱扩大术 ,降低逼尿肌压 ,增加膀胱顺应性。     

影像尿动力学评估先天性膀胱输尿管返流患儿的膀胱功能障碍

目的 采用影像尿动力学评估小儿先天性膀胱输尿管返流(VUR)与膀胱功能障碍的关系.方法 选取2011年4月至2013年7月在郑州大学第一附属医院就诊的67例VUR患儿为研究对象.患儿经影像尿动力学、尿常规、排泄性尿路造影等检查,记录患儿尿路感染、逼尿肌过度活动、逼尿肌括约肌协同失调及VUR程度等情况,根据尿动力学表现的不同分为正常组、单纯逼尿肌过度活动组和逼尿肌括约肌协同失调组(伴或不伴逼尿肌过度活动的逼尿肌括约肌协同失调),另外按照返流级别将患儿分为低级别返流(Ⅰ～Ⅱ度)和高级别返流(Ⅲ～Ⅴ度),分析膀胱功能与VUR侧别、返流程度以及尿路感染的关系.结果 VUR患儿合并膀胱功能异常占73.1％(49/67例),其中膀胱过度活动症占49.3％(33/49例),逼尿肌括约肌协同失调占23.8％(16/49例).单纯膀胱过度活动患儿多为单侧,Ⅰ～Ⅱ度返流,且较少合并尿路感染.而逼尿肌括约肌协同失调的患儿多为双侧,Ⅲ～Ⅳ度返流,且较多见尿路感染.结论 影像尿动力学可以准确诊断VUR,同时对患儿膀胱功能的评估,及临床制定治疗方案提供重要参考.     

膀胱输尿管反流的诊疗争议和研究进展

小儿原发性膀胱输尿管反流(vesicoureteric reflux,VUR)与尿路感染、排尿功能障碍相伴发生,常常导致肾疤痕、肾萎缩、高血压、肾功能减退等一系列反流性肾病的表现,重者甚至进展为终末期肾病.目前,随着对VUR治疗经验的累积,在诊断策略及治疗上都出现了一定的争议.无论手术治疗或非手术治疗结果仍不令人满意,VUR的发病机制目前还不清楚,需要进行进一步的研究和探索.     

CIC联合膀胱内灌注RTX治疗儿童神经源性膀胱并逼尿肌过度活动疗效观察

目的 探讨清洁间歇导尿(clean intermittent self-catheterization,CIC)联合膀胱灌注辣椒辣素类似物(resiniferatoxin,RTX)治疗儿童神经源性膀胱(neurogenic bladder,NB)并逼尿肌过度活动(detrusoroveractivity,DO)的疗效.方法 将NB并DO患儿38例,按随机数字表法分为CIC联合RTX灌注组(实验组,20例)和CIC联合30％乙醇灌注组(对照组,18例).采用前瞻性双盲平行对照试验,所有患儿在CIC期间每4周行1次灌注治疗,每3个月行尿动力学检查随访,治疗1年后对比两组患儿尿动力学参数异同.结果 治疗后3个月及12个月实验组患儿逼尿肌过度活动的发生率(40.0％和10.0％)明显低于对照组(94.4％和88.9％),差异有统计学意义(P＜0.01).治疗12个月后实验组首次过度活动膀胱容量明显增大[(107.8±46.3)ml vs (68.2±31.5)ml,膀胱安全容量明显增多[(206.8±50.6)ml vs (166.3±54.2)ml],与对照组比较,差异有统计学意义(P＜0.01).但实验组和对照组比较,膀胱顺应性[(20.8±11.5)ml/cmH2O vs (24±15.4) ml/cmH2O],最大尿流率[(9.5±5.1)ml/s vs (8.2±3.2) ml/s]差异均无统计学意义(P＞0.05).结论 CIC联合RTX膀胱灌注能显著控制神经源性膀胱患儿的逼尿肌过度活动,改善神经源性逼尿肌过度活动患儿的生活质量.     

儿童尿路感染与膀胱输尿管反流的诊断与干预

尿路感染(urinary tract infections,UTI)是儿童最常见的急性细菌性感染之一,其在儿童中的确切发病率由于受到标本采集方法及诊断标准的影响而尚未明确.     

托特罗定在小儿神经原性膀胱的应用评价

目的 评价托特罗定治疗小儿神经原性膀胱的有效性和安全性.方法 随访126例2002年1月至2009年9月收治的神经原性膀胱患儿,男71例,女55例,年龄(6.2±3.1)岁,全部病例行清洁间歇导尿,81例同时服用托特罗定(0.1 mg·kg-1·d-1,2次/d),45例未服用托特罗定.就诊时和治疗3个月后分别行尿动力学和临床评价.结果 导尿+药物组中8例因副作用终止治疗,其中3例出现口干,2例头晕,3例便秘加重,73例坚持服用托特罗定.就诊时导尿组膀胱容量、膀胱顺应性、逼尿肌压分别为(119.3±19.6)ml、(4.0±1.1)ml/cmH2O、(56.7±10.4)cmH2O.3个月后膀胱容量、膀胱顺应性、逼尿肌压压分别为(122.0±20.1)ml、(4.1±1.1)ml/cmH2O、(55.8±10.9)cmH2O,无明显变化.11例(24.4%)逼尿肌过度活动减轻,13例(28.9%)漏尿分数下降.药物+导尿组就诊时膀胱容量、膀胱顺应性、逼尿肌压分别为(119.8±17.6)ml、(4.4±1.3)ml/cmH2O、(55.1±11.7)cmH2O,3个月后膀胱容量、膀胱顺应性、逼尿肌压分别为(149.6±23.1)ml、(7.5±2.3)ml/cmH2O、(38.4±11.6)cmH2O,膀胱容量、膀胱顺应性明显增加,膀胱内压降低.58例(79.5%)逼尿肌过度活动减轻,53例(73%)漏尿分数下降及家长表示满意.结论 托特罗定可抑制逼尿肌过度活动,降低膀胱内压,增加膀胱顺应性和膀胱容量,较少有副作用,有利于保护上尿路功能,并可减轻尿失禁的程度,对于反射亢进型小儿神经原性膀胱的治疗是安全、有效的.

Abstract：

Objective To evaluate the efficacy and safety of tolteroding to treat neurogenic bladder in children. Methods 126 patients (71 boys and 55 girls of 6. 2 ± 3. 1 years old) with hyperreflexia neurogenic bladder who were treated during January 2002 to September 2009 were followed up. All patients were performed clean intermittent catheterization. 81 patients took tolterodine(0. 1mg· kg-1 ·d-1 ,2 times/d) and 45 patients did not use tolterodine. Urodynamic and leakage score were evaluated before the treatment and 3 months later. Results 8 patients stopped tolterodine due to side effect,such as dry mouth in 3, dizziness in 2, sever constipation in 3. 73 patients took tolterodine all the time. Before treatment, the bladder volume, compliance and detrusor pressure in catheterization group were 119. 3 ± 19. 6 ml、4. 0 ± 1. 1ml/cmH2O 、56. 7 ± 10. 4 cmH2O, respectively. Three months after the treatment, bladder volume, compliance and detrusor pressure were 122. 0 ± 20. 1 ml、4. 1 ± 1. 1ml/cmH2O 、 55. 8 ± 10. 9 cmH2O, respectively. There was no significant difference. Detrusor overactivity in 11 patients(24. 4％)and leakage score in 13 patients (28. 9％)decreased. Bladder volume, compliance and detrusor pressure in catheterization + tolterodine group in the beginning were 119. 8 ± 17. 6ml、4. 4 ± 1.3ml/cmH2O 、 55. 1 ± 11.7 cmH2O, respectively. 3 months later, bladder volume, compliance and detrusor pressure were 149. 6 ± 23. 1 ml、7. 5 ± 2. 3ml/cmH2O 、38. 4 ± 11.6 cmH2O, respectively. Bladder volume and compliance increased and detrusor pressure decreased significantly. Detrusor overactivity in 58 patients(79. 5％)and leakage score in 53 patients(73％)decreased. The parents satisfied with this result. Conclusions Tolterodine could inhibit the detrusor overactivity, so it could decrease detrusor pressure and increase bladder volume and compliance and protect kidney. It was effective to the children with hyperreflexia nerurogenic bladder.     

Management of vesicoureteral reflux secondary to neurogenic bladder

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH₂O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH₂O), reimplantation with bladder augmentation is recommended. Accepted: 6 January 1998     

膀胱顺应性对神经源性膀胱活动低下儿童清洁间歇导尿的影响

目的 初步探讨膀胱顺应性对神经源性膀胱活动低下(NUB)儿童自我清洁间歇导尿(CISC)的并发症和膀胱功能发育影响.方法 选取经尿动力学证实为NUB的学龄儿童109例进行CIFCS治疗,最终成功对93例(85%)进行2年随访.依据开始CISC膀胱顺应性(BC)分为正常顺应性组[49例,男30例,女19例,平均年龄(6.3±0.9岁)]和低顺应性组[44例,男29例,女15例,平均年龄(7.0±1.0岁)].比较二组随访2年后尿动力学参数和随访过程中并发症发生情况.结果CISC 2年随访时正常顺应性组最大膀胱压测定容量(MCC)和相对安全容量(RSCC)显著高于CISC治疗前,而低顺应性组RSCC显著低于治疗前.逼尿肌漏尿点压(DLPP)显著高于治疗前(P<0.05).同时,随访时低顺应性组BC、MCC和RSCC显著低于正常顺应性组,DLPP显著高于正常顺应性组(P<0.05).随访时菌尿和膀胱输尿管反流以及随访过程中出现发热性泌尿系感染和肉眼血尿发生率分别为33.3%(31例)、12.9%(12例)、24.7%(23例)和15.1%(14例).其中,低顺应性组发热性泌尿系感染和膀胱输尿管反流发生率均显著高于正常顺应性组(P<0.05).结论 膀胱顺应性可以影响NUB患儿CISC的并发症和膀胱发育,低顺应性患儿膀胱发育多进行性恶化,应进行严密随访监测.     

骶神经调节治疗青少年神经源性膀胱二例报告并文献复习

目的 探讨骶神经调节对青少年神经源性膀胱的疗效及安全性.方法 回顾性分析2013年6月至2013年11月收治的2例青少年神经源性膀胱应用骶神经调节技术治疗的临床资料,并结合文献复习讨论.2例患儿均表现为排尿费力,伴尿频及便秘,1例残余尿量120 ml,另1例残余尿量360 ml;尿动力学检查结果为逼尿肌收缩乏力.分别进行骶3神经电极植入体外测试4周,经排尿日记及尿动力学参数评估,均获得明显改善,随后行刺激器永久性植入术.结果 术后患儿排尿费力、尿频及便秘症状明显减轻,2例患儿残余尿量分别降至20 ml和50 ml.排尿日记及尿动力学参数评估(排尿量、最大尿流率、逼尿肌收缩压)较术前好转.分别随访6个月和11个月,疗效稳定,未见不良反应.结论 骶神经调节可以改善青少年神经源性膀胱的排尿及便秘症状,安全性高,但仍需大样本随机对照研究来确定此技术对儿童神经源性膀胱的长期疗效及安全性.     

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

ObjectiveWe report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence.Materials and methodsConsecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually.ResultsThere were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet).ConclusionsUpper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.