三种不同膀胱扩大术治疗神经源性膀胱分析

目的运用三种不同术式的膀胱扩大术治疗神经源性膀胱并观察疗效。方法10例神经源性膀胱患者接受膀胱扩大手术。其中7例(10侧)行乙状结肠膀胱扩大术,2例行自体膀胱扩大术,1例行输尿管膀胱扩大术。术后随访1~42月,经B超或磁共振尿路造影(MRU)、肾功能及影像尿动力学检查评估疗效。结果与术前比较,乙状结肠膀胱扩大术患者肾积水明显缓解或消失;4例血清肌酐明显下降;10侧膀胱输尿管返流均消失,膀胱容量和顺应性明显改善。自体膀胱扩大中的1例脊膜膨出患者,术后1月膀胱容量增加了13 mL,但顺应性改善不明显;另1例脊髓损伤患者的自主神经过反射症状得到部分缓解。接受输尿管膀胱扩大术的1例隐性骶裂患者,术后膀胱容量增加显著,肾积水状况改善,血清肌酐下降。本组9例患者术后均能掌握并坚持自行间歇导尿术。结论乙状结肠膀胱扩大术仍然是目前神经源性小容量低顺应性膀胱治疗的金标准。有返流性巨输尿管的患者(尤其小儿)可选择输尿管膀胱扩大术。自体膀胱扩大术的选择要慎重,相对乙状结肠膀胱扩大术来说其容量扩大有限,疗效尚待大样本长期的随访验证。

Analysis of three different bladder enlargement procedures for treatment of neurogenic bladder

Objective To observe the preliminary clinical results of three different bladder enlargement procedures for the treatment of neurogenic bladder. Methods Ten patients with neurogenic bladder were performed augmentation cystoplasty,with sigmoid colon enterocystoplasty for 7 patients(10 sides),detrusor myectomy(auto-augmentation)for 2 and ureterocystoplasty for 1.Follow-up was conducted for 1 to 42 months,and follow-up items included B ultrasound or magnetic resonance urography,examinations of renal function and videourodynamics. Results Compared with those before operation,significant relief or complete resolution in hydronephrosis was observed in the patients with sigmoid colon enterocystoplasty,and serum creatinine obviously decreased in 4 patients.The vesicoureteral reflux disappeared in all the 10 sides,and bladder capacity and compliance significantly increased.For the 2 patients with auto-augmentation,one was found limited increase in bladder capacity(13 mL of increase one month after operation) with no significant change in compliance,and the other was found partial relief in autonomic dysreflexia symptoms.For the patient with ureterocystoplasty,the bladder capacity significantly increased,the hydronephrosis resolved and the serum creatinine decreased after operation.Of all the patients,9 could empty bladder by intermittent self catheterization after operation.Conclusion Sigmoid colon enterocystoplasty remains the golden standard treatment for neurogenic small capacity and low compliance bladder.Ureterocystoplasty can be used for selected patients with reflux megaureter.Auto-augmentation should be selected cautiously due to the limited capacity increase compared to sigmoid colon enterocystoplasty,and its efficacy needs to be verified by large samples and long-term follow-up.