女性膀胱颈梗阻的诊断与治疗

目的 探讨女性膀胱颈梗阻的临床诊断和治疗方法。方法 对36例女性膀胱颈梗阻患者行超声、膀胱尿道镜检查及尿流动力学检查，8例行保守治疗，28例行经尿道膀胱颈电切术（transurethral resection of bladder neck，TURBn）。结果36例经治疗后排尿通畅，尿流率增大，症状改善，无尿失禁及尿瘘发生。结论超声、膀胱尿道镜检查结合尿流动力学检查是女性膀胱颈梗阻的可靠诊断手段，TURBn是治疗症状严重、剩余尿多的女性膀胱颈梗阻的首选方法，具疗效稳定、安全性高、患者恢复快及术后并发症少等优点，但手术适应证及范围应严格控制。     

女性膀胱颈梗阻的诊断与治疗

目的：探讨女性膀胱颈阻的诊断和治疗方法。方法;对２７例女性膀胱颈梗阻患者行尿流动力学检查和膀胱检查,对其中２２例行经光颈电切术（ＴＵＲＢｎ）５例行非选手治疗。结果：２２例行ＴＵＲＢＮ治疗者术后无明显乘余尿,２０例临床症状消失;５例非手术治疗者经定期饔主药物治疗,效果满意。结论：女性膀胱颈梗阻的尿流动客观评价排尿状况的有效指标;ＴＵＴＢＮ是治疗女性膀胱劲梗阻的首选方法,具有手术小和住院时间短等优点。     

尿流动力学检查在经尿道前列腺电切术术前的应用

目的探讨尿流动力学检查在经尿道前列腺电切术（TURP）术前的应用,对提高术前诊断水平及对手术指征、手术方法、手术时机选择的价值。方法回顾分析186例前列腺增生症患者在TURP术前尿流动力学检查的临床资料。结果186例前列腺增生症患者经尿流动力学检查,140例有不同程度的膀胱出口梗阻,且与其他动力学异常同时存在;140例患者行TURP手术治疗,8例行膀胱造瘘术,38例行药物保守治疗。结论TURP术前尿流动力学检查可提供前列腺增生疗患者膀胱尿道功能状况,对治疗方案及手术时机的选择以及术后疗效评估提供量化参数。     

尿流动力学在女性下尿路症候群诊治中的应用

目的评估尿流动力学在女性下尿路症候群（LUTS）分类和治疗中的作用。方法采用尿动力测定仪对127例女性下尿路症候群患者进行尿流动力学检查,并根据检查结果进行分类及相关治疗,治疗后观察临床症状变化并复查尿流动力学各项参数进行对照。结栗不稳定膀胱30例（26．8％）,低顺应性膀胱10例（8．9％）,逼尿肌无力12例（10．7％）,尿道压增高89例（79．5％）,尿动力学无明显异常15例（11．8％）。112例尿动力学异常患者经相应治疗后有效97例,有效率为86．6％。结论尿流动力学检查在女性LUTS的诊断分型及指导治疗上具有重要意义。     

儿童脑性瘫痪尿流动力学特征及其临床意义

目的：探讨儿童脑性瘫痪尿流动力学特征及其临床意义。材料和方法：本组病例为采用选择性脊神经后根切断术的脑瘫儿童78例,术前1周内行尿流动力学检查。结果：25例（32．05％）脑瘫儿童合并下尿路症状,尿流动力学检查其中20例为上运动神经元损害、3例为混合型运动神经元损害、1例为单纯下运动神经元损害、1例正常;53例（67．95％）脑瘫儿童无下尿道临床症状,尿流动力学检查中35例（66．04％）膀胱总容量及顺应性下降、膀胱充盈压增加。结论：尿流动力学检查可明确脑瘫儿童下尿道症状的神经病学原因,同时发现无下尿道症状的脑瘫儿童中至少50％以上合并临床静止性膀胱功能障碍,符合SPR适应证的患儿应尽早行SPR术。     

难治性慢性前列腺炎患者的尿流动力学表现及其在指导治疗中的应用

目的：观察难治性慢性前列腺炎患者尿流动力学相关参数,并评价尿流动力学检查结果对指导前列腺炎治疗的价值。方法：42例常规治疗效果不佳的慢性前列腺炎患者,年龄18～49岁,平均30.2岁,行尿流动力学检查,根据不同检查结果选用相应药物治疗,观察疗效。结果：42例患者中尿流动力学结果表现为膀胱出口梗阻14例（33.3%）,逼尿肌过度活动13例（30.9%）,膀胱感觉过敏5例（11.9%）,低顺应性膀胱4例（9.5%）,逼尿肌功能受损23例（54.8%）,前尿道有高压波5例（11.9%）,逼尿肌-外扩约肌协同失调4例（9.5%）,基本正常7例（16.7%）;治疗后,显效者14例（33.3%）,有效者22例（52.4%）,无效者6例（14.3%）。结论：对难治性慢性前列腺炎患者行尿动力学检查对指导治疗具有较大意义。     

直肠癌根治术后并发神经源性膀胱的诊断和处理

目的　提高直肠癌术后神经源性膀胱的诊断和治疗水平。方法　 2 3例直肠癌术后并发神经源性膀胱的患者行尿流动力学检查 ,明确诊断 ,并给予相应治疗 ,观察疗效。结果　 2 2例患者经治疗后恢复正常的排尿 ,1例尿失禁患者在随访 6个月后仍未恢复正常。结论　直肠癌术后并发神经源性膀胱的患者应早期行尿动力学检查 ,并根据尿流动力学检查的结果采取相应的治疗     

尿流动力学检查在前列腺增生术前的诊治及术后预防膀胱痉挛中的临床意义

目的 分析研究尿流动力学检查在前列腺增生(BPH)术前的诊治及术后预防膀胱痉挛中的临床意义.方法 选择2014年4月至2015年4月期间本院就诊的159例BPH患者为研究对象,在术前2d、术后2个月分别利用尿动力学测定仪对所有患者进行尿流动力学的测定.结果 治疗方法以行经尿道前列腺电切术占的比例最大,为74.84％;其次是膀胱造瘘术,占15.09％,其余的所占比例均较小.治疗前患者的膀胱出口梗阻指数(BOOI)、最大尿道压、Qmax、BC、PVR、Pdet-Qmax、VMCC、IPSS等8项尿流动力学参数在治疗后均得到不同程度的缓解,效果具有显著性(P＜0.05).治疗后发生膀胱痉挛的患者有54例,占总患者例数的33.96％.在膀胱痉挛患者中,低顺应性膀胱患者的发生率为35.19％,不稳定膀胱患者的发生率为50.00％,远高于逼尿肌收缩异常组和正常组.结论 尿流动力学的检查是对BPH患者的诊断、治疗及预后的客观依据,值得临床推广应用.     

小体积良性前列腺增生治疗方式的选择

目的：寻找治疗小体积良性前列腺增生（ＢＰＨ）患者的最佳治疗方式。方法：对４２例小体积ＢＰＨ患者采用直肠Ｂ超及尿动力学检查相结合方法进行综合分析，如移行区指数（ＴＺＩ）〉０．４且存在膀胱颈梗阻者，采用ＴＵＲＰ治疗；如ＴＺＩ≤０．４且存在膀胱颈梗阻者，则行药物治疗，结果：ＴＺＩ〉０．４者ＴＵＲＰ治疗效果好（９３．３％），药物治疗效果较差（５０．０Ａ％０；ＴＺＩ≤０．４者药物治疗优于ＴＵＲＰ治疗：ＴＺＩ≤０．４而无膀胱颈梗阻者手术及药物治疗均无效。结论：治疗小体积ＢＰＨ患者的原则是尿动力学检查有膀胱颈梗阻存在，如ＴＺＩ〉）．４，宜行ＴＵＲＰ治疗；如ＴＺＩ〉０．４，则行药物治疗，如尿动力学检查无膀胱颈梗阻存在，则应继续寻找病因。     

经尿道前列腺电切术后尿频原因分析

目的分析经尿道前列腺电切术（transurethral resection of the prostate，TURP）后尿频的原因，为临床诊治疗提供参考。方法84例以尿频为主要症状就诊的前列腺增生症（BPH）行TURP术后1个月的患者，采用尿常规、尿道膀胱镜、尿流动力学等检查手段，查找其术后尿频的原因，并根据具体原因采取治疗，随访至尿频症状消失。结果手术可有效解除BPH患者膀胱出口梗阻，部分患者因术后相关并发症使尿频改善不理想，其中单纯泌尿系感染22例（26．2％），尿道外口狭窄9例（10．7％），尿道狭窄12例（14．3％），逼尿肌不稳定29例（34．5％），膀胱颈纤维化3例（3．6％），不明原因尿频9例（10．7％）。根据病因采取相应的治疗措施，能获得较为理想的效果。结论TURP术后尿频的原因是多方面的，术前需向患者交代清楚；诊治过程中应该加以全面考虑，对因治疗是关键。     

Long-term results of Ingelman-Sundberg denervation procedure for urge incontinence refractory to medical therapy

PURPOSE: Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence. MATERIALS AND METHODS: Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10 ml. 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve. RESULTS: A total of 28 patients 28 to 83 years old (mean age 54.6) underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean followup was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged. CONCLUSIONS: Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.     

Congenital kyphosis in myelomeningocele. The effect of cordotomy on bladder function

To determine the effect of cordotomy on the function of the bladder during surgical correction of congenital kyphosis in myelomeningocele, we reviewed 13 patients who had this procedure between 1981 and 1996. The mean age of the patients at operation was 8.9 years (3.7 to 16) and the mean follow-up was 4.8 years (1.3 to 10.8). Bladder function before and after operation was assessed clinically and quantitatively by urodynamics. The mean preoperative kyphosis was 117 degrees (52 to 175) and decreased to 49 degrees (1 to 89) immediately after surgery. At the latest follow-up, a mean correction of 52% had been achieved. Only one patient showed deterioration in bladder function after operation. Eight out of the nine patients who had urodynamic assessment had improvement in bladder capacity and compliance, and five showed an increase in urethral pressure. One patient developed a spastic bladder and required subsequent surgical intervention. Cordotomy, at or below the level of the kyphosis, allows excellent correction of the structural deformity.     

Percutaneous needle bladder neck suspension for the treatment of stress urinary incontinence in women: long-term results

PURPOSE: We evaluated the long-term results of percutaneous needle suspension using bone anchor devices for treating stress urinary incontinence in women. MATERIALS AND METHODS: We retrospectively evaluated the long-term results of percutaneous bladder neck needle suspension performed at our institution. None of the women had undergone any anti-incontinence surgery before percutaneous needle suspension. A telephone survey was done for all available patients. Subjective cure was defined as no evidence of incontinence, significant improvement as 0 to 1 protective pad soaked daily and patient satisfaction with incontinence level, and failure as more than 1 pad used daily, lack of patient satisfaction or a secondary procedure required to treat stress urinary incontinence. In cases considered failures a detailed video urodynamic study was performed when possible before any secondary procedure. RESULTS: In 1996 and 1997, 49 patients underwent percutaneous needle bladder neck suspension with bone anchors, of whom 42 (86%) were available for telephone interview. Mean patient age was 57 years (range 31 to 77) and mean followup was 29 months (range 16 to 52). As defined, subjective outcome in the 42 women was cure in 2 (5%), significant improvement in 5 (12%) and failure in 35 (83%). Of the 35 patients with treatment failure who did not undergo a secondary procedure 25 were asked to present for video urodynamics and 18 were evaluated. Urodynamics revealed demonstrable urinary incontinence, urethral hypermobility in 16 (88%), intrinsic sphincter deficiency in 1 (6%) and detrusor instability in 1 (6%). In 2 cases x-ray revealed that a bone anchor had dislodged and migrated into the pelvis. Serious osteomyelitis at the bone anchor site in 1 case required surgical débridement and 6 weeks of intravenous antibiotics. CONCLUSIONS: Percutaneous needle suspension is associated with poor long-term results in women with stress urinary incontinence. Other procedures should be considered.     

Spinal cord injury in children: long-term urodynamic and urological outcomes

PURPOSE: Urological complications in adults with spinal cord injuries (SCIs) are well documented. We sought to determine the effect of SCI on the developing bladder and kidneys in the child. MATERIALS AND METHODS: We retrospectively reviewed cases of SCI with 1-year minimum followup. We identified 42 children with an average age at injury of 5.3 years (range 1 day to 14 years). Mean followup was 5.5 years (range 1 to 15.5). Videourodynamics, sonograms, infection, medications and continence were reviewed. Safe bladder capacity was defined as the pressure specific volume at 40 cm water or less. Patients were divided into 3 groups based on level of injury-cervical (10), thoracic (26) and lumbar (6). RESULTS: Bladder management included clean intermittent catheterization in 40 of 42 patients and antispasmodics in 37. No patient had reflux, hydronephrosis or renal scarring. In the cervical group safe bladder capacity was less than the expected capacity in 80% of patients but all patients undergoing multiple urodynamics had increasing capacity with time. In the thoracic group 58% of patients had a safe bladder capacity less than expected and 76% of those undergoing multiple urodynamics had increasing capacity. In the lumbar group 50% of patients had a safe bladder capacity less than expected and 67% of those undergoing multiple urodynamics had increasing capacity. CONCLUSIONS: To our knowledge this is the largest and longest urological study of young children with SCI. Early clean intermittent catheterization and use of anticholinergics appear to prevent upper tract deterioration, improve continence and decrease infections. Serial urodynamics confirm increasing safe capacity with growth in most children. Close followup is necessary as bladder characteristics may change with time.     

The impact of detrusor overactivity on the management of stress urinary incontinence in women

The presence of overactive bladder symptoms, urodynamic detrusor overactivity, and urge incontinence can complicate the diagnosis and management of stress urinary incontinence in women. The exact pathophysiology of mixed incontinence is not well characterized; in some patients, the stress and urge etiology may be pathologically linked. The role of urodynamics in evaluating patients with mixed incontinence remains controversial. Conservative therapies, such as bladder training, pelvic floor exercise, biofeedback, and electrical stimulation, offer moderate success in women with mixed incontinence. Surgery (colposuspension, bladder neck pubovaginal slings, and midurethral slings) offers excellent subjective and objective cure rates in patients with mixed incontinence. Preoperative detrusor overactivity is cured consistently ≥ 50% of the time with colposuspension and slings. Overall, the presence of preoperative detrusor overactivity does not appear to significantly worsen the outcome of conservative and surgical treatments for stress urinary incontinence in women.     

Determinants of cure by endoscopic suspension of the bladder neck in the incontinent female patient

Summary This paper reviews preoperative clinical observations that may predict the postoperative success of patients treated surgically for urinary incontinence. The impact of a surgical procedure on the bladder and urethra is evaluated using data obtained prospectively. All patients reviewed have been operated upon using endoscopic bladder neck suspension only. Parameters considered included the demonstration of urethral incontinence, history of urgency incontinence, prior urogenital surgery, and detrusor stability. The result of endoscopic suspension is evaluated in terms of cure rate or improvement one year after surgery. The postoperative outcome of bladder neck suspension is related to the preoperative considerations of detrusor stability, preoperative urgency and prior surgery. The results show that among the 161 patients complaining of incontinence only about half have demonstrable urethral incontinence. Of these, 23% have detrusor instability in addition to their urethral incontinence. The incidence of detrusor instability among the patients without demonstrable urethral incontinence was 48%. Patients with a stable detrusor preoperatively show the highest surgical cure rate (62% compared to 38% among patients with detrusor instability). Furthermore, patients without previous urogenital surgery that are stable report an even higher cure rate (90%). Presence of preoperative urgency compromises the possibility of complete surgical cure of incontinence. Urgency incontinence is present in approximately 48% of the patients whether stable or unstable. Endoscopic suspension will cure more than half of the patients with urgency incontinence if they have a stable detrusor function by urodynamic criteria preoperatively. However, patients with detrusor instability and urgency incontinence preoperatively are unlikely to report any improvement of their urgency incontinence following surgery. It is concluded that the determinants of successful bladder neck suspension are in order of priority: detrusor stability, preoperative urgency, and prior urogenital surgery.     

Female urinary incontinence: The incidence,identification, and characteristics of detrusor instabiiity

One hundred thirty-three women with urinary incontinence, including 51 patients who had undergone unsuccessful surgical treatment, were evaluated urodynamically. A high incidence (55%) of bladder instability was noted, and several patterns of instability were recognized. In 52% of the cases, provocation by erect fast fill and other provocative maneuvers were necessary to unmask the abnormal detrusor activity, and it was also noted that the patient's history did not accurately predict instability. A high incidence (33%) of seemingly inapproprate sphincter electrical silence occurred in those with an unstable bladder and appeared to be the precipitating event of the bladder contraction.     

Oxybutynin and bladder training in the management of female urinary urge incontinence: A randomized study

A randomized trial of 81 women with detrusor instability, low-compliance or sensory bladder was undertaken to compare the effects of 6 weeks' treatment with oxybutynin (5 mg t.i.d.) or bladder training for urge incontinence. Cystometry was repeated after treatment. Ten per cent of the 42 patients on oxybutynin discontinued the therapy; the cure rate decreased from 74% to 42% during the 6-month period following the treatment (from 93% to 57% in case of detrusor instability). The cure rate of bladder training remained quite high, being reduced only from 73% to 70% (from 81% to 75% in the case of sensory bladder). Twelve of the 13 patients with late relapse of incontinence were on oxybutynin. It was concluded that oxybutynin was not well tolerated and gave only early good results. Bladder training was well accepted and provided persistent results; it may be suggested as the first-line treatment for urge incontinence.Editorial Comment: The management of urinary urge incontinence in women remains a problem, especially because of the absence of physiopathologic and diagnostic certainties. In this article the authors compare the two types of conservative therapy, pharmacologic (anticholinergic) and behavioral (bladder training), in three groups of patients. The first group had unstable bladders, the second had decreased bladder-wall compliance and the third had sensory urge incontinence. Other causes of the urge symptoms were excluded. Comparisons were both clinical and urodynamic, with appropriate statistics applied. It is interesting to note that those patients using oxybutynin had an initial high success rate that rapidly dropped off with time, whereas bladder training results were more apt to persist with time, particularly in those patients with sensory urgency. The authors suggest that this may be due to the process of bladder training activating the pelvic-detrusor inhibitory reflex in opposition to the urethrovesical reflex. These interesting results show the need for further investigation into this poorly understood problem of urinary urgency with and without detrusor instability.     

Randomized trial of graft materials in transobturator tape operation: biological versus synthetic

Objective

To compare the outcome of outside–in biological and synthetic transobturator tape (TOT) operation, including subjective and objective success rates, urodynamics, and quality of life.

Materials and methods

One hundred patients suffering from clinical and/or urodynamic stress urinary incontinence (SUI) were randomized into biological material TOT (PELVILACE® TO) or synthetic material TOT (ALIGN®TO Urethral Support System) groups. Preoperative and at 1 year postoperative urogynecological symptom assessment, 1-h pad test, 4-day bladder diary, stress test, Q-tip test, and urodynamics were performed. For the evaluation of quality of life, the King’s Health Questionnaire, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7, and Prolapse Quality of Life were used.

Results

There was no significant difference between the two groups regarding objective and subjective cure rates and quality of life. At 1-year follow-up, the subjective cure rate was 68 % in the biological material TOT and 70 % in the synthetic material TOT group. No perioperative complications developed. Groin pain developed in 2 patients in the biological TOT group and 1 patient had dehiscence in the periurethral incision, which healed with local estrogen. Two patients had transient urinary retention in the synthetic TOT group, 1 patient developed groin pain, and 1 patient had mesh erosion observed at the 1-year follow-up.

Conclusion

Transobturator tape with biological material in the management of SUI has a rate of success and patient satisfaction similar to those of synthetic material at 1-year follow-up. Studies with longer follow-up and larger cohorts are necessary to evaluate possible autolysis and degradation of biological slings and a possible reduction in efficacy over time.     

Donald Munro Lecture 2003. Neurogenic bladder: past, present, and future

The foundation of the management of neurogenic bladder can be attributed to a pioneer in spinal cord injury medicine. Dr. Donald Munro, a neurosurgeon, who also had experience in urologic surgery, established the first Spinal Cord Injury Service of 10 beds in the Boston City hospital in the 1930s. He later became adviser to the US Army and the Veterans Administration (VA). On his recommendation, paraplegic centers were created in US army hospitals and later in the VA hospitals from 1943 to 1945. This article reviews the evolution of the management of neurogenic bladder in patients with spinal cord injuries from the past century to the present. The role of urodynamics in defining neurologic lesions is critical to the appropriate management of the voiding dysfunction. Key advances, such as the diagnosis of detrusor sphincter dyssynergia (DSD), recognition of its association with autonomic dysreflexia, and its definitive management, have been emphasized. The role of transrectal linear array sonography using a rectal probe was found useful for defining bladder outlet dysfunction during urodynamics. It also helped to recognize secondary bladder neck obstruction and diagnose false passages in the urethra. Clean technique intermittent catheterization (IC) was evaluated and recommended. In about 28% patients with DSD that led to secondary bladder neck obstruction, a consequence of IC was reported. Transurethral laser sphincterotomy (TURS) was first reported by me in 1991, and later, durable 7-year follow-up results were reported in 78% of the first 99 patients. We reported a surgical technique to lengthen the penis. We also reported the long-term success with semirigid implants in 92% of patients with SCI. This technique helped maintain external condom drainage on a small phallus and improved the sex life of patients, as well as their quality of life. The author's pertinent areas of interest in the past one-half century were aimed at recognizing specific urologic problems associated with neurologic impairment. Management was aimed at preventive care, early recognition, and timely management to reduce secondary complications and enhance quality of life.