女性原发性膀胱颈梗阻诊疗探讨

目的：总结女性原发性膀胱颈梗阻（PBNO）的诊断思路及步骤,以提高对女性PBNO的诊断水平,探讨经尿道膀胱颈切开术（TUIBN）对女性PBNO的治疗效果。方法：于2007年3月～2009年1月期间共确诊女性PBNO患者22例,其中19例通过常规尿动力学检查辅以膀胱尿道造影确诊,3例通过影像尿动力学检查确诊。全部患者均在口服α1-受体阻滞剂保守治疗无效后入院接受TUIBN治疗。收集患者术前及术后最大尿流率、最大尿流率时逼尿肌压、剩余尿量和国际前列腺症状评分（IPSS）指标进行比较,分析TUIBN术对女性PBNO的治疗效果。结果：术后22例随访2～24个月,其中12例随访尿动力学及IPSS评分;9例仅随访IPSS评分;1例失访。21例患者手术前后IPSS评分分别为（27．28±2．42）及（8．22±3．89）（P〈0．001）;复查尿动力学的12例手术前后指标比较,最大尿流率分别为（7．53上3．12）ml／s及（13．62±5．02）ml／s（P=0．017）;剩余尿量分别为（中位数80;QU-QL=155～65）ml及（46．11±19．97）ml（P=0．018）;最大尿流率时逼尿肌压分别为（8．82±3．23）kPa及（6．00±2．58）kPa（P=0．003）。结论：常规尿动力学结合膀胱尿道造影检查能较准确、有效地诊断女性PBNO,并能达到与影像尿动力学检查相接近的诊断水平。对口服α1-受体阻滞剂治疗无效的女性PBNO患者,TUIBN是安全、有效的治疗手段。     

Primary Bladder Neck Obstruction: Urodynamic Findings and Treatment Results in 36 Men

Purpose

We reviewed the urodynamic findings and treatment outcomes of a large series of men with primary bladder neck obstruction.

Materials and Methods

A retrospective review was done of the presenting symptoms and urodynamic findings of 36 men with primary bladder neck obstruction. Outcomes after treatment with alpha-blockers, transurethral incision of the bladder neck and prostate, or no long-term therapy were determined by chart review and patient survey in the majority of cases.

Results

Mean age of the men was 41 years. Patients had significant lower urinary tract symptoms, decreased peak urinary flow rates, elevated post-void residual, markedly elevated peak voiding pressures and poor funneling of the bladder neck during voiding. Although most patients initially chose alpha-blocker therapy, only 30 percent of those beginning alpha-blockers continued them long term, usually due to inadequate symptomatic improvement. A total of 18 men underwent transurethral incision, which resulted in significant improvements in symptom scores, peak urinary flow rates, post-void residual and peak voiding pressures. Patients reported a mean 87 percent overall improvement in symptoms after transurethral incision.

Conclusions

Video urodynamics facilitate diagnosis of primary bladder neck obstruction. Transurethral incision is the most effective therapy for primary bladder neck obstruction.     

经尿道绿激光膀胱颈汽化术治疗女性原发性膀胱颈梗阻的临床研究

目的评估采用经尿道绿激光膀胱颈汽化术治疗女性原发性膀胱颈梗阻(primary bladder neck obstruction,PBNO)的可行性及临床疗效。方法回顾性分析山东大学附属省立医院泌尿微创中心自2012年1月至2015年1月收治的55例女性原发性膀胱颈梗阻患者,采用经尿道绿激光膀胱颈汽化术进行治疗,记录并分析这些患者的术中、术后各项指标,评估手术治疗的效果。结果 55例患者手术均获成功,术中无明显出血,平均手术时间22分钟(15~30分钟),术后最大尿流率(maximum uroflow rate,Q_(max))(21.3±5.16)ml/s(14.7~26.9ml/s),排尿后平均膀胱残余尿量(postvoid residual,PVR)由术前(112.4±87.3)ml减少至(24.3±15.4)ml,术后最大尿流率时达到的逼尿肌压由术前的(67.22±12.33)cmH_2O减至(21.07±7.52)cmH_2O。55例患者的排尿功能均得到明显改善,无术中、术后严重并发症出现。结论对女性原发性膀胱颈梗阻患者采用经尿道绿激光膀胱颈汽化术是一种易于操作、创伤小、疗效好、并发症少的手术方法,值得推广。     

Overactive Bladder and Outlet Obstruction in Men

Lower urinary tract symptoms (LUTS), overactive bladder, (OAB), and benign prostatic hyperplasia (BPH) are very commonly experienced in men. The mainstay of pharmacotherapy for OAB is the antimuscarinic class of drugs. There has been reluctance to prescribe these agents to men with BPH due to the risk of precipitating urinary retention. Several trials have supported the efficacy and safety of antimuscarinics in treating men with LUTS, alone, or in combination with α-blocker therapy. The combination of 5-α-reductase inhibitors with antimuscarinic agents or surgery are other effective treatments for men with BPH and OAB.     

Bladder Neck Obstruction in Young Males with History of Bilharzial Infection

Introduction: Schistosomiasis is a parasitosis affecting 200 to 250 million people around the world, mainly in tropical and subtropical regions of Africa, Asia, Central and South America. Most clinical manifestations are related to egg deposition and the formation of granulomas and fibrous tissues around the eggs produced by the worms. Fibrosis of the ureter and the bladder are well-known occurrences. Obstruction of the bladder neck is also a known but rarely diagnosed manifestation. Our experience from the endemic area (Yemen) is presented. Patients: In two years bladder outlet obstruction was observed in 8 young (mean age: 33 years) Yemeni male patients. The symptoms were frequency, dysuria and - in 4 cases - suprapubic pain. For the diagnosis we obtained detailed history, performed proper ultrasound examination, plain X-ray, intravenous pyelography and urethro-cystoscopy. Results: One patient suffered from active bilharzial infection (the eggs were visible in the urine), all others developed the disease years (on average 10 years) later. Seven males have been previously treated for chronic prostatitis for months. Obstruction has been confirmed with postvoid residual urine measurement and cystoscopic evaluation. All patients showed hyperechoic wall at the base of the bladder. Four patients were treated. Treatment for these young patients should be chosen prudently in order to preserve normal ejaculation. In the active infection medical treatment (praziquantel 40 mg/kg), in late forms transurethral prostate incision were performed. All treated patients became symptom-free. Conclusion: Bladder neck obstruction is a known - nevertheless rarely diagnosed - manifestation of urinary schistosomiasis. On the endemic territory it is useful to keep in mind this disease in case of obstructive symptoms in young males. In the acute phase medical treatment and in late forms transurethral incision can be successful.Schistosomiasis or bilharziasis is a parasitosis affecting 200 to 250 million people around the world. Three main species of schistosomes are commonly affecting man: S. mansoni (endemic in much of Africa, parts of Southwest Asia, the Caribbean and South America); S. Japonicum (endemic in Japan, China, the Philippines and parts of Southeast Asia); S. haematobium endemic in much of Africa and parts of Southwest Asia). Around the world about 80 million people are infected with S. haematobium. This number is on the increase in endemic areas because of the construction of modern irrigation systems that provide favourable conditions for the intermediate host (Bulinus Truncatus). The life-cycle is similar in the three groups. The adult worm of S. haematobium lives in the perivesical plexus and lies the eggs into the lumen of the submucosal veins. The eggs penetrate the urothelium and pass into the lumen of the bladder and pass out with the urine. In active infection end-spined eggs are visible during urine analysis. Most clinical manifestations are related to egg deposition and the formation of granulomas and fibrous tissue around the eggs produced by the worms. Fibrosis of the ureter and the bladder are well-known events. Obstruction of the bladder neck is a known, but rarely diagnosed manifestation. In Yemen out of 17 million inhabitants 2–3 million suffer from the disease [1]. The accurate incidence is not known but there are areas where 60–70% of males are infected [2].     

Pressure-to-Cross-Sectional Area Relationships in the Proximal Urethra of Men with Bladder Outlet Obstruction

Purpose

Related values of pressure and cross-sectional area in the proximal urethra were measured in patients with bladder outlet obstruction. Urethral opening pressure and elastance (the inverse of compliance) were estimated.

Materials and Methods

We studied 15 men with standard urodynamic examinations. The pressure-to-cross-sectional area relationship in the prostatic urethra was determined using a special probe.

Results

Elastance varied significantly along the studied portion of the urethra, with higher values found in the sphincter area. The estimated urethral opening pressure appeared high compared to that in unobstructed cases and without variation along the prostatic urethra.

Conclusions

The most important effect of prostatic obstruction appears to be the increased urethral opening pressure.     

经尿道双极等离子电切术治疗女性膀胱颈梗阻(附18例临床分析)

目的探讨经尿道双极等离子电切术治疗女性膀胱颈梗阻的疗效。方法采用经尿道双极等离子膀胱颈电切术治疗18例女性膀胱颈梗阻患者。结果平均手术时间16(11～48)min,失血<10ml,无水中毒及尿失禁发生。术后病理报告为膀胱颈粘膜下纤维组织增生伴玻璃样变性,部分平滑肌变性增生及粘膜下炎性细胞浸润。本组18例患者均获随访,平均12(4～23)个月,治疗后生活质量评分由4.2±1.1降至1.7±0.5(P<0.01),最大尿流率由(3.8±2.9)ml/s升至(16.0±6.4)ml/s(P<0.01),残余尿量由(355.5±196.5)ml降至(34.5±18.9)ml(P<0.01)。结论经尿道双极等离子电切术是治疗女性膀胱颈梗阻有效的腔内治疗方法。     

老年急性肠梗阻的诊治体会

我院1999年～2004年共收治老年性急性肠梗阻64例,报道如下。1临床资料1.1一般资料本组64例,男34例,女30例,平均年龄72.14(60～94)岁。病程平均51d(6h～12d)。均经病史、典型临床表现及X线腹部平片确诊,并经手术证实。入院距手术时间平均41h(3h～4d)。1.2手术方法全部病例均经手     

胰管梗阻的诊断和治疗

提出胰管梗阻所致胰高压在胆胰疾病中造成病人剧烈腹痛和消化道功能紊乱的作用以及手术缓解胰高压的重要性。方法：２７例诊断为胰管梗阻的患者中,１１例为慢性胰腺炎,１６例为晚期胰腺癌或壶腹周围癌。其中慢性胰腺炎有６例为胰管多发性狭窄伴扩张,手术将胰管纵行劈开并与空肠行大口侧侧吻合,另５例仅出口狭窄者行胰管空肠侧端吻合;１６例晚期肿瘤患者,仅５例行胰管空肠内引流术。结果：１１例慢性胰腺炎内引流手术后经长期随访除一例偶有上腹轻度疼痛外,其余１０例症状均明显好转。其余消化道症状亦皆明显好转。１６例晚期肿瘤所致的胰管梗阻病人,５例行胰管空肠吻合术,术后病人疼痛均明显好转。结论：胰管阻塞可引起胰高压,后者可能是造成慢性疼痛和消化不良的重要原因,在胆胰手术过程中应充分地认识其重要性,以选择适当的术式。     

膀胱内翻性乳头状瘤的诊断与治疗

目的：提高膀胱内翻性乳头状瘤（Inverted papilloma of the bladder,IPB）的诊治水平。方法：回顾性分析我院13例膀胱内翻性乳头状瘤患者的临床资料,结合文献资料进行探讨。结果：13例患者接受经尿道膀胱肿瘤电切术（TURBt）治疗,术后随访无复发。结论：IPB呈良性肿瘤特点生长,预后良好。诊断依赖于膀胱镜检及术后病理检查,TURBt是IPB的标准治疗方法,术后予膀胱灌注化疗有利于预防复发。     

膀胱副神经节瘤的诊断和治疗

目的：探讨膀胱副神经节瘤的临床特点及诊治疗效。方法：对5例膀胱副神经节瘤患者的临床资料进行回顾性分析。结果：5例患者,男2例,女3例,平均46（36～77）岁。经尿道膀胱肿瘤电切（TURBT）2例,开放膀胱部分切除术3例。5例患者随访1～7年,1例术后3年肿瘤复发行TURBT,术后病理诊断为移行细胞癌1～2级。1例术后6年复发,伴有左肾重度积水,左肾无功能,行根治性膀胱切除加左肾输尿管切除加右输尿管皮肤造口。3例患者未见肿瘤复发及转移。结论：膀胱副神经节瘤临床少见,其临床表现有一定特点,对于排尿时伴有相应副神经节瘤临床表现的患者应除外膀胱副神经节瘤的可能,治疗方法主要以手术为主。     

经尿道内镜术治疗前列腺术后膀胱出口梗阻

目的：探讨经尿道内镜技术治疗前列腺术后膀胱出口梗阻的疗效。方法：采用经尿道内镜术治疗35例前列腺术后（经耻骨上前列腺除30例，经尿道电切5例）排出困难，经尿道膀胱造影或尿道膀胱镜检查证实为前列腺尿道部或膀胱颈狭窄的病人。结果：35例均获成功，拔除尿管后均排悄通畅，无尿液残余，少部分病人有尿频，但经对症处理很快改善。结论：经尿道内镜术处理前列腺术后膀胱出口梗阻安全、可靠，是首选的治疗方法。     

Clinical Diagnosis of Bladder Outlet Obstruction in Patients with Benign Prostatic Enlargement and Lower Urinary Tract Symptoms: Development and Urodynamic Validation of a Clinical Prostate Score for the Objective Diagnosis of Bladder Outlet Obstruction

Purpose

We attempted to improve the method of objective clinical evaluation of patients with benign prostatic enlargement and lower urinary tract symptoms.

Materials and Methods

We compared the results of free uroflowmetry and transrectal ultrasound prostate size determination with those of pressure-flow analysis of bladder outlet obstruction in 871 consecutive elderly men.

Results

Maximal flow, prostate size, and post-void residual and voided volumes were correlated with bladder outlet obstruction to derive a clinical prostate score.

Conclusions

Clinical prostate score shows a superior correlation with bladder outlet obstruction than isolated objective parameters or symptom scores.