神经源性膀胱活动低下儿童生命质量评估和尿动力学研究

目的 探讨神经源性膀胱活动低下(NUB)学龄儿童肠道膀胱扩大术(ECP术)联合自我清洁间歇导尿(CISC)或单一CISC治疗后生命质量和尿动力学参数改善情况.方法 采用Qualiveen量表对94例NUB学龄儿童进行生命质量评分,并依据尿动力学膀胱功能障碍类型进行ECP术联合CISC或单一CISC治疗,最终对62例(66%)完成1年随访.选取20例无明显排尿异常正常志愿儿童为对照组.结果 与治疗前相比,患儿随访时生命质量缺陷和强制评分均显著降低,膀胱顺应性和最大膀胱压测定容量均显著增加,但是生命质量焦虑和情感评分无显著改善.随访时生命质昔四方面评分均显著高于对照组.未合并反流性上尿路损害(RUUTD)患儿随访时无一例发生RUUTD.合并RUUTD患儿随访时无一例加重,血肌酐均正常,其中80%男性患儿出现不同程度改善,与女性患儿(69%)差异无统计学意义.结论 ECP术和CISC可显著改善NUB学龄患儿尿动力学参数,但Qualiveen生命质量仍较低,需要更有效的治疗方法.     

清洁间歇导尿联合睡眠时留置导尿对神经原性膀胱患儿上尿路影响的研究

目的 探讨清洁间歇导尿(CIC)联合睡眠时留置导尿对神经原性膀胱患儿上尿路的影响.方法 选取2007年3月至2008年2月我院尿动力学中心确诊为神经原性膀胱的患儿53例,随机分为CIC组(对照组27例)和CIC联合睡眠时留置尿管组(睡眠时留置尿管组26例).比较两组随访2年后膀胱尿路X线造影或影像尿动力学参数、尿路感染、肾积水的发生情况.结果 两组治疗后膀胱安全容量(SBC)分别为(213±24) ml和(190±21)ml、膀胱顺应性(BC)分别为(8.21±0.8)ml／cm H2O和(5.13±0.9) ml/cm H2O均有增加,膀胱漏尿点压(DLPP) (36.5±10.2)cm H2O和(42.9±11.3)cm H2O有所降低;CIC联合睡眠时留置尿管组随访时在SBC、BC和DLPP的改善方面明显高于单纯CIC组,差异有统计学意义.两组菌尿及尿路感染发生率差异无明显统计学意义(P＞0.05);肾积水、膀胱输尿管反流的改善差异有统计学意义(P＜0.05).结论 CIC联合睡眠时留置尿管未见增加尿路感染机会,有助于改善神经原性膀胱患儿上尿路损害,对上尿路有保护作用.     

神经源性膀胱患儿回肠浆肌层膀胱扩大术后长期随访

目的 探讨回肠浆肌层膀胱扩大术治疗神经源性膀胱患儿的远期疗效.方法 应用回肠浆肌层膀胱扩大术治疗神经源性膀胱患儿32例.男23例,女9例;8例术前合并双肾输尿管积水及双侧输尿管扩张,3例单侧膀胱输尿管返流,2例有轻度肾功能损害.对比手术前后主观症状[国际尿失禁咨询委员会问卷简表(ICI-Q-SF问卷)]、尿流动力学检查、泌尿系超声及逆行膀胱造影,评价术后疗效.术后所有患儿定期复查血电解质、肾功能及泌尿系超声,监测并发症.结果 随访5～12 a,26例(81.25%)临床症状好转或痊愈,6例(18.75%)无明显改善.术前ICI-Q-SF问卷评分为(18.1±1.0)分,随访结束为(7.8±2.5)分,二者比较差异有统计学意义(t=14.688,P=0.000).尿流动力学检查显示术后最大膀胱容量、膀胱顺应性较术前明显增加,充盈末逼尿肌压较术前降低.术后电解质、肾功能均正常.远期并发症5例:4例并症状性泌尿系感染,1例并膀胱结石.结论 回肠浆肌层膀胱扩大术治疗神经源性膀胱患儿并发症少,远期疗效比较理想.     

神经源性膀胱伴输尿管反流的尿动力学研究

目的 探讨有输尿管反流的神经源性膀胱(NB)患儿有或没有逼尿肌过度活动(DO)时的尿动力学差异,为临床治疗此类患儿提供理论参考依据.方法 选取2013～2015年就诊并经影像尿动力学检查发现膀胱输尿管反流的NB患儿68例,男30例,女38例,年龄4～12岁,平均7.5岁.按照充盈期有DO,将其分为DO组(n=20)与无DO组(n=48).观察记录两组发生膀胱输尿管反流时的膀胱灌注量、逼尿肌压并计算发生反流时的膀胱顺应性;记录两组充盈结束时最大膀胱测压容量、最大逼尿肌压、并计算充盈期膀胱顺应性.结果 DO组发生膀胱输尿管反流时的膀胱容量与顺应性分别为(98.7±16.1)ml和(5.2±1.9) ml/cmH2O,无DO组发生膀胱输尿管反流时的膀胱容量与顺应性分别为(127.3±36.3)ml,(7.1±2.1)ml/cmH2O,差异均有统计学意义(P＜0.05);两组的逼尿肌压分别为(21.6±9.2)cmH2O、(19.2±7.4)cmH2O,差异没有统计学意义;DO组充盈结束时的膀胱容量与顺应性分别为(182.7±31.2)ml、(5.4±1.7) ml/cmH2O,与无DO组充盈结束时的膀胱容量(230.6±34.6)ml与顺应性(6.5±1.1)ml/cmH2O相比,差异有统计学意义;两组尿动力学检查结束时逼尿肌压分别为(33.8±7.8)cmH2O、(36.4±8.1)cmH2O,差异没有统计学意义.结论 膀胱容量小,膀胱顺应性差是有输尿管反流的NB患儿伴发DO时的尿动力学特征.     

膀胱自体扩大术在神经性膀胱患儿中的应用评价

目的评价逼尿肌部分切除、膀胱自体扩大术的临床疗效。方法选择脊髓脊膜膨出患儿6例,其中男性3例,女性3例,年龄18个月至9岁。患儿均口服索利那新和行清洁间歇导尿3个月后无好转而行逼尿肌部分切除、膀胱自体扩大术,术后予清洁间歇导尿,手术前及术后1年行泌尿系超声、排泄性膀胱尿道造影,并行尿动力评价,评价指标为膀胱容量、膀胱顺应性和充盈末逼尿肌压。结果术前尿动力学检查显示6例患儿膀胱容量减小、膀胱顺应性下降及逼尿肌压升高,其中5例膀胱容量低于预期容量的50%。排泄性膀胱造影4例合并膀胱输尿管反流,其中左、右侧Ⅳ°反流各1例,双侧Ⅳ°反流2例。6例患儿手术后恢复顺利,无穿孔、感染发生。术后1年尿动力学检查显示6例患儿膀胱容量略有增加,但膀胱容量与预期膀胱容量(年龄×30+30)、膀胱顺应性及逼尿肌压力无明显变化,VCUG显示4例输尿管反流无减轻。结论对于膀胱容量明显变小的神经性膀胱患儿,逼尿肌部分切除、膀胱扩大术不能有效增加膀胱容量和顺应性,降低逼尿肌压,临床不能取得满意的效果。     

排尿性膀胱尿路造影术在诊断儿童膀胱输尿管反流中的意义

目的 探讨排尿性膀胱尿路X线造影术(MCU)在尿路感染患儿中的检查时机,为早期诊断膀胱输尿管反流提供依据.方法 分析2003年1月-2007年12月我院住院患尿路感染并行排尿期膀胱尿路X线造影术检查的患儿,分析相关的B超,放射性核素肾静态扫描,肾功能(血尿素氮、血肌酐),尿常规,尿微量蛋白(尿IgG、Alb、TRF、RBP、NAG、a1-MG),中段尿培养等检查.结果 [1]进行MCU检查的患儿共392例,年龄1个月-14岁,平均年龄(2.43±3.10)岁.无膀胱输尿管反流者230例;有膀胱输尿管反流者162例;其中原发性膀胱输尿管反流150例,男女比为1.23:1.[2]原发性膀胱输尿管反流阳性、阴性两组患儿间,放射性核素肾静态扫描(DMSA)中表现为急性期放射稀疏、肾疤痕、尿微量蛋白,差异有统计学意义(P<0.05).[3]原发性膀胱输尿管反流患儿年龄分布为<2岁93例(62%),2-7岁39例(26%),>7岁18例(12%).结论 对尿路感染伴随DMSA异常,尿微量蛋白明显增高的患儿应提高警惕,积极行MCU检查,特别是<2岁的男童更应重视.     

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.     

清洁间歇导尿在小儿神经源性膀胱治疗中的价值

目的 评价清洁间歇导尿在小儿神经源性膀胱治疗巾的临床意义.方法 脊髓栓系综合征患儿64例.男49例,女15例,年龄3～13岁.均已行脊髓栓系松解手术.临床表现为尿失禁,611例合并大便失禁.52例合并足畸形.就诊时和就诊后1年分别行尿动力学和排泄件膀胱尿道造影以及超声检查,治疗期间36例坚持间歇导尿.28例未能坚持间歇导尿.结果 导尿组开始有9例合并Ⅲ°以下输尿管反流.4例为单纯肾积水.膀胱容量、顺应性、逼尿肌压分别为(176±34.5)ml、(3.5±0.6)ml/cmH2O、(54.6±13.2)cmH2O.1年后3例输尿管反流消失,2例肾积水减轻,膀胱容量、顺应性、逼尿肌压分别为(188±30.3)ml、(3.7±0.9)ml/cmH2O、(50.6±11.8)cmH2O,4例发生尿路感染(11.1%).未导尿组开始有7例合并Ⅲ°以下输尿管反流,5例为单纯肾积水,膀胱容量、顺应性、逼尿肌压分别为(168±37.2)ml,(3.2±0.7)ml/cmH2O,(59.6±15.6)cmH2O.1年后13例合并输尿管反流.9例合并肾积水.膀胱容量、顺应性、逼尿肌压分别为(142±23.6)ml,(1.6±0.7)ml/cmH2O,(72.4±9.3)cmH2O.3例发生尿路感染(10.7%).结论清洁间歇导尿可保护膀胱功能.避免或减轻上尿路功能的损害,并不增加尿路感染的发生率.对于神经源性膀胱治疗有重要的应用价值.     

后尿道瓣膜切除术后尿动力学研究

目的探讨后尿道瓣膜患儿行经尿道镜瓣膜切除术后的尿动力学改变.方法回顾性分析2007年1月至2008年12月本院收治的17例因后尿道瓣膜经尿道镜瓣膜切除术患儿的临床资料.均采取问卷调查、排尿性膀胱尿道造影、静脉肾盂造影、泌尿系超声、尿动力学检查等进行随访,重点分析尿动力学检查结果.结果诊断时常见症状排序依次为排尿困难、泌尿系感染症状、尿失禁等.术前发现肾积水17例,膀胱输尿管反流9例.均行经尿道镜瓣膜切除术.平均随访时间27(15～40)个月.临床症状均消失或减轻,无尿道狭窄、尿道瘘,造影检查提示解剖性梗阻均已解除,9例肾积水较前好转;8例存在膀胱输尿管反流.16例(94.1%)存在尿动力学异常,7例(41.2%)表现为膀胱顺应性降低,平均最大逼尿肌压力降低,逼尿肌不稳定;7例(41.2%)表现为残余尿增多.8例(47.1%)膀胱容量低于同年龄正常预测值的80%.结论后尿道瓣膜切除术后膀胱功能异常仍然存在,尿动力学检查能及时发现膀胱功能损害及其程度,建议PUV患儿术后定期行尿动力学检查,以了解膀胱功能,保护上尿路.     

血清降钙素原对膀胱输尿管反流的诊断价值

目的探讨降钙素原(PCT)在膀胱输尿管反流诊断中的应用价值。方法对第一次发热的尿路感染患儿进行血清PCT检测,并对所有患儿进行排尿性膀胱尿道造影(VCUG)以确定是否存在膀胱输尿管反流,从而评估PCT对膀胱输尿管反流诊断的预测作用。结果膀胱输尿管反流组血清PCT值为(1.26±0.07)ng/ml,明显高于无膀胱输尿管反流组[(0.57±0.08)ng/ml],差异有非常显著性(P<0.01)。13例轻度膀胱输尿管反流患儿血清PCT水平为(1.02±0.14)ng/ml,6例重度膀胱输尿管反流患儿PCT水平为(1.79±0.20)ng/ml,差异有非常显著性(P<0.01)。血清PCT≥0.5ng/ml对所有膀胱输尿管反流患儿诊断的敏感度为84%,特异度为64%,对重度膀胱输尿管反流诊断的敏感度为100%,特异度为64%。结论血清PCT值可用于鉴别是否存在膀胱输尿管反流,且与反流程度相关。     

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     

Initial surgical treatment as a determinant of bladder dysfunction in posterior urethral valves

Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.     

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.     

Color Doppler ultrasonography in the assessment of vesicoureteric reflux in children with bladder dysfunction

To determine whether color Doppler ultrasound (DUS) evaluation of ureteric jets could predict vesicoureteric reflux (VUR) in children with non-neuropathic and neuropathic bladder/sphincter dysfunction, 129 children were evaluated to identify the vesicoureteric orifice and measure the distance from the orifice to the midline of the dorsal bladder wall (MVU distance). The type of bladder dysfunction was determined by urodynamic studies. Forty-two children with no history of kidney or bladder disease were examined by DUS as a control group. MVU distances were compared between several groups of children with different urodynamic findings, and the significance was tested. Jets were visualized in 81% of children. MVU distances were significantly lower in children without VUR compared to those with VUR. No statistically significant differences were observed between children without VUR and those with VUR and more severe urodynamic disturbances like dysfunctional voiding. In children with neuropathic bladders, jets were visible in only 57% of refluxive units and the range of MVU distances was very wide (5–22 mm). If a cut-off point of 10 mm is used, in children without bladder dysfunction the sensitivity of MVU measurement in the diagnosis of VUR was 87.5% and the specificity 97%. However, in children with non-neuropathic and neuropathic bladder dysfunction, the sensitivity was only 55% and the specificity 79%. Color Doppler (DUS) and measurement of the MVU distance proved useful in predicting VUR only in children with normal bladder function. In children with neuropathic and non-neuropathic bladder dysfunction it can be used to visualize ureteric jets, but cannot replace radiographic or radionuclide voiding cystourethrography. Accepted: 21 March 2001     

Delayed exstrophy repair (DER) does not compromise initial bladder development

ObjectiveDelayed exstrophy repair (DER) represents an alternative to early neonatal bladder closure. This study aims to define the consequence of DER on bladder growth in bladder exstrophy patients who underwent routine DER, compared with those who underwent immediate postnatal reconstruction.MethodsBetween 2000 and 2005, classic bladder exstrophy patients referred to the authors' institution underwent early neonatal bladder closure (group 1). Subsequently, classic bladder exstrophy patients referred to the authors' institution were treated with an elective DER (group 2). Bladder capacity was assessed between the age of 1 and 4 years with an unconscious cystogram. When dilating VUR was present, the volume of the contrast migrated into the ureter was calculated and subtracted.ResultsSixty patients were treated between 2000 and 2012. Complete follow-up data were available for 45 patients and they were included in the study: 21 in group 1 (11 males) and 24 in group 2 (14 males). The mean (SD) bladder volumes were 72.85 (28.5) ml in group 1 and 72.87 (34.9) in group 2 (p = 0.99).ConclusionIn the authors' experience, DER does not reduce the subsequent bladder capacities compared with neonatal exstrophy closure.     

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。     

Upper tract changes in patients with neurogenic bladder and sustained pressures >40 cm following bladder neck surgery without augmentation

ObjectiveWe report new hydronephrosis or VUR (vesicoureteral reflux) in patients with end filling pressures >40 cm for at least 1 year after bladder neck surgery without augmentation for neurogenic incontinence.MaterialsConsecutive children with neurogenic sphincteric incompetency had bladder neck surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually. Those with sustained end fill pressures >40 cm for ≥1 year were included as participants in the study.ResultsOf 79 patients, 17 (22%) had end fill pressures >40 cm for at least 1 year despite anticholinergics, with follow-up a mean of 39 months. New hydronephrosis or VUR developed in six (35%). All new hydronephrosis resolved with medical treatment, as did two out of three new VUR cases. The other patient with VUR had successful Dx/HA (dextranomer hyaluronic acid) injection.ConclusionsDespite sustained pressures >40 cm, upper tract changes developed in only 35% of patients, and resolved with medical management or minimally invasive interventions. End pressures should not be used as an independent indication for augmentation.