电针调节骶3神经治疗神经源性逼尿肌过度活动的效果研究

目的 观察电针调节骶3神经治疗脊髓损伤患者逼尿肌过度活动及尿失禁的临床疗效. 方法 20例脊髓损伤后经影像尿动力学检查证明存在逼尿肌过度活动的患者纳人本研究.男18例,女2例.年龄17～58岁.取侧卧位,在尿动力学检查过程中逼尿肌刚开始收缩时对双侧骶3神经予电针治疗,改变电刺激的强度,选择出抑制逼尿肌收缩的最适合刺激强度.予适合强度的电刺激治疗同时行膀胱充盈测压,观察即时效应.有效者进行长期治疗,每日30 min,10 d为一疗程,3及9个疗程后复查尿动力学检查,观察长期效应.结果患者平均每天尿失禁次数、尿垫使用量分别从治疗前的8.93±3.27、3.93±1.54减至治疗后的7.00±2.51、3.21±0.89(P<0.05).出现首次逼尿肌收缩的膀胱容量明显增加,最大膀胱压力明显下降(P<0.05).2例完成3个疗程,1例完成9个疗程.此3例患者平均每天尿失禁次数、尿垫使用量分别从治疗前11.67±7.64、6.67±4.16减至4.00±1.73、2.33±0.58,首次逼尿肌收缩的膀胱容积均值从(73.9±10.3)ml增加至(111.6±17.6)ml.6例进行0.025 V和0.080 V的2个强度刺激,2组结果相比认为0.025 V更有效.结论电针调节双侧中髎穴骶3神经可显著增大出现首次逼尿肌收缩的容积,减少每周尿失禁的实际次数.以0.025 V进行电刺激,延长疗程,疗效可能更佳.     

骶神经刺激和神经调节治疗排尿功能障碍

排尿功能障碍是一种常见的下尿路疾病 ,可以有明确病因 ,也可为特发性。临床实践中体会到 ,当保守治疗对急迫性尿失禁及尿急尿频等症状无效时 ,进一步处理极为困难 ;同样 ,对非梗阻性尿潴留患者 ,除间断导尿外几乎没有其他有效方法。神经调节 (ｎｅｕｒｏｍｏｄｕｌａｔｉｏｎ)     

骶神经调节术治疗顽固性便秘疗效观察

目的：观察骶神经调节术（SNM）治疗顽固性便秘的临床效果。方法第四军医大学西京消化病医院消化外科于2013年1月至2014年1月期间,采用骶神经调节测试系统经皮穿刺,刺激第3骶神经根,治疗7例复杂便秘患者,其中4例患者既往进行过至少1次的便秘手术。通过排粪日记、Cleveland便秘评分及视觉模拟评分（VAS）进行疗效评价。结果7例患者在接受体外临时测试治疗后,便秘症状均明显改善。其中6例接受永久性骶神经调节器植入术,围手术期未见并发症。术后随访中位时间4（2～12）月,6例患者的每周排粪次数由治疗前（0．6±0．5）次／周,增加到（8．0±2．5）次／周（P＜0．01）;排粪时间从（22．9±11．5） min减少到（3．7±0．8） min（P＜0．01）;Cleveland便秘评分从（24．6±4．2）分下降到（9．0±0．9）分（P＜0．01）;VAS评分从（8．1±0．9）分增加到（82．5±5．2）分（P＜0．01）。结论 SNM是治疗顽固性便秘的一种微创而安全有效的新方法。     

骶神经刺激/调节在下尿路功能障碍的应用

慢性排尿功能障碍临床十分常见,主要包括急迫性尿失禁、尿频尿急综合征、慢性尿潴留和慢性盆腔疼痛综合征.目前临床中,药物和其他保守治疗方法效果不确切,外科手术因创伤大,患者不易接受,因此此类排尿障碍成为当前泌尿外科临床实践的难题之一.20世纪90年代以来,排尿反射的神经调节概念越来越被人们重视,功能性神经电刺激治疗慢性排尿功能障碍得到应用.近年来出现并不断应用于临床的骶神经刺激(sacral nerve stimulation,SNS)和骶神经调节(sacral neuromodulation)为治疗排尿功能障碍患者提供了一种新途径.本文就有关骶神经调控技术(Interstim)的原理、适应证、临床操作技术及相关进展作一简介.     

全程管理在神经源性膀胱患者骶神经调节治疗的疗效评价

目的评价基于多学科团队协作的骶神经调节治疗神经源性膀胱患者全程管理方案的实践效果。 方法收集2018年1月至2019年12月中山大学孙逸仙纪念医院收治的36例神经源性膀胱行骶神经调节治疗患者的病例资料。将36例患者按入院时间分为对照组15例（2018年1~ 12月）和干预组21例（2019年1~12月）。对照组给予常规管理,干预组实施全程护理模式。比较两组骶神经调节二期手术转化率,两组患者一期术后3个月时膀胱功能管理效果、尿路感染发生率、患者满意度和生活质量的差异。 结果两组患者在骶神经调节二期手术转化率、平衡膀胱达标率、膀胱容量、患者满意度和生活质量的差异有统计学意义（P<0.05）,干预组均高于对照组。 结论多学科团队协作的全程管理实现了骶神经调节治疗神经源性膀胱患者连续的全程化、个性化管理,协调多学科团队协作,改善了患者的临床疗效,提高了患者满意度,是一种有效的患者管理照护模式。     

骶神经调节在女性糖尿病性膀胱功能障碍治疗中的应用

目的:总结骶神经调节(SNM)治疗女性糖尿病性膀胱功能障碍(DBD)患者的初步经验。方法:回顾性分析2017年5月～2018年8月我院采用SNM治疗的10例女性DBD患者的临床资料,年龄43～72岁,平均51岁,糖尿病病程2～23年,膀胱功能障碍病程0.5～8年,比较治疗前、Ⅰ期测试阶段及Ⅱ期永久刺激器植入后随访中相关症状的改善程度,观察该疗法的有效性及安全性,并初步总结相关经验。结果:10例患者均在局麻下接受了SNMⅠ期电极植入,4例因测试效果不佳,于局麻下取出测试电极。6例经测试后行Ⅱ期永久刺激器植入,Ⅰ期至Ⅱ期转换率为60%(6/10)。接受Ⅱ期刺激器永久植入患者在随访截止时与治疗前相比,日排尿次数[(11.2±9.6)次vs.(18.3±9.4)次,P=0.02]、每次排尿量[(181.3±61.5)ml vs.(104.5±55.3)ml,P0.01]、生活质量评分[(3.5±1.5)分vs.(6.2±1.3)分,P0.01]、残余尿量[(66.7±57.9)ml vs.(188.6±63.4)ml,P0.01]、排尿困难评分[(3.9±1.4)分vs.(8.2±1.7)分,P0.01]均显著改善。围手术期未见明显并发症发生,1例患者随访中出现手术侧臀部及下肢疼痛不适,通过程控改变电刺激模式后好转。5例在Ⅱ期植入术后症状持续缓解,1例出现症状反复,症状缓解不明显,予以保留刺激器并结合间断清洁自我导尿。结论:对于女性DBD患者,SNM是一种安全、有效的微创治疗方式。选择合适的患者、更精细的手术操作及适当延长测试的时间,可以提高转换率,改善患者疗效。     

骶神经前根电刺激治疗脊髓损伤病人的排尿功能障碍

圆锥上脊髓损伤（ＳＣＩ）占全部ＳＣＩ的８５％。这类病人绝大多数将并发高张力、高反射的痉挛性膀胱。泌尿系并发症造成的肾脏损害。是ＳＣＩ病人晚期死亡的主要原因。本文介绍了国外开展骶神经前根（Ｓ２￣４）电刺激（ＳＡＲＳ）恢复ＳＣＩ病人可控制性排尿的理论、手术方法和治疗效果。     

改良式阴茎背神经切断术治疗原发性早泄

目的 探讨改良式阴茎背神经切除术的效果.方法 回顾分析广州、乐清、哈尔滨三家三级医院在2008年7月到2010年5月期间开展的338例该项手术.对术后的疗效,并发症给予客观的评价.结果 对338例原发性早泄患者中的87例经2年以上随访,显效率59.8%.术后射精潜伏期没有明显变化5例,阴茎麻木感2例,勃起功能障碍1例,阴茎血肿1例,切口感染2例.结论 改良式阴茎背神经切断术治疗原发性早泄安全,有效.     

胶质细胞源性神经营养因子与脊髓损伤治疗

脊髓损伤治疗是医学界的热点和难点,从传统的大剂量激素冲击、手术解除压迫、术后康复锻炼等到干细胞移植、基因疗法等均未取得满意效果.大量研究证实,胶质细胞源性神经营养因子(GDNF)有促进脊髓损伤修复的作用,为脊髓损伤治疗带来新方法.该文就GDNF结构特性及在脊髓损伤修复中的作用研究进展作一综述.     

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).

Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.

Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.

Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.     

Sacral nerve stimulation in the treatment of bowel dysfunction from imperforate anus: A case report

IntroductionBowel dysfunction (fecal incontinence and constipation) presents in over 50% of patients after treatment of congenital anal malformations. Sacral nerve stimulation (SNS) for the treatment of fecal incontinence improves function in the majority of patients. We present a case report of the treatment of bowel dysfunction with sacral nerve stimulation in a patient with a history of an imperforate anus.Presentation of caseA twenty year-old female with a history of imperforate anus at birth, repaired during infancy with anorectoplasty, presented with fecal incontinence and constipation. Since childhood, she had been suffering from intermittent constipation with worsening fecal incontinence in early adulthood. Examination revealed mild anal stenosis and mucosal prolapse. Endoanal ultrasound demonstrated intact internal and external sphincter with low resting and squeeze pressures on anal manometry. Flexible sigmoidoscopy was normal. The patient underwent permanent sacral nerve stimulation with a primary goal of improvement in continence and, secondarily, for the alleviation of intermittent chronic constipation.DiscussionAt 15 month follow-up, the patient had improvement in fecal incontinence (CCIS of 14 pre-SNS to 1 post-SNS), constipation (CCCS of 28 pre-SNS to 20 post-SNS), and quality of life (FIQOL improved in lifestyle (3.7), coping/behavior (3.4), self perception (3.9), and social embarrassment (4.5).ConclusionSacral nerve stimulation for the treatment of bowel dysfunction in adults secondary to imperforate anus can be performed safely and with good results.     

选择性骶神经根切断治疗脊髓损伤后痉挛性膀胱的实验研究

目的：观察选择性骶神经根切断治疗脊髓损伤痉挛性膀胱的实际疗效,探讨骶神经根高选择性切断的治疗机制及最佳手术方式。方法：雄性家犬１２ 只,制备成脊髓损伤后痉挛性膀胱模型,根据骶神经切断方式分为Ａ、Ｂ、Ｃ、Ｄ４ 组,通过尿流动力学检测及电生理观察,记录并计算骶神经切断前（ 对照组）及术后各组各项功能性指标的变化,并进行比较分析。结果：Ａ、Ｂ、Ｃ、Ｄ４ 组术后膀胱容量均明显高于术前对照组,尿道压力均低于术前对照组,其中Ｂ 组的膀胱贮尿功能、排空能力、尿道压力均接近正常,且对犬阴茎勃起功能无明显影响。结论：高选择性骶神经根切断治疗脊髓损伤后痉挛性膀胱有确实明显的疗效,是一种值得研究的新方法。     

Neuromodulation for voiding dysfunction and fecal incontinence: a urology perspective

Neuromodulation is an effective, minimally invasive technique for the management of urinary urgency and frequency, urgency incontinence, nonobstructive urinary retention, and fecal incontinence. This article reviews the physiology of neuromodulation, indications, implantation methods, and outcomes.     

Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis

Context

Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear.

Objective

To assess the efficacy and safety of SNM for neurogenic LUTD.

Evidence acquisition

Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis.

Evidence synthesis

Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half (n = 13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase (n = 4) or permanent SNM (n = 9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50–87) and 92% (95% CrI, 81–98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0–2%) for the test phase and 24% (95% CrI, 6–48%) for permanent SNM.

Conclusions

There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.     

Digital rectal stimulation as an intervention in persons with spinal cord injury and upper motor neuron neurogenic bowel. An evidenced-based systematic review of the literature

Context: Need for evidential support of practice guideline recommendations for management of neurogenic bowel management in adults with spinal cord injury.Objective: To determine evidence for digital rectal stimulation (DRS) as an intervention in the management of upper motor neuron neurogenic bowels (UMN-NB) in persons with spinal cord injury (SCI).Methods: A systematic review of the literature including research articles and practice guidelines evaluating upper motor neuron neurogenic bowel treatments and the use of digital rectal stimulation was performed using OvidMedline, PubMed and the Cochrane database and included research articles and practice guidelines. Limitations were made related to English language, patient age and focus on spinal cord injured patients. Strength of evidence was assessed using the Johns Hopkins Nursing evidence-based practice model.Results: Eleven articles were included in the systematic review. Only one used DRS as a primary intervention. There was moderate evidence for DRS in persons with SCI and UMN-NB. There was evidence of the physiologic effect of DRS and support for combining DRS with other treatment regimens.Conclusion: There is insufficient evidence to promote any one intervention for the management of UMN-NB. The promotion of DRS, and education as to the proper technique for DRS should remain an emphasis of education of home management of UMN-NB in persons with SCI. Future research should focus on the use of standardized, validated tools to evaluate management techniques for UMN-NB.     

骶神经调节治疗慢性排尿功能障碍二例报告

目的　探讨骶神经调节治疗慢性排尿功能障碍的疗效与安全性。　方法　采用骶神经调节技术治疗 2例慢性排尿功能障碍患者 ,通过排尿日记和症状改善评价疗效。　结果　经皮穿刺测试结果表明 :例 1患者每日排尿次数降低 7.3% ,排尿量增加 118.2 % ,尿急程度减轻 72 .0 % ;例 2患者排尿次数降低 34.3% ,排尿量增加 6 5 .7% ,尿急程度减轻 6 8.1%。 2例分别随访 2 6和 17个月 ,各项排尿参数持续改善 ,例 1排尿次数减少 4 6 .8% ,排尿量增加 4 5 .3% ,尿急程度减轻 6 7% ;例 2排尿次数减少 39.7% ,排尿量增加 6 5 .6 % ,尿急程度减轻 86 %。随访期未发现并发症。　结论　骶神经调节是一种创伤小、安全、有效治疗慢性排尿功能障碍的方法 ,对某些神经原性膀胱尿道功能障碍有一定疗效。     

Electrical stimulation for the treatment of lower urinary tract dysfunction after spinal cord injury

Electrical stimulation for bladder control is an alternative to traditional methods of treating neurogenic lower urinary tract dysfunction (NLUTD) resulting from spinal cord injury (SCI). In this review, we systematically discuss the neurophysiology of bladder dysfunction following SCI and the applications of electrical stimulation for bladder control following SCI, spanning from historic clinical approaches to recent pre-clinical studies that offer promising new strategies that may improve the feasibility and success of electrical stimulation therapy in patients with SCI. Electrical stimulation provides a unique opportunity to control bladder function by exploiting neural control mechanisms. Our understanding of the applications and limitations of electrical stimulation for bladder control has improved due to many pre-clinical studies performed in animals and translational clinical studies. Techniques that have emerged as possible opportunities to control bladder function include pudendal nerve stimulation and novel methods of stimulation, such as high frequency nerve block. Further development of novel applications of electrical stimulation will drive progress towards effective therapy for SCI. The optimal solution for restoration of bladder control may encompass a combination of efficient, targeted electrical stimulation, possibly at multiple locations, and pharmacological treatment to enhance symptom control.     

Novel trends in pain management – Neuromodulation

Neuromodulation is one of the most exciting developments in pain management. Spinal cord stimulation, peripheral nerve stimulation and intrathecal drug delivery systems are used increasingly to provide pain relief and improve the quality of lives of patients in whom conventional medical management has failed to provide satisfactory results. Though initial costs may be high, these techniques have proven to be cost effective in the long term. A good understanding of the principles and techniques involved in neuromodulation and their benefits and limitations is essential to achieve best results.