脊柱裂患者的影像尿动力学特点分析

目的分析脊柱裂患者的影像尿动力学特点，探讨其发生上尿路损害的尿动力学危险因素。方法33例脊柱裂患者采用非完全同步影像尿动力学方法评估患者的膀胱尿道功能，了解膀胱的感觉、稳定性、顺应性、相对安全容量、逼尿肌漏尿点压力、有无膀胱输尿管返流等储尿功能参数，以及排尿期逼尿肌压力、有无逼尿肌内外括约肌协同失调（DSD）等排尿功能参数。将患者按照有无肾积水或返流、肾功能损害分为上尿路损害组和非损害组，统计比较各组中尿动力学参数的差异。结果脊柱裂患者上尿路损害的发生率约为51％（17／33），其中膀胱输尿管返流发生率为33％（11／33），无返流性肾积水发生率为18％（6／33）。在肾积水患者中，64．7％具有膀胱输尿管返流。上尿路损害组的膀胱顺应性和相对安全容量等参数与非损害组相比差异具有显著性（P〈0．05）。结论脊柱裂患者具有较高的上尿路损害发生率，其中膀胱输尿管返流占较大比例。膀胱顺应性下降及相对安全容量小可能是患者发生上尿路损害的主要尿动力学危险因素。     

骶髓下脊髓损伤患者尿动力学特点与处理

目的分析研究骶髓下脊髓损伤患者尿动力学特点,随访泌尿系康复治疗方法及疗效。方法回顾性分析骶髓下脊髓损伤患者169例影像尿动力检查结果和泌尿系管理方法,观察其泌尿系变化及并发症的发生情况。结果 129例(76.33%)表现为逼尿肌无反射,其中46例(27.22%)表现为膀胱顺应性增加,12例(7.10%)出现膀胱输尿管返流;21例(12.43%)表现为逼尿肌过度活动,膀胱顺应性下降,其中5例(2.96%)出现膀胱输尿管返流。根据尿动力检查结果选择不同的治疗方法,2年随访治疗效果满意,无特殊并发症。结论骶髓下脊髓损伤患者大多表现为逼尿肌无反射,膀胱顺应性增加。根据尿动力检查结果选择适当的综合康复治疗手段,能有效保护上尿路功能,预防泌尿系感染等并发症的出现。     

脑血管意外后排尿障碍患者影像尿动力学分析

目的分析脑血管意外对下尿路功能的影响。方法回顾性分析19例脑血管意外后排尿障碍患者、19例同期胸椎脊髓损伤患者的影像尿动力学检查结果,比较两组患者膀胱逼尿肌和尿道外括约肌功能障碍的特点。结果脑血管意外排尿障碍患者以逼尿肌反射亢进为主,膀胱顺应性下降,尿道外括约肌多为松弛状态,逼尿肌反射亢进患者病灶集中于基底节和额叶;胸椎脊髓损伤患者影像尿动力检查与之有差异。结论脑血管意外后排尿障碍患者影像尿动力学改变以逼尿肌反射亢进和尿道外括约肌松弛为主,与胸椎脊髓损伤后导致的神经源性膀胱影像尿动力学检查差异明显。     

尿流动力学检查在胸腰段脊髓损伤神经源性膀胱输尿管返流评估中的意义

目的探讨尿流动力学在胸腰段脊髓T10～L2损伤神经源性膀胱合并输尿管返流患者评估中的临床意义。 方法选取胸腰段脊髓损伤T10～L2排尿障碍合并膀胱输尿管返流患者26例,经膀胱尿道造影成像联合尿流动力学检测,将其分为逼尿肌反射亢进组（n=21）和逼尿肌无反射组（n=5）,并对2组在输尿管返流点和漏尿点的膀胱容量、逼尿肌压以及膀胱顺应性进行测定,应用SPSS 14.0进行数据处理和分析。 结果经膀胱尿道造影成像联合尿流动力学检测发现,逼尿肌反射亢进组患者输尿管返流点的膀胱容量和顺应性分别为（122.46±87.89）ml和（5.94±4.96）ml/H2O,与逼尿肌无反射组比较,差异均有统计学意义（P<0.01）;逼尿肌反射亢进组患者膀胱漏尿点的膀胱容量、逼尿肌压和顺应性分别为（210.81±69.72）ml、（42.29±9.57）cm H2O和（9.53±5.43）ml/H2O,与逼尿肌无反射组比较,差异均有统计学意义（P<0.01）;且逼尿肌反射亢进组输尿管返流点的逼尿肌压与组内膀胱漏尿点的逼尿肌压比较,差异亦有统计学意义（P<0.01）。 结论T10～L2脊髓损伤神经源性膀胱逼尿肌反射亢进患者在膀胱容量较小、顺应性较低,伤后早期即出现膀胱输尿管返流,发生返流时逼尿肌压<40cm H2O;而逼尿肌无反射患者在逼尿肌压较低时亦会出现输尿管返流和膀胱漏尿。     

脊髓损伤后膀胱尿动力学检查及分类

尿动力学检查已成为脊髓损伤后膀胱尿道功能障碍的常规检查技术,列举脊髓完全损伤后膀胱典型的尿动力学表现及不同部位、程度和时期的脊髓损伤所致的非典型的逼尿肌、括约肌功能障碍与其相应的尿动力学表现。目前 ,依据尿动力学检查对膀胱尿道功能障碍的分类方案较多 ,以Krane分类方案 (逼尿肌反射亢进与逼尿肌无反射 )应用为主。通过尿动力学检查可对膀胱尿道功能障碍进行分类外 ,还可为临床的诊断、治疗及疗效评价提供更多的客观指标。     

脊髓损伤患者泌尿系结石形成高危因素分析:128例报道

目的探讨影响脊髓损伤患者泌尿系结石形成的高危因素及其防治措施。方法回顾性分析128例脊髓损伤后泌尿系结石患者的临床资料及治疗方法。结果 128例患者中,膀胱造瘘32例,留置尿管定期更换34例,间歇导尿12例,叩击排尿19例,腹压排尿11例,间断尿失禁应用外部集尿器20例。128例患者中120例存在泌尿系感染,11例血钙升高。影像尿动力学提示逼尿肌无反射39例,逼尿肌过度活动63例,逼尿肌-尿道外括约肌协同失调41例,逼尿肌-膀胱颈协同失调11例,尿道外括约肌过度活动27例,尿道括约肌功能不全11例。部分患者同时存在数种上述病理生理状况。结论膀胱管理方式对脊髓损伤后泌尿系结石的形成有重要影响,脊髓损伤后下尿路感染、逼尿肌-尿道外括约肌协同失调等下尿路功能障碍、长期留置尿管和膀胱造瘘是泌尿系结石形成的高危因素。钙代谢异常可能是诱发泌尿系结石形成的高危因素之一。     

单纯间歇导尿改善神经源性膀胱并发上尿路扩张积水12例报道

目的探讨单纯间歇导尿改善神经源性膀胱患者上尿路扩张积水的影像尿动力学适应症。方法回顾性分析2008年1月至2016年6月采用单纯间歇导尿处理的12例神经源性膀胱并发上尿路扩张积水患者的临床资料。结果经系统规律随访,本组患者肾积水均得到缓解或消失。其影像尿动力学共同特点为无逼尿肌过度活动,测压容积300 ml,储尿期末逼尿肌压力40cm H2O,无膀胱输尿管返流,排空差,腹压排尿,残余尿150 ml。结论对于储尿功能尚可,主要表现为排尿障碍的神经源性膀胱并发上尿路扩张积水患者,建议首选间歇导尿。     

非完全同步影像尿动力学检查在临床诊断中的应用

目的 探讨非完全同步影像尿动力学检查的临床应用意义。方法 采用Laborie尿动力学检查仪和Toshiba放射检查床，对128例患者进行非完全同步影像尿动力学检查(一般取截石位及斜坐位)，其中脊髓损伤92例(71．9％)、骶裂5例(3．9％)、尿失禁8例(6．2％)、排尿困难2例(1．6％)、前列腺增生21例(16．4％)。灌注液中泛影葡胺含量为15％，灌注速度10—20ml／min，检查方法同普通尿动力学检查，记录膀胱压力(Pves)、直肠压力(Pabd)、逼尿肌压力(Pdet)、尿流率(Q)和肌电图等参数，采用膀胱储尿期及排尿期同步透视，点拍摄放射片4次，记录并保存影像。结果 发现膀胱输尿管返流6例(4．7％)、膀胱结石18例(14．1％)、膀胱憩室35例(27．3％)、膀胱颈开放78例(60．9％)、逼尿肌膀胱颈协同失调23例(18．0％)、逼尿肌尿道外括约肌协同失调59例(46．1％)、外括约肌痉挛31例(24．2％)。结论 非完全同步影像尿动力学检查能够利用现有设备进行影像尿动力学检查，对全面了解神经原性膀胱尿道功能障碍及LUTS患者的下尿路病理生理改变有重要价值。     

肉毒毒素注射尿道外括约肌对逼尿肌 尿道外括约肌失协调患者逼尿肌厚度的影响

目的 观察肉毒毒素A（BTX-A）注射尿道外括约肌对脊髓损伤后逼尿肌-尿道外括约肌收缩失协调（DSD）患者逼尿肌厚度及膀胱功能的影响。 方法 选取脊髓损伤后DSD成年患者21例,所有患者均在会阴超声引导下向尿道外括约肌注射BTX-A（100U）。于治疗前、治疗后4周、8周时进行尿动力学检查和下尿道超声评估,测定患者逼尿肌厚度、逼尿肌漏尿点压、残余尿量及最大膀胱容量。 结果 治疗后4周时入选患者残余尿量显著下降（P<0.05）,而逼尿肌厚度、逼尿肌漏尿点压及最大膀胱容量均无明显改变（P>0.05）。治疗后8周时入选患者逼尿肌厚度为（0.93±0.17）mm,较治疗前下降了17.2%（P<0.05）;逼尿肌漏尿点压、残余尿量及最大膀胱容量亦较治疗前明显改善（P<0.05）。 结论 在超声引导下向尿道外括约肌注射BTX-A可显著降低脊髓损伤后DSD患者逼尿肌厚度,改善膀胱功能,该疗法值得临床推广、应用。     

神经源性膀胱远期尿动力学变化的临床研究

目的:探讨神经源性膀胱的远期尿动力学变化及其影响因素。方法:72例入院超过 5年的神经源性膀胱患者采用尿动力学检查仪和肌电图测定有关尿动力学指标,同时配合B超及膀胱尿道造影(VCUG)观测尿液反流与形态学改变,比较入院前后及不同排尿方式的尿动力学变化。结果:残余尿量、最大尿流率、最大膀胱容量、相对安全容量(RSBC)、最大尿道闭合压、功能尿道长度及逼尿肌反射亢进、括约肌协同失调发生率等指标均较入院时降低(P<0.05),而膀胱低顺应性(BLG)与尿路积水发生率较入院时明显升高(P< 0.01),逼尿肌漏点压及安全容量下膀胱充盈压(FBP)则无显著变化。VCUG显示采用持续导尿者BLG及尿液反流发生率明显高于采用间隙导尿或 Crede法排尿者(P<0.01),且尿道形态学改变程度最重;尿液反流组RSBC明显低于非反流组(P<0.05),而BLG的发生率显著高于非反流组(P<0.01),FBP等相关指标两组差异无统计学意义(P>0.05)。结论:神经源性膀胱的远期尿动力学特点主要是膀胱顺应性降低,而排尿方式是较膀胱内压影响尿液反流与尿道形态改变的更重要因素。     

脊髓损伤后神经原性膀胱的功能康复

脊髓损伤后 ,神经原性膀胱的功能康复以非手术治疗为主。间歇导尿感染率低 ,并发症少 ,是目前最常用的尿液引流方法。抗胆碱能药物能提高膀胱顺应性和排尿节制功能。经尿道球囊扩张术和经尿道留置支架外括约肌成形术能有效改善尿道外括约肌痉挛 ,是很有发展前景的新技术。科学的膀胱再训练能促进自主排尿节律的建立。     

Association of bladder trabeculation and neurogenic bladder with spinal cord injury

ObjectiveTo compare clinical findings and urodynamic parameters according to trabeculation grade and analyze their correlations with trabeculation severity in neurogenic bladder caused by suprasacral spinal cord injury (SCI).MethodsA retrospective chart review was performed of neurogenic bladder caused by SCI. Bladder trabeculation grade was compared with SCI-related clinical parameters and bladder-related urodynamic parameters.ResultsIn SCI patients, factors such as disease duration, bladder capacity, detrusor pressure, peak detrusor pressure values, and compliance were significantly different between different grades of bladder trabeculation, while neurological level of injury, completeness, and detrusor sphincter dyssynergia had no clear relationship with bladder trabeculation grade. In the correlation analysis, vesicoureteral reflux was moderately correlated with trabeculation grade (correlation coefficient 0.433), while the correlation coefficients of disease duration, involuntary detrusor contraction, and bladder filling volume were between 0.3 and 0.4.ConclusionBladder trabeculation with suprasacral-type neurogenic bladder was graded. Although disease duration was positively correlated with bladder trabeculation grade, differences in the neurological level of injury or American Spinal Injury Association Impairment Scale score were not observed. Bladder volume, peak detrusor pressure, compliance, reflex volume, and vesicoureteral reflux also showed significant differences according to trabeculation grade. Vesicoureteral reflux was moderately correlated with trabeculation grade.     

网状尿道支架治疗神经原性下尿路功能障碍13例

目的：观察网状尿道支架植入术对神经原性下尿路功能障碍的治疗效果。方法：对13例神经原性下尿路功能障碍患者行网状尿道支架后尿道植入术，对比手术前后排尿功能、剩余尿量、肾积水程度、血清肌酐及尿素氮等指标的变化，评定手术对神经原性下尿路功能障碍的治疗效果。结果：13例患者中，7例术后能控制排尿，6例形成尿失禁，2例因术后不能耐受支架对尿道的刺激而取出支架，1例因术后仍存在排尿困难而行支架2次植入。所有患者的血清肌酐、尿素氮变化不明显，而剩余尿量和肾积水改善明显。结论：对神经原性下尿路功能障碍、逼尿肌-外括约肌协同失调患者，尿道支架植入术可显著减少残余尿量，改善肾盂积水状态。     

脊髓重复磁刺激对骶上脊髓损伤后神经源性膀胱的影响

目的观察脊髓重复磁刺激对骶上脊髓损伤(SCI)后神经源性膀胱患者下尿路功能和生活质量的影响。方法纳入骶上SCI后膀胱功能无再改善的神经源性膀胱患者15例。试验采取前、后对照设计, 第一阶段, 为期2周, 期间所有患者只接受饮水计划和间歇导尿治疗;第二阶段, 为期4周, 所有患者在饮水计划和间歇导尿的基础上增加脊髓重复磁刺激干预, 刺激位于第1腰椎棘突水平, 刺激频率1 Hz, 每日1次, 每周5 d, 连续干预4周。于入组时、第2周结束时和第6周结束时, 记录15例患者的排尿日记, 并分别对其进行尿流动力学检测, 以及神经源性膀胱症状评分(NBSS)和生活质量评分。结果第6周结束时, 15例患者的导尿次数和平均自排尿量与第2周结束时和入组前比较, 差异均有统计学意义(P<0.01)。第6周结束时, 15例患者的储尿期最大逼尿肌压, 最大膀胱容量, 排尿期最大尿道压和排尿效率与第2周结束时和入组前比较, 差异均有统计学意义(P<0.01)。第6周结束时, 15例患者的NBSS和生活质量评分分别为(23.80±6.88)分和(3.53±1.36)分, 与第2周结束时和入组时比较...     

大鼠完全脊髓横断损伤膀胱功能障碍模型的建立及评价

目的:建立和标准化一个骶髓上完全脊髓横断损伤引起的膀胱功能障碍的大鼠模型。方法:在16只成年雌性Sprague-Dawley大鼠脊髓T9—T11处进行椎板切除,造成完全脊髓横断。采用术后每天手动按摩膀胱排尿的尿量变化和脊髓损伤大鼠与健康大鼠的两组膀胱内压图比较来进行评价。6只鼠作为健康对照。结果:通过术后护理降低并发症。术后每天进行按摩排尿,尿量不断上升,1周左右达到峰值,之后开始下降。对健康大鼠和脊髓损伤大鼠的膀胱以相同灌注速度持续灌注生理盐水,正常大鼠的膀胱呈现稳定的周期性排尿收缩活动,而脊髓损伤大鼠在膀胱内压持续升高后产生重复性强烈的排尿收缩。结论:在脊髓休克期结束之后的脊髓恢复期内,所有脊髓损伤模型的大鼠膀胱都呈现逼尿肌—括约肌协同失调症状。本实验成功地建立了大鼠完全性脊髓损伤引起的膀胱功能障碍的模型,此模型简单经济,为进一步研究脊髓损伤下膀胱功能障碍的电刺激调节和康复提供了有价值的大鼠模型。     

Clean intermittent self-catheterization in neuro-urology

Neurogenic lower urinary tract dysfunction (NLUTD) is commonly encountered in rehabilitation settings, and is caused by a variety of pathologies. The management of spinal cord injury (SCI) has been the model of reference for the management of other pathologies with NLUTD. The introduction of intermittent catheterization (IC) led to decline in renal related mortality in SCI patients and allowed an improvement of quality of life (QoL) in all neurogenic patients with NLUTD. IC could be sterile, aseptic or clean. Sterile intermittent catheterization (SIC) is the preferred method of bladder drainage in emergency medicine units and during spinal shock in SCI patients, but it is costly and time-consuming. Catheterizations performed in institutions, such as rehabilitation hospitals and nursing homes, are done aseptically. Clean intermittent catheterization (CIC), i.e. self-catheterization (CISC) or third party catheterization, represents the "gold standard" method for bladder emptying in all neuropathic patients with NLUTD: the technique is safe and effective and results in improved kidney and upper urinary tract status, lessening of vesico-ureteral reflux and amelioration of urinary continence. CISC is mandatory in patients with NLUTD secondary to detrusor areflexia/hypocontractility and in patients suffering from neurogenic detrusor overactivity with detrusor external sphincter dyssynergia and high post void residual of urine, often in combination with antimuscarinics/bladder relaxants. The review summarizes the most important aspects of IC and CISC. Attention was focused on the history of urethral catheterization, aims, materials, advantages, indications, and present-day techniques of CISC, emphasizing the importance of teaching in order to perform correctly the catheterization technique.     

Management of detrusor external sphincter dyssynergia in neurogenic bladder

Spinal cord injury (SCI) affects 11.5 to 53.4 individuals per million of the population in developed countries each year. SCI is caused by trauma, although it can also result from myelopathy, myelitis, vascular disease or arteriovenous malformations and multiple sclerosis. Patients with complete lesions of the spinal cord between spinal cord level T6 and S2, after they recover from spinal shock, generally exhibit involuntary bladder contractions without sensation, smooth sphincter synergy, but with detrusor striated sphincter dyssynergia (DESD). Those with lesions above spinal cord level T6 may experience, in addition, smooth sphincter dyssynergia and autonomic hyperreflexia. DESD is a debilitating problem in patients with SCI. It carries a high risk of complications, and even life expectancy can be affected. Nearly half of the patients with untreated DESD will develop deleterious urologic complications, due to high intravesical pressures, resulting in urolithiasis, urinary tract infection (UTI), vesicoureteral reflux (VUR), hydronephrosis, obstructive uropathy, and renal failure. The mainstay of treatment is the use of antimuscarinics and catheterization, but in those for whom this is not possible external sphincterotomy has been a last resort option. External sphincterotomy is associated with significant risks, including haemorrhage; erectile dysfunction and the possibility of redo procedures. Over the last decade alternatives have been investigated, such as urethral stents and intrasphincteric botulinum toxin injection. In this review, we will cover neurogenic DESD, with emphasis on definition, classifications, diagnosis and different therapeutic options available.     

Intermittent catheterization failure and an approach to bladder rehabilitation in spinal cord injury patients

Forty-six patients with spinal injury with dysfunctional neurogenic bladder were analyzed. Fourteen patients on prolonged intermittent catheterization from 12 weeks to more than 1 year did not develop a balanced bladder, 14 patients had indwelling catheters after intermittent catheterization failed elsewhere and 18 patients on external condom drainage presented with difficult voiding and repeated infections. There were 16 quadriplegics (1 incomplete), 21 paraplegics, and 9 incomplete cauda equina lesions. Urologic and urodynamic evaluation revealed detrusor-sphincter dyssynergia in 15 patients, vesicoureteral reflux in 10, and areflexic bladders in 11. Five patients over the age of 55 years showed slight enlargement of the prostrate. Some degree of bladder neck fibrosis was suspected in 26. More than one urologic pathology was encountered in the same patient. Transurethral sphincterotomy was carried out in 38 patients and only one transurethral resection of the prostrate (TURP) in an incomplete quadriplegic patient. In seven patients with no obvious urodynamic abnormality, a balanced bladder was achieved with intermittent catheterization; however, one of these patients needed a transurethral sphincterotomy on subsequent admission. A balanced bladder was achieved in all patients except the one with incomplete quadriplegia. Significant improvement in vesicoureteral reflux and relief from autonomic dysreflexic symptoms were recorded in all patients.     

An implantable neuroprosthesis for restoring bladder and bowel control to patients with spinal cord injuries: a multicenter trial.

OBJECTIVE: To evaluate the safety and efficacy of an implanted neuroprosthesis for management of the neurogenic bladder and bowel in individuals with spinal cord injury (SCI). DESIGN: Prospective study comparing bladder and bowel control before and at 3, 6, and 12 months after implantation of the neuroprosthesis. SETTING: Six US hospitals specializing in treatment of SCI. PATIENTS: Twenty-three neurologically stable patients with complete suprasacral SCIs. INTERVENTION: Implantation of an externally controlled neuroprosthesis for stimulating the sacral nerves and posterior sacral rhizotomy. MAIN OUTCOME MEASURES: Ability to urinate more than 200mL on demand and a resulting postvoid residual volume of less than 50mL. RESULTS: At 1-year follow-up, 18 of 21 patients could urinate more than 200mL with the neuroprosthesis, and 15 of 21 had postvoid volumes less than 50mL (median, 15mL). Urinary tract infection, catheter use, reflex incontinence, anticholinergic drug use, and autonomic dysreflexia were substantially reduced. At 1-year follow-up, 15 of 17 patients reduced the time spent with bowel management. CONCLUSIONS: Neural stimulation and posterior rhizotomy is a safe and effective method of bladder and bowel management after suprasacral SCI.     

Detrusor-sphincter dyssynergia and botulinum toxin]

OBJECTIVE: Botulinum toxin (BT) injection into the external urethral sphincter is a promising therapy for neurogenic voiding disorders due to detrusor-sphincter dyssynergia (DSD). However the optimal treatment protocol remains unclear. METHOD: A PubMed reference search and manual bibliography review were performed, along with a search in the Annales de réadaptation et de médecine physique and in the reports of the International French-language Society of Urodynamics and the International Continence Society, which allowed us to select twelve pertinent articles with PubMed, two articles from the Annales and two conference reports. Our analysis gave special emphasis to assessment criteria, application, dosage and BT injection technique. RESULTS: Used for the first time in 1988 in spinal cord injury patients to reduce outflow obstruction due to DSD, BT injections have been shown to be a valuable alternative management of bladder dysfunction with DSD. They have been proposed in neurological patients unable to perform self-catheterisation, after drug failure and before surgery. Parameters for results assessment are mostly clinical (increased free interval between voiding, decreased post-void residual urine volumes), urodynamic (improvement in bladder emptying, increase in functional bladder capacity and decrease in urethral pressure) and electromyographic (denervation of striated urethral sphincter). The literature data regarding type of BT, dosage and protocol vary widely. Duration of action is from 2 to 12 months. Both transurethral and transperineal injections monitored by EMG are equally effective in improving detrusor-sphincter dyssynergia. CONCLUSION: With few side effects and satisfactory medium-term results, BT should be recommended as a component of DSD therapies. We propose a practical method for BT use.