利用膀胱黏膜肠浆肌层膀胱扩大术的尿动力学评价

目的　评价利用膀胱黏膜双层小肠浆肌层膀胱扩大术后的尿动力学表现。　方法　 2 5例逼尿肌反射亢进型神经性膀胱患者行利用膀胱黏膜的小肠浆肌层膀胱扩大术。男 16例 ,女 9例。年龄 4～ 14岁。 2 1例获随访 6～ 2 4个月。手术前后行IVU、尿动力学检查及临床评价。　结果　手术后膀胱容量 (2 4 2 .6 2± 6 0 .0 4 )ml、膀胱顺应性 (8.10± 3.0 0 )ml/cmH2 O(1cmH2 O =0 .0 98kPa)、最大尿流率 (7.6 0± 2 .90 )ml/s均较术前 [分别为 (14 2 .14± 4 5 .88)ml、(3.2 6± 1.5 7)ml/cmH2 O、(3.0 0± 1.0 0 )ml/s]增加 ,逼尿肌压力降低 [术前 (5 2 .0 0± 14 .11)cmH2 O、术后 (33.33± 15 .39)cmH2 O],剩余尿 /膀胱容量较术前减小 (术前 0 .33± 0 .11、术后 0 .16± 0 .10 ) ,P均 <0 .0 1。逼尿肌括约肌不协调和尿道闭合压无改变 ,无抑制收缩减轻。 7例恢复尿意 ,9例输尿管返流减轻。　结论　利用膀胱黏膜的双层肠浆肌层膀胱扩大术可增加膀胱容量及顺应性 ,降低逼尿肌压 ,减轻逼尿肌反射亢进的程度。逼尿肌括约肌不协调、逼尿肌反射亢进、尿道闭合压低是影响临床结果的主要因素。     

膀胱扩大术联合康复训练治疗反射亢进型神经源性膀胱

目的探讨回肠浆肌层补片代膀胱扩容术联合康复训练治疗反射亢进型神经源性膀胱的疗效。方法回顾分析2008年7月-2013年6月收治并获完整随访的61例反射亢进型神经源性膀胱患者临床资料。男36例,女25例;年龄6~23岁,平均10岁。导致神经源性膀胱原因:脊髓脊膜膨出术后43例,腰骶椎椎管内脂肪瘤术后4例,胸腰椎椎管内畸胎瘤2例,腰骶椎脊柱裂12例。尿流动力学检查示:膀胱容量减小,残余尿量增多。排尿性膀胱尿道造影(voiding cystourethrography,VCUG)示:合并Ⅴ级输尿管返流6例(10侧),Ⅳ级7例(12侧),Ⅲ级6例(8侧)。彩超检查示:轻度肾积水23例(41侧),中度25例(42侧),重度13例(22侧)。13例术前血生化检查提示肾功能不全。采取回肠浆肌层补片代膀胱扩容术,术后指导康复功能训练。结果手术时间(157±26)min,术中出血量(43±15)m L,术中均未输血。患者均获随访,随访时间1.5~6.0年,平均4.5年。术后4例并发膀胱瘘,5例次泌尿系感染,2例出现排尿困难症状,1例膀胱结石形成。术后1年,国际尿失禁咨询委员会尿失禁问卷表(ICIQ-SF)评分显著优于术前(H=89.813,P=0.000)。尿流动力学检查示:实测膀胱容量与理论膀胱容量差值、膀胱残余尿量、膀胱顺应性、最大尿流率及充盈末期逼尿肌压力均优于术前(P0.05)。彩超复查示:轻度肾积水34例(56侧),中度18例(33侧),重度9例(16侧)。VCUG复查提示:膀胱容量增加,补片处均良好成活并黏膜化,未发现膀胱挛缩患者;输尿管返流较术前改善。13例术前慢性肾功能不全患者术后肾功能明显好转。患者尿常规复查均未见黏液丝异常增高。结论回肠浆肌层补片代膀胱扩容术联合康复功能训练治疗反射亢进型神经源性膀胱可获得较好疗效。     

组织工程补片膀胱扩大术治疗神经源性膀胱的疗效分析

目的 探讨使用小肠黏膜下层(small intestinal submucosa,SIS)组织工程材料补片行膀胱扩大术治疗神经源性膀胱的可行性和有效性. 方法 2011年1月至2014年3月收治14例神经源性膀胱患者,男10例,女性4例.年龄14～65岁,平均29岁.脊髓发育不良8例,脊髓损伤6例.尿动力学检查:最大膀胱测压容量平均为(150.1±64.2) ml,膀胱顺应性平均为(5.2±3.9)ml/cmH2O(1 cmH2O=0.098 kPa),最大逼尿肌压力平均为(44.1±29.2) cmH2O.14例均接受SIS组织工程补片膀胱扩大术,术中将补片锁边缝合至纵向剖开的膀胱浆肌层,达到扩大膀胱的目的,其中7例同期行输尿管抗反流再植术.对术后并发症、影像尿动力学检查参数、尿路核磁水成像及肾功能进行观察评价. 结果 本组14例手术均顺利完成,手术时间平均为120 min.患者术后无代谢紊乱.复查肌酐水平均正常.术后随访6～48个月,平均24个月.尿动力学检查术后6、12、24个月最大膀胱测压容量分别为(274.9±88.7)、(322.5± 144.4)、(279.9± 157.9) ml,与术前比较差异有统计学意义(P＜0.05);术后12、24个月最大逼尿肌压力为(20.1±9.8)、(20.2± 19.1) cmH2O,与术前比较差异有统计学意义(P＜0.05);术后24个月膀胱顺应性为(26.1±29.4) ml/cmH2O,与术前比较差异有统计学意义(P＜0.05).术后1个月,2例出现膀胱吻合口尿外渗,更换导尿管引流通畅后愈合.术后3个月,1例出现膀胱结石,行经尿道取石术后未再复发.术后12个月,4例出现膀胱输尿管反流,其中2例予膀胱逼尿肌A型肉毒素注射术,术后留置尿管3个月复查反流消失;2例保留导尿,口服琥珀酸索利那新(5 mg,2次/d)和酒石酸托特罗定(4 mg,1次/d)6个月后,1例反流消失,1例仍存在反流.结论 SIS组织工程补片用于膀胱扩大术可达到有效增加膀胱容量的目的.生物工程补片的使用为治疗神经源性膀胱提供了新的选择.     

腰椎术后排尿功能障碍患者尿动力学改变及治疗

目的：探讨腰椎术后排尿功能障碍患者的尿动力学改变及治疗方法。方法：对27例腰椎术后排尿功能障碍患者行尿动力学检查，根据检查结果，对逼尿肌反射亢进、膀胱感觉过敏、逼尿肌反射减弱但膀胱容量缩小、逼尿肌漏尿点压力超过40cmH2O的患者先采用M受体阻滞剂或肉毒毒素A膀胱壁注射治疗．待膀胱有足够大的容量、能够低压储尿时再应用间歇导尿、留置导尿等方法在无膀胱内高压的条件下实现膀胱的完全排空；逼尿肌无反射和逼尿肌外括约肌协同失调患者选择间歇导尿。结果：27例患者中逼尿肌反射亢进2例，逼尿肌无反射18例，逼尿肌反射减弱7例；排尿期膀胱颈开放7例，部分开放12例，未开放8例；外括约肌痉挛24例，逼尿肌和外括约肌协同失调3例：无膀胱输尿管返流22例，右侧膀胱输尿管返流1例，左侧膀胱输尿管返流2例，双侧膀胱输尿管返流2例；10例患者逼尿肌漏尿点压力超过40cmH2O。10例逼尿肌反射亢进或膀胱容量缩小的患者中7例采用M受体阻滞剂治疗后膀胱容量均增加；3例M受体阻滞治疗无效改用肉毒毒素A膀胱壁注射治疗后膀胱容量均增加；逼尿肌无反射患者首选间歇导尿。结论：腰椎手术后发生排尿障碍的患者应行尿动力学检查，并以尿动力学结果为基础决定处理方案。     

回肠膀胱扩大术联合髂腰肌盆底肌加强术治疗神经源性膀胱的疗效分析

目的 探讨去黏膜带蒂回肠膀胱扩大术联合髂腰肌盆底肌加强术治疗神经源性膀胱的疗效.方法 前瞻性研究去黏膜带蒂回肠膀胱扩大联合髂腰肌盆底肌加强术治疗神经源性膀胱的疗效.神经源性膀胱患者12例.男9例,女3例.年龄18 ～ 27岁,平均25岁.临床表现为不同程度的尿失禁.病程6 ～ 64个月,平均23个月.应用超声、膀胱造影、尿动力学等检查前瞻性比较术前和术后1年的尿动力学参数,上尿路形态和肾功能情况.结果 12例手术顺利.术后出现切口延迟愈合2例,肠梗阻1例,膀胱腹壁尿瘘1例,未出现黏液尿.术后1年1例因发热性泌尿系感染行自我清洁间歇导尿,11例为腹压排尿.术前膀胱输尿管反流8例,术后反流消失5例,反流程度改善3例.术前肾功能不全5例,术后血肌酐水平下降至正常范围3例.术前和术后1年最大膀胱压测定容量[( 247±27)和(412±32) ml]、膀胱顺应性[(4.4±1.2)和(26.2±4.0)ml/cm H2O,1 cm H2O =0.098 kPa]、相对安全容量[(206±24)和(368±26) ml]、最大尿流率[(11±2)和(20±3)ml/s]、残余尿量[(136±25)和(26±8)ml]、逼尿肌漏点压[(63.1±4.9)和(17.8±3.6)cm H2O]比较差异均有统计学意义(P＜0.05).结论 去黏膜带蒂同肠浆肌层膀胱扩大联合髂腰肌盆底肌加强术可有效治疗神经源性膀胱.     

乙状结肠膀胱扩大术治疗神经源性低顺应性膀胱6例疗效观察

目的：探讨乙状结肠膀胱扩大术治疗神经源性低顺应性膀胱的疗效。方法：6例神经源性低顺应性膀胱患者行乙状结肠膀胱扩大术及双侧输尿管膀胱再植术。男5例,女1例。年龄16-40岁,病程5～20年。其中3例脊髓损伤,3例脊髓栓系。术后均自行间歇清洁导尿。结果：6例患者均随诊,术后B超示肾积水,较术前缓解或消失,血清肌酐水平较术前明显降低,尿动力学示膀胱容量为（458．6±37．2）ml,充盈期末膀胱内平均压为（17．8±4．6）cmH2O,无膀胱输尿管返流,2例出现泌尿系感染,1例出现肠粘液堵管,经对症治疗后缓解。结论：乙状结肠膀胱扩大术可有效地扩大膀胱容量,降低充盈期末膀胱压力,使患者有一个安全的储尿环境,是治疗神经源性低顺应性膀胱的最佳选择,提高了患者的生存质量。     

肠管浆肌层补片膀胱扩大术治疗反射亢进型神经性膀胱（附21例报告）

１９８６～１９９３年采用回肠或结肠浆肌层补片治疗反射亢进型神经性膀胱２１例，１７例随访０．５～７年，平均２．６年。通过临床、尿流动力学、血生化及膀胱尿道造影进行评价。治愈率５８．８％（１０／１７），总有效率８２．３％（１４／１７）；无死亡病例。重点讨论了去粘膜肠管浆肌层膀胱扩大术的去粘膜技术和术后挛缩问题，说明应用该技术的特点，强调神经性膀胱综合治疗的必要性。     

乙状结肠膀胱扩大术治疗神经原性低顺应性膀胱10例报告

目的探讨乙状结肠膀胱扩大术治疗神经原性低顺应性膀胱的疗效。方法采用乙状结肠膀胱扩大术治疗10例神经原性低顺应性膀胱患者。男6例,女4例。年龄4～32岁,平均16岁。病程4～20年。其中脊髓栓系综合征8例,脊髓损伤2例。术前均未接受过骶神经根切断和膀胱手术。有膀胱输尿管返流者同时作返流侧输尿管膀胱再植术。术后不能自行排尿或剩余尿量>50 ml者辅以间歇性清洁导尿。结果术后随访11～57个月。术前漏尿者10例,术后仅3例仍有漏尿,但程度明显减轻。血肌酐(SCr)由(263.8±109.8)μmol/L降至(113.1±23.2)μmol/L(P< 0.01),膀胱容量由(61.9±37.7)ml增至(373.0±88.1)ml(P<0.01),储尿期最大逼尿肌压力由(54.2±44.8)cm H2O(1 cm H2O=0.098 kPa)降至(17.7±10.6)cm H2O(P<0.01)。有膀胱输尿管返流者由9例17侧减少至1例1侧。需长期间歇性清洁导尿者4例,其中1例因未按时进行间歇性清洁导尿者导致代谢性酸中毒。按时间歇性清洁导尿后治愈。菌尿10例,其中1例需抗生素治疗。结论乙状结肠膀胱扩大术是治疗神经原性低顺应性膀胱的有效方法,能改善患者肾功能,提高患者生活质量。     

脊髓栓系患者的尿动力学评估和治疗对策

目的　探讨脊髓栓系对膀胱尿道功能的影响。　方法　采用影像尿动力学检查评估36例脊髓栓系患者的膀胱尿道功能 ;以膀胱顺应性和有无膀胱输尿管返流评估膀胱的储尿功能 ;以排尿期逼尿肌压力评估逼尿肌排尿功能 ;结合膀胱尿道透视和尿动力学检查了解有无逼尿肌 外括约肌的协同性 ,并结合压力 流率曲线了解尿道的控尿功能。采用 χ2 检验比较各组参数异常发生的频数。　结果　脊髓栓系后神经源性膀胱的类型主要为逼尿肌反射不能伴低顺应性膀胱 ,占 5 0 % (18/36 ) ;逼尿肌反射亢进占 2 2 % (8/ 36 )。逼尿肌反射不能伴低顺应性膀胱者其肾功能损害的发生率83% (15 / 18) ,明显高于逼尿肌反射亢进者 (38% ,3/ 8,P <0 .0 5 )。膀胱顺应性减低者肾功能异常占81% (17/ 2 1) ,明显高于顺应性正常者 (7% ,1/ 15 ,P <0 .0 1)。顺应性减低者膀胱输尿管返流发生率6 7% (14 / 2 1) ,明显高于顺应性正常者 (7% ,1/ 15 ,P <0 .0 1)。　结论　脊髓栓系所致的神经源性膀胱类型各异 ,治疗方案的制定应以尿动力学结果为依据。顺应性减低可能是造成肾功能损害和膀胱输尿管返流的主要原因 ,泌尿外科治疗目的在于创建一低压、足够容量和控尿的膀胱以保护上尿路功能     

膀胱粘膜肌瓣翻转术在抗膀胱输尿管返流术中的应用(附四例报告)

目的　提高治疗膀胱输尿管返流的手术疗效。　方法　采用膀胱粘膜肌瓣翻转抗返流术治疗膀胱输尿管返流 4例 ,其中因输尿管壁段结石行经尿道输尿管口切开致膀胱输尿管返流 2例 ,原发性膀胱输尿管返流 2例。Ⅲ°1例 ,Ⅳ°3例。　结果　术后 2例出现膀胱刺激症状及膀胱痉挛 ,1个月后症状明显改善 ,3个月后症状完全消失。 4例平均随访 2 2个月 ,患者症状消失 ;IVU示患侧肾功能良好 ,3例肾积水及输尿管扩张完全消失 ,1例改善 ;膀胱造影均未见膀胱输尿管返流 ;膀胱镜可见再造输尿管口呈唇状。　结论　膀胱粘膜肌瓣翻转抗返流术治疗膀胱输尿管返流简便、有效 ,但存在术后膀胱刺激症状重的缺点。     

Further experience with seromuscular colocystoplasty lined with urothelium

PURPOSE: We report our continuing experience with seromuscular colocystoplasty lined with urothelium. This procedure is designed to preserve the urothelium and potentially decrease the incidence of complications associated with standard bladder augmentation. MATERIALS AND METHODS: We retrospectively reviewed the charts of 32 patients who underwent seromuscular colocystoplasty lined with urothelium between April 1994 and July 1999. Data were collected on patient demographics, surgical indications, previous and adjunctive surgical procedures, preoperative and postoperative urinary continence, upper urinary tract changes, urodynamic parameters, surgical complications and histological findings. RESULTS: Mean patient age at surgery plus or minus standard deviation was 11.1 +/- 4.8 years. Mean followup was 1.6 +/- 1 years. A mean of 1.5 +/- 0.9 years postoperatively urodynamic studies available in 28 cases showed that total and safe bladder capacity increased by 1.8 and 2.4-fold, respectively. Continence was achieved in 71% of patients after the initial procedure, increasing to 81% after secondary procedures. Hourglass deformity developed in 7 cases (22%), augmentation failed in 4 (12.5%) and there were bladder calculi in 2 (6%). New onset or increased hydronephrosis and reflux were present in 6 of 62 (10%) and 9 of 60 (15%) evaluated renal units, respectively. Of the 7 interpretable biopsies 5 revealed various degrees of repeat colonic mucosal growth. There was no bladder perforation or metabolic abnormalities, and mucous production was not clinically significant. CONCLUSIONS: Seromuscular colocystoplasty lined with urothelium is a viable alternative to standard bladder augmentation. The 2 procedures have a similar overall complication rate. Comparatively there appears to be a low incidence of bladder calculi, mucous production has not been clinically significant, metabolic disturbances have not developed and perforation has not occurred during short-term followup. We are enthusiastic about this technique and continue to apply it in select patients.     

Gastrocystoplasty: is there a consensus?

The problems encountered with ileal and colocystoplasty have led to the use of the stomach for bladder augmentation, termed gastrocystoplasty. The advantages of gastrocystoplasty over intestinal segment augmentation include reduced chloride reabsorption, decreased mucus production, decreased urinary infection in the presence of acid urine, extremely low incidence of stones, and avoidance of complications from short bowel syndrome. The gastric patch provides comparable improvements in bladder volume, pressure, and continence. The thick muscular wall of the stomach facilitates ureteric reimplantation as compared with the small intestine, but the rate of stenosis and reflux may not be superior. The disadvantages of the gastric patch include complications of severe systemic alkalosis, which is usually manifest in dehydrated, renal compromised patients, and the hematuria-dysuria syndrome (HDS), which is more prevalent in patients with renal insufficiency, normal pelvic sensation, and urinary incontinence. The postoperative complication rate of gastrocystoplasty is comparable with that of other augmentation procedures and similarly warrants proper selection and close follow-up of patients. In this report we review the literature and present the results, including a discussion of the technique and the pathophysiology of its complications.     

Ureterocystoplasty in bilaterally functional kidneys

OBJECTIVE: Traditional augmentation cystoplasty using gastrointestinal segments is known to be associated with metabolic abnormalities and alterations in the bladder causing potential carcinogenesis. In this respect alternative techniques have been searched preferably lined by urothelium. We performed ureterocystoplasty in 7 patients with a diagnosis of neurogenic bladder and investigated the clinical and functional aspects. PATIENTS AND METHODS: Between 1995 and 1999, ureterocystoplasty was performed using both ureters in 4 male and 3 female children with bilaterally functional kidneys. Patients' ages varied between 1 and 7 (mean 4.7) years. Before the operation all the children were incontinent, had a small-capacity noncompliant bladder, and high-grade (IV-V, International Classification System) reflux on voiding cystouretrography (VCU). Technetium-99m DTPA renal scintigraphy was also performed in all children to evaluate renal function before and after the operation. RESULTS: Before the operation the mean end-filling intravesical pressure was 45.6 (35-60) cm H(2)O which decreased to 18.9 cm H(2)O 3 months postoperatively. The mean bladder capacity 3 months after ureterocystoplasty was found to be 279.3 (250-330) ml. All the children were continent and VCU showed the absence of reflux. There was mild to moderate improvement in renal function after surgery in both kidneys on technetium-99m DTPA renal scintigraphy. Three (43%) patients could void spontaneously with abdominal straining, whereas 4 (57%) children could empty their bladders by clean intermittent catheterization. A double-J stent was inserted in 1 (14%) patient because of a rise in serum creatinine after the removal of the ureteral catheter. Patients were followed for a mean period of 30 (8-50) months and all the children remained continent. The bladder capacity and end-filling pressure measurements were also stable. CONCLUSION: Ureterocystoplasty was found to be an effective method for bladder augmentation in bilaterally functional kidneys with an acceptable complication rate     

Transplantation of autologous differentiated urothelium in an experimental model of composite cystoplasty

Background

Enterocystoplasty is associated with serious complications resulting from the chronic interaction between intestinal epithelium and urine. Composite cystoplasty is proposed as a means of overcoming these complications by substituting intestinal epithelium with tissue-engineered autologous urothelium.

Objective

To develop a robust surgical procedure for composite cystoplasty and to determine if outcome is improved by transplantation of a differentiated urothelium.

Design, setting, and participants

Bladder augmentation with in vitro–generated autologous tissues was performed in 11 female Large-White hybrid pigs in a well-equipped biomedical centre with operating facilities. Participants were a team comprising scientists, urologists, a veterinary surgeon, and a histopathologist.

Measurements

Urothelium harvested by open biopsy was expanded in culture and used to develop sheets of nondifferentiated or differentiated urothelium. The sheets were transplanted onto a vascularised, de-epithelialised, seromuscular colonic segment at the time of bladder augmentation. After removal of catheters and balloon at two weeks, voiding behaviour was monitored and animals were sacrificed at 3 months for immunohistology.

Results and limitations

Eleven pigs underwent augmentation, but four were lost to complications. Voiding behaviour was normal in the remainder. At autopsy, reconstructed bladders were healthy, lined by confluent urothelium, and showed no fibrosis, mucus, calculi, or colonic regrowth. Urothelial morphology was transitional with variable columnar attributes consistent between native and augmented segments. Bladders reconstructed with differentiated cell sheets had fewer lymphocytes infiltrating the lamina propria, indicating more effective urinary barrier function.

Conclusions

The study endorses the potential for composite cystoplasty by (1) successfully developing reliable techniques for transplanting urothelium onto a prepared, vascularised, smooth muscle segment and (2) creating a functional urothelium-lined augmentation to overcome the complications of conventional enterocystoplasty.     

回肠代输尿管术治疗小儿重度肾积水疗效观察

为探讨回肠代输尿管术治疗小儿重度肾积水的疗效，采用回肠代输尿管术治疗小儿重度积水２０例，其中双侧肾积水７例，４例采用回肠Ｓ形吻合，３例采用回肠Ｙ形吻合，结果术后并发低血钾性肌病１例，尿路感染２例，经药物治愈；并发粘连性肠梗阻１例，膀胱结石２例，肾肠吻合口狭窄１例，均再手术治愈，随访１￣２５年均获得满意效果，肾功能及形态均较术前明显改善，有３例术后１年发生膀胱回肠返流，但均在Ｌ５模突以下，有１例在术     

去带乙状结肠膀胱扩大术治疗结核性膀胱挛缩11例报告

目的评价去带乙状结肠膀胱扩大术治疗结核性膀胱挛缩的疗效和安全性。方法回顾性分析11例因结核性膀胱挛缩行去带乙状结肠膀胱扩大术的临床资料。结果手术均取得成功,手术时间缩短约1h,围手术期无死亡和严重并发症。术后1年每次尿量达200~372mL,无排尿困难和尿失禁;肾功能改善,电解质和酸碱平衡正常。结论去带乙状结肠膀胱扩大术治疗结核性膀胱挛缩效果满意,操作简便,安全性高,值得推广。     

Case report: The theory of post-ileocystoplasty spherical configuration in patients with low-capacity bladder

IntroductionBladder augmentation can be performed by detubularization of the small or large intestine. A large capacity bladder is necessary to avoid frequent urination; thus, the ileal sac must be able to store the maximum volume of urine with relatively low pressure and the shortest length of the intestine. The acceptable pressure capacity should always be under ureteric pressure to avoid back pressure and kidney damage. Large capacity at low pressure is referred to as good compliance. Desirable preparations for augmentation, which is the use of the shortest length of the intestine, reduce the chance of diarrhea and vitamin deficiency and retain the intestines which may be required for augmentation.AimClinical and urodynamic evaluation of the recent postoperative condition of the patient who underwent ileocystoplasty, confirmed by the theory of detubularization (spherical) configuration.Case presentationPatient with complaints of frequent urination and small amount of urine. Ultrasound examination showed low volume bladder capacity and bilateral hydronephrosis and hydroureter. From cystography and VCUG examination, low capacity bladder, grade 1 VUR on the right side, grade 4 VUR on the left side accompanied by bilateral hydronephrosis and hydroureter. The patient has a history of right nephrectomy in 2014 for pyonephrosis due to kidney stones. The patient was then subjected to bladder augmentation using a segment of the ileum (ileocystoplasty) in 2015. In the postoperative evaluation, clinical symptoms, radiological and uroflowmetric examinations were evaluated.ConclusionThe detubularization form offers greater volume and lower pressure in the reservoir to augment the bladder.     

AN ALTERNATIVE URETEROILEAL REIMPLANTATION USED IN AUGMENTATION CYSTOPLASTY FOR NEUROGENIC BLADDER WITH BILATERAL VESICOURETERAL REFLUX

Purpose

We describe the use of a serous lined extramural tunnel for ureteral reimplantation during augmentation of a neurogenic bladder to prevent reflux.

Materials and Methods

A 46-year-old male C6 spinal cord injury patient presented with a high pressure bladder, detrusor-sphincter dyssynergia and bilateral grade II/III vesicoureteral reflux. Despite maximal anticholinergic therapy and intermittent catheterization, detrussor pressures were between 80 and 100 cm. water at volumes of 100 to 150 cc with consistent leakage between catheterizations. Preoperative ultrasound and voiding cystourethrogram demonstrated moderate bilateral hydronephrosis and a heavily trabeculated bladder. Augmentation cystoplasty with the formation of 3 cm. extramural ureteral tunnels as described by Ghoneim was performed. The serosa of the adjacent limbs of the ileal segment were opposed to form the back wall of a serosal lined tunnel.

Results

At 3 weeks postoperatively a cystogram demonstrated no extravasation or reflux. At 8 weeks an excretory urogram showed prompt function and excretion bilaterally with marked improvement of preoperative hydronephrosis.

Conclusions

Subserosal ureteral tunnels can be used as an alternative antireflux technique during augmentation cystoplasty when ureteral reimplantation is required. Two advantages of this technique include the elimination of staples and avoidance of ischemic problems associated with an afferent intussuscepted nipple valve.     

Detrusorectomy with rectus muscle hitch and backing

Purpose:

Bladder autoaugmentation is a procedure that includes detrusoromyotomy or detrusorectomy with an aim to release intact urothelium, which then prolapses and increases bladder capacity and compliance. Covering of the prolapsed urothelium usually is done by using deepithelialized pedicled colonic or gastric patch. The authors present their first experiences with detrusorectomy using rectus muscle for hitch and backing.

Methods:

Between August 1999 and February 2002, autoaugmentation was performed in 19 patients (12 girls and 7 boys) aged 4 to 12 years (median, 8). All patients had a neurogenic bladder with small capacity and poor compliance. Detrusorectomy usually involves the whole upper half of the bladder to achieve regular shape of the huge prolapsed urothelium. Both rectus muscles are dissected from their anterior and posterior sheaths. Urothelium is sutured to the muscle at several points to prevent its retraction and shrinkage. This way, bladder is fixed and hanged on rectus muscles.

Results:

Follow-up was 6 to 35 months (median, 21). The new bladder capacity was increased in all patients and ranged from 190 to 411 ml (median, 313). All patients had clinical improvement and better compliance.

Conclusions:

Detrusorectomy with rectus muscle hitch and backing is a safe and simple procedure. However, long-term results are needed to define value of this procedure.     

URETERAL TISSUE EXPANSION FOR BLADDER AUGMENTATION

Purpose

Ureteral augmentation is an effective method of bladder reconstruction using the native urothelium of a megaureter. Clinically this procedure is contingent on the presence of an enlarged ureter. We have iatrogenically produced a segmental megaureter, while preserving renal function in a pig model. The urothelium of the enlarged ureter was then used for augmentation cystoplasty.

Materials and Methods

A tissue expander suitable for insertion into the lumen of the ureter was constructed. The tissue expander was passed antegrade through a flank incision of 8 pigs, and a separate nephrostomy tube was left in place. During the ensuing 1 to 4 weeks the pigs underwent daily dilation of the tissue expander without anesthesia. After dilation the pigs underwent ureteral augmentation of the bladder. The segment of expanded ureter was isolated from the native ureter, opened and anastomosed to the bladder. The continuity of the left ureter was restored by primary ureteroureterostomy. The animals underwent cystograms at 1 and 4 weeks and were sacrificed 4 weeks after augmentation. Tissue was harvested for gross and microscopic histology.

Results

Of the 8 pigs starting the protocol 5 underwent successful ureteral tissue expansion followed by bladder augmentation. Tissue expansion was performed from 1 to 4 weeks, and volumes of 150 to 1,000 cc were obtained. Two to 3 weeks of dilation was optimal to achieve ease of dilation, and no animal showed evidence of discomfort or failure to thrive. All 5 animals underwent successful ureteral augmentation with primary ureteroureterostomy. Tissue expansion volumes of approximately 250 cc were optimal for tissue management and ease of augmentation. Cystograms of all augmented animals showed increased bladder capacity with filling of the ureteral segment. Histological examination of the ureteral augmentation revealed preservation and regeneration of the urothelial mucosa.

Conclusions

The use of a tissue expander in the lumen of the ureter is a novel method of generating urothelium for use in bladder augmentation. It may provide an alternative to bowel in patients who require bladder augmentation. Long-term studies are currently under way.