小儿尿道下裂尿道成形术后并发尿道扩张21例临床分析

一、临床资料　　我院 1988～ 1999年对 40 7例尿道下裂患儿行尿道成形术 ,术后并发尿道扩张 2 1例 ,发生率为 5 .14%。 2 1例全部为男性 ,年龄 2～ 8岁 ,其中Ｄｕｃｋｅｔｔ Ｄｕｐｌａｙ尿道成形术后 15例 ,带蒂阴囊中缝岛状皮瓣尿道成形术后 6例。治疗 :非手术保守观察和抗感染 3例 ,2年后无发展 ,占 14.3 % ;单纯尿道扩张后好转5例 ,占 2 3.8% ;手术解除尿道狭窄后好转 9例 ,占 42 .9% ;尿道扩张壁裁剪成形尿道 4例 ,占 19.0 % ,3例治愈 ,1例因感染 ,手术失败。二、讨论尿道扩张作为小儿尿道下裂术后并发症 ,发生率比尿瘘低。一般与尿道…     

小儿先天性十二指肠梗阻33例临床分析

我院收治33例小儿先天性十二指肠梗阻,男23例、女10例,年龄1天～12岁。33例中,肠旋转不良18例,梗阻部位多在十二指肠第3段;十二指肠闭锁或狭窄10例,其中闭锁3例;狭窄7例。其梗塞部位不固定,环状胰腺并闭锁或狭窄4例,其阻塞部位多在十二指肠的第2段。合并畸形者8例。     

神经性膀胱输尿管反流治疗对策的探讨

目的探讨神经性膀胱患儿输尿管反流的治疗措施。方法脊膜修补术后神经性膀胱并输尿管反流患儿45例,男29例,女16例,年龄4～14岁。排泄性膀胱尿道造影(VCUG)示膀胱输尿管反流左侧19例,右侧11例．双侧15例,其中Ⅰ°-Ⅲ°12例(15条),Ⅲ°-Ⅴ°33例(45条)。Ⅰ°-Ⅱ°中,5例(7条)仅行清洁间歇导尿,7例(8条)行保留膀胱黏膜肠浆肌层膀胱扩大术；Ⅲ°-Ⅴ°中,9例(12条)仅行间歇导尿。24例(33条)行保留膀胱黏膜肠浆肌层膀胱扩大术,其中19例(28条)同时行Lich-Gregoir手术,术后配合间歇导尿。结果6个月后随访,Ⅰ°-Ⅱ°15条中,7条行清洁间歇导尿,3条反流消失(42．9%),8条行保留膀胱黏膜肠浆肌层膀胱扩大术者,6条反流减轻或消失(75．0%)；Ⅲ°-Ⅴ°45条中,12条行间歇导尿者,10条反流程度进一步加重,5条单纯行膀胱扩大术者,2条反流减轻或消失(40．0%),28条同时行Lich-Gregoir手术者,23条反流减轻或消失(82．1%)。结论神经性膀胱输尿管反流的治疗方法取决于输尿管反流的程度。Ⅰ°-Ⅱ°单纯行膀胱扩大术,也可考虑只行清洁间歇导尿；Ⅲ°-Ⅴ°反流须在行膀胱扩大术的同时行输尿管抗反流术,术后配合间歇导尿。     

盆底肌悬吊术治疗女性尿道下裂合并排尿困难

目的探讨女性尿道下裂患儿合并排尿困难、尿失禁的原因，并寻找合适的治疗方法。方法总结11例排尿困难、尿失禁而同时合并有尿道下裂的女性病例，接受髂腰肌转移盆底肌悬吊术治疗。结果11例术后随访6～30个月，平均18个月，控尿满意（昼夜均能保持3h以上完全干燥）7例，好转（部分控尿，白天偶有尿失禁或夜间尿床）3例，无效（症状无改善）1例，总有效率为90．9％。术前最大膀胱容量（162．5±69．8）ml、漏点压（33．4±7．5）cmH2O（1cmH2O=0．098kPa）、最大尿道压（37．4±12．7）cmH2O、最大关闭压（23．8±12．2）cmH2O、功能尿道长度（2．4±1．6）cm；残余尿（93±56）ml；术后分别为（201．6±62．3）ml、（49．8±15．4）cmH2O、（52．8±14．3）cmH2O、（32．8±11．6）cmH2O、（3．6±2．0）cm，（25±20）ml，均较术前明显改善（P〈0．01）。泌尿系感染频率和程度较治疗前明显减少和减轻。结论髂腰肌转移盆底肌悬吊术可以作为女性尿道下裂合并尿失禁、排尿困难的可供选择的治疗方法。     

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。     

手术治疗小儿神经源性膀胱的术式选择

目的 探讨神经源性膀胱手术方式的选择方法与疗效。方法 对94例神经源性膀胱患者选择不同术式进行手术治疗，观察比较其手术前后尿动力学检查结果。结果 本组94例，常用手术方式为盆底肌加强、膀胱颈悬吊、膀胱扩大、Malone术和输尿管抗反流术，其中4种以上手术组合32例(34．04％)，3种手术组合53例(56．38％)，2种手术组合9例(9．57％)。手术后尿动力学指标明显改善。结论 手术是治疗神经源性膀胱的有效方法，但常需要数种手术的组合才能有效改善排尿、排便功能。     

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.     

臀大肌瓣移位在治疗神经源性大便失禁中的作用

目的 探讨臀大肌瓣移位肛提肌加强术在治疗儿童神经源性大便失禁中的作用.方法 2006年1月至2009年12月在我院行臀大肌瓣移位肛提肌加强术13例,其中男9例,女4例,手术年龄7～16岁,平均13.2岁,患儿术前均有明确的脊髓拴系松解手术史,在手术前均行盆底肌电图检查、盆底肌MR、结肠传输试验检查,严格掌握手术适应证,手术前后均行肛门直肠测压、临床疗效评价.结果 术后12例患儿获得随访,术前盆底肌电图均表现为神经源性损害,且为失代偿期.结肠传输试验表现为混合型10例,出口梗阻型3例,盆底肌MR见13例患儿肛提肌发育不对称或肛提肌不能清楚显示,肛门直肠测压手术前后均未见明显变化,临床评分结果示13例患儿均表现为完全性大便失禁,评分差,术后患儿的临床表现优0例,良8例,差4例.结论 臀大肌瓣移位肛提肌加强术有利于改善神经源性大便失禁的排便状况.

Abstract：

Objective To study the efficacy of gluteus maximus flap transposition for the treatment of neurogenic fecal incontinence in children.Methods Between January 2006 and December 2009,7 males and 4 females were diagnosed with neurogenic fecal incontinence and underwent surgery at this center.Their age ranged from 7 to 16 years old (mean age,13.2 years).All the children had a history of tethered spinal cord release surgery.Before surgery,all patients had pelvic floor electromyography,colonic transit test,anorectal manometry,and pelvic floor MRI.The patients were followed up after surgery.The clinical data were retrospectively analyzed to evaluate the efficacy of the surgery.Results Pelvic floor electromyography found the uncompensated nerve function impairment before surgery.Colonic transit test found 10 patients had neurogenic fecal incontinence,and 3 had outlet obstruction.Anorectal manometry measurements of these patients didn't have any changes after surgery.The anorectal function was scored fair on 8 patients,and poor on 4.Conclusions Gluteus maximus flap transposition is effective to improve the anorectal function on the patients with neurogenic fecal incontinence.     

Malone顺性灌肠治疗神经性大便失禁

目的:评价Malone顺性灌肠治疗神经性大便失禁的临床疗效。方法:1998年10月～1999年12月间对14例伴有大便失禁的脊髓拴系综合征患者(4～13岁)施行Malone手术,术后间断经阑尾造瘘口插管灌肠。对手术效果及肛门功能分别进行量化评分。结果:14例随访时间6个月～1年,2例造瘘口闭塞。余12例手术效果评分为21.4±1.3;肛门功能临床主观评分5郾05±0郾76,较术前(1郾23±0.64)明显增加(P<0郾01),其中优9例,良3例,差2例。结论:Malone顺性灌肠是治疗神经性大便失禁的有效方法,可明显提高患儿的生活质量。