膀胱扩容术联合输尿管再植术治疗神经源性膀胱的效果分析

Analysis of augmentation cystoplasty plus ureter reimplantation for children with neurogenic bladder

目的分析膀胱扩容术联合输尿管再植术治疗伴输尿管反流的小儿神经源性膀胱的效果。方法收集2014年1月至2020年8月郑州大学第一附属医院小儿外科诊断为神经源性膀胱伴膀胱输尿管反流并接受手术治疗的患儿临床资料,共36例,根据行膀胱扩容术的同时是否行输尿管再植术,将其分为单纯膀胱扩容术组(A组,22例、33条输尿管),膀胱扩容术联合输尿管膀胱再植术组(B组,14例、18条输尿管);两组患儿年龄、性别、膀胱输尿管反流级别、既往史及临床症状比较,差异均无统计学意义(P>0.05);比较两组手术时间、术中出血量、术后住院时间等指标,以及两组手术前后膀胱容量、膀胱顺应性、最大逼尿肌压力、输尿管反流残余率、尿路感染发生率、远端输尿管直径比等情况。结果所有患儿手术顺利,A、B两组手术时间[(152.6±24.4)min比(232.4±44.9)min]及术后输尿管反流残余率(57.58%比16.67%)比较,差异均有统计学意义(P<0.05);术中出血量[(19.8±4.8)mL比(21.1±5.3)mL]、术后住院时间[(30.2±6.5)d比(29.6±5.1)d]、反复发热性尿路感染发生率(22.73%比14.29%)比较,差异均无统计学意义(P>0.05)。A、B两组术前、术后远端输尿管直径比差异无统计学意义(P>0.05),但两组组内手术前后比较,差异具有统计学意义(Z=3.01,P=0.003);A、B两组术前术后膀胱容量、膀胱顺应性、最大逼尿肌压力差异均有统计学意义(P<0.001)。术后随访12~36个月,两组各出现1例膀胱瘘,经留置尿管后痊愈;A组1例因持续双侧输尿管反流经输尿管再植术治愈;B组1例因腹膜炎经腹腔探查术治愈,无一例膀胱输尿管连接处梗阻等情况发生。结论对伴有输尿管反流的神经源性膀胱患儿,膀胱扩容术联合输尿管再植术安全有效,可降低膀胱逼尿肌压力、提高膀胱容量及膀胱顺应性,同时降低术后输尿管反流残余率及远端输尿管直径比,且不增加术后住院时长及术中出血量;对伴有膀胱输尿管连接处梗阻或输尿管反流的神经源性膀胱,尤其是严重膀胱输尿管反流(高级别反流和(或)低压反流),在行膀胱扩容术的同时,行输尿管再植术纠正输尿管反流是可行的。

Objective To explore the efficacy of augmentation cystoplasty and simultaneous ureteral reimplantation for neurogenic bladder in children with concurrent ureteral reflux.Methods From January 2014 to August 2020,36 children with neurogenic bladder and vesicoureteral reflux were recruited.According to whether or not ureteral reimplantation was performed simultaneously as augmentation cystoplasty,they were divided into two groups of augmentation cystoplasty(group A,n=22,33 ureters)and augmentation cystoplasty plus ureter reimplantation(group B,n=14,18 ureters).No significant inter-group differences existed in age,gender,grade of vesicoureteral reflux,past history or clinical symptoms(P>0.05).Operative duration,intraoperative blood loss and postoperative hospital stay were compared between two groups.The changes of bladder volume,bladder compliance,maximal detrusor pressure,residual rate of ureteral reflux,urinary tract infection rate and distal ureteral diameter ratio were compared between two groups before and after operation.Results Operation was successful in all children.Significant inter-group differences existed in operative duration[(152.6±24.4)min vs.(232.4±44.9)min]and residual rate of postoperative ureteral reflux(57.58%vs.16.67%)(P<0.05).No significant difference existed in intraoperative blood loss[(19.8±4.8)ml vs.(21.1±5.3)ml],postoperative hospital stay[(30.2±6.5)days vs.(29.6±5.1)days]and rate of recurrent febrile urinary tract infection(22.73%vs.14.29%)(P>0.05).No significant inter-group difference existed in ratio of distal ureter diameter before and after operation(P>0.05).The inter-group difference was statistically significant before and after operation(Z=3.01,P=0.003).Significant inter-group differences existed in bladder volume,bladder compliance and maximal detrusor pressure(P<0.001).During a follow-up period of 12 to 36 months,one case of bladder fistula occurred in both groups and recovered after indwelling urinary catheter.In group A,one case became cured after ureter reimplantation due to continuous bilateral vesicoureteral reflux.One case in group B was cured after abdominal exploration due to peritoniti and there was no obstruction of ureter bladder junction.Conclusion For children with neurogenic bladder with vesicoureteral reflux,augmentation cystoplasty plus ureter reimplantation is both safe and effective.It can reduce bladder detrusor pressure,improve bladder volume and bladder compliance,reduce the residual rate of postoperative ureteral reflux,distal ureteral diameter ratio.It does not increase the length of hospital stay and intraoperative blood loss.For children with neurogenic bladder with vesicoureteral junction obstruction or ureteral reflux,especially severe vesicoureteral reflux(high-grade reflux or/and low-pressure reflux),it is feasible to correct the existing ureteral reflux through augmentation cystoplasty and ureter reimplantation simultaneously.