A型肉毒毒素注射治疗脊髓损伤后逼尿肌尿道外括约肌协同失调症

Effectiveness of botulinum toxin A urethral injection in patients with detrusor-external sphincter dyssynergia caused by spinal cord injury

目的评价A型肉毒素（BTX-A）注射治疗脊髓损伤患者尿道外括约肌协同失调症（DESD）的临床效果。方法脊髓损伤致DESD患者15例。男12例,女3例,平均年龄37岁。临床表现排尿无力、排尿等待,需要压腹以助排尿。200 U BTX-A溶解于8 ml生理盐水,使用尿道镜注射针分8点二平面注射于尿道外括约肌,1ml/点。记录治疗前后排尿症状,尿动力学检查,并观察毒副作用。结果治疗后2个月,尿动力学检查结果显示膀胱贮尿和排尿功能有不同程度改善,15例最大尿流率由（9．2±5．0）ml/s增加至（16．2±7．0）ml/s,单次尿量由（182．5±52．0）ml/次增加至（235．5±40．0）ml/次,剩余尿量由（288．7±122．5）ml下降至（155．4±81．2）ml（P＜0．01）；最大膀胱测压容积、膀胱顺应性及充盈末逼尿肌压力术前分别为（113．0±64．8）ml、（15．2±2．0）ml/cm H2O、（52．7±19．2）cm H2O,术后分别为（205．5±75．6）ml、（22．5±9．3）ml/cm H2O及（37．1±7．3）cm H2O（P＜0．01,P＜0．05,P＜0．01）。治疗前需要坐位排尿的8例患者均可以直立排尿。随访2～7个月,疗效稳定。结论BTX-A注射是一种治疗脊髓损伤患者逼尿肌无反射伴DESD的有效方法,长期疗效有待观察。

To evaluate the effectiveness of botulinum toxin A （BTX A） injection into the urethral external sphincter for treating detrusor-external sphincter dyssynergia（DESD）in patients with spinal cord injury （SCI）. Methods A total of 15 patients （12 men and 3 women;mean age, 37 years） with DESD were included in the study. All the patients underwent urodynamic examination and their voiding diaries were recorded. Under local anesthesia and cystoscopy,200 U of BTX-A was dissolved in 8 ml of normal saline, then the BTX-A solution was injected into 8 points （1ml per point） of the urethral external sphincter using a 5F flexible cystoscopic needle. The evaluation of the effects and follow-up included voiding diary, urodynamic examination and observation of adverse and toxic effects. Results Two months after treatment, all the patients had improvement in the urinary storage and voiding function. The mean maximum uroflow rate （Qmax） increased from （9.2 ＋ 5.0）ml/ s to （16.2±7.0）ml/s. The mean urine volume increased from （182.5±52.0）ml to （235.5±40.0）ml each time （P〈0.01） ;and mean post-void residual urine volume decreased from （288.7q-122.5）ml to （155.4 q-81. 2）ml each time （P〈0. 01 ）. The mean maximal cystometric capacity increased from （113.0 ± 64.8）ml to （205.5 ±75.6）ml （P〈0.01 ）the mean maximal voiding pressure decreased from （52.7 ± 19.2） cm H2O to （37.1± 7.3）cm H2O （ P 〈 0.01 ）, and mean bladder compliance increased from （15.2±2.0）ml/cm H2O to （22.5±9.3）ml/cm HzO （P〈0.05）. After treatment the patients could urinate at standing position with less abdominal straining. After a mean follow-up of 5.5 months （range, 2-7 months）, the therapeutic effects remained satisfactory. Conclusions BTX-A injection into urethral external sphincter is an effective,safe and feasible measure for treating DESD in patients with SCI. Further observation and more cases are needed for the long-term outcome.