腰椎术后排尿功能障碍患者尿动力学改变及治疗

Urodynamic study and treatment in the neurogenic bladder dysfunction caused by lumbar disease after surgical treatment

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。

Objective：To approach the manifestation and clinical significance of urodynamic study in iatrogenie neurogenic bladder dysfunction caused by lumbar surgery.Method：A retrospective review of a consecutive series of patients of neurogenic bladder dysfunction who were surgically treated for lumbar disease was carried out.All patients had undertaken urodynamic study,and the treatment were analyzed.Mantimuscarinic agent and botulinum toxin type A were the choice for detrusor hyperreflexia,bladder sensation hypersensibility, low bladder capacity with abnormal detrusor activity ,detrusor leak point pressure above 40cmH2O.Intermittent or indwelling catheterization could be taken ahen the bladder capacity and pressure for urinary storage.Intermittent catheterization was the first line choice for detrusor sphincter dyssynergia.Result：Videourodynamie study was carried out in all patients.Among them,detrusor hyperreflexia in 2 patients,detrusor areflex in 18 patients,abnormal detrusor activity in 7 patients.During voiding phase,bladder neck open in 7 patients,bladder neck partial open in 12 patients,bladder neck close in 8 patients.Non-relaxing urethral sphincter in 24 patients,detrusor sphincter dyssynergia in 3 patients.Non-vesicoureteral reflux in 22 patients,right vesicoureteral reflux in 1 patients,left vesicoureteral reflux in 2 patients,bilateral vesicoureteral reflux in 2 patients.Detrusor leak point pressure of 10 patients was over 40cmH2O.Mantimuscarinic agent was the first line choice in 7 cases for treating detrusor hyperreflexia or low bladder capacity,botulinum toxin type A was the second line choice in 3 cases,intermittent catheterization was the first line choice for treating detrusor areflexia.Conclusion：The complications of lumbar surgery can be abolished by fight selection of surgical indications,proper manipulation,early diagnosis and prompt management.Urodynamic study can be helpful in diagnosing and treating the iatrogenic neurogenic bladder dysfunction caused by lumbar surgery.