排尿功能障碍致上尿路损害216例临床分析

Upper urinary damage due to voiding dysfunction:clinical analysis of 216 cases

目的探讨排尿功能障碍致上尿路损害的致病机制。方法对216例排尿功能障碍导致上尿路功能损害病例的尿动力学、泌尿影像学及肾脏功能学资料进行回顾,观察膀胱残余尿、膀胱压力和膀胱容量与上尿路损害之间的关系并进行分析。结果在引起上尿路损害的216例患者中,膀胱出口梗阻是最主要的病变(89.4%,185/207);部分患者(21.2%,43/216)残余尿量不多(<50cmH2O),但已引起上尿路损害;70.1%(145/216)以上患者膀胱储尿期压力大于40cmH2O,初始尿意压力(47.4±3.2)cmH2O和最大尿意压力(51.7±9.3)cmH2O均在膀胱安全压力(40cmH2O)之上,初始尿意容量(438.4±81.7)ml明显大于安全容量(357.9±73.3)ml(P<0.01)。结论40cmH2O是上尿路损害的膀胱压安全临界值;达到或超过安全压仍继续储尿是上尿路损害的最重要原因;将膀胱压降至安全压以下以及在安全容量前排空膀胱是治疗和预防上尿路损害的重要措施。

Objective To clarify the urodynamic mechanism of upper urinary damage due to voiding dysfunction. Methods The medical history, radiographic studies and urodynamic results of 216 patients with voiding dysfunction who were treated at our hospital from January 1999 to June 2008 were reviewed retrospectively. The upper urinary tracts were assessed by type-B ultrasonic and excretolT urograpby to determine the incidence of hydronephrosis. The relationships between the urodynamie variables, including residual urine, vesical pressures to such upper tract deterioration were evaluated using both univariate and multiple logistic regression analysis. Results Bladder outlet obstruction （89.4% , n = 185） was the main pathologic change in 216 patients. Upper urinary tract damage occurred in patients with lower residual urine （ 〈 50 cmH2O）. The vesical pressures in 70.1% （ n = 145） of patients were higher than 40 cmH2O. The average volume [ （438.4 ±81.7） ml] at the first desire to voiding was higher than that of safety volume [ （357.9 ±73.3） ml, P 〈0.01 ], which meant it would damage to upper urinary tract. Conclusion The 40cmH2O of vesical pressure is a cut-off point and safety pressure. The vesical pressure lower than 40cmH2O is critical for avoiding of hydronephrosis caused by voiding dysfunction. Keeping bladder from filling after the safety pressure is the cardinal risk factor for hydronephrosis. To keep the vesical pressure under safety value and voiding before safety volume could prevent upper urinary from damaging.