新生儿后尿道瓣膜19例诊治分析

Diagnosis and treatment of posterior urethral valves in neonates： a report of 19 cases

目的 探讨新生儿后尿道瓣膜（posterior urethral valve,PUV）的早期诊断、治疗和疗效评估.方法 收集2009年2月至2015年10月我院收治的19例新生儿PUV患儿的临床资料,回顾性分析其诊断、治疗及疗效.术前行B型超声、排泄性膀胱尿道造影（voiding cystourethrography,VCUG）和CT尿路造影检查,所有患儿均行一期经尿道内瓣膜切开术（transurethral resection,TUR）.术后随访排尿情况,行VCUG、B型超声和尿流动力学检查,评价泌尿系统结构和功能恢复情况.结果 1例术后因酸中毒、呼吸衰竭死亡,2例失访,16例获术后随访.随访6个月～6.5年,平均3.2年.6例患儿因瓣膜残留再次行CT尿路造影,术后有1例发生尿道狭窄,予多次扩张尿道后缓解.正常排尿12例,其中5例可见夜间遗尿;偶有湿裤2例,尿频2例.19侧膀胱输尿管反流（vesieoureteral reflux,VUR）中10侧完全消失,6侧减轻,因严重反流不能缓解需行输尿管再植2例.术前有12例膀胱评分为严重（5或6）.16例患儿最后1次VCUG检查示,膀胱评分均改善至轻度.B型超声检查示肾积水、输尿管扩张缓解10例,6例减轻.12例患儿行尿流动力学检查,平均检查年龄为3.3岁;平均安全膀胱容量为（115±19）ml,与年龄匹配;8例表现为低顺应性;10例出现逼尿肌不稳定,并给予索利那新抑制膀胱过度活动,口服3个月后复查尿流动力学,7例逼尿肌不稳定获得改善.结论 新生儿期PUV改善一般情况后行尿道镜下瓣膜切除安全有效,部分患儿需二次切除.

Objective To explore the early diagnosis,treatment and outcomes of posterior urethral valves （PUV） in neonates.Methods From February 2009 to October 2015,a total of 19 PUV boys aged under 1 month were recruited and their clinical data were retrospectively analyzed.Ultrasonography,voiding cystourethrogram （VCUG） and intravenous urography （IVU） were performed preoperatively.Primary transurethral resection （TUR） was performed.And follow-ups were conducted with urination,urodynamic study,VCUG and ultrasonography.Results One died postoperatively from acidosis and respiratory failure,2 cases became lost to follow-ups and the remainder was followed up for a mean period of 3.2 （0.5-6.5） years.Six patients received VCUG and re-ablation for micturition weakness and repeat urethral dilation was applied for one case of postoperative urethral stricture.Normal urination was observed in 12 patients.And there were nocturnal enuresis （n =5）,occasional incontinence （n =2） and frequent micturition （n =2）.Vesicoureteral reflux （VUR） was present in 19 renal units.And the outcomes were resolution （n =10）,improvement （n =6） and ureteral reimplantation for high-grade reflux （n =2）.Preoperative bladder score was severe（5/6） in 12/19 patients and all cases turned mild at the last VCUG.And alleviations of hydronephrosis and ureterectasis were confirmed by ultrosound.Twelve patients underwent postoperative urodynamic study at a mean age of 3.3 years.The mean safety cystometric bladder capacity was（115 ± 19）ml as comparable to age-matched capacity.Eight boys developed hypocompliance.Detrusor instability was detected in 10 boys and 7 of them had a relief after 3-month therapy of solifenacin.Conclusions Primary transurethral resection is both safe and efficacious for PUV in neonates.And some patients may require re-operatior.