膀胱壁厚度预测神经源性下尿路功能障碍患者上尿路损害的价值

The value of bladder wall thickness in predicting upper urinary tract damage in patients with neurogenic lower urinary tract dysfunction

目的 探讨神经源性下尿路功能障碍（NLUTD）患者膀胱壁厚度（BWT）与上尿路损害（UTD）的相关性，以及BWT预测UTD的价值。方法 回顾性分析2013年1月至2017年10月收治的161例NLTUD患者的临床资料，男92例，女69例。年龄（39.5±18.4）岁，范围18-81岁。83例伴肾盂积水，64例伴单侧或双侧输尿管积水，14例伴输尿管膀胱反流。30例血肌酐（SCr）异常，SCr（290.7±164.0）μmol/L，范围125-938μmol/L。17例GFR〈90 ml/（min·1.73 m2），GFR（45.2±23.0）ml/（min·1.73 m2），范围84.3-14.6 ml/（min·1.73 m2）。将患者分为试验组（合并UTD）和对照组（无UTD）。试验组101例，男60例，女41例；年龄为（37.9±19.1）岁；伴肾盂积水59例，输尿管积水12例，膀胱输尿管反流14例，SCr异常30例，GFR异常17例。对照组60例，男32例，女28例；年龄（42.3±16.8）岁；伴肾盂积水5例，输尿管积水2例，无膀胱输尿管反流、SCr及GFR异常病例。两组性别比例、年龄差异无统计学意义（P〉0.05）。161例均行超声检查测量BWT。119例行尿动力学检查。比较试验组和对照组BWT和尿动力学参数的差异。采用ROC曲线确定BWT诊断UTD的临界值，分析BWT与UTD、尿动力学参数的相关性。结果 本研究161例的BWT为2-25 mm，中位值7.0 mm（7.1 mm）。尿动力学检查结果示，膀胱顺应性0.8-141.5 ml/cmH2O，中位值12.7 ml/cmH2O（22.8 ml/cmH2O）；膀胱最大测压容量（MCC）49-700 ml，中位值256 ml（171 ml）；充盈期最大逼尿肌压力（Pdetmax）3-144 cmH2O（1 cmH2O＝0.098 kPa），中位值34 cmH2O（19.1 cmH2O）。试验组和对照组的BWT中位值分别为9.0 mm（5.0 mm）和4.0 mm（5.7 mm），膀胱顺应性中位值分别为9.3 ml/cmH2O（15.3 ml/cmH2O）和24.2 ml/cmH2O（38.7 ml/cmH2O），MCC中位值分别为225.0 ml（159.0 ml）和310.6 ml（140.5 ml），Pdetmax中位值分别为40.0 cmH2O（20.4 cmH2O）和29.2 cmH2O（18.4 cmH2O），差异均有统计学意义（Z＝－5.931，P〈0.001；Z＝－4.07，P〈0.05；Z＝－2.22，P〈0.05；Z＝－2.92，P〈0.05）。多因素相关性分析结果显示，BWT与膀胱顺应性和MMC呈负相关（r＝－0.419，P〈0.001；r＝－0.198，P＝0.031），与Pdetmax呈正相关（r＝0.251，P＝0.006）。根据ROC曲线确定BWT临界值为4.8 mm，BWT≥4.8 mm预测UDT的敏感性为86.1%，特异性为53.3%。结论 BWT增厚是NLUTD患者存在UTD的危险因素之一。当BWT≥4.8 mm时，NLUTD患者存在UTD的可能性大。可考虑将BWT作为NLUTD患者诊断UTD的指标。

Objective To investigate correlation between bladder wall thickness（BWT） and upper urinary tract damage（UTD） in patients with neurogenic lower urinary tract dysfunction （NLUTD）, and to evaluate the value of BWT in predicting UTD.Methods To retrospectively analyze clinical data of NLTUD patients admitted from January 2013 to October 2017.Of the 161 patients, 92 were male and 69 were female. The mean age was （39.5±18.4） years old, ranged from 18 to 81 years old. 83 cases had hydronephrosis, 64 cases had unilateral or bilateral ureteral dilation and 14 cases had ureteral reflux. In 30 cases, the serum creatinine was abnormal （290.7±164.0） μmol/L, ranging 125-938 μmol/L. The mean GFR in 17 cases was（45.2 ± 23.0） ml/（min·1.73 m2）, ranged from 84.3 to 14.6 ml/（min·1.73 m2）. According to the presence or absence of UTD, NLUTD patients were divided into experimental group and control group, 101 cases of UTD combined experimental group, and 60 cases of UTD-free control group. There were 60 male patients and 41 female patients in the experimental group with mean age of （37.9±19.1） years old. In the control group, there were 32 male patients and 28 female patients with mean age of （42.3±16.8） years old, There was no statistical difference between the two groups （P〉0.05）. There were 59 cases and 5 cases of hydronephrosis in the experimental group and the control group, respectively. There were 12 cases and 2 cases of ureteral dilation patients in the experimental group and the control group, respectively. The differences in BWT and urodynamic parameters between the two groups were compared. The ROC curve was used to determine the cutoff value of BWT in the diagnosis of UTD and the correlation between BWT and UTD and urodynamic parameters was analyzed.Results 161 patients had a BWT of 2 to 25 mm with a median value of 7.0 （7.1） mm.119 patients underwent urodynamic examination with bladder compliance of 0.8 to 141.5 ml/cmH2O, median value of 12.7 （22.8） ml/cmH2O. The median value of median pressure capacity （MCC） was 256 （171）ml, ranged from 49 to 700 ml. The median value of Pdetmax was34 （19.1） cmH2O, ranged from 3 to 144 cmH2O. The median BWT values of the test and control groups were 9.0（5.0） mm and 4.0（5.7） mm, respectively （Z=-5.931, P〈0.001）. The median bladder compliance was 9.3（15.3） ml/cmH2O and 24.2（38.7）ml/cmH2O, respectively （Z=-4.07, P〈0.05）. The MCC was 225.0（159.0） ml and 310.6（140.5）ml, respectively （Z=-2.22, P〈0.05）. The median Pdetmax during filling was 40.0（20.4）cmH2O and 29.2（18.4）cmH2O, respectively （Z=-2.92, P〈0.05）. Using multivariate correlation analysis, BWT was negatively correlated with bladder compliance （r=-0.419, P〈0.001） and negatively correlated with maximum bladder pressure capacity （r=-0.198, P=0.031）, with the largest filling period. Pdetmax was positively correlated （r=0.251, P=0.006）. Using the ROC curve to determine the threshold, the sensitivity of the UTD is 86.1% and the specificity is 53.3% when BWT≥4.8 mm.Conclusions BWT thickening is one of the risk factors for UTD in patients with NLUTD. When BWT is greater than 4.8 mm, NLUTD patients are more likely to have UTD and can be used as an examination method for the diagnosis of UTD in NLUTD patients.