尿流改道术治疗顽固性间质性膀胱炎/盆腔疼痛综合征的有效性和安全性研究

Efficacy and safety of urinary diversion in patients with refractory interstitial cystitis/bladder pain syndrome

目的探讨尿流改道术治疗顽固性间质性膀胱炎/盆腔疼痛综合征(IC/BPS)的有效性和安全性。方法回顾性分析2008年1月至2018年7月北京朝阳医院采用尿流改道术治疗的15例顽固性IC/BPS患者的临床资料。均为女性,中位年龄64岁(29~79岁),中位病程5年(2~15年)。均应用≥2种方法(行为治疗、口服药物、膀胱灌注治疗、膀胱注射肉毒素、骶神经调节等)治疗后效果不佳。术前日间排尿次数(30.7±11.6)次/日,疼痛视觉模拟量表(VAS)评分中位值95分(50~100分),O’Leary-Sant评分中位值35分(31~36分)[其中间质性膀胱炎问题指数(ICPI)评分均为16分],盆腔疼痛和尿急尿频症状(PUF)评分中位值35分(32~36分)[其中困扰评分12分(11~12分)],生命质量(QOL)评分均为6分,血肌酐(81.1±13.5)μmol/L。在确认保守+微创治疗无效前提下,根据患者手术耐受情况及个人意愿,采用不同手术方式:3例行膀胱旷置手术,其中2例行输尿管皮肤造口术,1例行回肠通道术;其余12例行腹腔镜膀胱切除+回肠通道手术。分别记录末次随访时总体反应评价表(GRA)评分及并发症,比较手术前后VAS评分、O’Leary-Sant评分中的ICPI评分、PUF困扰评分、QOL评分及血肌酐水平的变化。结果所有患者术后随访6~110个月,平均24个月。3例术后3~6个月出现粘连性肠梗阻,予保守治疗后治愈。3例膀胱旷置患者未出现下尿路症状、残留膀胱疼痛、恶变及感染等与保留膀胱相关的并发症。所有患者末次随访GRA评分均为7分,中位VAS评分为0分(0~30分),O’Leary-Sant评分中的ICPI评分均为0分,PUF困扰评分均为0分,QOL评分中位值为2分(1~4分),均较术前有明显改善(P<0.01)。15例末次随访时肾脏超声均未见明显肾积水;血肌酐(83.8±12.5)μmol/L,与术前比较差异无统计学意义(t=1.28,P=0.22)。结论对于保守+微创治疗无效的顽固性IC/BPS患者,采用不同形式的尿流改道术可明显缓解患者疼痛及下尿路症状,明显提高患者生活质量。

Objective To evaluate the efficacy and safety of urinary diversion in patients with refractory interstitial cystitis/bladder pain syndrome (IC/BPS). Methods Clinical data of 15 female patients who underwent urinary diversion treatment for IC/BPS in our hospital from January 2008 to July 2018 were retrospectively analyzed. The mean age of the subjects was 64 years old (range 29-79), and the mean disease history of IC/BPS was 5 years (range 2-15). Behavior therapy, oral medicine therapy, intravesical instillation, bladder submucosal injection of botulinum toxin type A and sacral neuromodulation showed unsatisfied outcomes in these patients. Before the surgical intervention, the average urinary frequency was (30.7±11.6) per day, the median visual analogue scale (VAS) was 95 (range 50-100), the O′Leary-Sant Index was 35 (range 31-36)[all the interstitial cystitis problem index (ICPI) was 16], the pelvic pain and urgency/frequency patient symptom scale (PUF) was 35 (range 32-36)[the bother score was 12 (range 11-12)], all the quality of life (QOL) was 6, and the average serum creatinine was (81.1±13.5)μmol/L. Two patients underwent cutaneous ureterostomy without cystectomy, 1 patient underwent ileal conduit urinary diversion without cystectomy, and the other 12 patients underwent laparoscopic ileal conduit urinary diversion with cystectomy. The differences of the Global Response Assessment (GRA), complications, VAS, ICPI, PUF, QOL and the serum creatinine before and after the operation were compared. Results The mean postoperative follow-up period was 24 months (range 6-110). The last follow-up showed that all the GRA was 7, the median VAS was 0 (range 0-30), all the ICPI was 0, all the PUF(bother score)was 0, and the median QOL was 2 (1-4), which were significantly different with those before the surgery (all P<0.01). The last follow-up showed that the average serum creatinine was (83.8±12.5)μmol/L, which were not significantly different with that before the surgery (P=0.22). Postoperative adhesive intestinal obstruction occurred in 3 subjects. Conclusions Urinary diversion might be an effective and adequate treatment for refractory IC/BPS to eliminate pain or lower urinary tract symptom and improve quality of life of the patients.