骶神经调控治疗神经源性膀胱的疗效及其预测因素分析

Efficacy and predictive factors of sacral neuromodulation on neurogenic bladder

目的探讨骶神经调控(SNM)治疗神经源性膀胱(NB)患者的疗效,并对疗效的预测因素进行分析。方法回顾性分析中国康复研究中心2012年1月至2020年1月收治的91例接受SNM体验治疗的NB患者的临床资料。男53例,女48例,中位年龄36.5(28.0,52.5)岁。所有患者体验治疗前均记录排尿日记,监测残余尿量,评估肠道功能,并进行影像尿动力学检查及盆底电生理检查。91例中60例有储尿期症状(尿急-尿频和/或尿失禁),24 h排尿次数中位值13(11,18)次,次均排尿量(123.0±45.9)ml,尿急程度评分(3.5±1.0)分,24h漏尿量100.0(50.0,231.5)ml;78例有排尿期症状(慢性尿潴留),残余尿量200.0(132.3,300.0)ml。91例神经源性肠道功能障碍评分(NBDS)为11.00(6.25,13.00)分。影像尿动力学检查显示膀胱最大测压容量(MCC)250(117,369)ml,充盈期最大逼尿肌压力(P_(detmax))33(17,72)cmH_(2)O(lcmH_(2)O=0.098kPa),膀胱顺应性8.275(4.540,20.307)ml/cmH_(2)O。盆底电生理检查示,39例体感诱发电位(SEP)正常,19例异常,33例未检测到;39例球海绵体反射(BCR)正常,23例异常,29例未检测到。体验期末重新评估,以下至少一项获得>50%的改善,定义为体验治疗有效:24 h排尿次数、次均排尿量、尿急程度、24 h漏尿量、残余尿量。体验治疗有效者,行脉冲发生器永久植入术。对于体验治疗后上述评估指标改善未>50%的患者,但患者自觉症状明显改善,达到患者预期,也进行了永久植入。采用多元logistic回归分析SNM体验期治疗是否有效的预测因素。结果本组91例体验期治疗(18.7±6.7)d。体验期末43例(43/60,71.7%)储尿期症状至少一项指标获得>50%的改善;21例(21/78,26.9%)排尿期症状获得>50%的改善;NBDS评分下降至3(0,8)分(P<0.05)。19例复查影像尿动力学,MCC从术前173.0(98.0,326.0)ml增加至300.0(201.0,386.0)ml(P<0.05),P_(detmax)从术前40.0(27.0,84.0)cmH_(2)O下降至22.0(15.0,60.0)cmH_(2)O(P<0.05),膀胱顺应性从术前6.84(3.75,11.79)ml/cmH_(2)O增加至19.23(4.95,32.00)ml/cmH_(2)O(P<0.05)。体验期末,91例中50例(54.9%)治疗有效,其中45例选择永久脉冲发生器植入;另有9例评估指标改善未超过50%,也进行了永久植入术。永久植入术后中位随访25.5(11.5,60.5)个月。4例疗效丧失,2例出现输尿管2级反流,1例行膀胱扩大成形术。多因素分析结果显示慢性尿潴留症状是患者体验期治疗无效的预测因素(P<0.05)。结论SNM不仅能改善NB患者的下尿路症状,也能改善尿动力学指标和肠道功能。体验治疗前仅有慢性尿潴留症状的患者体验治疗有效率低。

Objective To explore the efficacy of sacral neuromodulation(SNM)in the treatment of neurogenic bladder(NB),and to analyze the predictive factors.Methods The clinical data of 91 patients underwent SNM testing therapy from January 2012 to January 2020 in China Rehabilitation Research Center were reviewed.There were 53 males and 48 females with the average age of 36.5(28.0-52.5)years.Urinary diary,residual urine,neurogenic bowel dysfunction score(NBDS),video-urodynamic and pelvic floor electrophysiological examination before treatment were recorded.Among the 91 patients,60 patients had symptoms of urinary storage period,including urgency,frequency and/or incontinence.The average number of voids/24 h was 13(11,18),the average volume per void was(123.0±45.9)ml,the average degree of urgency was(3.5±1.0),and the average 24-hour urine leakage was 100.0(50.0,231.5)ml.78 patients had chronic urinary retention symptoms,and the average post-void residual volume(PVR)was 200.0(132.3,300.0)ml.The neurogenic bowel dysfunction score(NBDs)of 91 patients was 11(6.25,13).The mean maximum cystometric capacity(MCC),maximum detrusor pressure(P_(detmax))and bladder compliance were 250(117,369)ml,33(17,72)cmH_(2)O and 8.275(4.540,20.307)ml/cmH_(2)O,respectively.Pelvic floor electrophysiological examination showed that somatosensory evoked potential(SEP)was normal in 39 cases,abnormal in 19 cases and undetected in 33 cases.Bulbocavernosus reflex(BCR)was normal in 39 patients,abnormal in 23 patients and undetected in 29 patients.At the end of the test phase,the patient was re-evaluated.If"effective"or the patient willing to implant,permanent implantation of pulse generator was done."Effective"was defined as improvement of more than 50%in at least one of the following conditions,including the number of voids in 24 hours,volume per void,degree of urgency,leakage volume in 24 hours,PVR.Quantitative values were compared using the t-test or non-parametric test.The potential risk factors were considered by logistic regression analysis.Results The average test time was(18.7±6.7)days.43/60 patients(71.7%)had improvement of more than 50%in at least one symptom of the storage period,and 21/78 patients(26.9%)had more than 50%improvement in urination symptoms.NBDS decreased from 11(6.25,13)to 3(0,8)(P<0.05).During the filling period,MCC increased from 173.0(98.0,326.0)ml to 300.0(201.0,386.0)ml(P<0.05),P_(detmax) decreased from 40.0(27.0,84.0)cmH_(2)O to 22.0(15.0,60.0)cmH_(2)O(P<0.05),and bladder compliance increased from 6.84(3.75,11.79)ml/cm H_(2)O to 19.23(4.95,32)ml/cm H_(2)O(P<0.05).At the end of the test phase,54(59.3%)patients underwent permanent implantation.The median follow-up was 25.5(11.5,60.5)months.Four patients lost their curative effect,two patients developed grade 2 vesicoureteral reflux,and one patient underwent cystoplasty.Risk factors analysis showed that chronic urinary retention was a statistically significant variable(P<0.05).Conclusions SNM can not only improve the lower urinary tract symptoms of patients with neurogenic bladder,but also improve the urodynamic parameters and bowel function.Patients with chronic urinary retention symptoms before treatment experienced low efficiency at the end of the test phase.