人工尿道括约肌植入术治疗压力性尿失禁长期随访结果

Long term follow up outcome of artificial urinary sphincter implantation to treat stress urinary incontinence

目的探讨人工尿道括约肌植入术治疗压力性尿失禁的长期疗效。方法回顾性分析中国康复研究中心2002年4月至2022年4月行人工尿道括约肌植入术治疗46例压力性尿失禁患者的临床资料。男45例,女1例;年龄19~80岁,平均45.6岁;患者病程8个月至33年。其中尿道外伤术后尿失禁24例,神经源性尿失禁9例,前列腺术后尿失禁13例。术前每日尿垫使用量(3.5±1.0)片,尿失禁对生活质量影响的视觉模拟症状(VAS)评分(7.1±1.2)分。46例均行人工尿道括约肌植入术,其中20例植入术前行药物治疗或尿路相关手术(口服抗胆碱能药物5例,尿道狭窄切开术2例,括约肌切开术3例,尿道扩张术5例,尿道结石碎石术1例,肠道膀胱扩大术4例)。45例男性中25例经会阴入路,20例经阴囊入路;1例女性采用经腹入路。根据术中测量球部尿道周径选择袖套,其中男性16例袖套周径为4.5 cm,29例为4.0 cm;1例女性患者袖套周径为8 cm。随访手术长期疗效,观察患者术后控尿情况(社交控尿定义为每日使用尿垫≤1片,完全干燥定义为无需使用尿垫),装置使用状态及并发症。对比不同病因、手术入路及袖套周径患者手术效果的差异。结果术后随访6个月至19年,平均7.1年。截至末次随访,32例(69.6%)仍正常使用初次安装的括约肌装置,3例(6.5%)行1次修复手术植入新装置后可维持控尿,11例(23.9%)因术后并发症取出装置。术后35例(76.1%)达到社交控尿,其中16例(34.8%)达到完全干燥。术后患者尿垫使用量为(1.2±0.6)片/日,较术前显著下降(P<0.001);尿失禁对生活质量影响的VAS评分为(2.6±1.9)分,较术前显著下降(P<0.001)。术后并发症发生率为32.6%(15/46),其中感染4例,局部侵蚀5例,机械故障3例,排尿困难2例,尿道萎缩1例。尿道外伤术后尿失禁、神经源性尿失禁、前列腺术后尿失禁患者术后社交控尿率[75.0%(18/24)与66.7%(6/9)与84.6%(11/13)]、并发症发生率[37.5%(9/24)与33.3%(3/9)与23.1%(3/13)]及装置修复手术率[37.5%(9/24)与33.3%(3/9)与15.4%(2/13)]差异均无统计学意义(P>0.05)。经会阴入路患者与经阴囊入路患者,术后完全干燥率差异无统计学意义[32%(8/25)与40%(8/20),P=0.76],术后装置使用无故障率差异无统计学意义[60%(15/25)与80%(16/20),P=0.20]。袖套周径为4.5cm与4.0cm患者的术后社交控尿率差异无统计学意义[75%(12/16)与65.5%(19/29),P=0.74]。结论人工尿道括约肌植入术为尿道括约肌功能不全导致压力性尿失禁的有效治疗方式。不同病因、手术入路及袖套周径患者术后控尿率及并发症发生率无差异。

Objective To investigate the long term outcome of artificial urinary sphincter implantation for patients with stress urinary incontinence.Methods The data of 46 patients who underwent artificial urethral sphincter implantation in China Rehabilitation Research Center from April 2002 to April 2022 were retrospectively analyzed.The patients'age ranged from 19-80 years old(median 45.6 years).There were 45 males and 1 female.The history of llness was 8 months to 33 years.The patients category were urethral injuries associated urinary incontinence(n=24),neurogenic urinary incontinence(n=9)and post-prostatectomy incontinence(n=13).Preoperative daily pad usage was 3.5±1.0.The impact of incontinence on the quality of life(QOL)measured by the visual analogue scale(VAS)was 7.1±1.2.All 46 patients underwent artificial urethral sphincter implantation,of which 20 patients were treated with anticholinergic drugs(5 cases)or urinary tract related surgery(urethral stenosis incision in 2 cases,sphincterectomy in 3 cases,urethral dilation in 5 cases,urethral calculus lithotripsy in 1 case,and augmentation cystoplasty in 4 cases)before artificial urethral sphincter implantation.Of the 45 male patients,25 patients had the transperineal approach and 20 had the trans-scrotal approach.The female case had a trans-retropubic approach.Different cuffs size was used based on individual circumference of bulbar urethra(45 male cases:4.5cm in 16 cases,4.0cm in 29 cases;one female case:8.Ocm).Long-term surgical efficacy was evaluated.Assessments included postoperative urinary continence(socially continent:one pad per day or less;complete dry:wearing no pads),artificial urinary sphincter status and complications.The influences of patients of different etiologies,surgical approaches and cuff size on surgical results were compared.ResultsThe mean follow-up time was 7.1 years ranged from 6 months to 19 years.At the latest visit,32 patients(69.6%)maintained the primary functional artificial urinary sphincter.Three patients(6.5%)had artificial urinary sphincter revisions and maintained continence with the new device.11 patients(23.9%)removed the artificial urinary sphincter because of post-complications.Thirty-five patients were socially continent,of which 16 patients were totally dry,leading to the overall social continent rate as 76.1%(35/46).There was a significant reduction in pad usage to 1.2±0.6 diapers per day(P<0.001).The impact of incontinence on the QOL measured by the VAS dropped to 2.6±1.9(P<0.001).The complication rate was 32.6%(15/46),including infections(n=4),erosions(n=5),mechanical failure(n=3),dysurie(n=2)and urethral atrophy(n=1).There were no significant differences in social continent rate between patients with different etiologies[75.0%(18/24)vs.66.7%(6/9)vs.84.6%(11/13)],perioperative complications[37.5%(9/24)vs.33.3%(3/9)vs.23.1%(3/13)]and device re-intervention rate[37.5%(9/24)vs.33.3%(3/9)vs.15.4%(2/13)].There were no statistically significant dfferences in postoperative complete dry rate[32%(8/25)vs.40%(8/20),P=0.76]and postoperative device failure free rate[60%(15/25)vs.80%(16/20),P=0.20]between transperineal group and trans-scrotal group.There was no statistically significant difference in postoperative social continent rate between 4.5cm cuff and 4.0 cuff[75%(12/16)vs.65.5%(19/29),P=0.74].ConclusionsArtificial urethral sphincter implantation is an effective treatment for stress urinary incontinence due to intrinsic sphincter deficiency.There was no difference in the continent rate and complication rate between patients of different etiologies,different surgical approaches and cuff size selection.