含三角区的逼尿肌内BTX-A重复注射术联合间歇导尿治疗成年男性脊髓损伤并NDO和尿失禁的疗效及安全性

Effect and safety of repeated trigone-including intradetrusor BTX-A injection with intermittent catheterization for male adults with NDO and urinary incontinence secondary to spinal cord injury

目的评估含三角区的逼尿肌内A型肉毒毒素(BTX-A)重复注射术联合间歇导尿治疗成年男性脊髓损伤并神经源性逼尿肌过度活动(NDO)和尿失禁的疗效和安全性。方法回顾性分析2012年1-8月广东省工伤康复医院采用含三角区的逼尿肌内BTX-A重复注射术治疗43例成年男性脊髓损伤伴NDO和尿失禁患者的资料。年龄(29.1±10.7)岁,术前尿失禁生活质量问卷评分(I-QOL)(39.0±4.8)分,每日尿失禁(11.9±2.6)次,每次排尿量(170.7±20.1)ml,首次出现NDO时膀胱逼尿肌最大压力(81.4±19.6)cmH_(2)O(1cmH_(2)O=0.098kPa),首次出现NDO时膀胱容量(169.1±40.0)ml。经尿道将300 U BTX-A分30个点注射于包括膀胱三角区的逼尿肌内。留置尿管1~3 d后改为间歇导尿。间隔6~9个月重复注射,共注射4次。记录每次注射12周后I-QOL、排尿日记及影像尿动力学检查结果,并观察不良事件。结果患者4次BTX-A注射间隔时间分别为(220.6±27.4)、(222.8±24.2)、(224.4±39.0)d(P=0.13)。与首次注射前基线值比较,第1、2、3、4次注射后患者I-QOL分别增加至(54.9±9.1)、(56.1±7.9)、(61.7±9.1)、(68.8±8.9)分;尿失禁例数分别降至36、35、35、33例;每日尿失禁次数分别减少至(4.4±0.6)、(3.8±0.4)、(2.2±0.5)、(2.1±0.3)次;每次排尿量分别增加至(288.3±40.2)、(300.0±38.6)、(316.8±46.8)、(319.5±36.7)ml;首次出现NDO时膀胱逼尿肌最大压力分别降至(29.4±11.0)、(26.1±8.7)、(20.3±5.9)、(18.5±6.0)cmH_(2)O;首次出现NDO时膀胱容量分别增加至(270.0±48.7)、(284.9±51.3)、(287.7±47.9)、(303.0±46.2)ml。4次注射后患者I-QOL、尿失禁例数、每次排尿量、首次出现NDO时膀胱逼尿肌最大压力和首次出现NDO时膀胱容量与术前比较差异均有统计学意义(P<0.05),4次注射后上述指标间差异均无统计学意义(P>0.05)。注射后无新发膀胱输尿管反流,术前2例一侧Ⅱ级VUR于第1次注射后消失。术后1周内,9例出现尿管内重度肉眼血尿,予延长留置尿管时间或膀胱冲洗后血尿消失。12例出现尿路感染症状,予留置尿管并予敏感抗生素治疗,感染控制后继续间歇导尿。结论含膀胱三角区逼尿肌内BTX-A注射术联合间歇导尿能显著降低男性脊髓损伤伴NDO和尿失禁患者的膀胱逼尿肌压力,部分恢复下尿路功能,减少尿失禁,提高生活质量;重复注射与首次注射效果相似,且安全性未降低。

Objective To assess the clinical result of repeated combined detrusor-trigone botulinum toxin A(BTX-A)injection and intermittent catheterization(IC)for male adults with neurogenic detrusor overactivity(NDO)and urinary incontinence(UI)secondary to spinal cord injury(SCI).MethodsFrom January to August 2021,the data of 43 adult male patients with NDO and UI secondary to SCI who received repeated trigone-including intradetrusor BTX-A injection in Guangdong Provincial Work Injury Rehabilitation Hospital were retrospectively analyzed.The mean age of the patients was(29.1±10.7)years.The mean incontinence specific quality of life(I-QOL)was(39±4.8).The UI episodes was(11.9±2.6),mean voiding volume was(170.7±20.1)ml,mean maximum detrusor pressure at first ND0 was(81.4±19.6)cmH,O and mean volume at first NDO was(169.1±40.0)ml.All patients received trigone-including intradetrusor BTX-A(300 U,30 sites)injection for four times and IC.Clinical data including I-QOL,bladder diary,video-urodynamic test and adverse events were recorded at baseline and 12 weeks after each injection.ResultsMean interval between four injections were(220.6±27.4),(222.8±24.1)and(224.4±39.0)d(P=0.13).Compared with baseline data before first injection,mean I-Q0L after the first,second,third and fourth injection increased to(54.9±9.1),(56.1±7.9),(61.7±9.1)and(68.8±8.9)(all P<0.001).The number of urinary incontinence cases decreased to 36,35,35 and 33(all P<0.05).The mean urinary incontinence episodes per day decreased to(4.4±0.6),(3.8±0.4),(2.2±0.5)and(2.1±0.3)(all P<0.001).Mean voiding volume increased to(288.3±40.2),(300.0±38.6),(316.9±46.8)and(319.5±36.7)ml(all P<0.001).Mean maximum detrusor pressure at first ND0 decreased to(29.4±11.0),(26.1±8.7),(20.3±5.9)and(18.5±6.0)cmH,0(all P<0.001)and mean volume at first ND0 increased to(270.0±48.7),(284.9±51.3),(287.7±47.9)and(303.0±46.2)ml(all P<0.001),respectively.Compared with four injections,no difference in response was found in the mean I-QOL,the number of urinary incontinence cases,mean urinary incontinence episodes mean voiding volume,mean maximum detrusor pressure at first NDO and mean volume at first NDO(all P>0.05).No de novo VUR occurred and 2 cases of grade II VUR at baseline had resolved after the first injection.9 patients experienced serious gross hematuria within first week after injection,but the urine returned to clear by prolonging the catheter indwelling time or bladder irrigation.12 patients with active urinary tract infection were treated with indwelling catheter and sensitive antibiotics.Patients continued IC when the symptoms,signs and laboratory examination were normal.Conclusions Combined detrusor-trigone BTX-A injection and IC could help decrease detrusor pressure,restore some of the lower urinary tract function and improve the quality of life for male patients with NDO and UI secondary to SCI.Repeated injection is as effective and safe as the first injection.