膀胱内灌注电灼联合水扩张法治疗女性间质性膀胱炎

Treatment of intravesical instillation with fulguration-hydrodistention on female interstitial cystitis

目的:探讨肝素/碱化利多卡因(利多卡因与碳酸氢钠混合)协同膀胱内灌注联合水扩张及经尿道电灼治疗女性间质性膀胱炎(interstitial cystitis,IC)的有效性和安全性。方法:选择2012年1月至2020年12月于中国医科大学附属第一医院泌尿外科就诊,符合美国泌尿外科协会指南的诊断标准,新诊断为IC的女性患者的病例资料进行回顾性分析,诊断时对可疑病变进行膀胱镜检查和活检。所有患者均接受持续12个月的2%(质量分数)利多卡因10 mL+5%(质量分数)碳酸氢钠5 mL+肝素25000 IU的膀胱内灌注治疗,根据患者的意愿,选择接受或不接受水扩张及经尿道电灼治疗,将患者分为水扩张和经尿道电灼(hydrodistension and transurethral fulguration,HD/TF)组和非HD/TF组,记录患者治疗前和治疗后1、6、12个月O’Leary-Sant间质性膀胱炎症状指标评分(interstitial cystitis patient symptom index scores,ICSI)、问题指标评分(interstitial cystitis patient problem index scores,ICPI)、耻骨上疼痛视觉模拟评分(visual analog scale,VAS)、功能性膀胱容量(functional bladder capacity,FBC)等。结果:共收集到患者79例,其中有4例(5.1%)患者因病理诊断为癌或治疗失败而行膀胱切除术被剔除,其余患者均在治疗后1、6、12个月成功随访。重复测量方差分析显示:治疗后ICPI、ICSI和VAS较治疗前均显著降低(P<0.05),FBC显著增加(P<0.05)。治疗后1、6、12个月随访期间FBC持续下降,差异有统计学意义(P<0.05);在治疗后1个月和6个月随访时ICSI持续降低,差异有统计学意义(P<0.05),而治疗后的6个月与治疗后12个月的ICSI差异无统计学意义(P>0.05)。HD/TF组在治疗后1个月和6个月随访时ICPI持续降低,差异有统计学意义(P<0.05),而治疗后6个月与12个月的ICPI差异无统计学意义(P>0.05)。治疗后1、6、12个月其余各项指标之间比较,差异均无统计学意义(P>0.05)。与非HD/TF组相比,HD/TF组的ICPI、ICSI、VAS和FBC改善更早,且VAS和FBC的变化更显著(P<0.05)。结论:肝素/碱化利多卡因协同膀胱内灌注加水扩张和经尿道电灼治疗IC是一种有效的治疗选择。膀胱内肝素/碱化利多卡因协同灌注可能成为首选治疗方法,可显著减轻患者和医保系统的经济负担,如果患者能接受,可考虑经尿道电灼联合水扩张的治疗方法。

Objective:To investigate the efficacy and safety of intravesical instillation of heparin/alkalized lidocaine(lidocaine mixed with sodium bicarbonate)combined with hydrodistension and transurethral fulguration in the treatment of female interstitial cystitis(IC).Methods:Female patients who attended the Department of Urology at the First Hospital of China Medical University between January 2012 and December 2020 and met the diagnostic criteria proposed in the guidelines of the American Urological Association with a new diagnosis of IC were selected for retrospective analysis.Cystoscopy and biopsy of suspicious lesions were performed at the time of diagnosis.All the patients were treated with an intravesical instillation regimen of 2%lidocaine 10 mL+5%sodium bicarbonate 5 mL+heparin 25000 IU for a continuous period of 12 months,with or without water dilatation and transurethral electrocautery according to the patient’s preference,categorized as hydrodistension and transurethral fulguration(HD/TF)group and non-HD/TF group.The patients were evaluated before and 1,6,and 12 months after treatment for O’Leary-Sant interstitial cystitis patient symptom index scores(ICSI),interstitial cystitis patient problem index scores(ICPI),visual analog scale(VAS)of suprapubic pain,and functional bladder capacity(FBC)changes.Results:A total of 79 patients were collected in this study.Four(5.1%)of these patients underwent cystectomy due to pathological diagnosis of cancer or treatment failure.The remaining patients were followed up 1,6 and 12 months after treatment.Repeated-measures ANOVA showed a significant decrease in ICPI,ICSI and VAS and an increase in FBC after treatment compared with before treatment(P<0.05).FBC continued to decrease during the 1,6 and 12 months’post-treatment follow-ups,with statistically significant differences;ICSI continued to decrease during the 1 and 6 months post-treatment follow-ups,with statistically significant differences,while the difference between ICSI at 6 months post-treatment and at 12 months’post-treatment was not statistically significant.In the HD/TF group,ICPI continued to decrease in the follow-up from 1 and 6 months after treatment,and the difference was statistically significant,while the difference between ICPI 6 months after treatment and 12 months after treatment was not statistically significant.There was no statistically significant difference between the remaining indicators 1,6 and 12 months after treatment.ICPI,ICSI,VAS and FBC improved earlier and the changes in VAS and FBC were more significant in the HD/TF group compared with the non-HD/TF group(P<0.05).Conclusion:Heparin/alkalized lidocaine combination of intravesical instillation with hydrodistension and transurethral fulguration for IC is an effective treatment option.Heparin/alkalized lidocaine combination of intravesical instillation may be the first choice of treatment,which can significantly reduce the economic burden of patients and medical insurance system.If patients can accept it,transurethral fulguration with hydrodistension may be considered.