脊髓栓系合并上尿路损害的治疗决策

Strategy for tethered spinal cord syndrome complicated with upper urinary deterioration

目的 探讨脊髓栓系合并上尿路损害的治疗策略。方法 1997年7月～2002年3月共收治合并上尿路损害的脊髓栓系综合征42例,男26例,女16例,年龄2～16岁,平均6.7岁。根据上尿路损害的程度分为两组:A组(严重组)26例,B组(轻组)16例,常规先行栓系松解术,其中10例术后上尿路损害加重。对36例上尿路损害严重患儿先后行膀胱功能重建术。27例获得随访,随访时间6～33个月,平均25个月。评价方法:手术前后行尿动力学、影像学及血生化检查。尿动力学评价采用配对资料t检验。结果 术前上尿路损害:静脉肾盂造影双侧不显影伴BUN略高1例,单侧不显影1例,中等以上肾盂积水11例,Ⅳ度以上膀胱输尿管反流14例。术后:静脉肾盂造影不显影片分别于1h、1.5h延时显影。肾盂积水减轻7例,4例无明显变化。输尿管反流消失7例,减轻6例,1例无变化。总有效率81.48％;膀胱容量、膀胱顺应性较术前提高,逼尿肌漏尿压较术前降低。结论 脊髓栓系合并严重上尿路损害时应先行膀胱功能重建术。对损害轻者常规先行性系松解术。膀胱功能重建术可有效降低膀胱内压,避免上尿路损害进一步加重。

Objective To explore strategy of treatment for tethered spinal cord syndrome(TCS) complicated with upper urinary deterioration. Methods From July 1997 to March 2002, 42 patients (male 26, female 16) aged from 2 to 16 years of TCS complicated with upper urinary deterioration were treated. According to the degree of deterioration, the patients were divided into group A (severe, n = 26) and group B (mild, n = 16). The patients of group B received a routine untethering operation of which 10 patients were getting worse postoperatively. These 10 cases and all patients from group A underwent bladder aug- mentation. Among them, 27 patients were followed-up from 6 to 33 months with an average of 25 months. Urodynamics, intravenous urography (IVU), voiding cystoureterography, serum urea nitrogen and creati- nine were compared before and after operation. Results There were bilateral renal with no visible contrast by IVU and slightly high BUN in one case, unilateral renal invisible contrast in one, moderate or severe hy- dronephrosis in 11, and grade Ⅳ or Ⅴ reflux in 14 before operation. Increased bladder volume and compli- ance and decreased leak point pressure could be noted in all patients after operation. The renal function of 2 cases were improved. Of 11 cases with hydronephrosis, 4 patients remained stable and 7 improved. Among the 14 cases with reflux, 7 cases recovered while 6 cases were alleviative with an overall effective rate 81.48 %. Conclusions Bladder augmentation is the first choice of TCS complicated with severe upper uri- nary deterioration. Surgical release procedure may be done routinely in patients with mild upper urinary de terioration.