后尿道瓣膜症幼儿行膀胱颈切开术的尿动力学检查临床分析

摘要

目的:探讨后尿道瓣膜症幼儿行膀胱颈切开术的尿动力学表现及其意义.方法:回顾性分析2012年7月~2016年5月收治的56例后尿道瓣膜症患儿资料,均行膀胱镜下后尿道瓣膜切除术,患儿平均年龄(2.0±0.8) 岁.2012年7月~2013年7月收治的13例为第一组,平均(1.8±0.6)岁;2013年8月~2016年5月收治的43例为第二组,平均 (2.3±0.9) 岁.术前完善泌尿系超声、磁共振泌尿系水成像(MRU)、肾核素扫描(ECT)、排尿性膀胱尿道造影(VCUG)等影像学检查.其中同时合并前尿道瓣膜2例,双肾输尿管积水(VUJO)36例(64.3%),膀胱输尿管反流23例(41.1%),反流均为Ⅲ度以上.术前术后均采用尿动力学检查进行评估.术后至尿动力学检查间隔时间约超过半年,对比两组尿动力学结果.结果:经尿道瓣膜切除后,每1~3个月行泌尿系超声、尿动力学检查.第一组中有8例在术后3个月排尿期逼尿肌压力与术前相比无改变,膀胱镜再次检查时发现尿道瓣膜结构已消除,但膀胱颈抬高,遂行膀胱颈切开术,术后1个月再次复查尿动力,发现最大逼尿肌收缩压力可明显减低,且自由尿流率(UFM)有提高.故对第二组病例,术中发现膀胱颈抬高的患儿均行膀胱颈切开术.第二组患儿排尿症状较第一组明显改善.第二组最大逼尿肌收缩压(Pdetmax) 和剩余尿量(PVR)分别为(42.2 ±14.1) cmH2O 和(21.6 ±12.4) ml,低于第一组Pdetmax (75.1 ±18.3) cm H2O 和PVR(32.8 ±8.9) ml;第二组最大膀胱容量(MBC)和膀胱顺应性(BC)分别为(90.4 ±33.7) ml和 (9.5 ±2.4)ml/cm H2O,高于第一组MBC (73.1 ±20.1) ml和BC(6.4 ±1.9) ml/cm H2O;第二组UFM(7.9±0.7)ml/s,高于第一组(5.6±2.0)ml/s,差异有统计学意义(P<0.05).两组患儿均无尿失禁出现.两组分别有6例和7例有逼尿肌不稳定(DI),Fisher''s 精确概率检验两者差异无统计学意义(P>0.05).结论:合并有膀胱颈抬高的后尿道瓣膜症患儿,瓣膜切除的同时,适当切开膀胱颈可使膀胱内压力明显减低.尿动力学检查能及时发现膀胱功能异常和指导下一步治疗.因此,后尿道瓣膜症患儿均应行该检查以了解膀胱功能,保护上尿路.%Objective:To investigate the urodynamic characteristics of children with posterior urethral valves (PUV) subject to bladder neck incision.Methods:A total of 56 children with a diagnosis of PUV during July 2012 to May 2016 after ablation of PUV were studied,and the average ages were (2.0±0.8) years old.The patients were categorized under 2 main groups.In the group 1 (n=13,2012.7-2013.7),the average ages were (1.8±0.6) years old.In the group 2 (n=43,2013.8-2016.5),the average ages were (2.3±0.9) years old.They were examined by ultrasonography,MRU,ECT and VCUG before the operation.The anterior urethral valve existed in 2 children.All children in these groups had different degrees of urologic concomitancy UVJO (36,64.3%) and vesicoureteral reflux (23,41.1% higher than Ⅲ°).The urodynamic results were compared between two groups pre-operation and beyond half a year post-operation.Results:After the operation,they were diagnosed by ultrasonography and urodynamic studies (UDS).There were no significant changes in Pdetmax in 8 patients in the group 1,who underwent bladder neck incision only,so we did the second cystoscopy,and it was found that the valve structure had been cleared,but the bladder neck was elevated significantly,then we did the bladder neck incision.Pdetmax and uroflowmetry (UFM) were improved significantly later.In the group 2,children with elevated bladder neck underwent valve ablation/bladder neck incision.In the group 2,the Pdetmax and PVR were (42.2 ± 14.1) cm H2O and (21.6 ± 12.4) mL respectively,lower than those [(75.1 ± 18.3) cm H2O and PVR (32.8 ± 8.9) mL] in the group 1.In the group 2,the MBC and BC were (90.4 ± 33.7) mL and (9.5 ± 2.4) mL/cm H2O respectively,higher than those [(73.1 ±20.1) mL and (6.4 ± 1.9) mL/cm H2O] in the group one.In group two,UFM was (7.9 ± 0.7) mL/s,higher than (5.6±2.0) mL/s in the group 1.There was no urinary incontinence in all children and voiding symptoms were significantly improved in the group two then in the group 1.Differences in the above-mentioned five parameters were significnat between two groups (P<0.05),while there was no significant difference in DI (P>0.05).Conclusions:In children with PUV in combination with elevated bladder neck,valve ablation/bladder neck incision at the same time can significantly reduce the pressure inside the bladder.Urodynamic examination can detect bladder dysfunction and guide the next step.Therefore,in children with PUV,the bladder function should be cheched to protect the upper urinary tract.