Tian Jun,Zhang Weiping,Sun Ning,et al.Relationship between bladder dysfunction and upper urinary tract damage after anterior urethral valve resection[J].Journal of Clinical Pediatric Surgery,2020,19(11):996-1001.[doi:10.3969/j.issn.1671-6353.2020.11.007]
前尿道瓣膜切除术后膀胱功能异常与上尿路损害的关系
- Title:
- Relationship between bladder dysfunction and upper urinary tract damage after anterior urethral valve resection
- Keywords:
- Anterior Urethral Valve; Surgical Procedures; Operative; Urodynamics
- 分类号:
- R726.1;R726.9;R694;R695
- 摘要:
- 目的 探讨前尿道瓣膜切除术后造成上尿路持续损害的尿动力学危险因素。方法 回顾性分析2007年1月至2020年1月26例前尿道瓣膜切除术后患儿的临床资料，平均年龄3.4岁（5个月至14岁）。瓣膜切除术后4个月至12.5年，平均5.5年。患儿术后均进行尿动力学检查。手术前后均进行血生化（包括尿素氮、肌酐）检查、泌尿系统B超检查、静脉肾脏造影（intravenous pyelography，IVP）和排尿性膀胱尿道造影（voiding cystourethrogram，VCUG）。比较瓣膜切除前后肾和输尿管积水以及膀胱输尿管反流情况，分析造成前尿道瓣膜术后上尿路持续损害的危险因素。结果 前尿道瓣膜切除手术前肾和输尿管积水患儿共15例24侧，占57.7%（15/26）；膀胱输尿管反流8例11侧，占30.8%（8/26）。瓣膜切除术后有5例7侧肾和输尿管积水消失，占19.2%（5/26）；2例3侧膀胱输尿管反流消失。瓣膜切除术后肾和输尿管积水患儿共10例17侧，占38.5%（10/26）；膀胱输尿管反流6例8侧，占23.1%（6/26）。有7例11侧肾和输尿管积水较术前加重，占26.9%（7/26），其中4例6侧膀胱输尿管反流较术前加重。根据术后肾和输尿管积水以及膀胱输尿管反流恢复情况，分为上尿路损害加重组（7例）和上尿路损害减轻或消失组（19例）。行瓣膜切除术后尿动力学检查发现，在上尿路损害加重组7例患儿中，压力流率图显示5例依然存在下尿路梗阻或可疑梗阻。上尿路损害减轻或消失组19例患儿压力流率图均显示无梗阻（P<0.05）；两组最大尿流率平均值、膀胱顺应性、排尿期最大逼尿肌压力值差异均存在统计学意义（P<0.05）；上尿路损害加重组中5例动态VUCG显示排尿时膀胱颈全程开放不全，行膀胱尿道镜检查发现3例膀胱壁增厚，呈小梁样改变和膀胱假性憩室形成，尤其膀胱基底以及膀胱内口附近组织明显增厚。结论 前尿道瓣膜是一种罕见的下尿路梗阻性疾病，瓣膜切除之后上尿路损害仍然会持续存在或加重，可能与患儿异常的膀胱功能有关。排尿期最大逼尿肌压力升高、最大尿流率低、膀胱顺应性低以及压力流率图显示梗阻仍存在是导致膀胱功能异常的尿动力学危险因素，可能与前尿道瓣膜患儿同时存在膀胱颈部功能与结构的异常有关。
- Abstract:
- Objective To explore the urodynamic risk factors for continuous damage of upper urinary tract after anterior urethral valve (AUV) resection.Methods A retrospective analysis was performed for 26 children undergoing AUV resection from January 2007 to January 2020.The mean age was 40.8(5-168) months after resection and the mean occurring time 66(4-150) months.Urodynamic examinations were performed.Before and after operation,blood biochemical tests of urea nitrogen and creatinine,ultrasonography of urinary system,intravenous pyelography (IVP) and voiding cystourethrogram (VCUG) were performed.Hydronephrosis and vesicoureteral reflux were compared before and after resection for analyzing the risk factor for continuous damage of upper urinary tract after AUV.Results There were 15 cases (24 sides) with hydroureteronephrosis,(57.7%,15/26) and 8 cases (11 sides) with vesicoureteral reflux (30.8%,8/26) before resection.Hydroureteronephrosis disappeared in 7 sides of 5 cases (19.2%) and vesicoureteral reflux was cured in 2 cases (3 sides).There were 10 cases (17 sides) with hydroureteronephrosis after resection (38.5%,10/26) and 6 cases (8 sides) with vesicoureteral reflux (23.1%,6/26).Hydroureteronephrosis in 7 cases (11 sides) worsened than that before operation,26.9%(7/26),including 4 cases with 6 sides of vesicoureteral reflux.According to postoperative hydroureteronephrosis and vesicoureteral reflux,they were divided into upper urinary tract damage aggravation group (n=7) and upper urinary tract damage reduction/disappearance group (n=19).Urodynamic examination after resection showed that lower urinary tract obstruction or suspected obstruction persisted in 5 cases of upper urinary tract damage aggravation group.However,no obstruction was found in 19 children in upper urinary tract damage reduction/disappearance group (P<0.05).Also significant inter-group differences existed in mean maximal flow rate,bladder compliance and maximal detrusor pressure during micturition (P<0.05).In 5 cases,bladder neck was not completely opened during micturition.And bladder wall thickening,trabecular changes and bladder pseudodiverticulum formation were found in 3 cases,especially thickening of bladder base and tissue around inner bladder orifice.Conclusion AUV is a rare obstructive disease of lower urinary tract.Damage of upper urinary tract persists or worsens after resection.The urodynamic risk factors of bladder dysfunction are elevated maximal detrusor pressure,low maximal flow rate,low bladder compliance and obstruction of pressure flow chart.These factors may be correlated with abnormal bladder neck function and structure in AUV children.
参考文献/References:
1 Clayton DB,Brock III JW.Lower urinary tract obstruction in the fetus and neonate[J].Clin Perinatol,2014,41:643-659.DOI:10.1016/j.clp.2014.05.012.
2 Prakash J,Dalela D,Goel A,et al.Congenital anterior urethral valve with or without diverticulum:A single-centre experience[J].J Pediatr Urol,2013,9:1183-1187.DOI:10.1016/j.jpurol.2013.05.006.
3 Tran CN,Reichard CA,McMahon D,et al.Anterior urethral valve associated with posterior urethral valves:report of 2 cases and review of the literature[J].Urol ogy,2014,84(2):469-471.DOI:10.1016/j.urology.2014.04.034.
4 张潍平,王朝旭,莫志强,等.后尿道瓣膜症治疗现状[J].中华实用儿科临床杂志,2017,32(11):801-804.DOI:10.3760/cma.j.issn.2095-428X.2017.11.001. Zhang WP,Wang CX,Mo ZQ,et al.Current status of treating posterior urethral valves[J].Chin J Appl Clin Pediatr,2017,32(11):801-804.DOI:10.3760/cma.j.issn.2095-428X.2017.11.001.
5 Parmar JP,Mohan C,Vora MP,et al.Anterior urethral valve:a rare but an important cause of infravesical urinary tract obstruction[J].Pol J Radiol,2016,81:209-211.DOI:10.12659/PJR.896230.
6 Routh JC,McGee SM,Ashley RA,et al.Predicting renal outcomes in children with anterior urethral valves[J].J Urol,2010,1844suppl:1615-1619.DOI:10.1016/j.juro.2010.03.119.
7 Berte N,Vrillon I,Larmure O,et al.Long-term renal outcome in infants with congenital lower urinary tract obstruction[J].Prog Urol,2018,28(12):596-602.DOI:10.1016/j.purol.2018.06.005.
8 黎思宇,田军.前尿道瓣膜诊疗现状[J].中华泌尿外科杂志,2019,40(8):638-640.DOI:10.3760/cma.j.issn.1000-6702.2019.08.019. Li SY,Tian J.Current status of diagnosing and treating anterior urethral valves[J].Chinese Journal of Urology,2019,40(8):638-640.DOI:10.3760/cma.j.issn.1000-6702.2019.08.019.
9 Cruz-Diaz O,Salomon A,Rosenberg E,et al.Anterior urethral valves not such a benign condition[J].Front Pediatr,2013,1:35.DOI:10.3389/fped.2013.00035.
10 Kajbafzadeh AM,Payabvash S,Karimian G.Urodynamic changes in patients with anterior urethral valves:before and after endoscopic valve ablation[J].J Pediatr Urol,2007,3(14):295-300.DOI:10.1016/j.jpurol.2006.11.002.
11 梁海燕,张潍平,孙宁,等.小儿后尿道瓣膜切除后合并排尿异常的尿动力学研究[J].中华小儿外科杂志,2014,35(9):683-686.DOI:10.3760/cma.j.issn.0253-3006.2014.09.011. Liang HY,Zhang WP,Sun N,et al.Effects of abnormal micturition in children with posterior urethral valves after valve ablation[J].Chin J Pediatr Surg,2014,35(9):683-686.DOI:10.3760/cma.j.issn.0253-3006.2014.09.011.
12 Kajbafzadeh AM,Payabvash S,Karimian G.The effects of bladder neck incision on urodynamic abnormalities of children with posterior urethral valves[J].J Urol,2007,178(5):2142-2149.DOI:10.1016/j.juro.2007.07.046.
13 Ansari MS,Nunia SK,Bansal A,et al.Bladder contractility index in posterior urethral valve:A new marker for early prediction of progression to renal failure[J].J Pediatr Urol,2018,14(2):162.e1-162.e5.DOI:10.1016/j.jpurol.2017.09.029.
14 Abraham MK,Nasir AR,Sudarsanan B,et al.Role of alpha adrenergic blocker in the management of posterior urethral valves[J].Pediatr Surg Int,2009,25(12):1113-1115.DOI:10.1007/s00383-009-2469-9.
15 Keihani S,Kajbafzadeh AM,Kameli SM,et al.Long-term impacts of concurrent posterior urethral valve ablation and bladder neck incision on urinary continence and ejaculation[J].Urol ogy,2017,99:278-280.DOI:10.1016/j.urology.2016.09.036.
相似文献/References:
[1]杜朝峻,丁力,胡英超,等.手术治疗婴幼儿法洛四联症83例[J].临床小儿外科杂志,2010,9(06):413.
DU Chao jun,DING Li,HU Ying chao,et al.Surgical treatment of Tetralogy of Fallot in infancy: Experiences of 83 cases.[J].Journal of Clinical Pediatric Surgery,2010,9(11):413.
[2]李勇,尹强,周小渔,等.术中胆道造影在先天性胆总管囊肿手术中的应用[J].临床小儿外科杂志,2010,9(06):430.
LI Yong,YIN Qiang,ZHOU Xiao yu,et al.The clinic application experience on intraoperative cholangiography in pediatric surgery.[J].Journal of Clinical Pediatric Surgery,2010,9(11):430.
[3]许芝林,王强,李琰,等.乙状结肠冗长症的术式选择探讨[J].临床小儿外科杂志,2010,9(06):432.
XU Zhi lin,WANG Qiang,LI Yan,et al.Initiatory exploration of the standard of surgical treatment methods for Dolichosigmoid.[J].Journal of Clinical Pediatric Surgery,2010,9(11):432.
[4]常绘文,沈振亚.右腋下小切口在儿童心内手术中的应用[J].临床小儿外科杂志,2010,9(06):439.
[5]胡明,施诚仁,严志龙.脐环小切口治疗婴幼儿腹盆腔疾病的探讨[J].临床小儿外科杂志,2010,9(06):471.
[6]丁勇,魏华,孔燕,等.横裁包皮岛状皮瓣法在尿道下裂治疗中的应用[J].临床小儿外科杂志,2010,9(06):474.
[7]江峰赵阳孙莲萍金惠明马杰.婴幼儿阻塞性脑积水两种手术方式的疗效比较[J].临床小儿外科杂志,2011,10(01):0.
JIANG Feng,ZHAO Yang,SUN Liang ping,et al.Endoscopic third ventricul ostomy versus ventricul operitoneal shunt:clinical study of obstructive hydro cephalus in infants.[J].Journal of Clinical Pediatric Surgery,2011,10(11):0.
[8]王伟程少文彭磊林忠勤张伟陈庆玉寇冬权.弹性髓内钉在儿童肱骨骨折中的应用[J].临床小儿外科杂志,2011,10(01):0.
WANG Wei,CHENG Shaowen,PENG Lei,et al.Application of elastic intramedullary nailing in pediatric humeral fractures.[J].Journal of Clinical Pediatric Surgery,2011,10(11):0.
[9]景登攀张根领孙蔓丽.改良Snodgrass术治疗尿道下裂疗效观察[J].临床小儿外科杂志,2011,10(01):0.
[10]陈快 黄金狮 戴康临 陶俊峰 赖勇强 陶强. 腹腔镜与开腹Ladd手术治疗新生儿肠旋转不良效果比较[J].临床小儿外科杂志,2011,10(02):128.
[J].Journal of Clinical Pediatric Surgery,2011,10(11):128.
备注/Memo
收稿日期:2020-08-16。
基金项目:北京市医院管理局"登峰"人才培养计划（编号：DFL20151102）
通讯作者:张潍平,Email:zhangwpp@163.com