Zuo Jinming,Wang Qingwei,Zhu Wen,et al.Efficacy and safety of detrusor and external urethral sphincter injections of botulinum toxin A in children with detrusor overactivity and impaired contractility[J].Journal of Clinical Pediatric Surgery,2024,(04):348-354.[doi:10.3760/cma.j.cn101785-202403060-009]
逼尿肌及尿道外括约肌A型肉毒毒素注射治疗儿童逼尿肌过度活动并收缩受损的疗效与安全性分析
- Title:
- Efficacy and safety of detrusor and external urethral sphincter injections of botulinum toxin A in children with detrusor overactivity and impaired contractility
- Keywords:
- Urinary Bladder; Overactive; Botulinum Toxins; IInjections; Intramuscular; Treatment Outcome; Child
- 摘要:
- 目的 初步评估逼尿肌及尿道外括约肌A型肉毒毒素(botulinum toxin A,BTX-A)注射治疗儿童逼尿肌过度活动并收缩功能受损(detrusor overactivity and impaired contractility,DOIC)的疗效与安全性。 方法 本研究为回顾性研究,以2022年5月至2023年6月在郑州大学第一附属医院接受逼尿肌及尿道外括约肌BTX-A注射治疗的25例DOIC患儿为研究对象,男18例、女7例,年龄(11.0±3.8)岁。分别于治疗前及治疗后1个月、6个月收集连续3 d排尿日记及尿失禁生活质量问卷评分表(incontinence specific quality of life,I-QOL)、生活质量评分量表、膀胱过度活动症评分量表(overactive bladder symptom score,OABSS)评分情况,于治疗前和治疗后1个月行影像尿动力学检查,术后6个月行自由尿流率和超声残余尿量测定,并收集治疗后不良事件。 结果 患儿术前平均每日尿失禁次数和排尿次数分别为(6.9±1.5)次和(10.8±1.7)次,生活质量评分(8.8±0.7)分,OABSS评分(10.5±1.8)分,I-QOL评分(43.6±4.6)分,每次排尿量(127.4±37.9)mL,功能性膀胱容量(functional bladder capacity,FBC)为(160.7±29.4)mL,最大尿流率(maximum flow rate,MFR)为(9.7±3.3)mL/s;导尿患儿每日导尿次数(8.0±0.5)次,残余尿量(postvoid residual,PVR)为(190.6±99.2)mL,膀胱排空效率(32.8±4.9)%。术后1个月和术后6个月随访中,每日尿失禁次数和排尿次数分别减少至(3.5±1.3)次、(4.9±1.4)次和(7.6±1.1)次、(8.5±1.4)次;生活质量评分减少至(5.8±0.9)分、(7.1±0.8)分;OABSS评分减少至(8.5±1.0)分、(9.0±1.3)分;每日导尿次数减少至(6.4±0.7)次、(7.3±0.8)次;PVR减少至(91.3±36.7)mL、(121.9±42.7)mL;I-QOL评分增加至(59.7±5.8)分、(50.1±4.7)分;每次排尿量增加至(164.9±31.1)mL、(146.0±24.5)mL;FBC增加至(198.3±27.5)mL、(176.2±24.3)mL;MFR增加至(13.8±3.1)mL/s、(11.0±2.5)mL/s;膀胱排空效率增加至(62.0±6.4)%、(47.8±6.7)%。术后1个月影像尿动力学随访情况与术前相比,最大膀胱压测定容量[(230.2±36.0)mL比(198.2±46.1)mL]、膀胱顺应性[(18.6±5.1)mL/cmH2O 比(14.4±6.6)mL/cmH2O]显著增加,充盈期逼尿肌过度活动频率[(2.8±1.3)次比(4.4±1.7)次]、最大逼尿肌压力[(64.4±6.0)cmH2O 比(80.0±5.1)cmH2O]、最大尿道压[(72.0±5.5)cmH2O 比(78.5±8.2)cmH2O]、最大尿道闭合压[(59.1±5.2)cmH2O 比(64.1±7.2) cmH2O]显著下降。4例术前存在一侧膀胱输尿管反流的患儿中,术后2例反流消失,2例获改善;11例术前存在逼尿肌外括约肌协同失调患儿中,5例术后恢复正常;7例术前存在逼尿肌膀胱颈协同失调患儿中,2例术后恢复正常。术后6个月随访情况与术后1个月相比,每日尿失禁次数[(4.9±1.4)次比(3.5±1.3)次]和排尿次数[(8.5±1.4 0)次比(7.6±1.1)次]、生活质量评分[(7.1±0.8)分比(5.8±0.9)分]及平均每日导尿次数[(7.3±0.8)次比(6.4±0.7)次]、PVR[(121.9±42.7)mL比(91.3±36.7)mL]均显著增加,每次排尿量[(146.0±24.5)mL比(164.9±31.1)mL]和FBC[(176.2±24.3)mL比(198.3±27.5)mL]、I-QOL[(8.5±1.0)分比(10.5±1.8)分]、MFR(8.5±1.0)mL/s 比(10.5±1.8)mL/s］、膀胱排空效率[(47.8±6.7)% 比62.0±6.4)%]均显著降低;差异均具有统计学意义(P＜0.05)。随访期间,7例出现一过性肉眼血尿,2例出现尿路感染,无其他不良事件发生。 结论 逼尿肌联合尿道外括约肌BTX-A注射治疗儿童DOIC安全、微创、有效,能显著改善患儿排尿异常,降低上尿路损害的风险,提高患儿生活质量,其疗效至少可持续6个月。
- Abstract:
- Objective To assess the efficacy and safety of detrusor and external urethral sphincter injections of botulinum toxin A in children with detrusor overactivity and impaired contractility (DOIC). Methods From May 2022 to June 2023,a total of 25 DOIC children received injections of botulinum toxin A in detrusor and external urethral sphincter.There were 18 boys and 7 girls with a mean age of (11.0±3.8) year.Three-day voiding diaries,quality of life questionnaires and incontinence-specific quality of life (I-QOL) assessments and overactive bladder symptom score (OABSS) were completed at baseline and Month 1/6.Also video-urodynamic examination at baseline and Month 1 and free uroflowmetry and residual urine measurement at baseline and Month 6 were performed.And the occurrences of adverse events were recorded. Results At baseline,mean urinary incontinence episode and daily voiding frequency were (6.9±1.5) and (10.8±1.7),quality of life questionnaire (8.8±0.7),OABSS (10.5±1.8),I-QOL score (43.6±4.6),mean voiding volume (127.4±37.9) ml,functional bladder capacity (FBC) (160.7±29.4) ml,maximum flow rate (MFR) (9.7±3.3) ml/s,mean daily frequency of catheterization (8.0±0.5),postvoid residual (PVR) (190.6±99.2) ml and bladder emptying efficiency (32.8±4.9)% in children undergoing intermittent catheterization (IC).At Month 1/6 post-injection,mean urinary incontinence episode and daily voiding frequency decreased to (3.5±1.3),(4.9±1.4) and (7.6±1.1),(8.5±1.4); quality of life questionnaire declined to (5.8±0.9),(7.1±0.8); OABSS score dropped to (8.5±1.0),(9.0±1.3); mean daily frequency of catheterization dipped to (6.4±0.7),(7.3±0.8),PVR decreased to (91.3±36.7),(121.9±42.7) ml; I-QOL score jumped to (59.7±5.8),(50.1±4.7); mean voiding volume increased to (164.9±31.1),(146.0±24.5) ml; FBC rose to (198.3±27.5),(176.2±24.3) ml; MFR spiked to (13.8±3.1),(11.0±2.5) ml/s; bladder emptying efficiency increased to (62.0±6.4),(47.8±6.7)%; Furthermore,the results of video-urodynamic examinations were compared between Month 1 and baseline.Maximum cystometric bladder capacity (MCC)(230.2±36.0 vs. 198.2±46.1 ml) and bladder compliance (BC)(18.6±5.1 vs.14.4±6.6 ml/cmH2O) increased.In addition,maximal detrusor pressure (64.4±6.0 vs.80.0±5.1 cmH2O) and frequency of DO during bladder filling period (2.8±1.3 vs.4.4±1.7),maximum urethral pressure (MUP)(72.0±5.5 vs.78.5±8.2 cmH2O) and maximum urethral closure pressure (MUCP)(59.1±5.2 vs.64.1±7.2 cmH2O) all decreased.Among 4 children of vesicoureteral reflux (VUR) at baseline,there were resolution (n=2) and improvement (n=2) at Month 1; 5/11 children of detrusor external sphincter dyssynergia (DESD) at baseline resolved at Month 1; 2/7 children of detrusor bladder neck dyssynergia (DBND) at baseline resolved at Month 1.Furthermore,as compared with Month 1,mean urinary incontinence episode (4.9±1.4 vs. 3.5±1.3) and daily voiding frequency (8.5±1.4 vs. 7.6±1.1),quality of life questionnaire (7.1±0.8 vs. 5.8±0.9),mean daily frequency of catheterization (7.3±0.8 vs. 6.4±0.7) and PVR (121.9±42.7 vs. 91.3±36.7 ml) increased while mean voiding volume (146.0±24.5 vs.164.9±31.1 ml),FBC (176.2±24.3 vs.198.3±27.5 ml),MFR (8.5±1.0 vs. 10.5±1.8 ml/s),I-QOL score (8.5±1.0 vs 10.5±1.8) and bladder emptying efficiency (47.8±6.7% vs. 62.0±6.4%) declined at Month 6 (all P<0.05).During follow-ups,there were transient gross in-catheter hematuria (n=7) and urinary tract infection (n=2).No other adverse events occurred. Conclusions Injections of botulinum toxin A in detrusor and external urethral sphincter is an effective,mini-invasive and safe treatment for DOIC children.It may effectively improve the symptoms of abnormal urination and lower the risks of upper urinary tract injury.Moreover,quality of life improves after injections.Efficacy remains for at least 6 months.
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备注/Memo
收稿日期:2023-06-28。
基金项目:国家自然科学基金(U1904208)
通讯作者:王庆伟,Email:uomn0824@126.com