Podestá M L, Ruarte A, Gargiulo C, Medel R, Castera R
Urology Unit, Department of Surgery, Hospital de Niños Ricardo Gutiérrez, Associated Hospital to the University of Buenos Aires, Buenos Aires, Argentina.
J Urol. 2000 Jul;164(1):139-44.
Primary valve ablation and temporary vesicostomy with delayed valve ablation are alternative initial management procedures in neonates and infants with posterior urethral valves. To investigate whether initial vesicostomy followed by delayed valve ablation and simultaneous vesicostomy closure may lead to more alterations in bladder function than primary valve ablation only we retrospectively compared postoperative urodynamic findings in 2 small groups of patients.
From 1980 to 1990, 15 male infants 19 days to 34 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including valve ablation only in 8 (group 1), and primary vesicostomy and delayed valve ablation associated with concomitant vesicostomy closure in 7 (group 2). Mean age at valve ablation and vesicostomy in groups 1 and 2 was 10.8 +/- 11.2 months (range 1 to 35) and 55.4 +/- 43.3 days (range 19 to 151), respectively. Average duration of vesicostomy diversion was 33.6 +/- 18.8 months (range 14 to 70). All patients underwent conventional urodynamics postoperatively using normal saline at room temperature. In groups 1 and 2 mean age at followup was 11.5 +/- 6.6 (range 5 to 16.2) and 9. 4 +/- 3.1 (range 4.10 to 14) years, respectively. Controls comprised 46 age matched males who underwent urodynamics using similar methodology.
Postoperative urodynamic assessment of maximum cystometric bladder capacity and the incidence of detrusor instability in each treatment group were not statistically different. In group 1 bladder capacity was significantly higher than that in controls (p <0.0001). In group 2 mean end filling detrusor pressure was increased compared with that in group 1 (29 cm. water, range 15 to 60 versus 8, range 4 to 21). Compliance was significantly lower in group 2 than in group 1 (p <0.0005). Analysis of detrusor voiding pressure at maximum flow was not significantly different in the 2 groups. We noted detrusor under activity in 1 group 1 and 2 group 2 cases. In these patients post-void residual urine volume was 8% to 66% of cystometric bladder capacity. However, only 1 of these 3 patients who required augmentation cystoplasty needed intermittent catheterization. Urodynamic patterns of outflow obstruction developed in 1 patient in each group, including urethral stricture and bladder neck obstruction. At followup we observed no difference in renal function impairment in the 2 groups.
Our retrospective study of rapid filling cystometry suggests that primary valve ablation for posterior urethral valves is associated with a better bladder function outcome than that in patients treated with vesicostomy and delayed valve ablation. Therefore, although cutaneous vesicostomy may be performed as initial management of posterior urethral valves, primary valve ablation is the most effective surgical option in these cases.
对于患有后尿道瓣膜的新生儿和婴儿，一期瓣膜消融术以及先行临时膀胱造瘘术并延期进行瓣膜消融术是可供选择的初始治疗方法。为了研究先行膀胱造瘘术，随后延期进行瓣膜消融术并同期关闭膀胱造瘘口是否比单纯一期瓣膜消融术导致更多的膀胱功能改变，我们回顾性比较了两组小样本患者术后的尿动力学检查结果。
1980年至1990年，15例年龄在19天至34个月的患有后尿道瓣膜的男婴接受了两种初始手术方法中的一种治疗，其中8例仅行瓣膜消融术（第1组），7例行一期膀胱造瘘术并延期进行瓣膜消融术及同期关闭膀胱造瘘口（第2组）。第1组和第2组瓣膜消融术及膀胱造瘘术时的平均年龄分别为10.8±11.2个月（范围1至35个月）和55.4±43.3天（范围19至151天）。膀胱造瘘引流的平均持续时间为33.6±18.8个月（范围14至70个月）。所有患者术后均使用室温生理盐水进行常规尿动力学检查。第1组和第2组随访时的平均年龄分别为11.5±6.6岁（范围5至16.2岁）和9.4±3.1岁（范围4.10至14岁）。对照组包括46例年龄匹配的男性，他们采用类似方法进行尿动力学检查。
各治疗组术后尿动力学检查评估的最大膀胱测压容量和逼尿肌不稳定发生率无统计学差异。第1组的膀胱容量显著高于对照组（p<0.0001）。与第1组相比，第2组的平均终末充盈期逼尿肌压力升高（29cm水柱，范围15至60cm水柱对8cm水柱，范围4至21cm水柱）。第2组的顺应性显著低于第1组（p<0.0005）。两组最大尿流率时逼尿肌排尿压力分析无显著差异。我们在第1组1例和第2组2例患者中发现逼尿肌活动低下。在这些患者中，排尿后残余尿量占膀胱测压容量的8%至66%。然而，这3例需要膀胱扩大成形术的患者中只有1例需要间歇性导尿。每组各有1例患者出现尿动力学模式的流出道梗阻，包括尿道狭窄和膀胱颈梗阻。随访时，两组肾功能损害无差异。
我们对快速充盈膀胱测压的回顾性研究表明，后尿道瓣膜一期瓣膜消融术比膀胱造瘘术及延期瓣膜消融术治疗的患者膀胱功能结局更好。因此，虽然皮肤膀胱造瘘术可作为后尿道瓣膜的初始治疗方法，但一期瓣膜消融术是这些病例中最有效的手术选择。
