Park J M, McGuire E J, Koo H P, Schwartz A C, Garwood C K, Bloom D A
Section of Urology, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.
J Urol. 2001 Jun;165(6 Pt 2):2383-8. doi: 10.1016/S0022-5347(05)66210-6.
We investigate the long-term outcome using external urethral sphincter dilation for high risk myelomeningocele.
Since 1984 external urethral sphincter dilation was performed in 25 patients with myelomeningocele who demonstrated passive leak point pressure greater than 40 cm. H2O and/or poor bladder compliance. Mean followup from the first dilation was 8.4 years. Overall 2.4 dilations were performed per patient (range 1 to 8). Cystometrography, imaging study and continence status were evaluated retrospectively.
Overall external urethral sphincter dilation produced durable improvements in mean leak point pressure (60.9 versus 34.4 cm. H2O), capacity (119.8 versus 233.3 ml.), initial compliance (11.5 versus 28.4 ml./cm. H2O) and terminal compliance (1.1 versus 7.7 ml./cm. H2O). Categorical analysis revealed 3 groups in terms of outcome. Group 1 consisted of 11 patients (44%) who demonstrated durable improvements in urodynamic parameters as well as preservation of the upper tracts. These patients demonstrated a 2-step compliance pattern on pre-dilation cystometrography, in which elevated leak point pressure was associated with excellent initial compliance. Group 2 consisted of 5 patients (20%) who failed to maintain safe leak point pressure and whose upper tracts deteriorated, including 4 who eventually underwent augmentation cystoplasty. This group demonstrated a 1-step hypertonicity in which elevated leak point pressure was associated with a steep pressure increase during early filling. Group 3 consisted of 9 patients (36%) who responded minimally in terms of leak point pressure reduction but whose upper tracts remained well preserved. They demonstrated a high pressure instability pattern associated with excellent baseline compliance.
External urethral sphincter dilation provides an effective long-term solution for select high risk myelomeningocele cases. Those who demonstrate elevated leak point pressure and poor bladder compliance at the time of external urethral sphincter dilation are less likely to respond, suggesting that the bladder may have already undergone irreversible changes due to high outlet resistance. Patients who demonstrate instability patterns are less likely to respond to external urethral sphincter dilation in terms of leak point pressure reduction but the upper tracts appear to be well preserved.
我们研究了采用尿道外括约肌扩张术治疗高危脊髓脊膜膨出的长期疗效。
自1984年起，对25例脊髓脊膜膨出患者实施了尿道外括约肌扩张术，这些患者的被动漏尿点压力大于40 cmH₂O和/或膀胱顺应性差。首次扩张后的平均随访时间为8.4年。每位患者平均进行了2.4次扩张（范围为1至8次）。对膀胱测压、影像学检查和控尿情况进行了回顾性评估。
总体而言，尿道外括约肌扩张术使平均漏尿点压力（60.9对34.4 cmH₂O）、容量（119.8对233.3 ml）、初始顺应性（11.5对28.4 ml/cmH₂O）和终末顺应性（1.1对7.7 ml/cmH₂O）得到了持久改善。分类分析显示，根据疗效可分为3组。第1组由11例患者（44%）组成；这些患者的尿动力学参数得到持久改善，上尿路也得以保留。这些患者在扩张前膀胱测压时呈现两步顺应性模式，即漏尿点压力升高与良好的初始顺应性相关。第2组由5例患者（20%）组成；这些患者未能维持安全的漏尿点压力，上尿路恶化，其中4例最终接受了膀胱扩大术。该组呈现一步高张性模式，即漏尿点压力升高与早期充盈时压力急剧升高相关。第组由9例患者（36%）组成；这些患者在漏尿点压力降低方面反应最小，但上尿路仍保存良好。他们呈现出与良好基线顺应性相关的高压不稳定模式。
尿道外括约肌扩张术为部分高危脊髓脊膜膨出病例提供了有效的长期解决方案。在进行尿道外括约肌扩张术时漏尿点压力升高且膀胱顺应性差的患者反应较小，这表明由于高出口阻力，膀胱可能已经发生了不可逆的变化。呈现不稳定模式的患者在漏尿点压力降低方面对尿道外括约肌扩张术的反应较小，但上尿路似乎保存良好。
