Puri A, Grover V P, Agarwala S, Mitra D K, Bhatnagar V
Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India.
Pediatr Surg Int. 2002 Sep;18(5-6):438-43. doi: 10.1007/s00383-002-0713-7. Epub 2002 Jul 24.
Bladder function in patients with posterior urethral valves (PUV) has an immense impact on long-term continence and renal function. Bladder dysfunction was corelated with the initial surgical treatment in 67 patients with PUV treated between 1985 and 2000. Age at presentation, current age, duration of follow-up, initial surgical treatment (diversion or valve fulguration), trends of renal function tests, voiding disturbances, and changes in the upper tracts were recorded. Urodynamic studies were done in all patients to determine urine flow rates, residual volume, maximal cystometric capacity (MCC), bladder compliance, involuntary detrusor activity, and pressure-specific bladder volume (PSBV) at 30 cm water. The patients were divided into three groups depending on the initial treatment: fulguration (n = 38), vesicostomy (n = 25), and ureterostomy (n = 4). At the time of this study voiding symptoms persisted in 45 patients. Mean percent MCC (% MCC) was 62%, 96%, and 100% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively (P = 0.002). Large-capacity bladders were seen in 10.9% of patients, mostly in pubertal and post-pubertal boys who were treated initially by either fulguration or ureterostomy; vesicostomy adversely affected bladder capacity and compliance (P = 0.007). PSBV was decreased in 48% of patients in the vesicostomy group and was significantly lower in the other groups (P = 0.01). Mean percent PSBV was 75%, 95%, and 96% of normal in the vesicostomy, fulguration, and ureterostomy groups, respectively. Uninhibited contractions were present in 21 patients (14 in the vesicostomy group) (P = 0.01). The highest incidence of upper-tract deterioration was seen with %MCC below 60% of normal (P = 0.001). The predominant urodynamic patterns were: (1) fulgurated group: good-capacity, compliant bladder; (2) vesicostomy group: small-capacity, hyperreflexic bladder; and (3) ureterostomy group: good capacity, compliant bladder. Primary valve ablation is associated with better bladder function than vesicostomy and should be the treatment of choice in PUV. Also, vesicostomy and ureterostomy have distinctly different effects on bladder function.
后尿道瓣膜（PUV）患者的膀胱功能对长期控尿和肾功能有巨大影响。1985年至2000年间接受治疗的67例PUV患者的膀胱功能障碍与初始手术治疗相关。记录了就诊时年龄、当前年龄、随访时间、初始手术治疗（改道或瓣膜电灼）、肾功能检查趋势、排尿障碍以及上尿路变化。对所有患者进行了尿动力学研究，以确定尿流率、残余尿量、最大膀胱容量（MCC）、膀胱顺应性、逼尿肌不自主活动以及30 cm水柱压力下的压力特异性膀胱容量（PSBV）。根据初始治疗将患者分为三组：电灼组（n = 38）、膀胱造瘘组（n = 25）和输尿管造口组（n = 4）。在本研究时，45例患者仍有排尿症状。膀胱造瘘组、电灼组和输尿管造口组的平均MCC百分比（%MCC）分别为正常的62%、96%和100%（P = 0.002）。10.9%的患者出现大容量膀胱，主要见于青春期和青春期后的男孩，他们最初接受电灼或输尿管造口治疗；膀胱造瘘对膀胱容量和顺应性有不利影响（P = 0.007）。膀胱造瘘组48%的患者PSBV降低，在其他组中显著更低（P = 0.01）。膀胱造瘘组、电灼组和输尿管造口组的平均PSBV百分比分别为正常的75%、95%和96%。21例患者存在无抑制性收缩（膀胱造瘘组14例）（P = 0.01）。当%MCC低于正常的60%时，上尿路恶化的发生率最高（P = 0.001）。主要的尿动力学模式为：（1）电灼组：容量良好、顺应性膀胱；（2）膀胱造瘘组：容量小、高反射膀胱；（3）输尿管造口组：容量良好、顺应性膀胱。原发性瓣膜消融与比膀胱造瘘更好的膀胱功能相关，应是PUV的首选治疗方法。此外，膀胱造瘘和输尿管造口对膀胱功能有明显不同的影响。
