Mosiello Giovanni, Capitanucci Maria Luisa, Gatti Claudia, Adorisio Ottavio, Lucchetti Maria Chiara, Silveri Massimiliano, Schingo Paolo S Maria, De Gennaro Mario
Department of Pediatric Surgery and Radiology, Urodynamic Unit, Bambino Gesù Children's Hospital, Rome, Italy.
J Urol. 2003 Oct;170(4 Pt 2):1610-3. doi: 10.1097/01.ju.0000083883.16836.91.
Neurovesical dysfunction (NVD) is common in children with anorectal malformation (ARM). NVD is mainly related to tethered cord or iatrogenic injury but how to investigate it is still debated. We evaluate the usefulness of routine magnetic resonance imaging (MRI) and urodynamics (UDS) for ARM.
A total of 89 children were screened for sacral, spinal or urological anomalies using sacrum x-ray, MRI, renal and spinal ultrasound, uroflowmetry and/or 4-hour voiding observation. UDS was performed in 60 patients with suspected NVD. Mean +/- SD followup was 9.8 +/- 5.2 years.
Of the 89 patients 29 presented with urinary tract anomalies. The prevalence of sacral (53 cases) and spinal cord (54) anomalies was no different between patients with low, intermediate and high ARM. Spinal cord tethering was present in 13 patients with a normal sacrum x-ray. NVD was found in 31 of the 89 patients (hyperreflexia 21 and hypo-areflexia 10), and was associated with sacral and spinal anomalies in 23, occult spinal dysraphism without bone lesion in 3 and sacral anomalies in 5. The incidence of NVD was 40% of cases with low and 51% with high ARM.
Because tethered cord occurs in children without sacral anomalies as well as in those with low ARM, we recommend evaluation of all patients using MRI. When MRI is positive UDS should be performed. We agree with a previous suggestion to evaluate all males with rectourethral fistula and females with cloaca malformations. Finally we recommend a noninvasive evaluation for all other children and UDS when neurogenic dysfunction is suspected.
神经膀胱功能障碍（NVD）在肛门直肠畸形（ARM）患儿中很常见。NVD主要与脊髓栓系或医源性损伤有关，但如何对其进行检查仍存在争议。我们评估了常规磁共振成像（MRI）和尿动力学检查（UDS）在ARM中的应用价值。
对89例儿童进行了骶骨、脊柱或泌尿系统异常筛查，采用骶骨X线、MRI、肾脏和脊柱超声、尿流率测定和/或4小时排尿观察。对60例疑似NVD的患者进行了UDS检查。平均随访时间为9.8±5.2年。
89例患者中，29例存在泌尿系统异常。低位、中位和高位ARM患者的骶骨（53例）和脊髓（54例）异常发生率无差异。13例骶骨X线正常的患者存在脊髓栓系。89例患者中有31例发现NVD（反射亢进21例，反射减退10例），其中23例与骶骨和脊柱异常有关，3例与无骨病变的隐匿性脊柱裂有关，5例与骶骨异常有关。NVD的发生率在低位ARM患者中为40%，在高位ARM患者中为51%。
由于脊髓栓系不仅发生在骶骨异常的儿童中，也发生在低位ARM儿童中，我们建议对所有患者进行MRI评估。当MRI结果为阳性时，应进行UDS检查。我们同意之前的建议，即对所有直肠尿道瘘男性患者和泄殖腔畸形女性患者进行评估。最后，我们建议对所有其他儿童进行无创评估，当怀疑有神经功能障碍时进行UDS检查。
