Kasabian N G, Bauer S B, Dyro F M, Colodny A H, Mandell J, Retik A B
Division of Urology, Children's Hospital, Boston, MA 02115.
Am J Dis Child. 1992 Jul;146(7):840-3. doi: 10.1001/archpedi.1992.02160190072024.
To determine if prophylactic use of clean intermittent catheterization and oxybutynin chloride is effective in preventing urinary tract deterioration in myelodysplastic children with high bladder pressure and detrusor-sphincter dyssynergia.
Sequential, nonrandomized trial.
Referral-based urodynamics facility and myelodysplasia program at a major city pediatric hospital.
Twenty-six of 71 consecutive newborns with myelodysplasia who exhibited these urodynamic findings were treated prophylactically over 5 years, whereas 56 of 105 consecutive newborns with the same findings treated during the previous 7 years were treated expectantly.
Clean intermittent catheterization and oxybutynin therapy were begun when these specific urodynamic findings were detected.
Follow-up urodynamic studies and roentgenographic assessment of the urinary tract were performed periodically over 5 years. Oxybutynin eliminated uninhibited contractions in two of 14 newborns and lowered peak contractile pressure in the remaining 12. Oxybutynin also lowered bladder-filling pressure at capacity in all 12 additional neonates with only hypertonicity. Twenty-four (92%) of 26 children had normal kidney function and drainage during the observation period, two (8%) developed hydroureteronephrosis, and one of these two had vesicoureteral reflux. In a prior study of children similarly at risk who were treated expectantly, the roentgenographic appearance of the upper urinary tract had changed in 48%. Minimal side effects were noted with oxybutynin, and no adverse effects of clean intermittent catheterization were detected.
Oxybutynin effectively reduces uninhibited contractions and lowers detrusor filling pressure, while clean intermittent catheterization allows bladder emptying at low pressures with no measurable side effects in these neonates. The overall effect maintains the integrity of the upper urinary tract in almost all myelodysplastic children at risk of urinary tract deterioration. Expectant therapy can no longer be advocated when these "at risk" children are identified because prophylactic treatment is so effective.
确定预防性使用清洁间歇性导尿术和氯化奥昔布宁是否能有效预防患有高膀胱压力和逼尿肌-括约肌协同失调的骨髓发育不良儿童的尿路恶化。
序贯非随机试验。
某大城市儿童医院基于转诊的尿动力学检查机构和骨髓发育不良治疗项目。
71例连续患有骨髓发育不良且有这些尿动力学检查结果的新生儿中，26例在5年期间接受了预防性治疗，而在之前7年期间接受治疗的105例有相同检查结果的连续新生儿中，56例采取了观察等待的方式。
当检测到这些特定的尿动力学检查结果时，开始进行清洁间歇性导尿术和奥昔布宁治疗。
在5年期间定期进行随访尿动力学研究和尿路的X线评估。奥昔布宁消除了14例新生儿中的2例的无抑制性收缩，并降低了其余12例的峰值收缩压。奥昔布宁还降低了另外12例仅有高张性的新生儿膀胱充盈时的压力。26例儿童中有24例（92%）在观察期内肾功能和引流正常，2例（8%）发生了肾盂输尿管积水，其中1例有膀胱输尿管反流。在之前一项对有类似风险且采取观察等待方式治疗的儿童的研究中，上尿路的X线表现有48%发生了改变。奥昔布宁的副作用极小，且未检测到清洁间歇性导尿术的不良反应。
奥昔布宁能有效减少无抑制性收缩并降低逼尿肌充盈压力，而清洁间歇性导尿术能使膀胱在低压下排空，在这些新生儿中未发现可测量的副作用。总体效果可维持几乎所有有尿路恶化风险的骨髓发育不良儿童上尿路的完整性。当识别出这些“有风险”的儿童时，不再提倡观察等待疗法，因为预防性治疗非常有效。
