Lee Michael W, Greenfield Saul P
Department of Pediatric Urology, Women and Children's Hospital of Buffalo, Buffalo, New York 14222, USA.
Urology. 2005 Mar;65(3):568-71. doi: 10.1016/j.urology.2004.11.034.
To characterize the clinical characteristics of a group of children with neurogenic bladder, high leak point pressures (LPPs), bladder wall changes, and hydronephrosis in whom medical management failed, who then underwent vesicostomy. Medical management can, rarely, fail in children with neurogenic bladder, high LPPs, bladder wall changes, and hydronephrosis. When it does, surgical intervention is necessary.
Between 1988 and 2001, 8 girls with spina bifida (4 with thoracic and 4 with lumbosacral) underwent vesicostomy after medical management. All had undergone neonatal back closure and five had ventriculoperitoneal shunts. The mean follow-up after vesicostomy was 6 years.
High-grade reflux was present at birth in 3 patients and developed later in 3 patients at 1 year. Two had undergone ureteral reimplantation before vesicostomy. Four girls had trabeculation at birth and it developed in three at 1 year and one at 3 years. Hydronephrosis was present at birth in 2 patients and developed later in 6. High LPPs were noted at younger than 10 months of age in 6 patients. Oral oxybutynin was begun in 7 patients before 1 year of age and 5 were later given intravesical oxybutynin. Six patients began clean intermittent catheterization in infancy. The indications for vesicostomy were persistently elevated LPPs and hydronephrosis. Six had recurrent urinary tract infections. The mean age at vesicostomy was 3 years. Hydronephrosis resolved in 7 patients, and only 1 had additional febrile urinary tract infections. Two underwent reversal along with bladder augmentation and were continent at last follow-up.
A small subset of girls with spina bifida are unresponsive to early and intensive medical therapy. Most have high LPPs and bladder wall and upper tract changes early in infancy. Vesicostomy reverses the clinical course. At an appropriate age, these children can undergo reconstruction with a high likelihood of continence.
描述一组神经源性膀胱、高漏尿点压力（LPP）、膀胱壁改变及肾积水且内科治疗失败后接受膀胱造瘘术的儿童的临床特征。在患有神经源性膀胱、高LPP、膀胱壁改变及肾积水的儿童中，内科治疗极少会失败。一旦失败，手术干预就很有必要。
1988年至2001年间，8名患有脊柱裂的女孩（4名胸段脊柱裂，4名腰骶段脊柱裂）在内科治疗后接受了膀胱造瘘术。所有患儿均在新生儿期进行了背部闭合手术，5名患儿进行了脑室腹腔分流术。膀胱造瘘术后的平均随访时间为6年。
3例患儿出生时即存在高级别反流，3例在1岁时出现反流。2例在膀胱造瘘术前接受了输尿管再植术。4名女孩出生时就有小梁形成，3名在1岁时出现，1名在3岁时出现。2例患儿出生时即有肾积水，6例在之后出现。6例患儿在10个月龄前出现高LPP。7例患儿在1岁前开始口服奥昔布宁，5例后来接受膀胱内注射奥昔布宁。6例患儿在婴儿期开始进行清洁间歇性导尿。膀胱造瘘术的指征为持续升高的LPP和肾积水。6例患儿反复发生尿路感染。膀胱造瘘术的平均年龄为3岁。7例患儿的肾积水得到缓解，只有1例再次发生发热性尿路感染。2例患儿在进行膀胱扩大术的同时进行了膀胱造瘘术逆转，在最后一次随访时实现了控尿。
一小部分患有脊柱裂的女孩对早期强化内科治疗无反应。大多数患儿在婴儿期早期就有高LPP以及膀胱壁和上尿路改变。膀胱造瘘术可逆转临床病程。在适当年龄，这些患儿可以接受重建手术，实现控尿的可能性很大。
