Guys J M, Camerlo A, Hery G
Service de chirurgie pédiatrique, Hôpital d'Enfants de la Timone, 13 385 Marseille 5, France.
Ann Urol (Paris). 2006 Feb;40(1):15-27. doi: 10.1016/j.anuro.2005.10.001.
The diagnosis of neurogenic bladder can be easy in myelomeningocele and much more difficult in occult dysraphia or medical etiologies. Careful clinical examinations and urodynamic investigations are mandatory for the diagnosis and the follow up of affected patients. Clinico-anatomical correlations are poor. If urinary leak is the first apparent symptom, preservation of the upper urinary tract is the main goal of the surgeon. If natural history of the neurogenic bladder is destruction of the detrusor and paralysis of the trigona, obstructive uropathy is the main physiological concern. Urinary leak must be integrated in the global context of the bladder function in order to determine urinary incontinence type. Ideal micturition is voluntary, must be complete, and needs the synergistic action of a reservoir with a good capacity, a normal compliance, and adequate sphincter outlet resistances. Continence is obtained by balancing these functions, and associating medical treatment and surgery is necessary. Bladder intermittent catheterization is the clue to obtain in most of the cases complete evacuation of the bladder and protection of the upper urinary tract. Increasing bladder capacity is achieved more often by augmentation cystoplasty (colon, ileus, stomach and ureter can be used). Autoplasty at the beginning, artificial tissue engineering will be the future. Augmentation of the bladder outlet resistances need surgical reconstruction (young dees, Pipi-salles procedures...) or uretral and bladder neck suspensions, artificial urinary sphincters, endoscopic injections of bulking agents. All these techniques can be proposed and combined according to the patient's gender, age and social environment. Continent cystostomy allows obtaining continence in difficult cases and after unsuccessful surgery of the bladder neck. Other techniques are under evaluation and sacral neuromodulation give at the moment some promising results. Managing neurogenic bladder must not be considered only in urological terms: orthopedic troubles, digestive and sexual disorders must not be forgotten in order to obtain at least an "acceptable social life".
神经源性膀胱在脊髓脊膜膨出患者中诊断较容易，而在隐性脊柱裂或医学病因导致的患者中则困难得多。对于受影响患者的诊断和随访，仔细的临床检查和尿动力学检查是必不可少的。临床解剖学相关性较差。如果尿漏是首要明显症状，保护上尿路是外科医生的主要目标。如果神经源性膀胱的自然病程是逼尿肌破坏和膀胱三角区麻痹，梗阻性尿路病是主要的生理问题。必须将尿漏纳入膀胱功能的整体背景中，以确定尿失禁类型。理想的排尿是自主的，必须完全排空，并且需要一个具有良好容量、正常顺应性和足够括约肌出口阻力的储尿器协同作用。通过平衡这些功能来实现控尿，联合药物治疗和手术是必要的。膀胱间歇性导尿是在大多数情况下实现膀胱完全排空和保护上尿路的关键。增加膀胱容量更多是通过膀胱扩大成形术（可使用结肠、回肠、胃和输尿管）来实现。起初是自体成形术，人工组织工程将是未来的发展方向。增加膀胱出口阻力需要手术重建（如Young-Dees手术、Pipi-Salles手术等）或尿道及膀胱颈悬吊术、人工尿道括约肌、内镜下注射填充剂。所有这些技术都可以根据患者的性别、年龄和社会环境提出并联合应用。可控膀胱造口术可在困难病例以及膀胱颈手术失败后实现控尿。其他技术正在评估中，目前骶神经调节取得了一些有希望的结果。管理神经源性膀胱不能仅从泌尿外科角度考虑：为了至少获得“可接受的社会生活”，不能忘记骨科问题、消化和性功能障碍。
