Pole Medico Chirurgical Pédiatrique, Hôpital d'enfants de la Timone, Marseille, France.
Scand J Surg. 2011;100(4):256-63. doi: 10.1177/145749691110000405.
Diagnosis of neurogenic bladder is straightforward in children with myelomeningocele. However, recognition is more difficult in patients with occult dysraphism or central nervous system disorders since clinico-anatomical correlations are poor. Careful clinical examination and urodynamic exploration are mandatory for diagnosis and follow-up. Even if urinary leak is the first symptom, the main goal of the pediatric surgeon must be to preserve the upper urinary tract. The ideal protection strategy consists of ensuring that micturition is voluntary and complete and that the bladder capacity is sufficient with adequate compliance and sphincter outlet resistances. Balancing these functions requires a combination of medical and surgical treatment. A variety of techniques can be used depending on gender and age of the patient and social environment. In most cases, intermittent bladder catheterization is necessary to obtain complete evacuation of the bladder. Bladder capacity can be increased by anticholinergic drugs, injection of botulinum toxin into the bladder, and augmentation cystoplasty. Augmentation of bladder outlet resistances requires endoscopic injection of bulking agents, surgical bladder neck reconstruction and urethral lengthening, bladder neck suspension, and artificial urinary sphincter. In difficult cases, continent cystostomy with closure of the bladder neck can achieve definitive continence. At the beginning endoscopic treatment combining anti reflux procedure, injection of the bladder neck and botulinum toxin can be considered as a "total endoscopic management" and should be our first line. Other techniques are under evaluation. Sacral neuro-modulation has given promising results. Artificial tissue engineering will probably be used in the next future. Management of neurogenic bladder is not limited to urological considerations. Orthopedic, digestive, and sexual problems must also be taken into account in order to obtain an "acceptable quality of life".
神经原性膀胱的诊断在脊髓脊膜膨出患儿中很简单。然而，对于隐匿性发育畸形或中枢神经系统疾病患者，由于临床解剖相关性较差，识别更为困难。仔细的临床检查和尿动力学检查对于诊断和随访是强制性的。即使尿漏是首发症状，小儿外科医生的主要目标也必须是保护上尿路。理想的保护策略包括确保排尿是自愿和完全的，并且膀胱容量充足，顺应性和括约肌出口阻力适当。平衡这些功能需要结合药物和手术治疗。根据患者的性别、年龄和社会环境，可以使用多种技术。在大多数情况下，间歇性膀胱导管插入术是获得膀胱完全排空所必需的。抗胆碱能药物、膀胱内肉毒杆菌毒素注射和膀胱扩大术可增加膀胱容量。增加膀胱出口阻力需要内镜下注射膨胀剂、膀胱颈重建和尿道延长、膀胱颈悬吊和人工括约肌。在困难情况下，膀胱颈闭合的可控性膀胱造口术可以实现永久性控制。在开始时，结合抗反流手术的内镜治疗、膀胱颈注射和肉毒杆菌毒素注射可以被认为是一种“全内镜管理”，应该是我们的一线治疗方法。其他技术正在评估中。骶神经调节已取得了有希望的结果。人工组织工程在未来可能会得到应用。神经原性膀胱的管理不仅限于泌尿科的考虑因素。为了获得“可接受的生活质量”，还必须考虑到骨科、消化和性问题。
