Klose A G, Sackett C K, Mesrobian H G
Section of Pediatric Urology, University of North Carolina School of Medicine, Chapel Hill.
J Urol. 1990 Dec;144(6):1446-9. doi: 10.1016/s0022-5347(17)39763-x.
Recent reports have suggested that the prophylactic use of clean intermittent catheterization in selected infants with myelodysplasia and with normal upper tracts may prevent their deterioration. The selection of these patients at risk depends on urodynamic criteria. We reviewed our experience with clean intermittent catheterization instituted when upper tract deterioration was found. Of 130 patients with myelodysplasia followed at our clinic 25 (19%) had or presented with radiological upper urinary tract deterioration. A total of 21 patients had vesicoureteral reflux and 4 had hydronephrosis without reflux. Treatment consisted of clean intermittent catheterization alone in 5 patients and combined with anticholinergic medication in 16. Four patients with no post-void residual urine were carefully observed without intervention. Urodynamic evaluation was performed selectively in 11 of these 25 patients for persistence of upper urinary tract deterioration or urinary incontinence after institution of treatment. Of the 21 children with reflux 19 (90%) had resolution or improvement for an average followup of 47 months. Hydronephrosis completely resolved in the 4 patients without reflux. Thus, the over-all resolution or improvement rate was 92% for an average of 41 months. Although these excellent results may not be superior to the prophylactic use of clean intermittent catheterization, they validate the assumption that upper tract deterioration can be reversed. The application of current urodynamic selection criteria may result in overtreating a significant number of infants who otherwise may not have upper tract deterioration. Further refinements in these criteria may be necessary to select better not only patients at risk but also to determine the frequency of imaging necessary in this urologically heterogeneous population. In addition, careful consideration should be given to urethral dilation as a third and equally viable alternative to prevent upper tract deterioration.
近期报告表明，对部分患有脊髓发育不良且上尿路正常的婴儿预防性使用清洁间歇性导尿术，可能会防止其病情恶化。这些高危患者的选择取决于尿动力学标准。我们回顾了在发现上尿路恶化时实施清洁间歇性导尿术的经验。在我们诊所随访的130例脊髓发育不良患者中，25例（19%）出现了放射学上的上尿路恶化。共有21例患者存在膀胱输尿管反流，4例无反流的肾积水患者。5例患者仅接受清洁间歇性导尿术治疗，16例患者联合使用抗胆碱能药物治疗。4例无残余尿量的患者在密切观察下未进行干预。在这25例患者中，有11例因上尿路恶化持续存在或治疗后出现尿失禁而进行了选择性尿动力学评估。在21例反流患儿中，19例（90%）病情缓解或改善，平均随访47个月。4例无反流的肾积水患者积水完全消退。因此，总体缓解或改善率为92%，平均随访41个月。尽管这些出色的结果可能并不优于预防性使用清洁间歇性导尿术，但它们证实了上尿路恶化可以逆转的假设。应用当前的尿动力学选择标准可能会导致对大量原本可能不会出现上尿路恶化的婴儿进行过度治疗。可能需要进一步完善这些标准，以便更好地筛选高危患者，并确定在这个泌尿系统情况各异的人群中进行影像学检查的频率。此外，应认真考虑尿道扩张作为预防上尿路恶化的第三种同样可行的替代方法。
