Department of Urology, University of Minnesota, Minneapolis, Minnesota.
Gillette Lifetime Specialty Healthcare, St. Paul, Minnesota.
Neurourol Urodyn. 2018 Aug;37(6):1943-1949. doi: 10.1002/nau.23535. Epub 2018 Feb 28.
Neurogenic bladders (NGB) with detrusor leak point pressures >40 cm H O (dLPP > 40) have been associated with deterioration of renal function in children with myelomeningocele. For these children, careful pressure management preserves renal function. However, similar evidence is lacking in adult congenital urology (ACU) patients with NGB. We describe renal functional outcomes of non-surgical management of adults with dLPP > 40 or premicturition detrusor pressure (PMDP) >40 cm H O, consisting of close follow-up with urodynamic studies (UDS) and renal ultrasound (RUS), paired with adjustments to clean intermittent catheterization (CIC) frequency, anticholinergics, and addition of onabotulinumtoxinA toxin (BTX) injection.
We retrospectively reviewed the UDS of all patients at an ACU clinic from 2011 to 2016. Patients with dLPP/PMDP > 40 cm who elected for non-surgical management were included. We describe their management and renal functional outcomes.
A total of 33/42 patients with dLPP/PMDP > 40 elected for non-surgical management. 28/33 (85%) were successfully managed without bladder augmentation or urinary diversion at follow-up of nearly 3 years. The median index dLPP/PMDP was 49 cm H O (IQR 44, 63) and final dLPP/PMDP was 28 (IQR 18, 43). There was a significant decrease in dLPP/PMDP and increase in bladder compliance between index and final UDS (P < 0.001). No patients advanced their CKD stage and 6/10 with baseline hydronephrosis had improvement or resolution of hydronephrosis with non-surgical management.
A non-surgical protocol for ACU patients with NGB and dLPP/PMDP > 40, utilizing CIC, anticholinergics, and BTX is safe and effective when coupled with coordinated care and close follow-up.
逼尿肌漏点压力>40cmH₂O（dLPP>40）的神经原性膀胱与脊髓脊膜膨出患儿肾功能恶化有关。对于这些儿童，仔细的压力管理可保护肾功能。然而，在先天性泌尿外科（ACU）成人患者中，没有类似的证据。我们描述了逼尿肌漏点压力>40 或排尿前逼尿肌压力（PMDP）>40cmH₂O 的成人非手术治疗的肾功能结果，包括密切随访尿动力学研究（UDS）和肾脏超声（RUS），并根据需要调整清洁间歇性导尿（CIC）频率、抗胆碱能药物和添加肉毒杆菌毒素 A （BTX）注射。
我们回顾性分析了 2011 年至 2016 年在 ACU 诊所进行的所有患者的 UDS。选择非手术治疗的逼尿肌漏点压力/排尿前逼尿肌压力>40cmH₂O 的患者被纳入研究。我们描述了他们的管理和肾功能结果。
共有 33/42 例逼尿肌漏点压力/排尿前逼尿肌压力>40 的患者选择了非手术治疗。在近 3 年的随访中，28/33（85%）患者成功地避免了膀胱扩大或尿流改道。中位指数逼尿肌漏点压力/排尿前逼尿肌压力为 49cmH₂O（IQR 44,63），最终逼尿肌漏点压力/排尿前逼尿肌压力为 28cmH₂O（IQR 18,43）。在指数和最终 UDS 之间，逼尿肌漏点压力/排尿前逼尿肌压力显著下降，膀胱顺应性增加（P<0.001）。没有患者进展为 CKD 期，基线时存在肾积水的 6/10 例患者通过非手术治疗后肾积水得到改善或缓解。
对于逼尿肌漏点压力/排尿前逼尿肌压力>40 的先天性泌尿外科成人患者，采用 CIC、抗胆碱能药物和 BTX 的非手术方案是安全有效的，同时需要协调护理和密切随访。
