Austin P, Spyropoulos E, Lotenfoe R, Helal M, Hoffman M, Lockhart J L
Department of Surgery, University of South Florida Health Sciences Center, Tampa General Hospital, USA.
Urology. 1996 Jun;47(6):890-4. doi: 10.1016/S0090-4295(96)00072-6.
To evaluate a group of women with voiding dysfunction and a low maximum flow rate (MFR) (less than or equal to 12 mL/s) after surgery for stress urinary incontinence (SUI); to establish diagnostic parameters indicating obstruction in an attempt to determine treatment selection; and to evaluate preliminary surgical results.
Eighteen women who underwent anti-incontinence surgery for SUI were diagnosed as having infravesical obstruction (IO). Thirteen women (group A [72%]) presented with clinically predominant symptoms of urgency, frequency, intermittency, and a variable vesical residual volume (RV), and five (group B [28%]) had as their most significant symptoms a high vesical RV and urinary tract infection that had been managed with intermittent catheterization (IC). The diagnosis of IO, suspected after clinical history, was established after physical examination and cystoscopic, cystographic and urodynamic investigations.
Bladder instability was demonstrated in 6 group A patients (46%) and 1 group B patient (20%) (P = NS). Mean MFRs were 8.07 and 7.2 mL/s, respectively, in both groups (P = NS). Mean maximal voiding pressures (MVPs) were 20.23 and 5 cm H20, and mean RVs were 57.46 and 174 mL, respectively; both differences were statistically very significant (P <0.01 and P <0.001, respectively). High to normal MVPs occurred in 2 patients overall (11%). Bladder neck overcorrection, midurethral distortion, and postsurgical cystocele were demonstrated in both groups in 11 (85%), 0, and 2 (15%) patients in group A and 3 (60%), 2 (40%), and 3 (60%) patients in group B, respectively (P = NS). Patients in group A were treated surgically with cystourethrolysis and a repeated, less obstructive anti-incontinence operation. In group B 2 women (40%) had a similar surgical procedure; 1 (20%) underwent isolated urethrolysis; and 2 (40%) are currently maintained with IC.
Among these 18 patients with voiding dysfunction after anti-incontinence surgery, a primary diagnosis of IO was established clinically. Only patients with a low MFR were selected for this study. Cytographic and endoscopic investigation as well as the presence of postsurgical cystocele assisted in establishing the diagnosis. The success rate with urethrolysis and resuspension was 60% for the 13 women with predominantly urgency, frequency, and the highest MVPs (20.23 +/- 9.67 cm H20 [group A) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group A]) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group B]). An added resuspension procedure is probably unnecessary in the latter group of patients and requires careful individual selection in the former group.
评估一组压力性尿失禁（SUI）手术后出现排尿功能障碍且最大尿流率（MFR）较低（小于或等于12 mL/s）的女性患者；建立指示梗阻的诊断参数以确定治疗方案；并评估初步手术结果。
18例接受SUI抗尿失禁手术的女性被诊断为膀胱颈以下梗阻（IO）。13名女性（A组[72%]）表现出以尿急、尿频、排尿间断和膀胱残余尿量（RV）变化为主的临床症状，5名（B组[28%]）以膀胱RV高和尿路感染为最显著症状，此前通过间歇性导尿（IC）进行处理。IO的诊断在临床病史怀疑后，经体格检查、膀胱镜检查、膀胱造影和尿动力学检查得以确立。
A组6例患者（46%）和B组1例患者（20%）表现出膀胱不稳定（P = 无显著性差异）。两组的平均MFR分别为8.07和7.2 mL/s（P = 无显著性差异）。平均最大排尿压力（MVP）分别为20.23和5 cmH₂O，平均RV分别为57.46和174 mL；两者差异均具有统计学极显著性（分别为P <0.01和P <0.001）。总体2例患者（11%）出现高至正常的MVP。A组11例（85%）、0例和2例（15%）患者以及B组3例（60%）、2例（40%）和3例（60%）患者分别出现膀胱颈过度矫正、尿道中段扭曲和术后膀胱膨出（P = 无显著性差异）。A组患者接受膀胱尿道松解术及重复的、梗阻性较小的抗尿失禁手术治疗。B组2名女性（40%）接受了类似的手术；1名（20%）接受了单纯尿道松解术；2名（40%）目前通过IC维持治疗。
在这18例抗尿失禁手术后出现排尿功能障碍的患者中，临床上确立了IO的初步诊断。本研究仅选取了MFR较低的患者。膀胱造影和内镜检查以及术后膀胱膨出的存在有助于确立诊断。对于以尿急、尿频为主且MVP最高（20.23±9.67 cmH₂O [A组]）的13名女性，尿道松解术和尿道悬吊术的成功率为60%；对于MVP最低（5.00±7.07 cmH₂O [A组]）且有尿潴留的5名女性，成功率为33%；对于MVP最低（5.00±7.07 cmH₂O [B组]）且有尿潴留的5名女性，成功率为33%。后一组患者可能无需额外的悬吊手术，而前一组患者则需要谨慎进行个体选择。
