Mutchnik S E, Hinson J L, Nickell K G, Boone T B
Scott Department of Urology, Baylor College of Medicine, Houston, Texas 77030, USA.
Urology. 1997 Mar;49(3):353-7. doi: 10.1016/S0090-4295(96)00510-9.
Bladder management in tetraplegic patients traditionally has been intermittent catheterization by a caretaker, placement of indwelling suprapubic or urethral catheters, sphincterotomy and external catheter drainage, or supravesical urinary diversion with an ileal conduit. The aim of this study was to examine the ileovesicostomy as an alternative form of bladder management in such patients.
We report our experience with ileovesicostomy as an incontinent cutaneous urinary diversion not requiring ureteral reimplantation. Six tetraplegic patients who had experienced significant morbidity with their preoperative form of bladder management were managed with an ileovesicostomy fashioned like a funnel from the bladder dome to the right lower quadrant. All patients underwent preoperative and postoperative fluoroscopic and urodynamic evaluations. Patients were evaluated preoperatively and followed postoperatively with serum chemistries, upper urinary tract imaging, and urine bacteriologic studies.
There were no perioperative complications. Postoperative urodynamics demonstrated subjects to have a mean stomal leak-point pressure of 7.7 cm H2O (range 5 to 10). Radiographically, patients carried low urinary residuals (less than 100 cc) and did not exhibit vesicoureteral reflux. In follow-up of 12 to 15 months, no patient has demonstrated calculus formation, hydronephrosis, autonomic dysreflexia, or worsening renal function.
This procedure successfully creates continuous urinary drainage without catheterization, while maintaining the native antireflux mechanism of the ureterovesical junction and avoiding indwelling foreign materials in the urinary tract. Longer follow-up with more cases will be necessary to confirm these findings and to support a recommendation of the incontinent ileovesicostomy as a standard method for managing the neurogenic bladder in tetraplegic patients.
四肢瘫痪患者的膀胱管理传统上一直是由护理人员进行间歇性导尿、留置耻骨上或尿道导管、括约肌切开术和外部导管引流，或采用回肠导管进行膀胱上尿路改道。本研究的目的是探讨回肠膀胱造口术作为此类患者膀胱管理的一种替代形式。
我们报告了回肠膀胱造口术作为一种无需输尿管再植的失禁性皮肤尿路改道的经验。6例四肢瘫痪患者在术前膀胱管理方式下出现了严重的并发症，采用了从膀胱顶部到右下腹呈漏斗状的回肠膀胱造口术进行治疗。所有患者均接受了术前和术后的荧光镜检查和尿动力学评估。术前对患者进行评估，并在术后进行血清化学检查、上尿路成像和尿液细菌学研究。
围手术期无并发症。术后尿动力学显示，受试者的平均造口漏点压力为7.7 cm H2O（范围为5至10）。影像学检查显示，患者的残余尿量较低（小于100 cc），且未出现膀胱输尿管反流。在12至15个月的随访中，没有患者出现结石形成、肾积水、自主神经反射异常或肾功能恶化。
该手术成功地实现了无需导尿的持续尿液引流，同时保留了输尿管膀胱连接部的天然抗反流机制，避免了尿路中留置异物。需要更多病例的更长时间随访来证实这些发现，并支持将失禁性回肠膀胱造口术作为四肢瘫痪患者神经源性膀胱管理的标准方法的建议。
