Izes J K, Bihrle W, Bihrle R
Department of Urology, Lahey Hitchcock Medical Center, Burlington, Massachusetts 01805, USA.
J Urol. 1997 Oct;158(4):1369-71. doi: 10.1016/s0022-5347(01)64217-4.
Periurethral injection of glutaraldehyde cross-linked collagen is a well-established modality for the treatment of patients with incontinence caused by structural defects at the bladder outlet. Little is known about the potential usefulness of this approach to the nonfunctioning continence mechanism of a leaking continent urinary reservoir. An animal model of an incontinent Indiana reservoir was created using the naturally incompetent canine ileocecal valve. The effectiveness and feasibility of endoscopic submucosal injection of glutaraldehyde cross-linked collagen into the ileocecal valve to increase resistance were examined.
Seven beagle dogs underwent isolation of the ileocecal segment. The right colon and ileum were brought to the skin as 2 stomas. Baseline leak point pressures of the ileocecal valve were determined while infusing contrast material into the right colon. The leak point was observed fluoroscopically, and the pressure at which contrast material crossed the valve was measured. Glutaraldehyde cross-linked collagen, 4 to 10 ml., was injected endoscopically into the valve in a circumferential pattern. Leak point pressures were measured immediately, 1 month after injection and 3 months after injection.
An average of 7.1 gm. (range, 4.1 to 10.1 gm.) was required to create an endoscopically "closed" ileocecal valve. Leak point pressure increased from a mean 3.8 mm. water (range, 2.5 to 6.0 mm. water) at baseline to mean 35.7 mm. water after injection (range, 22.0 to 57.0 mm. water). At 1 month, mean leak point pressure decreased slightly to 26.7 mm. water. This pressure stabilized at 3 months at 29.5 mm. water.
Endoscopic delivery of glutaraldehyde cross-linked collagen into the ileocecal valve consistently enhanced resistance as measured by leak point pressure. This effect was durable over a 3-month period of observation. Admittedly, this period of observation is relatively short. Longer followup may have demonstrated significant diminution of collagen migration or resorption. However, this feasibility study demonstrates that collagen injections may provide a minimally invasive means of treating the incontinent continent urinary reservoir.
膀胱尿道周围注射戊二醛交联胶原是治疗因膀胱出口结构缺陷导致尿失禁患者的一种成熟方法。对于这种方法在有渗漏的可控性尿流改道储尿囊控尿机制失灵方面的潜在作用，人们了解甚少。利用天然功能不全的犬回盲瓣建立了一个可控性印第安纳储尿囊尿失禁动物模型。研究了内镜下将戊二醛交联胶原注射到回盲瓣黏膜下层以增加阻力的有效性和可行性。
7只比格犬接受回盲段分离术。将右结肠和回肠作为两个造口引至皮肤表面。在向右结肠注入造影剂时测定回盲瓣的基线漏点压力。通过荧光镜观察漏点，并测量造影剂通过瓣膜时的压力。将4至10毫升戊二醛交联胶原以环形方式内镜下注入瓣膜。在注射后即刻、注射后1个月和注射后3个月测量漏点压力。
平均需要7.1克（范围为4.1至10.1克）才能在内镜下使回盲瓣“闭合”。漏点压力从基线时的平均3.8毫米水柱（范围为2.5至6.0毫米水柱）增加到注射后的平均35.7毫米水柱（范围为22.0至57.0毫米水柱）。在1个月时，平均漏点压力略有下降至26.7毫米水柱。该压力在3个月时稳定在29.5毫米水柱。
通过漏点压力测量，内镜下将戊二醛交联胶原注入回盲瓣可持续增强阻力。在3个月的观察期内这种效果持久。诚然，这一观察期相对较短。更长时间的随访可能会显示胶原迁移或吸收明显减少。然而，这项可行性研究表明，胶原注射可能为治疗有渗漏的可控性尿流改道储尿囊提供一种微创方法。
