Kohn I J, Balsara R K, Rabinovitch H
Department of Urology, Temple University Hospital, Philadelphia, Pennsylvania, USA.
Urology. 1998 Jun;51(6):1027-30. doi: 10.1016/s0090-4295(98)00131-9.
Numerous surgical procedures have been developed in an attempt to increase bladder compliance and/or outlet resistance for the treatment of intractable incontinence in children with neurogenic lower urinary tract dysfunction. We report our experience with the development of a biocompatable purse-string cuff to increase outlet resistance by providing circumferential compression at the bladder neck.
A total of 12 children (6 boys, 6 girls) with myelodysplasia and persistent incontinence despite clean intermittent catheterization (CIC) and pharmacotherapy underwent urodynamic testing and cystoscopy that revealed neurogenic bladders with concomitant intrinsic sphincter deficiency. Through an anterior approach, the bladder neck was mobilized and wrapped with 5-mm polytetrafluoroethylene tubing. Five-millimeter woven polyester tape was then placed circumferentially within the polytetrafluoroethylene tubing lumen, purse-stringed under tension with a silicone tubing shod to appose the mucosa of the bladder neck, and secured under such tension with a surgical clip. Ten of the 12 patients underwent concomitant augmentation cystoplasty.
Nine of 12 children (age range at time of operation 2.5 to 16 years) are continent on CIC in follow-up ranging from 6 months to 12 years. Four cuffs had to be surgically removed postoperatively. Two were removed secondary to inadvertent transvaginal placement. Two other cuffs were removed for infection. One child with persistent postoperative incontinence had the cuff retightened through a minor surgical procedure and has remained dry. Annual renal ultrasound examinations reveal stabilization of upper urinary tracts throughout the follow-up period in all but 1 patient. Postoperative urodynamic studies reveal increased bladder capacity, decreased intravesical pressures, and increased leak point pressures.
The purse-string bladder neck cuff in combination with augmentation cystoplasty, when warranted, provides excellent, durable continence rates in children with myelodysplasia and neurogenic bladders. Attributes of the cuff are its relative low cost, ease of construction, unchanged angle of the bladder neck making catheterization easy, and potential adjustability in patients with persistent incontinence.
为治疗神经源性下尿路功能障碍患儿的顽固性尿失禁，已开发出多种外科手术方法，试图提高膀胱顺应性和/或出口阻力。我们报告了我们在开发一种生物相容性荷包缝扎袖套方面的经验，该袖套通过在膀胱颈处提供圆周压迫来增加出口阻力。
共有12名患有脊髓发育不良且尽管进行了清洁间歇性导尿（CIC）和药物治疗仍持续尿失禁的儿童（6名男孩，6名女孩）接受了尿动力学测试和膀胱镜检查，结果显示为神经源性膀胱并伴有内在括约肌缺陷。通过前路手术，游离膀胱颈并用5毫米聚四氟乙烯管包裹。然后将5毫米编织聚酯带沿圆周放置在聚四氟乙烯管腔内，用带硅胶套的管在张力下进行荷包缝合以贴合膀胱颈黏膜，并用手术夹在这种张力下固定。12例患者中有10例同时进行了膀胱扩大术。
12名儿童中有9名（手术时年龄范围为2.5至16岁）在随访6个月至12年期间通过CIC实现了控尿。术后有4个袖套不得不通过手术取出。2个因无意中经阴道放置而取出。另外2个袖套因感染而取出。1名术后持续尿失禁的儿童通过一次小手术重新收紧了袖套，此后一直保持干爽。年度肾脏超声检查显示，除1名患者外，所有患者在整个随访期间上尿路均保持稳定。术后尿动力学研究显示膀胱容量增加、膀胱内压降低以及漏点压力增加。
荷包缝扎膀胱颈袖套与膀胱扩大术联合应用（必要时），可为患有脊髓发育不良和神经源性膀胱的儿童提供出色且持久的控尿率。该袖套的优点包括成本相对较低、易于制作、膀胱颈角度不变便于导尿，以及对持续尿失禁患者具有潜在的可调节性。
