Silveri M, Capitanucci M L, Mosiello G, Broggi G, De Gennaro M
Paediatric Surgery Department, Bambino Gesù Children's Hospital, Palidoro, Rome, Italy.
Br J Urol. 1998 Nov;82(5):694-7. doi: 10.1046/j.1464-410x.1998.00810.x.
To verify, in a retrospective analysis, the effectiveness of endoscopic treatment (collagen injection) in children with neurogenic bladder and neurogenic urinary incontinence.
From January 1992 to March 1997, 36 endoscopic collagen injections were performed to treat neurogenic urinary incontinence in 23 patients (mean age 10.9 years, range 6-17 at the time of the first procedure) selected on the basis of clinical status and the patient's motivation. Nineteen patients were affected by myelomeningocele and four had an occult spinal dysraphism. All patients underwent a preoperative cystometric urodynamic evaluation (without urethral pressure measurement) which showed detrusor areflexia in 12, normal reflexia in one and hyper-reflexia in 10 patients. Bladder compliance was considered good (> or =20 cmH2O) in 13 patients and low (10-20 cmH2O) in 10, four of whom had detrusor areflexia. Twenty-one children emptied their bladder by intermittent clean catheterization. The mean (range) follow-up was 19.2 (6-54) months. Twenty (group A) and 16 (group B) procedures, performed early and late in the series, were analysed separately to determine any increase in effectiveness with surgical experience. The evaluation criteria were; the increase in the 'dry' interval (between catheterizations) before and after treatment/s (delta dry); the patient's and parent's satisfaction; the number of endoscopic procedures and quantity of injected materials.
There was an improvement (dryness of at least 2 h: delta dry of 1 h) in 13 of 23 patients after 1-3 (mean 1.5) procedures; 10 patients had a 0.2 h increase in delta dry after 1-3 injections and none was satisfied. There was no difference in the delta dry (0.9 vs. 0.7 h) between groups A and B, and/or the patient's/parent's satisfaction. Success rates differed with urodynamic patterns; seven of 10 patients showing no improvement had hyper-reflexia and three of the remaining 12 with areflexia had hypocompliant bladders, while nine of the 13 showing improvement had an areflexic detrusor and low-pressure bladders.
The efficacy of the treatment depends largely on the urodynamic selection of patients (mainly those with detrusor areflexia and good compliance). The outcome may be improved further by increasing the quantity of injected material and with a longer follow-up, performing the procedure again if advisable. A close postoperative clinical (pad test) and personal observation is necessary to evaluate the outcome and thus optimize the strategy of treatment.
通过回顾性分析，验证内镜治疗（胶原蛋白注射）对患有神经源性膀胱和神经源性尿失禁儿童的有效性。
1992年1月至1997年3月，对23例患者（首次手术时平均年龄10.9岁，范围6 - 17岁）进行了36次内镜下胶原蛋白注射，以治疗神经源性尿失禁。这些患者是根据临床状况和患者意愿挑选出来的。19例患者患有脊髓脊膜膨出，4例患有隐性脊柱裂。所有患者均接受了术前膀胱测压尿动力学评估（未测量尿道压力），结果显示12例患者逼尿肌无反射，1例正常反射，10例反射亢进。13例患者膀胱顺应性良好（≥20 cmH₂O），10例患者膀胱顺应性低（10 - 20 cmH₂O），其中4例患有逼尿肌无反射。21名儿童通过间歇性清洁导尿排空膀胱。平均（范围）随访时间为19.2（6 - 54）个月。分别对该系列中早期和晚期进行的20例（A组）和16例（B组）手术进行分析，以确定手术经验是否会提高治疗效果。评估标准为：治疗前后“干爽”间隔时间（导尿之间）的增加量（Δ干爽）；患者及家长的满意度；内镜手术次数和注射材料的量。
23例患者中，13例在接受1 - 3次（平均1.5次）手术后情况有所改善（干爽时间至少增加2小时：Δ干爽增加1小时）；10例患者在接受1 - 3次注射后Δ干爽增加0.2小时，且无人表示满意。A组和B组之间的Δ干爽（0.9小时对0.7小时）以及患者/家长的满意度没有差异。治疗成功率因尿动力学模式而异；10例无改善的患者中有7例反射亢进，其余12例无反射患者中有3例膀胱顺应性低，而13例有改善的患者中有9例逼尿肌无反射且膀胱压力低。
治疗效果在很大程度上取决于对患者的尿动力学选择（主要是那些逼尿肌无反射且顺应性良好的患者）。通过增加注射材料的量并延长随访时间，如果合适可再次进行手术，可能会进一步改善治疗结果。术后密切的临床（尿垫试验）和个人观察对于评估治疗结果从而优化治疗策略是必要的。
