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目的:探讨后尿道瓣膜症幼儿行膀胱颈切开术的尿动力学表现及其意义。方法:回顾性分析2012年7月~2016年5月收治的56例后尿道瓣膜症患儿资料,均行膀胱镜下后尿道瓣膜切除术,患儿平均年龄(2.0±0.8)岁。2012年7月~2013年7月收治的13例为第一组,平均(1.8±0.6)岁;2013年8月~2016年5月收治的43例为第二组,平均(2.3±0.9)岁。术前完善泌尿系超声、磁共振泌尿系水成像(MRU)、肾核素扫描(ECT)、排尿性膀胱尿道造影(VCUG)等影像学检查。其中同时合并前尿道瓣膜2例,双肾输尿管积水(VUJO)36例(64.3%),膀胱输尿管反流23例(41.1%),反流均为Ⅲ度以上。术前术后均采用尿动力学检查进行评估。术后至尿动力学检查间隔时间约超过半年,对比两组尿动力学结果。结果:经尿道瓣膜切除后,每1~3个月行泌尿系超声、尿动力学检查。第一组中有8例在术后3个月排尿期逼尿肌压力与术前相比无改变,膀胱镜再次检查时发现尿道瓣膜结构已消除,但膀胱颈抬高,遂行膀胱颈切开术,术后1个月再次复查尿动力,发现最大逼尿肌收缩压力可明显减低,且自由尿流率(UFM)有提高。故对第二组病例,术中发现膀胱颈抬高的患儿均行膀胱颈切开术。第二组患儿排尿症状较第一组明显改善。第二组最大逼尿肌收缩压(Pdetmax)和剩余尿量(PVR)分别为(42.2±14.1)cmH2O和(21.6±12.4)ml,低于第一组Pdetmax(75.1±18.3)cm H2O和PVR(32.8±8.9)ml;第二组最大膀胱容量(MBC)和膀胱顺应性(BC)分别为(90.4±33.7)ml和(9.5±2.4)ml/cm H2O,高于第一组MBC(73.1±20.1)ml和BC(6.4±1.9)ml/cm H2O;第二组UFM(7.9±0.7)ml/s,高于第一组(5.6±2.0)ml/s,差异有统计学意义(P<0.05)。两组患儿均无尿失禁出现。两组分别有6例和7例有逼尿肌不稳定(DI),Fisher’s精确概率检验两者差异无统计学意义(P>0.05)。结论:合并有膀胱颈抬高的后尿道瓣膜症患儿,瓣膜切除的同时,适当切开膀胱颈可使膀胱内压力明显减低。尿动力学检查能及时发现膀胱功能异常和指导下一步治疗。因此,后尿道瓣膜症患儿均应行该检查以了解膀胱功能,保护上尿路。
Objective: To investigate the urodynamic manifestations of bladder neck incision in children with posterior urethral valve disease and its significance. Methods: The data of 56 cases of posterior urethral valve disease admitted from July 2012 to May 2016 were retrospectively analyzed. The patients underwent cystoscopic posterior urethral valve resection. The mean age was 2.0 ± 0.8 years. From July 2012 to July 2013, 13 cases were treated as the first group, mean (1.8 ± 0.6) years; 43 cases were treated in the second group from August 2013 to May 2016, with an average of (2.3 ± 0.9) year old. Preoperative urinary ultrasound, magnetic resonance urinary tract imaging (MRU), renal scintigraphy (ECT), urinary bladder and urethroplasty (VCUG) and other imaging studies. There were 2 cases of anterior urethral valve, 36 cases of bilateral ureteral hydronephrosis (VUJO), 23 cases of vesicoureteral reflux (41.1%) and Ⅲ ° or more of reflux. Preoperative and postoperative urodynamic studies were used to assess. Postoperative to urodynamic examination interval of more than six months, compared two groups of urodynamic results. Results: After transurethral resection of the valve, urodynamic and urodynamic tests were performed every 1 to 3 months. In the first group, there were 8 cases of detrusor pressure during urination during 3 months after operation. No change was found in the detrusor pressure during the urination. The urethral valve structure was eliminated after cystoscopy re-examination, but the bladder neck was elevated and the bladder neck was incised Surgery, 1 month after the re-examination of urinary motility and found that the maximum detrusor systolic pressure can be significantly reduced, and free urinary flow rate (UFM) increased. Therefore, the second group of patients, intraoperative findings in patients with bladder neck elevation bladder neck incision. The second group of children urination symptoms than the first group significantly improved. The maximum detrusor Pdetmax and residual urine volume (PVR) in the second group were (42.2 ± 14.1) cmH2O and (21.6 ± 12.4) ml, respectively, which were lower than those in the first group (Pdetmax 75.1 ± 18.3 cm H2O and PVR (32.8 ± 8.9) ml in the first group; MBC and BC in the second group were (90.4 ± 33.7) ml and (9.5 ± 2.4) ml / cm H2O, ± 20.1) ml and BC (6.4 ± 1.9) ml / cm H2O respectively; the second group of UFM (7.9 ± 0.7) ml / s was higher than the first group (5.6 ± 2.0) ml / <0.05). No urinary incontinence occurred in both groups. There were 6 and 7 cases of detrusor instability (DI) in the two groups, Fisher’s exact test showed no significant difference (P> 0.05). CONCLUSIONS: In children with posterior urethral valve disease with bladder neck elevation, the bladder pressure can be significantly reduced by proper resection of the bladder neck. Urodynamics can detect bladder dysfunction and guide the next step in treatment. Therefore, children with posterior urethral valve disease should be checked in order to understand the bladder function, protect the upper urinary tract.