美國(guó)泌尿外科學(xué)會(huì)（AUA）報(bào)告美國(guó)肖氏手術(shù)三年結(jié)果　　

虹橋科教論壇 http://www.rainbowplan.org/bbs/edu/　　

送交者: WWWW 于 2011-04-29 03:37:07

【這是新聞發(fā)布會(huì)前和朋友的通信：附上AUA年會(huì)3年結(jié)果（先不要對(duì)外透漏)。專業(yè)數(shù)據(jù)非常好，比預(yù)期的還好。另外，你們結(jié)合UROLOGY Times的報(bào)道，就會(huì)明白美國(guó)的手術(shù)難度比中國(guó)大得多，其中4個(gè)人做了神經(jīng)移植。術(shù)前我就對(duì)美方和美國(guó)病人講：你們3個(gè)做過(guò)宮內(nèi)手術(shù)的都需做神經(jīng)移植，成功的可能最多30%（好了1個(gè)半：一個(gè)homerun，另一個(gè)大便好了），這位37歲的脊髓膨出病人膀胱本來(lái)就發(fā)育不好，又受損太久，效果難定，其余6位有把握。現(xiàn)在的結(jié)果完全如我所料：總共7人自主排尿，8人自主大便。
另外：肖氏反射弧“消失”及其重要科學(xué)意義:
和截癱不同，在脊膜膨出患者，我在最初20例就觀察患兒到最后都無(wú)須利用肖氏反射弧排尿，都能像正常人一樣意識(shí)控制排尿，這我在J.UROL2005文章中已經(jīng)報(bào)告。其實(shí)這是肖氏反射弧一個(gè)非常重要的科學(xué)現(xiàn)象，證明了異類周圍神經(jīng)再生形成肖氏反射弧后能刺激、導(dǎo)致中樞包括大腦的功能重組。我973項(xiàng)目的一項(xiàng)重要內(nèi)容就是證明這個(gè)重組。我已經(jīng)在20多個(gè)SB病人完成了術(shù)前和術(shù)后獲得排尿功能后fMRI研究，證明了這類患者術(shù)后在PONS新建立了一個(gè)排尿中樞，其位置與正常人不同！中樞的TAKEOVER非常有意思！我在SIU講座時(shí)略微帶了一下（你可去看看那視頻）。已成文。這項(xiàng)研究非常辛苦不易，歷經(jīng)6-7年。】

美國(guó)泌尿外科學(xué)會(huì)（AUA）報(bào)告美國(guó)肖氏手術(shù)三年結(jié)果

Tuesday, May 17, 2011 華盛頓 D.C

背景和目標(biāo)：通過(guò)顯微神經(jīng)手術(shù)吻合腰-骶神經(jīng)運(yùn)動(dòng)支，從而建立皮膚-中樞-膀胱反射弧來(lái)重建先天脊柱裂脊膜膨出病人膀胱和腸道功能的理論和手術(shù)是肖傳國(guó)發(fā)明的。我們應(yīng)用此創(chuàng)新手術(shù)已3年，現(xiàn)報(bào)告結(jié)果。

方法：這項(xiàng)為期3年的臨床研究計(jì)劃共收治9位病人（3男6女）平均年齡8歲（6-37歲）。本計(jì)劃得到倫理委員會(huì)批準(zhǔn)。經(jīng)過(guò)詳盡的術(shù)前檢查和評(píng)估后，為每個(gè)病人在神經(jīng)電生理監(jiān)控下施行了腰-骶神經(jīng)通路重建手術(shù)（即肖氏反射弧手術(shù)---譯者注）。術(shù)后評(píng)估包括隨訪問(wèn)卷，尿流動(dòng)力學(xué)測(cè)定，排尿日記，腎功能研究和大腸功能評(píng)估。

結(jié)果：9個(gè)病人中，5個(gè)曾在出生后24小時(shí)內(nèi)做過(guò)脊膜膨出修補(bǔ)手術(shù)，3個(gè)則在胎兒期用內(nèi)窺鏡作了子宮內(nèi)脊髓膜膨出修補(bǔ)術(shù)，僅一人無(wú)手術(shù)史。手術(shù)平均時(shí)間為183分鐘（127-278分鐘），無(wú)任何術(shù)中并發(fā)癥。術(shù)后有一個(gè)病人發(fā)生左足下垂，8個(gè)病人出現(xiàn)暫時(shí)性小腿肌肉力量減弱（均在6個(gè)月左右恢復(fù)至術(shù)前肌力—譯者注：見(jiàn)術(shù)后一年報(bào)告J.Urol，Peters）。在術(shù)后12個(gè)月，9個(gè)病人中有7個(gè)經(jīng)檢測(cè)證實(shí)已建立皮膚-膀胱反射弧（即肖氏反射弧-譯者注）在進(jìn)行術(shù)后第3年隨訪時(shí)，有2位病人沒(méi)能回訪，暫列為失隨訪。其余7位病人術(shù)后3年結(jié)果如下：尿流動(dòng)力學(xué)檢查證實(shí)：膀胱平均容量從210毫升增加到293毫升。7個(gè)病人中術(shù)前有4個(gè)是高反射膀胱，現(xiàn)僅一位還有高反射。平均膀胱順應(yīng)性從術(shù)前12.2 ml/H2O改善為28.4 ml/H2O，其中3位術(shù)前順應(yīng)性低于10者（表示逼尿肌基本無(wú)功能-譯者注）術(shù)后變成正常（從7到34.3, 從9.4到21.2, 從8.3到28.4）。 7個(gè)病人中，術(shù)前僅2人能排出平均23毫升尿，現(xiàn)6人已完全不需導(dǎo)尿管自行排尿，6個(gè)病人自己記錄每次可排出平均156毫升尿，但尿流率測(cè)定證實(shí)每次平均排出高達(dá)248毫升，殘余尿93毫升，有效排尿率為73% 所有6個(gè)病人都能排空至少超過(guò)59%的膀胱容量。7個(gè)病人中，5個(gè)需借助些許腹壓排尿；7個(gè)病人中一個(gè)已無(wú)尿失禁，6個(gè)仍有壓力性尿失禁（即打噴嚏或劇烈咳嗽時(shí)滴尿，因?yàn)槟虻览s肌還較弱所致-譯者注）：其中3個(gè)僅偶有滴尿，3個(gè)較易滴尿。7個(gè)病人中，3個(gè)在術(shù)前認(rèn)為自己腸道功能正常，一個(gè)沒(méi)有大便失禁。在術(shù)后3年隨訪時(shí)，6個(gè)報(bào)告腸道功能已正常，4個(gè)已無(wú)大便失禁。除一位還有高反射膀胱的病人外，其余所有病人都不再需要服用抗膽堿能藥物。腎臟B超檢查和血肌酐均正常。所有病人均無(wú)長(zhǎng)期并發(fā)癥。7個(gè)病人中有6個(gè)很高興自己作了本手術(shù)。

結(jié)論：腰-骶神經(jīng)改道重建手術(shù)（即肖氏反射弧手術(shù)-譯者注）能夠改善先天性脊柱裂脊膜膨出并發(fā)神經(jīng)性膀胱病人的大小便功能。

Tuesday, May 17, 2011 8:00 AM-10:00 AM

Urodynamics/Incontinence/Female Urology: Neurogenic Voiding Dysfunction

Moderated Poster

Source of Funding: Ministrelli Program for Urology Research and Education (MPURE)

1502: THREE-YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA

Kenneth Peters，Kevin Feber， Benjamin Girdler， William Nantau， Evan Kass， Jose Gonzalez， Gary Trock ，Ananias Diokno，Royal Oak, MI

INTRODUCTION AND OBJECTIVES: The concept of restoring bladder and bowel function inspina bifida by the creation of a skin-CNS-bladder reflex arc by an intradural lumbar to sacral motor root microanastomosis was introduced by Xiao. We report our three-year experience with the novel procedure.

METHODS: Nine patients (3 males, 6 females) with median age of 8 (range 6 to 37) years enrolled in this institutional review board approved protocol. After extensive preoperative evaluation, lumbar to sacral nerve rerouting was performed using intraoperative neurophysiological monitoring. Postoperative evaluation included follow-up questionnaires,urodynamic testing (UDT), voiding diaries, renal function studies and bowel assessment.

RESULTS: Of the 9 patients, 5 patients had defect closure within 24 hours of birth, 3 had intrauterine closure and 1 had no prior surgery. Mean operative time was 183 (range 127-278) minutes. No intraoperative complications occurred. One patient developed permanent foot drop and 8 had transient lower extremity weakness. By 12 months, 7 of 9 had a documented cutaneous to bladder reflex. At 3 years, 2 patients did not return for follow-up and were considered non-responders. Seven patients returned for 36-month evaluation. On UDT, maximum cystometric capacity improved from mean 210 cc to 293 cc. At baseline 4/7 had neurogenic detrusor overactivity (NDO); at 36 months 1/7 had NDO. Median compliance improved from 12.2 ml/H20 to 28.4 ml/H2O and 3 with a baseline compliance of less than 10 had normalization (7 to 34.3, 9.4 to 21.2, and 8.3 to 28.4). At baseline, 2/7 were able to void with an average void of 23 cc. At 36 months, 6/7 no longer required catheterization and 6/7 reported mean voided volume of 156cc on voiding diaries. Uroflow demonstrated a mean voided volume of 248 cc with a 93 cc post void residual and a voiding efficiency of 73%. All 6 patients were voiding > 59% of their bladder capacity. 5 of 7 require some valsalva to void. 6/7 subjects had persistent stress incontinence with 1 subject dry, 3 with occasional leak, 3 frequent leaks. At baseline, 3/7 considered their bowels normal and 1/7 were continent of stool. At 36-months 6/7 considered bowels normal and 4/7 continent of stool. Antimuscarinics were stopped in all subjects except the 1 with persistent NDO. Renal ultrasounds and serum creatinines remained stable. No long-term complications were identified and 6/7 would undergo the procedure again.

CONCLUSIONS:

Lumbar to sacral nerve rerouting can improve bladder and bowel function in patients withneurogenic bladder associated with spina bifida.

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