学术分享骶神经调节治疗非神经源性、非机械梗阻性排尿困难的经验初探

学术分享骶神经调节治疗非神经源性、非机械梗阻性排尿困难的经验初探引言作者张鹏张建忠吴栗洋张朝华张小东作者单位首都医科大学附属北京朝阳医院泌尿外科通信作者张鹏（Email：*******************）摘要目的初步总结骶神经调节（sacral neuromodulatin，SNM）治疗非神经源性、非机械梗阻性排尿困难的相关经验。

方法2013年1月至2017年5月28例患者，男20例，女8例, 临床表现为尿频、尿急、尿等待、尿流中断、尿不尽感、尿潴留等，院前治疗时间2～25年（7.1±6.9）年，疗效不佳或无效后纳入本研究。

经影像尿动力检查确诊为非神经源性、非机械梗阻性排尿困难，其中原发性尿道括约肌痉挛17例，特发性逼尿肌无力11例。

应用美敦力公司骶神经调控产品（InterStim）进行骶神经调节疗法治疗。

28例患者均局麻下行SNMⅠ期自固定电极体验治疗，效果不佳者将拔除电极。

效果良好者行Ⅱ期永久刺激器植入。

比较术前与Ⅱ期永久刺激器植入后短期随访中的24 h排尿次数、残余尿量、排尿困难程度、夜尿次数、次平均尿量、尿急程度等相关症状的改善程度。

结果本组28例中11例（男8例，女3例）Ⅰ期自固定电极体验治疗效果不佳，于局麻下拔除电极。

17例（男12例，女5例）接受Ⅱ期永久刺激器植入，28例Ⅰ-Ⅱ期转换率为60.7%（17/28），其中原发性尿道括约肌痉挛患者的Ⅰ-Ⅱ期转换率为64.7%（11/17），特发性逼尿肌无力患者的Ⅰ-Ⅱ期转换率为54.5%（6/11）。

17例Ⅱ期永久刺激器植入术后随访10～46个月，平均16.7个月。

17例治疗前后的24 h平均排尿次数分别为（16.3±6.1）次和（8.8±4.1）次，排尿困难及等待程度评分分别为（7.8±2.3）分和（4.3±1.2）分，夜尿次数分别为（4.0±1.8）次和（2.5±1.7）次，尿急程度评分分别为（3.1±1.7）分和（1.9±1.1）分，生活质量评分分别为（5.4±0.7）分和（4.0±1.0）分，差异有统计学意义（均P＜0.05）。

残余尿量分别为（43.0±73.4）ml和（37.8±67.1）ml，平均尿量分别为（145.7±73.5）ml和（189.0±66.4）ml，差异无统计学意义（P=0.18，P=0.48）。

17例随访中，11例症状持续缓解；6例出现症状反复，其中4例调节参数后症状缓解，2例调节参数后排尿困难症状持续存在（尿频、排尿费力、排尿等待等症状恢复至术前水平），认定为失效。

结论SNM是治疗非神经源性、非机械梗阻性排尿困难安全、有效的微创治疗方式。

尿道括约肌痉挛导致排尿困难患者的Ⅰ-Ⅱ期手术转换率高，是较好的手术适应证。

关键词骶神经调节；非神经源性；非机械梗阻性，排尿困难基金项目：北京市卫生系统高层次卫生技术人才培养项目（2015-3-030）The initial experiences of sacral neuromodulation on non-neurogenic， non-obstructive dysuria.AuthorZhang Peng，Zhang Jianzhong，Wu Liyang，Zhang Chaohua，Zhang Xiaodong.AddressDepartment of Urology，Beijing Chaoyang Hospital，Capital Medical University，Beijing 100020，ChinaCorrespondence AuthorZhang Peng（Email：*******************）AbstractObjectiveTo summarize the initial treatment experiences of SNM on non-neurogenic，non-obstructive dysuria during short follow-up.MethodsFrom January 2013 to April，2017，28 patients with non-neurogenic，non-obstructive dysuria who were diagnosed by video-urodynamic study （including 20 male patients and 8 female patients；17 patients suffered from urethra sphincter spasm and 11 from idiopathic detrusor weakness）were recruited in our study. All these patients had various symptoms such as frequency, urgency, hesitation, interruption and urinary retention, all of them received no-working treatments from 2 to 25 years（7.1±6.9 years in average）and finally were recruited in our study. They were all received sacral neuromodulationtreatment with Medtronic company product（InterStim）. We tried to compare the data（such as frequency in 24 hours，residual urine，dysuria degree， nocturia，average volume and urgency） before operation and the data of short term follow-up after stage Ⅱ implanted pulse generator （IPG） embedded in order to summarize the initial experiences of sacral neuromodulation for non-neurogenic，non-obstructive dysuria.ResultsAll 28patients received stage Ⅰ operation with percutaneous approach to implant a tined lead，11 patients （8 male patients and 3 female patients） finally removed the tined lead because of poor testing effects. 17 patients （12 male patients and 5 female patients）choose embedding IPG at the end of stage Ⅰ. During 28 patients，the conversion rate of stage Ⅰ to stage Ⅱ is 60.7%（17/28，among them，the conversion rate of urethra sphincter spasm is 64.7%（11/17）and the conversion rate of idiopathic detrusor weakness is 54.5%（6/11）.The follow-up time after stage Ⅱ was16.7 months（10-46 months）. The data of voiding frequency in 24 hours，residual urine，dysuria degree，nocturia， urgency，average voiding amount and quality of life （QOL） between baseline （before stage Ⅰ） and at the follow-up time were 16.3±6.1vs.8.8±4.1（p=0.000），（43.0±73.4）mlvs.（37.8±67.1）ml（p=0.178）；7.8±2.3vs.4.3±1.2（p=0.001）； 4.0±1.8 vs.2.5±1.7（p=0.003），3.1±1.7vs.1.9±1.1（p=0.001），（145.7±73.5）mlvs. （189.0±66.4）ml（p=0.48），5.7vs.1.4 （p＜0.05）and 5.4±0.7vs.4.0±1.0（p=0.000），respectively. During the follow-up period， 11 patients satisfied with symptoms relieve withoutrecurrence. Six patients had symptoms recurrence，4/6 patients regain the effects after reprogramming，but two patients remained serious recurrence even after repeated reprogramming （frequency，dysuria and hesitation recurred as before SNM）.ConclusionsSNM is an effective，safe and minimally invasive procedure for patients with non-neurogenic，non-obstructive dysuria. Primary，non-neurogenic urinary sphincter spasm is a good indication for SNM and had high transfer rate.Key wordsSacral neuromodulation；Non-neurogenic，non-obstructive；Dysuria无明显诱因的排尿困难甚至尿潴留在实际诊断和治疗方面都是临床难点问题。