頚髄損傷患者の排尿管理経尿道的括約筋切開術の長期成績  [in Japanese] LONG-TERM FOLLOW UP OF SPHINCTEROTOMY IN SPINAL CORD INJURED MEN  [in Japanese]

(目的)当院では頚髄損傷四肢麻疹患者に対して,良好な失禁性排尿を獲得・維持する目的にて経尿道的括約筋切開術(以下,括約筋切開術)を積極的に施行してきた.今回はその長期成績について検討した.(対象と方法)当院開設(1979年6月)以降,受傷急性期より当院にて排尿管理を行い括約筋切開術を施行,現在まで外来にて5年以上経過観察可能な39症例とした.性別は全て男性.平均年齢は36.2歳,平均経過観察期間は13.1年(5〜27年)であった.(結果)39症例中30症例は失禁性排尿を維持していたが,9症例では何らかの尿路管理の変更を要していた(膀胱瘻造設4例,自己導尿可能2例,介助者による導尿必要2例,その他1例).その主な原因は「尿排出不良に伴う自律神経過緊張症状の増悪」であり,その要因のひとつとして術後徐々に排尿筋反射が減弱することが考えられた.また上記原因にて尿路管理変更を要した群では,術前の排尿筋反射時の最大膀胱内圧が有意に低値であった.(結論)括約筋切開術を含む失禁性排尿による排尿管理は長期成績も比較的良好であり,今後も頚損患者の排尿管理において有用な一選択肢と考えられた.しかしながら排尿筋反射は術後徐々に減弱していく傾向にあり,経過観察時にはこのことに留意しておくべきと考えられた.

(Objectives) The long-term outcome of transurethral sphincterotomy (sphincterotomy) for the management of male quadriplegic patients with neurogenic bladder was examined. (Materials and methods) A total of 39 men with at least 5-years follow-up after sphincterotomy at our institute were included in this retrospective analysis. The mean age was 36.2 years (range 15-61). The mean follow-up period was 13.1 years (range 5-27). (Results) Of the 39 patients, 30 patients (77%) were successfully maintained in reflex voiding with a condom catheter and remaining 9 patients (23%) have received another urinary management, including 4 suprapubic cystostomy, 2 clean intermittent catheterization and 2 clean intermittent catheterization by care giver. The main reason that required another urinary management was the augmentation in autonomic hyperreflexia due to poor urinary drainage. Analysis of the urodynamic parameters revealed that the detrusor overactivity is hard to occur with time and this would be one of the reasons for the change of urinary management. In addition, the preoperative maximum bladder pressure in patients who has changed the urinary management due to the augmentation in AH was significantly lower than that in patients that has been successfully followed up m reflex voiding. (Conclusions) The long-term outcome of sphincterotomy was relatively good. However detrusor overactivity is hard to occur with time and this would be one of the important points during the postoperative routine follow up.