The Urodynamic Study On The Artificial Somatic-autonomic Reflex Arc Procedure For Neurogenic Bladder After Spinal Cord Injury

Purpose: Neurogenic bladder is bladder and urethral dysfunction that caused by neurogenic injury reasons. Spinal cord injury caused by trauma, congenital aberrance, or nervous systerm disease is the most common reason. Spinal cord is the primary center of urine, so spinal cord injury will arouse dysfuction of urine, such as dysuria and incontinence. That results in urinary tract infection and hydronephrosis easily and lead to renal failure at last, and it is the most important dead reason to these patients. Neurogenic bladder have no effective treatment for years, and it is a difficult medical and social problem. There are some traditional procedures such as pharmacological agents, clean intermittent catheterization, suprapubic cathterisation, sacral nerve stimulation, bladder augmentation, et al, but none is a definitive solution. In 1988, Xiao CG started animal experiments to establish a new reflex pathway to regain controliable micturition after spinal cord injury and set up the artificial somatic-autonomic reflex arc theory. The artificial somatic-autonomic reflex arc was constructed by intradural microanastomosis of the left somatic nerve ventral root to autonomic nerve ventral root, the somatic motor axon can regenerate into autonomic nerves. And the new modified nerve can replace the autonomic nerve function. From 1995, Xiao CG applied the theory to treat the neurogenic bladde patients caused by spinal cord injury and spina bifida, and gained effective results. It is a new and effective procedure for neurogenic bladder. With the development of urodynamic, we can evaluate bladder and urethral function and gain important objective basis. It is very helpful to provide the individualizing therapy for neurogenic bladder patients. The study used urodynamic, by contrasting the changes between peroperation and postoperation, to evaluate the effectiveness of the artificial reflex arc procedure for neurogenic bladder, and to explore the possible mechanism.Materials and methods: 138 neurogenic bladder patients caused by spinal cord injury gained artificial somatic-autonomic reflex arc procedure and examined by urodynamic preoperation. 42 patients were followed up over 6 months up to now, and 16 cases have gotten comprehensive clinical materials. In the 16 patients(1 hemirachischisis, 14 meningomyelocele, 1 vertebra fracture spinal cord injury) 12 male and 4 female, median age 10.5 years(range from 2 to 35 years). In the patients, 13 were treated by closed, 6 were treated by released and one was gained bladder augmentation. They are all dysuria, incontinence and enuresis. Urodynamic and neurological assessment involving spinal magnetic resonance imaging were examined preoperation. All the patients were divided into areflexic or hyperreflexic neurogenic bladder by urodynamic, preoperation and postoperation groups. All the patients were followed up and examined by urodynamic after 6 months postoperative. Urodynamic evaluation included residual volume, maximun cystometric capacity, bladder compliance, detrusor constract pressure, external sphincter electromyograpm and detrusor-sphincter synergia. We contrast the changes preopetation and postsurgery, evaluate the effectiveness and explore the possible mechanism. The other patients are being followed up still. The data was analyzed by SPSS11.0 statistical software and Paired-Samples t-test was used, a=0.05 was considered significant.Results: In all the 138 patients, 42 cases have followed up over 6 months, and 16 patients haved gotten comprehensive clinical materials. Twelve of the 16 (83.3%) patients with areflexic bladder gained controllable voiding, void interval increased gradually to 2 hours. Two patients have no change yet. In the 12 areflexic bladder patients, residual volume reduced from 151.92±95.73ml preoperation to 91.08±53.93ml postoperation, bladder maximun cystometric capacity increased from 179.25±71.83ml preoperation to 234.00+ 121.55ml postoperation, bladder compliance changed from 7.00±4.53ml/cmH₂O preoperation to 11.06±4.39ml/cmH₂O postoperation, maximal detrusor constract pressure increased from 5.42±4.06cmH₂O preoperation to 12.50±8.75cmH₂O postoperation. The difference between preoperation and postoperation is significant (P<0.05). Four patients with hyperreflex bladder and detrusor external sphincter dyssynergia all gained voluntary control of the bladder, three patients regained continence, but one patient has urgency incontinence occasionally. Four hyperreflex bladder residual volume reduced from 84.25±43.42ml preoperation to 27.00±30.43ml postoperation, bladder maximun cystomertic capacity increased from 119.25±37.05ml preoperation to 190.75±48.07ml postoperation, bladder compliance changed from 4.35±0.65ml/cmH₂O preoperation to 9.30±1.95 ml/cmH₂O postoperation, detrusor constract pressure decreased from 56.50±28.08cmH2O preoperation to 25.50±13.92cmH₂O postoperation, detrusor external sphincter dyssynergia disappeared. The difference between preoperation and postoperation is significant(P<0.05).Conclusions: 1. The artificial somatic-autonomic reflex arc procedure for neurogenic bladder can reduce residual volume, improve bladder maximun cystometric capacity and bladder compliance, increase detrusor constract pressure of areflexic bladde, decreased detrusor constract pressure of hyperreflex bladder, detrusor external sphincter dyssynergia disappeared. The patients gained controllable voiding postoperation. The procedure is an very effective and satisfied treatment for neurogenic bladder.2. Urodynamic can evaluate bladder and urethral function exactly and it is important for the artificial somatic-autonomic reflex arc procedure to evaluate the surgery effectiveness. Urodynamic parameter supplys important objective basis of bladder function postoperation and instructs the further treatment.3. The artificial somatic-autonomic reflex arc provides us a new method to regain function for other important organs dysfunction after spinal cord injury.