1带蒂腹内斜肌肌瓣逼尿肌肌成形术治疗逼尿肌无收缩的实验研究【摘要】 目的 探讨腹内斜肌肌瓣（internal oblique flap，IOF）逼尿肌肌成形术治疗逼尿肌无收缩（acontractile detrusor，AD）的可行性，以期为构建新的临床治疗方法提供实验依据。方法 2006年 35 月，以 6只雄性犬为实验对象。解剖游离腹内斜肌肌瓣，包绕膀胱模型，电流刺激支配腹内斜肌的腰神经腹支，记录模型内的压力。暴露膀胱，测压管插入膀胱，行膀胱基础状态尿动力学检测（A 组） 。在膀胱底部，去掉整个膀胱 50%的逼尿肌肌层，保留膀胱黏膜完整，制作 AD动物模型，行 AD模型尿动力学检测（B 组） 。腹内斜肌肌瓣近肋弓端向内下翻转，包绕 70%的膀胱，腹内斜肌肌瓣与膀胱余壁吻合。腹内斜肌肌瓣膀胱逼尿肌肌成形术后再次行尿动力学检测（C 组） 。电流刺激支配腹内斜肌的腰神经支行膀胱测压，观测排空情况，术后 5周，行 B超检查、尿动力学检测（D 组） ，肌瓣标本行病理检查。结果 术后犬健康 4例，死亡 2例。IOF 包绕膀胱模型分别注射生理盐水 40 ml、80 ml、120 ml，刺激支配 IOF之腰神经支，模型内压力分别达到（12.32.3）cm H2O、 （26.810.1）cm H2O、 （40.311.0）cm H2O，压力和模型容量正相关（P0.05） 。膀胱最大灌注容量（ml）：A 组 345.839.1，B 组 340.227.5，C 组 315.718.8，D 组326.813.5。膀胱内最大压力（cm H2O）：A 组 25.521.0，B 组10.28.0，C 组 14.74.0，D 组 15.34.1。顺应性（ml/cm H2O）：A 组19.69.8，B 组 45.921.4，C 组 23.17.4，D 组 22.86.7。未发现逼尿肌的主动收缩，膀胱具有良好的稳定性。腹内斜肌肌瓣逼尿肌肌成形术完毕，灌注150 ml时，刺激神经，1 例排出 17 ml，1 例排出 22 ml，平均排空率 13%；术后5周，刺激神经，1 例排出 15 ml，排空率 10%。B 超检查：膀胱形态规整，膀胱壁光滑，无憩室，无尿瘘，无上尿路积水。光镜和电镜病理提示转移之 IOF肌束有活力，生长良好。结论 带蒂腹内斜肌肌瓣逼尿肌肌成形术可以增强或部分替代缺失的逼尿肌功能，治疗逼尿肌无收缩具备可行性。 【关键词】 逼尿肌无收缩 逼尿肌肌成形术 腹内斜肌肌瓣 实验研究Experimental study on pedicled internal oblique muscle flap detrusor myoplasty for detrusor assistance in case of acontractile detrusorAbstract Objective Experimental studies were undertaken to investigate the practicability of transfering pedicled internal oblique muscle flap to the bladder，and to look for possible techniques enhancing evacuation of a reservoir as the bladder by the muscle flap.To elucidate the potential value of the technically feasible surgical procedure that may eventually provide a treatment alternative.Methods From March to May 2005，six male dogs were used for the studies.The internal oblique muscle was dissected and tailored 2to be muscle flap was and then wrapped around a bladder model varying sizes.The intraluminal pressure measurements were recorded when the innervated muscle flap was being stimulated.The bladder was explored and urodynamic studies were performed （group A）.At the dome，the bladder wall was removed，with up to 50 percent of the mucosal layer being left intact and urodynamic studies were performed （group B）.The pedicled internal oblique muscle flap was rotationed and wrapped about 70% of the bladder，urodynamic studies were performed again（group C）.The evacuation situation were measured when the innervated muscle flap being stimulated.After five weeks of the operation，ultrasound B examination,histopathologic and urodynamic studies were done（group D）.Results Four cases recovered well but two dead.The intraluminal pressure of the model were （12.32.3）cm H2O， （26.810.1）cm H2O,（40.311.0）cm H2O respectively when the innervated muscle flap was being stimulated，depending on the varying volume （40 ml,80 ml,120 ml respectively）.The maximum capacity of the bladder were group A （345.839.1）ml，group B （340.227.5）ml，group C （315.718.8）ml，group D （326.813.5）ml;the maximum pressure（cm H2O） were group A 25.521.0，group B 10.28.0，group C 14.74.0，group D 15.34.1;and the compliance of the bladder（ml/cm H2O） were group A 19.69.8，group B 45.921.4，group C 23.17.4，group D 22.86.7 respectively.No detrusor activity was notable during regular filling of the bladder and the detrusor kept well stability.The voided volume with internal oblique muscle flap stimulation were 17ml and 22ml from the capacity of 150 ml（13%） ，and resulting in an evacuation of 10% postoperatively.During ultrasound B examination the bladder outline was smooth and no kidney harm was found.Light and electron microscopic examinations confirmed viable，transferred flap muscle.Conclusion The pedicled internal oblique muscle flap detrusor myoplasty can partly augment lost detrusor function，being a technically feasible surgical procedure may be an alternative treatment in case of acontractile detrusor.Key words acontractile detrusor;detrusor myoplasty;internal oblique muscle flap;experimental study逼尿肌无收缩（acontractile detrusor，AD）是指患者不能自主排尿，尿动力学检查之压力-流率曲线分析提示逼尿肌缺乏收缩1 。对 AD患者，治疗目标是提高膀胱安全压力、减少残余尿、排尿自控。尽管治疗方法多样，但是都难以获得理想效果，治疗困难，具备挑战性2 。2006 年 35 月，以犬为实验对象，行带蒂腹内斜肌肌瓣（internal oblique flap，IOF）逼尿肌肌成形术治疗逼尿肌无收缩的动物实验研究，以期为构建新的临床治疗方法提供实验依据。1 材料和方法31.1 实验材料1.1.1 实验动物 雄性犬 6只，1015 月龄，平均（12.32.0）个月；体重 1328 kg，平均（19.25.8）kg。1.1.2 主要仪器 尿动力学检查仪，Dantec 公司，型号：Duet 131；微量注射泵，Braun 公司，型号：Perfusor compact S；多用电生理刺激器，北京海淀电子医疗仪器厂，CCC-2A 型；B 超机，意大利百盛公司，Esaote DU3 彩色超声扫描仪，探头频率 24 MHz；光学显微镜，Olympus 公司，型号 CX40 RF200；透射电子显微镜，型号：JEOL 100CX-2。1.2 实验方法1.2.1 犬的麻醉 戊巴比妥（30 mg/kg）静脉注射全麻3 ，气管插管，呼吸机管理呼吸。1.2.2 解剖游离腹内斜肌肌瓣 取侧腹部纵向切口，下段偏向内侧，长约15 cm；依次切开皮肤、皮下组织、腹外斜肌及其腱膜；腹直肌向内侧牵开，腹外斜肌及其腱膜向外侧牵开，暴露腹内斜肌；在白线处锐性剪开腹内斜肌内侧缘；在腹内斜肌深面分离腹内斜肌与腹横肌之间的平面，向上达肋弓下，向下达耻骨上，底达肌肉起始部，妥善保护肌肉的血运；支配腹内斜肌最主要的运动神经为腰神经腹支，直径 2 mm，位于腹内斜肌中点处，将腰神经腹支入肌点处作为腹内斜肌肌瓣的蒂；肋弓下 3 cm处切断腹内斜肌，向下游离至肌瓣蒂处，蒂上处肌瓣约 7 cm5 cm，蒂下处肌瓣约 8 cm5 cm，肌瓣血运良好，电流刺激腰神经腹支，腹内斜肌肌瓣有力收缩。1.2.3 腹内斜肌肌瓣膀胱模型测压 普通无菌 7号橡胶手套，剪去指部，掌部丝线结扎。放入尿动力测压管，袖口收紧，丝线结扎。经测压管注射生理盐水，将其内空气抽净。尿动力测压管连接尿动力学检测仪，备测压。以腹内斜肌肌瓣完整包绕，成为腹内斜肌肌瓣膀胱模型。将模型分别注入生理盐水 40 ml、80 ml、120 ml，应用神经保护电极，电流刺激支配腹内斜肌的腰神经腹支（