RESUMO
OBJECTIVE: To describe two cases of vesicoureteric reflux associated with neurogenic bladder treated by endoscopic subureteric injection of collagen. METHOD: A 22 Fr cystoscope was introduced with the patient in the lithotomy position. The meatus was identified, a 6 Fr needle was introduced beneath the meatus and collagen was injected until the terminal ureter had been raised with the meatus at the top. RESULTS: One year later the first patient consulted for recurrent urosepsis and severe incontinence between catheterizations. Patient assessment disclosed multiple bladder lithiasis and bilateral vesicoureteric reflux grade III-IV. Endoscopic electrohydraulic lithotripsy was performed, the urine sterilized and collagen injected under the ureter on both sides without result. The procedure was repeated later and reflux disappeared completely. The control ultrasound was satisfactory, urosepsis was controlled and incontinence had improved. Recovery of the upper urinary tract was observed six months later. The second patient consulted one year later for frequent urosepsis, urge incontinence and increasing residual urine. Patient evaluation disclosed vesicoureteric reflux grade III on the right side and signs suggestive of external sphincter hypertony, external sphincter disease and bladder trabeculation. Subureteric injection of collagen combined with endoscopic external sphincterotomy reduced the reflux from grade III to grade I. Collagen injection was repeated and reflux disappeared. The control ultrasound was satisfactory, urine sterile and urinary continence was acceptable. Recovery of the upper urinary tract was observed six months later. CONCLUSION: Subureteric injection of collagen was effective in both cases. It permitted precise evaluation of bladder function and did not interfere with bladder reeducation. Bladder emptying and urinary continence improved, urinary infection was better controlled and it facilitated upper urinary tract recovery. The procedure is fast and can be performed on an outpatient basis. It is safe, repeatable and does not interfere with subsequent therapeutic modalities. No differences between teflon and collagen have been found in the literature.
Assuntos
Colágeno/uso terapêutico , Cistoscopia , Bexiga Urinaria Neurogênica/complicações , Refluxo Vesicoureteral/terapia , Administração Intravesical , Adolescente , Adulto , Colágeno/administração & dosagem , Terapia Combinada , Endoscopia , Humanos , Masculino , Recidiva , Traumatismos da Medula Espinal/complicações , Uretra/cirurgia , Cálculos da Bexiga Urinária/etiologia , Incontinência Urinária/etiologia , Incontinência Urinária/terapia , Infecções Urinárias/etiologia , Infecções Urinárias/prevenção & controle , Refluxo Vesicoureteral/etiologia , Refluxo Vesicoureteral/cirurgiaRESUMO
Objetivo: Explorar la inyeccin subureteral endoscpica de colÿgeno como tratamiento del reflujo v sicoureteral asociado a la vejiga neurog nica. M todo: En posicin de litotoma introducimos el citoscopio, identificamos el meato a inyectar, introducimos la aguja por debajo del mismo e inyectamos hasta alcanzar la elevacin del ur ter terminal con el meato en la cspide. Resultados: Un a o mÿs tarde acude presentando urosepsis rebelde al tratamiento e incontinencia marcada entre los cateterismos. Se estudi y detect litiasis vesical mltiple y reflujo v sico-ureteral grado III-IV bilateral. Se realiz litotricia electrohidrÿulica endoscpica se esteriliz la orina y posteriormente se realiz la inyeccin subureteral de colÿgeno bilateralmente sin resultado. Se repiti posteriormente y se logr la total desaparicin del reflujo en ambos lados. El control ecogrÿfico fue satisfactorio. Se control la urosepsis y mejor la incontinencia. Hubo recuperacin del tracto urinario superior seis meses mÿs tarde. El segundo paciente es masculino, blanco de 18 a os de edad que sufri lesin medular por arma de fuego en abril de 1994. Acudi un a o mÿs tarde por urosepsis a repeticin, urgencia incontinencia y volumen residual creciente. Se demostr en los estudios reflujo v sico-ureteral grado III derecho e imagen sugerente de hipertrofia del esfnter externo, enfermedad esfinteriana y trabeculacin vesical. Se realiz infiltracin subureteral con colÿgeno, asociada a esfinterotoma externa endoscpica logrÿndose una disminucin del grado del reflujo de III a I, se le realiz una nueva infiltracin ureteral y se obtuvo la desaparicin total del mismo. Control ecogrÿfico satisfactorio. Se lograron orinas est riles y continencia aceptable. Seis meses mÿs tarde se observ recuperacin del tracto urinario superior. El tiempo quirrgico en ambos casos fue como promedio de 15 a 20 min. para cada lado. Conclusiones: La inyecin subureteral de colÿgeno fue eficaz en nuestros casos. Permiti una evaluacin veraz de la funcin vesical. Mejor el vaciamiento vesical y la continencia. No constituy una espina irritativa para la reeducacin vesical. Permiti un mejor control de la infeccin. Facilit la recuperacin del tracto urinario superior. Fue de rÿpida ejecucin y realizable por consulta externa. Se comprob que es repetible, inocua y no compromete procedimientos ulteriores. En la literatura revisada no se sugieren diferencias en la utilizacin del tefln o el colÿgeno(AU)