Zusammenfassung
Hintergrund
Für den Neurourologen ist eine der größten Herausforderungen die Wiederherstellung der willentlich steuerbaren Miktion bei Patienten mit einer kompletten Querschnittlähmung.
Tiermodelle
Carlsson u. Sundin publizierten 1968 über die Wiederherstellung der Blasenfunktion durch eine Nervenanastomose oberhalb der spinalen Verletzung . Später wurde im Ratten- und Katzenmodell ein „Reflexbogen“ unterhalb der Querschnittsverletzung durch eine Nervenanastomose erzeugt, wodurch die Blase vermittelt durch einen starken Hautreiz entleert werden kann.
Richtungsweisende Forschung
In Berichten über Zell- bzw. Gentherapie wurden kleinere Nervendefekte „repariert“ oder Stammzellen i.v. appliziert, um unmittelbar nach der Verletzung die Regeneration positiv zu beeinflussen.
Klinische Gegenwart
Bereits 1967 wurde über die nervale Rekonstruktion der Harnblase bei Patienten berichtet. In zwei Fällen wurde durch die intradurale Anastomose zwischen Th12 und S2+3 nach 8–12 Monaten die Miktion wieder willkürlich möglich. Durch Modifikation der Op.-Technik wurde neben der sensorischen Reinervation die Wiedererlangung der genitalen Reflexe in 72% der Fälle erreicht. Xiao et al. publizierten bei einem Mindest-Follow-up von 3 Jahren einen 67%igen Miktionserfolg nach einem Jahr mittels eines somatischen Reflexbogens unterhalb der Querschnittsläsion durch Anastomose der Vorderwurzel von L5 auf S2/3 unilateral.
Fazit
Die Zelltherapie bedarf noch weiterer Fortschritte bis zur Anwendung am Patienten. Schon heute sollte bei ausgewählten Patienten eine Therapie der neurogenen Blase bei Rückenmarkverletzung angeboten werden. Derzeit sollten diese Op.-Techniken, wie am UKT angeboten, nur in Zentren durchgeführt werden, die über entsprechende Erfahrung damit verfügen und ein Follow-up zur Evaluation dieser Techniken gewährleisten können.
Abstract
Introduction
One of the major challenges in neuro-urology is the restoration of voluntary voiding in a patient after spinal cord injury (SCI).
Animal experiments
The earliest reports on reconstruction of urinary bladder function by bridging nerve roots from above the SCI to the below this level were published by Carlsson and Sundin 1968. In another approach, a possible reflex pathway below the SCI to reinitiate voluntary voiding was investigated. The result was a modified somatic reflex arc rostral to the sacral spinal micturition center.
Future research
Medical reports in numerous publications are still very enthusiastic about the possibility of cell or gene therapy. Such results report the successful bridging of small nerve gaps. The latest approach is the intravenous application of stem cells to aid the recovery of the SCI.
Clinical approach
The first reports on attempts to reconstruct the nervous pathways to the bladder in patients were published 1967. In two cases, a nerve anastomosis from Th12 (the lowest intact segment) to S2+3, bilaterally to the SCI, allowed spontaneous micturition after 8–12 months with reported sensitivity at the base of the penis. With a modification in surgical technique, another group reported a success rate of 100% using the anastomosis of intercostal nerves Th11+12 to sacral roots S2+3 to establish a reflex voiding and, in 72% of patients, reappearance of the bulbocavernous and cremaster reflexes. Xiao et al. published, with a 3 year follow-up, the creation of a micturition reflex through anastomosing the ventral roots of L5 to S2/3 in complete SCI patients with a 67% success rate a year after surgery.
Conclusion
There is still a great deal of work required before cell therapy becomes a therapeutic option. Today, the published data strongly suggest that it is possible to treat first line urinary bladder dysfunctions in SCI or spina bifida patients. Before one of these techniques becomes widely used, it should be proven effective in specialized institutions, such as the Department of Urology in collaboration with the Department of Neurosurgery at the University of Tuebingen, Germany.
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Sievert, KD., Xiao, CG., Hennenlotter, J. et al. Willentlich steuerbare Miktion durch intradurale Nervenanastomose. Urologe 44, 756–761 (2005). https://doi.org/10.1007/s00120-005-0849-x
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DOI: https://doi.org/10.1007/s00120-005-0849-x
Schlüsselwörter
- Willentlich steuerbare Miktion
- Intradurale Nervenanastomose
- Reflexbogen
- Querschnittlähmung
- Blasenfunktion