Hiperactividad neurogénica del detrusor refractaria a tratamiento conservador: experiencia con el uso de segmentos intestinales

A pesar de la gran variedad de terapias descritas para el manejo de hiperactividad neurogenica del detrusor (HND), existe un numero importante de pacientes que no logran mejoria con alternativas conservadoras. En ellos, bajar la presion y disminuir el porcentaje de dano renal mediante ampliacion vesical con segmentos intestinales detubulizados, es una alternativa vigente. Objetivo: Describir la experiencia en el manejo de pacientes con HND refractaria a tratamiento conservador, que fueron tratados en forma quirurgica con tecnicas que utilizan segmentos intestinales, su evolucion a traves del tiempo y sus principales complicaciones. Materiales y metodos: Se revisaron fichas clinicas de 75 pacientes con diagnostico de HND, operadas de enterocistoplastia entre 1988 y 2009. Se analizan: causa de dano neurologico, segmentos intestinales usados, tecnica quirurgica, necesidad de ostomia continente y complicaciones. Resultados: La serie estudiada esta compuesta por 46 (61,33 por ciento) varones y 29 (38,67 por ciento) mujeres, con edad promedio 32,2 anos (2,75 a 68 anos). Las principales causas de dano neurologico fueron traumatismo raquimedular en 37 pacientes (49,43 por ciento) y mielomeningocele en 15 pacientes (20 por ciento). En total se realizaron 81 cirugias con uso de intestino: 6 corresponden a reintervenciones (3 ampliaciones con cierre de cuello y ostomia y 3 ostomias). De las 75 cirugias primarias se realizaron73 (97,33 por ciento) enterocistoplastias de aumento (en el 40 por ciento de los casos asociado a una ostomia continente), 1 cirugia de solamente ostomia continente y 1 reservorio. El segmento intestinal mas utilizado para ampliacion fue sigmoides; en los casos de ampliacion y ostomia se prefirio ciego-ileon. La tendencia en los ultimos 15 pacientes, es realizar la ostomia con tecnica de Yang- Monti con colon o con doble segmento de ileon. El 30 por ciento de los pacientes requirio algun tipo de revision quirurgica en el... Despite the wide variety of therapies described for the management of neurogenic detrusor over activity (NDH), a significant number of patients fail to improve with conservative treatment. In them, lowering pressure and decreasing the percentage of kidney damage by bladder augmentation with intestinal segments is a valid alternative. Objective: To describe the experience in the management of patients with NDH refractory to conservative treatment that were treated surgically with techniques using intestinal segments, their evolution over time and common complications. Materials and methods: We reviewed medical records of 75 patients with NDH with enterocystoplasty surgery between 1988 and 2009. We assessed: cause of neurological damage, intestinal segments used, surgical technique, need for continent ostomy and complications. Results: The studied group consists of 46 (61.33 percent) males and 29 (38.67 percent) females, mean age 32.2 years (2.75 to 68). The main causes of neurological damage were spinal cord injury in 37 patients (49.43 percent) and myelomeningocele in 15 patients (20 percent). A total of 81 surgeries using bowel were performed: 6 correspond to re-intervention (3 extensions with neck closure and ostomy; and 3 ostomies). Of the 75 primary surgeries, 73 (97.33 percent) were enlargement enterocystoplasty (in 40 percent of cases associated with a continent ostomy), 1 contienent ostomy surgery alone and 1 reservoir. The most widely used bowel segment for enlargement was sigmoid, in cases of expansion and ostomy a cecum-ileum segment was preferred. The trend in the last 15 patients was to perform an ostomy with Yang-Monti technique using colon or ileal double segment. On follow up over 5 years, 30 percent of the patients required some type of surgical revision and their main indications were incontinence, impaired opening of the bladder neck, urethral lithiasis and stenosis. Continence was good in 90.67 percent and 5.33 percent average...