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Volltext (PDF) Experimentelle Grundlagen der Behandlung neurogener Blasenfunktionsstörungen mittels lokaler Hyperthermie und sakraler Elektrostimulation Hohenfellner M, Dahms SE Homepage: Gleason CA, Muscheck M, Tanagho EA Thüroff JW www.kup.at/urologie Journal für Urologie und Urogynäkologie 2001; 8 (2) (Ausgabe Online-Datenbank mit für Schweiz), 12-18 Autoren- und Stichwortsuche Journal für Urologie und Urogynäkologie 2001; 8 (2) (Ausgabe für Österreich), 14-21 Indexed in Scopus Member of the www.kup.at/urologie P.b.b. 02Z031116M, Verlagspostamt: 3002 Purkersdorf, Erscheinungsort: 3003 Gablitz M. Hohenfellner, S. E. Dahms, M. Muscheck, C. A. Gleason, J. W. Thüroff, E. A. Tanagho EXPERIMENTELLE EXPERIMENTELLE GRUNDLAGEN DER GRUNDLAGEN DER BEHANDLUNG BEHANDLUNG NEUROGENER NEUROGENER BLASENFUNKTIONSSTÖRUNGEN BLASENFUNKTIONS- STÖRUNGEN MITTELS LOKALER HYPERTHERMIE UND SAKRALER ELEKTROSTIMULATION wurde beobachtet, wenn der Summary rature necessary to induce these Schwellenwert (Temperatur bei effects was 44.5 ± 1.4 °C. Restitu- der frühesten Änderung der Detrusor-sphincter dyssynergia is tion of bladder and sphincter Druckantworten) nur über kurze one of the leading problems of function during electrostimulation Zeit appliziert wurde. Im Gegen- sacral ventral root stimulation. was observed within 1–5 minutes satz dazu fand sich bei längerer Aim of our study was to evaluate if the minimal threshold tempera- Hitzeapplikation ein irreversibler the efficacy of sacral hyper- ture was applied only over a short Verlust der Druckantworten unter thermia and ventral sacral root period. Longer periods of heat Stimulation. stimulation for reduction of application resulted in irreversible detrusor-sphincter dyssynergia loss of local nerve conductivity. Erste tierexperimentelle Resultate during acute canine experiments We conclude that local heat der sakralen Wärmeapplikation (n = 5). For application of heat application may open a new and/ während der Elektrostimulation during ventral sacral root stimu- or additional possibility to reduce deuten auf eine Möglichkeit, lation a modified cuff electrode detrusor-sphincter dyssynergia infolge einer Nervenleitungs- was utilized. Its activation resul- during ventral sacral root stimu- blockade der Sakralnerven eine ted in a significant reduction of lation. To warrant functional Reduktion von Blasen- und the pressure response of sphincter restitution after local heat appli- Sphinkterdruckanstieg zu erzie- (78 ± 17.1 %) and detrusor (36 ± cation a close monitoring of len. Um eine funktionelle Erho- 13 %) during ventral sacral root threshold and duration of tempe- lung nach Hyperthermie zu ge- stimulation. The minimal tempe- rature increase is mandatory. währleisten, ist jedoch ein enges Monitoring von Temperatur- stimulation wurde eine Reduktion Schwellenwert und Dauer der ZUSAMMENFASSUNG von Sphinkter- und Detrusor- applizierten Wärme notwendig. antwort beobachtet. Im direkten Vergleich wurde eine signifikante Ziele dieser experimentellen Verminderung des intraurethralen Studien waren Untersuchungen (78 ± 17,1 %) und des intravesi- EINLEITUNG zur lokalen sakralen Hyperther- kalen Druckanstieges (36 ± 13 %) mie und Vorderwurzelstimulation während der intraduralen Elektro- hinsichtlich der Reduktion der stimulation ermittelt. Die Auswer- Trotz der mittlerweile ausgereiften Detrusor-Sphinkter-Dyssynergie tung der Daten unterschiedlicher chirurgischen Technik und der als im Akutversuch am Hund. Insge- Sakralnerven ergab in 11 von 12 etabliert geltenden sakralen samt wurde bei 5 Tieren experi- Experimenten eine in Abhängig- Deafferentation ist es ein bisher mentell nach Laminektomie die keit von steigenden Temperaturen ungelöstes Problem der sakralen Möglichkeit einer Nervenleitungs- kontinuierliche Abnahme der Vorderwurzelstimulation, daß blockade der Sakralnerven wäh- Druckantworten. Der eine Fall, in neben einer Detrusorkontraktion rend einer intraduralen Vorder- dem dieser Effekt nicht beobach- durch Erregung parasympathi- wurzelstimulation durch eine tet wurde, resultierte aus einem scher Motoneurone simultan eine lokal Wärme applizierende modi- kompletten Nervenleitungsblock Aktivierung des Kontinenz- fizierte Cuff-Elektrode untersucht. bei zu rascher Temperaturerhö- apparates durch Stimulation der Mit Hilfe intravesikaler und intra- hung. Früheste Veränderungen somatischen Neurone im Spinal- urethraler Druckmessungen wur- der Druckparameter wurden bei nerven eingeleitet wird [1]. Die den die Stimulationsantworten Temperaturen von 44,5 ± 1,4 °C so begründete „Detrusor-Spinkter- von Sphinkter und Detrusor unter ermittelt. Eine typische Erholungs- externus-Dyssynergie“ kann Wärmeapplikation ermittelt. phase mit einer partiellen Funk- durch periodische Unterbrechung tionseinbuße (Sphinkter: 33,8 ± des Stimulationsstromes zur Sen- Während extraduraler Wärme- 11,1 %; Detrusor: 25 ± 15,4 %) kung des intravesikalen Wider- applikation und sakraler Elektro- innerhalb von 1 bis 5 Minuten standes bei fortbestehendem 14 J. UROL. UROGYNÄKOL. 2/2001 For personal use only. Not to be reproduced without permission of Krause & Pachernegg GmbH. Homepage Journal für Urologie und Urogynäkologie: http://www.kup.at/urologie EXPERIMENTELLE GRUNDLAGEN DER BEHANDLUNG NEUROGENER BLASENFUNKTIONS- STÖRUNGEN Detrusordruck umgangen wer- gner Tumoren zum Knochener- Körpertemperatur und elektro- den, da die Miktion im Intervall satz findet, signifikant hohe Tem- kardiale Aktivität wurden konti- erfolgt („post-stimulus voiding“) peraturen freisetzt [10]. Allerdings nuierlich überwacht. Über die [2]. Nachteil dieser unphysiolo- finden sich keine spezifischen rechte Vena accesorica cephalica gischen Miktion ist die Notwen- Literaturquellen, die den thera- wurde kontinuierlich physiologi- digkeit einer kontinuierlichen, peutischen Einsatz einer lokalen sche Kochsalzlösung (0,1 ml/kg urodynamisch orientierten Kon- Hitzeschädigung sakraler Nerven KG/min) infundiert. Eine Wärme- trolle der Stimulationsparameter, und deren Folgen hinsichtlich matratze wurde zur Aufrechter- da ansonsten das Risiko patholo- Funktionalität der Detrusorkon- haltung der Körpertemperatur gisch erhöhter Miktionsdrücke traktion bzw. des Sphinkter-Ver- verwandt. Zur simultanen intra- besteht. Darüber hinaus führt die schlußmechanismus erarbeitet vesikalen und intraurethralen Massenstimulation der entspre- haben. Aus diesem Grunde wurde Druckmessung wurde ein 7- chenden sakralen Spinalnerven am Hund ein experimentelles French-Vierkanal-Membran- zu einer starken und damit sub- Modell entwickelt, welches es katheter (Mentor, Goleta, CA) jektiv unangenehmen Spastizität ermöglichen sollte, die lokale unter rektal-digitaler Kontrolle der unteren Extremitäten während Hyperthermie am Sakralnerven transurethral eingeführt und zur der Miktion. Die von unserer und deren Auswirkung auf intra- intraabdominellen Druck- Arbeitsgruppe untersuchte Metho- vesikales und intraurethrales erfassung ein konventioneller 18- dik der Dissektion der einzelnen Druckverhalten unter sakraler French Foley-Ballonkatheter über Fila radicularia der sakralen Vor- Vorderwurzelstimulation zu un- eine minimale Laparotomie posi- derwurzel erfordert den Einsatz tersuchen. tioniert. Die Katheter wurden mikrochirurgischer Instrumente entsprechend über Polyethylen- und eines Operationsmikroskopes schläuche (PE 50) mit Druckauf- [3–5]. Diese Technik stellt damit nehmern (Baxter Uniflow ein – wenn auch attraktives – MATERIAL UND METHODIK Pressure Transducer, Baxter relativ zeitaufwendiges Verfahren Health Care Corp., Irvine, CA) dar, bei dem immer auch das konnektiert. Zur elektrischen Risiko einer permanenten Insgesamt wurden Versuche an 5 Spannungsversorgung der Druck- Nervenschädigung gegeben männlichen Mischlingshunden aufnehmer wurde ein SCXI-1121 ist. durchgeführt. Alle Tiere wurden Signal-Prozessor (National Instru- entsprechend den Richtlinien des ments Corp.) eingesetzt; die ana- Ziel unserer Versuche war es, Institute of Laboratory Animal logen Daten (Druckwerte) mittels Fragen zu beantworten, die sich Resources, Commission on Life eines NB-N1016 I/O-Konverters im Zusammenhang mit der oben Sciences, National Research (National Instruments Corp.) in geschilderten klinischen Proble- Council (Guide for the Care and digitale Werte konvertiert. Ein matik der Detrusor-Sphinkter- Use of Laboratoy Animals) ver- Macintosh Quadra 800 PC und Dyssynergie während der Neuro- sorgt [11]. im Labor entwickelte virtuelle stimulation stellen. Unter Berück- Software [Laboratory Virtual In- sichtigung der oben geschilderten Zur Vorbereitung wurde 12 Stun- strument Engineering Workbench Problematik ist das neurourolo- den vor Versuchsbeginn die feste (LabVIEW‚ 4.0), (National Instru- gische Interesse an Studien zu Nahrung entzogen. Nach ments Corp.)] wurden zur Daten- sehen, die die Möglichkeit einer Prämedikation der Tiere mit erfassung und -speicherung ein- temporären Nervenleitungs- Azepromazin (0,15 mg/kg KG gesetzt. Vor Beginn der Messun- blockade mittels lokaler Hyper- i.m.) wurde die Anästhesie mit gen wurden alle Katheter gegen thermie untersuchten [6–9]. Ins- Ketamin (5 mg/kg KG i.v.) einge- den Atmosphärendruck auf Null besondere klinisch-orthopädische leitet und mit 2 %igem Isofluran geeicht. Das EMG des querge- Arbeiten sind in diesem Zusam- nach Intubation aufrechterhalten. streiften Musculus urethralis wur- menhang zu erwähnen, die zeig- Die Hunde wurden mechanisch de mittels zweier Teflon-isolierter, ten, daß eine Polymerisation von mit 100 %igem Sauerstoff beat- aber an den Spitzen blanker Pla- Knochenzement, wie
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