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| 發表人 | 討論主題 | 發表時間 | 討論數 |
| 顧明軒 | 針對患有脊髓損傷的醫療相對弱勢族群，探討泌尿道重建手術後的長期決策後悔因素分析 | 2025/5/26 下午 05:38:52 | 0 |
| 原 文 | 題 目 | Long-Term Decision Regret and Associated Factors After Urinary Reconstruction in Underserved Patients With Spinal Cord Injury |
| 作 者 | Aidin Abedi, Luis Morales Ojeda, Stefania Montero, Nhi Ha, Priya Kohli, Petr Gaburak, Armita Abedi, David Chapman, Evgeniy Kreydin , and David A. Ginsber | |
| 出 處 | Abedi, Aidin, et al. Journal of Urology (2024): 10-1097. | |
| 出版日期 | December 17, 2024. | |
| 評 論 |
本研究的作者主要為南加州大學 (University of Southern California, USC)附設醫院的醫師。USC於神經泌尿領域具有重要研究地位，收案病患來自Rancho Los Amigos National Rehabilitation Center，是當地一間社會安全網醫院，部分病患屬低收入、無保險或少數族群。針對脊髓損傷所致的神經性泌尿功能障礙，如果出現尿失禁或膀胱順應性不良等情形，而藥物治療或膀胱肉毒桿菌注射效果不佳時，為避免腎臟功能因膀胱壓力過高或反覆泌尿道感染受損，醫師通常建議患者接受尿路重建手術，包括使用腸道進行膀胱擴大手術或合併建立導尿通道。儘管這些手術有助於降低膀胱儲尿壓力，但目前缺乏對患者接受此類重大手術的長期滿意度追蹤研究，本研究補足了此部分缺口。 本研究針對曾在該醫院因神經性膀胱接受尿路重建手術並追蹤至少十年的患者進行收案，除了症狀問卷調查外，亦使用決策後悔量表（Decision Regret scale）直接詢問患者是否後悔接受此手術，以及再次面臨相同選擇時是否願意再接受該手術，該量表包括五個問題，每個問題可轉換成0-100分，分數越高代表後悔程度越高。共收案52名患者，其中41位為男性，平均術後追蹤21.9 ± 5.3年，手術方式中73.1%為膀胱擴大手術，17.3%為膀胱擴大手術合併導尿通道造口手術，絕大多數患者為完全脊髓損傷的拉丁美洲裔患者。整體而言，尿路重建手術的長期決策後悔分數僅7.5分（0-100分），表示絕大多數患者對手術後的長期效果屬低後悔程度。 本研究收案病患，其中有31位患者長期需要進行間斷性膀胱灌洗治療，這些病患的決策後悔分數較高，分數隨膀胱灌洗頻率增加而上升。此外，排便症狀問卷分數亦與長期決策後悔分數呈現正相關性，先前研究顯示，切除腸道手術後約54%的患者會出現排便次數增加或大便失禁等症狀，這些症狀越嚴重，決策後悔程度亦越高。在本研究中，有3名患者發生術後持續性腎積水，另有1名患者進展為慢性腎病變，腎功能變差代表最初尿路重建手術並沒有達到預期的效果，因此需要進一步治療以避免腎功能持續受損，這些患者的決策後悔分數亦顯著較高，但由於個案數太稀少，未達研究上顯著意義。 總體而言，本研究顯示，對於難治性神經性膀胱患者，尿路重建手術具備持久效果，病患對於手術後悔程度低，滿意度高。在與患者討論醫療決策時，應將術後可能出現的腸胃道症狀，或必要時需進行間斷性膀胱灌洗納入討論，讓患者對手術有更合理的期待與了解。 |
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| abstract |
Purpose: Patients with refractory neurogenic bladder dysfunction may require urinary reconstruction due to severe incontinence, difficulty with catheterization, and to prevent upper urinary tract compromise. We evaluated long-term decisional regret and associated factors after urinary reconstruction in patients with spinal cord injury. Materials and Methods: We interviewed patients with spinal cord injuries who underwent bladder reconstruction surgery at least 10 years ago, administering validated surveys on bowel quality of life (QoL) and dysfunction, UTIs, and decisional regret. Daily bladder management and symptoms were assessed using the Neurogenic Bladder Symptom Score, a validated questionnaire consisting of 3 domains that examine incontinence, storage and voiding, and other health and QoL consequences of neurogenic lower urinary tract dysfunction. Demographics, injury characteristics, and surgical modality were collected through chart reviews. Decisional regret was compared among subgroups and correlated with patient-reported outcomes. Results: We evaluated 52 patients (41 men, 78.8%; mean age 54.9 ± 10 years) with average follow-up of 30 ± 8.6 years of postinjury and 21.9 ± 5.3 years of postsurgery. Reconstruction procedures mostly included bladder augmentation (n= 38, 73.1%) and augmentation with continent catheterizable stoma (n= 9, 17.3%). Most of the patients were of Hispanic origin (n [ 41, 78.8%) with complete spinal cord injuries (n=39, 76%). The median decision regret score was 7.5 (IQR: 0-25), indicating low regret among most participants. Bladder irrigation frequency (P = .002) was associated with decision regret, while other patient and surgical factors (eg, demographics, UTI frequency, and surgery type) were not. Surgical regret was moderately correlated with diminished bowel-related QoL (r = 0.333, P = .016) and increased Neurogenic Bladder Symptom Score (r = 0.328, P= .018). The Incontinence (r = 0.286, P = .040) and Consequences (r = 0.299, P =.031) domains of this measure showed weak statistically significant correlations with regret, while the Storage and Voiding domain did not reach significance (r =0.245, P = .080). Conclusions: Long-term follow-up suggests that lower urinary tract reconstruction with bowel interposition is a well-accepted and durable approach for managing refractory neurogenic bladder. Factors associated with decision regret, such as need for irrigation, should be incorporated in patient-centered decision-making. |
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