【作者】 王宇雄；

【导师】 刘春晓；

【作者基本信息】 南方医科大学 ， 泌尿外科学， 2013， 博士

【摘要】 背景氯胺酮(Ketamine, K)是苯环己哌啶衍生物,俗称k粉,吸食有成瘾性,有欣快感,可另人产生幻觉,如：盘旋、失重和漂浮等感觉,其致幻作用大约在持续1小时后消失。氯胺酮的代谢方式有主要有两种：一种是通过肝脏微粒体的CYP3A4酶代谢,另一种通过肾脏的尿液排泄,可排除小部分氯胺酮原液及其代谢产物。目前青少年滥用状况正日益突出,国内外关于氯胺酮的毒性损害的研究仍主要集中在心血管和神经精神系统,近来滥用氯胺酮所致的泌尿系统损害的报道也逐渐出现,但对氯胺酮相关性泌尿系统损害的机理及诊疗手段报道少,而对其引起的泌尿系损害的基础研究则更少。2007年,Shanhani等首次报道了长期吸食氯胺酮的患者会出现不同程度的下尿路损害症状,称之为氯胺酮相关的下尿路症状。国内外学者对氯胺酮滥用所造成的危害进行深入研究发现：长期吸食氯胺酮的人群会出现不同程度的膀胱过度活动症(Overactive Bladder, OAB)症状,如尿频、尿急、尿痛,严重者甚至伴有疼痛性血尿与急迫性尿失禁,尿流动力学检测示膀胱过度敏感,不稳定性膀胱,尿流率低下,逼尿肌不稳定收缩；膀胱镜检示膀胱壁可见广泛的黏膜充血和红肿；B超、CT等影像学检查发现膀胱明显挛缩,容积减小(最小可达30～1OOml)；病理学检查发现膀胱黏膜上皮细胞大量炎性细胞侵润及新生肉芽组织生长；血尿常规一般无明显异常；抗生素对其治疗往往难以收效。国内外学者将氯胺酮滥用引起的下尿路损害称之为氯胺酮相关性膀胱炎。目前氯胺酮相关性膀胱炎的发生、发展机制尚不十分明确,治疗效果受限,缺乏有效治疗药物,该疾病常被误诊为“膀胱炎”、“前列腺炎”并与单纯的“OAB”相混淆。氯胺酮相关性泌尿系统损害发病率近年来在全球呈逐步上升的趋势,在泛珠三角等经济发达地区泌尿外科门诊患者逐年增多,但很多医师甚至专科医师尚未全面认识该病给患者及其家庭带来的痛苦和巨大负担,氯胺酮性膀胱炎有严重的躯体和社会危害性,因此从实验和临床方面研究氯胺酮与下尿路症候的关系和有效的治疗方法很有必要。Meng等用麻醉剂量(80～150mg/kg)盐酸氯胺酮注射液每天腹腔注射C57BL/6小鼠并进行尿动力学检查,发现小鼠排尿间隔时间显著减少,膀胱容量显著减小。Shu-Mien则通过每日腹腔注射氯胺酮(25mg/kg),成功诱导构建氯胺酮相关溃疡性膀胱炎大鼠模型。在氯胺酮性膀胱炎的诊断中,尿流动力学检测发挥着不可替代的作用,尿流动力学的主要依据是电生理学与流体力学的基本原理和方法,检测尿路各部的压力、生物电活动以及尿流率,从而了解尿路运输尿液的功能与机制,以及排尿功能障碍性疾病的病理生理学变化。尿流动力学检查是直观、量化地反映尿路功能较为理想的方法,因此通过给患者测量尿流动力学,观察分析其各项指标的改变对排尿功能障碍性疾病的临床诊疗具有重要的实用价值。关于氯胺酮性膀胱炎的发病机理,有学者认为,在膀胱黏膜表面存在一层保护层,如氨基葡聚糖(Glycosaminoglycans, GAG)、不对称的单位膜、离子泵及高密度的蛋白聚糖等成分。氯胺酮或其代谢产物破坏保护层后,进而破坏上皮通透性屏障,损害膀胱壁的深层组织。若尿液中的细菌、微晶体、蛋白和离子的粘附或离子型及非离子型溶质残渣(如尿素)的迁徙,使毒性物质进入黏膜下及逼尿肌层,损伤神经和肌肉,使分布在膀胱壁上的神经纤维受到异常刺激,则可引起尿急、尿频等下尿路反射性症状。关于氯胺酮性膀胱炎的治疗,目前临床上尚无统一、公认、有效的治疗方法。氯胺酮性膀胱炎患者一般具有严重的膀胱过度活动征(OAB)症状,而膀胱水扩张、药物膀胱灌注是目前临床上治疗OAB症状的主要手段,麻醉下水扩张后,可能有助于促进膀胱黏膜的生长。膀胱水扩张治疗机理被认为可能是水扩张导致膀胱壁内感觉神经的缺血坏死,减少膀胱壁内的感觉神经分布密度,从而达到治疗的目的。目的基于上述原因,笔者通过建立氯胺酮相关性膀胱炎大鼠模型,对膀胱水扩术合并碱性利多可因、地塞米松膀胱灌注治疗前后的尿动力学指标改变实验评价,并通过临床回顾性研究评价膀胱水扩术的临床治疗效果,以期为治疗氯胺酮相关性膀胱炎提供一个有效的新途径。方法1.氯胺酮相关性膀胱炎大鼠模型建立选取雌性Sprague-Dawley (SD)2月龄青年大鼠30只,初始体重无统计学差异(F=0.332,P=0.720),纳入实验研究。分为对照组(A组,10只)和模型组(B组,20只),其中B组大鼠腹腔注射氯胺酮(30mg/kg)共12周,A组同时注射0.9%生理盐水作为空白对照。并分别在第4、8、12周结束时行尿流动力学检查,获得尿动力学参数以评估膀胱功能下降情况；停止注射氯胺酮3天后,胶体金法检测大鼠尿中高浓度的氯胺酮及其代谢产物残留,证实模型诱导成功。麻醉状态下,取两组大鼠一小块膀胱组织,应用常规HE染色,观察膀胱黏膜及逼尿肌病理形态学变化。探讨氯胺酮相关性膀胱炎大鼠膀胱结构与功能改变的病理基础。2.大鼠尿动力学检测方法乌拉坦(25%,1ml/kg)腹腔麻醉,尿道插入自制单根3F膀胱测压导管,同时用自制直肠测压管插入肛门3～4cmm左右,分别将两根测压管与尿动力仪压力传感器及微量灌注泵相连,注水速度定为0.1ml/min,测定经处理不同时间氯胺酮腹腔注射后的大鼠排尿间隔,膀胱最大容量(maximum bladder capacity, MBC),最大膀胱排尿压(maximum voiding pressure, MVP)及逼尿肌不稳定收缩频率,分析氯胺酮相关性膀胱炎大鼠尿动力学参数指标的变化意义。3.膀胱水扩术合并碱性利多卡因、地塞米松膀胱灌注方法在盐酸氯胺酮腹腔注射大鼠处理12周后,各组均停用氯胺酮,将建模成功后的模型B组又随机分为B1、B2两小组(10只/组),停药后3天后开始第1、3、5周对B1组行碱性利多卡因、地塞米松膀胱灌注,B2组行膀胱水扩术合并碱性利多卡因、地塞米松膀胱灌注。停止治疗1周后行尿流动力学检测经过不同方法治疗的大鼠排尿间隔时间、膀胱最大容量(MBC)、最大膀胱排尿压(MVP)、逼尿肌不稳定收缩频率的改变。B1、B2组间对比,及组内施加处理前后对比,探讨膀胱水扩术对氯胺酮性膀胱炎的治疗效果。4.数据处理所有数据采用spss16.0软件进行处理,计量资料均以x±s表示,氯胺酮模型组与对照组尿动力学各指标比较采用两独立样本t检验；两组不同时间点尿动力学指标比较采用通过重复测量的方差分析；治疗前后尿动力学指标结果的对比采用配对设计t检验；三组大鼠治疗后尿动力学指标比较采用方差分析法。以P<0.05为有统计学意义。结果1.尿流动力学检查结果显示,生理盐水对照组和氯胺酮性膀胱炎组大鼠膀胱容量(MBC)分别为(0.663+0.091)ml和(0.234±0.060)ml,两组间差异显著,有统计学意义(t=15.527,P=0.000)。两组大鼠排尿间隔分别为(6.680±0.884)min和(2.433±0.614)min,两组间差异显著,有统计学意义(t=15.404,P=0.0000)。两组大鼠逼尿肌不稳定收缩频率分别为0.000和(3.500±0.827),两组间差异显著,有统计学意义(t=-16.170,P=0.000)。两组大鼠膀胱最大排尿压(MVP)分别为(35.400±6.096)cmH20和(36.005±6.095)cmH2O,两组间无显著差异,无统计学意义(t=-0.256,P=-0.800)。在诱导第4周、第8周、第12周后氯胺酮性膀胱炎模型组大鼠(B组)行尿流动力学检查结果显示,最大膀胱容量(MBC)分别为(0.456±0.089)ml.(0.290±0.096)ml.(0.234±0.060)ml,组内差异显著,有统计学意义(F=101.640,P=0.000)。排尿时间间隔分别为(4.615±0.899)min、(3.102±0.735)min、(2.433±0.614)min,组内差异显著,有统计学意义(F=I10.441,=0.000)。逼尿肌不稳定收缩频率分别为(0.850±0.745)次/分、(2.200±0.696)次/分、(3.500±±0.827)次/分,组内差异显著,有统计学意义(F=41.704,P=0.000)。膀胱最大排尿压(MVP)分别为(35.445±5.864)cmH20、(35.705±5.934)cmH20、(36.005±6.095)cmH20,组内差异不显著,无统计学意义(F=0.029,P=-0.993)。常规HE染色可见氯胺酮性膀胱炎大鼠膀胱黏膜上皮细胞变性,黏膜水肿、大量炎性细胞浸润,淋巴管扩张,并有淋巴细胞浸润和肥大细胞渗入。2.在氯胺酮性膀胱炎模型大鼠(B组)中。尿流动力学检查结果显示,经膀胱水扩术合并碱性利多卡因、地塞米松膀胱灌注(B2)注治疗前后的大鼠膀胱容量(MBC)分别为(0.228±0.055)ml和(0.609±0.090)ml,前后差异显著,有统计学意义(t=-21.265P=0.000)；排尿间隔分别为(2.345±0.561)min和(6.110±0.923)min,前后差异显著,有统计学意义(t=-21.421P=0.000)；逼尿肌不稳定收缩频率分别为(3.500±0.850)次／分和(0.800±0.632)次／分,前后差异显著(t=9.000P=0.000)。经单纯碱性利多卡因、地塞米松膀胱灌注治疗前后的大鼠膀胱容量(MBC)分别为(0.240±±0.067)ml和(0.242±0.069)m1,前后无显著差异,无统计学意义(t=-I.000P=0.343)；排尿间隔分别为(2.520±0.681)min和(2.550±0.675)min,前后无显著差异,无统计学意义(t=-I.964P=0.081)；逼尿肌不稳定收缩频率分别为(3.500±0.850)次／分和(1.500±0.527)次／分,前后差异显著,有统计学意义(t=9.487P=0.000)。3.通过膀胱水扩术+碱性利多卡因、地塞米松膀胱灌注治疗氯胺酮性膀胱炎患者11例,治疗前后O’Leary-Sant ICPI评分分别为(9.363±±2.378)和(3.000±1.612)前后差异显著,有统计学意义(t=20.553P=0.000)；0’Leary-Sant ICSI评分分别为(13.727±3.523)和(4.091±2.022)前后差异显著,有统计学意义(t=19.616P=0.000)；尿流动力学检查结果显示治疗前与治疗后1个月的最大膀胱容量膀胱容量(MBC)分别为(57.727±15.787)ml和(181.272±21.261)ml,前后差异显著,有统计学意义(t=-24.894P--0.000)；排尿间隔分别为(29.000±7.797)min和(75.27±10.02)min,前后差异显著,有统计学意义(t=-40.417P=0.000)；逼尿肌不稳定收缩频率分别为(2.545±1.036)次／分和(0.455±0.522)次/分,前后差异显著(t=-9.898P=0.000)。最大尿流率分别为(6.627±1.872)ml/s和(15.118+1.884)ml/s前后差异显著(t=-122.429P=0.000)；日间排尿次数分别为(26.909±8.068)次和(10.091±1.640)次前后差异显著(t=8.192P=0.000)；夜间排尿次数分别为(4.546±1.440)次和(1.364±0.924)次,前后差异显著(t=14.056P=0.000)；膀胱最大排尿压(MVP)分别为(44.000±4.313)cmH20、(43.814±4.262)cmH20,前后差异不显著,无统计学意义(t=0.154P=0.881)。结论1.腹腔注射氯胺酮诱导的氯胺酮性膀胱炎大鼠膀胱在病理和功能上的病变与人类相似,可以作为比较可靠的动物模型来研究氯胺酮性膀胱炎。2.膀胱水扩术+碱性利多卡因灌注对氯胺酮性膀胱炎大鼠有良好的治疗效果,尿流动力学指标改善。3.膀胱水扩术合并碱性利多卡因、地塞米松膀胱灌注可显著改善氯胺酮性膀胱炎患者症状,特别是膀胱容量的扩大,可为治疗氯胺酮性膀胱炎的一种有效合理的方法。更多还原

【Abstract】 BackgroundKetamine is a phencyclidine derivative, commonly known as k powder, smoked with addiction and euphoria,which can produce hallucinations, such as:hovering, weightless and floating feel.After1hour its hallucinogenic effects dies away. The metabolism of ketamine in body mainly through two ways:one is the liver microsomal CYP3A4enzyme metabolism, the other way is urinary system. The substantial part of ketamine and its metabolites can secret by the excretion of urine.The youth abuse situation is increasingly prominent.Domestic and foreign research ontoxic damage of ketamine is still mainly in the cardiovascular and neuropsychiatric systems, Recently reported urinary system damage caused by ketamine abuse gradually, but the reports,which contains treatment means and the damage-mechanism to urinary system,is so less, less their cause damage to the urinary tract of basic research.2007, Shanhani et al first reported the ketamine-abused in patients occur with varying degrees of lower urinary tract damage symptoms, and called it ketamine associated lower urinary tract symptoms. Domestic and foreign scholars found that:long-term abuse of ketamine crowd there will be varying degrees of overactive bladder (OAB) symptoms, such as urinary frequency, urgency, dysuria,hematuria and urge incontinence.Urodynamic testing shows overly sensitive bladder, instability Bladder, urinary flow rate is low;Cystoscopy find bladder wall can be seen extensive mucosal congestion and redness;Imaging studies revealed obvious bladder contracture and volume reduction (minimum of30～100ml);Pathological examination confirmes that a large number of inflammatory cells in the the bladder mucosal epithelial cells invade with granulation of tissue growth;Generally no abnormal of blood and urine routine and antibiotic treatment is often not significant.Some scholars have called the lower urinary tract damage of ketamine abuseketamine-associated cystitis.The pathogenesis of Ketamine-associated cystitis is not very clear.there is a lack of effective therapies.It is often misdiagnosed as cystitis, prostatitis "and confused with a simple" overactive bladder(OAB)"The incidence rate was gradually rising trend in the world in recent years, especially in the Pan-Pearl River Delta and other economically developed areas is very obvious.Many doctors are not yet fully understand the pain and huge burden of the disease to patients and their families.So it is necessary that study ketamine-associated cystitis from the experimental and clinical.Meng used anesthetic dose of ketamine hydrochloride injection (80-150mg/kg),intraperitoneal injection of C57BL/6mice.The urodynamic study found that the voiding interval and bladder capacity was significantly reduced. Shu-Mien build ketamine ulcerative cystitis rat model induced by intraperitoneal injection of ketamine (25mg/kg).Urodynamics was based primarily on the basic principles and methods of electrophysiology and hydrodynamics.It understand the function and mechanism of the urinary tract on transportation urine and pathophysiology of the voiding dysfunction disease by detection of urinary tract pressure, bioelectrical activity and urinary flow rate.The urodynamic a ideal method which can reflect urinary tract function intuitively quantitatively.Therefore,for the disease of voiding dysfunction,urodynamic testing has important practical value on clinical diagnosis and treatment. Some scholars believe that in the bladder mucosa surface existence a protective layer, such as the ingredients of glycosaminoglycan (GAG), the asymmetric unitmembrane, ion pump and a high-density proteoglycans.After the destruction of the protective layer, Ketamine or its metabolites destroy the epithelial permeability barrier and damage to the bladder wall deep tissue.If the toxic substances enter the submucosal and detrusor layer and damage muscles and nerves, nerve fibers of the bladder wall been abnormal stimulation,then causing irritation symptoms of urgency, frequency, etc.Bladder hydrodistention with drug perfusion is the primary means for the treatment of OAB symptoms of clinical treatment,after which under anesthesia may contribute to the growth of the bladder mucosa.The mechanism of treatment of the bladder hydrodistention is considered that hydrodistention led to the ischemic and necrosis of the sensory nerves in the bladder wall,and reduce the density of sensory nerves in the bladder wall.PurposeBased on the above reasons,author through the establishment of ketamine-associated cystitis rat model,evaluate the urodynamic indicators before and after the treatment of bladder hydrodistention with infusion of drug.Besides, through clinical retrospective study evaluated the clinical effect of the bladder hydrodistention. In order to provide a new and effective way for the treatment of ketamine-associated cystitis.Method1. Establish theketamine-associated cystitis rat modelSelected female Sprague-Dawley2-month-old young rats30.Based on urodynamic examination was normal, all30rats were included in the experiment study.All rats were divided into a control group (A,10) and model group (B,20), all rats of group B were injected ketamine (30mg/kg) by intraperitoneal a total of12weeks. At the end of the4th,8th and12th weeks,take4times urodynamic testing on model rats to evaluate the bladder function.3days after the withdrawal the model rats were detected to find whether ketamine and its metabolites exist in their body. After he model is confirmed induction success, take two groups of rats a small bladder tissue under anesthesia,which was applicated to the conventional HE staining,for observing the pathomorphological changes of bladder mucosa and detrusor.Discuss the pathological basis which caused thed structural and functional changes of bladder.of ketamine-associated cystitis rats.2. The method for urodynamic detection on ratUse urethane anesthetized rats by intraperitoneal injection. Inserted the homemade single3F cystometry cathet into the urethra of rat. Inserted the homemade anorectal manometry tube into the anus about4cm.Then connected the two pipes with urodynamic gauge pressure sensors and micro-infusion pump.The infusion rate of the pump is adjusted to0.1ml/min.The measurement indicators include voiding interval, the maximum bladder capacity(MBC), the maximum bladder voiding pressure (MVP)and detrusor instability contraction frequency.Then the significance of urodynamic indicators changing is analysised on ketamine associated cystitis rats.3. The method of bladder hydrodistention with drug perfusionAfter12weeks each group stop using ketamine.At the same time Group B were randomly divided into two groups (B1, B2)(10rats/group). After stopping useing ketamine1,3,5weeks, the group B2was dealed with "bladder hydrodistention with drug perfusion"contrast the B1group were treated with drugs perfusion only.1week after cessation of treatment, urodynamic was processed to detect the changes of rat voiding interval, MBC, MVP, detrusor instability contraction frequency.Compare the difference betweenB1and B2groups, and the difference between before and after application of the treatment.Disscuss the therapeutic effect of bladder hydrodistention to the ketamine-associated cystitis.4.The statistical analysisUse spss16.0software deal with data analyzed by t-test and analysis of variance. In the case of P<0.05data is considered statistically significant.Result1. Urodynamic results show:The maximum bladder capacity (MBC) in saline control group (A group)and ketamine-associated cystitis rats (B group) were (0.663±0.091) and(0.234±0.060)and the difference between two groups were statistical significance (t=15.527,P=0.000).The voiding interval in two groups were (6.680±0.884VS2.433±0.614),and the difference between two groups were statistical significance (t=15.404,P=0.000).The instability contraction frequency in two groups were(0.100±0.316VS3.500±0.827)and the difference between two groups were statistical significance (t=-16.170,P=0.000).The maximum bladder voiding pressure(MVP) in two groups were (35.400±6.096VS36.005±6.095),but the difference between two groups were not statistical significance (t=-0.256,P=0.800).After the begining of induction4weeks、8weeks、12weeks, The urodynamic study results of ketamine-associated cystitis model (B group) suggested that the maximum bladder capacity (MBC) in three Point-in-time were (0.456±0.089VS0.290±0.096VS0.234±0.060) and the difference among group internally were statistically significant (F=101.64,P=0.000).The voiding interval in three Point-in-time were (4.615±0.899VS3.102±0.735VS2.433±0.614) and the difference among group internally were statistically significant(F=110.441,P=0.000).The instability contraction frequency in three Point-in-time were(0.850±0.745VS2.200±0.696VS3.500±0.827)and the difference among group internally were statistically significant (F=41.704,P=0.000).The maximum bladder voiding pressure(MVP) in three Point-in-time were (35.445±5.864VS35.705±5.934VS36.005±6.095) but the difference among group internally were not statistically significant (F=0.029,P=0.993).It can be seen that epithelial cell degeneration, mucosal edema, inflammatory cell infiltration on bladder mucosal of ketamine-associated cystitis rat model and fibroplasia, lymphangiectasia,infiltration of lymphocytes and mast cells infiltrate on detrusor layer by routine HE staining.2. In the group of ketamine-associated cystitis rat model (B), urodynamic results show that the maximum bladder capacity (MBC) before and after bladder hydrodistention with drug infusion were (0.228±0.055VS0.609±0.090) and the difference were statistically significant (t=-21.265P=0.000).The voiding interval were (2.345±0.561VS6.110±0.923) and the difference were statistically significant (t=-21.421P=0.000).The detrusor instability contraction frequency were (3.500±0.850VS0.800±0.632)and the difference were statistically significant (t=9.000P=0.000). The maximum bladder capacity (MBC) before and after drug infusion only were (0.240±0.067VS0.242±0.069) and the difference were not statistically significant (t=-1.000P=0.343).The voiding interval were (2.520±0.681VS2.550±0.675) and the difference were not statistically significant (t=-1.964P=0.081).The detrusor instability contraction frequency were (3.500±0.850VS1.500±0.527) and the difference were not statistically significant (t=9.487P=0.000).3.11patients of ketamine-associated cystitis were treated by bladder hydrodistention with drug infusion.The O’Leary-SantICPI score of the before and after treatment were (9.363±2.378VS3.000±1.612) and the difference were statistically significant (t=20.553P=0.000).The O’Leary-SantICSI score of the before and after treatment were (13.727±3.523VS4.091±2.022) and the difference were statistically significant (t=19.616P=0.000).Urodynamic results show The maximum bladder capacity (MBC) before treatment and1month after treatment were (57.727±15.787VS181.272±21.261) and the difference were statistically significant (t=-29.894P=0.000).The voiding interval were (29.000±7.797VS75.27±10.02) and the difference were tatistically significant (t=-40.417P=0.000).The detrusor instability contraction frequency were (2.545±1.036VS0.455±0.522) and the difference were statistically significant (t=-9.898P=0.000).The maximum flow rate were (6.627±1.872VS15.118±1.884) and the difference were statistically significant (t=-122.429P=0.000).The frequency of urination at daytimewere (26.909±8.068VS10.091±1.640) and the difference were statistically significant((t-8.192P=0.000). The frequency of urination at night were (4.546±1.440VS1.364±0.924) and the difference were statistically significant(t=14.056P=0.000). The maximum bladder voiding pressure(MVP) were (44.000±4.313VS43.814±4.262) and the difference were not statistically significant (t=0.154P=0.881).Conclusionl.The bladder of ketamine-associated cystitis induced by intraperitoneal injection of ketamine in pathology and functional lesions are similar to that of humans.2.Bladder hydrodistention with infusion of drug treats the rat of ketamine-associated cystitis with good effect.3.Bladder hydrodistention with infusion of drug can significantly improve the bladder function of ketamine-associated cystitis patient.It may be a effective and reasonable way which is uesd to treat ketamine-associated cystitis.更多还原