Tbilisis sax. samedicino akademiis

urologiis kaTedra

urologiur daavadebebs Soris gamorCeuli adgili uWiravs paTologiur mdgomareobebs, gamowveuls Sardis buStis inervaciis darRveviT, rac klinikurad vlindeba sxvadasxva tipis neirogenuli disfunqciis saxiT, romelTa mkurnaloba kvlavac seriozul problemad rCeba Tanamedrove urologiaSi.

travma, simsivneebi, anTebiTi da degeneraciuli daavadebebi, romlebic iwveven zurgis tvinis ganiv disociacias gava-welis segmentebSi an maT zeviT aucileblad gamoiwveven Sardis buStis funqciis moSlas misi denervaciis, anu zurgis tvinsa da Tavis tvinis qerqSi arsebuli moSardvis aqtis makontrolebel centrebTan kavSiris gawyvetis gamo (Васильев А. И. 1959, Гресь А. А., 1980, 1984).

Sardis buStis spinaluri centrebi ganlagebulia gava-welis midamoSi. simpaTikuri inervacia xorcieldeba L _II-IV segmentebis lateraluri rqebidan da nawilobriv Th _X-XI-XII da L _I segmentebidan. postgangliuri boWkoebi qmnian faSvis nervebs, romlebic parasimpaTikur boWkoebTan erTad qmnian buStis wnuls da mTavrdebian buStisa da sfinqterebis kunTebSi.

parasimpaTikuri inervacia xorcieldeba S _II-IV segmentebis birTvebiT, romlebic ganlagebulia zurgis tvinis konusSi. simpaTikuri inervacia iwvevs detruzoris modunebasa da gluvkunTiani (Sida) sfinqteris SekumSvas, parasimpaTikuri-detruzoris SekumSvasa da ganivzoliani (gareTa) sfinqteris modunebas.

Sardis buStidan aferentuli impulsebi tardeba hipogastruli nervebiT, romelTa nawili miemarTeba zurgis tvinis ukana rqebTan da iqmneba spinaluri refleqtoruli rkali, nawili ki miemarTeba golis viwro konis SigniT Tavis tvinSi, uzrunvelyofs ra moSardvis aqts. moSardvis centri qerqSi mdebareobs paracentralur wilakSi, qerqveSa centrebi ki mxedvelobis borcvisa da borcvqveSa midamoebSi.

amgvarad, moSardvis aqti xorcieldeba cerebralur, spinalur da periferiul doneze da warmoadgens rTul neirofiziologiur process (Буянов М. И. 1985).

Sardis buStis inervaciis Semdgomi Seswavlisas aRmoCnda, rom garda ZiriTadisa, arsebobs agreTve aferentuli inervaciis SemovliTi gzebi (Булыгин И. А., 1949-1966), kerZod, isini iwyebian zurgis tvinis gulmkerdis segmentebidan da gaivlian muclisa da menjis Rruebis vegetatiuri nervebis SemadgenlobaSi (sqema#1). es gzebi ZiriTadisagan gansxvavdebian raodenobrivi, Tvisobrivi, funqcionaluri da individualuri maxasiaTeblebiT. aqedan gamomdinare iSva idea axali xelovnuri SemovliTi inervaciis gzebis Seqmnisa Sardis buStze wvrili nawlavis dakerebiT (Голуб Д. М. 1957). SemdgomSi nacadi iqna Sardis buStze nawlavTa sxvadasxva segmentebis, badeqonis, muclis wina kedlis kunTebis dakereba (e. w. vezikopeqsia) da dadginda, rom Sexorcebis ubnebSi viTardeba ara mxolod axali nervuli totebi, aramed axali refleqsogenuri zonebi da nervul-refleqtoruli centrebic ki (Хейнман Ф. Б. 1957-1966).

Мохорт В. А. da Савченко Н. Е. (1964-1970) Caatares mravali eqsperimenti, ris Sedegadac daadgines, rom yvelaze ufro mizanSewonilia Sardis buStis reinervaciisa da revaskularizaciis mizniT Sardis buStze demukozirebuli gaSlili wvrilnawlavovani zoliseburi segmentis dakereba, romelsac SenarCunebuli aqvs jorjali (sqema #2). detaluri eqsperimentuli gamokvlevebiT avtorebma daadgines, rom organoTa SeerTebis adgilas ukve meore kviridan iwyeba regenerirebadi aqsonebis zrda, gatotianebuli konebis saxiT da procesi mravalferovani da daxvewili xdeba 1 wlis Semdeg. imis gamo, rom axalwarmoqmnil nervul elementebs axasiaTebT maRali mgrZnobeloba meqanikuri deformaciisadmi, maT SeuZliaT gaataron signalebi centraluri nervuli sistemisaken Sardis buStis avsebis xarisxis Sesaxeb, rac uzrunvelyofs moSardvis aqtis Catarebas.

Sardis buStis reinervaciis, kerZod, axali nervuli centris Seqmnis mizniT Голуб Д. М. da Хейнман Ф. Б. (1967-1970) daiwyes Sardis buStis kedelSi jorjlis kaudaluri gangliis Canergva (e. w. ganglio-vezikopeqxia) da daadgines, rom Sedegad viTardeba mravalricxovani nervuli elementebi, romelTa raodenoba mniSvnelovnad sWarbobs kidec ileovezikopeqsiis dros ganviTarebuls. Tumca aRniSnulma meTodma klinikuri gamoyeneba ver hpova.

Sardis buStis inervaciis darRveva iwvevs misi mgrZnobelobis cvlilebas hipo- an arefleqsiis da hiperrefleqsiis saxiT. amave dros irRveva buStis detruzorisa da misi sfinqteris funqcia da maTi koordinirebuli urTierTqmedebac, rac klinikurad gamoixateba Sardis Sekavebasa an SeukaveblobaSi.

sadReisod miRebulia simptomuri mkurnalobis 3 ZiriTadi mimarTuleba: medikamenturi, eleqtrostimulacia da paliaturi operaciebi.

medikamenturi mkurnalobis SerCeva damokidebulia disfunqciis tipze, magaliTad detruzoris hiperrefleqsiis dros saWiroa buStis relaqsantebis (antiqolinerguli preparatebis), xolo hiporefleqsiis dros b-adrenoblokatorebis gamoyeneba. gasaTvaliswinebelia, agreTve sfinqteris refleqtoruli mdgomareoba. medikamentebis miReba SesaZlebelia oraluri da parenteraluri gziT da lokaluri Terapiis (intravezikaluri instilacia da buStis kedelSi endoskopiuri ineqciebi) saxiT. magram medikamenturi mkurnalobis sqemebis SerCeva rTulia da is ZiriTadad Sedegiania msubuqi dazianebebis dros (Державин В. И., Вишневский Е. А. 1984).

eleqtrostimulaciis meTodebi 2 tipisaa: garegani (ureTraluri da reqtaluri stimulacia specialuri gadamwodebis gamoyenebiT) da Sinagani (implantaciuri). kerZod, wina sakraluri fesvebis stimulatoris implantacia, misi efeqti Seadgens 85%-s sruli suprasakraluri spinaluri dazianebebis dros. meTodi mowodebulia G. Brindley-s mier 1978 w. 80-ian wlebSi gamoyenebulma intravezikalurma eleqtrostimulaciam popularoba ver hpova sirTulisa da mkurnalobis kursis xangrZlivobis gamo.

operaciuli mkurnaloba: sakraluri deaferentacia, sakraluri fesvebis eleqtrostimulatoris implantacia. Sardis buStis augmentacia. Sardis buStis substitucia an Sardis derivacia, sfinqterotomia. aRniSnuli operaciebi Seadgenen e. w. paliatiur-simptomatiur operaciebs.

operaciebi, romlebic uzrunvelyofen Sardis buStis reinervaciis aRdgenas, warmoadgenen paTogenezurad dasabuTebul operaciebs: ileovezikopeqsia (Савченко da Мохорт); ileovezikopeqsia Sardis buStis yelis gamagrebasTan kombinaciaSi (Державин В. М.); Sardis buStis remuskularizacia muclis swori kunTebis nafleTebis dakerebiT (Boshamer-Snicer-Leitese).

amgvarad, Sardis buStis neirogenuli darRvevebis mkurnalobis sakiTxi miuxedavad arsebuli mravalricxovani konservatiuli da operaciuli meTodebisa, sabolood gadawyvetili mainc ar aris. arsebul meTodebs Soris ki paTogenezurad dasabuTebuli da gamarTlebulia is operaciebi, romlebic mimarTulia Sardis buStis inervaciis aRdgenisadmi. meTodi moiTxovs Semdgom Seswavlasa da daxvewas.

gamoyenebuli literatura

1. Буянов М. И. Недержание мочи и кала. Изд. «Медицина», Москва, 1985

2. Голуб Д. М., Хейнман Ф. Б. Восстановление иннервации мочевого пузыря. Изд. «Наука и техника», Минск, 1974

3. Лопаткин Н. А. и соавт. Руководство по Урологии в 3-х томах, том 2. Изд. «Медицина», Москва, 1998

4. Савченко Н. Е., Мохорт В. А. Нейрогенные расстройства мочеиспускания. Изд. «Беларусь», Минск, 1970

5. Хейнман Ф. Б. Иннервация мочевыводящих органов. Изд. «Наука и техника», Минск, 1973

6. Cartwright PC, Snow BW. Bladder autoaugmentation: early clinical experience. J. Urol. 1989; 142: 505-508

7. Madersbacher H. Current concepts of the urological management of spinal cord injured patients. EAU organized course at the time of the congress of the Georgian Urological Assotistion. 8-9 June 2002, Tbilisi, Georgia, pp 27-45

8. Stohrer M., Kramer G et al. Bladder autoaugmentation in adult patients with neuriogenic voiding dysfunction. J. Urol. 1997; 35: 456-462.

The modern aspects of bladder reinnervation

Phiran Kalandadze

Docent, Chair of Urology at Medical Academy

Summary

The article represents the literary review of modern methods of treatment of the neurogenic dysfunction of the bladder in spinal cord injured patients and of methods of the bladder reinnervation.

The author concludes, that the most of current methods of treatment are symptomatic and less effective. The methods of bladder reinnervation: implantation of a sacral anterior root stimulator and operation of ileo-vesicopexy, represent the way of pathogenetic treatment and are much more effective and perspective.

___________________________________

sqema #1. Sardis buStis inervacia. sqema #2. Sardis buStis reinervacia

punqtiriT aRniSnulia damatebiTi da impulsebis gadacemis gzebi

(SemovliTi) wyaroebi da spinaluri wvrili nawlavis nervuli gzebiT,

aferentuli inervaciis gzebi; romlebic monawileoben Sardis

uwyvetiT – ZiriTadi wyaroebi da buStis reinervaciaSi, dazianebuli

spinaluri aferentuli inervaciis gava-welis centrebisa da periferi-

gzebi. 1_ inervaciis adgilobrivi uli gangliebis SemovliT.

centrebi Sardis buStis kedlebSi.