送交者: cornbug 于 2015-09-11, 12:00:32:
回答: 是，多谢 由 gang 于 2015-09-11, 11:23:02:
Chuan-Guo Xiao
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doi:10.1016/j.juro.2015.06.083
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Refers To
Mikkel Mylius Rasmussen, Yazan F. Rawashdeh, Dorte Clemmensen, Hatice Tankisi, Anders Fuglsang-Frederiksen, Klaus Krogh, Peter Christensen
The Artificial Somato-Autonomic Reflex Arch Does Not Improve Lower Urinary Tract Function in Patients with Spinal Cord Lesions
The Journal of Urology, Volume 193, Issue 2, February 2015, Pages 598-604
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Reply by Authors
The Journal of Urology, Available online 4 September 2015,
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To the Editor:
As the inventor and promoter of the Xiao procedure, I was disappointed in the 10 of 10 negative results in this trial from Denmark. However, I was not at all surprised due to my experience in trying to convince other research teams to test the Xiao procedure in the right way. When I read of the negative results in the abstract, I believed that there must be something fundamentally wrong in the trial. I know now that the authors continued anticholinergic treatment following the reinnervation procedure. As noted previously, this treatment can result in failure of the somato-autonomic reflex pathway.1 The authors note my recommendation regarding “rigorous patient selection criteria … [including] preoperative and perioperative electrophysiological evaluation, patient education, discontinuation of anticholinergics, maintenance of less than 700 ml bladder capacity and a suprapubic catheter left in situ until reflex arch voiding is established.” They report that most criteria were met, save the upper limit of bladder capacity and cessation of anticholinergics, as they judged the medication essential for patient well-being throughout the 18-month study. They state, “As reinnervation occurs at the level of the preganglionic (nicotinic) receptors, and anticholinergics mainly target postganglionic (muscarinic) receptors, we cannot exclude … that treatment may have diminished the reflex … [but] we do not believe that it would have abolished the reflex completely.”
Anticholinergics and clean intermittent catheterization have been the gold standard treatment for neurogenic bladder caused by spinal cord injury (SCI) for more than half a century in developed counties. This approach aims to block the neural connection between postganglionic nerves and detrusor, paralyze the detrusor, inhibit the bladder contraction and make the bladder a low pressure storage tank for clean intermittent catheterization. However, the goal of the Xiao procedure is to reestablish neural control of the lower urinary tract via somato-autonomic reinnervation to allow voluntary voiding. The postganglionic nerve to detrusor connection is the last and most important leg of the somatic-central nervous system-autonomic reflex arch, and if this leg is blocked by anticholinergics continuously, the newly established reflex arch could never be activated to initiate detrusor contraction and voiding, as is the case in this report.
This trial is well designed and rigorously carried out by an outstanding team with credible expertise in multiple specialties related to SCI. However, the anticholinergics issue is a fundamental scientific error, which is unfortunate and likely makes all of the results meaningless. For example the baseline as well as postoperative urodynamic test results are influenced by anticholinergic treatment and do not reflect the real reflex activity of the bladder. With the anticholinergic medication the results should be the same, and, indeed, they were the same.
Moreover, antimuscarinics not only block the bladder response to reflex activation, but also may suppress development of the new reflex pathway by interfering with the mechanisms of reinnervation. For example reinnervation may depend on release of neurotrophic factors in the bladder, and suppression of bladder activity by the drugs may reduce neurotrophic factor production. Why was decreased leakage the only statistically positive result? It is because the external urethra was simultaneously reinnervated by somatic motor axons and became functional, which cannot be blocked by anticholinergics.
Nonetheless, this study should not be the end of the Denmark trial. I am confident regarding the success of neural microanastomosis performed by skilled neurosurgeons I met in China, and the expertise of the electrophysiology and urodynamic staff as shown in the article. I am also confident that the somato-autonomic reflex arch has been established and can be activated for voiding after discontinuation of anticholinergics. I suggest that the authors discontinue anticholinergics for 2 months and then repeat the postoperative assessment as designed. Discontinuation of anticholinergics for a few months under close watch will not affect “patient well-being,” but may prove that anticholinergics are no longer necessary, as many other centers have reported. Finally, I would advise anyone who may try the Xiao procedure not to do it if they are determined to keep using anticholinergics.
Respectfully,
Reference
1
C.G. Xiao
Xiao procedure for neurogenic bladder in spinal cord injury and spina bifida
Curr Bladder Dysfunct Rep, 7 (2012), p. 83
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