肖傳國教授在世界上第一個提出並證實 “人工建立體神經-內臟神經反射弧” 用於治療各種脊髓損傷導致的排尿障礙。這一發現在肖傳國與方舟子之間挑起了一場科學與反科學長達五年的論戰。為幫助公眾了解這場論戰的事實真相，本文首先從學術角度根據科學文獻和科學事實對“肖氏反射弧”作一番解析。
反射是神經支配機體生理機能的基本方式。反射弧一般由感受器，傳入神經，反射中樞，傳出神經和效應器組成。正常的排尿反射由位於腦幹和大腦皮層的高級排尿中樞控制達骶髓的排尿反射初級中樞完成。膀胱充盈時，膀胱壁的牽張感受器受到刺激而興奮。衝動傳入高級中樞產生排尿欲。中樞經過判斷認為可以排尿，於是發出神經衝動沿下行傳導束到脊髓初級排尿中樞，然後由副交感神經元發出發出神經衝動導致膀胱逼尿肌肌收縮，同時尿道括約肌放鬆，尿便經尿道口排出。中樞神經系統（從頭部到骶髓）損傷的早期可導致逼尿肌無反射和尿道擴約肌張力的提高。膀胱失去隨意排尿的能力。
“肖氏反射弧”是媒體炒作生成的名詞。肖傳國的論文使用的術語是“體神經—自主神經反射弧”或者“皮膚-中樞神經-膀胱反射通道”。“皮膚-中樞神經-膀胱反射通道”是由手術建立的人造神經反射。目的是治療因脊髓損傷導致的排尿障礙。具體方法是切斷左側腰5前角神經根並將其與控制膀胱逼尿肌的骶2或/和骶3前角神經根吻合。保持腰5后角神經根完整無損。通過刺激腰5相應的皮膚區，神經衝動從腰5后角神經根傳入。激發腰5前角神經元發出動作電位，由腰5前角神經根傳到膀胱引起逼尿肌收縮，到達可控排尿的目的。
這一構想的實驗研究必須證明以下幾個問題。第一，左側腰5前角神經根與控制膀胱逼尿肌的骶2或/和骶3前角神經根吻合後，神經是否能夠再生。通過神經切片電鏡和顯微鏡觀察，可以證明神經吻合後是死的還是活的。第二，再生的神經是否能對膀胱逼尿肌形成支配。通過神經纖維酶示蹤觀察可以證明吻合後的神經是否可以傳遞神經介質。第三，吻合後的腰5前角神經，在皮膚感覺衝動傳入脊髓腰5后角時，是否能向膀胱釋放動作電位。通過神經電生理記錄可以得到確認。第四，腰5前角神經衝動到達膀胱時，是否可以激發逼尿肌收縮。通過膀胱內壓力測定可以證明。以上每一步實驗必須得到重複實驗證明。
通過本人複習肖傳國從1999年到2006年在中國期刊和英文國際期刊的論文，毫無疑問，肖傳國通過上述的實驗證明了他的構想是可行的。這些論文發表的期刊均屬泌尿外科頂級期刊。論文的引用少的有20次，多的達70次。本人沒有查到否定肖傳國以上實驗結果的論文。發現有兩個中國作者發表了與肖傳國相同的結果。根據上述事實，肖傳國第一個提出並證明的“皮膚-中樞神經-膀胱反射通道”在實驗室條件下是一個可以重複證實的客觀存在。到目前為止，沒有看到任何學者通過正式的學術交流媒介對此提出反對意見。（附錄1，肖傳國論文部分目錄）
但是，在大眾傳播媒介，我們可以看到有的專家學者發表不同的觀點。北京大學泌尿外科研究所名譽所長、中國泌尿外科學唯一的中國工程院院士郭應祿表示“肖傳國的這個手術在道理上能講得通，但不是所有病人的神經都能接得上的而且你得能找得到神經才能接”，郭應祿說，“所以，就算他說得對，能起作用也是有限制的。”武警總醫院病理科主任紀小龍也表示，神經癒合至今仍是醫學上的一個難題，“神經是很難長在一起的。打個比方，每根神經就像電話線，裡面有好多分支，只有每一根分支都對上了，它才能長好。而現有的任何顯微手術都做不到這點，只能靠兩根神經自己去找，手術能否成功存在偶然因素。“我是專門研究神經再生的，我認為這種想法根本就是無稽之談。”中日友好醫院神經外科主任於炎冰告訴《北京科技報》，“肖式反射弧”技術原理就是讓重新連接後的中樞神經再生，但是想要使中樞神經再生基本上沒有可能。因為一個器官它是由很多條神經共同支配的，如何尋找到與器官控制相對應的神經其實非常困難，如果接錯或破壞了原有的神經，手術後的結果可能會導致想恢復的功能沒有恢復，而原來的功能也會受到影響。
Nile根據肖傳國的實驗結果結合已經得到廣泛接受的醫學理論對以上的觀點分析如下。以上引述三位專家的意見可以歸結為兩個問題。第一個問題，手術後神經能否再生，能否長在一起。肖式反射弧”技術原理就是讓重新連接後的中樞神經再生，但是想要使中樞神經再生基本上沒有可能。Nile可以肯定中日友好醫院神經外科主任於炎冰沒有看過肖傳國的論文，不了解“皮膚-中樞神經-膀胱反射通道”的具體手術方法。具體手術方法是切斷左側腰5前角神經根並將其與控制膀胱逼尿肌的骶2或/和骶3前角神經根吻合。根據神經科學的基本理論，脊髓神經根不是中樞神經，是外周神經。手術對脊髓中的中樞神經不造成任何損害。中樞神經損傷後不可能再生。但是，外周神經損傷後是可以再生的。如果外周神經損傷後不可再生，那麼所有的斷肢再植手術都不可能成功。如果有人對這個問題有疑問，請參閱附錄2中樞神經外周神經的定義和神經再生的理論。另外，神經吻合後，理論上可以再生，而實際上究竟是否能成功再生，是否每次手術都可以成功再生。這是一個完全可以通過實驗操作來回答的問題。根據肖傳國和其他作者的實驗結果。吻合後神經的再生是一個可以不斷反覆驗證的科學事實。
第二個問題。神經吻合會不會把神經接錯。神經吻合的確有把神經接錯的問題。可以把傳出的運動神經與傳入的感覺神經錯接。但是，把腰5前角神經與骶2，3前角神經吻合不可能發生上述的錯誤。第一，所有的前角神經都沒有任何感覺神經纖維成分。因此把腰5前角神經與骶2，3前角神經吻合不可能出現錯把感覺與運動神經對接的問題。第二，腰5前角神經根由軀體運動神經纖維組成，而骶2，3前角神經根包含副交感和軀體運動神經。肖傳國的基本構想就是用軀體運動神經代替原有的副交感神經來人工造成膀胱收縮。因此這個手術的另一個名稱就是“體神經—自主神經反射弧” （somatic-central nervous system-autonomic reflex pathway）這裡的自主神經既副交感神經。因此用運動神經與副交感神經吻合是治療的手段，也不存在神經錯接的問題。
“皮膚-中樞神經-膀胱反射通道”的根本目的是治療脊髓損傷導致的排尿障礙。這一方法用於臨床療效究竟如何，是這一發現究竟有沒有醫學價值的關鍵問題。把一種探索性的手術方法用於臨床治療，本身就面臨一個從動物到人的溝壑。動物神經組織的再生速度比人快。動物實驗可以人為設定實驗初始條件，而病人的病情可以千差萬別。動物實驗可以有一致的標準判斷成功還是失敗，而病人很難用同一個標準判斷有效無效。動物實驗不需要考慮手術的副作用，而在人身上，很可能副作用帶來的損害超過療效帶來的利益。因此任何一種治療的療效評定都必須將上述的條件考慮在內科學地建立評定標準。
對於反射弧手術的療效評定，從有關論文來看，比較一致的標準是：1.恢復自主排尿的程度；2. 尿流動力學指標的改善；3. 能否不依賴導尿管。如果以完全恢復自主排尿為有效。那麼這個手術的療效很可能就是零。如果僅僅以尿流動力學指標改善為有效，療效很可能就接近100%。從1995年到2010年，肖傳國進行反射弧手術2000例。在最大的一個樣本是1500例患者中的500例得到隨訪，有效率85%。學術界引用的是肖傳國本人在國際專業期刊的兩個大宗病例報道：92例脊髓損傷患者88%術後一年達到可控排尿和110例脊髓膨出患兒87%在術後一年可以成功完成可控排尿。
而堅持指控肖傳國是學術騙子的方舟子們對手術的有效率進行了山寨調查。根據發表在新語絲的一篇題為《肖氏手術”治癒率：85%，還是0%？》，可以看到他們調查的結果：“2009年9月，當資金較為充裕之時，調查取證的工作再次啟動。這一次，據患者彼此通信獲得的150多人中，打通電話的有80多人，現場尋訪人數15人。彭劍說，目前數字還在不斷增加，每天至少有2個，多至三四個電話打過來為案件提供佐證。在迄今為止所接觸過的接受了肖氏手術的病友中，調查結果顯示沒有一例完全成功，手術有明顯效果的比率也很低——這與醫院方面所宣傳的“治癒率85%”形成鮮明對照。”
以上的文字用正式的療效評估語言可以作這樣的解讀：本寨以電話和現場採訪的方式對95名反射弧術後患者進行了調查。結果表明，手術完全成功率為零。明顯有效率不祥。調查過程採用的問卷不予公布。這一調查結果與85%的“治癒率”的確是有天壤之別。但是與肖傳國在專業文獻中報道的87%-88%的有效率沒有任何矛盾。
任何治療方法都有副作用，反射弧手術的主要副作用就是下肢運動功能受損。這個問題對完全截癱病人沒有影響，但是對本來保留有一定程度的下肢運動功能的脊髓膨出患兒就是一個問題。這一副作用完全在醫生和患者的預料之中，因為是該手術用本來是負責下肢運動的神經去支配膀胱排尿，不可能不影響左下肢的運動。對此，肖傳國已經對手術方法進行了改良。把原來用全部左側腰5前角神經根改為用1/3到一半的神經根，這一改良減輕了對下肢運動的副作用。
美國William Beaumont醫院泌尿外科主任Kenneth M. Peters 2010年4月在《當代膀胱功能紊亂報道》雜誌發表文章，對肖傳國發現的反射弧手術方法予以綜述：（附錄3）
Dr. C. G. Xiao from China was the first to popularize bladder reinnervation through an intradural nerve anastomosis of a lumbar-to-sacral nerve. This concept has gained international attention, and attempts to create other somatic-to-autonomic reflex arcs to assist with voluntary voiding have been studied. In this review, we discuss the current state of the literature in this new field.
2010年8月Peters與同行們在美國泌尿學雜誌發表論文。報告9名患者的反射弧手術結果：（附錄4）
Results
At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months.
Conclusions
At 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.
兩位該雜誌編輯對這篇論文發表了評論，認為這9例手術的結果與肖傳國作的110例87%有效率不同，缺乏對照，沒有統計學意義（附錄5）。同時刊載了論文作者Peter等人對編輯的評論做出了回應。Peter等人認為，發表這9例一年隨訪結果的目的是證明皮膚到膀胱反射弧是可以實現的，同時也應該了解到手術可能帶來的副作用，並以此喚起全美醫學界對這項研究的注意，加強對這種手術研究。William Beaumont醫院泌尿外科2009年底得到美國衛生研究所NIH 230萬美元研究基金，由Beaumont醫院牽頭，在美國幾個主要醫學院多中心推廣研究反射弧手術（附錄6）。
從肖傳國1999年在美國得到NIH RO1基金64萬開展反射弧手術實驗室研究到William Beaumont醫院泌尿外科2009年得到美國衛生研究所NIH RO1 基金230萬美元，十年中肖傳國發現的“皮膚-中樞神經-膀胱反射通道”已經產生了近百篇論文，2000餘例有效率80%以上的手術，並兩度寫入外科學教科書。肖傳國的反射弧手術從他一個人單槍匹馬的實驗室研究發展到美國多家醫院共同參與的臨床應用研究。就在他因雇凶打人下獄前的一周，還在阿根廷講學並實施了8例示範手術。
方舟子2005年發表《腳踏兩隻船的院士候選人》。文章列舉四項證據證明肖傳國是學術騙子。1.在美國擔任全職工作。2. 在國際期刊上發表的文章只有4篇。3. 從來沒有得到美國泌尿學會獎。4. 用“肖氏手術”在網上只找到一個結果。武漢兩級法院根據肖傳國提供的證據判決方舟子捏造證據誹謗他人罪名成立。北京兩級法院駁回肖傳國對方舟子的訴訟根據的不是他們經過研判認定方舟子的證據確實可信，而是他們強行把上述證據界定為“學術爭論”而拒絕法律干預。
事實上，在所有打擊肖傳國的“肖氏反射弧”是學術造假的文章中，方舟子集團從來沒有是根據醫學理論，學術文獻，或者他們自己的研究結果對肖傳國的工作進行學術質疑。方舟子最近發表了一篇文章《美國泌尿學雜誌質疑“肖氏手術”》又是一次偷梁換柱，本末倒置的拙劣表演。美國泌尿學雜誌2010年8月發表的Peter等人的論文證明反射弧手術後一年，大多數病人的自主排尿能力有了改善，而手術導致的下肢無力是有限的。論文同時也認為需要更長時間的隨訪來評價療效。真正質疑肖氏手術的不是這篇論文，而是雜誌編輯對該論文的評論。而且原文作者Peter等人對編輯的質疑也作出了恰如其分的回應。但是，事實到了方舟子手裡就面目全非。方舟子刻意突出雜誌編輯對原始論文的負面評價，並附上了全文。可是論文最重要的部分，原始論文本身的結果和結論居然在他的文章中完全失蹤了。很明顯，文章的結果和結論是方舟子們最不願意看到的。而他們最不願意看到的部分恰恰是最原始的科學事實。
學術爭論，學術打假應該運用科學理論以及研究結果辨別學術問題本身的真偽。避開學術問題本身而對研究者進行人格攻擊，這種行為與科學問題沒有任何關係。學術爭論，學術打假也必需同行的監督與評議，以文獻的方式發表在正式的學術平台，決不可以通過大眾媒體來進行，因為大眾傳媒沒有辨別科學問題正確與謬誤的能力。中國學術界人士應該自覺地把自己的言論置於同行的學術監督之下，拒絕在學術平台之外，發表對他人學術成果的評價。對於這些在科學的幌子下用謊言任意誹謗他人的騙子們，打擊他們最有效的手段就是用事實說明真相。是騙子一定害怕事實，隱瞞事實，歪曲事實，甚至偽造事實。但是，事實就像陽光，誰也休想壟斷。
附錄1：肖傳國論文部分目錄
“SKIN-CNS-BLADDER” REFLEX PATHWAY FOR MICTURITION AFTER SPINAL CORD INJURY AND ITS UNDERLYING MECHANISMS
CGUO XIAO, WC DE GROAT, CJ GODEC, C DAI, … - The Journal of …, 1999 - Elsevier
A detrusor contraction was initiated at short latency by scratching the skin or by percutaneous
electrical stimulation in the L7 dermatome. Maximal bladder pressures during this stimulation
were similar to those activated by bladder distension in control animals. ...
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An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients
CG Xiao, MX Du, C Dai, B Li, VW Nitti, WC de … - The Journal of …, 2003 - Elsevier
... Fig. 1. Skin-CNS-bladder reflex pathway. View Within Article. ... Test of skin-CNS-bladder reflex
by scratching L5 dermatome caused immediate response of detrusor and external urethral
sphincter but voiding was not yet synergic and bladder emptying was incomplete. ...
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Reinnervation for neurogenic bladder: historic review and introduction of a somatic-autonomic reflex pathway procedure for patients with spinal cord injury or spina …
CG Xiao - European urology, 2006 - Elsevier
... related skin. A new concept may be derived from the skin-CNS-bladder reflex pathway:
the impulses delivered from the efferent neurons of a somatic reflex arc can be
transferred to initiate responses of an autonomic effector [22]. ...
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An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida
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... through the S2, S3 or S4 VR. The efferent impulses of the skin-CNS-bladder reflex
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[PDF] 體神經 2 內臟神經吻合後神經纖維再生過程的光鏡電鏡觀察
zhengdasifuyuan.com [PDF]肖傳國， 李兵 - 中華實驗外科雜誌, 2002 - 88889595.zhengdasifuyuan.com
基金項目:國家自然科學基金重點資助項目(39830370) ;國家傑出
青年人才基金資助項目(39925033) 作者單位:430022 武漢,華中科技大學同濟醫學院附屬協和醫院泌
尿外科 ... Light microscope and electron microscope study of nerve regenerated ...
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[PDF] 人工體神經 2 內臟神經反射弧傳出通路神經追蹤研究
zhengdasifuyuan.com [PDF]肖傳國， 李兵 - 中華實驗外科雜誌, 2003 - 88889595.zhengdasifuyuan.com
基金項目:國家自然科學基金重點資助項目(39830370) ;國家傑出 青年人才基金項目(39925033)
作者單位:430022 武漢,華中科技大學同濟醫學院附屬協和醫院泌 尿外科 ... Neural tracing study
of efferent pathway of the artificial somatic2autonomic reflex arc XIAO Chuan2guo ,LI ...
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SKIN-CNS-BLADDER REFLEX ARC FOR MICTURITION AFTER SCI
Chuan-guo Xiao
New York University School Of Medicine New York, Ny 10016
Grant 5R01DK053063-05 from National Institute Of Diabetes And Digestive And Kidney Diseases IRG: ZRG1
Abstract: The neurological bladder caused by spinal cord injury (SCI) presents a significant medical and social problem. There is no satisfactory treatment yet. Supported by the Paralyzed Veterans of America and NIH, a new reflex pathway, "Skin-CNS-Bladder" for controlled micturition after SCI has been successfully established in rat, cat and canine models. Preliminary clinical application of 14 SCI patients also provided very promising results. The study proposed here is to transfer the Skin-CNS-Bladder reflex functions. The ventral root (VR) of a lumbar nerve (L5) below the spinal cord lesion will be anastomosed to the sacral VR (S2 and/or S3) which innervate the bladder, while leaving the intact L5 dorsal root (DR) as a started of micturition. After the axonal regeneration, controllable voiding would be initiated by scratching the L4 dermatome. Effect of the new reflex pathway on bladder function will be evaluated by means of electrophysiology and urodynamics. Its effect on bowel and sexual functions will also be studied. The procedure may revolutionize the treatment of neurogenic bladder after SCI, It requires relatively minor surgery on 2 paralyzed nerves. It does not involve implantation of electrodes or other devices but provides unique voluntary control of bladder emptying. Scientifically, the study will further prove the new concept derived from the unique somatic-autonomic reflex that the impulses delivered from the efferent neurons of a somatic reflex arc may be transferred to initiate response of an autonomic effector. This new concept may be widely useful, not only for neurogenic bladder, but also for other problems caused by the spinal cord injury or diseases.
Keywords: electrophysiology, human therapy evaluation, neurogenic urinary bladder disorder, neuroregulation, neurosurgery, somatic reflex, spinal cord injury, urination, central nervous system, clinical trial, functional ability, outcomes research, quality of life, skin, urinary electronic stimulator, clinical research, human subject
Project start date: 1999-09-30
Project end date: 2007-12-31
5R01DK053063-05 (2004): $642796
附錄2：中樞神經外周神經的定義和神經再生的理論
The peripheral nervous system, or PNS, consists of the nerves and ganglia outside of the brain and the spinal cord.[1] The main function of the PNS is to connect the central nervous system (CNS) to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood-brain barrier, leaving it exposed to toxins and mechanical injuries. The peripheral nervous system is divided into the somatic nervous system and the autonomic nervous system; some textbooks also include sensory systems.[2]
Neuroregeneration in the PNS occurs to a significant degree.[5] Axonal sprouts form at the proximal stump and grow until they enter the distal stump. The growth of the sprouts are governed by chemotactic factors secreted from Schwann cells.
Injury to the peripheral nervous system immediately elicits the migration of phagocytic cells, Schwann cells, and macrophages to the lesion site in order to clear away debris such as damaged tissue. When a nerve axon is severed, the end still attached to the cell body is labeled the proximal segment, while the other end is called the distal segment. After injury, the proximal end swells and experiences some retrograde degeneration, but once the debris is cleared, it begins to sprout axons and the presence of growth cones can be detected. The proximal axons are able to regrow as long as the cell body is intact, and they have made contact with the neurolemmocytes in the endoneurial channel. Human axon growth rates can reach 2 mm/day in small nerves and 5 mm/day in large nerves.[4] The distal segment, however, experiences Wallerian degeneration within hours of the injury; the axons and myelin degenerate, but the endoneurium remains. In the later stages of regeneration the remaining endoneurial tube directs axon growth back to the correct targets. During Wallerian degeneration, Schwann cells grow in ordered columns along the endoneurial tube, creating a band of Bungner (boB) that protects and preserves the endoneurial channel. Also, macrophages and Schwann cells release neurotrophic factors that enhance re-growth.
Unlike peripheral nervous system injury, injury to the central nervous system is not followed by extensive regeneration.
附錄3：美國William Beaumont醫院泌尿外科主任Kenneth M. Peters對肖傳國發現的反射弧手術方法予以綜述
Bladder Reinnervation: Is it Becoming a Reality?
Don Bui, Kevin Feber and Kenneth M. Peters
Abstract
Management of neurogenic voiding dysfunction presents a clinical challenge. Traditional therapies such as clean intermittent catheterization and antimuscarinics have saved countless lives. However, a desire remains to normalize the voiding in patients suffering from spinal cord injuries. Bladder reinnervation is a novel surgical technique that shows promise in helping those with spinal cord-related neurogenic voiding dysfunction. Dr. C. G. Xiao from China was the first to popularize bladder reinnervation through an intradural nerve anastomosis of a lumbar-to-sacral nerve. This concept has gained international attention, and attempts to create other somatic-to-autonomic reflex arcs to assist with voluntary voiding have been studied. In this review, we discuss the current state of the literature in this new field.
Keywords Neurogenic bladder - Nerve transfer - Incontinence - Spina bifida - Spinal cord injury
Current Bladder Dysfunction Reports Volume 5, Number 2, 59-62,
附錄4：Kenneth M. Peters在美國泌尿學雜誌發表論文。報告9名患者的反射弧手術結果：
THE JOURNAL OF UROLOGY, Vol. 184, 702-708, August 2010
Outcomes of Lumbar to Sacral Nerve Rerouting for Spina Bifida
Kenneth M. Petersa, Benjamin Girdlera, Cindy Turzewskia, Gary Trockc, Kevin Febera, William Nantaub, Brian Bushb, Jose Gonzaleza, Evan Kassa, Juan de Benitoa, Ananias Dioknoa
Received 25 November 2009 published online 21 June 2010.
Purpose
Restoring bladder and bowel function in spina bifida by creation of a skin-central nervous system-bladder reflex arc via lumbar to sacral nerve rerouting has a reported success rate of 87% in China. We report 1-year results of the first North American trial on nerve rerouting.
Materials and Methods
Nine subjects were enrolled in the study. Intradural lumbar to sacral nerve rerouting was performed. Subjects underwent urodynamic testing with stimulation of the cutaneous dermatome and careful neurological followup. Adverse events were closely monitored along with changes in bowel and bladder function.
Results
At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle groups at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months.
Conclusions
At 1 year a novel reflex arc with stimulation of the appropriate dermatome was seen in the majority of subjects. Improvements in voiding and bowel function were noted. Lower extremity weakness was mostly self-limited, except in 1 subject with a persistent foot drop. More patients and longer followup are needed to assess the risk/benefit ratio of this novel procedure.
Key Words: nerve transfer, spina bifida cystica, spina bifida occulta, urinary bladder, neurogenic
Abbreviations and Acronyms: DR, dorsal root, EMG, electromyography, VR, ventral root
http://www.jurology.com/article/S0022-5347(10)03053-3/abstract
附錄5：對Kenneth M. Peters論文雜誌編輯的評論和論文作者Peter等的回應
EDITORIAL COMMENTS
The Beaumont Hospital in Michigan is one of the first American institutes that took up clinical trials of the controversial Xiao Procedure. We have previously questioned their clinical outcomes and their misleading propaganda in our Open Letter of Complaint against the Xiao Procedure.
More recently, the hospital has also become the first institute to publish clinical results of Xiao Procedure in an established scientific journal. Dr. Kenneth Peters and his coauthors wrote in the Journal of Urology of their results:
At 1 year 7 patients (78%) had a reproducible increase in bladder pressure with stimulation of the dermatome. Two patients were able to stop catheterization and all safely stopped antimuscarinics. No patient achieved complete urinary continence. The majority of subjects reported improved bowel function. One patient was continent of stool at baseline and 4 were continent at 1 year. Of the patients 89% had variable weakness of lower extremity muscle group at 1 month. One child had persistent foot drop and the remainder returned to baseline by 12 months.
The authors present the first North American experience with lumbar to sacral nerve rerouting for patients with spina bifida. The results from this study and previous animal and clinical studies by Xiao clearly demonstrate that nerve rerouting produces a somatic-autonomic or cutaneous/bladder reflex with stimulation of the lower extremity dermatome. What is also clear is that the clinical benefit of the procedure is not at all similar to previous reports.
Although the authors did an excellent job of following the patients and characterizing their changes, the results are hard to validate without a control population going through the same rigorous surveillance regimen. In particular the improved bowel continence and minimal changes in bladder compliance may not be statistically significant. The fact that most patients were still on clean intermittent catheterization and none achieved complete urinary continence is troubling in light of the report of 87% success with 110 children with spina bifida presented by Xiao. One has to wonder if most of these children are not voiding volitionally or using the newly developed cutaneous reflex, and how much reinnervation has a role in this surgery. Is it possible that unilateral denervation of the S3 ventral motor nerve produced improved compliance and continence, as previously reported in numerous clinical series?
I congratulate the authors for taking on this challenge. I hope this study leads to a rebirth or refocus regarding neurosurgical treatments of neuropathic bowel and bladder. I strongly agree with the authors that this procedure should remain on a research protocol only.
Eric A. Kurzrock
Pediatric Urology
U. C. Davis Children’s Hospital
Sacramento, California
One of the most curious findings is the discrepancy between urodynamic data and subjective voiding. One patient exhibited a decrease in capacity and an absence of reflex arc, and yet he subjectively reported improved bladder and bowel function! I could not help but speculate that his voiding after the procedure could simply be the bladder emptying via intra-abdominal pressure generation against an open bladder neck, given his preoperative stress incontinence. Xiao reported that more than 87% of 110 patients gained sensation and continence within 1 year (reference 7 in article). In comparison, the current patients undergoing the identical procedure with the help of Xiao himself only showed a modest improvement in objective urodynamic studies and subjective reporting. Unless the innovators provide a sound argument and data for the validity of the procedure, there is a great danger of its improper and rapid adaptation by patients and the medical community at large.
John M. Park
Department of Urology
University of Michigan Medical School
Ann Arbor, Michigan
REPLY BY AUTHORS
We agree this is a challenging study on many levels. The intent of publishing these 1-year data was to understand the potential complications associated with lumbar to sacral nerve rerouting, demonstrate that a cutaneous to bladder reflex is achievable and, given the nationwide interest in this procedure, reinforce the need to continue this rigorous research protocol until more is known about the risk-benefit profile. Hopefully our 36-month data will shed more light on the clinical usefulness of this innovative procedure.
附錄6：William Beaumont醫院泌尿外科2009年底得到美國衛生研究所NIH 230萬美元研究基金
http://projectreporter.nih.gov/project_info_description.cfm?aid=7696321
