背景:失禁儿童神经源性膀胱(NB)患者面临社会排斥和潜在的肾脏恶化。重建手术,经过最大限度的药物治疗,需要一个艰难的决策过程。目前关于NB手术的文献很难解释给定的干燥定义,使用扩大膀胱成形术(AC)和缺乏肾脏保存。本研究评估了治疗失禁NB患者的手术方案的结果。使用新的综合结果衡量标准,其中包括上束状态和干燥的定义。
方法:这是一项回顾性队列研究,评估了在2008年至2021年期间接受2项手术之一的33例连续失禁NB患者(脊柱裂31,骶骨-2)。在逼尿肌漏点压力(DLPP)高且膀胱小梁严重的患者中进行了Mitrofanoff手术(MP)的AC(N=21,第1组)。低DLPP和非小梁膀胱的儿童,接受改良的Young-Dees-Leadbetter/Mitchell手术,采用360°自体直肌筋膜吊带(BOP),并伴随AC和MP(N-12,第2组)。使用评估干燥度的综合成功分级来定义术后成功。上消化道稳定性和药物使用。
结果:手术时的平均年龄为11.6岁(SD=6岁),第1组21人,第2组12人。平均随访3.25年,至少24个月的随访期。第1组的成功率为90%,第2组的成功率为66%。手术后没有患者出现上尿路恶化。重做手术干预,1组38%和2组50%的患者需要。这些包括第1组中的3次膀胱颈注射和第2组中的2次膀胱颈闭合,最终成功率在第1组中达到95%,在第2组中达到83%。
结论:在失禁NB患者中实现干燥和保留上束是一个挑战。这项研究中获得的干燥率是可比的,给予并发症和重做手术。原发性膀胱颈闭合是一种根治性干预措施,但第二组病人,可能会受益于对膀胱颈闭合的利弊的前期讨论,主要是或作为次要程序。
结论:孤立的AC对于一组有明显膀胱小梁的失禁NB患者获得了可接受的结果。对于那些需要防喷器的人,成功率相对较低,潜在并发症发生率较高,需要进行重做手术.
BACKGROUND: Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness.
METHODS: This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N = 21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use.
RESULTS: The mean age at surgery was 11.6 years (SD = 6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2.
CONCLUSIONS: Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure.
CONCLUSIONS: Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.