Alpert Seth A, Cheng Earl Y, Kaplan William E, Snodgrass Warren T, Wilcox Duncan T, Kropp Bradley P
Division of Pediatric Urology, Children's Memorial Hospital, Chicago, Illinois 60614, USA.
J Urol. 2005 Oct;174(4 Pt 2):1687-89; discussion 1689-90. doi: 10.1097/01.ju.0000176621.99922.35.
The major goals of complete primary repair of exstrophy (CPRE) are the re-creation of normal anatomy which allows bladder cycling and to reduce the number of future procedures necessary to achieve continence. It is unclear whether CPRE is associated with a higher bladder neck fistula rate than the traditional staged repair. We review a multi-institutional experience with the CPRE technique to evaluate the rate of bladder neck fistula.
A retrospective review of 18 boys and 4 girls who underwent CPRE at 4 tertiary pediatric urology referral centers during the last 6 years was performed. All pertinent technical aspects were reviewed, including timing of procedure, whether osteotomies were performed, and number of layers used to reconstruct the bladder neck and urethra. Complications were noted, especially that of bladder neck fistula.
Mean followup was 22.6 months. Of the patients 14 (64%) underwent primary closure within the first 48 hours of life and only 1 required osteotomies. The remaining 8 patients underwent closure between 5 days and 3 months of age (mean 24.6 days) and all required osteotomies. Bladder neck fistula occurred postoperatively at the pubic junction in 9 males (41%). Four cases had a 2 layer closure that was covered with a single layer small intestinal submucosa onlay (Surgisis) and no patient had a fistula. Fistulas developed in 62.5% of patients with delayed closure vs 29% of those with immediate closure (p = 0.135). Two fistulas closed spontaneously and 7 required surgical closure at a mean of 7.5 months after the fistula occurred.
This multi-institutional study demonstrates that bladder neck fistulas occur in almost half of patients following CPRE by experienced pediatric urologists. While spontaneous closure is possible, most will eventually require repair. The long-term implications of this finding with regard to continence and the need for additional bladder neck procedures remain to be seen. We are encouraged by the preliminary results of small intestinal submucosa coverage and will continue to evaluate its use at the time of primary exstrophy closure.
完全性膀胱外翻一期修复术（CPRE）的主要目标是重建正常解剖结构，实现膀胱周期性排尿，并减少未来为实现控尿所需的手术次数。目前尚不清楚CPRE与传统分期修复相比，膀胱颈瘘发生率是否更高。我们回顾了多机构应用CPRE技术的经验，以评估膀胱颈瘘的发生率。
对过去6年在4家三级儿科泌尿外科转诊中心接受CPRE的18名男孩和4名女孩进行回顾性研究。回顾了所有相关技术细节，包括手术时机、是否进行截骨术以及重建膀胱颈和尿道所用的层数。记录并发症情况，尤其是膀胱颈瘘。
平均随访22.6个月。14例（64%）患者在出生后48小时内接受一期闭合，仅1例需要截骨术。其余8例患者在出生后5天至3个月（平均24.6天）接受闭合，均需要截骨术。9例男性（41%）术后在耻骨联合处发生膀胱颈瘘。4例采用两层闭合，并用单层小肠黏膜下层覆盖物（Surgisis）覆盖，无一例发生瘘。延迟闭合患者中62.5%发生瘘，而立即闭合患者中为29%（p = 0.135）。2例瘘自行闭合，7例在瘘发生后平均7.5个月需要手术闭合。
这项多机构研究表明，经验丰富的儿科泌尿外科医生进行CPRE后，几乎一半的患者会发生膀胱颈瘘。虽然有可能自行闭合，但大多数最终仍需要修复。这一发现对控尿的长期影响以及是否需要额外的膀胱颈手术仍有待观察。小肠黏膜下层覆盖的初步结果让我们受到鼓舞，我们将继续评估其在膀胱外翻一期闭合时的应用。
