Godley Shelley P, Sturm Renea M, Durbin-Johnson Blythe, Kurzrock Eric A
Department of Urology, University of California Davis, Sacramento, CA, USA.
Division of Biostatistics, University of California Davis, Davis, CA, USA.
J Pediatr Urol. 2015 Feb;11(1):38.e1-6. doi: 10.1016/j.jpurol.2014.09.006. Epub 2015 Feb 4.
The literature on treatment of meatal stenosis is limited to single center series. Controversy exists regarding choice of meatotomy versus meatoplasty and need for general anesthesia. Our objective was to analyze treatment efficacy, current practice patterns and utilization of anesthesia. We hypothesized that meatoplasty would be associated with a lower re-operative rate.
We used a hospital consortium database to identify children who were diagnosed with meatal stenosis between January 1, 2009 and December 31, 2012. Both univariate and multivariate analyses were completed to evaluate correlations between patient, surgeon and hospital characteristics and type of procedure. The propensity of surgeons to operate with or without general anesthesia was analyzed.
We identified 4373 male patients with a diagnosis of meatal stenosis treated by 123 surgeons. Fifty-percent of boys had procedural intervention during the 4-year period. Median follow-up was 25 and 22 months after meatotomy and meatoplasty, respectively. There was a re-operative rate of 3.5% and 0.2% for office meatotomy versus meatoplasty with general anesthesia. Multivariate analysis demonstrated that being White and living in the Northeast independently increased odds of intervention. Half of the surgeons treated meatal stenosis exclusively under general anesthesia.
This study is limited by an inability to determine recurrence rates. Only patients having secondary surgery at the same institution within the time period captured by the database (6 months-4 years) could be identified. As such, the true recurrence of meatal stenosis is likely higher. Although the re-operative rate is not equivalent to the recurrence rate, the two are correlated. Likewise, the surgeon's propensity to operate could be biased by their propensity to diagnosis meatal stenosis and this could affect the rates cited. In addition to the cost benefit achieved with avoidance of general anesthesia (estimated to be a 10-fold cost reduction, the 2012 Consensus Statement of the International Anesthesia Research Society has highlighted that there is increasing evidence from research studies suggesting the benefits of general anesthesia should be considered in the context of its possible harmful effects. Although this study and others have highlighted that in-office procedures are a viable alternative to meatoplasty with general anesthesia, there are multiple factors in being able to perform an office meatotomy. Arguably, the two most important are the patient's ability to cooperate and his anatomy.
The large sample size, over 4000 patients, allowed us to show that the hypothesis, that meatoplasty would be associated with a lower re-operative rate (0.2%), is true. With a low re-operative rate (3.5%), office meatotomy is a reasonable choice of surgical treatment if the child can cooperate and the anatomy is appropriate. On the other hand, if general anesthesia is utilized, formal meatoplasty is associated with a lower re-operative rate.
关于尿道口狭窄治疗的文献仅限于单中心研究系列。在尿道口切开术与尿道口成形术的选择以及全身麻醉的必要性方面存在争议。我们的目的是分析治疗效果、当前的实践模式以及麻醉的使用情况。我们假设尿道口成形术与较低的再次手术率相关。
我们使用了一个医院联盟数据库来识别在2009年1月1日至2012年12月31日期间被诊断为尿道口狭窄的儿童。完成了单变量和多变量分析，以评估患者、外科医生和医院特征与手术类型之间的相关性。分析了外科医生在有或没有全身麻醉情况下进行手术的倾向。
我们识别出4373例被诊断为尿道口狭窄的男性患者，由123位外科医生进行治疗。在这4年期间，50%的男孩接受了手术干预。尿道口切开术和尿道口成形术后的中位随访时间分别为25个月和22个月。门诊尿道口切开术与全身麻醉下尿道口成形术的再次手术率分别为3.5%和0.2%。多变量分析表明，白人以及居住在东北部独立增加了干预的几率。一半的外科医生仅在全身麻醉下治疗尿道口狭窄。
本研究的局限性在于无法确定复发率。只能识别在数据库所涵盖的时间段内（6个月至4年）在同一机构进行二次手术的患者。因此，尿道口狭窄的真正复发率可能更高。虽然再次手术率不等于复发率，但两者相关。同样，外科医生的手术倾向可能因其诊断尿道口狭窄的倾向而存在偏差，这可能会影响所引用的比率。除了避免全身麻醉所带来的成本效益（估计成本降低10倍）外，国际麻醉研究学会2012年的共识声明强调，越来越多的研究证据表明，在考虑全身麻醉可能的有害影响的背景下，应权衡其益处。虽然本研究和其他研究强调门诊手术是全身麻醉下尿道口成形术的可行替代方案，但能够进行门诊尿道口切开术有多个因素。可以说，两个最重要的因素是患者的配合能力和其解剖结构。
超过4000例患者的大样本量使我们能够证明，尿道口成形术与较低的再次手术率（0.2%）相关这一假设是正确的。如果儿童能够配合且解剖结构合适，门诊尿道口切开术的再次手术率较低（3.5%），是一种合理的手术治疗选择。另一方面，如果使用全身麻醉，正规的尿道口成形术与较低的再次手术率相关。
