Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
J Urol. 2017 Apr;197(4):1138-1143. doi: 10.1016/j.juro.2016.09.114. Epub 2016 Oct 5.
Successful primary bladder exstrophy closure provides the best opportunity for patients to achieve a functional closure and urinary continence regardless of the method of repair. Use of osteotomy during initial closure has significantly improved success rates. However, failures can still occur. We identify factors that contribute to a failed primary exstrophy closure with osteotomy.
We reviewed a prospectively maintained institutional database for classic bladder exstrophy cases primarily closed with osteotomy at our institution or referred after primary closure between 1990 and 2015. Data were collected regarding patient gender, closure, osteotomy, immobilization, orthopedics and perioperative pain control. Univariate and multivariable analyses were performed to determine predictors of failure.
A total of 156 patients met inclusion criteria. Overall failure rate was 30% (13% from our institution and 87% from referrals). On multivariable analysis use of Buck traction (OR 0.11, 95% CI 0.02-0.60, p = 0.011) and immobilization time greater than 4 weeks (OR 0.19, 95% CI 0.04-0.86, p = 0.031) had significantly lower odds of failure. Osteotomy performed by general orthopedic surgeons had significantly higher odds of failure (OR 23.47, 95% CI 1.45-379.19, p = 0.027). Type of osteotomy and use of epidural anesthesia did not significantly impact failure rates.
Proper immobilization with modified Buck traction and external fixation, immobilization time greater than 4 weeks and undergoing osteotomy performed by a pediatric orthopedic surgeon are crucial factors for successful primary closure with osteotomy.
无论采用何种修复方法，成功的初次膀胱外翻修复术都为患者实现功能性关闭和尿控提供了最佳机会。初次关闭时使用截骨术显著提高了成功率。然而，失败仍有可能发生。我们确定了导致初次使用截骨术的膀胱外翻修复失败的因素。
我们回顾了一个前瞻性维护的机构数据库，其中包括 1990 年至 2015 年期间在我们机构进行初次使用截骨术关闭的经典膀胱外翻病例，或在初次关闭后转诊的病例。收集了患者性别、关闭、截骨术、固定、矫形和围手术期疼痛控制等数据。进行了单变量和多变量分析，以确定失败的预测因素。
共有 156 名患者符合纳入标准。总体失败率为 30%（我们机构为 13%，转诊患者为 87%）。多变量分析显示，使用 Buck 牵引（OR 0.11，95%CI 0.02-0.60，p = 0.011）和固定时间超过 4 周（OR 0.19，95%CI 0.04-0.86，p = 0.031）的患者失败的可能性显著降低。由普通矫形外科医生进行的截骨术失败的可能性显著增加（OR 23.47，95%CI 1.45-379.19，p = 0.027）。截骨术的类型和硬膜外麻醉的使用并未显著影响失败率。
使用改良 Buck 牵引和外固定进行适当的固定、固定时间超过 4 周以及由儿科矫形外科医生进行截骨术是初次使用截骨术成功修复的关键因素。
