B.J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India.
Gandhi Medical College, Bhopal, India.
JAMA Surg. 2018 Jul 1;153(7):618-624. doi: 10.1001/jamasurg.2018.0067.
International collaboration to alleviate the massive burden of surgical disease is recognized by World Health Organization as an urgent need, yet the surgical mission model to treat reconstructive surgical challenges is often constrained in ensuring adequate patient follow-up, optimal outcomes, and sustainability.
To determine whether a collaboration predicated on long-term commitment by surgeons returning to the same institution annually combined with an experienced host surgical team and infrastructure to ensure sustained patient follow-up could provide surgical care with acceptable outcomes to treat bladder exstrophy-epispadias complex (BE) and penopubic epispadias (PE).
DESIGN, SETTING, AND PARTICIPANTS: In this prospective, observational study, long-term collaboration was created and based at a public hospital in Ahmedabad, India, between January 2009 and January 2015. The entire postoperative cohort was recalled in January 2016 for comprehensive examination, measurement of continence outcomes, and assessment of surgical complications. Seventy-six percent of patients (n = 57) who underwent complete primary repair of exstrophy during the study interval returned for annual follow-up in 2016 and formed the study cohort: 23 patients with primary BE, 19 patients with redo BE, and 11 patients with PE repair.
Demographics, operative techniques, and perioperative complications were recorded. A postoperative protocol outlining procedures to ensure monitoring of study participants was followed including removal of ureteral stents, urethral catheter, external fixators, imaging, and patient discharge.
Of the 57 patients, 4 were excluded because they underwent ureterosigmoidostomy. Median age at time of surgery was 3 years (primary BE), 7 years (redo BE), and 10 years (PE), with median follow-up of 3 years, 5 years and 3 years, respectively; boys made up more than 70% of each cohort (n = 17 for primary BE, n = 15 for redo BE, and n = 9 for PE). All BE and 3 PE repairs (27%) were completed with concurrent anterior pubic osteotomies. Seventeen of 53 patients (32%) experienced complications. Only 1 patient with BE (4%) had a bladder dehiscence and was repaired the following year.
A unique surgical mission model consisting of an international collaborative focused on treating the complex diagnoses of BE and PE offers outcomes comparable with those in high-income countries, demonstrating a significant patient retention rate and an opportunity to rigorously study outcomes over an accelerated interval owing to the high burden of disease in India. Postoperative care following a systematized algorithm and rigorous follow-up is mandatory to ensure safety and optimal outcomes.
世界卫生组织认识到，国际合作以减轻外科疾病的巨大负担是当务之急，但治疗重建外科挑战的外科任务模式往往难以确保充分的患者随访、最佳结果和可持续性。
确定是否可以通过外科医生每年返回同一机构的长期承诺、有经验的宿主外科团队和基础设施来确保持续的患者随访来提供可接受的结果来治疗膀胱外翻-尿道上裂（BE）和阴茎耻骨上尿道上裂（PE）。
设计、地点和参与者：在这项前瞻性观察研究中，于 2009 年 1 月至 2015 年 1 月在印度艾哈迈达巴德的一家公立医院建立并开展了长期合作。2016 年 1 月，整个术后队列被召回进行全面检查、评估控尿结果和评估手术并发症。在研究期间接受完全初次修复的 76%（n=57）的患者在 2016 年接受了年度随访，并形成了研究队列：23 例原发性 BE、19 例再发性 BE 和 11 例 PE 修复。
记录了人口统计学、手术技术和围手术期并发症。遵循了一项术后方案，概述了确保研究参与者监测的程序，包括输尿管支架、尿道导管、外部固定器、影像学和患者出院的去除。
57 名患者中有 4 名因接受输尿管乙状结肠吻合术而被排除在外。初次手术时的中位年龄分别为 3 岁（原发性 BE）、7 岁（再发性 BE）和 10 岁（PE），中位随访时间分别为 3 年、5 年和 3 年；每个队列的男孩比例均超过 70%（原发性 BE 组 17 例，再发性 BE 组 15 例，PE 组 9 例）。所有 BE 和 3 例 PE 修复（27%）均完成了同期耻骨前截骨术。53 例患者中有 17 例（32%）出现并发症。只有 1 例 BE 患者（4%）膀胱裂开，次年修复。
由专注于治疗 BE 和 PE 复杂诊断的国际合作组成的独特外科任务模式提供的结果与高收入国家相当，表明由于印度疾病负担沉重，患者保留率高，并有机会在加速的时间内严格研究结果。需要遵循系统化算法和严格随访的术后护理，以确保安全和最佳结果。
