Duke University School of Medicine, Department of Surgery, Division of Pediatric Urology, USA.
The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
J Pediatr Urol. 2018 Oct;14(5):426.e1-426.e6. doi: 10.1016/j.jpurol.2018.02.025. Epub 2018 Mar 29.
Successful primary closure is one of the main factors for achieving continence in a classic bladder exstrophy (CBE) patient. Even with contemporary management, patients still have failed primary closures. We sought to understand the role of training, surgical technique, and their impacts on outcomes of CBE closure.
A retrospective cohort study from the largest single-institution database of primary and re-closure CBE patients in the world was performed. Failed closure was defined as developing bladder outlet obstruction, wound dehiscence, bladder prolapse, or any need for a re-closure operation. Patient demographics and surgical factors were abstracted and analyzed. Multivariable analysis was performed to test for associations with successful exstrophy closure.
Data from 722 patients were analyzed. On bivariate analysis, successful closure was associated with gestational age at presentation, time of closure, location of closure, credential of surgeon performing the closure, closure type, concomitant osteotomy, and type of immobilization. Multivariable analysis, adjusting for patient comorbidity and location of closure, demonstrated increased odds of failure for closure by pediatric surgeon compared with pediatric urologist (OR 4.32, 95% CI 1.98-9.43; p = 0.0002), closure by unknown credentialed surgeon (OR 1.86, 95% CI 1.15-2.99; p = 0.011), Complete Primary Repair of Exstrophy (CPRE) closure compared with Modern Staged Repair of Exstrophy (OR 2.05, 95% CI 1.29-2.99; p = 0.0024), and unknown closure type (OR 4.81, 95% CI 2.94-7.86; p < 0.0001) (Table).
Many factors associated with failure on bivariate analysis can be explained by these patients presenting to a center of excellence or the selection bias of this cohort stemming from a single center database that have been previously published. However, the finding on adjusted multivariable logistic regression analysis that closure by a pediatric surgeon is associated with higher odds of failure is novel. The additional finding that CPRE closure is associated with failure is most likely secondary to these patients being referred to our institution after having been closed with CPRE which falsely increases its impact on closure failure. Nevertheless, as a center with a large exstrophy volume, this study draws from a cohort that is larger than any other.
Classic bladder exstrophy closure should be performed at a center with pediatric urologists to ensure the best chance of a successful primary closure.
在经典膀胱外翻（CBE）患者中，成功的一期闭合是实现控尿的主要因素之一。即使采用现代管理方法，仍有部分患者的一期闭合失败。我们旨在了解培训、手术技术及其对 CBE 闭合结果的影响。
对来自世界上最大的单一机构原发性和再闭合 CBE 患者数据库的回顾性队列研究进行了分析。闭合失败定义为发生膀胱出口梗阻、伤口裂开、膀胱脱垂或任何需要再次闭合手术的情况。提取并分析了患者的人口统计学和手术因素。采用多变量分析来检验与成功的外生部闭合相关的因素。
对 722 例患者的数据进行了分析。在单变量分析中，成功的闭合与出生时的胎龄、闭合时间、闭合部位、进行闭合手术的医生的资质、闭合类型、伴发的截骨术和固定类型有关。在调整了患者合并症和闭合部位的多变量分析中，与小儿泌尿科医生相比，小儿外科医生进行的闭合术（OR 4.32，95%CI 1.98-9.43；p=0.0002）、未知资质的医生进行的闭合术（OR 1.86，95%CI 1.15-2.99；p=0.011）、完全一期修复外生部（CPRE）与现代分期修复外生部（OR 2.05，95%CI 1.29-2.99；p=0.0024）、以及未知的闭合类型（OR 4.81，95%CI 2.94-7.86；p<0.0001）（表）。
许多与单变量分析中失败相关的因素可以通过以下方式来解释：患者就诊于卓越中心或该队列的选择偏差源自先前发表的单中心数据库。然而，调整后的多变量逻辑回归分析发现，小儿外科医生进行的闭合术与更高的失败几率相关，这是一个新的发现。CPRE 闭合术与失败相关的发现可能是由于这些患者在 CPRE 闭合后转诊至我院，这错误地增加了其对闭合失败的影响。尽管如此，作为一个外生部患者较多的中心，本研究的队列规模大于其他任何研究。
经典膀胱外翻的闭合术应在具有小儿泌尿科医生的中心进行，以确保一期闭合成功的最佳机会。
