Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, Maryland MD, USA.
J Pediatr Urol. 2018 Oct;14(5):430.e1-430.e6. doi: 10.1016/j.jpurol.2018.04.025. Epub 2018 Jun 7.
Primary bladder closure of classic bladder exstrophy (CBE) is a major operation that occasionally requires intraoperative or postoperative (within 72 h) blood transfusions.
This study reported perioperative transfusion rates, risk factors for transfusion, and outcomes from a high-volume exstrophy center in primary bladder closure of CBE patients.
A prospectively maintained, institutional exstrophy-epispadias complex database of 1305 patients was reviewed for primary CBE closures performed at the authors' institution (Johns Hopkins Hospital) between 1993 and 2017. Patient and surgical factors were analyzed to determine transfusion rates, risk factors for transfusions, and outcomes. Patients were subdivided into two groups based upon the time of closure: neonatal and delayed closure.
A total of 116 patients had a primary bladder closure during 1993-2017. Seventy-three patients were closed in the neonatal period, and 43 were delayed closures. In total, 64 (55%) patients received perioperative transfusions. No transfusion reactions were observed. Twenty-five transfusions were in the neonatal closure group, yielding a transfusion rate of 34%. In comparison, 39 patients were transfused in the delayed closure group, giving a transfusion rate of 91%. Pelvic osteotomy, delayed bladder closure, higher estimated blood loss (EBL), larger pubic diastasis, and longer operative time were all associated with blood transfusion. In multivariable logistic regression, pelvic osteotomy (OR 5.4; 95% CI 1.3-22.8; P < 0.001), higher EBL-to-weight ratio (OR 1.3; 95% CI 1.1-1.6; P = 0.029), and more recent years of primary closure (OR 1.1; 95% CI 1.0-1.2; P = 0.018) remained independent predictors of receiving a transfusion (Summary Table). No adverse transfusion reactions or complications were observed.
This was the first study from a single high-volume exstrophy center to explore factors that contribute to perioperative blood transfusions. Pelvic osteotomy as a risk factor was unsurprising, as the osteotomy may bleed both during and immediately after closure. However, it is important to use osteotomy for successful closure, despite the increased transfusion risk. The risks accompanying contemporary transfusions are minimal and osteotomies are imperative for successful bladder closure.
More than half of CBE patients undergoing primary closure at a single institution received perioperative blood transfusions. While there was an association between transfusions and osteotomy, delayed primary closure, larger diastasis, increased operative time, and increased length of stay, only the use of pelvic osteotomy, higher EBL-to-weight ratio, and recent year of closure independently increased the odds of receiving a transfusion on multivariate analysis.
经典膀胱外翻（CBE）的初次膀胱关闭术是一项重大手术，偶尔需要术中或术后（72 小时内）输血。
本研究报告了高容量膀胱外翻中心在初次 CBE 关闭术中的围手术期输血率、输血的危险因素和结果。
对作者所在机构（约翰霍普金斯医院） 1993 年至 2017 年间进行的 1305 例初次 CBE 关闭患者的前瞻性维护机构性膀胱外翻-尿道上裂复合数据库进行了回顾性分析。分析患者和手术因素，以确定输血率、输血的危险因素和结果。根据关闭时间将患者分为两组：新生儿期和延迟关闭。
共有 116 例患者在 1993-2017 年期间进行了初次膀胱关闭术。73 例患者在新生儿期关闭，43 例患者延迟关闭。共有 64 例（55%）患者接受了围手术期输血。未观察到输血反应。在新生儿关闭组中，有 25 例输血，输血率为 34%。相比之下，在延迟关闭组中有 39 例患者接受了输血，输血率为 91%。骨盆截骨术、延迟膀胱关闭术、更高的估计失血量（EBL）、更大的耻骨分离和更长的手术时间均与输血有关。在多变量逻辑回归中，骨盆截骨术（OR 5.4；95%CI 1.3-22.8；P<0.001）、更高的 EBL-体重比（OR 1.3；95%CI 1.1-1.6；P=0.029）和最近的初次关闭年份（OR 1.1；95%CI 1.0-1.2；P=0.018）仍然是接受输血的独立预测因素（总结表）。未观察到不良输血反应或并发症。
这是来自单一高容量膀胱外翻中心的第一项研究，探讨了导致围手术期输血的因素。骨盆截骨术作为一个危险因素并不奇怪，因为截骨术可能在关闭过程中和关闭后立即出血。然而，尽管输血风险增加，但使用截骨术进行成功的关闭仍然很重要。当代输血的风险很小，截骨术对于成功的膀胱关闭是必不可少的。
在单一机构接受初次膀胱关闭术的 CBE 患者中，超过一半的患者接受了围手术期输血。虽然输血与截骨术、延迟初次关闭、更大的耻骨分离、手术时间延长和住院时间延长之间存在关联，但只有骨盆截骨术、更高的 EBL-体重比和最近的年份使用独立增加了多变量分析中接受输血的可能性。
