Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
Department of Urology, University of Texas Southwestern, Dallas, TX, USA.
J Pediatr Urol. 2018 Aug;14(4):319.e1-319.e7. doi: 10.1016/j.jpurol.2018.05.023. Epub 2018 Jun 27.
Baseline and interval dimercaptosuccinic acid (DMSA) scans and urodynamic (UD) studies are often obtained in infants and young children with spinal dysraphism (SD).
To identify practical UD parameters which accurately stratify urologic risk young children with SD.
130 expectantly managed infants/young children with SD and initial DMSA and UD before age 2 were reviewed. End fill pressure (EFP), bladder trabeculations, vesicoureteral reflux (VUR), initial volume (IV) drained at UD catheter placement, and detrusor pressure at initial volume (DPIV) were evaluated for association with subsequent febrile urinary tract infection (UTI), DMSA abnormalities, and early clean intermittent catheterization (CIC). A combination of factors to accurately stratify risk was sought. Groups were compared by log-rank test. The association of CIC and febrile UTI incidence was evaluated.
31/130 patients developed DMSA abnormalities, 52/130 started early CIC, and 61/130 developed a febrile UTI with median follow-up of 3.8 years. Trabeculations, VUR, EFP ≥40 cm HO, IV ≥50% estimated bladder capacity (EBC), and DPIV >10 cm HO were associated with subsequent abnormal DMSA scan (p < 0.001). The best predictor was combination of trabeculation and/or VUR (p < 0.001) (Figure). Among patients who maintained a non-trabeculated bladder without VUR during follow-up, 0/51 developed DMSA abnormalities compared with 31/79 who developed one or both (p < 0.001). Patients with trabeculations and/or VUR were more likely to start early CIC (8/51 vs. 44/79; p < 0.001) and have febrile UTI (11/51 vs. 50/79; p < 0.001). In those with trabeculations, CIC was associated with decreased incidence of febrile UTI (incidence rate ratio (IRR) 0.5, 95% CI 0.3-0.9); in those without trabeculations, CIC was associated with increased incidence of febrile UTI (IRR 1.8, 95% CI 1.1-3.1).
VUR, bladder trabeculations, EFP ≥40 cm H0, IV ≥50% of EBC, and DPIV >10 cm HO were associated with subsequent DMSA abnormalities in young children with SD managed expectantly. Many of these parameters were associated with febrile UTI and early CIC. The combination of trabeculations and/or VUR outperformed other UD parameters in identifying those high and low-risk for adverse urologic outcomes. Routine DMSA scan may have limited utility in patients with a non-trabeculated bladder without VUR, as none developed an abnormal DMSA. Most (71%) abnormal DMSAs were in patients with trabeculations and/or VUR following a febrile UTI. Given these findings and that incidence of febrile UTI may be lower in those with trabeculations while on CIC, patients with trabeculations and/or VUR should be managed aggressively to protect kidneys.
基线和间隔性二巯丁二酸（DMSA）扫描和尿动力学（UD）研究通常在患有脊柱裂（SD）的婴儿和幼儿中进行。
确定准确分层有泌尿风险的年轻脊柱裂儿童的实用 UD 参数。
回顾了 130 名接受期望管理的患有脊柱裂的婴儿/幼儿，他们在 2 岁之前进行了初始 DMSA 和 UD，并在 UD 导管放置时评估了终末充盈压（EFP）、膀胱小梁、膀胱输尿管反流（VUR）、初始容量（IV）、初始容量时的逼尿肌压（DPIV），以评估其与随后的发热性尿路感染（UTI）、DMSA 异常和早期间歇性导尿（CIC）的关系。寻找准确分层风险的因素组合。通过对数秩检验比较组间差异。评估 CIC 和发热性 UTI 发生率的相关性。
31/130 例患者出现 DMSA 异常，52/130 例患者早期开始 CIC，61/130 例患者发生发热性 UTI，中位随访时间为 3.8 年。小梁、VUR、EFP≥40cm H2O、IV≥50%估计膀胱容量（EBC）和 DPIV＞10cm H2O 与随后的异常 DMSA 扫描相关（p＜0.001）。最佳预测因素是小梁和/或 VUR 的组合（p＜0.001）（图）。在随访期间保持无小梁且无 VUR 的膀胱的患者中，0/51 例患者出现 DMSA 异常，而 31/79 例患者出现一种或多种异常（p＜0.001）。有小梁和/或 VUR 的患者更可能早期开始 CIC（8/51 例比 44/79 例；p＜0.001），并且更易发生发热性 UTI（11/51 例比 50/79 例；p＜0.001）。在有小梁的患者中，CIC 与发热性 UTI 发生率降低相关（发病率比（IRR）0.5，95%CI 0.3-0.9）；在无小梁的患者中，CIC 与发热性 UTI 发生率增加相关（IRR 1.8，95%CI 1.1-3.1）。
在接受期望管理的脊柱裂幼儿中，VUR、膀胱小梁、EFP≥40cm H2O、IV≥50%EBC 和 DPIV＞10cm H2O 与随后的 DMSA 异常相关。这些参数中有许多与发热性 UTI 和早期 CIC 相关。小梁和/或 VUR 的组合在识别具有不良泌尿结局高风险和低风险的患者方面优于其他 UD 参数。在无小梁和 VUR 的患者中，常规 DMSA 扫描可能没有太大的作用，因为这些患者无一例出现异常的 DMSA。大多数（71%）异常 DMSA 出现在有小梁和/或 VUR 的患者中，这些患者发生了发热性 UTI。鉴于这些发现，以及在进行 CIC 治疗时小梁患者的发热性 UTI 发生率可能较低，因此应积极治疗有小梁和/或 VUR 的患者，以保护肾脏。
