Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
J Pediatr Urol. 2020 Dec;16(6):834.e1-834.e7. doi: 10.1016/j.jpurol.2020.09.003. Epub 2020 Sep 10.
With current trends towards delaying the closure of classic bladder exstrophy (CBE), bladder growth rate or ultimate capacity may be impacted.
To examine consecutive bladder capacities in CBE patients who had primary closures at differing ages and determine whether there is an optimal age for closure, with reference to bladder capacity.
A retrospective review was performed using an institutional database.
CBE, successful neonatal (i.e. ≤28 days old) or delayed (i.e. >28 days old) primary closure, at least three consecutive bladder capacities or two measures taken 18 months apart, and first bladder capacity measured ≥3 months after closure. Only capacities prior to continence surgery and before 14 years of age were considered. Two cohorts were created: neonatal and delayed closure. To account for repeated measurements per patient, a linear mixed model evaluated effects of age and length of delay on bladder capacity based on closure cohort. Individuals in the delayed closure group were further stratified into quartiles to assess for detriment to the bladder based on length of delay.
The cohort included 128 neonatal and 38 delayed patients. Median age at closure for the delayed group was 193 days (IQR 128-299). Based on univariate analysis, for the first three capacity measurements, the delayed group had significantly lower capacities despite having a similar median age when the measurements were taken. Linear mixed effects model showed significantly decreased total bladder capacity in delayed closure compared to neonates. The 2nd and 4th quartile groups had the most significant decreases in capacity.
Time points for the most significant decline appear after the 2nd and 4th quartiles, representing 4-6 months and beyond 9 months, respectively. From this, the authors theorize that the appropriate time to close an exstrophy patient is as early as possible (1st quartile), or, if a delay is needed for growth of a bladder template, then between 6 and 9 months (3rd quartile). There may be a detriment to growth rate, however, statistical power may be lacking to discern this. Study limitations include the single-centered, retrospective design. However, results described here fill an important deficit in the knowledge of managing CBE.
All patients in the delayed bladder closure group demonstrated a decline in bladder capacity compared to the control neonatal closure group, with significant differences in the 2nd and 4th quartiles. Thus, closing the bladder prior to nine months of age is recommended.
随着目前延迟经典膀胱外翻（CBE）闭合的趋势，膀胱生长速度或最终容量可能会受到影响。
检查不同年龄接受初次闭合的 CBE 患者的连续膀胱容量，并确定与膀胱容量相关的最佳闭合年龄。
使用机构数据库进行回顾性研究。
CBE、新生儿（即≤28 天）或延迟（即>28 天）初次闭合、至少连续测量 3 次或两次测量相隔 18 个月、且首次测量在闭合后≥3 个月。仅考虑在控尿手术前和 14 岁之前的容量。创建了两个队列：新生儿和延迟闭合。为了考虑每个患者的重复测量，基于闭合队列，线性混合模型评估了年龄和延迟时间对膀胱容量的影响。将延迟闭合组中的个体进一步分层为四分位数，以根据延迟时间评估对膀胱的损害。
该队列包括 128 例新生儿和 38 例延迟患者。延迟组的中位闭合年龄为 193 天（IQR 128-299）。基于单变量分析，在最初的三次容量测量中，尽管测量时的中位年龄相似，但延迟组的容量明显较低。线性混合效应模型显示，与新生儿相比，延迟闭合的总膀胱容量显著降低。第 2 和第 4 四分位组的容量下降最为显著。
容量显著下降的时间点似乎出现在第 2 和第 4 四分位数之后，分别代表 4-6 个月和 9 个月以后。由此，作者推测，尽早关闭膀胱外翻患者（第 1 四分位数）是合适的，或者，如果需要为膀胱模板的生长留出时间，那么在 6 到 9 个月（第 3 四分位数）之间。然而，可能会对生长速度造成损害，但缺乏足够的统计能力来辨别这一点。研究的局限性包括单中心、回顾性设计。然而，这里描述的结果填补了管理 CBE 知识中的一个重要空白。
与对照组新生儿闭合组相比，所有延迟膀胱闭合组的患者的膀胱容量均下降，第 2 和第 4 四分位组的差异具有统计学意义。因此，建议在 9 个月龄之前闭合膀胱。
