Division of Urology, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA.
Scott Department of Urology, Baylor College of Medicine, Houston, Texas, USA.
Neurourol Urodyn. 2021 Mar;40(3):829-839. doi: 10.1002/nau.24629. Epub 2021 Feb 19.
Urologic substudies of prenatal myelomeningocele (MMC) closure have focused primarily on continence without significant clinical benefit. Fetoscopic MMC repair (FMR) is a newer form of prenatal intervention and touts added benefits to the mother, but urological outcomes have yet to be analyzed. We set out to focus on bladder safety rather than continence and examined bladder outcomes with different prenatal MMC repairs (FMR and prenatal open [POMR]) and compared bladder-risk-categorization to traditional postnatal repair (PSTNR).
An IRB-approved retrospective analysis of all patients undergoing all forms of MMC repairs with inclusion and exclusion criteria based on the MOMS trial was performed. Bladder safety assessment required initial urodynamic studies (UDS), renal bladder ultrasound (RBUS), and/or voiding cystourethrogram (VCUG) within the 1st year of life. Follow-up analyses within the cohorts required follow-up studies within 18 months after initial evaluations. Outcomes assessed included bladder-risk-categorization based on the CDC UMPIRE study (high, intermediate, and safe), hydronephrosis (HN), and vesicoureteral reflux (VUR). A single reader evaluated each UDS.
Initial UDS in 93 patients showed that the prevalence of high-risk bladders were 35% FMR versus 36% PSTNR and 60% POMR. Follow-up UDS showed only 8% of FMR were high-risk compared to 35% POMR and 36% PSTNR. Change from initial to follow-up bladder-risk-category did not reach significance (p = .0659); however, 10% PSTNR worsened to high-risk on follow-up, compared to none in either prenatal group. Subanalysis of follow-up UDS between the prenatal cohorts also was not significant (p = .055). Only 8% of FMR worsened or stayed high-risk compared to 35% with POMR (p = .1). HN was significantly different at initial and subsequent follow up between the groups with the least in the FMR group.
Early outcome UDS analyses demonstrated lower incidence of high-risk bladders in FMR patients with a trend toward clinically significant improvement compared to POMR in regard to all evaluated metrics. Larger, prospective, confirmatory studies are needed to further evaluate the potential benefits on FMR on bladder safety and health.
产前脊髓脊膜膨出（MMC）闭合的泌尿科亚研究主要集中在控尿上，但没有显著的临床获益。胎儿镜 MMC 修复（FMR）是一种较新的产前干预形式，对母亲有额外的好处，但泌尿系统的结果尚未进行分析。我们着手关注膀胱安全性，而不是控尿，并检查了不同产前 MMC 修复（FMR 和产前开放[POMR]）的膀胱结果，并将膀胱风险分类与传统的产后修复（PSTNR）进行了比较。
对所有接受 MMC 修复的患者进行了基于 MOMS 试验的纳入和排除标准的回顾性分析。膀胱安全性评估需要在生命的第 1 年内进行初始尿动力学研究（UDS）、肾脏膀胱超声（RBUS）和/或排尿性膀胱尿道造影（VCUG）。在队列内的随访分析需要在初始评估后 18 个月内进行随访研究。评估的结果包括基于 CDC UMPIRE 研究的膀胱风险分类（高、中、安全）、肾积水（HN）和膀胱输尿管反流（VUR）。一位读者评估了每个 UDS。
93 例患者的初始 UDS 显示，高危膀胱的患病率为 35% FMR 与 36% PSTNR 和 60% POMR。随访 UDS 仅显示 8% FMR 为高危，而 35% POMR 和 36% PSTNR 为高危。从初始到随访的膀胱风险分类的变化没有达到统计学意义（p=0.0659）；然而，10% PSTNR 在随访时恶化至高危，而产前组中没有任何组恶化。产前队列之间的随访 UDS 亚分析也没有统计学意义（p=0.055）。只有 8%的 FMR 恶化或仍为高危，而 35%的 POMR 为高危（p=0.1）。HN 在各组之间的初始和后续随访中均有显著差异，FMR 组最少。
早期 UDS 分析显示 FMR 患者高危膀胱的发生率较低，与 POMR 相比，所有评估指标均有改善的趋势。需要更大规模、前瞻性、确证性研究来进一步评估 FMR 对膀胱安全性和健康的潜在益处。
