Ege University Department of Pediatric Surgery Division of Pediatric Urology, Turkey.
Yale School of Medicine - Department of Urology, USA.
J Pediatr Urol. 2022 Jun;18(3):325.e1-325.e9. doi: 10.1016/j.jpurol.2022.02.012. Epub 2022 Feb 19.
The management of neurogenic bladder mostly relies on urodynamic studies; however, several studies have shown low interobserver reproducibility. The aim of this study was to evaluate if a new objective cystometric parameter was superior to other cystometric measures.
A new parameter (pressure adjusted area under curve ratio, PAUC) was formulated from the ratio of area under the cystometry curve to a DLPP-adjusted total area (A). A was figured from a rectangle designed on the cystometrogram curve with a fixed height of 200 cmHO and a width defined by the filling phase (figure). Two different estimated pressure measures derived from this (upper mean static pressure, UMSP and theoretical end filling pressure TEFP) were then calculated. Medical records of myelomeningocele patients with ultrasonography and renal scintigraphy performed at the time of urodynamics (with an interval of >5 years) were reviewed. Hydronephrosis and new scars in scintigraphy were used as the outcome measures.
The study group consisted of 115 subjects with a median age of 4 (0-23) years at the time of the first urodynamic study. The median follow-up was 6 (5-14) years. PAUC and its derivatives (UMSP and TEFP) had the best discriminative power in predicting high grade hydronephrosis (0.830, 95% CI:0.732-0.927, p < 0.001), worsening in hydronephrosis (0.827, 95% CI:0.723-0.931, p < 0.001), and new scar formation (0.704, 95% CI: 0.576-0.832, p = 0.002). PAUC>0.1 significantly correlated with urinary tract dilatation (p < 0.001) and new scar formation (p = 0.002). In the multivariate analysis, our three parameters and having scars at admission were the only independent risk factors for new scars (p = 0.001 and p = 0.002, respectively) and worsening in hydronephrosis (p < 0.001 and p = 0.001, respectively).
Our results show that our three parameters derived from area under the urodynamic curve are more reliable than other urodynamic measures. Their major theoretical advantage is to incorporate all the pressure during filling phase giving a more accurate picture of what the intravesical pressure milleu is. Using these measures, we demonstrated their superiority in predicting clinical outcomes. Major limitations of this study are the retrospectively collected data and lack of longitudinal follow-up starting from infancy in each patient.
Our new parameters (PAUC, UMSP and TEFP) which incorporate the impact of entire filling phase pressure changes in the analysis, may be useful tools to identify those patients who are under the risk of kidney damage with neurogenic lower urinary tract dysfunction.
神经原性膀胱的管理主要依赖于尿动力学研究；然而，多项研究表明，其观察者间的可重复性较低。本研究旨在评估新的客观膀胱测压参数是否优于其他膀胱测压指标。
从膀胱测压曲线下面积与压力调节后的总面积(A)之比中得出一个新的参数(压力调整后的曲线下面积比，PAUC)。A 通过在膀胱测压图上设计一个高度为 200cmHO 的矩形并根据充盈相来定义宽度(图)计算得出。然后，从这个矩形中计算出两个不同的估计压力值(上平均静水压，UMSP 和理论充盈期末压，TEFP)。对行尿动力学检查时同时进行超声和肾闪烁显像的脊髓脊膜膨出患者的病历进行了回顾。肾积水和闪烁显像中的新疤痕用作结局指标。
研究组包括 115 名中位年龄为 4 岁(0-23 岁)的患者，他们在第一次尿动力学检查时接受了检查。中位随访时间为 6 年(5-14 年)。PAUC 及其衍生物(UMSP 和 TEFP)在预测高级别肾积水(0.830，95%CI：0.732-0.927，p<0.001)、肾积水恶化(0.827，95%CI：0.723-0.931，p<0.001)和新疤痕形成(0.704，95%CI：0.576-0.832，p=0.002)方面具有最佳的鉴别能力。PAUC>0.1 与尿路扩张(p<0.001)和新疤痕形成(p=0.002)显著相关。在多变量分析中，我们的三个参数和入院时的疤痕是新疤痕形成(p=0.001 和 p=0.002)和肾积水恶化(p<0.001 和 p=0.001)的唯一独立危险因素。
我们的结果表明，我们从膀胱测压曲线下面积中得出的三个参数比其他膀胱测压指标更可靠。它们的主要理论优势是将充盈相期间的所有压力都纳入其中，从而更准确地描述膀胱内压力环境。使用这些参数，我们证明了它们在预测临床结局方面的优越性。本研究的主要局限性是数据是回顾性收集的，并且缺乏对每个患者从婴儿期开始的纵向随访。
我们的新参数(PAUC、UMSP 和 TEFP)纳入了分析中整个充盈相压力变化的影响，可能是识别那些有神经原性下尿路功能障碍相关肾损伤风险的患者的有用工具。
