Department of Surgery, Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.
Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
Neurourol Urodyn. 2022 Aug;41(6):1406-1413. doi: 10.1002/nau.24962. Epub 2022 Jun 7.
Deferring bladder augmentation (BA) may be desirable in a pediatric neurogenic bladder (NGB) with worsening compliance, but prior studies have questioned whether onabotulinum toxin A (BTX) demonstrates durable improvement in compliance. We present our overall experience with BTX and its role in mitigating the "at-risk" NGB, as determined by urodynamic characteristics.
A retrospective single-institution review of all BTX procedures performed during January 2010 to October 2018 was conducted. Patients with <12 months follow-up after first BTX injection were excluded. Urodynamic studies (UDS) were reviewed to assign National Spina Bifida Patient Registry (NSBPR) as well as institutionally developed (LCH) risk classification groups. Patients were considered "at-risk" for BA if they had any of the following: NSBPR risk grade of intermediate or hostile; LCH risk grades indicating end-fill pressure >25 cmH O or detrusor sphincter dyssynergia (DSD); upper tract changes including new hydronephrosis; new or worsening vesicoureteral reflux; or other signs of a hostile urinary tract (i.e., febrile UTIs). UDS risk grades pre and post-first BTX injection were compared in this "at-risk" group, when available.
Thirty-nine patients underwent 162 injection procedures over a median follow-up of 65 months interquartile range (IQR 49-81). Median age at first BTX was 10 years and the median number of BTX injections per patient was 4 (IQR 2-7; range 1-12) with a median time of 6 months between injections (IQR 4-10). Twenty-six patients were deemed "at-risk" at the time of first BTX injection, and of those, 16 (61.5%) proceeded to BA at a median of 36 months (IQR 22.5-42). A small number (four) had BA due to upper tract changes or worsening pressures on BTX, while nine patients (five with CKD) proceeded to BA given a lack of sufficient improvement to consider BTX a long-term viable option. Post-first BTX UDS demonstrated downgrading of risk group in 38% and 63% using NSBPR and LCH classifications, respectively.
Encouraging improvements in the urodynamic risk group were noted in some patients. With careful counseling and follow-up, BTX may safely extend the time to BA in some "at-risk" patients.
对于伴有顺应性恶化的小儿神经源性膀胱（NGB），延迟膀胱扩大术（BA）可能是可取的，但先前的研究质疑肉毒毒素 A（BTX）是否能在顺应性方面表现出持久的改善。我们介绍了我们在 BTX 方面的整体经验及其在确定为“有风险”的 NGB 时的作用，这是根据尿动力学特征确定的。
对 2010 年 1 月至 2018 年 10 月期间进行的所有 BTX 手术进行了回顾性单机构审查。将首次 BTX 注射后随访时间<12 个月的患者排除在外。回顾尿动力学研究（UDS）以分配国家脊髓脊膜膨出患者登记处（NSBPR）以及机构制定的（LCH）风险分类组。如果患者有以下任何一种情况，则被认为有 BA 的风险：NSBPR 风险等级为中危或高危；LCH 风险等级表示充盈期末压>25cmH 2 O 或逼尿肌括约肌协同失调（DSD）；上尿路改变，包括新发肾积水；新出现或恶化的膀胱输尿管反流；或其他有敌意的尿路迹象（即发热性尿路感染）。在“有风险”组中，当可获得时，比较了首次 BTX 注射前后的 UDS 风险等级。
39 例患者接受了 162 次注射治疗，中位随访时间为 65 个月（四分位距 49-81）。首次 BTX 的中位年龄为 10 岁，每位患者的 BTX 注射中位数为 4 次（四分位距 2-7；范围 1-12），两次注射之间的中位时间为 6 个月（四分位距 4-10）。26 例患者在首次 BTX 时被认为“有风险”，其中 16 例（61.5%）在中位 36 个月（四分位距 22.5-42）时进行了 BA。少数（4 例）由于上尿路改变或 BTX 压力升高而进行了 BA，而 9 例（5 例患有 CKD）由于 BTX 未能充分改善而考虑 BA，认为 BTX 是一种长期可行的选择。首次 BTX 后 UDS 显示，分别使用 NSBPR 和 LCH 分类，风险组降级的比例分别为 38%和 63%。
在一些患者中，尿动力学风险组的改善得到了令人鼓舞的改善。经过仔细的咨询和随访，BTX 可能可以安全地延长一些“有风险”患者的 BA 时间。
