Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Pediatr Urol. 2023 Aug;19(4):372.e1-372.e7. doi: 10.1016/j.jpurol.2023.04.022. Epub 2023 Apr 23.
Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. Interposing layers including human acellular dermis (HAD) and pedicled adipose tissue are routinely placed between the transected bladder neck and distal urethral stump to reinforce the BNC and minimize failure due to fistula development from the bladder.
The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. Specifically, we hypothesize that increased operations on the bladder urothelium leads to a higher rate of urinary fistula.
CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression.
A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider pubic diastasis at time of primary exstrophy closure (4.4 vs 4.0 cm, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0002). Kaplan-Meier analysis of fistula-free survival after BNC, demonstrated an increased fistula rate with additional MVs (p=0.0004, Figure 1). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). Of the 23 failed BNC's, 16 were surgically closed including 9 using a pedicled rectus abdominis muscle flap which was secured to the bladder and pelvic floor.
This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more prior MVs may benefit from a pedicled muscle flap, in addition to HAD and pedicled adipose tissue, to prevent fistula development by providing wellvascularized coverage to further reinforce the BNC.
恢复有功能性尿控的泌尿生殖解剖结构是膀胱外翻-尿道上裂（EEC）的重建目标。对于无法实现尿控或不适合行膀胱颈部重建（BNR）的患者，考虑行膀胱颈部闭合（BNC）。在横断的膀胱颈部和远端尿道残端之间，常规放置包括人脱细胞真皮（HAD）和带蒂脂肪组织等夹层，以加强 BNC 并最大程度减少因膀胱瘘管形成导致的失败。
本研究旨在回顾经典膀胱外翻（CBE）患者接受 BNC 的情况，以确定 BNC 失败的预测因素。具体而言，我们假设膀胱尿路上皮的手术次数增加会导致更高的尿瘘发生率。
对接受 BNC 的 CBE 患者进行研究，以确定 BNC 失败的预测因素，即膀胱瘘管的发展。预测因素包括先前的骨切开术、夹层组织层的使用和先前的膀胱黏膜损伤（MV）次数。MV 定义为膀胱黏膜开放或闭合的手术：膀胱外翻关闭术、BNR、膀胱扩大成形术或输尿管再植入术。使用多变量逻辑回归评估预测因素。
共 192 例患者接受了 BNC，其中 23 例失败。与初次膀胱外翻关闭时耻骨间距离为 4.0cm 的患者相比，耻骨间距离较宽（4.4cm）的患者发生瘘管的可能性更大（4.4 vs 4.0cm，p=0.0016），且更可能发生膀胱外翻关闭失败（p=0.0084）或 BNC 前有 3 次或更多 MV（p=0.0002）。Kaplan-Meier 分析显示，BNC 后无瘘管生存的患者，MV 次数越多，瘘管发生率越高（p=0.0004，图 1）。MV 次数在多变量逻辑回归分析中仍然具有统计学意义，每次损伤的优势比为 5.1（p<0.0001）。在 23 例 BNC 失败的患者中，有 16 例患者接受了手术修复，其中 9 例患者使用带蒂腹直肌肌瓣，将其固定于膀胱和骨盆底部。
本研究提出了 MV 及其在膀胱活力中的作用概念。MV 次数增加会增加 BNC 失败的风险。在考虑 BNC 时，有 3 次或更多 MV 的 CBE 患者可能受益于带蒂肌肉瓣，此外还可使用 HAD 和带蒂脂肪组织，通过提供血运良好的覆盖来预防瘘管形成，进一步加强 BNC。
