Division of Pediatric Urology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.
Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Neurourol Urodyn. 2023 Aug;42(6):1431-1436. doi: 10.1002/nau.25219. Epub 2023 May 30.
Surgical interventions in the urologic management of children with neurogenic bladder secondary to spina bifida aim to preserve upper tract function, prevent urinary tract infections, and optimize quality of life. However, since the introduction of intravesical onabotulinumtoxinA (Botox) in the management of these patients, the indications for choosing Botox over augmentation cystoplasty (AC) remain undefined. The objective of this study was to determine which factors lead patients to undergo Botox versus AC as a primary surgical treatment after failing medical management.
We retrospectively reviewed the records of pediatric patients with myelomeningocele undergoing either primary Botox or primary AC at our institution between 2013 and 2018. We recorded demographic and clinical information. We identified 10 important clinical decision-making factors: bladder trabeculation, vesicoureteral reflux, or hydronephrosis on imaging; end-filling pressure (EFP) ≥40 cm H2O, detrusor overactivity, detrusor-sphincter dyssynergia, or reduced capacity on urodynamic studies; physician-perceived bladder hostility; and patient/family desire for continence and independence. The presence of these factors was compared between patients undergoing either primary Botox or primary AC.
We identified 14 and 50 myelomeningocele patients who underwent primary AC and primary Botox, respectively. We found no significant differences in age, sex, race, or history of reconstructive surgery (antegrade continence enema or catheterizable channel). For the 10 decision-making factors, desire for independence/continence (p = <0.001) and reduced capacity (p = 0.002) were significantly associated with AC, while trabeculation (p = 0.006), EFP ≥40 cm H2O (p = 0.029), rising slope (p = 0.019), and physician-perceived hostility (p = 0.012) were significantly more common with Botox.
At our institution, quality of life measures prompted AC over objective urodynamic or imaging findings before attempting Botox. These findings support a shared decision-making approach when considering surgical intervention for neurogenic bladder secondary to myelomeningocele.
在治疗继发于脊髓脊膜膨出的神经源性膀胱的泌尿科手术中，外科干预旨在保护上尿路功能、预防尿路感染和优化生活质量。然而，自从在这些患者的管理中引入膀胱内注射肉毒毒素 A（Botox）以来，选择 Botox 而不是膀胱扩大成形术（AC）的指征仍未确定。本研究的目的是确定哪些因素导致患者在药物治疗失败后选择 Botox 而不是 AC 作为主要的手术治疗方法。
我们回顾性地审查了 2013 年至 2018 年期间在我们机构接受原发性 Botox 或原发性 AC 治疗的患有脊髓脊膜膨出的儿科患者的病历。我们记录了人口统计学和临床信息。我们确定了 10 个重要的临床决策因素：影像学上存在膀胱小梁化、膀胱输尿管反流或肾盂积水；充盈期末压（EFP）≥40cmH2O、逼尿肌过度活动、逼尿肌括约肌协同失调或尿动力学研究中容量减少；医生感知到的膀胱敌意；以及患者/家属对控尿和独立性的需求。将接受原发性 Botox 或原发性 AC 的患者的这些因素进行比较。
我们分别确定了 14 名和 50 名接受原发性 AC 和原发性 Botox 的脊髓脊膜膨出患者。我们发现年龄、性别、种族或重建手术史（逆行性清洁灌肠或可导尿通道）无显著差异。对于这 10 个决策因素，独立性/控尿的需求（p<0.001）和容量减少（p=0.002）与 AC 显著相关，而小梁化（p=0.006）、EFP≥40cmH2O（p=0.029）、斜率升高（p=0.019）和医生感知到的敌意（p=0.012）在 Botox 治疗中更为常见。
在我们的机构中，生活质量测量促使我们在尝试 Botox 之前，根据客观的尿动力学或影像学发现选择 AC。这些发现支持在考虑脊髓脊膜膨出继发神经源性膀胱的手术干预时采用共同决策方法。
