Li Yilong, Stern Noah, Wang Peter Zhantao, Braga Luis H, Dave Sumit
Western University Schulich School of Medicine and Dentistry, London ON, N6A 5C1, Canada.
Western University Schulich School of Medicine and Dentistry, Division of Urology, London ON, N6A 5W9, Canada.
J Pediatr Urol. 2023 Dec;19(6):730-741. doi: 10.1016/j.jpurol.2023.08.033. Epub 2023 Sep 7.
To review the urological outcomes of proactive versus delayed management of children with a neurogenic bladder (NB).
We performed a literature search on EMBASE, MEDLINE, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials between January 1, 2000 to August 21, 2023 for studies investigating the management of spina bifida-associated NB in pediatric patients (0-18 years of age). Proactive management was defined as use of clean intermittent catheterization, and/or anticholinergics at presentation, or based on initial high-risk urodynamic findings by 1 year of age. Delayed management was defined as beginning management after 1 year of age or no intervention. Outcomes included incidence or diagnosis of secondary vesicoureteral reflux (VUR), urinary tract infection (UTI), and renal deterioration, which included renal scarring, loss of differential renal function on a nuclear scan, or a decrease in renal function defined by glomerular filtration rate or serum creatinine estimation. Forest plots were synthesized using the Inverse Variance method with random-effect model. The Risk of Bias was assessed using the ROBINS-I tool.
We included 8 observational studies on 652 pediatric patients with spina bifida-associated NB (mean follow-up - 7 years). Proactive management following initial assessment was associated with significantly lower risks of secondary VUR (OR 0.37 [0.19, 0.74], p = 0.004), non-febrile UTI (OR 0.35 [0.19, 0.62], p = 0.0004), and renal deterioration (OR 0.31 [0.20, 0.47], p < 0.00001).
Delayed management of NB potentially has 3 times higher risks of secondary VUR, non-febrile UTI, and renal deterioration. However, the evidence is limited by the high risk of bias due to lack of randomization and standardized reporting in observational studies.
While further well-defined prospective studies with long-term follow-up should be conducted to confirm this finding, this study supports the EAU/ESPU recommendations for early intervention in children with NB.
回顾对神经源性膀胱（NB）患儿采取积极管理与延迟管理的泌尿外科治疗结果。
我们在2000年1月1日至2023年8月21日期间，对EMBASE、MEDLINE、Scopus、Web of Science和Cochrane对照试验中央注册库进行了文献检索，以查找有关小儿患者（0至18岁）脊柱裂相关NB管理的研究。积极管理定义为在就诊时或基于1岁时最初的高危尿动力学检查结果使用清洁间歇性导尿和/或抗胆碱能药物。延迟管理定义为1岁后开始管理或不进行干预。结果包括继发性膀胱输尿管反流（VUR）、尿路感染（UTI）和肾脏恶化的发生率或诊断，其中肾脏恶化包括肾瘢痕形成、核素扫描中肾微分功能丧失，或根据肾小球滤过率或血清肌酐估计定义的肾功能下降。采用随机效应模型的逆方差法合成森林图。使用ROBINS-I工具评估偏倚风险。
我们纳入了8项关于652例脊柱裂相关NB患儿的观察性研究（平均随访7年）。初始评估后进行积极管理与继发性VUR（OR 0.37 [0.19, 0.74]，p = 0.004）、非发热性UTI（OR 0.35 [0.19, 0.62]，p = 0.0004）和肾脏恶化（OR 0.31 [0.20, 0.47]，p < 0.00001）的风险显著降低相关。
NB的延迟管理可能使继发性VUR、非发热性UTI和肾脏恶化的风险高出3倍。然而，由于观察性研究缺乏随机化和标准化报告，证据受到高偏倚风险的限制。
虽然应进行进一步明确的长期随访前瞻性研究以证实这一发现，但本研究支持欧洲泌尿外科学会/欧洲小儿泌尿外科学会对NB患儿进行早期干预的建议。
