| Background and objectiveSpina bifida is one of the most common birth faults.The epidemic materials in the Seventh Five-Year key research project "Neutarl Tube Faults" indicated that the living birth rate of the open spina bifida is 8.5 per 10 thousand.Meningomyelocele(MMC) accounts for more than 90%of all open spinal dysraphism cases.Almost all children with MMC have some degree of lower urinary tract dysfunction,depending on the level and completeness of the neurological injury.The dyfunction of the bladder-sphincter may result in the upper urinary tract deterioration.If untreated,the patient will die of the renal failure.Although existing different diagnostic methods in this field including B-mode ultrasound,intravenous urogram(IVU),renogram,computerized tomography(CT), magnetic resonance image(MRI),each of them exists limitation and can not figure out the spectrum and grades of dysfunction of the bladder-sphicteric complex in the children with MMC and upper urinary tract dilation.It has been reported that manifestations and routine urological and neurologic examination can not evaluate the bladder-sphincter dysfunction accurately.Advances in urodynamic techniques specially designed for infants and young children have allowed more accurate assessment of bladder-sphincter dysfunction in the children with MMC.It is well known today that identification of children with MMC at risk for upper urinary tract deterioration with selective urodynamic parameters.There is still controversy that whether the timing of primary neurosurgical repair in children with MMC after the birth can have an influence on the changes of pathophysiology dysfunction and the resume effect of the bladder function after the operation.Most newborn with MMC will have complication or die rapidly if early primary surgical closure is not attempted.In the United States most cases are repaired within 48 hours of after birth.However,in other countries where the same kind of health care is not available the timing of the primary spinal repair may vary to a great extent.Moreover,it was believed that some children with MMC have not symptom of urinary and lower extremities during their lives,and some of them become secondary tethering cord symptom due to primary neurosurgical repair,so they suggested that it was completed when the children with MMC have symptom.Furthermore,although immediate repair is generally accepted,no study was found in the literature that addresses the drawbacks of late spinal closure in terms of the prognosis of the neurogenic bladder.The purpose of this study was to assess the impact of primary neurosurgical repair time on the changes of pathophysiology of bladder function in children with MMC by urodynamic evaluation.Materials and methods1.PatientsWe retrospectively reviewed the records of 97 children with MMC who were operated primary neurosurgical repair at Children's hospital of Zhengzhou between 1999 and 2004.The 97patients(55 males,42 females) were included in the study based on the availability of urological followup data at age 3 years.To evaluate the outcome of early vs late primary neurosurgical intervention,the population was divided into 2 groups—those who underwent primary repair within 6 months after birth(Operative groupâ… ) and those underwent repair after 6 months(Operative groupâ…¡).According to time of primary spinal repair,operative groupâ… was subdivided into two groups: operative group A(primary neurosurgical repair within one month )and operative group B(primary neurosurgical repair between two months and six months).There were 43 patients with MMC in operative group A including 25 boys and 18 girls,of which the level of MMC was cervical in 1,thoracic in 1,lumbar in 20,sacral in 3 and lumbosacral in 18,and Median primary age at repair was 7±6 days(range 1 day to 30 days).There were 24 patients with MMC in operative group B including 15 boys and 9 girls,of which the level of MMC was thoracic in 1,lumbar in 10,sacral in 4 and lumbosacral in 9,and Median primary age at repair was 3±1 months(range 1 month to 6 months).There were 30 patients with MMC in operative groupâ…¡including 15 boys and 15 girls,of which the level of MMC was cervical in 2,thoracic in 1,lumbar in 20,sacral in 2 and lumbosacral in 5,and Median primary age at repair was 11±3 months(range 6 months to 30 months).2.Methods2.1 Regular Urological followup Urological followup consisted of an initial history and physical examination followed by urinalysis,urine culture,serum creatinine determination,renal ultrasonography,voiding cystourethrogram and MRI.The urological variables assessed included febrile urinary tract infections(FUTI,defined that fever 38℃or greater associated with a positive urine culture for uropathogenic bacteria),upper urinary tract deterioration(UUTD,including vesicoureteral reflux and or hydronephrosis),and secondary tethered cord symptom(STCS).2.2 Urodynamic examination In this study free uroflowmetry,filling cystometry and pressure-flow- electromyography were performed in all patients according to the recommendations of the International Children Continence Society(ICCS). Urodynamic parameters inclucing maximum cystometric capacity(MCC),detrusor leak point pressure,bladder compliance and bladder underactivity.Bladder underactivity included detrusor underactivity and acontractile detrusor.The former is a contraction of decreased strength and/or duration,resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span.The latter demonstrates no contraction whatsoever during urodynamic studies.3.Statistical analysisStatistical analyses were carried out by using the Statistical Package for Social Sciences(SPSS),version 10.0 for windows.Chi-square test and two independent-samples t test was used.P-values of＜0.05 were considered to be statistically significant.Results1.The incidence of bacterials urinary tract infections,upper urinary tract deterioration and secondary tethered cord symptom in operative groupâ… was 15%,19%and 12%, significantly lower than those in operative groupâ…¡(37%,50%å'Œ43%,P＜0.05) respectively.2.There were no significant differences in bacterial urinary tract infections,upper urinary tract deterioration and secondary tethered cord symptom between operative group A and B(12%,14%and 7%vs21%,29%and 21%,P＞0.05).3.The maximum cystometric capacity and bladder compliance of operative groupâ… were significantly higher than those of operative groupâ…¡,detrusor leak point pressure and incidence of bladder underactivity were significantly lower than those of operative groupâ…¡(P＜0.05).4.The maximum cystometric capacity and bladder compliance of operative group A were also significantly higher than those of operative group B,detrusor leak point pressure and incidence of bladder underactivity were significantly lower than those of operative groupB(P＜0.05).Conclusions1.There is relation between time of primary neurosurgical repair and influence on the changes of pathophysiology dysfunction and the resume effect of the bladder function after the operation.Primary neurosurgical repair of the spinal defect within the first 6 months after birth in patients with MMC provides an improved neurogenic bladder prognosis compared to repair at a later time.Closure of the spinal lesion on the first month of life seems to provide the best chance for lower urinary tract function.2.Urodynamic study is an important tool to evaluate outcome,prognosis and close followup of primary neurosurgical repair in chidren with MMC. |
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