送交者: 大胖星 于 2005-9-21, 03:23:02:
回答: 请xj找到那篇state-of-the-“ART” 由 Yush 于 2005-9-21, 03:06:04:
Bladder Rehabilitation in Children with Spina Bifida: State-of-the-“ART”
[Editorials]
Joseph, David B.
University of Alabama at Birmingham
Children’s Hospital
Birmingham, Alabama
Indications for bladder rehabilitation in children with spina bifida have become well established. It is recognized that neurogenic bladder dysfunction can lead to secondary upper urinary tract deterioration and is often the etiology of chronic urinary incontinence. Operative reconstruction of the bladder has become a mainstay for bladder rehabilitation particularly when pharmacological management and intermittent catheterization have reached their usefulness. Intermittent catheterization has opened the door to a multitude of operative procedures for bladder reconstruction. Subjectively these procedures are associated with improvement in the well-being of our spina bifida population.
The focus of our operative experience with the neurogenic bladder is not truly repair but reconstruction of a hostile environment. For most children this is a reactionary attempt to prevent upper tract deterioration or it is undertaken to assist in gaining continence and independence. While it appears that we have been able to accomplish our goals of improving or preserving renal function and achieving continence, can we objectively quantify our outcome? What is the “expense” of undertaking these operative procedures as it relates to patient morbidity and long-term “success”? When alternative therapeutic options are presented how do we compare them to our current state-of-the-art?
The innovative article on an artificial somatic-autonomic reflex pathway by Xiao et al (page 2112) in this issue of The Journal provides an interesting alternative to traditional therapy. The authors approach the treatment of the refractory neurogenic bladder using neuromodulation. Microanastomosis of the 5th lumbar ventral root to the 3rd sacral ventral root is undertaken to bypass the pathological etiology of spina bifida. This intervention treats the cause of neurogenic dysfunction and not the end result of the neuropathy as with bladder reconstruction. Their impressive success with improved compliance and continence in children with spina bifida parallels their results with spinal cord injured patients.1 The potential benefits, if confirmed by others, could radically change the future of children with spina bifida, eliminating the consequences of bladder reconstruction and intermittent catheterization.
The authors are commended for expanding their work on spinal cord injured patients who have a previously normal neural road map and normal bladder to that of children with spina bifida who have a unique distribution and pathway of the lumbar and sacral nerves, and a bladder that is typically characterized by hypertrophy and fibrosis. The success of this intervention leads to speculation that the pathological structural changes of the bladder in the spina bifida population can be reversed.
The artificial somatic-autonomic reflex pathway is novel but neuromodulation is not new. Direct bladder stimulation in children with spina bifida dates back to the late 1950s with the work of Katona and Berényi,2 which was vigorously promoted by Kaplan and Richards in the 1980s.3 Intravesical bladder stimulation did not result in the elimination of intermittent catheterization, but it did set the stage for an alternative approach to the treatment of the neurogenic bladder. The potential benefits of neuromodulation can be greatly appreciated when compared to the success and morbidity of our current reconstructive measures. However, to make this comparison we have to be able to assess the outcome of current reconstructive bladder therapy.
Contemporary medicine encourages us to critically evaluate our outcomes to determine how we move forward regarding perfecting existing procedures and stimulating future innovations. The importance of this is clearly recognized when reviewing operative options for the treatment of the neurogenic bladder. Objective tools measuring the reliability of clinical outcomes have been established and are defined through protocols assessing the scientific methodology used to derive a conclusion. Unfortunately, these objective protocols do not easily translate into an operative model.
A multidisciplinary conference on evidence based practice in spina bifida was held in May 2003 sponsored by the Spina Bifida Association of America and several federal agencies.4 The International Classification of Functioning, Disability and Health developed by the World Health Organization was chosen as the framework for determining outcome, and the level of evidence was based on criteria developed by the Center for Evidence Based Medicine.4 A panel of pediatric urologists (Mark C. Adams, Stuart B. Bauer, Earl Y. Cheng, Dawn MacLellan, Steven J. Skoog and me) reviewed the available urological literature as it pertained to the operative treatment of children with spina bifida. More than 450 contemporary articles relating to attributes of bladder reconstruction in regard to bowel segment used, improvement in renal function, continence, morbidity and long-term success were systematically scored and objectively graded for scientific validity. None of the papers scored high for scientific validity. The articles were simply reports of large non-randomized series and expert opinion. This lack of scientific validity was consistent across all questions generated for urological care and interestingly a similar outcome was noted by all operative specialties.4
Purists can argue that the lack of rigorous scientific standards in the treatment of children with a neurogenic bladder prevents us from comparing outcome data between various operative modalities such as that of neuromodulation and reconstructive bladder techniques. Any comparison made is based on the “art” of experts and not scientifically designed protocols. But does that diminish the usefulness of reviewing our past experiences and does it prevent us from moving forward? I do not think it does.
The limitations of evidence based medicine are not unique to the treatment of the neurogenic bladder. Operative protocols will always have difficulty qualifying for high levels of scientific evidence because of the lack of “black and white” issues and the inherent hurdles in surgery that prevent creating a blinded study with sham controls. This does expose a problem with the methods of our protocols but it may also reflect on a flaw with applying the current criteria to operative studies. We owe it to ourselves to seriously consider all limitations and establish sound scientific protocols when exploring future operative innovations and creating prospective studies. This will position us better to compare alternative therapeutic options. As it stands, the artificial somatic-autonomic reflex pathway may become a useful addition in the “art” of neurogenic bladder care.
David B. Joseph
University of Alabama at Birmingham
Children’s Hospital
Birmingham, Alabama
1. Xiao, C. G., Du, M. X., Dai, C., Li, B., Nitti, V. W. and de Groat, W. C.: An artificial somatic-central nervous system-autonomic reflex pathway for controllable micturition after spinal cord injury: preliminary results in 15 patients. J Urol, 170: 1237, 2003 [Context Link]
2. Katona, F. and Berényi, M.: Intravesical transurethral electrotherapy in myelomeningocele patients. Acta Paediatr Acad Sci Hung, 16: 363, 1975 [Context Link]
3. Kaplan, W. E. and Richards, I.: Intravesical bladder stimulation in myelodysplasia. J Urol, 140: 1282, 1988 [Context Link]
4. Liptak, G. S.: Evidence-Based Practice in Spina Bifida: Developing a Research Agenda. Washington, D.C.: Spina Bifida Association of America, 2003 [Context Link]
Accession Number: 00005392-200506000-00007