Original article
Long-term outcomes of augmentation cystoplasty: A retrospective view of 54 children
Resultados a largo plazo de la cistoplastia de ampliación: una evaluación retrospectiva de 54 niños
Department of Pediatric Urology, Kanuni Sultan Süleyman Training and Research Hospital/Health Sciences University, İstanbul, Turkey
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Kuzdan, H. Demirkan" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M.Ö." "apellidos" => "Kuzdan" ] 1 => array:4 [ "nombre" => "H." "apellidos" => "Demirkan" "email" => array:1 [ 0 => "drhdemirkan@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Pediatric Urology, Kanuni Sultan Süleyman Training and Research Hospital/Health Sciences University, İstanbul, Turkey" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados a largo plazo de la cistoplastia de ampliación: una evaluación retrospectiva de 54 niños" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1595 "Ancho" => 2091 "Tamanyo" => 69287 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Postoperative 10th year serum cystatin C levels.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bladder augmentation (BA) (augmentation cystoplasty as generic terminology) is a substantial armamentarium of the pediatric urology practice for the management of congenital urinary bladder anomalies that reduce storage capacity such as neurogenic bladder, congenital urinary tract defects (exstrophia vesica, posterior urethral valve (PUV)) or idiopathic causes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In literature, the use of small bowel segments to augment the bladder was first described by Von Mikulicz in 1899 and the method was popularized by Couvelaire in 1950.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The goals of the BA are to protect renal functions by creating an adequate functional bladder storage capacity with low end-filling pressure, to reduce the high intravesical pressure, and to preserve the upper urinary system from damage by secondary vesicoureteral reflux (VUR).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The actual, prevailing technique for pediatric BA is cystoplasty with gastrointestinal tissue (stomach, ileocaecal, ileum, and small/large bowel).<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The part of the bowel utilized determines the terminology. Detubularised patch of ileum is the most commonly preferred bowel segment for BA.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Conventionally, BA is an open abdominal surgery. The technique is based on coronal or sagittal bi-valving of the bladder and anastomosis of a detubularised bowel segment onto the indigenous bladder. As BA is a demanding surgical procedure, an elaborately patient assignment and convenient pre-operative counseling are crucial. Furthermore, post-operative management and transitional care are critical in the urological care of children who underwent BA.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The frequency of postoperative complications following BA alters from study to study.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> This diversity is based on the extent of follow-up, the type of augmentation procedure, and the patient’s ability to obey with medical directives. Whilst previous clinical reports have demonstrated several clinical trials about BA outcomes, it is certain that data of long term follow-up are required to confirm the practicability and effectiveness of BA in children.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of our study is to determine the effectiveness of the BA regarding the preoperative renal status of children with particularly three congenital urinary defects which are the most frequent indications of BA. We hypothesized preservation of renal functions of patients with congenital bladder defects depends on the underlying disease rather than the technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We used Institutional Review Board (Date: 26.02.2020-No:2020/28) approved study protocol and databases at Kanuni Sultan Süleyman Training and Education Hospital to identify patients. The medical records of 54 children who underwent BA in the medical history were evaluated retrospectively. They were admitted to the pediatric urology outpatient clinic between March 2019 and May 2021 for their routine follow-up. Patients who were followed up less than 3-years, those who were lost to follow-up, and those who underwent reconstructive surgery without BA were excluded. The following data were collected from the hospital automation system: age at BA, tissue utilized during the procedure, localization of ureter implantation, degree of hydronephrosis according to annual ultrasonography (USG) records, urine culture results, serum creatinine-cystatin C levels, and information regarding the development of malignancy in cystoscopic evaluations and USG monitoring.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Urinary USG was performed in annual visits for bladder or renal stones and also presence of hydro-ureteronephrosis. Hydro-ureteronephrosis was graded according to the Fetal Urology Association (SFU) staging system.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Postoperatively, a voiding cystourethrography (VCUG) was performed annually for the presence or absence of VUR. Before BA, cystoscopy was applied directly to document any lower urinary tract abnormality and to affirm the capacity of bladder.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data on surgical procedures performed pre-BA, concomitant BA, and post-BA and postoperative complications were extracted from patients’ medical records.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main indications for augmentation were described as follows: (1) high bladder pressure (>40 cmH2O) or decreased bladder capacity; (2) decreased bladder compliance; (3) high-grade VUR with mild-to-moderate upper urinary tract deterioration; and (4) formation of renal parenchymal scarring.</p><p id="par0045" class="elsevierStylePara elsevierViewall">At the initiation of operation, following abdominal incision the bladder was opened via a vertical incision. Using a portion of the ileum or sigmoid colon, the surgeon detubularized the bowel connection with double sutures and attached it to the apex of the bladder. The bladder and bowel were then sutured together to enlarge the bladder.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In case of catheterization problem from the urethra, Mitrofanoff or Monti-Yag was applied as simultaneous procedures. After 3 weeks, patients were discharged with an introduction to clean intermittent catheterization (CIC) and training to perform CIC six times a day. CIC drains urine through a catheter placed in the urethra, thus preventing the accumulation of mucus.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Data were recorded and then analyzed using SPSS version 22 (SPSS Inc., Chicago, IL, USA). Pre- and postoperative continuous variables were compared using Student's <span class="elsevierStyleItalic">t</span>-test for paired series. Among the descriptive statistics, mean ± standard deviation was used for normally distributed variables, median (minimum-maximum) was used for non-normally distributed variables, and number (%) was used for categorical variables. A <span class="elsevierStyleItalic">P</span>-value <.05 was considered to be statistically significant.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 54 children (61% were boys and 39% were girls) were underwent BA. One patient was excluded due to the etiology of trauma. The data of preoperative diagnoses, follow-up durations, postoperative complications, hydronephrosis and VUR development on 10th year of surgery for each group are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The segments utilized were: colon in 41 patients (75.9%) and ileum in 11 patients (20.3%). The resected ileum and colon segments were an average of 33.8 ± 4 cm, and 29.5 ± 5.5 cm respectively. Colonic augmentation complications were; bladder fistula (n = 2), colonic anastomosis leakage (n = 1) and death (n = 3) in postoperative early period. Diagnoses of the patients in that death occurred were spina bifida (n = 2) and bladder exstrophy (n = 1).</p><p id="par0070" class="elsevierStylePara elsevierViewall">In subjects who underwent colonic augmentation, reoperation was required due to ureterovesical stenosis (n = 1), VUR (n = 1), and bridectomy (n = 1). Therewithal, in ileal augmentation group, ureterovesical stenosis (n = 1) and bridectomy (n = 1) indicated reoperation.</p><p id="par0075" class="elsevierStylePara elsevierViewall">When the diversion was required, Mitrofanoff procedure was applied to 20 (37%) patients and Yang-Monti procedure was applied to 5 (9.2%) patients. Since they were not catheterized, a revision was needed for 2 cases. In one of them with Mitrofanoff conduit, because the appendix obliterated on the 11th year, Yang-Monti with ileum was applied.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In 4 cases catheterized with Mitrofanoff procedure, mucosal excision was required on the 7th year due to mucosal hyperplasia; however, the hyperplasia was not bothersome in terms of the usage of the channel effectively. Only one of the 8 patients that were followed-up for more than 15 years following Mitrofanoff, needed revision operation in the 17th year of BA. Two patients had 20- and 25-years follow-ups, and both of them were catheterized sufficiently.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Three of 5 cases catheterized with Monti technique, had no problem with catheterization at an average of 9 years. Two of them were augmented with ileum and 1 was with the ureter. However, 2 of them were dead in the early period.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Among the whole group, 11 (20.37%) patients were operated on for stone formation in the bladder. Two of them were augmented with ileum and 8 of them were augmented with the colon. Bladder stones formed in an average of 4.5 years in cases with ileocystoplasty, while it occurred in an average of 8.22 years in cases with colocystoplasty. In stone analysis, 8 patients had struvite stone, 1 had calcium oxalate, 1 had calcium oxalate-carbonate and 1 had calcium carbonate stone. Two cases were reoperated due to recurrent stone development.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Comparison of serum creatinine levels and serum cystatin C levels among groups by years are detailed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, respectively. Also, while <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> demonstrates the trend of serum creatinine levels by years, serum cystatin C levels are clarified in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. Data of serum cystatin C levels could be obtained for the postoperative 10th year.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Urine culture records of 31 cases could be obtained at the 10th year follow-up of the patients. A positive urine culture confirmed urinary tract infection in 25 (80.6%) patients (≥100,000 colony-forming units/mL of an uropathogen) but only 6 (19.3%) had a negative urine culture. Of these 6 cases, 2 had ileal and 4 had colonic augmentation history associated with bladder exstrophy.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although histological evaluation of enlarged bladders was not performed during the follow-up period, no macroscopic evidence of malignancy was found in USG monitoring and periodic cystoscopies at routine visits.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">This study has an extended postoperative follow-up duration of 17.32 years after augmentation and according to our knowledge, this period is distinctly and significantly longer than the previous eligible studies regarding BA.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,12</span></a> In a report by Snodgras et al., mean follow-up duration was 60 months after bladder neck sling, 38 months following Leadbetter/Mitchell bladder neck revision plus sling, and 29 months after bladder neck closure.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the study of 34 patients by Molina et al., the mean duration was 34.35 months.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Ileocystoplasty and colocystoplasty are the current most common cystoplasty procedures in BA because the ileum and colon are sufficiently long and provide satisfactory capacity.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> However, recent reports regarding ileal and colonic cystoplasty are accumulating by pointing to the complications and the long-term outcomes. In 2011, Obermayr et al. evaluated the outcome of BA and bladder substitution in children. They reported that BA was performed in 19 patients, utilizing the ileum (n = 15), ileocecum (n = 1), sigmoid colon (n = 2) and demucosalized sigmoid colon after detrusor myectomy (n = 1).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> They achieved good functional results by detubularization of the bowel segments in all cases. In the series of Madersbacher et al.,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> 45% of the subjects with ileal conduit developed complications regarding renal function, utilized bowel segment, stoma, urinary tract infection, uretero-intestinal anastomosis, and urolithiasis within 5 years of the operation. The percentage of patients with complications increased to 94% within 15 years after the operation. In our study, the colonic segment was utilized in 41 patients (75.9%) and the ileal segment in 11 patients (20.3%). Postoperative complications were bladder fistula, colonic anastomosis leakage, and death. Reoperation was required in 5 patients.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The frequency of postoperative complications following augmentation cystoplasty alters from study to study. This diversity is based on the extent of follow-up visits, the type of augmentation technique, and the patient’s ability to comply with medical directives. Bladder lithiasis is a well-known complication of BA, especially when a colon segment is used.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The colonic segment causes the obstruction of the bladder outlet and the formation of calculi by its property of mucus production.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the study of Mathoera et al., bladder stones developed in 14 (16%) of 89 cases, and stone formation was observed in an average of 3 years.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In the prospective study of Kispal et al., stone formation occurred in 20 (23%) of the 86 patients who underwent BA. Sixteen of them had a history of colosystoplasty, 2 had ileocystoplasty, 1 had gastrocystoplasty, and 1 patient had a history of bladder replacement. The average time from BA to the first stone formation period was 3.9 years.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In the study of Casey et al., 2 of 11 patients developed symptomatic bladder stones requiring surgery and both stones were infectious.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> In our study, 11 (20.37%) patients were operated on due to the development of bladder stones in accordance with the literature. There was no significant difference on the risk of stone formation between ileocystoplasty (37.6%) and colosystoplasty (35.3%).</p><p id="par0125" class="elsevierStylePara elsevierViewall">The creation of a continuous urinary diversion based on the Mitrofanoff method is a major milestone for the surgical repair of congenital neuropathic bladders.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> The long-term use of the procedure without complications is very important for surgical success and patient comfort. The mean follow-up period in our cases with Mitrofanoff was 11.21 years and it could be used effectively for a very long time. Revision operation was needed in only 2 (8%) cases because they could not be catheterized. In the first case, ileum was performed in the 11th year due to obliteration of the appendix. In the second case, a revision operation was performed in the 17th year due to inadequate catheterization. The longest problem-free working duration of Mitrofanoff was 20 and 25 years in 2 patients, and during this period, both of them were catheterized effectively. As far as we know, no literature data is showing that the Mitroffanof operation can be used for such a long time without any complications. Lefevre et al. performed revision in 38% of 34 cases in 6.2 years of follow-up.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> On the other hand, Iqbal et al.'s 29 cases of Mitrofanoff follow-up were 9.54 years on average and revision was required in 4 (13.79%) cases.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Preservation of kidney function is critical in augmented patients and assessment of renal reserve in infancy is currently the best indicator of long-term renal outcomes. In the study of 53 patients with bladder exstrophy by Fontaine et al. GFR measurements showed a reduction of >20% at 10-year follow-up.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In our study, postoperative serum creatinine levels ​​showed renal functions ​​could be preserved at the 20th year of BA in children with bladder exstrophy. Otherwise, in PUV and spina bifida patients, it was observed that serum creatinine levels tend to increase significantly by the 10th year, especially in PUV cases. In another study conducted by Pereia et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> including 29 patients with congenital neuropathic bladder, serum cystatin C levels ​​were 1.38 mg/l in 2 patients during the 8-year follow-up and <0.9 mg/l in other patients. In the evaluation of 19 boys with PUV, the likelihood of worsening renal function despite of the elimination of the valves was considered by Bhatti et al.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The management of VUR in BA is still a controversial issue among surgeons and pediatric nephrologists and in the postoperative period, clinicians should take care of patients in terms of VUR and hydronephrosis in each visit. In ten-year results of renal and bladder outcomes for children with spina bifida, Rensing et al. found many had early hydronephrosis (72%).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In our study, PUV was a major risk for patients who had VUR (37.5%) and hydronephrosis (50%) in the late postoperative period.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The major limitation of the study is that retrospective nature of it led to follow-up of patients systematically and thus the lack of data.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0145" class="elsevierStylePara elsevierViewall">The BA is a traditional surgical method that currently has limited postoperative data in terms of long-term follow-up. Whilst previous clinical reports have demonstrated several clinical trials about BA outcomes, longer follow-up data are required to confirm the feasibility and effect of BA for bladder regeneration in children with distinct disorders of bladder. Particularly when patients with PUV were augmented kidney functions are worsened sooner. In conclusion, we suggest that the main factor determining the success of BA is the underlying etiology.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1778921" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1561791" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1778922" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1561792" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack628661" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-09-16" "fechaAceptado" => "2021-12-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1561791" "palabras" => array:6 [ 0 => "Bladder augmentation" 1 => "Congenitalurinary defects" 2 => "Vesical exstrophy" 3 => "Spinal dysraphism" 4 => "Posterior urethral valve" 5 => "Mitrofanoff" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1561792" "palabras" => array:6 [ 0 => "Aumento de la vejiga" 1 => "Anomalías urinarias congénitas" 2 => "Extrofia vesical" 3 => "Disrafismo espinal" 4 => "Válvula uretral posterior" 5 => "Mitrofanoff" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Throughout the years, clinicians dealing with pediatric urology disorders have resorted to bladder augmentation (BA), a demanding surgical procedure, to preserve renal functions in sundry congenital urinary tract defects. This study aimed to reveal the very long-term outcomes of BA in a large sample of pediatric patients and the role of underlying disease on renal prognosis after BA.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">A retrospective cross-sectional study was conducted on 54 children with congenital urinary defects who underwent BA. The utilized augmentation technique, the location of ureter implantation, complications, and ultrasonography findings were analyzed. Data on serum creatinine levels were collected from preoperative records and anniversaries following BA.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Among 54 children, 33 (61.1%) were boys. Diagnoses were spinal dysraphism (SD) (n = 13), posterior urethral valve (PUV) (n = 8), bladder exstrophy (n = 32) and trauma (n = 1). The median follow-up duration was 18 (3–31) years. The comparisons of serum creatinine levels between groups revealed that, despite no meaningful difference was present between bladder exstrophy and PUV group in the preoperative period and postoperative 1st year, cases with PUV had significantly higher levels of serum creatinine levels in the following postoperative years. Therewithal compared with the SD group, subjects with PUV had significantly higher levels at the postoperative 2nd year (<span class="elsevierStyleItalic">P</span> = .035) and 10th year (<span class="elsevierStyleItalic">P</span> = .006).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">In our study, significantly long-term follow-up outcomes could facilitate the pre- and postoperative approach for enterocystoplasty in children. According to our results, it is noteworthy that kidney functions are at high risk of worsening in subjects with PUV and underwent BA.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Materials and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción y objetivos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">A lo largo de los años, los médicos que se ocupan de los trastornos urológicos pediátricos han recurrido a la ampliación vesical (AV), un procedimiento quirúrgico altamente desafiante desarrollado para preservar las funciones renales en diversos casos de anomalías urinarias congénitas. Este estudio tiene como objetivo revelar los resultados de la AV a muy largo plazo en una amplia muestra de pacientes pediátricos, así como el papel de la enfermedad subyacente en el pronóstico renal tras la AV.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y métodos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio transversal retrospectivo en 54 niños con anomalías urinarias congénitas que fueron sometidos a una AV. Se evaluó la técnica de ampliación utilizada, la localización de la implantación del uréter, las complicaciones y los hallazgos ecográficos. Se recogieron datos sobre los niveles de creatinina sérica en los registros preoperatorios y posteriores a la AV anuales.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De los 54 niños, 33 (61,1%) eran varones. Los diagnósticos fueron disrafismo espinal (DE) (n = 13), válvula uretral posterior (VUP) (n = 8), extrofia vesical (n = 32) y traumatismo (n = 1). La duración media del seguimiento fue de 18 (3–31) años. Las comparaciones de los niveles de creatinina sérica entre los grupos revelaron que, a pesar de que no existían diferencias significativas entre el grupo de extrofia vesical y el de VUP en el periodo preoperatorio ni en el primer año postoperatorio, los casos con VUP presentaban niveles de creatinina sérica significativamente más altos en los siguientes años posteriores a la cirugía. Además, en comparación con el grupo de DE, los sujetos con VUP tenían niveles significativamente más altos en el segundo (<span class="elsevierStyleItalic">P</span> = ,035) y décimo año (<span class="elsevierStyleItalic">P</span> = ,006) año del postoperatorio.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">En nuestro estudio, los resultados del seguimiento a largo plazo podrían facilitar el abordaje pre y postoperatorio de la enterocistoplastia en edad pediátrica. Debemos destacar que, según nuestros resultados, la función renal tiene un alto riesgo de empeoramiento en los sujetos con VUP sometidos a AV.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción y objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Materiales y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Kuzdan MÖ, Demirkan H. Resultados a largo plazo de la cistoplastia de ampliación: una evaluación retrospectiva de 54 niños. Actas Urol Esp. 2022;46:487–493.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1595 "Ancho" => 2091 "Tamanyo" => 69287 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Postoperative 10th year serum cystatin C levels.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1214 "Ancho" => 2508 "Tamanyo" => 147845 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Serum creatinine levels of patients by years.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">VUR: Vesicoureteral reflux; PUV: Posterior urethral valve.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bladder exstrophy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PUV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spina Bifida \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (59.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (14.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (24%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up duration, median (minimum-maximum), (Year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20 (7−31) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.5 (3−21) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.5 (4−30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Augmentation age, median (minimum-maximum), (Year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (0.5−18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (0.8−12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5 (1−12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative follow-up duration, median (minimum-maximum), (Year) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.5 (3−25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (0−18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (0−22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Death (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bladder Stone (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydronephrosis grade 1−2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (28.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (12.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (23.07%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hydronephrosis grade 3−4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (23.07%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VUR (grade 1-2-3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (6.2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (15.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VUR (grade 4−5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (3.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (37.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (7.69%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative mean bladder storage capacity (cc) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">327 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">700 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">513 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Follow-up durations and complications.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">PUV, Posterior urethral valve; SB, Spina bifida.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean serum creatinine levels (mg/dl) (Mean ± SD, <span class="elsevierStyleItalic">P</span>) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bladder exstrophy -PUV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PUV-SB \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bladder exstrophy -SB \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preoperative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.47 (±0.27)-0.61 (±0.31), <span class="elsevierStyleItalic">0.15</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.61 (±0.31)-0.68 (±0.34), <span class="elsevierStyleItalic">0.55</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.47 (±0.27)-0.68 (±0.34), <span class="elsevierStyleItalic">0.06</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative 1st year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.52 (±0.28)-1.02 (±0.45), <span class="elsevierStyleItalic">0.13</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.02 (±0.45)-0.78 (±0.38), <span class="elsevierStyleItalic">0.28</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.52 (±0.28)-0.78 (±0.38), <span class="elsevierStyleItalic">0.05</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative 2nd year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 (±0.29)-1.3 (±0.78), <span class="elsevierStyleItalic">0.009</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 (±(0.78)-0.66 (±0.36), <span class="elsevierStyleItalic">0.035</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 (±0.29)-0.66 (±0.36), <span class="elsevierStyleItalic">0.72</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative 5th year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66 (±0.36)-1.8 (±0.83), <span class="elsevierStyleItalic">0.003</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 (±0.83)-1.02 (±0.7), <span class="elsevierStyleItalic">0.055</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66 (±0.36)-1.02 (±0.7), <span class="elsevierStyleItalic">0.21</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative 10th year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.76 (±0.48)-3.13 (±1.06), <span class="elsevierStyleItalic">0.002</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.13 (±1.06)-1.27 (±0.37), <span class="elsevierStyleItalic">0.006</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.76 (±0.48)-1.27 (±0.37), <span class="elsevierStyleItalic">0.013</span><a class="elsevierStyleCrossRef" href="#tblfn0001">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0001" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0001">p < 0.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Serum creatinine levels by years.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">PUV, Posterior urethral valve; SB, Spina bifida.</p>" "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bladder exstrophy-PUV \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">PUV-SB \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bladder exstrophy-SB \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Postoperative 10th year serum cystatin C levels (mg/l) (Mean ± SD, <span class="elsevierStyleItalic">P</span>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.11 (±0.49)-3.26 (±0.51), <span class="elsevierStyleItalic"><.001</span><a class="elsevierStyleCrossRef" href="#tblfn0002">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.26 (±0.51)-1.9 (±0.73), <span class="elsevierStyleItalic">.002</span><a class="elsevierStyleCrossRef" href="#tblfn0002">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.11 (±0.49)-1.9 (±0.73), <span class="elsevierStyleItalic">.03</span><a class="elsevierStyleCrossRef" href="#tblfn0002">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0002" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0002">p < 0.05.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Serum cystatin C levels.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Augmentation cystoplasty: what are the indications?" 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