anatomic factors predict urinary continence in patients with anorectal€¦ · background •...
TRANSCRIPT
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Anatomic factors
predict urinary
continence in patients
with anorectal
malformation
Molly E Fuchs, Devin R Halleran, Yuri Sebastião, Laura Weaver, Hira Ahmad, Christina B Ching, Marc A Levitt, Richard J Wood and Daniel G Dajusta
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Background
• Anorectal malformation a complex
spectrum diagnosis characterized by anal
mislocation
• Associated with spinal cord and sacral
anomalies
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Background
AR
M IN
DEX
ARM Subtype
Sacral Ratio
Spine abnormalities
Distal rectal anatomy
Lateral radiograph
Degree of sacral development
Tethered cord or
myelomeningocele
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Background
• ARM index has been shown to predict
fecal continence
• No tool exists to predict urinary continence
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Purpose
• To identify if the anatomic factors that
make up the ARM index are associated
with urinary continence in ARM
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Methods
• Review of large ARM database
• Inclusion criteria
– Age > 4 yrs
– Complete data
– Patient reported continence
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Methods
• Definition of continence
– Volitional voiding per urethra
– Dry between daytime voids
– ≤ 1 accident per week
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MethodsA
RM
IND
EX
ARM Subtype
Sacral Ratio
Spine abnormalities
Simple
Moderate
Complex
Perineal, bulbar, vestibular, imperforate anus, anal stenosis,
rectal atresia, H type fistula
Cloacal < 3cm, Rectoprostatic, Rectovaginal
Cloaca > 3cm, Cloacal exstrophy, Rectobladder neck
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Methods
≥ 0.7
0.4 – 0.6
< 0.4
AR
M IN
DEX
ARM Subtype
Sacral Ratio
Spine abnormalities
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Methods
Normal
Tethered cord
Low conus
MMC
AR
M IN
DEX
ARM Subtype
Sacral Ratio
Spine abnormalities
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Results
• n = 434
• 57.5% male (n = 251)
• Median age 8.4 yrs (IQR 6 – 12.3)
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ResultsARM Severity
Simplen = 245
57%Moderate
n = 10123%
Complex
n = 88
20%
Lateral Sacral Ratio
≥ 0.7n = 229
53%
0.4 – 0.6n = 157
36%
< 0.4n = 4811%
Spinal Cord Findings
Normaln = 264
61%
MMCn = 19
4%
Tethered
Cordn = 151
35%
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Results
75.5%
57.4%
31.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Simple Moderate Complex
Continence Rates ARM Severity
(n = 245)
p < 0.0001p = 0.004reference
(n = 88)
(n = 101)
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Results
72.9%
56.1%
31.2%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
≥ 0.7 0.4 - 0.6 < 0.4
Continence Rate By Sacral Ratio
p = 0.000p = 0.001reference
(n =157)
(n = 229)
(n = 48)
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Results
73.5%
47.0%
26.3%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Normal Tethered Cord Myelomeningocele
Continence Rate By Spinal Cord Findings
p = 0.008p < 0.0001reference
(n = 264)
(n = 19)
(n = 151)
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Summary of findings
75.4
57.4
31.8
72.9
56.1
31.2
73.5
47
26.5
0
10
20
30
40
50
60
70
80
90
100
mild moderate severe
Summary of Results
ARM subtype
Sacral Ratio
Spinal CordFindings
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Future Directions
• Further analysis
– Weighted influence of each anatomic factors
– Determine which anatomic factor over rides
the others
• Continence calculator based on ARM index
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Conclusion
• Anatomic factors are independently
predictive of achieving urinary continence
in ARM
– ARM subtype
– Lateral sacral ratio
– Spinal abnormalities