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Tariqi R, Hamdaoui J, Boualaoui I, Ibrahimi A, El Sayegh H, Nouini Y. The latissimus dorsi flap for the repair of an eventration on bladder exstrophy in an adult patient: A case report. Int J Surg Case Rep 2024; 121:109939. [PMID: 38917698 DOI: 10.1016/j.ijscr.2024.109939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE This case report describes the successful use of a latissimus dorsi muscle flap attached to the femoral vessels to cover a large mass loss in a 27-year-old woman with bladder exstrophy. The two-stage reconstruction showed excellent results six months after surgery. CASE PRESENTATION A 27-year-old woman with bladder exstrophy and previous enterocystoplasty with Mitrofanoff-type urinary diversion combined with a late fascial flap presented 10 years later with disembowelment near the pubic symphysis. A two-stage reconstruction using a latissimus dorsi flap and polypropylene mesh was performed with excellent aesthetic and functional results. CLINICAL DISCUSSION The latissimus dorsi muscle flap, described by J.M. Servant in 1984 as the "apple turnover" technique, is highly reliable for reconstructing large substance losses with minimal functional sequelae. The procedure in this case resulted in very satisfactory aesthetic and functional results at six months postoperatively. This approach provided a safe and effective technique of last resort. CONCLUSION the two-stage latissimus dorsi flap technique was a reliable, safe and effective solution for this complex reconstructive challenge.
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Affiliation(s)
- Reda Tariqi
- Department of Urologic Surgery "A" Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco.
| | - Jihane Hamdaoui
- Department plastic surgery Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Imad Boualaoui
- Department of Urologic Surgery "A" Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Ahmed Ibrahimi
- Department of Urologic Surgery "A" Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Hachem El Sayegh
- Department of Urologic Surgery "A" Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
| | - Yassine Nouini
- Department of Urologic Surgery "A" Ibn Sina University Hospital, Mohammed V University, Rabat, Morocco
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Haney NM, Crigger CB, Sholklapper T, Mudalegundi S, Griggs-Demmin A, Nasr IW, Sponseller PD, Gearhart JP. Pelvic osteotomy in cloacal exstrophy: A changing perspective. J Pediatr Surg 2023; 58:478-483. [PMID: 35906108 DOI: 10.1016/j.jpedsurg.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The type of osteotomy and pelvic fixation in the management of primary cloacal exstrophy (CE) closure is variable. The purpose of this study was to evaluate primary CE closure outcomes with osteotomy, immobilization, and multi-staging procedure trends over time. METHODS An institutional database was retrospectively reviewed for patients who underwent primary CE closure from 1960 to 2020. Demographics, osteotomy, fixation, and outcomes were noted. Subanalyses by location of primary closure (AH=author's hospital; OH=outside hospital). RESULTS Out of 122 patients, multi-stage became more common than single-stage procedures (p = 0.019), with multi-stage associated with higher success rates (77.4% v 45.7%; p = 0.001). The use of any osteotomy increased over time (p = 0.007), with a posterior approach falling out of favor and increasing prevalence of a combined osteotomy (p<0.001). The use of any osteotomy compared to no osteotomy was associated with successful closure (77.6% v 41.7%; p = 0.007). The combined, posterior, and anterior approaches were associated with 90%, 76.2%, and 60.9% successful primary closure rates, respectively (p<0.001). Fixation modalities changed over time as Buck's traction (p<0.001) and external fixation (p<0.001) became more prevalent. Spica casting has become less common (p = 0.0002). Immobilization type was associated with success rates with Buck's (92.1%; p<0.001) and external fixation (86.0%; p<0.001) performing best. CONCLUSIONS The use of osteotomy and fixation in the CE spectrum has changed markedly. In this cohort, a staged approach with combination osteotomy was associated with better outcomes when using a multidisciplinary team approach. LEVEL OF EVIDENCE This is a retrospective comparative study (Type of Study: Treatment; Evidence Level: III).
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Affiliation(s)
- Nora M Haney
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States.
| | - Chad B Crigger
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Tamir Sholklapper
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Shwetha Mudalegundi
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Angelica Griggs-Demmin
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Isam W Nasr
- Department of Pediatric Surgery, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Paul D Sponseller
- Department of Pediatric Orthopedics, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - John P Gearhart
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
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Mini-open Anterior Pelvic Osteotomy and Spica Casting for Primary Closure of the Pelvis in Infants With Classic Bladder Exstrophy. J Pediatr Orthop 2022; 42:e1001-e1007. [PMID: 36053027 DOI: 10.1097/bpo.0000000000002260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study was to investigate the efficacy and safety of mini-open Salter-like anterior pelvic osteotomy followed by spica casting as an adjunct to urological reconstruction in infants with classic bladder exstrophy (CBE). METHODS Twenty-eight infants with CBE were operated upon according to the following protocol: initial bilateral mini-open Salter-like osteotomies followed by urological reconstruction and subsequent spica casting for 3 to 4 weeks. Postoperative clinical and radiologic assessments of wound complications and union were done, respectively. During subsequent follow-ups, the foot progression angle (FPA), the interpubic (IP) distance, interischial (IS) distance, and the IS/IP ratio were measured. The Pearson correlation was used to correlate between age at the time of last follow-up, the FPA, the IP and IS distances, and the IS/IP ratio. RESULTS The mean age at the time of operation was 5.89±0.89 months. The operative procedure took 10 to 15 minutes (mean of 12.5±1.5 min) for each side and the blood loss was negligible. Tension-free complete approximation of the symphysis was achieved in all cases. No wound complications were reported in any case. The total duration of the cast was 3.07±0.14 weeks. The mean duration of follow-up was 4.78±3.09 years. Strong positive correlation was found between the IP and IS distances ( r =0.833, P <0.0001) as well as the IS distance and age (r=0.455, P =0.015). CONCLUSION Mini-open anterior pelvic osteotomy and spica casting may provide a minimally invasive and effective option for closure of the pelvis in infants with CBE. LEVEL OF EVIDENCE Level IV-case series.
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Hip Prognosis in Patients With Congenital Diastasis of the Pubic Symphysis. J Pediatr Orthop 2022; 42:246-252. [PMID: 35180723 DOI: 10.1097/bpo.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Congenital diastasis of the pubic symphysis (CDPS) is a rare musculoskeletal malformation in the exstrophy-epispadias complex that is potentially associated with the development of hip dysplasia. The purpose of this study was to investigate the incidence and prognostic factors of hip dysplasia in patients with CDPS. METHODS Fifty-four hips in 27 patients with CDPS initially evaluated between 1983 and 2016 were retrospectively reviewed. The mean age at the first visit was 2.3 (0 to 8) years. The mean follow-up duration was 10.5 (1 to 36) years. Patient characteristics at the first visit, the clinical course at the most recent follow-up, and radiologic parameters on pubic malformation and hip dysplasia during at least 2 time points (first visit or age 1, and either the most recent visit or before hip surgery) were evaluated. Prognostic factors associated with the development of hip dysplasia were analyzed using univariate/multivariate analysis. The Kaplan-Meier survival curves were generated and compared based on these factors. RESULTS Nine of 27 patients (33%) and 13 of 54 hip joints (24%) with CDPS developed hip dysplasia. Paraplegia (odds ratio, 10.0; 95% confidence interval, 1.7-76.6) and center-edge angle of <5 degrees at the first visit or age 1 (P<0.001) were independent predictors of the development of hip dysplasia. Patients with CDPS and either paraplegia or center-edge angle <5 degrees at the first visit or age 1 were significantly more likely to develop hip dysplasia than other patients (hazard ratio, 29.3; 95% confidence interval, 3.4-250). CONCLUSIONS Approximately one third of patients with CDPS develop hip dysplasia. Paraplegia and center-edge angle of <5 degrees at the first visit are independent risk factors. LEVEL OF EVIDENCE Level III.
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Goetze C, Migliorini F, Peterlein CD. Total hip arthroplasty in patients with severe hip dysplasia and congenital pubic diastasis: report of two cases. BMC Musculoskelet Disord 2021; 22:814. [PMID: 34556076 PMCID: PMC8461941 DOI: 10.1186/s12891-021-04702-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/13/2021] [Indexed: 11/21/2022] Open
Abstract
Background Congenital bladder exstrophy is a rare malformation which is often associated with pubic diastasis and hip dysplasia. We reported the case two patients who underwent total hip arthroplasty (THA) due to advanced osteoarthritis combined with large congenital pubic diastasis (> 10 cm). Case presentation The first patient, a 39 years old woman with a pubic diastase and severe hip dysplasia on both sides was treated with a primary two-staged bilateral THA. Both hips were treated with a cementless osteoconductive cup (TM, Zimmer-Biomet) and a cementless stem (Alloclassic SL, Zimmer-Biomet). A 10° elevated rim liner of the cup was used in order to avoid dislocation. The main problem was represented by the fixation of the cup, given the retroverted acetabulum along with the elevated rotation centre due to the dysplastic hips. In the case two, a 52 years woman presented dysplastic osteoarthritis of the left hip. A conventional hemispherical cup (Alloclassic-Allofit, Zimmer-Biomet) was placed in the retroverted acetabulum combined with a cementless stem (Fitmore A, Zimmer-Biomet) attached at the metaphyseal proximal femur bone. Conclusion Our results suggest that THA may be a good strategy to manage advanced hip osteoarthritis in patients with dysplasia and congenital pubic diastasis. Level of evidence IV, case series.
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Affiliation(s)
- Christian Goetze
- Department of Orthopaedics, Auguste-Viktoria Clinic, Ruhr University Bochum, 32545, Bad Oeynhausen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany.
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Shamseer C M, Pandiyan A, Rao P A, Shafeekh M, Theruvil B. Pubic Diastasis in Polytrauma Patients: Traumatic or Congenital?: A Report of 2 Cases. JBJS Case Connect 2021; 11:01709767-202109000-00013. [PMID: 34237037 DOI: 10.2106/jbjs.cc.20.00835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report 2 patients who were involved in high-velocity road traffic accidents. Both these patients had congenital pubic diastasis with very subtle clinical and radiological signs that were misdiagnosed as posttraumatic diastasis on initial radiographic evaluation. CONCLUSION Trauma surgeons should be aware of this anomaly because congenital pubic diastasis could present without any major clinical signs and could easily be mistaken for a traumatic diastasis.
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Affiliation(s)
| | - Alagu Pandiyan
- Deparment of Orthopaedics, Medical Trust Hospital, Kochi, India
| | - Anush Rao P
- Deparment of Orthopaedics, VPS Lakeshore Hospital, Kochi, India
| | | | - Bipin Theruvil
- Deparment of Orthopaedics, VPS Lakeshore Hospital, Kochi, India
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Role of the Pubic Symphysis in Osseous Pelvic Development: A Novel Model of Bladder Exstrophy in Rabbits. J Pediatr Orthop 2021; 41:e181-e187. [PMID: 33136931 DOI: 10.1097/bpo.0000000000001698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND It has been posited that the osseous pelvic anomalies seen in patients with classic bladder exstrophy (CBE) result from disruption of the pubic symphysis. This hypothesis, however, has not been tested. In the present animal study, our objective was to determine whether the tension of the pubic symphysis helps maintain the shape of the pelvic ring, or whether the growing bones maintain a ring shape even without the tension of the symphysis. METHODS In total, 12 neonatal New Zealand White rabbits underwent pubic symphysiotomy (experimental group, n=9) or sham surgery (control group, n=3) on days 3 or 4 of life. Rabbits were scanned with cone-beam computed tomography at 1, 4, 12, and 20 weeks postoperatively to monitor changes in the following pelvic parameters, which are known to be altered in CBE: anterior segment angle, anterior segment length, intertriradiate distance, interpubic distance, and posterior segment angle. Changes within the experimental and control groups were evaluated using repeated-measures analysis of variance and post hoc Tukey honest significant difference testing. Two-tailed t tests were used to compare treatment groups at each time point. RESULTS Both groups showed increases in anterior segment length and intertriradiate distance during the study period; rabbits in the experimental group also showed a steady increase in interpubic distance (F=43.9; P<0.001). Experimental rabbits had significantly larger mean values for anterior segment angle, intertriradiate distance, interpubic distance, and posterior segment angle than did control rabbits at all time points. We found no difference in mean anterior segment length between control and experimental groups at any time point. The difference in interpubic distance was particularly pronounced by 20 weeks (experimental group, 13±2.7 mm; control group, 1.1±0.1 mm; P<0.001). CONCLUSIONS The pubic symphysis is essential for normal pelvic development. Its absence led to early pelvic angulation and progressive pubic separation in a rabbit model. However, we found no significant difference in the mean anterior segment length, and it is likely that other factors are also implicated in the growth disturbance seen in CBE. LEVEL OF EVIDENCE Level V.
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James Sam C, Kurian JJ, Kishore R, Arunachalam P, Sen S. Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction. J Pediatr Urol 2020; 16:836.e1-836.e8. [PMID: 33067135 DOI: 10.1016/j.jpurol.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA). AIM The aim of this study is to assess the outcome of dehisced exstrophy, using a RAM flap assisted redo closure (without PBA) with concomitant or subsequent further reconstruction. MATERIALS AND METHODS This is a retrospective analysis of children who presented with dehisced exstrophy after repair in other institutions and who have undergone redo repair using RAM flap in two tertiary care centers from 2001 to 2019. The outcome of the redo closure and subsequent or concomitant further reconstruction as regards dryness, stability of the upper tracts and resolution of vesico ureteric reflux (VUR) was studied. RESULTS Fifty five children (34 boys) underwent redo exstrophy repair for dehisced exstrophy using the RAM flap. Epispadias repair was performed concomitantly in 31 boys. In 26 children (group1) of mean age 12 months further surgery was deferred while in 29 children (group 2) of mean age 69 months underwent concomitant BA. Nine group 1 children underwent BA subsequently. Ureteric reimplantation was done at the time of BA in 54 ureters, 40 into the bladder plate and rest into the bowel segment of BA. 22 ureters were not reimplanted. Bladder neck surgery including 18 bladder neck closure and Mitrofanoff port for Clean Intermittent catheterization (CIC) were done along with BA. The RAM assisted bladder closure was event free and none needed redo operation. 35/38 augmented children are dry on Mitrofanoff CIC and one unaugmented boy voids normally. The upper tracts remain stable on ultrasound and VUR has resolved in 67/76 ureters. At current follow up, after a mean period of 53 months eGFR was normal in all except 3 who had initially presented with severe hydro uretero nephrosis. CONCLUSION We present a simple and reliable method of repair of dehisced exstrophy using RAM flap with the feasibility of concomitant BA. Dryness was achieved with stable upper tracts in 36/39 children, 27 of them with a single reconstructive attempt.
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Affiliation(s)
- Cenita James Sam
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
| | - Jujju Jacob Kurian
- Department of Paediatric Surgery, Christian Medical College, Vellore, Tamilnadu, 632004, India.
| | - Ravi Kishore
- Department of Paediatric Surgery, Christian Medical College, Vellore, Tamilnadu, 632004, India.
| | - Pavai Arunachalam
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
| | - Sudipta Sen
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India
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New Insights on the Basic Science of Bladder Exstrophy-epispadias Complex. Urology 2020; 147:256-263. [PMID: 33049233 DOI: 10.1016/j.urology.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 11/20/2022]
Abstract
The exstrophy-epispadias complex is a rare congenital anomaly presenting as a wide spectrum of disorders. The complex nature of this malformation leads to continuous investigations of the basic science concepts behind it. Elucidating these concepts allows one to fully understand the mechanisms behind the disease in order to improve diagnosis, management, and treatment ultimately leading to improvement in patient quality of life. Multiple technological advancements within the last 10 years have been made allowing for new studies to be conducted. Herein, the authors conduct a literature review of studies from 2009 to 2019, considering novel theories regarding the genetics, embryology, bladder, bony pelvis, prostate, and genitalia of patients with bladder exstrophy-epispadias complex.
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Abstract
OBJECTIVE. The purpose of this article is to describe the imaging findings associated with complex fetal abdominal wall defects and provide an algorithmic method for arriving at a final diagnosis. CONCLUSION. Fetal ventral abdominal wall defects are a complex group of conditions with a broad spectrum of associated multisystem anomalies and manifestations. Correct characterization and classification of these defects require not only familiarity with imaging findings but also a systematic approach to avoid diagnostic confusion.
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Jayman J, Michaud J, Maruf M, Trock BJ, Kasprenski M, Sponseller P, Gearhart J. The dual-staged pathway for closure in cloacal exstrophy: Successful evolution in collaborative surgical practice. J Pediatr Surg 2019; 54:1761-1765. [PMID: 31003729 DOI: 10.1016/j.jpedsurg.2019.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION A successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures. METHODS A prospective database of 1332 Exstrophy-Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected. RESULTS There are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011). CONCLUSION The standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- John Jayman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Jason Michaud
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Bruce J Trock
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew Kasprenski
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Paul Sponseller
- Division of Pediatric Orthopedic Surgery, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
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Abstract
Bladder exstrophy is a congenital and rare malformation of the lower abdominal wall with exposure of the bladder mucosa to the external environment, and it is related to pelvis abnormalities. Eighteen patients with bladder exstrophy were treated with bilateral oblique pelvic osteotomy in conjunction with urologic reconstruction after they were stabilized by cast. No failure of midline closure was observed (wound dehiscence or recurrence of bladder exstrophy). Follow-up showed no leg length discrepancy or problems in walking. Bilateral oblique pelvic osteotomy is a safe procedure to treat bladder exstrophy, and it results in good orthopedic and urological function.
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Nhan DT, Sponseller PD. Bilateral Anterior Innominate Osteotomy for Bladder Exstrophy. JBJS Essent Surg Tech 2019; 9:e1. [PMID: 31086719 DOI: 10.2106/jbjs.st.18.00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Bladder exstrophy is a congenital condition that affects the genitourinary and musculoskeletal systems, and less commonly affects the intestinal system, with cloacal exstrophy. This condition results from abnormal migration of the mesenchyme, between the endoderm and ectoderm, leading to anterior rupture of the cloacal membrane. Numerous osseous morphologic changes are observed in bladder exstrophy. Rotational anomalies include external rotation of the posterior part of the pelvis and iliac wings, on average 12°, and acetabular retroversion1-3. Although various osteotomy types have been described for initial bladder exstrophy closure, the anterior approach has demonstrated positive outcomes in improving daytime continence, gait, and correction of the diastasis4. Thus, the anterior iliac osteotomy provides an effective method to help close the pelvic ring and decrease stress on the anterior abdominal wall during exstrophy closure. In addition, this technique promotes continence by reconfiguring, and thereby restoring, the fibrous symphyseal bar and pelvic floor musculature5. Description The steps of the procedure include (1) preoperative planning, (2) patient positioning, (3) incision, (4) identification of the lateral femoral cutaneous nerve, (5) subperiosteal dissection of the iliac wing, (6) guide pin placement and anterior osteotomy, (7) posterior hinge osteotomy (for cloacal exstrophy and for patients ≥2 years old), (8) external fixator pin placement, (9) anterior internal fixation of the pubic symphysis (for cloacal exstrophy and for patients ≥2 years old), and (10) resumption of the urologic procedure followed by wound closure and application of external fixator. Alternatives Numerous previous techniques for osteotomies in bladder exstrophy have been developed, starting with Shultz in 1958, who recognized the importance of bringing the pubic bones together for gait correction in exstrophy repair6. O'Phelan was the first, to our knowledge, to document outcomes of this bilateral posterior osteotomy technique to reduce tension from the externally rotated iliac bones and widened pubic symphysis in a 2-stage bladder exstrophy closure7. Other approaches have included an oblique iliac wing osteotomy and pubic ramotomy, described by Frey and Cohen in 19898. However, the latter approach inadequately restores the pelvic osseous relations except in female newborns who would have a small diastasis after manual rotation of the pelvis. Rationale This procedure has several advantages over the prior conventional posterior approach. These include better approximation and improved mobility of the pubic rami at the time of closure, prevention of vertical migration of the hemipelvis, direct visual placement of an external fixator and adjustment postoperatively, and no requirement for turning the patient during the operation. In addition, this procedure allows for adjunctive posterior osteotomy from the anterior approach to provide adequate closure in those with cloacal exstrophy, prior failed closure, or extreme diastasis of >6 cm9.
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Preece J, Asti L, Ambeba E, McLeod DJ. Peri-operative transfusion risk in classic bladder exstrophy closure: Results from a national database review. J Pediatr Urol 2016; 12:208.e1-6. [PMID: 27282549 DOI: 10.1016/j.jpurol.2016.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/22/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Classic bladder exstrophy (CBE) is one of the most complex pediatric urologic conditions, with patients often requiring multiple procedures throughout their lives. Patients undergoing these complex surgeries may require blood transfusion, exposing them to the risks of transfusion including antibody reactions, transmission of infectious diseases, and transfusion-related immunomodulation. We sought to determine the prevalence of and risk factors for peri-operative transfusion in patients undergoing closure for CBE. Because of the complexity of CBE management, we hypothesized that a significant number of patients undergoing closure of CBE would require peri-operative transfusion. METHOD Patients undergoing CBE closure between 2012 and 2014 were retrospectively identified by Current Procedure Terminology codes from The National Surgical Quality Improvement Program Pediatric database, which includes data from 64 participating hospitals. Patient demographics, pre-operative characteristics including comorbidities, intra-operative characteristics, and post-operative outcomes were analyzed for associations with transfusion requirement intra-operatively or in the first 72 h post-operatively. RESULTS Seventy-eight patients met our criteria, of whom 45 (57.7%) underwent transfusion. Patient characteristics and outcomes are noted in the Table. There was no difference between the groups in terms of age or gender. Patients who underwent transfusion were more likely to be over 3 days of age than those who did not (93.3% versus 75.8%; p = 0.046). Transfused patients were also more likely to have undergone osteotomy (82.2% versus 48.5%; p = 0.002), had an external fixation (46.7% versus 6.1%; p < 0.001), had longer median operative times (447 versus 295 min; p < 0.001), and had longer median post-operative lengths of stay (LOS) (35 versus 17 days; p = 0.003). There was no difference between the groups in terms of pre-operative risk factors or post-operative complications. CONCLUSIONS A significant number of patients undergoing CBE closure required transfusion in the peri-operative period (57.7%). Patient characteristics found to have a higher rate of transfusion included osteotomy, external fixation, increased operative times, and longer post-operative LOS. In children undergoing closure for CBE, a large number require transfusion. The rate of transfusion is greater in older children and children undergoing osteotomy. Although osteotomy has a potentially important clinical role, especially in older patients, this study emphasizes the need for proper family counseling to include the increased likelihood of a blood transfusion and the risks associated with blood transfusion if osteotomies are performed.
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Affiliation(s)
- Janae Preece
- Section of Pediatric Urology at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Lindsey Asti
- Nationwide Children's Hospital Center for Surgical Outcomes Research, Columbus, OH, USA
| | - Erica Ambeba
- Nationwide Children's Hospital Center for Surgical Outcomes Research, Columbus, OH, USA
| | - Daryl J McLeod
- Section of Pediatric Urology at Nationwide Children's Hospital, Columbus, OH, USA; Nationwide Children's Hospital Center for Surgical Outcomes Research, Columbus, OH, USA
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Roller BL, Dyer RB. The "manta ray" pelvis. Abdom Radiol (NY) 2016; 41:1666-7. [PMID: 26971339 DOI: 10.1007/s00261-016-0706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Brandon L Roller
- Department of Radiology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27157, USA.
| | - Raymond B Dyer
- Department of Radiology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, Medical Center Blvd., Winston-Salem, NC, 27157, USA
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Kohler JE, Friedstat JS, Jacobs MA, Voelzke BB, Foy HM, Grady RW, Gruss JS, Evans HL. Reconstruction of the symphysis pubis to repair a complex midline hernia in the setting of congenital bladder exstrophy. Hernia 2014; 19:681-4. [PMID: 25156539 DOI: 10.1007/s10029-014-1294-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 07/28/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE A 40-year-old man with congenital midline defect and wide pubic symphysis diastasis secondary to bladder exstrophy presented with a massive incisional hernia resulting from complications of multiple prior abdominal repairs. Using a multi-disciplinary team of general, plastic, and urologic surgeons, we performed a complex hernia repair including creation of a pubic symphysis with rib graft for inferior fixation of mesh. METHODS The skin graft overlying the peritoneum was excised, and the posterior rectus sheath mobilized, then re-approximated. The previously augmented bladder and urethra were mobilized into the pelvis, after which a rib graft was constructed from the 7th rib and used to create a symphysis pubis using a mortise joint. This rib graft was used to fix the inferior portion of a 20 × 25 cm porcine xenograft mesh in a retro-rectus position. With the defect closed, prior skin scars were excised and the wound closed over multiple drains. RESULTS The patient tolerated the procedure well. His post-operative course was complicated by a vesico-cutaneous fistula and associated urinary tract and wound infections. This resolved by drainage with a urethral catheter and bilateral percutaneous nephrostomies. The patient has subsequently healed well with an intact hernia repair. The increased intra-abdominal pressure from his intact abdominal wall has been associated with increased stress urinary incontinence. CONCLUSIONS Although a difficult operation prone to serious complications, reconstruction of the symphysis pubis is an effective means for creating an inferior border to affix mesh in complex hernia repairs associated with bladder exstrophy.
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Affiliation(s)
- J E Kohler
- Department of Surgery, Harborview Medical Center, Box 359796, Seattle, WA, 98104-2499, USA
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Abstract
Intoeing, a common entrance complaint in infants, toddlers, and young children, is best defined as internal rotation of the long axis of the foot to the line of progression. Intoeing may be caused by primary deformities within the foot, issues with tibial torsion, and femoral antetorsion (anteversion). Problems within the foot include hallux varus, metatarsus adductus, talipes equinovarus, and pes cavus, each of which has specific treatments available. Treatment must be individualized, and the risks and complications weighed against the predictable morbidity of intoeing.
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Affiliation(s)
- Edwin Harris
- Department of Orthopaedics and Rehabilitation, Loyola University Chicago, Stritch School of Medicine, 2160 South First Avenue, Maywood, IIlinois; Private Practice, 10540 West Cermak Road, Westchester, IL 60154, USA.
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Wallis MC, Oottamasathien S, Wicher C, Hadley D, Snow BW, Cartwright PC. Padded self-adhesive strap immobilization following newborn bladder exstrophy closure: the Utah straps. J Urol 2013; 190:2216-20. [PMID: 23810641 DOI: 10.1016/j.juro.2013.06.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Several methods have been described for immobilization of the pelvis following bladder exstrophy closure, which can be challenging to manage. We hypothesized that immobilization can be significantly simplified using a modified mermaid wrap with padded Velcro® straps around the thigh and lower leg. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent bladder exstrophy closure in the newborn period at our institution from 1990 through 2010. Patients with cloacal exstrophy and those who underwent delayed closure due to other medical conditions were excluded. We collected data on closure technique, length of stay and complications of the primary closure as outcomes. RESULTS A total of 20 boys and 7 girls underwent closure of classic bladder exstrophy. Followup ranged from 2 to 22 years. Seven boys underwent complete primary repair and 13 underwent staged repair. All patients had the legs stabilized with a modified wrap technique using 2 lengths of Velcro straps lined with self-adhering open cell foam pads for 3 weeks. Complications of exstrophy closure included bladder dehiscence in 1 patient (4%) and incisional hernia in 2 (7%). Following complete primary repair urethrocutaneous fistula developed in 2 patients and urethral stricture in 2. Average length of stay for patients without significant prematurity was 15 days. CONCLUSIONS Padded Velcro strap immobilization simplifies postoperative care, provides secure fixation, decreases length of stay, and enables parents to hold and bond with the child shortly after repair. We advocate this simplified technique, which can be applied with a rate of complications that is comparable to other procedures.
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Affiliation(s)
- M Chad Wallis
- Division of Pediatric Urology, University of Utah School of Medicine, Salt Lake City, Utah.
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