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Haffar A, Hirsch A, Morrill C, Harris TGW, Crigger C, Garcia A, Maxon V, Di Carlo HN, Monitto C, Gearhart JP, Hunsberger JB. Perioperative management of primary classic bladder exstrophy: A single institutional pathway to success. J Pediatr Urol 2024; 20:406.e1-406.e7. [PMID: 38245430 DOI: 10.1016/j.jpurol.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 12/04/2023] [Accepted: 01/08/2024] [Indexed: 01/22/2024]
Abstract
PURPOSE Appropriate perioperative management is crucial in patients undergoing classic bladder exstrophy closure (CBE). Therefore, the authors sought to review their intra and postoperative management of patients with CBE undergoing primary closure and examine the impact of this pathway on patient outcomes. METHOD A prospectively maintained institutional approved exstrophy-epispadias complex database was reviewed for patients with CBE who had undergone primary closure between 2016 and 2022 and whose closure was performed within one year of age. Electronic medical records for eligible patients were retrospectively reviewed to examine patient demographics, use of pelvic osteotomy, immobilization status, pediatric intensive care unit (PICU) admission and management, perioperative analgesia and sedation, nutritional support, drainage tubes, blood transfusions, antibiotic coverage, hospital length of stay, postoperative complications, and closure failure. RESULTS A total of 25 patients were identified, 22 with CBE and 3 with variant CBE. Closure was performed at a median age of 84 days with patients ranging in age from 9 to 351 days. All patients underwent osteotomy and immobilization with modified Buck's traction and external fixation for a median duration of 41 days. A suprapubic tube was placed in all patients for a median duration of 46.5 days. All patients underwent PICU admission following closure for a median duration of 8 days. Ventilator support was required in 68 % of patients for a median of 3 days. Epidural analgesia was used in all patients and catheters were maintained for a median duration of 19 days. All patients received a blood transfusion over the course of their admission. Patient-controlled analgesia was used in most patients as an adjunct for a median duration of 38.5 days. Other commonly used analgesic adjuncts included acetaminophen, diazepam, clonidine, and dexmedetomidine. TPN was used in 80 % of patients for a median of 7 days with a return of oral feeding thereafter. Overall, the closure success rate in this cohort of patients was 100 %. DISCUSSION The outcome of primary bladder closure can have inauspicious consequences that can affect a child's continence for years. The incidence of failed bladder closure can be minimized with the implementation of a detailed plan for immobilization, analgesia, and nutrition guided by an experienced multi-disciplinary team. CONCLUSION We have identified several guiding principles for perioperative success in exstrophy patients at our center including Buck's traction with external fixation, provision of adequate postoperative analgesia and sedation, aggressive nutritional support, renal and bladder drainage, and robust antibacterial support. Our high success rate in managing this complex pathology demonstrates its validity and use as a pathway to success.
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Affiliation(s)
- Ahmad Haffar
- 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.
| | - Alexander Hirsch
- 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
| | - Christian Morrill
- 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
| | - Thomas G W Harris
- 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
| | - Chad Crigger
- 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
| | - Adelaide Garcia
- 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
| | - Victoria Maxon
- 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
| | - Heather N Di Carlo
- 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
| | - Constance Monitto
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John P 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
| | - Joann B Hunsberger
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Khandge P, Morrill CC, Wu WJ, Harris KT, Haffar A, Maruf M, Patel HD, Di Carlo HN, Gearhart JP. Achieving goal capacity for continence surgery: A cumulative event analysis of bladder exstrophy patients. J Pediatr Urol 2023; 19:563.e1-563.e8. [PMID: 37246118 DOI: 10.1016/j.jpurol.2023.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Following successful closure of patients with classic bladder exstrophy (CBE), the next major milestone is the establishment of urinary continence. Prior to determining the most appropriate continence surgery, it is imperative to reach an adequate bladder capacity minimum of 100 cc in order to make the decision between bladder neck reconstruction (BNR) or continent stoma, with or without augmentation cystoplasty (AC). OBJECTIVE To examine the timing of when patients achieve threshold bladder capacity for BNR eligibility. We hypothesize most patients will achieve an adequate bladder capacity (100 cc) by 7 years old when continence surgeries will begin to be considered. STUDY DESIGN An institutional database of 1388 exstrophy patients was retrospectively reviewed for CBE patients after successful primary bladder closure. Bladder capacities were measured via gravity cystography and data presented as descriptive statistics. The cohort was stratified by location, neonatal (≤28 days) or delayed closure period and osteotomy status. The bladder capacities were categorized to either reaching goal or not and a cumulative event analysis was performed. The event being reaching 100 cc capacity or greater and time being the number of years between bladder closure and attainment of goal capacity. RESULTS 253 patients met inclusion criteria between 1982 and 2019. The majority were of male gender (72.9%), had their closure performed at the authors' institution (52.5%), within the neonatal period (80.7%), and without an osteotomy (51.7%). 64.9% of patients reached goal bladder capacity. There were no significant differences in those who did or did not achieve goal except for clinical follow up. Cumulative event analysis demonstrated a median time of 5.73 years (95% CI 5.2-6.20) corresponded with a 50% event probability of reaching goal capacity. Cox-proportional hazards showed location of closure was significantly associated with hazards of reaching goal bladder capacity (HR = 0.58, CI 0.40-0.85, p = 0.005). Based on this model, the median time to event would be 5.20 years (95% CI 4.76-5.80) for cases done at the authors' hospital and 6.26 years for those performed at an outside hospital (95% CI 5.77-7.24). CONCLUSIONS These findings help surgeons counsel families appropriately on the odds of attaining goal capacity at various ages. For those who do not reach 100 cc by five years of age, it helps further characterize the odds of requiring a continent stoma with bladder augmentation and the best timing for reconstructive surgery in order to safely gain urinary continence. Families may also be assured that most patients would have the breadth of surgical options when it comes to continence as more than half of patients reached the bladder capacity threshold.
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Affiliation(s)
- Preeya Khandge
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Christian C Morrill
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Wayland J Wu
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kelly T Harris
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmad Haffar
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahir Maruf
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Hiten D Patel
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Heather N Di Carlo
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John P Gearhart
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Rudin AY, Rudin YE, Sokolov YY. Anatomical features of the malformation, methods and results of bladder exstrophy primary closure. Literature review. ANDROLOGY AND GENITAL SURGERY 2023. [DOI: 10.17650/2070-9781-2022-23-4-55-63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- A. Yu. Rudin
- Children’s City Clinical Hospital of St. Vladimir of the Moscow Healthcare Department
| | - Yu. E. Rudin
- Children’s City Clinical Hospital of St. Vladimir of the Moscow Healthcare Department; N.A. Lopatkin Scientific Research Institute of Urology and Interventional Radiology – branch of the National Medical Research Radiological Centre, Ministry of Health of Russia; Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia
| | - Yu. Yu. Sokolov
- Children’s City Clinical Hospital of St. Vladimir of the Moscow Healthcare Department; Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia
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Hofmann A, Haider M, Promm M, Neissner C, Badelt G, Rösch WH. Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery. J Pediatr Surg 2022; 57:303-308. [PMID: 35000729 DOI: 10.1016/j.jpedsurg.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Successful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management. MATERIAL AND METHODS We reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay. RESULTS 66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13-34 d). CONCLUSION Delayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aybike Hofmann
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany.
| | - Maximilian Haider
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Claudia Neissner
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Gregor Badelt
- Department of Pediatric Anesthesiology, Clinic St. Hedwig, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
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Agbara KS, Moulot OM, Ehua MA, Konan JM, Yapo Kouamé GS, Traoré I, Anon GA, Ajoumissi I, Konvolbo J, Bankolé RS. Bladder exstrophy: Modern staged repair experience in our institution. Afr J Paediatr Surg 2022; 19:167-170. [PMID: 35775519 PMCID: PMC9290361 DOI: 10.4103/ajps.ajps_167_20] [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] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Bladder exstrophy is a major malformation in paediatric urology. The treatment results are not still completely satisfactory, and their management is an enormous problem in Sub-Saharan Africa. While outlining our challenges, we report our management experience to improve our results. SUBJECTS AND METHODS We retrospectively reviewed the records of patients undergoing surgical repair of classic bladder exstrophy at our department between January 2010 and December 2019 (10 years). Epidemiological, clinical, therapeutic and evolution data were analysed. RESULTS Twenty-five children with classic bladder exstrophy were treated. Our series included 16 boys and 9 girls with a sex ratio of 1.7. Age ranged from 0 day to 6 years. Twenty-five bladder closures were performed, associated to pelvic osteotomy in 11 cases. Epispadias repair was performed on nine boys. Eight cases of bladder neck reconstruction and three cases of bladder enlargement were performed. We observed six bladder fistulas, four wound dehiscence, of which three partial, two parietal suppurations and six cases of urinary tract infection. Eight children had a continence of 1-2 h. CONCLUSION The treatment of bladder exstrophy in our context is still limited because of financial difficulties encountered by the population and the insufficient technical platform in our country.
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Affiliation(s)
- Kouam Soroboua Agbara
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Olivier Martial Moulot
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Manuela Adjoba Ehua
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Jean Marie Konan
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Guy Serge Yapo Kouamé
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody, Abidjan, Ivory Coast
| | - Ibrahim Traoré
- Department of Mother-Children, Teaching Hospital, Bouaké, Ivory Coast
| | - Ghislain Anon Anon
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Idalia Ajoumissi
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Josaphat Konvolbo
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Roumanatou Sanni Bankolé
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
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Promm M, Otto W, Weber F, Götz S, Burger M, Müller K, Rubenwolf P, Neuhuber W, Roesch WH. Expression of Low Affinity Nerve Growth Factor Receptor p75 in Classic Bladder Exstrophy. Front Pediatr 2021; 9:634343. [PMID: 33692976 PMCID: PMC7937696 DOI: 10.3389/fped.2021.634343] [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: 11/27/2020] [Accepted: 02/01/2021] [Indexed: 12/04/2022] Open
Abstract
Successful primary closure of classic bladder exstrophy (BE) is crucial for development of bladder capacity and voided continence. It is universally agreed that an intensive pain management including the use of caudal epidural anesthesia is an essential cornerstone for the outcome of this complex surgery. Whether and to what extent pain is caused by structural or functional changes is not yet known. The nerve growth factor (NGF) is regarded as a marker for pain in different bladder disorders. This prospective study investigated the role of histological alterations and NGF in patients with BE including 34 patients with BE and 6 patients with congenital vesicoureterorenal reflux (VUR) who served as controls. Between January 2015 and April 2020 transmural bladder biopsies were taken from the posterior bladder wall during delayed primary bladder closure. The samples were stained for histological evaluation and subjected to immunohistochemistry to analyze NGFR p75. Differences in histological alterations were examined with Fisher's exact test, and Mann-Whitney-U-test was used to compare the NGFR p75 staining intensity between patients with BE and controls. Patients with BE showed significantly more often acute inflammation (p < 0.001), squamous metaplasia (p = 0.002), and cystitis glandularis (p = 0.005) as well as NGFR p75 in the urothelium (p = 0.003) than patients with VUR. A limitation of this study is the small number of participants due to the rare disease entity. Similar to other painful bladder disorders, pain transmission in BE after intitial closure may in part be facilitated by elevated NGF signaling through its receptor.
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Affiliation(s)
- Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany
| | - Wolfgang Otto
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Florian Weber
- Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Stefanie Götz
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Peter Rubenwolf
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany.,Department of Urology, University Medical Center Frankfurt, Frankfurt, Germany
| | - Winfried Neuhuber
- Institute of Anatomy and Cell Biology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang H Roesch
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany
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Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience. Int Urol Nephrol 2020; 53:191-198. [PMID: 32980929 DOI: 10.1007/s11255-020-02648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To represent the 15 years' experience of an academic referral center for the reconstruction of bladder exstrophy-epispadias complex with a modified single-stage approach. Single-staged reconstruction techniques are commonly used for classic bladder exstrophy. However, combined bladder closure and epispadias repair have been taken into great consideration in patients with initially failed reconstruction or delayed primary closure. METHODS A total of 49 boys underwent 1-stage bladder and epispadias repair with pubic bone adaptation and without the application of pelvic osteotomy. The mean ± SD age at surgery was 5.23 ± 2.04 months. Continence and social dryness were assessed in the follow-ups with 3 months intervals for the first year and biannually thereafter. RESULTS The mean ± SD of follow-up was 127.25 ± 71.32 months. Urethrocutaneous fistula, stricture, wound infection, and hemiglans were developed in six distinct patients. However, no other major complications were noted. Three patients (6.1%) remained incontinent; while 32 (65.3%) children were socially continent and 14 (28.6%) children were waiting for toilet training. All the patients without previous failed closure were socially continent, while all incontinent patients had two failed closures in their history. No patient was rendered hypospadiac. CONCLUSION Based on the experience of this institution, the application of single-stage reconstructive techniques can lead to continence, cosmetically pleasing appearance with promising outcomes, and reduction of overall operations, hospital stay and costs in the majority of cases as compared to multiple surgical procedures.
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Sabetkish S, Kajbafzadeh AM. Bladder Herniation as an Auto-Augmentation Technique in Bladder Exstrophy: Initial Experience in Patients with Small Bladder Plate. Urology 2020; 139:151-155. [PMID: 32105656 DOI: 10.1016/j.urology.2020.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To present our long-term experience of bladder plate herniation technique in patients with bladder exstrophy epispadias complex (BEEC) and inadequate bladder plate. METHODS Ten BEEC patients with inadequate bladder plates were referred. The bladder underlying fascia was opened and the exstrophic bladder was fixed above the peritoneal cavity to herniate the peritoneal contents beneath the bladder plate so that the abdominal pressure would be directly transferred to the posterior bladder wall; causing gradual bladder expansion and auto-augmentation. In 5 patients, the inguinal hernia was fixed to increase the pressure transferred to the exstrophic bladder. The bladder capacity was measured while the patient was crying and when the bladder was enlarged. Cystometry and voiding cystourethrogram were performed before the application of this technique and during the next 6 to 8 months, to determine the bladder capacity for further primary bladder closure. RESULTS The bladder was enlarged during straining/crying without any complications. The average bladder capacity was increased about 2.5 to 3 times after 8 months of follow-up so that it was suitable for undergoing primary closure. None of the children needed bladder augmentation following the single-stage total BEEC reconstruction. CONCLUSION This technique seems to be safe, effective, and feasible in patients with small-sized bladder and may be performed before the primary closure to increase the success rate. This technique may be effective in increasing the bladder capacity for staged bladder closure and bladder neck reconstruction without further need for bladder augmentation.
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Affiliation(s)
- Shabnam Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI).
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Ebert AK, Zwink N, Reutter HM, Jenetzky E, Stein R, Hölscher AC, Lacher M, Fortmann C, Obermayr F, Fisch M, Mortazawi K, Schmiedeke E, Promm M, Hirsch K, Schäfer FM, Rösch WH. Treatment Strategies and Outcome of the Exstrophy-Epispadias Complex in Germany: Data From the German CURE-Net. Front Pediatr 2020; 8:174. [PMID: 32509709 PMCID: PMC7248227 DOI: 10.3389/fped.2020.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: To evaluate the impact of reconstructive strategies and post-operative management on short- and long-term surgical outcome and complications of classical bladder exstrophy (CBE) patients' comprehensive data of the multicenter German-wide Network for Congenital Uro-Rectal malformations (CURE-Net) were analyzed. Methods: Descriptive analyses were performed between 34 prospectively collected CBE patients born since 2009, median 3 months old [interquartile range (IQR), 2-4 months], and 113 cross-sectional patients, median 12 years old (IQR, 6-21 years). Results: The majority of included individuals were males (67%). Sixty-eight percent of the prospectively observed and 53% of the cross-sectional patients were reconstructed using a staged approach (p = 0.17). Although prospectively observed patients were operated on at a younger age, the post-operative management did not significantly change in the years before and after 2009. Solely, in prospectively observed patients, peridural catheters were used significantly more often (p = 0.017). Blood transfusions were significantly more frequent in males (p = 0.002). Only half of all CBE individuals underwent inguinal hernia repair. Cross-sectional patients after single-stage reconstructions showed more direct post-operative complications such as upper urinary tract dilatations (p = 0.0021) or urinary tract infections (p = 0.023), but not more frequent renal function impairment compared to patients after the staged approach (p = 0.42). Continence outcomes were not significantly different between the concepts (p = 0.51). Self-reported continence data showed that the majority of the included CBE patients was intermittent or continuous incontinent. Furthermore, subsequent consecutive augmentations and catheterizable stomata did not significantly differ between the two operative approaches. Urinary diversions were only reported after the staged concept. Conclusions: In this German multicenter study, a trend toward the staged concept was observed. While single-stage approaches tended to have initially more complications such as renal dilatation or urinary tract infections, additional surgery such as augmentations and stomata appeared to be similar after staged and single-stage reconstructions in the long term.
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Affiliation(s)
- Anne-Karoline Ebert
- Department of Pediatric Urology, University Hospital for Urology and Pediatric Urology, University Medical Center Ulm, Ulm, Germany
| | - Nadine Zwink
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Heiko M Reutter
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany.,Institute of Human Genetics, University Hospital Bonn, Bonn, Germany
| | - Ekkehart Jenetzky
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Child Center Maulbronn GmbH, Hospital for Pediatric Neurology and Social Pediatrics, Maulbronn, Germany
| | - Raimund Stein
- Department of Pediatric and Adolescent Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Alice C Hölscher
- Department of Pediatric Surgery and Pediatric Urology, Children's Hospital Amsterdamer Straße Köln, Köln, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Caroline Fortmann
- Center of Pediatric Surgery Hannover, Hannover Medical School and Bult Children's Hospital, Hannover, Germany
| | - Florian Obermayr
- Department of Pediatric Surgery and Pediatric Urology, University Hospital for Child and Adolescent Medicine Tübingen, Tübingen, Germany
| | - Margit Fisch
- Department of Urology and Pediatric Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kiarasch Mortazawi
- Department of Pediatric Surgery, Klinik für Kinderchirurgie, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Pediatric Urology, Center for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Karin Hirsch
- Department of Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Frank-Mattias Schäfer
- Pediatric Surgery and Pediatric Urology, Cnopfsche Children's Hospital, Nürnberg, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
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Di Carlo HN, Maruf M, Jayman J, Benz K, Kasprenski M, Gearhart JP. The inadequate bladder template: Its effect on outcomes in classic bladder exstrophy. J Pediatr Urol 2018; 14:427.e1-427.e7. [PMID: 29909193 DOI: 10.1016/j.jpurol.2018.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/23/2018] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Newborns with classic bladder exstrophy (CBE) may present with a bladder template that is inadequate for closure in the neonatal period (figure). In these cases, a delayed primary closure (DPC) is conducted to permit growth of the bladder template. This study reports the surgical and long-term urinary continence outcomes of poor template CBE patients undergoing DPC and compares them to patients who underwent DPC for reasons unrelated to bladder quality (i.e., prematurity, comorbidities, or a late referral). METHODS An institutionally approved, prospectively maintained database of 1330 exstrophy-epispadias complex patients was reviewed for CBE patients who underwent DPC at the authors' institution. A bladder template was considered inadequate for neonatal closure if found to be inelastic, <3 cm in diameter, and/or covered in hamartomatous polyps. RESULTS In total, 63 patients (53 male and 10 female) undergoing DPC were identified. Of these, 36 had poor bladder templates (group 1). The remaining 27 patients (group 2) had adequate templates and their bladder closure was delayed for reasons unrelated to bladder quality. At the time of DPC, those in group 1 were relatively than those in group 2 (median of 229 vs. 128 days, p = 0.094). All 36 group 1 patients and 26 (96%) group 2 patients underwent pelvic osteotomy during DPC (p = 0.429). All patients in this study had a successful primary closure. There was little difference in longitudinal bladder capacities between group 1 and group 2 (p = 0.518). Also, there was minimal difference in the median number of continence procedures between groups, with both groups having 1 (IQR 1-1) continence procedure (p = 0.880). Eight patients in group 1, and three patients in group 2 underwent a bladder neck transection with urinary diversion. Of the 13 and 16 patients who have undergone a continence procedure in group 1 and 2, respectively, 11 (84.6%) and 13 (81.3%) are continent of urine. The age of first continence procedure was different between groups 1 and 2 at 8.0 years (5.8-9.9 years) and 4.8 (3.5-6.0 years), respectively p = 0.009. The majority of patients in group 1 established continence at a relatively later age when compared to those in group 2, at 11.4 (8.0-14.8) years and 7.9 (2.6-13.2) years of age respectively p = 0.087. DISCUSSION In the authors' view, neonatal bladder closure is ideal for CBE patients as it minimizes potential damage to exposed bladder mucosa. However, prior studies indicate that the rate of bladder growth for patients undergoing a delayed primary closure does not differ from patients with a neonatal closure. Results from this study show continued evidence that patients with poor templates who undergo delayed closure have excellent primary closure outcomes, which is critical for further management. Furthermore, this study shows that an inadequate bladder does not affect DPC outcomes or the continence outcomes in DPC patients. However, the inadequate template does affect the type of continence procedure available to a DPC patient, the age of first continence procedure, and the age of continence. CONCLUSIONS DPC of the exstrophic bladder has a high rate of success when pelvic osteotomy is utilized as an adjunct. Patients having a DPC for reasons of an inadequate bladder template have comparable rates of bladder growth when compared to DPC of an adequate bladder template. The inadequate bladder template affects the type of continence procedure, with the majority of patients requiring urinary diversion for continence. Patients with an inadequate bladder template have a later age of first continence procedure and a relatively later age of continence, because of an inherently smaller bladder template at birth. The inadequate bladder template patients require a longer period of surveillance to access bladder growth and capacity in preparation of a continence procedure. Furthermore, as the majority of inadequate bladder template patients require a catheterizable channel for continence, the age of continence is also likely influenced by the patient's preparation as they transition from volitional voiding to catheterization.
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Affiliation(s)
- Heather N Di Carlo
- 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
| | - 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
| | - Karl Benz
- 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
| | - Mathew 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
| | - John P 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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Kasprenski M, Benz K, Jayman J, Lue K, Maruf M, Baumgartner T, Gearhart JP. Combined Bladder Neck Reconstruction and Continent Stoma Creation as a Suitable Alternative for Continence in Bladder Exstrophy: A Preliminary Report. Urology 2018; 119:133-136. [DOI: 10.1016/j.urology.2018.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/27/2018] [Accepted: 05/08/2018] [Indexed: 11/25/2022]
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Jayman J, Tourchi A, Shabaninia M, Maruf M, DiCarlo H, Gearhart JP. The Surgical Management of Bladder Polyps in the Setting of Exstrophy Epispadias Complex. Urology 2017; 109:171-174. [DOI: 10.1016/j.urology.2017.06.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/09/2017] [Accepted: 06/14/2017] [Indexed: 11/30/2022]
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Goldstein SD, Inouye BM, Reddy S, Lue K, Young EE, Abdelwahab M, Grewal M, Wildonger S, Stec AA, Gearhart JP. Continence in the cloacal exstrophy patient: What does it cost? J Pediatr Surg 2016; 51:622-5. [PMID: 26775195 DOI: 10.1016/j.jpedsurg.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical advancements have made cloacal exstrophy (CE) a survivable condition, though management remains complex. Urologic, orthopedic, colorectal and gynecologic interventions are not standardized, and the cost of this care is high. While the importance of a successful primary closure in terms of outcomes is known, the economic consequences of failure remain uncharacterized. METHODS A prospectively maintained institutional database of epispadias-exstrophy complex patients was reviewed for continent CE patients. Hospital charges for all inpatient admissions prior to achieving urinary continence were inflation-adjusted to year 2013 values using Consumer Price Index for medical care published by the United States Bureau of Labor Statistics. Records for which charge data were incomplete were completed by using single mean imputation, also inflation-adjusted. Descriptive data are presented as mean±standard deviation (SD). RESULTS Of 102 CE patients, 35 had available hospital charge data: 15 who underwent successful primary closure at the authors' institution and 20 who presented after previously failed primary closures at referring institutions. The mean±SD hospital charges for primary closure in the success group were $136,201±$48,920. These patients then underwent subsequent additional surgeries that accrued charges of $59,549±$25,189 in order to achieve continence. Overall, successful primary closures accumulated hospital charges of $200,366±$40,071. In comparison, patients referred after prior failure required significantly more hospital admissions and additional charges of $207,674±$65,820 were required to achieve continence (p<0.001). Patients who failed primary closure are estimated to accumulate 70% more total health care charges compared to the group following successful primary closure. CONCLUSION The cost of CE management until urinary continence is high, averaging more than $200,000 in inpatient hospital charges alone. Initial success is desirable from both an outcomes and economic perspective, as the cost of salvaging a failed primary closure at our institution is similar to the overall costs of a successful closure; this is in addition to the cost of any previous failed closures. Further studies will be required to determine the optimal timing of surgical management in terms of both patient outcomes and financial consequences.
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Affiliation(s)
- Seth D Goldstein
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005.
| | - Brian M Inouye
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Sunil Reddy
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Kathy Lue
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Ezekiel E Young
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Mahmoud Abdelwahab
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Mehnaj Grewal
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Spencer Wildonger
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005
| | - Andrew A Stec
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - John P Gearhart
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
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Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast. J Pediatr Urol 2015; 11:212.e1-4. [PMID: 25982019 DOI: 10.1016/j.jpurol.2015.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/02/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION/OBJECTIVE Secure closure of the pubic diastasis during bladder exstrophy and epispadias repair decreases the abdominal wall tension at the time of reconstruction. Pelvic osteotomies are routinely performed at the time of abdominal wall and bladder reconstruction in order to more easily facilitate pubic symphyseal diastasis approximation. Postoperative pelvic immobilization is performed by methods that include modified Buck's traction, modified Bryant's traction, and spica casting. People undergoing closure often require inpatient hospitalization for 2-8 weeks because of the pelvic immobilization. The present study examined the findings from a clinical pathway for early discharge after complete primary repair of exstrophy (CPRE) and proximal epispadias repair with spica casting. METHODS The present study is a retrospective review of patients that underwent pelvic osteotomies with spica casting at the time of CPRE or proximal epispadias repair from November 2006 to March 2013. All patients had anterior innominate osteotomies and spica cast pelvic immobilization. RESULTS Pelvic osteotomies and spica cast pelvic immobilization were performed on 17 children. The median postoperative stay was 6.0 days and the subdivided results are in Table. No children experienced an abdominal or orthopedic complication. A few children required minor cast adjustments to relieve pressure. After cast removal, no skin breakdown, pressure necrosis, or nerve palsy were found. The median length of casting without pinning was 31 (26-48) days. DISCUSSION The use of spica cast pelvic immobilization after exstrophy and epispadias repair is safe and allows for earlier discharge when compared to other methods of pelvic immobilization. However, although the family appreciates early discharge and additional bonding, the priority is the success of the closure. The present findings demonstrate, and are corroborated by other spica cast publications, that spica casting is as effective as modified Bryant's traction or modified Buck's traction. The success rates for CPRE with spica casting are similar to published staged repairs and have the benefit of allowing for bladder cycling, which potentially enables better bladder growth and development. If success and complication rates are comparable amongst the different pelvic immobilization groups, then variables including hospital length of stay and cost become appropriate comparisons. CONCLUSION The shortened discharge time, along with a significant decrease in acuity of care leads to significant decreases in hospital costs. Additional hospital stay when using modified Bryant's traction or modified Buck's traction with external fixation will accrue significant hospital costs.
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Pakdaman R, Woodward PJ, Kennedy A. Complex Abdominal Wall Defects: Appearances at Prenatal Imaging. Radiographics 2015; 35:636-49. [DOI: 10.1148/rg.352140104] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Sub-urothelial polyp enucleation resection and urothelial auto-augmentation cystoplasty: a simple method for bladder exstrophy-epispadias complex reconstruction in bladder plate polyposis. Pediatr Surg Int 2014; 30:669-76. [PMID: 24802675 DOI: 10.1007/s00383-014-3510-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To report the results of a novel technique of sub-urothelial polyp enucleation resection (SUPER) and urothelial auto-augmentation cystoplasty (UAAC) in patients with bladder exstrophy and polyposis plate. METHODS Twenty-eight patients with bladder exstrophy covered by plate polyposis were referred for further management. From these, 12 patients had undergone SUPER, UAAC technique, and subsequent bladder closure. In this technique, the urothelium covering the polyps was utilized as tissue for auto-augmentation cystoplasty. Sixteen patients had been operated by simple polyps' excision and bladder closure. Biopsies of polyps were obtained in both groups at the time of closure for pathological evaluations. The bladder plate was measured pre-and post-bladder plate augmentation. The patients were evaluated every 3 months for 1 year and biannually thereafter for urinary continence and social dryness. Dry period of >3 h during the day with or without nocturnal incontinence was defined as social dryness. RESULTS All patients experienced an uneventful postoperative period. No sign of metaplasia or dysplasia was observed in the histological and cystoscopy evaluations. These findings suggest that neither polyp recurrence nor bladder tumor development has occurred in any of the groups. The urinary continence improved significantly in the polyp's urothelial coverage augmentation cystoplasty technique (66.7%), while 31.3% of patients in simple closure technique achieved continence. Significantly higher mean bladder capacity was obtained in the augmentation group (190 ± 38 ml) and (119 ± 21 ml), respectively. Postoperative mild hydronephrosis and vesicoureteral reflux were significantly lower in auto-augmentation technique. CONCLUSION The final clinical outcome of children with bladder exstrophy polyposis is promising. The combined SUPER and UAAC technique is feasible, safe and reproducible option for bladder exstrophy-epispadias complex (BEEC) patients with bladder plate polyposis. However, it will add one supplementary operation to the single or staged bladder reconstruction. These patients may warrant further surveillance with histopathological evaluations during the adult life.
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Mushtaq I, Garriboli M, Smeulders N, Cherian A, Desai D, Eaton S, Duffy P, Cuckow P. Primary bladder exstrophy closure in neonates: challenging the traditions. J Urol 2013; 191:193-7. [PMID: 23871929 DOI: 10.1016/j.juro.2013.07.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2013] [Indexed: 11/17/2022]
Abstract
PURPOSE We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy. MATERIALS AND METHODS We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test. RESULTS A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were $42,732 for patients admitted to the intensive care unit and $16,214 for those admitted directly to the surgical ward (p <0.0001). CONCLUSIONS Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.
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Affiliation(s)
- I Mushtaq
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - M Garriboli
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom; Department of Pediatric Surgery, UCL Institute of Child Health, London, United Kingdom
| | - N Smeulders
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - A Cherian
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - D Desai
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - S Eaton
- Department of Pediatric Surgery, UCL Institute of Child Health, London, United Kingdom
| | - P Duffy
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| | - P Cuckow
- Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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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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Massanyi EZ, Gearhart JP, Kost-Byerly S. Perioperative management of classic bladder exstrophy. Res Rep Urol 2013; 5:67-75. [PMID: 24400236 PMCID: PMC3826855 DOI: 10.2147/rru.s29087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare congenital malformation of the genitourinary system, abdominal wall muscles, and pelvic structures. Modern surgical repairs focus on reconstruction of the bladder and its adjacent structures, with the goal of achieving urinary continence, a satisfactory cosmetic result, and a high quality of life. Complex surgery in neonates and young children, as well as a prolonged postoperative course require close collaboration between surgeons, anesthesiologists, intensivists, pediatricians, and an experienced nursing staff. This article will review the spectrum of bladder exstrophy anomalies, the surgical repair, and the perioperative interdisciplinary management.
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Affiliation(s)
- Eric Z Massanyi
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - John P Gearhart
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - Sabine Kost-Byerly
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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