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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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Annabell L, Lee T, Barnett S, Ralston K, Lee R, Borer JG, Kim YJ. Is Immobilization Technique Associated With Postoperative Pubic Rami Diastasis Following Bladder Exstrophy Closure? J Pediatr Orthop 2024; 44:e469-e473. [PMID: 38477339 DOI: 10.1097/bpo.0000000000002664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE Pelvic osteotomies relieve tension of the bladder and fascial closures during bladder exstrophy repair. Multiple techniques for postoperative immobilization of the pelvis and lower extremities have been described. The primary aim of this study was to assess differences in short and long-term changes in pubic rami diastasis when comparing Bryant traction to spica cast immobilization. Secondary aims included a comparison of length of stay, skin-related complications, and urologic outcomes. METHODS We performed a single-institutional retrospective review of bladder exstrophy patients younger than 18 months of age who underwent posterior pelvic osteotomy and bladder exstrophy closure from April 2005 to April 2020. Short-term and long-term pubic rami diastasis were defined as postoperative measurements ≤6 months and ≥12 months, respectively. Secondary outcomes included length of stay, pressure ulcer, skin rash/abrasion, urethrocutaneous fistula, and bladder or fascial dehiscence rates. Multivariable logistic regression assessed for an association between immobilization type and degree of diastasis while controlling for age at the time of diastasis measurement and sex. RESULTS Fifteen patients underwent Bryant traction and 36 patients underwent spica cast immobilization. In both the short-term and long-term, there was a greater reduction in pubic diastasis in the spica cast group ( P = 0.002 and P = 0.05, respectively). After adjustments, there were higher odds of having a greater reduction in pubic rami diastasis in both the short-term (odds ratio: 2.71, 95% CI: 1.52-4.86, P = 0.001) and long-term (odds ratio: 2.41, 95% CI: 1.00-5.80, P = 0.05). Length of stay was significantly higher in Bryant's traction group (26 vs 19 d, P < 0.001). Rates of pressure ulcers were higher in the Bryant traction group (26.7% vs 0%, P = 0.005). Rates of skin rash/abrasions, urethrocutaneous fistula, and bladder/fascial dehiscence did not differ. CONCLUSIONS Spica cast immobilization is a safe and effective immobilization method. Compared with Bryant traction, spica cast immobilization was associated with a greater reduction in postoperative pubic diastasis both short and long-term, along with a shorter length of hospitalization and reduced rate of pressure ulcers. LEVEL OF EVIDENCE Level III-therapeutic study.
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Affiliation(s)
- Lucas Annabell
- Department of Orthopaedics, Royal Children's Hospital, Australia
| | | | - Samuel Barnett
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
| | | | | | | | - Young-Jo Kim
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
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Haffar A, Hirsch AM, Morrill CC, Crigger CC, Sponseller PD, Gearhart JP. Classic Bladder Exstrophy Closure Without Osteotomy or Immobilization: An Exercise in Futility? Urology 2023; 181:128-132. [PMID: 37696307 DOI: 10.1016/j.urology.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/11/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To review the outcomes of classic bladder exstrophy (CBE) closure without the use of osteotomy or lower extremity/pelvic immobilization. METHODS A prospectively maintained institutional approved exstrophy-epispadias complex database of 1487 patients was reviewed for patients with CBE who had undergone closure without osteotomy nor immobilization. All patients were referred to the authors' institution for reconstruction later in life or for failed closure. RESULTS Of a total of 1016 CBE patients, 56 closure events were identified that met inclusion with a total of 47 unique patients. Thirty-eight closures were completed prior to 1990 (67.9%). Forty-five closure events developed eventual failure (45/56, 80.4%) (Table 1). Thirteen closure events were secondary closures (13/56, 23.2%). The primary closure failure rate was 83.7% (36/43) while the secondary closure failure rate was 69.2% (9/13). Failures were attributed to one or more of dehiscence, bladder prolapse, and vesicocutaneous fistula (25/45, 55.6%) (23/45, 51.1%) (6/45, 13.3%), respectively. Thirty-seven patients developed social continence (37/47, 78.7%), while only 8 patients developed spontaneous voided continence (7/47,17.0%) (Table 2). The most common methods of voiding were continent catheterizable channels (25/47, 53.2%) of which all were socially continent. CONCLUSION These results illustrate the critical role osteotomy and postoperative immobilization can play in both primary and secondary exstrophy closure. While this is a historical case series, the authors believe that these results remain relevant to contemporary exstrophy surgeons.
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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
| | - Alexander M 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
| | - Christian C 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
| | - Chad C 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
| | - Paul D Sponseller
- Division of Pediatric Orthopedics, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Baltimore, MD
| | - 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.
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Haffar A, Morrill C, Crigger C, Sponseller PD, Gearhart JP. Fixation with lower limb immobilization in primary and secondary exstrophy closure: A saving grace. J Pediatr Urol 2022; 19:179.e1-179.e7. [PMID: 36610926 DOI: 10.1016/j.jpurol.2022.12.009] [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: 10/12/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE A pivotal factor in the success of bladder closure in patients with classic bladder exstrophy (CBE) is the postoperative immobilization of the pelvis and lower extremities after pelvic osteotomy. This study investigates the outcomes of closure among patients with lower limb immobilization using many techniques. The authors hypothesize that the addition of external fixation (pelvic immobilization) in patients with any form of limb immobilization will be associated with improved outcomes. METHODS A prospectively maintained institutional exstrophy-epispadias complex database of 1415 patients was reviewed for patients with CBE who had undergone closure with available immobilization and osteotomy data. Association between closure outcomes and immobilization techniques were determined. Univariate analysis was performed using Chi-Square or Fischer-Exact test as appropriate for categorical variables. Multivariate analysis via binomial logistic regression was used to identify factors leading to successful closure. RESULTS A total of 747 closure events matching the inclusion criteria were identified. Patients included 508 males and 239 females. There were 597 primary closures (79.9%) with 150 reclosure events (20.1%). Limb immobilization was used in 627 (83.9%) of closure events. Successful closures were associated with osteotomy use (p < 0.0001) and limb immobilization (p < 0.0001); specifically, the combined anterior innominate with posterior vertical iliac osteotomy and modified Buck's traction with external fixation (p < 0.0001, p < 0.0001). Among the group of 33 patients who received external fixation alone and no other type of immobilization, the failure rate was 33.3%, comparatively, patients with any form of combined immobilization (external fixation with lower limb immobilization) had a failure rate of 7.1% ( Table 1). Among patients immobilized with mummy wrap, spica casting, or knee immobilizers, external fixation was associated with 3.76 increased odds of successful closure (p = 0.0005, 95% CI 1.79-7.90). In a unique group of 67 patients without pelvic osteotomy or any form of pelvic or limb immobilization, the failure rate was 74.6%. DISCUSSION This study confirms, in a larger series, previous findings of improved outcomes when patients are immobilized with modified Buck's traction and external fixation. The authors apply this technique in most all closures and recommend this technique be utilized whenever feasible. However, regardless of the manner of lower limb immobilization, external fixation is a critical factor to optimize closures and ensure success. CONCLUSION The results of this study clearly suggest the use of external fixation can be protective against bladder closure failure. The use of pelvic immobilization, in addition to post-operative lower limb immobilization should be strongly considered.
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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
| | - 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
| | - 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
| | - Paul D Sponseller
- Division of Pediatric Orthopedics, 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.
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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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Ben Ahmed Y, Boulma R, Landolsi M, Boukesra T, Boussetta R, Hamza M, Chibani I, Guitouni A, Charieg A, Nouira F, Jlidi S. Quality of life of children operated for bladder exstrophy. Prog Urol 2021; 32:146-154. [PMID: 34244063 DOI: 10.1016/j.purol.2021.05.002] [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: 11/10/2020] [Revised: 05/13/2021] [Accepted: 05/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Bladder exstrophy is a rare malformation with functional and psychological issues affecting children's quality of life. This study aims to evaluate the urinary continence and the quality of life of patients operated for bladder exstrophy in our institution. METHODS This is a retrospective study including fifteen patients operated for bladder exstrophy between 1995 and 2015. All patients underwent a physical examination and an interview with a psychiatrist. Urinary continence was evaluated by dryness periods. Quality of life was evaluated by the QoL SF-36 scale. RESULTS All patients underwent primary early bladder closure. Posterior osteotomy was performed initially in 6 cases, and during the redo surgery in 7 cases. Leakage was recorded in 4 cases, fistula in 9 patients. Twelve patients had one or more redo surgery. Final bladder closure success rate was of 80%. Additional continence surgical procedures were performed by a Young Dees technique in 8 cases and with bladder enlargement associated with Mitrofanoff continent derivation in 5 cases. Only two patients over fifteen did not use diapers. All the items of QoL score according SF-36 were under the normal value (75%) except physical functioning and physical limitation. These scores go worst with age. Scores were better for continent boys in both physical and psychological items, but the difference was not significant However, significant difference was observed between boys having less than 3 surgeries and those having more than three procedures. Psychological and social scores were better for girls than for boys and differences were significant. CONCLUSIONS The risk of urinary incontinence is high in children managed for bladder exstrophy. Boys are more affected than girls with subsequent psychological and social repercussions. In our study, quality of life depends more on number of surgery than continence results. Psychological problems should be screened early for accurate treatment. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Y Ben Ahmed
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - R Boulma
- Urology unit surgery department FSI Hospital Tunis, Tunisia.
| | - M Landolsi
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - T Boukesra
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - R Boussetta
- Paediatric orthopedy department Children Hospital Bachir Hamza, Tunis, Tunisia
| | - M Hamza
- Pedo-psychiatric department, Marsa Hospital, Tunisia
| | - I Chibani
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - A Guitouni
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - A Charieg
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - F Nouira
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - S Jlidi
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
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Zaman M, Kasprenski M, Maruf M, Benz K, Jayman J, Friedlander D, Di Carlo H, Sponseller P, Gearhart J. Impact of pelvic immobilization techniques on the outcomes of primary and secondary closures of classic bladder exstrophy. J Pediatr Urol 2019; 15:382.e1-382.e8. [PMID: 31104999 DOI: 10.1016/j.jpurol.2019.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/14/2019] [Accepted: 04/10/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION A potential determinant of successful bladder closures in patients with classic bladder exstrophy (CBE) is the postoperative pelvic immobilization technique. This study investigates the success rates of primary and secondary bladder closures based on various immobilization techniques from a high-volume exstrophy center. METHODS A prospectively maintained institutional exstrophy-epispadias complex database of 1336 patients was reviewed for patients with CBE who have undergone primary or secondary closures between 1975 and 2018 and subsequently had a known method of pelvic immobilization. Patients were divided into two groups: primary and secondary closures. Associations between closure outcomes and immobilization techniques were determined. RESULTS A total of 476 patients with primary closures and 101 patients with secondary closures met the inclusion criteria. In total, 343 (72.1%) primary closures were successful. As shown in the table, the success rates of primary closures were highest in patients immobilized with modified Buck's and Bryant's traction (95.0% and 79.3%, respectively) and lowest in those with spica cast (49.6%). A propensity score-adjusted logistic regression (adjusting for osteotomy status, period of closure, location of closure, and closure type) revealed that modified Buck's traction had a 5.60 (95% confidence interval 1.74-23.1, p = 0.008) greater odds of success compared to spica casting during the primary closure. For the secondary closure group, there were 92 (92.1%) successful secondary closures. Success rates were highest in modified Buck's traction (97.3%) and lowest with spica casting (66.7%). DISCUSSION This study confirms previous findings of better outcomes when patients are immobilized with external fixation and Buck's traction after adjusting for potential confounding factors. Immobilization with modified Buck's or Bryant's traction yielded significantly higher primary closure success rates when compared to spica casting. It is the authors' belief that despite a longer hospital length of stay, external fixation with Buck's traction provides the best chance of a successful closure and, thus, a financially responsible method to care for these children in the postoperative period. CONCLUSIONS Success rates for primary closures were highest when using modified Buck's traction with external fixation and lowest for spica casts. Similarly, for secondary closures, the best outcomes were achieved using modified Buck's traction with external fixation and the lowest success rates were associated with spica casts.
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Affiliation(s)
- M Zaman
- 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
| | - M 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
| | - M 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
| | - K 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
| | - J 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
| | - D Friedlander
- 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
| | - H 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
| | - P Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - J 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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Sack BS, Borer JG. A single-institution experience of complete primary repair of bladder exstrophy in girls: risk factors for urinary retention. J Pediatr Urol 2019; 15:262.e1-262.e6. [PMID: 31023568 DOI: 10.1016/j.jpurol.2019.02.019] [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: 11/15/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Historically after complete primary repair of exstrophy (CPRE) in girls, it had been more likely to observe urinary incontinence than retention. Following recent technical modifications of elongating the urethra and narrowing the bladder neck, the authors have observed a high rate of urinary retention in girls after CPRE. OBJECTIVE The aim was to identify factors that may be responsible for this observation by reviewing historical and current outcomes. The authors hypothesized that differences in anatomic dimensions at the time of CPRE may contribute to urinary retention. STUDY DESIGN A retrospective review of girls who underwent CPRE from December 1998 through September 2016 from a single institution was performed. Patients were deemed in retention if their clinical course was consistent with such, required a procedure to relieve urinary retention, and/or required clean intermittent catheterization. RESULTS Nineteen girls underwent CPRE during this period. In 2012, a change to delaying CPRE to approximately 2 months of age was made, and this led the authors to divide their experience into CPRE performed as a newborn (<72 h of age, 8 patients) versus delayed (>72 h, 11 patients) subgroups. There were no girls with retention in the newborn group and three (38%) girls with retention in the delayed group. In the delayed group, girls had a longer urethral plate and narrower bladder neck compared with the newborn group. Long-term outcomes greater than 9 years are available for six girls in the newborn group and two (33%) required bladder neck procedures for incontinence. None in the delayed group have required incontinence procedures; however, follow-up is limited at 25 months. DISCUSSION The absence of retention in the newborn group is concerning for the delayed group incurring a higher risk of retention after CPRE. This may be secondary to excessive compression of the urethra at the time of pubic symphysis approximation potentially leading to urethral ischemia. Different from the newborn CPRE girls, additional technical revision of CPRE, namely, elongation of the urethra and the dissection it involves and narrowing of the bladder neck, may increase the risk for retention. CONCLUSIONS The multiple factors that were identified as potential contributors to post-CPRE urinary retention should result in a cautious reevaluation of female bladder exstrophy management at the time of CPRE. The authors now create a gradual tapered transition at the bladder neck and, similar to their previous experience, a more generous (wider) bladder neck and a shorter length for urethral plate.
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Affiliation(s)
- B S Sack
- The Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - J G Borer
- The Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Ahn JJ, Shnorhavorian M, Katz C, Goldin AB, Merguerian PA. Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis. J Pediatr Urol 2018; 14:27.e1-27.e5. [PMID: 29352663 DOI: 10.1016/j.jpurol.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/01/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods. OBJECTIVE The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure. STUDY DESIGN The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications. RESULTS Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999 to 2010, delayed closure was performed more frequently in this cohort (71% vs 27%). DISCUSSION The NSQIPP provides standardized reporting of peri-operative characteristics and 30-day complications, allowing a comparison of early to delayed closure of bladder exstrophy across multiple institutions. Assessing short-term risks in conjunction with long-term follow-up is crucial for determining optimal management of this rare but complex condition. CONCLUSION Delayed closure of bladder exstrophy is performed frequently, yet it carries a high rate of 30-day complications worthy of further investigation. This can be useful in counseling patients and families, and to understand practice patterns across the country.
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Affiliation(s)
- J J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - M Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - C Katz
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - A B Goldin
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA
| | - P A Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Abstract
Surgical repair of bladder exstrophy is an ongoing challenge for pediatric urologists. Postoperative immobilization is a mainstay of care to decrease tension on the repair site and is often utilized in conjunction with pelvic osteotomies performed in the same operative setting by pediatric orthopedic surgeons. Multiple pelvic immobilization techniques have been developed in conjunction with repair techniques including special techniques for neonates. The most commonly utilized techniques for pelvic immobilization are Buck's and Bryant's traction and spica casting. A multimodal pain management approach is critical with pelvic immobilization to minimize postoperative pain and anxiety associated with reconstructive surgery at a young age.
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Editorial Comment. J Urol 2016; 197:1143. [PMID: 28011225 DOI: 10.1016/j.juro.2016.09.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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