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Bar-Yosef Y, Savin Z, Ekstein M, Ben-David R, Dekalo S, Bar-Yaakov N, Sofer M, Ben-Chaim J. Preoperative Bladder Capacity Predicts Social Continence following Bladder Neck Reconstruction in Children Born with Exstrophy-Epispadias Complex. Eur J Pediatr Surg 2023; 33:510-514. [PMID: 36549335 DOI: 10.1055/a-2003-1823] [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: 12/24/2022]
Abstract
INTRODUCTION The aim of the study is to review the continence and volitional voiding rate in a single center cohort of exstrophy-epispadias patients following Young-Dees-Leadbetter bladder neck reconstruction and to explore factors which predict continence. MATERIALS AND METHODS Children who underwent Young-Dees-Leadbetter bladder neck reconstruction as a final stage of repair in a large single low-volume center in a small-population country between 1997 and 2019 were included. Demographic and clinical details were extracted from the patients' charts. The primary end point was continence and volitional voiding. Patients were categorized as incontinent, socially continent (daytime dry intervals > 3 hours, wet nights) and fully continent (daytime dry intervals > 3 hours, dry nights). RESULTS The study cohort included 27 patients whose median age at reconstruction was 5 years, and median follow-up was 7.8 years (interquartile range [IQR] 6-11.2). The cohort included 24 classic exstrophy patients (89%, 17 males and 7 females) and 3 isolated complete epispadias patients (11%, 1 male and 2 females). Nine (33%) patients achieved full continence and social continence was achieved by nine (33%) patients, for an overall social continence rate of 67%. Preoperative bladder capacity of 110 mL or more was associated with achieving social continence (odds ratio = 6.4, p = 0.047). The overall volitional voiding rate was 67%. CONCLUSION Young-Dees-Leadbetter bladder neck reconstruction yielded rates of 33% for full continence and 67% for social continence and volitional voiding. These rates are comparable to those of large high-volume centers. A preoperative capacity of 110 mL or more was the sole predictor of social continence.
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Affiliation(s)
- Yuval Bar-Yosef
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Ziv Savin
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Margaret Ekstein
- Department of Pediatric Anesthesia, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Reuben Ben-David
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Snir Dekalo
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Noam Bar-Yaakov
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Mario Sofer
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
| | - Jacob Ben-Chaim
- Department of Pediatric Urology, Dana-Dwek Children's Hospital, Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel
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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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Maruf M, Zhu J, Haffar A, Morrill C, Michaud J, Zaman MH, Sholklapper T, Jayman J, Manyevetch R, Davis R, Wu W, Harris TGW, Di Carlo HN, Yenokyan G, Gearhart JP. Bladder capacity and growth in classic bladder exstrophy: A novel predictive tool. J Pediatr Urol 2023; 19:564.e1-564.e7. [PMID: 37244839 DOI: 10.1016/j.jpurol.2023.05.005] [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: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 05/29/2023]
Abstract
INTRODUCTION Bladder capacity (BC) is an important metric in the management of patients with classic bladder exstrophy (CBE). BC is frequently used to determine eligibility for surgical continence procedures, such as bladder neck reconstruction (BNR), and is associated with the likelihood of achieving urinary continence. OBJECTIVE To use readily available parameters to develop a nomogram that could be used by patients and pediatric urologists to predict BC in patients with CBE. STUDY DESIGN An institutional database of CBE patients was reviewed for those who have undergone annual gravity cystogram 6 months after bladder closure. Candidate clinical predictors were used to model BC. Linear mixed effects models with random intercept and slope were used to construct models predicting log transformed BC and were compared with adjusted R2, Akaike Information Criterion (AIC), and cross-validated mean square error (MSE). Final model evaluated via K-fold cross-validation. Analyses were performed using R version 3.5.3 and the prediction tool was developed with ShinyR. RESULTS In total, 369 patients (107 female, 262 male) with CBE had at least one BC measurement after bladder closure. Patients had a median of 3 annual measurements (range 1-10). The final nomogram includes outcome of primary closure, sex, log-transformed age at successful closure, time from successful closure, and interaction between outcome of primary closure and log-transformed age at successful closure as the fixed effects with random effect for patient and random slope for time since successful closure (Extended Summary). DISCUSSION Using readily accessible patient and disease related information, the bladder capacity nomogram in this study provides a more accurate prediction of bladder capacity ahead of continence procedures when compared to the age-based Koff equation estimates. A multi-center study using this web-based CBE bladder growth nomogram (https://exstrophybladdergrowth.shinyapps.io/be_app/) will be needed for widespread application. CONCLUSION Bladder capacity in those with CBE, while known to be influenced by a broad swath of intrinsic and extrinsic factors, may be modeled by the sex, outcome of primary bladder closure, age at successful bladder closure and age at evaluation.
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Affiliation(s)
- Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jiafeng Zhu
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ahmad Haffar
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Christian Morrill
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jason Michaud
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mohammad H Zaman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Tamir Sholklapper
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John Jayman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Roni Manyevetch
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Rachel Davis
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Wayland Wu
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Thomas G W Harris
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Heather N Di Carlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins Biostatistics Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Michaud JE, Qiu H, DiCarlo HN, Gearhart JP. Inflammatory Expression Profiles in Bladder Exstrophy Smooth Muscle: Normalization Over Time. Urology 2023; 176:143-149. [PMID: 36921842 DOI: 10.1016/j.urology.2023.02.042] [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: 01/12/2023] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE To test the hypothesis that phenotypes in bladder exstrophy result from alterations in detrusor smooth muscle cell (SMC) gene expression. METHODS We generated primary human bladder smooth muscle cell lines from patients with classic bladder exstrophy (CBE) undergoing newborn closure (n = 6), delayed primary closure (n = 5), augmentation cystoplasty (n = 6), and non-CBE controls (n = 3). Gene expression profiles were then created using RNA sequencing and characterized using gene set enrichment analysis (GSEA). RESULTS We identified 308 differentially expressed genes in bladder exstrophy SMC when compared to controls, including 223 upregulated and 85 downregulated genes. Bladder exstrophy muscle cell lines from newborn closure and primary delayed closures shared expression changes in 159 genes. GSEA analysis revealed increased expression in the inflammatory response and alteration of genes for genitourinary development in newborn and delayed closure SMC. However, these changes were absent in SMC from older exstrophy patients after closure. CONCLUSION Bladder exstrophy SMC demonstrate gene expression changes in the inflammatory response and genitourinary development. However, gene expression profiles normalized in exstrophy SMC from older patients after closure, suggesting a normalization of exstrophy SMC over time. Our in vitro findings regarding the normalization of exstrophy SMC gene expression following bladder closure suggest that the development of poor detrusor compliance in bladder exstrophy has a complex multifactorial etiology. Taken together, our findings suggest that alterations in SMC gene expression may explain abnormalities in the exstrophy bladder seen prior to and immediately after closure and suggest that surgical closure may allow exstrophy SMC to normalize over time.
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Affiliation(s)
- Jason E Michaud
- Children's Hospital and Medical Center, University of Nebraska Medical Center, Omaha, NE.
| | - Haowen Qiu
- Center for Biotechnology, University of Nebraska-Lincoln, Lincoln, NE
| | - Heather N DiCarlo
- Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - John P Gearhart
- Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD
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A Single Center's Changing Trends in the Management and Outcomes of Primary Closure of Classic Bladder Exstrophy: An Evolving Landscape. Urology 2023:S0090-4295(23)00200-5. [PMID: 36898588 DOI: 10.1016/j.urology.2022.12.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 03/10/2023]
Abstract
OBJECTIVE To investigate management trends in a single institution with a large referral population in classic bladder exstrophy (CBE) over the past twenty years. METHODS An institutional database of 1415 exstrophy-epispadias complex patients was retrospectively reviewed for CBE patients with primary closure between 2000 and 2019. Osteotomy, location of closure, age of closure, and outcome of closures were reviewed. RESULTS A total of 278 primary closures were identified, with 100 occurring at author's hospital (AH) and 178 at outside hospitals (OSH). Osteotomies were performed in 54% of cases at AH and 52.8% of cases at OSH. Osteotomy use increased over 20 years from 48.6% in 00's to 62.1% in 10's (p=0.046). The total success rate at AH was 96% and 62.9% at OSH. The median age at primary closure at AH increased from 5 days (00's) to 20 days (10's), compared to the OSH which increased from 2 days (00's) to 3 days (10's). CONCLUSION Closure of CBE may be delayed for several reasons including insurance difficulties, transfer to another hospital, desire for second opinions, or surgeon preference. Delaying primary closure of bladder exstrophy gives families time to adjust lifestyle, arrange travel, and seek care at centers of excellence.
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Morrill CC, Manyevitch R, Haffar A, Wu WJ, Harris KT, Maruf M, Crigger C, Di Carlo HN, Gearhart JP. Complications of delayed and newborn primary closures of classic bladder exstrophy: Is there a difference? J Pediatr Urol 2023:S1477-5131(23)00002-5. [PMID: 36690520 DOI: 10.1016/j.jpurol.2023.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/29/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The authors aim to compare single institutional 30-day complication rates between delayed and neonatal closure of classic bladder exstrophy (CBE). MATERIALS AND METHODS An institutional database of 1415 exstrophy-epispadias patients was reviewed retrospectively for CBE patients who underwent primary closures at the authors' institution between 1990 and 2020. Patients were identified as having received either neonatal or delayed (at age >28 days) closures. All 30-day complications were recorded, including wound infection and dehiscence, genitourinary and non-genitourinary infections, bowel obstruction, blood transfusions, and others. Descriptive statistics were performed to summarize patient level data. Categorical variables were reported by count and percentages and were compared using Exact Cochran-Armitage trend analysis by decade, or with Fisher's Exact Test and Chi-square test when directly comparing categories and outcomes. Continuous variables were analyzed via Mann Whitney U and one-way ANOVA as appropriate. RESULTS The cohort included 145 patients: 50 delayed and 95 neonatal closures. The total complication rate was 58% in delayed closures compared to 48.4% for neonatal closures (p = 0.298), with the majority being Clavien-Dindo grade I or II. Excluding blood transfusion, complication rates fell to 26% and 34.7% in delayed and neonatal closures, respectively (p = 0.349). The most common single complication was unplanned post-operative blood transfusion (38% delayed; 26.3% neonatal; p = 0.34), followed by pyelonephritis (2% delayed; 8.4% neonatal), and urinary fistula (6% delayed; 1.1% neonatal). Grade III Clavien-Dindo complications occurred in 2% delayed and 7.4% neonatal groups (n = 1; n = 7 respectively; p = 0.263). A single delayed patient had grade IV complications compared to three neonatal patients (p = 0.66). CONCLUSIONS Delayed primary closure has become a frequently performed alternative in the modern treatment of bladder exstrophy for patients who do not undergo newborn closure because of prohibitive circumstances or surgeon's discretion. The majority of the complications associated with delayed closure are a low Clavien-Dindo grade and easily managed during the postoperative inpatient hospital stay. Families should be counseled about the possibility of minor, conservatively managed complications and likelihood of a blood transfusion with osteotomy.
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Affiliation(s)
- Christian C Morrill
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Roni Manyevitch
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmad Haffar
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Wayland J Wu
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kelly T Harris
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Chad Crigger
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Heather N Di Carlo
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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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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Wiener JS, Huck N, Blais AS, Rickard M, Lorenzo A, Di Carlo HNM, Mueller MG, Stein R. Challenges in pediatric urologic practice: a lifelong view. World J Urol 2020; 39:981-991. [PMID: 32328778 DOI: 10.1007/s00345-020-03203-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
Abstract
The role of the pediatric urologic surgeon does not end with initial reconstructive surgery. Many of the congenital anomalies encountered require multiple staged operations while others may not involve further surgery but require a life-long follow-up and often revisions. Management of most of these disorders must extend into and through adolescence before transitioning these patients to adult colleagues. The primary goal of management of all congenital uropathies is protection and/or reversal of renal insult. For posterior urethral valves, in particular, avoidance of end-stage renal failure may not be possible in severe cases due to the congenital nephropathy but usually can be prolonged. Likewise, prevention or minimization of urinary tract infections is important for overall health and eventual renal function. Attainment of urinary continence is an important goal for most with a proven positive impact on quality of life; however, measures to achieve that goal can require significant efforts for those with neuropathic bladder dysfunction, obstructive uropathies, and bladder exstrophy. A particular challenge is maximizing future self-esteem, sexual function, and reproductive potential for those with genital anomalies such as hypospadias, the bladder exstrophy epispadias complex, prune belly syndrome, and Mullerian anomalies. Few endeavors are rewarding as working with children and their families throughout childhood and adolescence to help them attain these goals, and modern advances have enhanced our ability to get them to adulthood in better physical and mental health than ever before.
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Affiliation(s)
- John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Nina Huck
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Anne-Sophie Blais
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Mandy Rickard
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada
| | - Armando Lorenzo
- Division of Pediatric Urology, Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Heather N McCaffrey Di Carlo
- The James Buchanan Brady Urologic Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret G Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Departments of Obstetrics & Gynecology and Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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