Delayed Primary Repair of Bladder Exstrophy: Ultimate Effect on Growth

Bladder capacity and growth in classic bladder exstrophy: A novel predictive tool

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.

Complications of delayed and newborn primary closures of classic bladder exstrophy: Is there a difference?

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.

Intraoperative laser angiography in bladder exstrophy closure: A simple technique to monitor penile perfusion

BACKGROUND

The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach.

OBJECTIVE

We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure.

STUDY DESIGN

Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1 mg per 10 kg body weight. Measurements were taken at 80 s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure.

RESULTS

Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up.

CONCLUSIONS

This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality.

An evaluation of perioperative surgical procedures and complications in classic bladder exstrophy patients Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P)

INTRODUCTION

Classic bladder exstrophy (CBE) repair report wide variation in success. Given the complexity of CBE care, benefit would be derived from validation of reported outcomes. Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data, this manuscript evaluates surgical complications for bladder closure and advanced urologic reconstruction in CBE patients.

AIM

The primary aim of this study was to determine complication rates in the CBE population for bladder closure and advanced urologic reconstruction in national studies compared to single-institutional studies.

STUDY DESIGN

Pediatric cases and complications were identified in the 2012-2019 NSQIP-P database in CBE patients who had either bladder closure or advanced urologic reconstruction. Bladder closure was further defined as early (<7 days) or delayed (>7 days). Differences were assessed using Fisher's exact test and analysis was conducted using SPSS with significance defined as p-value <0.05.

RESULTS

302 patients were included; 152 patients underwent bladder closure, and 150 patients underwent advanced urologic reconstruction. The 30-day complication rate for bladder closure is 30.3% and for advanced urologic reconstruction is 24.0% in the CBC cohort. No differences were found in the rates of NSQIP complications between early and delayed bladder closure, though significant differences (p < 0.001) were found in the rates of blood transfusion (17.9 vs 65.3%). This may be due to the different rates of osteotomy (25.0 vs 48.3%) between early and delayed bladder closure. Rates of readmission are 14.7% and rates of reoperation are 8.0% for advanced urologic reconstruction procedures. Both bladder closure and advanced urologic reconstruction had infectious issues in greater than 10% of the population.

DISCUSSION

CBE surgeries nationally carry a higher risk of complications than is reported in most institutional studies. Infectious complications occur greater than 10% of the time in both bladder closure and advanced urologic reconstruction, which should be the source of additional study given the inverse relationship infections pose to surgical success in BE patients. A limitation of this study is that the data is derived from Children's hospitals that elect to participate and includes only data from 30 days after a procedure.

CONCLUSION

CBE complication data for both bladder closure and advanced urologic reconstruction may be underrepresented in the literature.

Contemporary Management of Urinary Tract Infections in Children

Purpose of Review

Urinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice.

Recent Findings

With recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs.

Summary

The American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.

Delaying primary closure of classic bladder exstrophy: When is it too late?

INTRODUCTION

With current trends towards delaying the closure of classic bladder exstrophy (CBE), bladder growth rate or ultimate capacity may be impacted.

OBJECTIVE

To examine consecutive bladder capacities in CBE patients who had primary closures at differing ages and determine whether there is an optimal age for closure, with reference to bladder capacity.

STUDY DESIGN

A retrospective review was performed using an institutional database.

INCLUSION CRITERIA

CBE, successful neonatal (i.e. ≤28 days old) or delayed (i.e. >28 days old) primary closure, at least three consecutive bladder capacities or two measures taken 18 months apart, and first bladder capacity measured ≥3 months after closure. Only capacities prior to continence surgery and before 14 years of age were considered. Two cohorts were created: neonatal and delayed closure. To account for repeated measurements per patient, a linear mixed model evaluated effects of age and length of delay on bladder capacity based on closure cohort. Individuals in the delayed closure group were further stratified into quartiles to assess for detriment to the bladder based on length of delay.

RESULTS

The cohort included 128 neonatal and 38 delayed patients. Median age at closure for the delayed group was 193 days (IQR 128-299). Based on univariate analysis, for the first three capacity measurements, the delayed group had significantly lower capacities despite having a similar median age when the measurements were taken. Linear mixed effects model showed significantly decreased total bladder capacity in delayed closure compared to neonates. The 2nd and 4th quartile groups had the most significant decreases in capacity.

DISCUSSION

Time points for the most significant decline appear after the 2nd and 4th quartiles, representing 4-6 months and beyond 9 months, respectively. From this, the authors theorize that the appropriate time to close an exstrophy patient is as early as possible (1st quartile), or, if a delay is needed for growth of a bladder template, then between 6 and 9 months (3rd quartile). There may be a detriment to growth rate, however, statistical power may be lacking to discern this. Study limitations include the single-centered, retrospective design. However, results described here fill an important deficit in the knowledge of managing CBE.

CONCLUSIONS

All patients in the delayed bladder closure group demonstrated a decline in bladder capacity compared to the control neonatal closure group, with significant differences in the 2nd and 4th quartiles. Thus, closing the bladder prior to nine months of age is recommended.

Practice patterns in classic bladder exstrophy: A global perspective

INTRODUCTION

While evaluation and management options for classic bladder exstrophy (CBE) patients are numerous and varied, little is known regarding the relative utilization of these different methods throughout the world. A large group of exstrophy surgeons practicing globally was surveyed, seeking to document their methods of care.

METHODS

A list of international exstrophy surgeons' email addresses was compiled using professional contacts and referral networking. An online survey was sent to each email address. Surgeons who had not performed a CBE closure within the previous 5 years were excluded. Survey questions queried the respondents' surgical practice type, years since training, and their preferred methods of preoperative evaluation, operative management, and postoperative management. Survey invitations were sent out starting in December 2014 and responses were collected for approximately 6 months.

RESULTS

A total of 1152 valid email addresses were invited, resulting in 293 respondents (25%) from 39 countries and every American Urological Association (AUA) section. Seventy-six were excluded, leaving 217 respondents (Table). Respondents reported a median of 17 years since finishing their surgical training (IQR 8-25 years). Practice types included pediatric urology (n = 209), general urology (n = 9), pediatric surgery (n = 59), and other practice makeup (n = 3). On subgroup analyses, there were no significant regional practice differences, with the exception of complete primary repair of exstrophy (CPRE) and oral opioid prescribing being significantly higher in North America compared to other regions.

DISCUSSION

Findings indicate that there may be diversity in CBE practice patterns globally. While most responding surgeons from regions outside of North America indicated modern staged repair of exstrophy (MSRE) as their preferred closure technique, a relatively equal distribution of respondents from North America selected CPRE and MSRE. A majority of North American surgeons chose performing osteotomies for both newborn and delayed closures, while an appreciable number of respondents from other regions selected never using osteotomies in their closures. Limitations to this study include a low survey response rate, particularly from surgeons outside of the United States, which may have significantly impacted the ability to draw meaningful global comparisons.

CONCLUSIONS

Global variation among practices of surgeons performing CBE closures may exist. The wide range of methods demonstrated by this survey suggests the need for more conclusive comparative studies to elucidate whether an optimal standard exists. Local social factors, access to surgical expertise and transportation to referral centers, and finances play a role in what constitutes the best operative approach.

Delaying reclosure of bladder exstrophy leads to gradual decline in bladder capacity

INTRODUCTION

After unsuccessful repair of bladder exstrophy, when to repeat surgical intervention is unclear. One must balance time required for tissue healing with the damaging effects of an exposed urothelium to the environment.

OBJECTIVE

The authors aim to study whether a relationship exists between bladder growth/capacity and time till eventual successful closure.

STUDY DESIGN

An institutional database of exstrophy-epispadias complex patients was queried for failed exstrophy closure with successful repeat reconstruction, at least three consecutive bladder capacity measurements, and measurements obtained at least three months following successful closure. Patients closed successfully in the neonatal period were used as a comparative group. Linear mixed effects models were used to study the effect of time and age on bladder capacity.

RESULTS

Forty-seven patients requiring reclosure and 117 who had successful neonatal closures were included. Two models were created. The first linear mixed effects model found that for a given age, the bladder capacity declined approximately 9.6 mL per year (p = 0.016). The second model found that when time to successful closure was grouped by quartiles, compared to neonates, those in the fourth quartile had significantly decreased bladder capacity of 28.8 cc (p = 0.042). An interaction model comparing neonates and those requiring reclosure did not demonstrate a significant change in bladder growth rate (p = 0.098). A model stratified by quartiles similarly did not find any significant impact to bladder growth rate.

DISCUSSION

From the general linear mixed effects models, the authors conclude when compared to neonates, (1) there was an approximate 9.6 cc loss of total bladder capacity per year taken until successful closure, and that (2) those who were delayed the longest had the most significant difference in bladder capacity. This study required stricter inclusion criteria compared to previous publications, and therefore the conclusions that can be drawn regarding bladder growth rates may be more reliable. Future studies will examine the effects of delayed closure on the bladder at the cellular level.

CONCLUSIONS

There is a demonstrable significant impact on overall bladder capacity with increasing delay to successful reclosure. One should be cautious when prolonging reconstruction of the bladder as these data demonstrate a time dependent decline in overall capacity.

A less invasive technique for delayed bladder exstrophy closure without fascia closure and immobilisation: can the need for prolonged anaesthesia be avoided?

INTRODUCTION

It is believed that the main factors enhancing security of the bladder exstrophy closure are use of osteotomy, pubic bones approximation or transferred flaps for rectus fascia closure. However, these methods increase operating time, surgical trauma and carry risks for the patient.

OBJECTIVES

To demonstrate that the goal of secure bladder exstrophy closure can be achieved easier technically and safer for the child than previously thought. The paper examines the hypothesis that less invasive bladder exstrophy closure achieved without fascia closure can reduce pain and avoid the need for immobilization and prolonged analgesia.

STUDY DESIGN

Patients aged 34 days to 15 years (n = 36) from 37 who consecutively referred to the institution with classical bladder exstrophy between 2004 and 2016 underwent modified delayed primary (25) or redo (11) closure. One boy with low weight was excluded. Patient and treatment features were analysed to determine needs for immobilisation and anaesthesia in the postoperative period, and outcomes.

PROCEDURE

Bladder exstrophy closure with proximal urethroplasty was performed with the detachment of crura from the ishiopubic rami and levators-from obturator internus muscle. Abdominal wall closure was accomplished with skin and subcutaneous fat mobilisation without rectus fascia closure. No method of immobilization was applied.

RESULTS AND LIMITATIONS

Bladder closures have been successful in all 36 children in this report after 37 months (22-138) follow up. The surgeries took time between 126 and 215 min (mean - 148). After 1 day in the ICU the majority of the patients (34/36) were returned to the ward. No bladder spasms or signs of acute pain were noted in the ward; therefore, no local anesthesia or opioids were needed. Intravenous analgesia with non-narcotic analgesics was used for all patients in the ward for an average period 2.2 days (95% CI 2-4 days).

COMPLICATIONS

Minor complications: two fistulas, which closed spontaneously; three bladder outlet obstructions, each required one endoscopic incision. No major complications of exstrophy closure such as dehiscence or bladder prolapse were occurred.

CONCLUSIONS

The proposed less invasive technique with relieved postoperative program is the way to obtain successful bladder exstrophy closure as well as to reduce some risks for the patients. Absence of major complications, and avoiding the need for immobilisation and prolonged analgesia, contribute to the benefits of this approach.

Oblique pelvic osteotomy in the treatment of bladder exstrophy in neonates

Bladder exstrophy is a congenital and rare malformation of the lower abdominal wall with exposure of the bladder mucosa to the external environment, and it is related to pelvis abnormalities. Eighteen patients with bladder exstrophy were treated with bilateral oblique pelvic osteotomy in conjunction with urologic reconstruction after they were stabilized by cast. No failure of midline closure was observed (wound dehiscence or recurrence of bladder exstrophy). Follow-up showed no leg length discrepancy or problems in walking. Bilateral oblique pelvic osteotomy is a safe procedure to treat bladder exstrophy, and it results in good orthopedic and urological function.

One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results

BACKGROUND

The radical soft-tissue mobilization (RSTM, or Kelly repair) is an anatomical reconstruction of bladder exstrophy generally performed as a second part of a two-step strategy, following successful neonatal bladder closure.

OBJECTIVE

The objective of this study is to determine the feasibility of a combined procedure of delayed bladder closure and RSTM in one stage without pelvic osteotomy, in both primary and failed initial closure.

DESIGN, SETTING, AND PARTICIPANTS

From 11/2015 to 01/2018, 27 bladder exstrophy patients underwent combined bladder closure with RSTM by the same surgical team at four cooperating tertiary referral centers for bladder exstrophy, including 20 primary repairs (delayed bladder closure, median age 3.0m [0.5-37m]) and seven secondary repairs after failed attempt at neonatal closure, median age 10m [8-33m].

INTERVENTION

RSTM included full mobilization of the bladder plate, urogenital diaphragm, and corpora cavernosa from the medial pelvic walls, followed by anatomical reconstruction with antireflux procedure, bladder closure, urethrocervicoplasty, muscle sphincter approximation, and penile/clitoral reconstruction.

OUTCOME MEASUREMENTS

The main criteria were bladder dehiscence or prolapse. Secondary outcomes included bladder neck fistula or urethral fistula, urethral stenosis, and parietal hernia. Continence and voiding have not been addressed at this stage.

RESULTS AND LIMITATIONS

All bladder exstrophy cases were successfully closed without osteotomy, with no case of bladder dehiscence after 12 m [3-30] follow-up.

COMPLICATIONS

Urethral fistula or stenosis occurred in eight patients: 4/5 fistulae closed spontaneously in less than 3 months; four urethral stenoses were successfully treated with 1-3 sessions of endoscopic high-pressure balloon dilatation or meatoplasty; one patient with persistent bladder neck fistula is currently awaiting repair. Although the follow-up is short, it does allow examination of the main outcome criterion, namely bladder dehiscence, which is usually expected to happen very early after surgery.

CONCLUSION

The Kelly RSTM can be safely combined with delayed bladder closure without osteotomy in both primary and redo cases in classic bladder exstrophy.

How to close classic bladder exstrophy: Are subspecialty training and technique important?

INTRODUCTION

Successful primary closure is one of the main factors for achieving continence in a classic bladder exstrophy (CBE) patient. Even with contemporary management, patients still have failed primary closures. We sought to understand the role of training, surgical technique, and their impacts on outcomes of CBE closure.

MATERIALS AND METHODS

A retrospective cohort study from the largest single-institution database of primary and re-closure CBE patients in the world was performed. Failed closure was defined as developing bladder outlet obstruction, wound dehiscence, bladder prolapse, or any need for a re-closure operation. Patient demographics and surgical factors were abstracted and analyzed. Multivariable analysis was performed to test for associations with successful exstrophy closure.

RESULTS

Data from 722 patients were analyzed. On bivariate analysis, successful closure was associated with gestational age at presentation, time of closure, location of closure, credential of surgeon performing the closure, closure type, concomitant osteotomy, and type of immobilization. Multivariable analysis, adjusting for patient comorbidity and location of closure, demonstrated increased odds of failure for closure by pediatric surgeon compared with pediatric urologist (OR 4.32, 95% CI 1.98-9.43; p = 0.0002), closure by unknown credentialed surgeon (OR 1.86, 95% CI 1.15-2.99; p = 0.011), Complete Primary Repair of Exstrophy (CPRE) closure compared with Modern Staged Repair of Exstrophy (OR 2.05, 95% CI 1.29-2.99; p = 0.0024), and unknown closure type (OR 4.81, 95% CI 2.94-7.86; p < 0.0001) (Table).

DISCUSSION

Many factors associated with failure on bivariate analysis can be explained by these patients presenting to a center of excellence or the selection bias of this cohort stemming from a single center database that have been previously published. However, the finding on adjusted multivariable logistic regression analysis that closure by a pediatric surgeon is associated with higher odds of failure is novel. The additional finding that CPRE closure is associated with failure is most likely secondary to these patients being referred to our institution after having been closed with CPRE which falsely increases its impact on closure failure. Nevertheless, as a center with a large exstrophy volume, this study draws from a cohort that is larger than any other.

CONCLUSION

Classic bladder exstrophy closure should be performed at a center with pediatric urologists to ensure the best chance of a successful primary closure.

The inadequate bladder template: Its effect on outcomes in classic bladder exstrophy

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.

Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis

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.

The long-term outcomes after staged repair of exstrophy-epispadias complex

Introduction:

Classic bladder exstrophy (BE) is a rare malformation of the genito-urinary tract affecting 1:50,000 to 1:100,000 live births. The surgical reconstruction of the BE-epispadias complex is challenging for the most experienced pediatric urologists, surgeons, and orthopedists.

Purpose:

To assess the success of staged reconstruction of the BE and long-term effects on the upper urinary tract, renal function, and continence.

Materials and Methods:

This is retrospective study; between 1994 and 2013, 30 patients with BE have undergone stage 1 repair at the institute. Eighteen male patients have been operated for epispadias repair and thirteen patients have undergone Guy Leadbetter bladder neck reconstruction. Three patients required augmentation cystoplasty one child is continent after epispadias repair only and one child attained continence after single-stage repair.

Results:

Hence, out of 17 patients, 14 are socially continent, four patients require clean intermittent self-catheterization for bladder emptying. Four patients, who are coming for regular follow-up, are awaiting continence procedure. Two patients who underwent augmentation cystoplasty are on hemodialysis for renal failure and one child has altered renal function.

Conclusion:

In our experience, the modern staged repair offers a low risk of renal scarring with acceptable continence opportunity with acceptable cosmetic appearance of external genitalia in the males and females.

Delayed exstrophy repair (DER) does not compromise initial bladder development

OBJECTIVE

Delayed exstrophy repair (DER) represents an alternative to early neonatal bladder closure. This study aims to define the consequence of DER on bladder growth in bladder exstrophy patients who underwent routine DER, compared with those who underwent immediate postnatal reconstruction.

METHODS

Between 2000 and 2005, classic bladder exstrophy patients referred to the authors' institution underwent early neonatal bladder closure (group 1). Subsequently, classic bladder exstrophy patients referred to the authors' institution were treated with an elective DER (group 2). Bladder capacity was assessed between the age of 1 and 4 years with an unconscious cystogram. When dilating VUR was present, the volume of the contrast migrated into the ureter was calculated and subtracted.

RESULTS

Sixty patients were treated between 2000 and 2012. Complete follow-up data were available for 45 patients and they were included in the study: 21 in group 1 (11 males) and 24 in group 2 (14 males). The mean (SD) bladder volumes were 72.85 (28.5) ml in group 1 and 72.87 (34.9) in group 2 (p = 0.99).

CONCLUSION

In the authors' experience, DER does not reduce the subsequent bladder capacities compared with neonatal exstrophy closure.