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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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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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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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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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Hofmann A, Haider M, Promm M, Neissner C, Badelt G, Rösch WH. Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery. J Pediatr Surg 2022; 57:303-308. [PMID: 35000729 DOI: 10.1016/j.jpedsurg.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Successful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management. MATERIAL AND METHODS We reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay. RESULTS 66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13-34 d). CONCLUSION Delayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aybike Hofmann
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany.
| | - Maximilian Haider
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Claudia Neissner
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Gregor Badelt
- Department of Pediatric Anesthesiology, Clinic St. Hedwig, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
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Agbara KS, Moulot OM, Ehua MA, Konan JM, Yapo Kouamé GS, Traoré I, Anon GA, Ajoumissi I, Konvolbo J, Bankolé RS. Bladder exstrophy: Modern staged repair experience in our institution. Afr J Paediatr Surg 2022; 19:167-170. [PMID: 35775519 PMCID: PMC9290361 DOI: 10.4103/ajps.ajps_167_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Bladder exstrophy is a major malformation in paediatric urology. The treatment results are not still completely satisfactory, and their management is an enormous problem in Sub-Saharan Africa. While outlining our challenges, we report our management experience to improve our results. SUBJECTS AND METHODS We retrospectively reviewed the records of patients undergoing surgical repair of classic bladder exstrophy at our department between January 2010 and December 2019 (10 years). Epidemiological, clinical, therapeutic and evolution data were analysed. RESULTS Twenty-five children with classic bladder exstrophy were treated. Our series included 16 boys and 9 girls with a sex ratio of 1.7. Age ranged from 0 day to 6 years. Twenty-five bladder closures were performed, associated to pelvic osteotomy in 11 cases. Epispadias repair was performed on nine boys. Eight cases of bladder neck reconstruction and three cases of bladder enlargement were performed. We observed six bladder fistulas, four wound dehiscence, of which three partial, two parietal suppurations and six cases of urinary tract infection. Eight children had a continence of 1-2 h. CONCLUSION The treatment of bladder exstrophy in our context is still limited because of financial difficulties encountered by the population and the insufficient technical platform in our country.
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Affiliation(s)
- Kouam Soroboua Agbara
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Olivier Martial Moulot
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Manuela Adjoba Ehua
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Jean Marie Konan
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Guy Serge Yapo Kouamé
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody, Abidjan, Ivory Coast
| | - Ibrahim Traoré
- Department of Mother-Children, Teaching Hospital, Bouaké, Ivory Coast
| | - Ghislain Anon Anon
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Idalia Ajoumissi
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Josaphat Konvolbo
- Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
| | - Roumanatou Sanni Bankolé
- Department of Mother-Children, Félix Houpouet Boigny University, Cocody; Department of Mother-Children, Teaching Hospital, Treichville, Abidjan, Ivory Coast
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Barrier-Forming Potential of Epithelial Cells from the Exstrophic Bladder. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:943-955. [PMID: 35358476 PMCID: PMC9194657 DOI: 10.1016/j.ajpath.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/04/2022] [Accepted: 03/03/2022] [Indexed: 11/20/2022]
Abstract
Bladder exstrophy (BEX) is a rare developmental abnormality resulting in an open, exposed bladder plate. Although normal bladder urothelium is a mitotically quiescent barrier epithelium, histologic studies of BEX epithelia report squamous and proliferative changes that can persist beyond surgical closure. The current study examined whether patient-derived BEX epithelial cells in vitro were capable of generating a barrier-forming epithelium under permissive conditions. Epithelial cells isolated from 11 BEX samples, classified histologically as transitional (n = 6) or squamous (n = 5), were propagated in vitro. In conditions conducive to differentiated tight barrier formation by normal human urothelial cell cultures, 8 of 11 BEX lines developed transepithelial electrical resistances of more than 1000 Ω.cm2, with 3 squamous lines failing to generate tight barriers. An inverse relationship was found between expression of squamous KRT14 transcript and barrier development. Transcriptional drivers of urothelial differentiation PPARG, GATA3, and FOXA1 showed reduced expression in squamous BEX cultures. These findings implicate developmental interruption of urothelial transcriptional programming in the spectrum of transitional to squamous epithelial phenotypes found in BEX. Assessment of BEX epithelial phenotype may inform management and treatment strategies, for which distinction between reversible versus intractably squamous epithelium could identify patients at risk of medical complications or those who are most appropriate for reconstructive tissue engineering strategies.
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Morgan C, Lees MC, MacLellan DL, Blackmore C, Romao RL. A survey of management preferences for bladder exstrophy and cloacal anomalies among Canadian pediatric surgeons and urologists. J Pediatr Surg 2022; 57:816-823. [PMID: 35105453 DOI: 10.1016/j.jpedsurg.2021.12.044] [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: 12/14/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study examined the current referral patterns and preferences of Canadian Association of Paediatric Surgeons (CAPS) and Pediatric Urologists of Canada (PUC) members for management of bladder exstrophy and cloacal anomalies (BECA). METHODS We invited CAPS and PUC members to participate in an online survey using RedCap. Demographic variables, years in practice, current referral patterns and local expertise at the participants' institution were collected. Participants' preferences towards three distinct referral models were assessed using Likert scales: no centralization of care, centralization in one or two national centres of excellence, or a consortium-based approach. RESULTS There were 82 survey respondents (2/3 were CAPS members, 35.4% female, 72% in practice for >10 years). Although >90% of participants agreed/somewhat agreed that surgical volumes impact outcomes, 58% reported not referring out BECA patients for treatment; about 50% recognized the existence of a local dedicated expert. In terms of referral preferences, 84% of participants favoured identification of a few centres with expertise based on geographic location (a consortium-based approach), while only 7% chose a one or two national centres of excellence model. Over half of participants agreed/somewhat agreed with participating in trials of a consortium-based approach in Canada. CONCLUSION Most CAPS and PUC members do not refer BECA patients elsewhere for treatment. Nonetheless, most surgeons recognize the importance of volume to improve outcomes and show willingness to participate in trials to concentrate experience; most participants favour a consortium-based approach through identification of a few centres of excellence based on geographic location.
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Affiliation(s)
- Catherine Morgan
- Department of Family Medicine, McGill University, Queen Elizabeth Health Complex, 2100 Avenue de Marlowe, Montréal, QC, Canada, H4A 3L5
| | - Mackenzie C Lees
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, IWK Health, Dalhousie University, 5850 University Ave, PO BOX 9700, Halifax, NS, Canada, B3H 6R8
| | - Dawn L MacLellan
- Division of Pediatric Urology, Department of Urology, IWK Health, Dalhousie University, 5850 University Ave, PO BOX 9700, Halifax, NS, Canada, B3H 6R8
| | - Christopher Blackmore
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, IWK Health, Dalhousie University, 5850 University Ave, PO BOX 9700, Halifax, NS, Canada, B3H 6R8
| | - Rodrigo Lp Romao
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, IWK Health, Dalhousie University, 5850 University Ave, PO BOX 9700, Halifax, NS, Canada, B3H 6R8; Division of Pediatric Urology, Department of Urology, IWK Health, Dalhousie University, 5850 University Ave, PO BOX 9700, Halifax, NS, Canada, B3H 6R8.
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Kelly JH, Taghavi K, Mushtaq I. Justin H. Kelly and his procedure for bladder exstrophy and epispadias. J Pediatr Surg 2022; 57:314-321. [PMID: 34772513 DOI: 10.1016/j.jpedsurg.2021.09.005] [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: 08/11/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
The operations involved in the repair of complete bladder exstrophy (CBE), familiarly known as the Kelly procedure, evolved over more than 100 years. Through repeated cycles of trial and error, some of the most prominent urologists in the world developed techniques that addressed each of the formidable surgical challenges presented by CBE and epispadias. A key figure is Justin H. Kelly of the Royal Children's Hospital, Melbourne, who made surgery for CBE his life's work. He took the lessons of his surgical predecessors, giants like: Friedrich Trendelenburg, Hugh Hampton Young, John Dees, and Guy Leadbetter, applied techniques for anorectal anomalies from his contemporary Alberto Peña, and saw his procedures improved by the next generation of leaders in paediatric urology that included Phillip Ransley, Peter Cuckow, Patrick Duffy, and John Gearhart. Over his long career, Mr Kelly modified and perfected his eponymous procedure patient-by-patient through a painstaking process of trial-and-error, bearing with his young patients and their families through every heart-breaking complication, and gradually creating the standard operation for children with CBE and epispadias.
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Affiliation(s)
- Justin H Kelly
- Department of Paediatric Urology, The Royal Children's Hospital, Melbourne, Australia
| | - Kiarash Taghavi
- Department of Paediatric Urology, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia.
| | - Imran Mushtaq
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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Osteotomy in the newborn classic bladder exstrophy patient: A comparative study. J Pediatr Urol 2021; 17:482.e1-482.e6. [PMID: 33966998 DOI: 10.1016/j.jpurol.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Pelvic osteotomy is indicated in classic bladder exstrophy (CBE) patients with a wide pubic diastasis or non-malleable pelvis. While the safety of pelvic osteotomy in delayed and failed closures is established, there remains less clarity on their safety in newborns. The authors herein sought to present their experience with CBE patients who underwent pelvic osteotomy for assistance with bladder closure during both the newborn and delayed time periods. OBJECTIVE The authors hypothesize that pelvic osteotomy during exstrophy closure may be performed safely in newborns with few perioperative or post-operative negative sequelae. STUDY DESIGN A prospectively maintained IRB-approved database was reviewed for CBE patients who underwent osteotomy during primary closure. Patient demographics, performing institution (authors' or outside), closure outcome, diastasis width, and post-operative complications were noted. Patient subgroups included newborn and delayed (>28 days of life) closures. Failure was defined as bladder dehiscence, prolapse, outlet obstruction, or vesicocutaneous fistula requiring reoperation. Orthopedic complications included nerve palsies, superficial pin-site infection, and bladder neck erosion by orthopedic hardware. Analyses were performed using a Chi-square test. RESULTS 286 patients were included: 186 newborn and 100 delayed closures. The authors' institution performed 109 cases (44 newborn and 65 delayed). Within the overall newborn closure cohort, no significant differences were found in outcomes among the osteotomy types with success rates of 80%, 60.8%, and 71.4% in the combined, posterior iliac, and anterior innominate groups, respectively (p = 0.24). In the delayed group, success rates were significantly different with rates of 100%, 72.4%, and 93.8% in the combined, posterior iliac, and anterior innominate groups, respectively (p < 0.001). Febrile urinary tract infection (UTI) was the most common complication at 8% (23/286). Only 1.7% (5/286) of patients had orthopedic complications with 3 patients in the newborn cohort, 2 patients in the delayed cohort, and only one patient requiring reoperation. DISCUSSION Orthopedic complications are rare in CBE patients who undergo osteotomies regardless of the closure period. No clinically significant difference in orthopedic complication rate was found between newborn and delayed closure periods. CONCLUSIONS While current trends have moved toward delayed primary closures, there remains a role for osteotomy during exstrophy closure in select newborn patients and can be performed safely with few complications.
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11
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Promm M, Otto W, Weber F, Götz S, Burger M, Müller K, Rubenwolf P, Neuhuber W, Roesch WH. Expression of Low Affinity Nerve Growth Factor Receptor p75 in Classic Bladder Exstrophy. Front Pediatr 2021; 9:634343. [PMID: 33692976 PMCID: PMC7937696 DOI: 10.3389/fped.2021.634343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/01/2021] [Indexed: 12/04/2022] Open
Abstract
Successful primary closure of classic bladder exstrophy (BE) is crucial for development of bladder capacity and voided continence. It is universally agreed that an intensive pain management including the use of caudal epidural anesthesia is an essential cornerstone for the outcome of this complex surgery. Whether and to what extent pain is caused by structural or functional changes is not yet known. The nerve growth factor (NGF) is regarded as a marker for pain in different bladder disorders. This prospective study investigated the role of histological alterations and NGF in patients with BE including 34 patients with BE and 6 patients with congenital vesicoureterorenal reflux (VUR) who served as controls. Between January 2015 and April 2020 transmural bladder biopsies were taken from the posterior bladder wall during delayed primary bladder closure. The samples were stained for histological evaluation and subjected to immunohistochemistry to analyze NGFR p75. Differences in histological alterations were examined with Fisher's exact test, and Mann-Whitney-U-test was used to compare the NGFR p75 staining intensity between patients with BE and controls. Patients with BE showed significantly more often acute inflammation (p < 0.001), squamous metaplasia (p = 0.002), and cystitis glandularis (p = 0.005) as well as NGFR p75 in the urothelium (p = 0.003) than patients with VUR. A limitation of this study is the small number of participants due to the rare disease entity. Similar to other painful bladder disorders, pain transmission in BE after intitial closure may in part be facilitated by elevated NGF signaling through its receptor.
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Affiliation(s)
- Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany
| | - Wolfgang Otto
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Florian Weber
- Department of Pathology, University of Regensburg, Regensburg, Germany
| | - Stefanie Götz
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Maximilian Burger
- Department of Urology, Caritas-St. Josef Medical Center, University of Regensburg, Regensburg, Germany
| | - Karolina Müller
- Center for Clinical Studies, University Medical Center Regensburg, Regensburg, Germany
| | - Peter Rubenwolf
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany.,Department of Urology, University Medical Center Frankfurt, Frankfurt, Germany
| | - Winfried Neuhuber
- Institute of Anatomy and Cell Biology, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Wolfgang H Roesch
- Department of Pediatric Urology, Clinic St. Hedwig, University of Regensburg, Regensburg, Germany
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12
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Ebert AK, Zwink N, Reutter HM, Jenetzky E, Stein R, Hölscher AC, Lacher M, Fortmann C, Obermayr F, Fisch M, Mortazawi K, Schmiedeke E, Promm M, Hirsch K, Schäfer FM, Rösch WH. Treatment Strategies and Outcome of the Exstrophy-Epispadias Complex in Germany: Data From the German CURE-Net. Front Pediatr 2020; 8:174. [PMID: 32509709 PMCID: PMC7248227 DOI: 10.3389/fped.2020.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: To evaluate the impact of reconstructive strategies and post-operative management on short- and long-term surgical outcome and complications of classical bladder exstrophy (CBE) patients' comprehensive data of the multicenter German-wide Network for Congenital Uro-Rectal malformations (CURE-Net) were analyzed. Methods: Descriptive analyses were performed between 34 prospectively collected CBE patients born since 2009, median 3 months old [interquartile range (IQR), 2-4 months], and 113 cross-sectional patients, median 12 years old (IQR, 6-21 years). Results: The majority of included individuals were males (67%). Sixty-eight percent of the prospectively observed and 53% of the cross-sectional patients were reconstructed using a staged approach (p = 0.17). Although prospectively observed patients were operated on at a younger age, the post-operative management did not significantly change in the years before and after 2009. Solely, in prospectively observed patients, peridural catheters were used significantly more often (p = 0.017). Blood transfusions were significantly more frequent in males (p = 0.002). Only half of all CBE individuals underwent inguinal hernia repair. Cross-sectional patients after single-stage reconstructions showed more direct post-operative complications such as upper urinary tract dilatations (p = 0.0021) or urinary tract infections (p = 0.023), but not more frequent renal function impairment compared to patients after the staged approach (p = 0.42). Continence outcomes were not significantly different between the concepts (p = 0.51). Self-reported continence data showed that the majority of the included CBE patients was intermittent or continuous incontinent. Furthermore, subsequent consecutive augmentations and catheterizable stomata did not significantly differ between the two operative approaches. Urinary diversions were only reported after the staged concept. Conclusions: In this German multicenter study, a trend toward the staged concept was observed. While single-stage approaches tended to have initially more complications such as renal dilatation or urinary tract infections, additional surgery such as augmentations and stomata appeared to be similar after staged and single-stage reconstructions in the long term.
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Affiliation(s)
- Anne-Karoline Ebert
- Department of Pediatric Urology, University Hospital for Urology and Pediatric Urology, University Medical Center Ulm, Ulm, Germany
| | - Nadine Zwink
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Heiko M Reutter
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany.,Institute of Human Genetics, University Hospital Bonn, Bonn, Germany
| | - Ekkehart Jenetzky
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Child Center Maulbronn GmbH, Hospital for Pediatric Neurology and Social Pediatrics, Maulbronn, Germany
| | - Raimund Stein
- Department of Pediatric and Adolescent Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Alice C Hölscher
- Department of Pediatric Surgery and Pediatric Urology, Children's Hospital Amsterdamer Straße Köln, Köln, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Caroline Fortmann
- Center of Pediatric Surgery Hannover, Hannover Medical School and Bult Children's Hospital, Hannover, Germany
| | - Florian Obermayr
- Department of Pediatric Surgery and Pediatric Urology, University Hospital for Child and Adolescent Medicine Tübingen, Tübingen, Germany
| | - Margit Fisch
- Department of Urology and Pediatric Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kiarasch Mortazawi
- Department of Pediatric Surgery, Klinik für Kinderchirurgie, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Pediatric Urology, Center for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Karin Hirsch
- Department of Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Frank-Mattias Schäfer
- Pediatric Surgery and Pediatric Urology, Cnopfsche Children's Hospital, Nürnberg, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
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13
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Nikolaev VV. A less invasive technique for delayed bladder exstrophy closure without fascia closure and immobilisation: can the need for prolonged anaesthesia be avoided? Pediatr Surg Int 2019; 35:1317-1325. [PMID: 31388752 DOI: 10.1007/s00383-019-04530-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Vasily V Nikolaev
- Department of Paediatric Surgery, Pirogov Russian National Research Medical University (RNRMU), Ostrovitianov Str. 1, Moscow, 117997, Russia.
- Departments of Paediatric Surgery and Uroandrology, Russian Children's Clinical Hospital, Leninsky Prosp. 117, Moscow, 119571, Russia.
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Promm M, Roesch WH. Recent Trends in the Management of Bladder Exstrophy: The Gordian Knot Has Not Yet Been Cut. Front Pediatr 2019; 7:110. [PMID: 30984727 PMCID: PMC6449419 DOI: 10.3389/fped.2019.00110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/06/2019] [Indexed: 01/31/2023] Open
Abstract
Although enormous effort has been made to further improve the operative techniques worldwide, the management of bladder exstrophy (BE) remains one of the most significant challenges in pediatric urology. Today it is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome with regard to bladder capacity, renal function and continence. Due to a number of reasons, including a lack of comparable multicenter studies, a range of concepts is currently used to achieve successful primary closure. We review the literature of the last 15 years on the current concepts of bladder exstrophy repair with regard to the time of primary closure (initial vs. delayed closure), the concepts of primary closure (single-stage vs. staged approach; without osteotomy vs. osteotomy) and their outcomes. There is a worldwide lack of multicenter outcome studies with adequate patient numbers and precisely defined outcome parameters, based on the use of validated instruments. The modern staged repair (MRSE) in different variations, the complete primary reconstruction of exstrophy (CPRE), and the radical soft-tissue mobilization (RSTM) had been the most extensively studied and reported procedures. These major concepts are obligatory stable now for more than 20 years. Nevertheless, there are still a lot of open-ended questions e.g., on the potential for development of the bladder template, on continence, on long-term orthopedic outcome, on sexuality and fertility and on quality of life. Management of BE remains difficult and controversial. Further, clinical research should focus on multi-institutional collaborative trials to determine the optimal approach.
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Affiliation(s)
- Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center of Regensburg, Regensburg, Germany
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15
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Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience. J Pediatr Urol 2019; 15:76.e1-76.e8. [PMID: 30600203 DOI: 10.1016/j.jpurol.2018.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/27/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shifts and require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects. We present nine years of caudal epidural anaesthesia in delayed bladder exstrophy repair and describe its facilitation of early extubation and early feeding (within 12 h) without surgical complication. METHODS We retrospectively evaluated consecutive infants with classic bladder exstrophy undergoing delayed primary closure with anterior pelvic osteotomies between November 2007 and January 2016. Outcomes and complications were evaluated in terms of postoperative comfort (using the FLACC score-Face, Legs, Activity, Cry, Consolability), epidural failure rate, re-intubation rate and gastrointestinal complications. RESULTS Forty-four infants had average age of 5.8 months (range 1.6-17.1 months) and weight of 7.0 kg (range 3.5-11.8 kg), and their duration of surgery was 9.5 h (range 6.9-14.3 h). Forty-two of 44 (95.5%) patients received caudal epidural catheters. At 24 h, 15 of 42 (35.7%) caudal epidurals required supplementation with intravenous opioids. Fewer patients with optimally functioning epidurals required postoperative ventilation (1/27 [3.7%] compared with 3/15 [20.0%]). None of the patients with caudal epidural catheters required re-intubation. Pain scores were lower in infants with isolated caudal epidurals catheters than those with caudal epidurals supplemented by intravenous opioids (day 1 [18 vs 53; P = 0.008]; day 2 [8 vs 15; P > 0.05] and overall [32 vs 65; P = 0.014]). Infants with intravenous opioids experienced higher complications: pruritus (25% [95% confidence interval {CI}: 5%-57%] vs 0% [95% CI: 0%-13%]; P = 0.026) and nausea and vomiting (25% [95% CI: 5%-57%] vs 8% [95% CI: 1%-25%]; P = 0.30) requiring treatment. Nineteen of 44 (43.1%) infants were fed early (within 12 h of surgery). Infants who were fed early had lower pain scores than infants feeding late (day 1 [17.5 vs 31; P > 0.05]; day 2 [5.5 vs 15; P = 0.045]; overall [26 vs 55.5; P = 0.015]) without increase in complications (nausea and vomiting [6.3% vs 20.0%; P = 0.06]; ileus [0.0% vs 0.0%]; aspiration [0.0% vs 0.0%] and re-intubation aspiration [0.0% vs 0.0%]). CONCLUSIONS Caudal epidural analgesia facilitates postoperative extubation in infants undergoing delayed exstrophy repair. Early feeding (within the first 12 h) in delayed bladder exstrophy repair is likely to improve patient comfort and consolability without increasing the incidence of gastrointestinal complications. Intravenous opioid may be associated with increased postoperative complications that may influence peri-operative outcomes.
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16
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Meeting the challenges of reconstructive urology - Where are we now? J Pediatr Surg 2019; 54:223-228. [PMID: 30527758 DOI: 10.1016/j.jpedsurg.2018.10.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
Abstract
This is based on the 2018 Storz Urology Lecture at the BAPS Conference and is a personal review of three reconstructive paediatric urological conditions: hypospadias, congenital adrenal hyperplasia, and bladder exstrophy from the perspective of changing expectations and outcomes. LEVEL OF EVIDENCE: V (Expert Opinion).
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17
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One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results. J Pediatr Urol 2018; 14:558-564. [PMID: 30126745 DOI: 10.1016/j.jpurol.2018.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 11/22/2022]
Abstract
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.
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Arenas Hoyos J, Pedraza Bermeo A, Pérez Niño J. Experiencia en el abordaje de pacientes con complejo extrofia-epispadias en un centro de alto nivel de complejidad en Colombia, 10 años. UROLOGÍA COLOMBIANA 2018. [DOI: 10.1016/j.uroco.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objetivos El complejo extrofia-epispadias (CEE) se considera una de las malformaciones más severas de la línea media de compromiso multisistémico. La extrofia vesical es la presentación más frecuente en el espectro del complejo. Esta patología tiene un alto impacto en la calidad de vida. A pesar de la relación entre un cierre primario temprano y mejores resultados, en nuestro medio la remisión es tardía y la experiencia es escasa. El objetivo del siguiente estudio es mostrar la experiencia en el abordaje de CEE en los últimos 10 años en una institución de alto nivel de complejidad y remisión en Colombia.Materiales y métodos Se realiza un estudio observacional descriptivo, con una serie de casos del 2006 al 2016.Resultados En 10 años, se presentaron 5 casos de CEE en un centro de alta complejidad y remisión en Colombia. La mayoría de los pacientes han tenido múltiples intervenciones; la edad del primer procedimiento fue 829 días en promedio (27,6 meses). Se ha tenido un seguimiento postoperatorio promedio de 2,8 años. No se han presentado neoplasias en el seguimiento. Las comorbilidades más frecuentes son infección y litiasis. Ninguno de los pacientes contactados reportó inicio de vida sexual. La escala International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) tuvo un promedio de 9 puntos. Existen factores sociales asociados en nuestro medio.Conclusión El CEE requiere un abordaje temprano y multidisciplinario en instituciones con experiencia; los resultados en continencia urinaria, función sexual, desarrollo psicosocial y calidad de vida están sujetos a tratamiento oportuno de la patología.
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Affiliation(s)
- Juliana Arenas Hoyos
- Estudiante de Medicina, quinto año, División de Investigación en Urología y Genética, Departamento de Urología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Adriana Pedraza Bermeo
- Residente de Urología, tercer año, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Jaime Pérez Niño
- Especialista en Urología, jefe del Departamento de Urología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio-Fundación Santa Fe de Bogotá, Bogotá, Colombia
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19
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Alam A, Blachman-Braun R, Delto JC, Moscardi PRM, Castellan M, Tidwell MA, Labbie A, Gosalbez R. Bladder exstrophy closure in the newborn period with external pelvic fixation performed without osteotomy: A preliminary report. J Pediatr Urol 2018; 14:32.e1-32.e7. [PMID: 29195831 DOI: 10.1016/j.jpurol.2017.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Successful primary bladder closure is the most crucial element for urinary continence in patients with classic bladder exstrophy (CBE). In the newborn period, bladder closure can be performed in the first 48 h without pelvic osteotomy or external fixation, but requires postoperative lower extremity immobilization (i.e., spica cast, Bryant's or Buck's traction). OBJECTIVE To present a novel surgical approach for primary bladder closure for CBE using two-pin external fixation without pelvic osteotomy, and without postoperative lower extremity immobilization. STUDY DESIGN A retrospective chart review of patients with CBE was performed at the current institution from 2000 to 2016, including all primary bladder closures with external fixation and without osteotomy or lower extremity immobilization. Patients were discharged with the external fixator in place, which was later removed in clinic. Baseline clinical and demographic variables, and follow-up data were recorded. RESULTS Thirteen patients were analyzed; eight (61.5%) were male. Pre-operative intersymphysial distance was 3.68 ± 1.0 cm (2.0-5.0). Mean follow-up was 56.8 ± 40.3 months (10-131). One patient had a partial bladder neck dehiscence, due to pin displacement on postoperative day 1: he had the lowest gestational age of 34 weeks (Summary table). DISCUSSION This approach used external fixation to bring the pubic bones together intra-operatively, and to decrease the tension in closing the pelvic ring and abdominal wall without osteotomy. External fixation with osteotomy and long-term immobilization, or using a spica cast without osteotomy offered the added advantage of improved wound care, due to lack of lower limb immobilization, less patient discomfort, and facilitation of mother/caregiver and newborn bonding. CONCLUSION The two-pin external fixator without osteotomy as an adjunct to primary bladder closure in CBE patients was technically feasible. At the current institution this approach had an equivalent success rate to previous reports in the literature for primary bladder closure, decreased the length of hospital stay, and precluded the need for lower extremity immobilization. Early data for bladder capacity were encouraging.
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Affiliation(s)
- A Alam
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA.
| | - R Blachman-Braun
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
| | - J C Delto
- Urology Department, Mount Sinai Medical Center, Miami Beach, USA
| | - P R M Moscardi
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
| | - M Castellan
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
| | - M A Tidwell
- Department of Orthopedic Surgery, Nicklaus Children's Hospital, Miami, USA
| | - A Labbie
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
| | - R Gosalbez
- Division of Pediatric Urology, Nicklaus Children's Hospital, Miami, USA
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Sabetkish N, Sabetkish S, Kajbafzadeh AM. Preoperative care of Polypoid exposed mucosal template in bladder exstrophy: the role of high-barrier plastic wraps in reducing inflammation and polyp size. Int Braz J Urol 2018; 44:591-599. [PMID: 29368874 PMCID: PMC5996800 DOI: 10.1590/s1677-5538.ibju.2017.0196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 09/12/2017] [Indexed: 11/22/2022] Open
Abstract
Objective To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstro- phy cases, and to compare the results with the application of low-barrier wrap. Materials and Methods Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps. Results The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC. Conclusion Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more “exstrophy-friendly”.
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Affiliation(s)
- Nastaran Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
| | - Shabnam Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
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Hanna MK, Bassiouny I. Challenges in salvaging urinary continence following failed bladder exstrophy repair in a developing country. J Pediatr Urol 2017; 13:270.e1-270.e5. [PMID: 28262536 DOI: 10.1016/j.jpurol.2016.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 12/09/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The management of urinary incontinence following failed bladder exstrophy repairs is not well defined, some surgeons recommend urinary diversion, others would pursue reconstructive surgery. OBJECTIVE Herein we review our experience with various strategies for management of urinary incontinence and their outcome in 61 patients born with bladder exstrophy who failed their initial repairs. We also examine the impact of diverse factors in making the surgical decision for patients with limited resources in a developing country. MATERIAL AND METHODS Between 1981 and 2014, 61 incontinent patients (age 3-18 years) born with bladder exstrophy were referred for secondary or tertiary repair. In nine children the bladder was exposed following wound dehiscence and 52 had had one or more attempted repairs resulting in contracted bladders. The primary treatment included: re-closure and bilateral iliac osteotomy in five patients (group 1); urinary diversion in Mainz II pouch in 15 patients (group 2); and 41 patients (group 3) underwent bladder augmentation and bladder neck reconstruction (31 patients) or bladder substitution and cystectomy (10 patients). RESULTS In group 1, three out of five patients were voiding with dry intervals. One child was dry between catheterization, and one was incontinent and underwent Mainz II diversion. All 16 patients with Mainz II pouch were continent of urine and stool. Of the 41 patients in group 3, follow-up was available for 34 patients, of whom 31 (91%) were dry between catheterization. However, additional surgery was performed in 15/34 (44%). Malignant changes were noted in 2/26 cystectomy specimens. DISCUSSION The quality of the bladder plate may deteriorate following failed bladder exstrophy surgeries. A few selected cases who had maintained a relatively healthy bladder plate were candidates for re-closure with osteotomy. Other surgical options included complex reconstruction with catheterizable channel, and internal urinary diversion. In this series the following factors were considered: a) pre-operative bladder biopsy to rule out pre-cancerous lesions, b) counseling the parents about possible additional surgeries after bladder augmentation or continent reservoir, and c) patients' geographic and socio-economic status. CONCLUSIONS Children born with bladder exstrophy are best treated at pediatric centers with expertise in their management. The exstrophied bladder should be protected and covered with non-adherent plastic wrap to prevent mucosal irritation and ulceration by the diaper. However, following failed surgeries the majority of incontinent patients can be salvaged to become continent/dry. It would appear that the Mainz II internal diversion offers a reasonable surgical option for selected patients, especially for females and those who have endured multiple surgical failures.
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Mishra P, Rajendran S, Mushtaq I. Neonatal closure of bladder exstrophy. J Pediatr Urol 2016; 12:213. [PMID: 27593919 DOI: 10.1016/j.jpurol.2016.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 01/12/2016] [Indexed: 11/19/2022]
Affiliation(s)
- P Mishra
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - S Rajendran
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
| | - I Mushtaq
- Department of Urology, Great Ormond Street Hospital for Children, London, UK
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Bonitz RP, Hanna MK. Use of human acellular dermal matrix during classic bladder exstrophy repair. J Pediatr Urol 2016; 12:114.e1-5. [PMID: 26750184 DOI: 10.1016/j.jpurol.2015.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The extent of the abdominal wall defect in people with classic bladder exstrophy (CBE) varies, and can be extensive. In this study, human acellular dermis (HAD) was used to bridge the fascial gap, as an alternative to osteotomy, to support a fascial repair of the abdominal wall, and as a filler in selected cases of CBE. OBJECTIVE To demonstrate the efficacy of the employed techniques of using HAD within the bladder exstrophy population. MATERIALS AND METHODS The medical records of six males, born with CBE, and who had abdominal wall defects were reviewed. Two children, aged 6 and 8 years old, were referred from overseas with unrepaired bladder exstrophy plates and large abdominal wall defects (8 cm and 12 cm wide). Both had their bladders reconstructed, placed within the pelvis, and HAD was used to replace the absent abdominal wall (bridged repair) without the use of pelvic osteotomy. In three other patients, HAD reinforced the native fascial repair (bolster repair). In three patients, HAD also served as a filler for the abdominal depression that was present following initial staged repair. Where HAD was used for bridged or bolster repair, the edges of the allograft were extended 2-3 cm circumferentially beyond the perimeter of the abdominal wall defect. RESULTS All six patients healed well, without evidence of abdominal wall hernias at 1-3 years postoperatively. Functionally, each patient regained an appropriate level of abdominal wall strength. Two children successfully underwent a secondary procedure through the bridged allograft repair, as each required bladder neck reconstruction and bilateral ureteral reimplantation through the reconstructed abdominal wall. Continence was achieved in these two patients, with one child voiding at 2-hourly intervals and the second at 3-hourly intervals. One patient developed a urethral-cutaneous fistula, distant to location of the allograft. There were no associated wound complications. CONCLUSIONS In this series of patients born with classic bladder exstrophy, HAD acted as a biologic scaffold and allowed native cellular ingrowth and tissue remodeling. It served as an alternative to pelvic osteotomy in older patients with unrepaired CBE. The material reinforced a weak or potentially suboptimal fascial repair and filled a tissue gap, resulting in improved aesthetics. Given its ease of preparation and the lack of significant morbidity associated with its use, combined with the functional and esthetic results in the present series, HAD may be considered during delayed reconstruction of abdominopelvic tissues in people born with CBE.
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Affiliation(s)
- Robert Paul Bonitz
- Urology Division, Rutgers-New Jersey Medical School, Newark, NJ, USA; Children's Hospital of New Jersey, Saint Barnabas Health System, Livingston, NJ, USA.
| | - Moneer K Hanna
- Urology Division, Rutgers-New Jersey Medical School, Newark, NJ, USA; Children's Hospital of New Jersey, Saint Barnabas Health System, Livingston, NJ, USA; New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA.
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Goldstein SD, Inouye BM, Reddy S, Lue K, Young EE, Abdelwahab M, Grewal M, Wildonger S, Stec AA, Gearhart JP. Continence in the cloacal exstrophy patient: What does it cost? J Pediatr Surg 2016; 51:622-5. [PMID: 26775195 DOI: 10.1016/j.jpedsurg.2015.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgical advancements have made cloacal exstrophy (CE) a survivable condition, though management remains complex. Urologic, orthopedic, colorectal and gynecologic interventions are not standardized, and the cost of this care is high. While the importance of a successful primary closure in terms of outcomes is known, the economic consequences of failure remain uncharacterized. METHODS A prospectively maintained institutional database of epispadias-exstrophy complex patients was reviewed for continent CE patients. Hospital charges for all inpatient admissions prior to achieving urinary continence were inflation-adjusted to year 2013 values using Consumer Price Index for medical care published by the United States Bureau of Labor Statistics. Records for which charge data were incomplete were completed by using single mean imputation, also inflation-adjusted. Descriptive data are presented as mean±standard deviation (SD). RESULTS Of 102 CE patients, 35 had available hospital charge data: 15 who underwent successful primary closure at the authors' institution and 20 who presented after previously failed primary closures at referring institutions. The mean±SD hospital charges for primary closure in the success group were $136,201±$48,920. These patients then underwent subsequent additional surgeries that accrued charges of $59,549±$25,189 in order to achieve continence. Overall, successful primary closures accumulated hospital charges of $200,366±$40,071. In comparison, patients referred after prior failure required significantly more hospital admissions and additional charges of $207,674±$65,820 were required to achieve continence (p<0.001). Patients who failed primary closure are estimated to accumulate 70% more total health care charges compared to the group following successful primary closure. CONCLUSION The cost of CE management until urinary continence is high, averaging more than $200,000 in inpatient hospital charges alone. Initial success is desirable from both an outcomes and economic perspective, as the cost of salvaging a failed primary closure at our institution is similar to the overall costs of a successful closure; this is in addition to the cost of any previous failed closures. Further studies will be required to determine the optimal timing of surgical management in terms of both patient outcomes and financial consequences.
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Affiliation(s)
- Seth D Goldstein
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005.
| | - Brian M Inouye
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Sunil Reddy
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Kathy Lue
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Ezekiel E Young
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Mahmoud Abdelwahab
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Mehnaj Grewal
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - Spencer Wildonger
- The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, 600 N. Wolfe Street/Harvey 319, Baltimore, MD, USA, 21287-0005
| | - Andrew A Stec
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287
| | - John P Gearhart
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 1800 Orleans St. Suite 7304, Baltimore, MD, USA, 21287.
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Inouye BM, Lue K, Abdelwahab M, Di Carlo HN, Young EE, Tourchi A, Grewal M, Hesh C, Sponseller PD, Gearhart JP. Newborn exstrophy closure without osteotomy: Is there a role? J Pediatr Urol 2016; 12:51.e1-4. [PMID: 26395216 DOI: 10.1016/j.jpurol.2015.07.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 07/31/2015] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Recent articles document successful classic bladder exstrophy (CBE) closure without osteotomy. Still, many patients require osteotomy if they have a large bladder template and pubic diastasis, or non-malleable pelvis. OBJECTIVE To understand the indications and outcomes of bladder closure with and without pelvic osteotomy in patients younger than 1 month of age. METHODS An institutional database of 1217 exstrophy-epispadias patients was reviewed for CBE patients closed at the authors' institution within the first month of life. Patient demographics, closure history, pubic diastasis distance, bladder capacity, and outcomes were recorded and compared using chi-square tests between osteotomy and non-osteotomy patients. Failure was defined as bladder dehiscence, prolapse, vesicocutaneous fistula, or bladder outlet obstruction requiring reoperation. Bladder capacity >100 mL was deemed sufficient for bladder neck reconstruction (BNR). RESULTS One hundred CBE patients were included for analysis: 38 closed with osteotomy (26 male, 12 female), and 62 closed without osteotomy (42 male, 20 female). There were four failed closures in the osteotomy group (2 dehiscence, 2 prolapse) and four failed closures in the non-osteotomy group (2 dehiscence, 2 prolapse). This corresponded to statistically equivalent rates of failure between the osteotomy and non-osteotomy groups (10.5% vs. 6.5%, p = 0.466). There was no statistically significant difference between the groups' ability to achieve bladder capacity sufficient for BNR (82% vs. 71%, p = 0.234). DISCUSSION A successful primary bladder closure, regardless of the use of osteotomy, has been shown to be the single most important predictor of eventual continence. Because of the complexity of exstrophy manifestations, a multidisciplinary team approach is of the utmost importance. Based on our institutional experience, closure without osteotomy is considered when patients are <72 h of life, have a pubic diastasis <4 cm, malleable pelvis, and pubic apposition without difficulty. Rates of successful closure and attaining sufficient capacity for BNR were both statistically equivalent across groups. This retrospective study is limited by selection bias and the significant difference in follow-up time between groups. Nevertheless, as a high-volume exstrophy center this study draws from one of the largest cohorts available. CONCLUSIONS Regardless of the type of closure undertaken, there clearly is a role for newborn CBE closure without pelvic osteotomy in patients considered suitable for closure by both the pediatric urologist and orthopedic consultant. However, if there is any doubt concerning pubic diastasis width, pelvic malleability, or ease of pubic apposition, an osteotomy is highly recommended.
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Affiliation(s)
- Brian M Inouye
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Kathy Lue
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Mahmoud Abdelwahab
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Heather N Di Carlo
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Ezekiel E Young
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Ali Tourchi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Mehnaj Grewal
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Christopher Hesh
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Paul D Sponseller
- The Johns Hopkins University School of Medicine, Division of Pediatric Orthopaedics, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John P Gearhart
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
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Abstract
BACKGROUND It is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome. Due to a number of reasons, including a lack of comparable multicenter studies, there are numerous concepts for initial exstrophy closure. DISCUSSION Therefore, we describe our concept of delayed, staged reconstruction without osteotomy in classical bladder exstrophy, while taking into considerion the available literature on long-term follow-up as well as on own clinical and research data. CONCLUSION Most notably there are multiple medical but also psychological advantages of a delayed procedure. Primary closure without osteotomy is feasible and has no disadvantages in the long-term follow-up when compared to the invasive procedure of osteotomy. Due to high intravesical pressure, initial bladder neck surgery might have negative effects on bladder development and on the upper urinary tract.
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Affiliation(s)
- W H Rösch
- Klinik für Kinderurologie in Kooperation mit der Universität Regensburg, Klinik St. Hedwig Regensburg, Steinmetzstr. 1-3, 93049, Regensburg, Deutschland.
| | - M Promm
- Klinik für Kinderurologie in Kooperation mit der Universität Regensburg, Klinik St. Hedwig Regensburg, Steinmetzstr. 1-3, 93049, Regensburg, Deutschland
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Inouye BM, Di Carlo HN, Gearhart JP. Re: Are Osteotomies Necessary for Bladder Exstrophy Closure? J Urol 2014; 192:281-2. [DOI: 10.1016/j.juro.2014.01.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Brian M. Inouye
- James Buchanan Brady Urological Institute, The Johns Hopkins Children's Center, Baltimore, Maryland
| | - Heather N. Di Carlo
- James Buchanan Brady Urological Institute, The Johns Hopkins Children's Center, Baltimore, Maryland
| | - John P. Gearhart
- James Buchanan Brady Urological Institute, The Johns Hopkins Children's Center, Baltimore, Maryland
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Kurbet SB, Prashanth GP, Patil MV, Mane S. A retrospective analysis of early experience with modified complete primary repair of exstrophy bladder (CPRE) in neonates and children. Indian J Plast Surg 2014; 46:549-54. [PMID: 24459348 PMCID: PMC3897103 DOI: 10.4103/0970-0358.122015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: To study the problems faced during the surgery and follow-up of modified complete primary repair of exstrophy (CPRE) technique. Initial experience with CPRE and its short- and long-term outcomes with respect to continence status and psychosocial impact are reported. Materials and Methods: A retrospective review of the hospital case records from March 2008 to September 2012 was performed. Data of patients with bladder exstrophy managed by a single paediatric surgeon using modified CPRE technique were analysed. Quality of life and psychosocial impact of the surgery were assessed using Pediatric Quality of Life Inventory (PedsQL 4.0) and compared with those of typical peers. Results: Eight children (age 4 days-12 years) underwent CPRE using modified Mitchell's technique. Two patients (25%) experienced early postoperative complications, with infection and fistula developing in one each. All the patients were doing well on follow-up, with variable continence rates and good cosmesis. Mean duration of follow-up was 18.5 months (range 6 months-4 years). Five out of seven (71%) children were continent or partially continent. One case was lost to follow-up. PedsQL scores were comparable with those of age-matched peers in all domains except the social functioning domain in 8-12 years age group (83.53 ± 9.70 vs. 77.86 ± 10.22, P < 0.05). Conclusion: Our preliminary results with modified CPRE in neonates and children have been encouraging. No major complications were observed. Continence rate was satisfactory and cosmetic results were good. Though the technique is being practiced at several Indian centres, there is a paucity of comprehensive Indian data on CPRE.
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Affiliation(s)
- Santosh B Kurbet
- Department of Pediatric Surgery, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Gowda P Prashanth
- Department of Pediatrics, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Mahantesh V Patil
- Department of Pediatrics, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Shivaji Mane
- Department of Pediatric Surgery, Grant Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, Maharashtra, India
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Modern management of the exstrophy-epispadias complex. Surg Res Pract 2014; 2014:587064. [PMID: 25374956 PMCID: PMC4208497 DOI: 10.1155/2014/587064] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/28/2013] [Accepted: 12/09/2013] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications.
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Baskin LS. This Month in Pediatric Urology. J Urol 2014. [DOI: 10.1016/j.juro.2013.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ritchey ML. This Month in Pediatric Urology. J Urol 2013. [DOI: 10.1016/j.juro.2013.08.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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