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Zaman MH, Young EE, Maruf M, Hesh CA, Harris KT, Manyevitch R, Davis R, Wu WJ, Hall SA, DiCarlo H, Gearhart J. Practice patterns in classic bladder exstrophy: A global perspective. J Pediatr Urol 2020; 16:425-432. [PMID: 32299766 DOI: 10.1016/j.jpurol.2020.02.017] [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: 04/11/2019] [Accepted: 02/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While evaluation and management options for classic bladder exstrophy (CBE) patients are numerous and varied, little is known regarding the relative utilization of these different methods throughout the world. A large group of exstrophy surgeons practicing globally was surveyed, seeking to document their methods of care. METHODS A list of international exstrophy surgeons' email addresses was compiled using professional contacts and referral networking. An online survey was sent to each email address. Surgeons who had not performed a CBE closure within the previous 5 years were excluded. Survey questions queried the respondents' surgical practice type, years since training, and their preferred methods of preoperative evaluation, operative management, and postoperative management. Survey invitations were sent out starting in December 2014 and responses were collected for approximately 6 months. RESULTS A total of 1152 valid email addresses were invited, resulting in 293 respondents (25%) from 39 countries and every American Urological Association (AUA) section. Seventy-six were excluded, leaving 217 respondents (Table). Respondents reported a median of 17 years since finishing their surgical training (IQR 8-25 years). Practice types included pediatric urology (n = 209), general urology (n = 9), pediatric surgery (n = 59), and other practice makeup (n = 3). On subgroup analyses, there were no significant regional practice differences, with the exception of complete primary repair of exstrophy (CPRE) and oral opioid prescribing being significantly higher in North America compared to other regions. DISCUSSION Findings indicate that there may be diversity in CBE practice patterns globally. While most responding surgeons from regions outside of North America indicated modern staged repair of exstrophy (MSRE) as their preferred closure technique, a relatively equal distribution of respondents from North America selected CPRE and MSRE. A majority of North American surgeons chose performing osteotomies for both newborn and delayed closures, while an appreciable number of respondents from other regions selected never using osteotomies in their closures. Limitations to this study include a low survey response rate, particularly from surgeons outside of the United States, which may have significantly impacted the ability to draw meaningful global comparisons. CONCLUSIONS Global variation among practices of surgeons performing CBE closures may exist. The wide range of methods demonstrated by this survey suggests the need for more conclusive comparative studies to elucidate whether an optimal standard exists. Local social factors, access to surgical expertise and transportation to referral centers, and finances play a role in what constitutes the best operative approach.
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Affiliation(s)
- Mohammad H Zaman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Ezekiel E Young
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Christopher A Hesh
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Kelly T 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
| | - Roni Manyevitch
- 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
| | - Rachel Davis
- 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
| | - Wayland J Wu
- 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
| | - Saran A Hall
- 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 DiCarlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John 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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Initial Experience of Pediatric Urology Consortium in Taking Care of Children with Bladder Exstrophy: the Search for the Holy Grail. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00585-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jayman J, Tourchi A, Feng Z, Trock BJ, Maruf M, Benz K, Kasprenski M, Baumgartner T, Friedlander D, Sponseller P, Gearhart J. Predictors of a successful primary bladder closure in cloacal exstrophy: A multivariable analysis. J Pediatr Surg 2019; 54:491-494. [PMID: 30029844 DOI: 10.1016/j.jpedsurg.2018.06.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 06/06/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To investigate the factors affecting primary bladder closure in cloacal exstrophy (CE). A successful primary closure is important for optimizing reconstructive outcomes, and it is a critical first-step in the reconstruction of CE. The authors' hypothesize that a smaller diastasis and use of an osteotomy are independent predictors of a successful closure. METHODS A prospectively maintained database of 1332 exstrophy-epispadias complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. Univariate and multivariable analyses were performed to identify significant factors associated with CE primary bladder closure. RESULTS Of 143 CE patients identified, 99 patients met inclusion criteria. Median follow-up time was 8.82 [IQR 5.43-14.26] years. In the multivariable model, the odds of having a successful closure are about 4 times greater for the staged cloacal approach compared to the 1-stage approach (OR, 3.7; 95% CI 1.2-11.5; p-value = 0.023). Also, having an osteotomy increases the chance of a successful closure by almost six-fold (OR, 5.8; 95% CI 1.7-19.6; p-value = 0.004). CONCLUSIONS Using the staged approach with a pelvic osteotomy is paramount to a successful primary closure in CE. The authors strongly recommend using the staged approach and osteotomy as these factors independently increase the chance for a successful primary bladder closure. STUDY TYPE Therapeutic study. LEVEL OF EVIDENCE Level III, Retrospective comparative study.
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Affiliation(s)
- John Jayman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Ali Tourchi
- 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
| | - Zhaoyong Feng
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bruce J Trock
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Karl Benz
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Matthew Kasprenski
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Timothy Baumgartner
- 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
| | - Daniel Friedlander
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Paul Sponseller
- Division of Pediatric Orthopedic Surgery, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John 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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Inouye BM, Purves JT, Routh JC, Maruf M, Friedlander D, Jayman J, Gearhart JP. How to close classic bladder exstrophy: Are subspecialty training and technique important? J Pediatr Urol 2018; 14:426.e1-426.e6. [PMID: 29627154 DOI: 10.1016/j.jpurol.2018.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 02/15/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Successful primary closure is one of the main factors for achieving continence in a classic bladder exstrophy (CBE) patient. Even with contemporary management, patients still have failed primary closures. We sought to understand the role of training, surgical technique, and their impacts on outcomes of CBE closure. MATERIALS AND METHODS A retrospective cohort study from the largest single-institution database of primary and re-closure CBE patients in the world was performed. Failed closure was defined as developing bladder outlet obstruction, wound dehiscence, bladder prolapse, or any need for a re-closure operation. Patient demographics and surgical factors were abstracted and analyzed. Multivariable analysis was performed to test for associations with successful exstrophy closure. RESULTS Data from 722 patients were analyzed. On bivariate analysis, successful closure was associated with gestational age at presentation, time of closure, location of closure, credential of surgeon performing the closure, closure type, concomitant osteotomy, and type of immobilization. Multivariable analysis, adjusting for patient comorbidity and location of closure, demonstrated increased odds of failure for closure by pediatric surgeon compared with pediatric urologist (OR 4.32, 95% CI 1.98-9.43; p = 0.0002), closure by unknown credentialed surgeon (OR 1.86, 95% CI 1.15-2.99; p = 0.011), Complete Primary Repair of Exstrophy (CPRE) closure compared with Modern Staged Repair of Exstrophy (OR 2.05, 95% CI 1.29-2.99; p = 0.0024), and unknown closure type (OR 4.81, 95% CI 2.94-7.86; p < 0.0001) (Table). DISCUSSION Many factors associated with failure on bivariate analysis can be explained by these patients presenting to a center of excellence or the selection bias of this cohort stemming from a single center database that have been previously published. However, the finding on adjusted multivariable logistic regression analysis that closure by a pediatric surgeon is associated with higher odds of failure is novel. The additional finding that CPRE closure is associated with failure is most likely secondary to these patients being referred to our institution after having been closed with CPRE which falsely increases its impact on closure failure. Nevertheless, as a center with a large exstrophy volume, this study draws from a cohort that is larger than any other. CONCLUSION Classic bladder exstrophy closure should be performed at a center with pediatric urologists to ensure the best chance of a successful primary closure.
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Affiliation(s)
- Brian M Inouye
- Duke University School of Medicine, Department of Surgery, Division of Pediatric Urology, USA
| | - J Todd Purves
- Duke University School of Medicine, Department of Surgery, Division of Pediatric Urology, USA
| | - Jonathan C Routh
- Duke University School of Medicine, Department of Surgery, Division of Pediatric Urology, USA
| | - Mahir Maruf
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Daniel Friedlander
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John Jayman
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, 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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Ahn JJ, Shnorhavorian M, Katz C, Goldin AB, Merguerian PA. Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis. J Pediatr Urol 2018; 14:27.e1-27.e5. [PMID: 29352663 DOI: 10.1016/j.jpurol.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/01/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods. OBJECTIVE The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure. STUDY DESIGN The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications. RESULTS Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999 to 2010, delayed closure was performed more frequently in this cohort (71% vs 27%). DISCUSSION The NSQIPP provides standardized reporting of peri-operative characteristics and 30-day complications, allowing a comparison of early to delayed closure of bladder exstrophy across multiple institutions. Assessing short-term risks in conjunction with long-term follow-up is crucial for determining optimal management of this rare but complex condition. CONCLUSION Delayed closure of bladder exstrophy is performed frequently, yet it carries a high rate of 30-day complications worthy of further investigation. This can be useful in counseling patients and families, and to understand practice patterns across the country.
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Affiliation(s)
- J J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - M Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - C Katz
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - A B Goldin
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA
| | - P A Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Ben-Chaim J, Binyamini Y, Segev E, Sofer M, Bar-Yosef Y. Can Classic Bladder Exstrophy be Safely and Successfully Reconstructed at a Low Volume Center? J Urol 2016; 195:150-4. [DOI: 10.1016/j.juro.2015.06.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Jacob Ben-Chaim
- Pediatric Urology Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yosef Binyamini
- Pediatric Urology Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eitan Segev
- Pediatric Orthopedics Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mario Sofer
- Pediatric Urology Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yuval Bar-Yosef
- Pediatric Urology Unit, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Stuhldreher PP, Inouye B, Gearhart JP. Exstrophy-Epispadias Complex. CURRENT BLADDER DYSFUNCTION REPORTS 2015. [DOI: 10.1007/s11884-015-0306-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schaeffer AJ, Johnson EK, Logvinenko T, Graham DA, Borer JG, Nelson CP. Practice patterns and resource utilization for infants with bladder exstrophy: a national perspective. J Urol 2014; 191:1381-8. [PMID: 24300484 PMCID: PMC4130705 DOI: 10.1016/j.juro.2013.11.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Substantial variability exists in bladder exstrophy care, and little is known about costs associated with the condition. We define the care patterns and first year cost for patients with bladder exstrophy at select freestanding pediatric hospitals in the United States. MATERIALS AND METHODS We used the Pediatric Health Information System database to identify patients with bladder exstrophy born between January 1999 and December 2010 who underwent primary closure in the first 120 days of life. Demographic, surgical, postoperative and cost data for all encounters were assessed. Multivariate linear regression was used to examine the association between patient, surgeon and hospital characteristics and costs. RESULTS Of the 381 patients who underwent primary closure within the first 120 days of life 279 (73%) did so within the first 3 days of life. A total of 119 patients (31%) underwent pelvic osteotomy, including 51 of 279 (18%) who underwent closure within the first 3 days of life, 38 of 67 (56%) who underwent closure between 4 and 30 days of life, and 30 of 35 (86%) who underwent closure between 31 and 120 days of life (p = 0.0017). Median inflation adjusted, first year cost in United States dollars per patient was $66,577 (IQR $45,335 to $102,398). Presence of nonrenal comorbidity and completion of primary closure after 30 days of life increased first year costs by 24% and 53%, respectively. Increased post-closure length of stay was associated with greater costs. CONCLUSIONS At select freestanding United States pediatric hospitals the majority of bladder exstrophy closures are performed within the first 3 days of life. Most, but not all, patients undergoing closure after the neonatal period undergo osteotomy. The presence of nonrenal comorbidity and increased postoperative length of stay are associated with greater costs.
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Affiliation(s)
| | - Emilie K Johnson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Tanya Logvinenko
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Dionne A Graham
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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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: 13] [Impact Index Per Article: 1.3] [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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Wallis MC, Oottamasathien S, Wicher C, Hadley D, Snow BW, Cartwright PC. Padded self-adhesive strap immobilization following newborn bladder exstrophy closure: the Utah straps. J Urol 2013; 190:2216-20. [PMID: 23810641 DOI: 10.1016/j.juro.2013.06.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Several methods have been described for immobilization of the pelvis following bladder exstrophy closure, which can be challenging to manage. We hypothesized that immobilization can be significantly simplified using a modified mermaid wrap with padded Velcro® straps around the thigh and lower leg. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent bladder exstrophy closure in the newborn period at our institution from 1990 through 2010. Patients with cloacal exstrophy and those who underwent delayed closure due to other medical conditions were excluded. We collected data on closure technique, length of stay and complications of the primary closure as outcomes. RESULTS A total of 20 boys and 7 girls underwent closure of classic bladder exstrophy. Followup ranged from 2 to 22 years. Seven boys underwent complete primary repair and 13 underwent staged repair. All patients had the legs stabilized with a modified wrap technique using 2 lengths of Velcro straps lined with self-adhering open cell foam pads for 3 weeks. Complications of exstrophy closure included bladder dehiscence in 1 patient (4%) and incisional hernia in 2 (7%). Following complete primary repair urethrocutaneous fistula developed in 2 patients and urethral stricture in 2. Average length of stay for patients without significant prematurity was 15 days. CONCLUSIONS Padded Velcro strap immobilization simplifies postoperative care, provides secure fixation, decreases length of stay, and enables parents to hold and bond with the child shortly after repair. We advocate this simplified technique, which can be applied with a rate of complications that is comparable to other procedures.
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Affiliation(s)
- M Chad Wallis
- Division of Pediatric Urology, University of Utah School of Medicine, Salt Lake City, Utah.
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Inouye BM, Massanyi EZ, Di Carlo H, Shah BB, Gearhart JP. Modern Management of Bladder Exstrophy Repair. Curr Urol Rep 2013; 14:359-65. [DOI: 10.1007/s11934-013-0332-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Massanyi EZ, Gearhart JP, Kost-Byerly S. Perioperative management of classic bladder exstrophy. Res Rep Urol 2013; 5:67-75. [PMID: 24400236 PMCID: PMC3826855 DOI: 10.2147/rru.s29087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare congenital malformation of the genitourinary system, abdominal wall muscles, and pelvic structures. Modern surgical repairs focus on reconstruction of the bladder and its adjacent structures, with the goal of achieving urinary continence, a satisfactory cosmetic result, and a high quality of life. Complex surgery in neonates and young children, as well as a prolonged postoperative course require close collaboration between surgeons, anesthesiologists, intensivists, pediatricians, and an experienced nursing staff. This article will review the spectrum of bladder exstrophy anomalies, the surgical repair, and the perioperative interdisciplinary management.
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Affiliation(s)
- Eric Z Massanyi
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - John P Gearhart
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - Sabine Kost-Byerly
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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Stec AA, Baradaran N, Schaeffer A, Gearhart JP, Matthews RI. The modern staged repair of classic bladder exstrophy: a detailed postoperative management strategy for primary bladder closure. J Pediatr Urol 2012; 8:549-55. [PMID: 22094235 DOI: 10.1016/j.jpurol.2011.09.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Accepted: 09/01/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE Successful primary bladder closure of classic bladder exstrophy sets the stage for development of adequate bladder capacity and eventual voided continence. The postoperative pathway following primary bladder closure at the authors' institution is quantitatively and qualitatively detailed. MATERIALS AND METHODS Sixty-five consecutive newborns (47 male) undergoing primary closure of classic bladder exstrophy were identified and data were extracted relating to immediate postoperative care. Overall success rate was utilized to validate the pathway. RESULTS Mean age at time of primary closure was 4.6 days and mean hospital stay was 35.8 days. Osteotomy was performed in 19 patients (mean age 8.8 days), and was not required in 39 infants (mean age 2.9 days). All patients were immobilized for 4 weeks. Tunneled epidural analgesia was employed in 61/65 patients. All patients had ureteral catheters and a suprapubic tube, along with a comprehensive antibiotic regimen. Postoperative total parenteral nutrition was commonly administered, and enteral feedings started around day 4.6. Our success rate of primary closure was 95.4%. CONCLUSIONS A detailed and regimented plan for bladder drainage, immobilization, pain control, nutrition, antimicrobial prophylaxis, and adequate healing time is a cornerstone for the postoperative management of the primary closure of bladder exstrophy.
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Affiliation(s)
- Andrew A Stec
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA.
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Bible JE, Lee RS, Friedlaender GE. The need for increased access to the U.S. health-care system. J Bone Joint Surg Am 2009; 91:476-84. [PMID: 19181995 DOI: 10.2106/jbjs.h.00735] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse E Bible
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA.
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Nelson CP. Evidence of variation by race in the timing of surgery for correction of pediatric ureteropelvic junction obstruction. J Urol 2007; 178:1463-8; discussion 1468. [PMID: 17706705 DOI: 10.1016/j.juro.2007.05.167] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We used a national pediatric database to investigate the association of patient race with timing of surgery for ureteropelvic junction obstruction. MATERIALS AND METHODS The Kids' Inpatient Database is a national database containing 5.5 million pediatric hospitalizations (patients younger than 21 years) during the years 2000 to 2003. We used International Classification of Disease-9 codes to identify patients undergoing pyeloplasty, and investigated patient and hospital factors associated with timing of surgery using multivariable linear and mixed models. RESULTS A total of 2,989 patients underwent pyeloplasty. Mean patient age was 72.3 months (median 36). Of the patients 69.3% were male and 66.0% were white. White patients were significantly older than nonwhite patients (82.3 vs 52.8 months, p <0.0001). The proportion of patients undergoing surgery during the first 12 months of life also varied by race (31.3% among white vs 46.9% among nonwhite patients, p <0.0001). Other factors associated with younger age included male gender (p = 0.0002), hospital volume and teaching status (p <0.0001), and Medicaid insurance (p <0.0001). Socioeconomic status at the zip code level was not associated with timing of surgery. Using a multivariable mixed model to adjust for all variables, including random effects of individual hospitals, nonwhite race was still associated with earlier surgery (p = <0.0001). CONCLUSIONS This study confirms that nonwhite patients undergo pyeloplasty an average of more than 2.5 years earlier than white patients (even after adjusting for insurance status and other factors). Future research should elucidate the clinical factors that influence surgical decision making in ureteropelvic junction obstruction, including socioeconomic and cultural factors among families and providers, as well as possible biological differences between racial groups in the natural history of ureteropelvic junction obstruction.
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Affiliation(s)
- Caleb P Nelson
- Department of Urology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02155, USA
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Bibliography. Current world literature. Reconstructive surgery. Curr Opin Urol 2006; 16:460-3. [PMID: 17053527 DOI: 10.1097/mou.0b013e328010dc58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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