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Kenawey M, Morakis E, Cervellione R, Keene D, Kelley SP. The true pelvic volume change with various corrective osteotomy techniques for exstrophy-epispadias complex spectrum: the value of computer-assisted virtual surgery. J Pediatr Orthop B 2024; 33:413-419. [PMID: 38189741 DOI: 10.1097/bpb.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Pelvic osteotomies are essential to approximate widened symphysis pubis in the exstrophy-epispadias complex, yet it is unknown which osteotomy type has the greatest effect on pelvic volume. We therefore used virtual surgery to study pelvic volume change with anterior, oblique, and posterior iliac osteotomies. Preoperative CT scans of two cloacal and one classic bladder exstrophy patients were used. Simulations were free-hand or constrained to keep minimal strain in the sacrospinous SSL and sacrotuberous STL ligaments. Changes in inter-pubic distance, pelvic volume, SSL and STL strains were measured. Mean pelvic volume decreased by 10% with free hand compared to 23% with constrained simulations ( P = 0.171) and decreased by 7% with posterior, 17% with diagonal and 26% with horizontal osteotomies ( P = 0.193). SSL and STL were strained by 20% and 26%, respectively, with free-hand simulations. A statistically significant moderate positive correlation was found between the decrease in inter-pubic distance and reduction in pelvic volume (r = 0.6, P = 0.004). Mean pelvic volume decreased 0.05, 0.37 and 0.62% for each mm of pubic symphysis approximation with posterior, diagonal and horizontal osteotomies, respectively. Differences in effect on pelvic volume were identified between the osteotomies using virtual surgery which predicted residual diastasis in actual cloacal exstrophy surgical reconstructions. Oblique osteotomies are a compromise, avoiding difficulties with posterior osteotomies and excessive pelvic volume reduction with horizontal osteotomies. Understanding how osteotomy type affects pelvic morphology with virtual surgery may be an effective adjunct to pre-operative planning in exstrophy spectrum.
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Affiliation(s)
- Mohamed Kenawey
- Paediatric Orthopaedic Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Orthopaedic Department, Sohag University Faculty of Medicine, Sohag, Egypt
| | - Emmanouil Morakis
- Paediatric Orthopaedic Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Raimondo Cervellione
- Paediatric Urology Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - David Keene
- Paediatric Urology Department, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon P Kelley
- Division of Orthopaedic Surgery, The Hospital for Sick Children
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Back SJ, Weiss DA, Marshall B, Akbari E, Mackey M, Hinton E, Horn BD, Kidd M, Francavilla ML. Radiographic calibration for pubic diastasis assessment in bladder exstrophy-epispadias complex: a phantom study. Pediatr Radiol 2024; 54:1489-1496. [PMID: 38935137 PMCID: PMC11324702 DOI: 10.1007/s00247-024-05972-y] [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: 12/17/2023] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The assessment of pubic diastasis is important for the surgical planning of patients with bladder exstrophy-epispadias complex. Understanding how the diastasis changes during surgical follow-up may help predict patient morbidity. Radiography can follow diastasis but may be affected by patient and technical imaging factors including body size, imaging protocol, and equipment. Using imaging calibration and anatomic ratios may mitigate differences due to these aspects. OBJECTIVE Use imaging phantoms to assess the effect of radiographic calibration on measurements of pubic diastasis and an internal anatomic ratio as a child grows. MATERIALS AND METHODS Radiographic images were obtained of three different sizes of computed tomography phantoms (older child, child, and infant) using three imaging techniques that include the osseous pelvis in children. All phantoms were imaged with abdomen and pelvis techniques. The infant phantom was additionally imaged using a thoracoabdominal technique. These exposures were all repeated with systems from three manufacturers. Linear measurements were made between radiographic markers placed to simulate pubic diastasis and sacral width. A ratio was also created between these distances. Measurements with and without image calibration were made by two pediatric radiologists using rulers placed at the time of image acquisition. RESULTS There was excellent interrater agreement for measurements, ICC >0.99. Anterior distances were more affected by magnification than posterior ones with a significant difference between uncalibrated versus calibrated anterior distances (p=0.04) and not for posterior ones (p=0.65). There was no difference between radiographic equipment manufacturers without or with calibration (p values 0.66 to 0.99). There was a significant difference in simulated pubic distance between thoracoabdominal and abdomen (p=0.04) as well as pelvic (p=0.04) techniques which resolved with calibration, each p=0.6. The ratio between the simulated pubic diastasis and sacral width differed by phantom size (all p<0.01) and imaging technique (p values 0.01 to 0.03) with or without calibration. However, the numerical differences may not be clinically significant. CONCLUSION Image calibration results in more uniform measurements that are more accurate than uncalibrated ones across patient size, imaging techniques, and equipment. Image calibration is necessary for accurate measurement of inter-pubic distances on all projection imaging. Small differences in the pelvic ratio likely are not clinically significant, but until there is a better understanding, image calibration may be prudent.
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Affiliation(s)
- S J Back
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - D A Weiss
- Division of Urology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - B Marshall
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E Akbari
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Mackey
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E Hinton
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B D Horn
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kidd
- Centre for Statistical Consultation, University of Stellenbosch, Stellenbosch, South Africa
| | - M L Francavilla
- Department of Radiology, University of South Alabama, Whiddon College of Medicine, Mobile, AL, USA
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Annabell L, Lee T, Barnett S, Ralston K, Lee R, Borer JG, Kim YJ. Is Immobilization Technique Associated With Postoperative Pubic Rami Diastasis Following Bladder Exstrophy Closure? J Pediatr Orthop 2024; 44:e469-e473. [PMID: 38477339 DOI: 10.1097/bpo.0000000000002664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE Pelvic osteotomies relieve tension of the bladder and fascial closures during bladder exstrophy repair. Multiple techniques for postoperative immobilization of the pelvis and lower extremities have been described. The primary aim of this study was to assess differences in short and long-term changes in pubic rami diastasis when comparing Bryant traction to spica cast immobilization. Secondary aims included a comparison of length of stay, skin-related complications, and urologic outcomes. METHODS We performed a single-institutional retrospective review of bladder exstrophy patients younger than 18 months of age who underwent posterior pelvic osteotomy and bladder exstrophy closure from April 2005 to April 2020. Short-term and long-term pubic rami diastasis were defined as postoperative measurements ≤6 months and ≥12 months, respectively. Secondary outcomes included length of stay, pressure ulcer, skin rash/abrasion, urethrocutaneous fistula, and bladder or fascial dehiscence rates. Multivariable logistic regression assessed for an association between immobilization type and degree of diastasis while controlling for age at the time of diastasis measurement and sex. RESULTS Fifteen patients underwent Bryant traction and 36 patients underwent spica cast immobilization. In both the short-term and long-term, there was a greater reduction in pubic diastasis in the spica cast group ( P = 0.002 and P = 0.05, respectively). After adjustments, there were higher odds of having a greater reduction in pubic rami diastasis in both the short-term (odds ratio: 2.71, 95% CI: 1.52-4.86, P = 0.001) and long-term (odds ratio: 2.41, 95% CI: 1.00-5.80, P = 0.05). Length of stay was significantly higher in Bryant's traction group (26 vs 19 d, P < 0.001). Rates of pressure ulcers were higher in the Bryant traction group (26.7% vs 0%, P = 0.005). Rates of skin rash/abrasions, urethrocutaneous fistula, and bladder/fascial dehiscence did not differ. CONCLUSIONS Spica cast immobilization is a safe and effective immobilization method. Compared with Bryant traction, spica cast immobilization was associated with a greater reduction in postoperative pubic diastasis both short and long-term, along with a shorter length of hospitalization and reduced rate of pressure ulcers. LEVEL OF EVIDENCE Level III-therapeutic study.
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Affiliation(s)
- Lucas Annabell
- Department of Orthopaedics, Royal Children's Hospital, Australia
| | | | - Samuel Barnett
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
| | | | | | | | - Young-Jo Kim
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
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Haffar A, Hirsch AM, Morrill CC, Crigger CC, Sponseller PD, Gearhart JP. Classic Bladder Exstrophy Closure Without Osteotomy or Immobilization: An Exercise in Futility? Urology 2023; 181:128-132. [PMID: 37696307 DOI: 10.1016/j.urology.2023.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/11/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To review the outcomes of classic bladder exstrophy (CBE) closure without the use of osteotomy or lower extremity/pelvic immobilization. METHODS A prospectively maintained institutional approved exstrophy-epispadias complex database of 1487 patients was reviewed for patients with CBE who had undergone closure without osteotomy nor immobilization. All patients were referred to the authors' institution for reconstruction later in life or for failed closure. RESULTS Of a total of 1016 CBE patients, 56 closure events were identified that met inclusion with a total of 47 unique patients. Thirty-eight closures were completed prior to 1990 (67.9%). Forty-five closure events developed eventual failure (45/56, 80.4%) (Table 1). Thirteen closure events were secondary closures (13/56, 23.2%). The primary closure failure rate was 83.7% (36/43) while the secondary closure failure rate was 69.2% (9/13). Failures were attributed to one or more of dehiscence, bladder prolapse, and vesicocutaneous fistula (25/45, 55.6%) (23/45, 51.1%) (6/45, 13.3%), respectively. Thirty-seven patients developed social continence (37/47, 78.7%), while only 8 patients developed spontaneous voided continence (7/47,17.0%) (Table 2). The most common methods of voiding were continent catheterizable channels (25/47, 53.2%) of which all were socially continent. CONCLUSION These results illustrate the critical role osteotomy and postoperative immobilization can play in both primary and secondary exstrophy closure. While this is a historical case series, the authors believe that these results remain relevant to contemporary exstrophy surgeons.
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Affiliation(s)
- Ahmad Haffar
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD
| | - Alexander M Hirsch
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD
| | - Christian C Morrill
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD
| | - Chad C Crigger
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD
| | - Paul D Sponseller
- Division of Pediatric Orthopedics, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Baltimore, MD
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD.
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Esmaeilizadeh AH, Ebrahimisaraj G, Sarafi M, Rouzrokh M, Mohajerzadeh L, Ghoroubi J, Tabari AK, Ebrahimian M. The outcome and complications of modern staged repair surgery in newborns with classic bladder exstrophy in different genders: A retrospective study. Birth Defects Res 2023; 115:1469-1474. [PMID: 37507850 DOI: 10.1002/bdr2.2228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/20/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Classic bladder exstrophy (CBE) is a rare anterior midline birth defect that remains a challenge for pediatric surgeons. Despite multiple reconstructive methods, outcomes vary widely in various reports. This study aims to compare the success rate and complications of modern staged repair of exstrophy (MSRE) in each gender and compare together. METHODS This retrospective cross-sectional study included cases of CBE between 2010 and 2020 that underwent MSRE. Short-term follow-up results, including incontinence rate, vesicoureteral reflux (VUR), urinary infections, deformed genitalia, and so on, were measured in each gender, and their differences were reported. RESULTS Among the 40 newborns with CBE who underwent MSRE, 25 (62.5%) were boys, while the others had non-male genitalia. The rates of incontinence, VUR, dehiscence, and fistulas did not differ significantly between genders. However, chronic urinary tract infections (UTIs) were more frequent in girls, and boys were more likely to have malformed genitalia (p < .05). CONCLUSION Our findings indicate a similar rate of complications in each gender. However, chronic UTIs and external genitalia deformities were significantly more common in girls and boys, respectively. Further large-sized controlled trials may be needed to corroborate these findings.
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Affiliation(s)
- Amin Haj Esmaeilizadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Ebrahimisaraj
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Sarafi
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Rouzrokh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leily Mohajerzadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Javad Ghoroubi
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad Khaleghnejad Tabari
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Manoochehr Ebrahimian
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Wongcharoenwatana J, Adulkasem N, Ariyawatkul T, Eamsobhana P, Chotigavanichaya C, Chotivichit A. A long-term outcome (up to 29 years) of bilateral iliac wings "bayonet osteotomies" for closure of bladder exstrophy. J Orthop Surg Res 2023; 18:329. [PMID: 37131198 PMCID: PMC10152618 DOI: 10.1186/s13018-023-03810-9] [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: 03/29/2023] [Accepted: 04/23/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Several types of pelvic osteotomy techniques have been reported and employed by orthopedic surgeons to enhance the approximation of symphyseal diastasis in bladder exstrophy patients. However, there is limited evidence on a long-term follow-up to confirm which osteotomy techniques provide the most suitable and effective outcomes for correcting pelvic deformities. This study aimed to describe the surgical technique of bilateral iliac bayonet osteotomies for correcting pelvic bone without using fixation in bladder exstrophy and to report on the long-term clinical and radiographic outcomes following the bayonet osteotomies. METHODS We retrospectively reviewed patients with bladder exstrophy who underwent bilateral iliac bayonet osteotomies with the closure of bladder exstrophy between 1993 and 2022. Clinical outcomes and radiographic pubic symphyseal diastasis measurements were evaluated. From a total of 28 operated cases, eleven were able to attend a special follow-up clinic or were interviewed by telephone by one of the authors with completed charts and recorded data. RESULTS A total of 11 patients (9 female and 2 male) with an average age at operation of 9.14 ± 11.57 months. The average followed-up time was 14.67 ± 9.24 years (0.75-29), with the average modified Harris Hip score being 90.45 ± 1.21. All patients demonstrated decreased pubic symphyseal diastasis distance (2.05 ± 1.13 cm) compared to preoperative (4.58 ± 1.37 cm) without any evidence of nonunion. At the latest follow-up, the average foot progression angle was externally rotated 6.25° ± 4.79° with full hips ROM, and no patients reported abnormal gait, hip pain, limping, or leg length discrepancy. CONCLUSIONS Bilateral iliac wings bayonet osteotomies technique demonstrated a safe and successful pubic symphyseal diastasis closure with an improvement both clinically and radiographically. Moreover, it showed good long-term results and excellent patient's reported outcome scores. Therefore, it would be another effective option for pelvic osteotomy in treating bladder exstrophy patients.
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Affiliation(s)
- Jidapa Wongcharoenwatana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Nath Adulkasem
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanase Ariyawatkul
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Perajit Eamsobhana
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatupon Chotigavanichaya
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Areesak Chotivichit
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Haney NM, Crigger CB, Sholklapper T, Mudalegundi S, Griggs-Demmin A, Nasr IW, Sponseller PD, Gearhart JP. Pelvic osteotomy in cloacal exstrophy: A changing perspective. J Pediatr Surg 2023; 58:478-483. [PMID: 35906108 DOI: 10.1016/j.jpedsurg.2022.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The type of osteotomy and pelvic fixation in the management of primary cloacal exstrophy (CE) closure is variable. The purpose of this study was to evaluate primary CE closure outcomes with osteotomy, immobilization, and multi-staging procedure trends over time. METHODS An institutional database was retrospectively reviewed for patients who underwent primary CE closure from 1960 to 2020. Demographics, osteotomy, fixation, and outcomes were noted. Subanalyses by location of primary closure (AH=author's hospital; OH=outside hospital). RESULTS Out of 122 patients, multi-stage became more common than single-stage procedures (p = 0.019), with multi-stage associated with higher success rates (77.4% v 45.7%; p = 0.001). The use of any osteotomy increased over time (p = 0.007), with a posterior approach falling out of favor and increasing prevalence of a combined osteotomy (p<0.001). The use of any osteotomy compared to no osteotomy was associated with successful closure (77.6% v 41.7%; p = 0.007). The combined, posterior, and anterior approaches were associated with 90%, 76.2%, and 60.9% successful primary closure rates, respectively (p<0.001). Fixation modalities changed over time as Buck's traction (p<0.001) and external fixation (p<0.001) became more prevalent. Spica casting has become less common (p = 0.0002). Immobilization type was associated with success rates with Buck's (92.1%; p<0.001) and external fixation (86.0%; p<0.001) performing best. CONCLUSIONS The use of osteotomy and fixation in the CE spectrum has changed markedly. In this cohort, a staged approach with combination osteotomy was associated with better outcomes when using a multidisciplinary team approach. LEVEL OF EVIDENCE This is a retrospective comparative study (Type of Study: Treatment; Evidence Level: III).
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Affiliation(s)
- Nora M Haney
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States.
| | - Chad B Crigger
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Tamir Sholklapper
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Shwetha Mudalegundi
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Angelica Griggs-Demmin
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Isam W Nasr
- Department of Pediatric Surgery, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Paul D Sponseller
- Department of Pediatric Orthopedics, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - John P Gearhart
- Department of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Johns Hopkin Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
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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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Kaefer M, Saad K, Gargollo P, Whittam B, Rink R, Fuchs M, Bowen D, Reddy P, Cheng E, Jayanthi R. Intraoperative laser angiography in bladder exstrophy closure: A simple technique to monitor penile perfusion. J Pediatr Urol 2022; 18:746.e1-746.e7. [PMID: 36336625 DOI: 10.1016/j.jpurol.2022.10.012] [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: 02/06/2022] [Revised: 09/13/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach. OBJECTIVE We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition. This will reduce the risk of tissue compression and potential loss of penile tissue that has been reported to occur as a complication of the procedure. STUDY DESIGN Consecutive patients presenting with bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (ICG) at a dose of 1 mg per 10 kg body weight. Measurements were taken at 80 s post infusion and the medial thigh served as the reference control. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure. RESULTS Eight consecutive patients were included in this study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion increased slightly following bladder dissection. Internal rotation of the hips with apposition of the symphysis pubis resulted in an average 50% reduction in penile blood flow. Patients undergoing CPRE experienced an additional mean 33% drop in blood flow. In all eight cases the penis was symmetric and healthy with no sign of tissue loss at three months follow up. CONCLUSIONS This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion is markedly reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair. Future correlation with measures of penile viability and function are needed to define the clinical utility of this modality.
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Affiliation(s)
- Martin Kaefer
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Kahlil Saad
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Benjamin Whittam
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard Rink
- Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Molly Fuchs
- Nationwide Children's Hospital, Columbus, OH, USA
| | - Diana Bowen
- Lurie Children's Hospital, Northwestern University, Chicago, IL, USA
| | - Pramod Reddy
- Cincinatti Children's Hospital, Cincinnati, OH, USA
| | - Earl Cheng
- Lurie Children's Hospital, Northwestern University, Chicago, IL, USA
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Mini-open Anterior Pelvic Osteotomy and Spica Casting for Primary Closure of the Pelvis in Infants With Classic Bladder Exstrophy. J Pediatr Orthop 2022; 42:e1001-e1007. [PMID: 36053027 DOI: 10.1097/bpo.0000000000002260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The objective of this study was to investigate the efficacy and safety of mini-open Salter-like anterior pelvic osteotomy followed by spica casting as an adjunct to urological reconstruction in infants with classic bladder exstrophy (CBE). METHODS Twenty-eight infants with CBE were operated upon according to the following protocol: initial bilateral mini-open Salter-like osteotomies followed by urological reconstruction and subsequent spica casting for 3 to 4 weeks. Postoperative clinical and radiologic assessments of wound complications and union were done, respectively. During subsequent follow-ups, the foot progression angle (FPA), the interpubic (IP) distance, interischial (IS) distance, and the IS/IP ratio were measured. The Pearson correlation was used to correlate between age at the time of last follow-up, the FPA, the IP and IS distances, and the IS/IP ratio. RESULTS The mean age at the time of operation was 5.89±0.89 months. The operative procedure took 10 to 15 minutes (mean of 12.5±1.5 min) for each side and the blood loss was negligible. Tension-free complete approximation of the symphysis was achieved in all cases. No wound complications were reported in any case. The total duration of the cast was 3.07±0.14 weeks. The mean duration of follow-up was 4.78±3.09 years. Strong positive correlation was found between the IP and IS distances ( r =0.833, P <0.0001) as well as the IS distance and age (r=0.455, P =0.015). CONCLUSION Mini-open anterior pelvic osteotomy and spica casting may provide a minimally invasive and effective option for closure of the pelvis in infants with CBE. LEVEL OF EVIDENCE Level IV-case series.
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Alshryda S, Majid I, Jaber G, Mohammad D, Al Marzouqi M. The Y-Pelvic Osteotomy in Treating Bladder Exstrophy: A Surgical Technique. Cureus 2022; 14:e30520. [DOI: 10.7759/cureus.30520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/07/2022] Open
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12
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Hip Prognosis in Patients With Congenital Diastasis of the Pubic Symphysis. J Pediatr Orthop 2022; 42:246-252. [PMID: 35180723 DOI: 10.1097/bpo.0000000000002114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Congenital diastasis of the pubic symphysis (CDPS) is a rare musculoskeletal malformation in the exstrophy-epispadias complex that is potentially associated with the development of hip dysplasia. The purpose of this study was to investigate the incidence and prognostic factors of hip dysplasia in patients with CDPS. METHODS Fifty-four hips in 27 patients with CDPS initially evaluated between 1983 and 2016 were retrospectively reviewed. The mean age at the first visit was 2.3 (0 to 8) years. The mean follow-up duration was 10.5 (1 to 36) years. Patient characteristics at the first visit, the clinical course at the most recent follow-up, and radiologic parameters on pubic malformation and hip dysplasia during at least 2 time points (first visit or age 1, and either the most recent visit or before hip surgery) were evaluated. Prognostic factors associated with the development of hip dysplasia were analyzed using univariate/multivariate analysis. The Kaplan-Meier survival curves were generated and compared based on these factors. RESULTS Nine of 27 patients (33%) and 13 of 54 hip joints (24%) with CDPS developed hip dysplasia. Paraplegia (odds ratio, 10.0; 95% confidence interval, 1.7-76.6) and center-edge angle of <5 degrees at the first visit or age 1 (P<0.001) were independent predictors of the development of hip dysplasia. Patients with CDPS and either paraplegia or center-edge angle <5 degrees at the first visit or age 1 were significantly more likely to develop hip dysplasia than other patients (hazard ratio, 29.3; 95% confidence interval, 3.4-250). CONCLUSIONS Approximately one third of patients with CDPS develop hip dysplasia. Paraplegia and center-edge angle of <5 degrees at the first visit are independent risk factors. LEVEL OF EVIDENCE Level III.
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Peng Z, Huang Y, Tang W, Shen Y, Chen Y, Xie H, Lyu Y, Wu Y, Chen F. Pelvic floor anatomical variations in children with exstrophy-epispadias complex using MRI. Urology 2022; 165:305-311. [PMID: 35038493 DOI: 10.1016/j.urology.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/21/2021] [Accepted: 01/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To quantitatively measure the anatomical variations of the pelvic floor in children with exstrophy-epispadias complex (EEC) using magnetic resonance imaging (MRI). MATERIALS AND METHODS Six cases of classic bladder exstrophy (CBE), 5 cases of penile epispadias (PE) and 11 cases of penopubic epispadias (PPE) were included. Another 8 cases with the testicular tumor were taken as the controls. A series of measurements obtained from the pelvic floor MRI were analyzed, and the measurements with significant differences were obtained by ANOVA. RESULTS The pelvic floor of the CBE was significantly different from that of controls in measurements including wider pubic diastasis (p<0.001), greater posterior anal distance (p=0.019), greater posterior bladder neck distance (p=0.004), larger iliac wing angle (p<0.001), diminutive ischial angle (p<0.001), bigger puborectalis angle (p<0.001), larger ileococcygeous angle (p=0.002) and shortened anterior corporal length (p<0.001). For the PE, the posterior bladder neck distance (p=0.038) was greater than that of controls. In the PPE, the posterior bladder neck distance (p=0.001) and puborectalis angle (p=0.026) was greater than that of controls, respectively. CONCLUSIONS CBE shows severe anatomical variations of the pelvic floor. The bladder neck moves more anteriorly both in PE and PPE than the control. The enlarged puborectalis angle resulting from wider pubic diastasis and more anterior position of the anorectal canal is also noticed in PPE.
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Affiliation(s)
- Zhiwei Peng
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yichen Huang
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
| | - Wenjuan Tang
- Department of Radiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Shen
- Department of Orthopedics, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Chen
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Xie
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqing Lyu
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuchun Wu
- Department of Radiology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Goetze C, Migliorini F, Peterlein CD. Total hip arthroplasty in patients with severe hip dysplasia and congenital pubic diastasis: report of two cases. BMC Musculoskelet Disord 2021; 22:814. [PMID: 34556076 PMCID: PMC8461941 DOI: 10.1186/s12891-021-04702-x] [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: 01/25/2021] [Accepted: 09/13/2021] [Indexed: 11/21/2022] Open
Abstract
Background Congenital bladder exstrophy is a rare malformation which is often associated with pubic diastasis and hip dysplasia. We reported the case two patients who underwent total hip arthroplasty (THA) due to advanced osteoarthritis combined with large congenital pubic diastasis (> 10 cm). Case presentation The first patient, a 39 years old woman with a pubic diastase and severe hip dysplasia on both sides was treated with a primary two-staged bilateral THA. Both hips were treated with a cementless osteoconductive cup (TM, Zimmer-Biomet) and a cementless stem (Alloclassic SL, Zimmer-Biomet). A 10° elevated rim liner of the cup was used in order to avoid dislocation. The main problem was represented by the fixation of the cup, given the retroverted acetabulum along with the elevated rotation centre due to the dysplastic hips. In the case two, a 52 years woman presented dysplastic osteoarthritis of the left hip. A conventional hemispherical cup (Alloclassic-Allofit, Zimmer-Biomet) was placed in the retroverted acetabulum combined with a cementless stem (Fitmore A, Zimmer-Biomet) attached at the metaphyseal proximal femur bone. Conclusion Our results suggest that THA may be a good strategy to manage advanced hip osteoarthritis in patients with dysplasia and congenital pubic diastasis. Level of evidence IV, case series.
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Affiliation(s)
- Christian Goetze
- Department of Orthopaedics, Auguste-Viktoria Clinic, Ruhr University Bochum, 32545, Bad Oeynhausen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstr. 30, 52074, Aachen, Germany.
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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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Margalit A, Suresh KV, Hayashi B, Sponseller PD. Surgical Treatment of Unstable Pelvic Ring Injury in a Young Child: A Case Report. JBJS Case Connect 2021; 11:01709767-202106000-00108. [PMID: 34111040 DOI: 10.2106/jbjs.cc.20.00942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe an anterior and posterior pelvic ring construct, with emphasis on the posterior construct, to treat a vertical displacement fracture in a 2-year-old girl who was struck by a motor vehicle. Eighteen months after her injury, radiographs showed intact sacroiliac joints and symmetrical pubic symphysis. CONCLUSION Although commonly performed in adults, pelvic fixation is challenging in children because of the small size of the child's pelvis and osseous fixation pathways. However, this approach enabled successful vertical stabilization of the pelvis, complete resolution of symphyseal diastasis, and recovery of function and mobility.
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Affiliation(s)
- Adam Margalit
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
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Madan AJ, Alhindi S. Treatment strategies for OIES complex/cloacal extrophy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.101824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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18
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Bilateral horizontal salter osteotomies with anterior symphyseal closure using a nylon tape in the treatment of exstrophy of the bladder. J Pediatr Orthop B 2020; 29:209-213. [PMID: 30921248 DOI: 10.1097/bpb.0000000000000631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this case series study is to describe the orthopedic management of bladder exstrophy and to report on the intermediate-term outcomes following bilateral horizontal Salter osteotomies with anterior symphyseal closure using a nylon tape. This retrospective study included seven patients (five boys and two girls) who underwent bilateral horizontal osteotomies after reconstruction of the urogenital deformity using the Cantwell-Ransley technique and symphyseal closure by nylon tape number 2-5. the age range was between 7 months and 8 years (median age = 17 months). Three patients had recurrent bladder exstrophy after they underwent "ramotomy" early in their life, whereas four were operated primarily. All patients were followed up over 2 years, with a mean follow-up duration of 3.27 years (2-5 years). Petrie cast was applied, with both legs abducted and internally rotated till bony union had been achieved. This allowed free handling of the wounds and catheters. Removal of k-wires was performed in an outpatient clinic after the complete union of bony osteotomies had been achieved (6-8 weeks). Satisfactory bladder closure was achieved in all patients. None of the patients had a bone infection or nonunion at the osteotomy sites. No postoperative wound dehiscence has occurred for up to 5 years. The foot progression angle improved from 37°-70° (median = 45°) preoperatively to 0°-15° (median = 5°) postoperatively. Symphyseal diastasis was closed well in all of our patients in postoperative plain radiography compared with 5.8-11 cm (median = 8.2 cm) diastasis preoperatively. One patient had a superficial wound infection. Another patient had a sutured bladder neck by a nylon tape during the symphyseal closure. Bilateral horizontal Salter osteotomies with anterior symphyseal closure using nylon tape are safe and effective in the management of bladder exstrophy, especially in older children and in extreme diastasis (> 6 cm); with improvement in the gait as it corrects the acetabular external rotation.
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Irfan O, Ladiwala ZFR, Zaidi Z. Long-term Follow-up of Exstrophy-epispadias Complex from a Lower-middle Income Country: A Case Report and Review of the Literature. Cureus 2020; 12:e7723. [PMID: 32432001 PMCID: PMC7234001 DOI: 10.7759/cureus.7723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bladder exstrophy-epispadias complex (EEC) is a rare congenital defect where the abdominal muscles and bones fail to close in the mid-pelvis. It is crucial to understand the health-related quality of life (QOL) of exstrophy patients who have undergone multiple correctional surgeries. We herein discuss a case of bladder EEC that was repaired through a series of procedures at a resource-limited hospital in Karachi, Pakistan. A 21-year-old male, who was born with EEC, underwent bladder augmentation, Mitrofanoff procedure, bladder neck reconstruction, ureter implantation and a right nephrectomy in a single one-stage procedure during late childhood for urinary incontinence. However, this required a further revision because the urinary incontinence persisted, with difficulty in catheterizing the Mitrofanoff channel. On follow-up after 10 years, our patient currently describes normal QOL with near-normal sexual function. Validated questionnaires for QOL, erectile dysfunction, incontinence and prostatic function were used to assess the patient's post-operative status in these domains. Through our report, we conclude that such patients can have a normal QOL by means of a holistic multidisciplinary management, which includes timely surgical corrections along with an additional focus on the psycho-social and sexual aspects of this condition.
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Affiliation(s)
- Omar Irfan
- Pediatrics, Centre for Global Child Health, Hospital for Sick Children, Toronto, CAN
| | | | - Zafar Zaidi
- Urology, The Indus Hospital, Indus University of Health Sciences, Karachi, PAK
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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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21
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Abstract
Bladder exstrophy is a congenital and rare malformation of the lower abdominal wall with exposure of the bladder mucosa to the external environment, and it is related to pelvis abnormalities. Eighteen patients with bladder exstrophy were treated with bilateral oblique pelvic osteotomy in conjunction with urologic reconstruction after they were stabilized by cast. No failure of midline closure was observed (wound dehiscence or recurrence of bladder exstrophy). Follow-up showed no leg length discrepancy or problems in walking. Bilateral oblique pelvic osteotomy is a safe procedure to treat bladder exstrophy, and it results in good orthopedic and urological function.
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Nhan DT, Sponseller PD. Bilateral Anterior Innominate Osteotomy for Bladder Exstrophy. JBJS Essent Surg Tech 2019; 9:e1. [PMID: 31086719 DOI: 10.2106/jbjs.st.18.00018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Bladder exstrophy is a congenital condition that affects the genitourinary and musculoskeletal systems, and less commonly affects the intestinal system, with cloacal exstrophy. This condition results from abnormal migration of the mesenchyme, between the endoderm and ectoderm, leading to anterior rupture of the cloacal membrane. Numerous osseous morphologic changes are observed in bladder exstrophy. Rotational anomalies include external rotation of the posterior part of the pelvis and iliac wings, on average 12°, and acetabular retroversion1-3. Although various osteotomy types have been described for initial bladder exstrophy closure, the anterior approach has demonstrated positive outcomes in improving daytime continence, gait, and correction of the diastasis4. Thus, the anterior iliac osteotomy provides an effective method to help close the pelvic ring and decrease stress on the anterior abdominal wall during exstrophy closure. In addition, this technique promotes continence by reconfiguring, and thereby restoring, the fibrous symphyseal bar and pelvic floor musculature5. Description The steps of the procedure include (1) preoperative planning, (2) patient positioning, (3) incision, (4) identification of the lateral femoral cutaneous nerve, (5) subperiosteal dissection of the iliac wing, (6) guide pin placement and anterior osteotomy, (7) posterior hinge osteotomy (for cloacal exstrophy and for patients ≥2 years old), (8) external fixator pin placement, (9) anterior internal fixation of the pubic symphysis (for cloacal exstrophy and for patients ≥2 years old), and (10) resumption of the urologic procedure followed by wound closure and application of external fixator. Alternatives Numerous previous techniques for osteotomies in bladder exstrophy have been developed, starting with Shultz in 1958, who recognized the importance of bringing the pubic bones together for gait correction in exstrophy repair6. O'Phelan was the first, to our knowledge, to document outcomes of this bilateral posterior osteotomy technique to reduce tension from the externally rotated iliac bones and widened pubic symphysis in a 2-stage bladder exstrophy closure7. Other approaches have included an oblique iliac wing osteotomy and pubic ramotomy, described by Frey and Cohen in 19898. However, the latter approach inadequately restores the pelvic osseous relations except in female newborns who would have a small diastasis after manual rotation of the pelvis. Rationale This procedure has several advantages over the prior conventional posterior approach. These include better approximation and improved mobility of the pubic rami at the time of closure, prevention of vertical migration of the hemipelvis, direct visual placement of an external fixator and adjustment postoperatively, and no requirement for turning the patient during the operation. In addition, this procedure allows for adjunctive posterior osteotomy from the anterior approach to provide adequate closure in those with cloacal exstrophy, prior failed closure, or extreme diastasis of >6 cm9.
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Benz KS, Jayman J, Maruf M, Baumgartner T, Kasprenski MC, Friedlander DA, Di Carlo HN, Sponseller PD, Gearhart JP. Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children. J Pediatr Surg 2018; 53:2160-2163. [PMID: 29370895 DOI: 10.1016/j.jpedsurg.2017.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/18/2017] [Accepted: 11/27/2017] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. METHODS The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. RESULTS Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059). CONCLUSION Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years). LEVEL OF EVIDENCE Level III, Retrospective comparative study STUDY TYPE: Therapeutic study.
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Affiliation(s)
- Karl S 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
| | - 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
| | - 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
| | - 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
| | - Matthew C 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
| | - Daniel A 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
| | - 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
| | - Paul D Sponseller
- Department of Orthopedic Surgery, The Johns Hopkins University, 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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Jones B, Berent AC, Weisse CW, Hart R, Alvarez L, Fischetti A, Horn BD, Canning D. Surgical and endoscopic treatment of bladder exstrophy-epispadias complex in a female dog. J Am Vet Med Assoc 2018; 252:732-743. [PMID: 29504860 DOI: 10.2460/javma.252.6.732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 14-week-old 7.7-kg (16.9-lb) sexually intact female Golden Retriever was evaluated because of urine dripping from the caudoventral aspect of the abdomen. CLINICAL FINDINGS Ultrasonography, radiography, excretory CT urography, and vaginocystourethroscopy were performed. Results indicated eversion of the bladder through the ventral abdominal wall with exposure of the ureterovesicular junctions, pubic diastasis, and an open vulva and clitoral fossa. Clinical findings were suggestive of bladder exstrophy, a rare congenital anomaly. TREATMENT AND OUTCOME The dog was anesthetized and bilateral ileal osteotomies were performed. Two ureteral catheters were passed retrograde into the renal pelves under fluoroscopic guidance. The lateral margins of the bladder, bladder neck, and urethra were surgically separated from the abdominal wall, and the bladder was closed, forming a hollow viscus. The symphysis pubis was closed on midline with horizontal mattress sutures. The defects in the vestibule and clitoral fossa were closed. Lastly, the iliac osteotomies were stabilized. The dog was initially incontinent with right hind limb sciatic neuropraxia and developed pyelonephritis. Over time, the dog became continent with full return to orthopedic and neurologic function, but had recurrent urinary tract infections, developed renal azotemia likely associated with chronic pyelonephritis, and ultimately was euthanized 3.5 years after surgery because of end-stage kidney disease. CLINICAL RELEVANCE Bladder exstrophy and epispadias is a treatable but rare congenital abnormality. The procedure described could be considered for treatment of this condition, but care should be taken to monitor for urinary tract infections and ascending pyelonephritis.
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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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Abstract
PURPOSE OF REVIEW Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health. RECENT FINDINGS Contemporary data suggest 30-50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery. This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.
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Affiliation(s)
- Melissa R Kaufman
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232-2765, USA.
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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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Kusakabe H, Ueoka K, Takayama S, Seki A. Gradual bone transfer for the correction of the pubic diastasis using the Ilizarov technique in closure of bladder and cloacal exstrophy. J Orthop Sci 2018; 23:144-150. [PMID: 28893435 DOI: 10.1016/j.jos.2017.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 08/16/2017] [Accepted: 08/26/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND In the patient of the cloacal exstrophy, cloaca with local abdominal wall is disrupted and exposed inner surface of the bladder needs early closure. Pelvic osteotomies are required for severe cases whose bladder cannot be closed by the suture of soft tissue only. We developed a technique involving the gradual positioning of bone fragments using a light, Ilizarov external fixator. The usefulness of the technique was assessed. METHODS We enrolled 3 patients with cloacal exstrophy and 1 with bladder exstrophy as a gradual transfer group and 6 patients who were treated by other osteotomies as a control group. The patients aged 6.7-8.4 months at the time of surgery were followed up for 4.0-8.6 years. An external fixator with carbon fiber half-rings was placed to internally rotate and anteriorly move the distal bone fragment over 2 weeks. Then, the bladder was closed. Computed tomography (CT) images were used to assess the pelvis form. Wound dehiscence and number of the surgeries after the osteotomies are also compared between the two groups. RESULTS CT analysis of correction of the pelvic deformity achieved more and less decreasing its volumetric capacity in the gradual transfer group. No patients had wound dehiscence after the primary closure with pelvic osteotomy in the gradual transfer group but all had them in the control group. The mean number of the surgeries after the osteotomies were 2.25 in the gradual transfer group whereas 5.5 in the control group. CONCLUSIONS Sufficient closure of the abdominal wall and bladder was achieved in all cases in the gradual transfer group. The correction of pelvic bones were more with less decreasing of their pelvic capacities, no patients had wound dehiscence after the closure and there was an effect to decrease the number of the surgeries after the treatment by this method.
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Affiliation(s)
- Hiroshi Kusakabe
- Division of Orthopedics, Department of Surgical Subspecialties, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo 157-8535, Japan.
| | - Katsuhiko Ueoka
- Division of Urology, Department of Surgical Subspecialties, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Shinichiro Takayama
- Division of Orthopedics, Department of Surgical Subspecialties, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo 157-8535, Japan
| | - Atsuhito Seki
- Division of Orthopedics, Department of Surgical Subspecialties, National Medical Center for Children and Mothers, National Center for Child Health and Development, Tokyo 157-8535, Japan
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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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Sirisreetreerux P, Lue KM, Ingviya T, Friedlander DA, Di Carlo HN, Sponseller PD, Gearhart JP. Failed Primary Bladder Exstrophy Closure with Osteotomy: Multivariable Analysis of a 25-Year Experience. J Urol 2017; 197:1138-1143. [DOI: 10.1016/j.juro.2016.09.114] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Pokket Sirisreetreerux
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathy M. Lue
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thammasin Ingviya
- Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Daniel A. Friedlander
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Heather N. Di Carlo
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul D. Sponseller
- Division of Pediatric Orthopaedics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John P. Gearhart
- Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
Classic bladder exstrophy is a rare disorder involving an externalized bladder through an associated pelvic diastasis. Difficulty of closure of pelvic diastasis is often encountered following urological reconstruction. Traditionally, an anterior innominate osteotomy is performed to increase pelvic volume, allowing closure of the rudimentary pubic symphysis and anatomical reduction of pelvic contents; however, this procedure can be technically difficult and has associated morbidity. We describe a novel technique of bilateral iliac wing osteotomies to achieve the same function that has not been described previously in the literature.
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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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Farid IS, Kendrick EJ, Adamczyk MJ, Lukas NR, Massanyi EZ. Perioperative Analgesic Management of Newborn Bladder Exstrophy Repair Using a Directly Placed Tunneled Epidural Catheter with 0.1% Ropivacaine. ACTA ACUST UNITED AC 2016; 5:112-4. [PMID: 26402021 DOI: 10.1213/xaa.0000000000000191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Effective multimodal analgesia and sedation reduce the postoperative morbidity and mortality associated with newborn bladder exstrophy repair. Epidural analgesia is safe and effective for major surgery in neonates and infants, reducing the need for muscle relaxants, opioids, and ventilator support postoperatively. The risk of epidural catheter colonization typically dictates removal after 3 to 5 days. Tunneling the catheter subcutaneously reduces the risk of colonization, providing prolonged analgesia for patients requiring an extended immobilization to prevent compromise of the repair. In this report, we describe the postoperative analgesic management of an infant undergoing bladder exstrophy repair using a directly placed tunneled epidural catheter with ropivacaine 0.1% infusion. Because of the prolonged infusion, we also monitored plasma ropivacaine levels to preclude systemic toxicity from local anesthetic overdose.
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Affiliation(s)
- Ibrahim S Farid
- From the Department of Anesthesia, Pain Center, Akron Children's Hospital, Akron, Ohio
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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
In the management of conjoined twins the orthopedic surgeon may be involved directly, as part of the surgical team at operation or indirectly, in dealing with associated anomalies or the sequelae of surgery. The overwhelming indication for orthopedic involvement is ischiopagus, either tripus or tetrapus. The main role of the orthopedic surgeon is to facilitate midline closure through the use of pelvic osteotomies, which allow the symphysis pubis to be approximated.
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Affiliation(s)
- David Jones
- Great Ormond Street Hospital for Children NHS Trust, London WC1N 3JH, UK.
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Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast. J Pediatr Urol 2015; 11:212.e1-4. [PMID: 25982019 DOI: 10.1016/j.jpurol.2015.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/02/2015] [Indexed: 11/23/2022]
Abstract
INTRODUCTION/OBJECTIVE Secure closure of the pubic diastasis during bladder exstrophy and epispadias repair decreases the abdominal wall tension at the time of reconstruction. Pelvic osteotomies are routinely performed at the time of abdominal wall and bladder reconstruction in order to more easily facilitate pubic symphyseal diastasis approximation. Postoperative pelvic immobilization is performed by methods that include modified Buck's traction, modified Bryant's traction, and spica casting. People undergoing closure often require inpatient hospitalization for 2-8 weeks because of the pelvic immobilization. The present study examined the findings from a clinical pathway for early discharge after complete primary repair of exstrophy (CPRE) and proximal epispadias repair with spica casting. METHODS The present study is a retrospective review of patients that underwent pelvic osteotomies with spica casting at the time of CPRE or proximal epispadias repair from November 2006 to March 2013. All patients had anterior innominate osteotomies and spica cast pelvic immobilization. RESULTS Pelvic osteotomies and spica cast pelvic immobilization were performed on 17 children. The median postoperative stay was 6.0 days and the subdivided results are in Table. No children experienced an abdominal or orthopedic complication. A few children required minor cast adjustments to relieve pressure. After cast removal, no skin breakdown, pressure necrosis, or nerve palsy were found. The median length of casting without pinning was 31 (26-48) days. DISCUSSION The use of spica cast pelvic immobilization after exstrophy and epispadias repair is safe and allows for earlier discharge when compared to other methods of pelvic immobilization. However, although the family appreciates early discharge and additional bonding, the priority is the success of the closure. The present findings demonstrate, and are corroborated by other spica cast publications, that spica casting is as effective as modified Bryant's traction or modified Buck's traction. The success rates for CPRE with spica casting are similar to published staged repairs and have the benefit of allowing for bladder cycling, which potentially enables better bladder growth and development. If success and complication rates are comparable amongst the different pelvic immobilization groups, then variables including hospital length of stay and cost become appropriate comparisons. CONCLUSION The shortened discharge time, along with a significant decrease in acuity of care leads to significant decreases in hospital costs. Additional hospital stay when using modified Bryant's traction or modified Buck's traction with external fixation will accrue significant hospital costs.
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Tourchi A, Di Carlo HN, Inouye BM, Young E, Gupta A, Abdelwahab M, Gearhart JP. Ureteral Reimplantation Before Bladder Neck Reconstruction in Modern Staged Repair of Exstrophy Patients: Indications and Outcomes. Urology 2015; 85:905-8. [DOI: 10.1016/j.urology.2014.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 11/24/2014] [Accepted: 12/05/2014] [Indexed: 10/24/2022]
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Lavien G, Di Carlo HN, Shah BB, Eifler J, Massanyi E, Stec A, Sponseller PD, Gearhart JP. Impact of pelvic osteotomy on the incidence of inguinal hernias in classic bladder exstrophy. J Pediatr Surg 2014; 49:1496-9. [PMID: 25280654 DOI: 10.1016/j.jpedsurg.2014.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Revised: 04/30/2014] [Accepted: 05/03/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND/PURPOSE The high prevalence of inguinal hernias in the bladder exstrophy population is well documented. The authors' aim is to determine whether pelvic osteotomy reduces the incidence of primary and recurrent inguinal hernias in patients with classic bladder exstrophy. METHODS Using an institutionally-approved database, patients who underwent immediate or delayed primary bladder closure between 1974 and 2012 were identified and stratified by the use of pelvic osteotomy at the time of closure. Data were analyzed using Fisher's exact test and multivariate logistic regression analysis. RESULTS One hundred thirty-six patients were identified with a median follow up of 8years. The incidence of inguinal hernias following closure was 25% in the osteotomy group versus 46% in the non-osteotomy group (p=0.017). Osteotomy was associated with a significant decrease in recurrence of inguinal hernias amongst patients who underwent previous repair (17% versus 47%, osteotomy versus non-osteotomy, p=0.027) and the development of primary inguinal hernias in whom initial groin exploration was negative (20% versus 39%, p=0.029). Osteotomy and female sex were associated with a decreased rate of inguinal hernia development after bladder closure while age at closure was not. CONCLUSIONS Pelvic osteotomy at the time of exstrophy closure decreases the likelihood of primary or recurrent inguinal hernia development.
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Affiliation(s)
- Garjae Lavien
- University of Maryland School of Medicine, Division of Urology, 22S. Greene Street, Suite NGE19, Baltimore, MD 21201
| | - 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, 1800 Orleans St., Suite 7203, Baltimore, MD 21287.
| | - Bhavik B Shah
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - John Eifler
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Eric Massanyi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
| | - Andrew Stec
- Medical University of South Carolina, Department of Urology, 96 Jonathan Lucas St, CSB 644, Charleston, SC 29425
| | - Paul D Sponseller
- The Johns Hopkins University School of Medicine, Division of Pediatric Orthopedics, The Johns Hopkins Outpatient Center, 601N. Caroline St., Room 5152, Baltimore, MD 21287
| | - John P Gearhart
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Suite 7203, Baltimore, MD 21287
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Kenawey M, Wright JG, Hopyan S, Murnaghan ML, Howard A, Kelley SP. Can neonatal pelvic osteotomies permanently change pelvic shape in patients with exstrophy? Understanding late rediastasis. J Bone Joint Surg Am 2014; 96:e137. [PMID: 25143505 DOI: 10.2106/jbjs.m.01235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pelvic osteotomies are frequently used as part of the surgical management of bladder exstrophy. The outcomes are often measured on the basis of the residual symphyseal diastasis. The aims of this study were to evaluate and validate a more reliable radiographic measure of ischiopubic rotation, to utilize this measure in analyzing pelves from patients with exstrophy and controls, and to propose a model for rediastasis in a pelvis with exstrophy. METHODS Pelvic radiographs of 164 normal children two months to eighteen years of age were used to determine the changes in interpubic and interischial distances and in the interischial/interpubic (IS/IP) ratio with age. Twenty-one pelvic CT (computed tomography) studies of normal children, two to sixteen years of age, were also used to study the change in the ischiopubic divergence angle. The same parameters were measured on radiographs or CT or magnetic resonance imaging studies of seventy-three patients with classic bladder exstrophy who were followed for two to nineteen years after exstrophy closure with or without pelvic osteotomies. RESULTS In normal children, the interpubic distance and the ischiopubic divergence angle had a narrow range and were constant with age, whereas the interischial distance and the IS/IP ratio increased progressively and were strongly correlated with age. In the patients with exstrophy, the interpubic distance was positively correlated with the interischial distance, whereas the IS/IP ratio was lower than that in normal controls and was not correlated with age. CONCLUSIONS The IS/IP ratio is a useful measure of ischiopubic rotation and can be used to characterize pelvic growth, including the phenomenon of rediastasis in patients with exstrophy. Pelvic rediastasis is a progressive increase in interpubic distance resulting from growth without loss of rotational correction, as shown by the constancy of the IS/IP ratio with age in these patients. A better rotational position at the time of osteotomy may lead to a better pelvic shape at maturity. CLINICAL RELEVANCE Symphyseal rediastasis following neonatal pelvic osteotomies in patients with exstrophy is not due to loss of correction and progressive derotation of the hemipelves but is a consequence of the normal three-dimensional growth of the pelvis. The best correction of the pelvic deformity should always be the aim even in neonatal pelvic osteotomies because this will permanently change the pelvic shape.
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Affiliation(s)
- Mohamed Kenawey
- Department of Orthopaedic Surgery, Sohag University, Sohag 82524, Egypt. E-mail address:
| | - James G Wright
- Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Sevan Hopyan
- Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Michael Lucas Murnaghan
- Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Andrew Howard
- Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
| | - Simon P Kelley
- Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
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Staged management of pseudoexstrophy with omphalocele and wide pubic diastasis. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Ferrara F, Dickson AP, Fishwick J, Vashisht R, Khan T, Cervellione RM. Delayed exstrophy repair (DER) does not compromise initial bladder development. J Pediatr Urol 2014; 10:506-10. [PMID: 24331166 DOI: 10.1016/j.jpurol.2013.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Delayed exstrophy repair (DER) represents an alternative to early neonatal bladder closure. This study aims to define the consequence of DER on bladder growth in bladder exstrophy patients who underwent routine DER, compared with those who underwent immediate postnatal reconstruction. METHODS Between 2000 and 2005, classic bladder exstrophy patients referred to the authors' institution underwent early neonatal bladder closure (group 1). Subsequently, classic bladder exstrophy patients referred to the authors' institution were treated with an elective DER (group 2). Bladder capacity was assessed between the age of 1 and 4 years with an unconscious cystogram. When dilating VUR was present, the volume of the contrast migrated into the ureter was calculated and subtracted. RESULTS Sixty patients were treated between 2000 and 2012. Complete follow-up data were available for 45 patients and they were included in the study: 21 in group 1 (11 males) and 24 in group 2 (14 males). The mean (SD) bladder volumes were 72.85 (28.5) ml in group 1 and 72.87 (34.9) in group 2 (p = 0.99). CONCLUSION In the authors' experience, DER does not reduce the subsequent bladder capacities compared with neonatal exstrophy closure.
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Affiliation(s)
- Francesco Ferrara
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK.
| | - Alan P Dickson
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK.
| | - Janet Fishwick
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK.
| | - Rita Vashisht
- Department of Paediatric Anaesthesia, Royal Manchester Children's Hospital, Manchester, UK.
| | - Tahair Khan
- Department of Paediatric Orthopaedic, Royal Manchester Children's Hospital, Manchester, UK.
| | - Raimondo M Cervellione
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK.
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Baka-Ostrowska M, Kowalczyk K, Felberg K, Wawer Z. Complications after primary bladder exstrophy closure - role of pelvic osteotomy. Cent European J Urol 2014; 66:104-8. [PMID: 24579005 PMCID: PMC3921855 DOI: 10.5173/ceju.2013.01.art31] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 01/03/2012] [Accepted: 02/01/2013] [Indexed: 11/24/2022] Open
Abstract
Introduction Bladder exstrophy is the most common form of the exstrophy – epispadias complex. It is observed in 1:30 000 life births, about four times more often in boys than in girls. Iliac osteotomy is used to facilitate bringing together pubic bones and to minimize the tension of fused elements. To analyze complications after primary bladder exstrophy closure with a special consideration of the role of pelvic osteotomy. Material and method It is a retrospective study evaluating 100 patients (chosen by chance out of 356) with bladder exstrophy (65 boys and 35 girls), treated in Pediatric Urology Department of the Children's Memorial Health Institute in Warsaw, Poland between 1982 and 2006. All children underwent primary bladder exstrophy closure, among them 32 elsewhere. Primary bladder exstrophy closure with contemporary iliac osteotomy was done in 36 children. In the rest 64 patients bladder was closed without osteotomy, regardless child's age. Results Dehiscence after primary closure followed with bladder prolaps occurred in 31 patients, among them 13 out of 68 (19%) operated in our department and 18 out of 32 (56%) operated in another hospital. Primary bladder exstrophy closure with contemporary iliac osteotomy was done in 32 infants above 72 hours of life. Conclusions Osteotomy performed at primary bladder exstrophy closure diminishes the risk of wound dehiscence independently of patient's age. Posterior iliac osteotomy is sufficient and safe and could be repeated if necessary.
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Affiliation(s)
| | - Kinga Kowalczyk
- Department of Pediatric Urology of the Children's Memorial Health Institute, Warsaw, Poland
| | - Karina Felberg
- Department of Pediatric Urology of the Children's Memorial Health Institute, Warsaw, Poland
| | - Zbigniew Wawer
- Department of Pharmacokinetics of the General Laboratory in the Children's Memorial Health Institute, Warsaw, Poland
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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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Massanyi EZ, Shah B, Schaeffer AJ, DiCarlo HN, Sponseller PD, Gearhart JP. Persistent vesicocutaneous fistula after repair of classic bladder exstrophy: a sign of failure? J Pediatr Urol 2013; 9:867-71. [PMID: 23246077 DOI: 10.1016/j.jpurol.2012.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/26/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the potential predisposing clinical characteristics at initial closure, the treatments of and outcomes associated with vesicocutaneous fistula (VCF) after primary bladder closure. MATERIALS AND METHODS Eighteen patients were referred for VCF after primary bladder exstrophy closure. Aspects from the primary closure such as gender, timing of diagnosis and repair, osteotomies, pelvic immobilization, layers of closure, use of tissue adjuncts, and complications in addition to details from their required treatment of VCF were retrospectively extracted from the medical record. RESULTS A diagnosis of failed closure was made at the time of evaluation in 13 of 18 patients who presented with VCF. All 13 patients underwent delayed single-layer closures and had a widened pubic diastasis. Five patients with secure closures who underwent successful simple fistula repairs were all closed early in life, had multi-layered closures with pelvic osteotomies, and had minimal change in pubic diastasis. CONCLUSION VCF may represent a failed bladder closure. Factors which may suggest failure are a fistula tract in the lower abdominal midline between the pubic rami, a pubic diastasis increased from pre-closure measurement, and cystoscopic evidence of an anteriorly positioned bladder.
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Affiliation(s)
- Eric Z Massanyi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7308, Baltimore, MD 21201, USA.
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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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Suson KD, Sponseller PD, Gearhart JP. Bony abnormalities in classic bladder exstrophy: the urologist's perspective. J Pediatr Urol 2013; 9:112-22. [PMID: 22105005 DOI: 10.1016/j.jpurol.2011.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/09/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION As the primary practitioner managing patients with classic bladder exstrophy (CBE), it is incumbent upon the pediatric urologist to understand the associated orthopedic anomalies and their management. METHODS A Pubmed search was performed with the keyword exstrophy. Resulting literature pertaining to orthopedics and published references were reviewed. RESULTS Anatomic changes to the bony pelvis include outward rotation, acetabular retroversion with compensatory femoral anteversion, anterior pubic shortening, and pubic diastasis. Imaging options have improved, which impacts surgical planning. Surgical approach, including type of osteotomy and method of pubic approximation, is evolving. Most centers employ immobilization after surgery, with external fixation, Bryant's traction, Buck's traction, and spica casting being the most common methods. Orthopedic complications range from minor pin-site infections to neurologic and vascular compromise. Most experts agree osteotomy aids bladder closure beyond 72 h of life, but effect on continence remains controversial. Although no significant orthopedic benefit has been expounded, it may be too early to appreciate improvement in frequency or severity of osteoarthritis or hip dysplasia. CONCLUSION While orthopedic surgeons remain vital to managing exstrophy patients, knowledge of the anatomy, imaging, surgical approaches, and immobilization enable effective communication with parents and other physicians, improving care for these complicated patients.
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Affiliation(s)
- Kristina D Suson
- Division of Pediatric Urology, The James Buchanan Brady Urological Insititute, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Abstract
Despite advances in the management of exstrophy epispadias complex (EEC), the quality of life of these patients is far from good. The post-operative period is complicated by numerous and variable events - infection, dehiscence, upper tract dilatation with deterioration, fistulas, stone formation and incontinence to name a few of the major complications. Redo surgery for bladder closure, bladder neck reconstruction, epispadias repair and closure of fistulas are frequently required. The current focus is on limiting the frequency and morbidity of the reconstructive procedures. A successful initial closure and early satisfactory cosmetic and functional results are gratifying for the family and the health care team, but this is only the beginning of the lifelong care necessary for bladder exstrophy (BE) patients. In this article, the long-term outcome of various treatment options and the continent procedures in BE has been reviewed, tracing the journey of these patients into adolescence and adulthood.
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Affiliation(s)
- Jai K Mahajan
- Department of Paediatric Surgery, Institute- Advanced Paediatric centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Anusionwu I, Baradaran N, Trock BJ, Stec AA, Gearhart JP, Wright EJ. Is Pelvic Osteotomy Associated with Lower Risk of Pelvic Organ Prolapse in Postpubertal Females with Classic Bladder Exstrophy? J Urol 2012; 188:2343-6. [DOI: 10.1016/j.juro.2012.08.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Ifeanyi Anusionwu
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Nima Baradaran
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Bruce J. Trock
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Andrew A. Stec
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - John P. Gearhart
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - E. James Wright
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
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Suominen JS, Helenius I, Taskinen S. Long-term orthopedic outcomes in patients with epispadias and bladder exstrophy. J Pediatr Surg 2012; 47:1821-4. [PMID: 23084190 DOI: 10.1016/j.jpedsurg.2012.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 04/22/2012] [Accepted: 04/23/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND/PURPOSE The aim of the study was to explore long-term orthopedic outcomes in patients with epispadias and bladder exstrophy (BE). METHODS Sixty-three adult patients with epispadias or BE were mailed the Modified Nordic Musculoskeletal Questionnaire, of which 33 (52%) responded. The patients were reviewed for possible pain in the lower back, hips, knees, and ankles, and their physical activity was scored, and the effect of possible pelvic osteotomy at the time of primary closure among patients with BE was evaluated. RESULTS Patients with BE had more low-back pain during the last 12 months compared with patients with epispadias (84%/43%, P < .05). In terms of physical activity, the ability to run continuously without stopping was significantly reduced in patients with BE (P < .05). Patients with BE, especially women, who underwent pelvic osteotomy suffered more from hip pain compared with patients without pelvic osteotomy (45%/0%, P < .05). CONCLUSIONS Patients with BE suffer more from low-back pain and have decreased running performance compared with patients with epispadias. Although pelvic osteotomy is widely used to achieve tension-free primary closure of abdominal wall, patients with osteotomy suffered more from hip pains, suggesting that pelvic osteotomy is indicated mainly when primary closure either is impossible or fails in BE reconstruction.
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Affiliation(s)
- Janne S Suominen
- Department of Paediatric Surgery, Hospital for Children and Adolescents, University of Helsinki, 00029-HUS, Helsinki, Finland.
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Abstract
Classic bladder exstrophy is an embryologic malformation that results in complex deficiency of the anterior midline, with urogenital and skeletal manifestations. Urogenital reconstruction is a challenging procedure that can be facilitated by closure of the bony pelvic ring by an orthopaedic team. Surgical options include a multiyear staged approach and the single-stage complete repair for exstrophy. The goals of urologic surgery include closure of the bladder and abdominal wall with eventual bladder continence, preservation of renal function, and cosmetic and functional reconstruction of the genitalia. Pelvic osteotomy is done at the time of bladder closure in the patient in whom the anterior pelvis cannot be approximated without tension. Traction or spica casting is used postoperatively. Good outcomes are probable with appropriate management at specialized treatment centers.
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