Classic bladder exstrophy: orthopaedic surgical considerations

Is Immobilization Technique Associated With Postoperative Pubic Rami Diastasis Following Bladder Exstrophy Closure?

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.

Pubic Diastasis in Polytrauma Patients: Traumatic or Congenital?: A Report of 2 Cases

CASE

We report 2 patients who were involved in high-velocity road traffic accidents. Both these patients had congenital pubic diastasis with very subtle clinical and radiological signs that were misdiagnosed as posttraumatic diastasis on initial radiographic evaluation.

CONCLUSION

Trauma surgeons should be aware of this anomaly because congenital pubic diastasis could present without any major clinical signs and could easily be mistaken for a traumatic diastasis.

Long-term Follow-up of Exstrophy-epispadias Complex from a Lower-middle Income Country: A Case Report and Review of the Literature

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.

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

INTRODUCTION

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

OBJECTIVES

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

STUDY DESIGN

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

PROCEDURE

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

RESULTS AND LIMITATIONS

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

COMPLICATIONS

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

CONCLUSIONS

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

Oblique pelvic osteotomy in the treatment of bladder exstrophy in neonates

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

Bilateral Anterior Innominate Osteotomy for Bladder Exstrophy

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 retroversion^1-3. 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.

Bladder exstrophy closure in the newborn period with external pelvic fixation performed without osteotomy: A preliminary report

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.

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

INTRODUCTION

Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods.

OBJECTIVE

The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure.

STUDY DESIGN

The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications.

RESULTS

Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999 to 2010, delayed closure was performed more frequently in this cohort (71% vs 27%).

DISCUSSION

The NSQIPP provides standardized reporting of peri-operative characteristics and 30-day complications, allowing a comparison of early to delayed closure of bladder exstrophy across multiple institutions. Assessing short-term risks in conjunction with long-term follow-up is crucial for determining optimal management of this rare but complex condition.

CONCLUSION

Delayed closure of bladder exstrophy is performed frequently, yet it carries a high rate of 30-day complications worthy of further investigation. This can be useful in counseling patients and families, and to understand practice patterns across the country.

Postoperative Immobilization and Pain Management After Repair of Bladder Exstrophy

Surgical repair of bladder exstrophy is an ongoing challenge for pediatric urologists. Postoperative immobilization is a mainstay of care to decrease tension on the repair site and is often utilized in conjunction with pelvic osteotomies performed in the same operative setting by pediatric orthopedic surgeons. Multiple pelvic immobilization techniques have been developed in conjunction with repair techniques including special techniques for neonates. The most commonly utilized techniques for pelvic immobilization are Buck's and Bryant's traction and spica casting. A multimodal pain management approach is critical with pelvic immobilization to minimize postoperative pain and anxiety associated with reconstructive surgery at a young age.

Aesthetic, urological, orthopaedic and functional outcomes in complex bladder exstrophy-epispadias's management

BACKGROUND

Postoperative complications are related to the surgical procedures, of failures of initial bladder closure and influence the urological, aesthetical and orthopaedic outcomes.

MATERIALS AND METHODS

We reviewed four patients who underwent complex bladder exstrophy-epispadias repair over a period of 14 years. The outcomes of treatment were assessed using, aesthetic, urological and orthopaedic examination data. Orthopaedic complications were explored by a radiography of the pelvis.

RESULTS

Out of four patients who underwent bladder exstrophy surgical management, aesthetic, functional outcomes and complications in the short and long follow-up were achieved in three patients. The first patient is a male and had a good penis aspect. He has a normal erection during micturition with a good jet miction. He has a moderate urinary incontinence, which requires diaper. In the erection, his penis-measures 4 cm long and 3 cm as circumference. The second patient was a female. She had an unsightly appearance of the female external genitalia with bipartite clitoris. Urinary continence could not be assessed; she did not have the age of cleanness yet. The third patient had a significant urinary leakage due to the failure of the epispadias repair. He has a limp, a pelvic obliquity, varus and internal rotation of the femoral head. He has an inequality of limbs length. Pelvis radiograph shows the right osteotomy through the ilium bone, the left osteotomy through the hip joint at the acetabular roof.

CONCLUSION

When, the epispadias repair is performed contemporary to initial bladder closure, its success is decisive for urinary continence. In the female, surgical revision is required after the initial bladder closure for an aesthetic appearance to the external genitalia. Innominate osteotomy must be performed with brilliancy amplifier to avoid osteotomy through to the hip joint to prevent inequality in leg length.

Can neonatal pelvic osteotomies permanently change pelvic shape in patients with exstrophy? Understanding late rediastasis

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.

Practice patterns and resource utilization for infants with bladder exstrophy: a national perspective

PURPOSE

Substantial variability exists in bladder exstrophy care, and little is known about costs associated with the condition. We define the care patterns and first year cost for patients with bladder exstrophy at select freestanding pediatric hospitals in the United States.

MATERIALS AND METHODS

We used the Pediatric Health Information System database to identify patients with bladder exstrophy born between January 1999 and December 2010 who underwent primary closure in the first 120 days of life. Demographic, surgical, postoperative and cost data for all encounters were assessed. Multivariate linear regression was used to examine the association between patient, surgeon and hospital characteristics and costs.

RESULTS

Of the 381 patients who underwent primary closure within the first 120 days of life 279 (73%) did so within the first 3 days of life. A total of 119 patients (31%) underwent pelvic osteotomy, including 51 of 279 (18%) who underwent closure within the first 3 days of life, 38 of 67 (56%) who underwent closure between 4 and 30 days of life, and 30 of 35 (86%) who underwent closure between 31 and 120 days of life (p = 0.0017). Median inflation adjusted, first year cost in United States dollars per patient was $66,577 (IQR $45,335 to $102,398). Presence of nonrenal comorbidity and completion of primary closure after 30 days of life increased first year costs by 24% and 53%, respectively. Increased post-closure length of stay was associated with greater costs.

CONCLUSIONS

At select freestanding United States pediatric hospitals the majority of bladder exstrophy closures are performed within the first 3 days of life. Most, but not all, patients undergoing closure after the neonatal period undergo osteotomy. The presence of nonrenal comorbidity and increased postoperative length of stay are associated with greater costs.