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CLINICAL PATHWAY FOR EARLY DISCHARGE AFTER CPRE AND EPISPADIAS REPAIR WITH PELVIC OSTEOTOMIES BY USING A SPICA CAST
Bryan Sack, MD1, John Kryger, MD2, Michael Mitchell, MD2, Charles Durkee, MD2, Roger Lyon, MD2, Travis Groth, MD2.
1Medical College of Wisconsin, Milwaukee, WI, USA, 2Children's Hospital of Wisconsin, Milwaukee, WI, USA.

BACKGROUND:
Pelvic osteotomies and fixation is used at the time of complete primary repair of exstrophy (CPRE) and Epispadias repair. Our clinical pathway using SPICA casting allows for early discharge without increased morbidity. Neonates undergoing this procedure with external fixation in traditional pathways have a reported average post-operative hospital stay of 3-5 weeks.
METHODS:
Records of patients that underwent pelvic osteotomies with SPICA casting at the time of CPRE or epispadias repair from November 2006 to March 2013 were reviewed.
RESULTS:
Pelvic osteotomies and SPICA casting was performed in 17 children. They were subdivided into primary bladder exstrophy (11), bladder exstrophy revision (4), and epispadias (2). The median post−operative hospital stay was 6 (3−15) days. The results are in Table 1. One primary bladder exstrophy child had a seizure disorder requiring prolonged hospitalization (35 days) and is not included in the hospital stay calculation. No child experienced an abdominal complication (ie: abdominal dehiscence, bladder prolapse) or orthopedic complication (ie: osteotomy infection, skin breakdown) related to SPICA casting. One older patient (4.8 yrs) required prolonged casting (64 days) because of pelvic pinning. The median length of casting without pinning (n=16) was 31 (26−48) days.
CONCLUSIONS:
This clinical pathway is safe and allows for an earlier discharge compared to other post−operative pathways. Children may experience minor cast irritation or tightness, but these issues can be overcome with minor cast adjustments. Earlier discharge certainly leads to decreased cost, but further investigation is needed to assess the difference between these pathways.
Table 1
TotalM/FMedian Age at Surgery (Days)Median Post-op Stay (Days)
Primary Bladder Exstrophy115/64.0 (1-125)6.5 (3-15)
Bladder Exstrophy Revision42/2404 (79-1764)5.5 (5-8)
Epispadias21/1134 (71-197)5.0 (4-6)
Total178/915.0 (1-1764)6.0 (3-15)


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