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BACKGROUND: With near-universal survival rates in cloacal exstrophy (CE) over the last twenty years, the aims of surgical management have shifted to optimizing outcomes and quality of life while minimizing morbidity. In this study, the authors reviewed the single-institution experience of bladder closure in CE patients. Operative and follow-up data were analyzed to assess complications of bladder closure in these patients and associations with osteotomy and reoperative closure.
METHODS: Patients with CE were identified from a prospectively-maintained, IRB-approved database of bladder exstrophy-epispadias complex patients. Data were collected on demographics, operative history, and outcomes. Failed closure was defined as bladder prolapse, bladder dehiscence, or vesicocutaneous fistula. Complications included were: wound infection, orthopedic complications, pyelonephritis, urethrocutaneous fistula, bladder outlet obstruction within one year of closure, and bowel obstruction. Chi-squared tests were used to compare complication and failure rates between closures performed with and without osteotomy and primary versus reoperative closures.
RESULTS: Of 134 patients followed with CE, 112 had data on closure, osteotomy, and operative outcome. There were 62 females (55.4%) and mean follow-up time was 5.2 years. There were 112 first closures with 20 patients (17.9%) having at least one complication. For the 27 reoperative closures, 9 patients had a complication (33.3%, p=0.076 vs. primary closures). There were 35 failed primary closures, of which 30 were referred from outside hospitals (OSH), and 14 failed reoperative closures, 10 closed at OSH. The failure rates between primary and reoperative closure were 31.3% and 51.9%, respectively (p=0.044). Seventy-five primary closures were performed with osteotomy, of which 37 were referred from OSH. Among this group, there were 18 failures (14 from OSH), compared with 17 failures (16 from OSH) in those closed without osteotomy (failure rates 24.0% vs. 45.9%, p=0.018). Among primary closures with osteotomy, 16 patients had a complication versus 4 patients closed without osteotomy (21.3% vs. 10.8%, p=0.171).
CONCLUSIONS: CE is a major multisystem birth defect requiring numerous complex reconstructive surgical interventions. Complications of bladder closure are common in these patients. While closures performed with osteotomy showed a trend toward higher complication rates compared to closures done without osteotomy, this difference was not statistically significant. The majority of the orthopedic complications were superficial pin site infections. Closures performed with osteotomy had a statistically significant lower failure rate compared to those closed without osteotomy, further indicating the importance of osteotomy in a successful primary or reoperative closure. There was no statistically significant difference in complication rates between reoperative and primary closures. However, this study showed that reoperative closures were more likely to fail, emphasizing the importance of a successful primary closure. Modern treatment of CE can ensure successful outcomes, minimize morbidity, and increase quality of life with appropriate use of osteotomy, pain control, and pelvic immobilization.