Failed Primary Bladder Exstrophy Closure with Osteotomy: A Multivariate Analysis of a 25-year Experience
Pokket Sirisreetreerux, M.D.1, Kathy M. Lue, M.D.1, Thammasin Ingviya, PhD2, Daniel A. Friedlander, BA&Sc1, Heather N. Di Carlo, M.D.1, Paul D. Sponseller, M.D.3, John P. Gearhart, M.D.1.
1Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 3Division of Pediatric Orthopedics, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
A successful primary bladder exstrophy closure provides the best opportunity for patients to achieve a functional closure and urinary continence. Use of osteotomy during initial closure has significantly improved success rates, however failures can still occur. This study aimed to identify factors that contribute to a failed primary exstrophy closure with osteotomy.
MATERIALS & METHODS
A prospectively-maintained institutional database was reviewed for classic bladder exstrophy patients who were primarily closed with osteotomy at our institution or referred after primary closure from 1990 to 2015. Data were collected regarding gender, closure, osteotomy, immobilization, orthopedics, and perioperative pain control. Univariate and multivariate analyses were performed to determine predictors of failure.
A total of 156 (115 males, 41 females) patients met inclusion criteria. Overall failure rate was 30% (13% from the authors’ institution and 87% from outside centers). Patients who failed their initial closure with osteotomy presented to the authors’ institution with a mean pubic diastasis of 4.8 ± 1.5 cm (range 2.7-12.3). Following re-closure, average diastasis was 2.1 ± 0.6 cm (range 1.0-3.4). Types of failure consisted of 12 (26.1%) bladder dehiscence, 11 (23.9%) bladder prolapse, 9 (19.6%) bladder outlet obstruction, 7 (15.2%) vesicocutaneous fistula, and 7 (15.2%) complex failures. Failure rates were significantly higher for patients closed during 1990-2000 when compared to subsequent years (38.8% vs. 23.2%, p = 0.032). On multivariate analysis, use of Buck’s traction (OR 0.11; 95% CI 0.02-0.60, p = 0.011) and immobilization time greater than 4 weeks (OR 0.19; 95% CI 0.04-0.86, p=0.031) had significantly lower odds of failure. Osteotomy performed by non-pediatric orthopedic surgeons had significantly higher odds of having a failed closure (OR 23.47; 95% CI 1.45-379.19, p = 0.027). Type of osteotomy and use of epidural anesthesia did not significantly impact failure rates.
Application of pelvic osteotomy during bladder exstrophy closure has become widely incorporated into current treatment plans to facilitate a successful outcome. However, osteotomy use alone does not circumvent a failed closure. Proper immobilization with modified Buck’s traction and an external fixator, immobilization time greater than 4 weeks, and having the osteotomy undertaken by a pediatric orthopedic surgeon are crucial factors for a successful primary exstrophy closure with osteotomy.
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