The Northeastern Society of Plastic Surgeons

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A Single Institution Experience of Complete Primary Repair of Bladder Exstrophy in Girls: Risk Factors for Urinary Retention
Bryan S. Sack, MD, Joseph G. Borer, MD.
Boston Children's Hospital, Boston, MA, USA.

BACKGROUND: Following recent technical modifications, we have observed a high rate of urinary retention in girls post-complete primary repair of exstrophy (CPRE). The aim of this investigation was to identify factors that may be responsible for this observation by reviewing our historical outcomes in comparison to current outcomes. We hypothesized that the use of pelvic osteotomy and differences in anatomic dimensions at the time of CPRE (narrower bladder neck and longer urethral plate) may contribute to urinary retention. METHODS: A retrospective review of all girls that underwent CPRE from December 1998 through September 2016 from a single institution was performed. Operative age and weight, anatomic dimensions, type of pelvic immobilization, use of posterior iliac pelvic osteotomies, imaging, clinical course, and need for additional surgical procedures were recorded. Patients were deemed in retention if their clinical course was consistent with such, required a procedure or procedures to relieve urinary retention, and/or a required clean intermittent catheterization (CIC). RESULTS: Nineteen girls underwent CPRE in this time period. In 2007, a change to delaying CPRE to approximately 2-months of age was made and this led us to divide our experience into CPRE performed as a newborn (<72 hours of age) versus delayed (>72 hours) subgroups. Eight (42%) had newborn and eleven (58%) had delayed repair (Table). There were no girls with retention in the newborn group. One delayed repair was complicated by bladder rupture, necessitating surgical exploration/repair and CIC. A second delayed CPRE required CIC, and a third required endoscopic bladder neck incision. In the delayed CPRE group, girls had a significantly longer urethral plate and narrower bladder neck compared to the newborn group. Long-term outcomes greater than nine years are available for six girls in the newborn group and two (33%) required bladder neck procedures for incontinence. None in the delayed group have required incontinence procedures, however follow up is limited. CONCLUSIONS: The absence of retention in the newborn group (without osteotomy) is concerning for the delayed (with osteotomy) group incurring a higher risk of retention post-CPRE. The increased risk of retention may be secondary to compression of the urethra at the time of pubic symphysis approximation facilitated by osteotomy, which may cause a compartment syndrome-like phenomenon leading to urethral ischemia. Different from the newborn CPRE girls, additional technical revision of CPRE, namely elongation of the urethra and the dissection it involves, and narrowing of the bladder neck, may also place the delayed CPRE girls at risk for urinary retention.

Table 1: Female CPRE Characteristics and Outcomes
Newborn RepairDelayed Repair
Number of Girls (%)8 (42)11 (58)
Age at surgery (days, range) *1.75 (1-3)129 (42-513)
Osteotomies (%) ****0 (0)11 (100)
Bladder neck width (mm, range)*19 (16-20)16 (15-20)
Urethral plate length (mm, range)*11 (8-15)14 (12-18)
Pelvic Immobilization ****
Modified Bryant's Traction81
Spica Casting010
Clinically Obstructed (%)0 (0)3 (38)

Significance: * p<0.05, **** p<0.0001


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