The Role of Pelvic and Lower Limb Immobilization in Classic Bladder Exstrophy: An Institutional Study of Three Mainstay Techniques
Timothy Baumgartner, M.D., John Jayman, B.A., Daniel Friedlander, M.D., Heather Di Carlo, M.D., Paul Sponseller, M.D., John Gearhart, M.D..
Johns Hopkins, Baltimore, MD, USA.
BACKGROUND: Achieving a successful primary bladder closure in classic bladder exstrophy (CBE) is paramount in establishing a foundation for bladder growth and establishment of future continence. A failed closure, both in the primary and reoperative settings, can have devastating long-term ramifications for bladder growth and continence. Successful closure relies on the expertise of a multi-disciplinary team in the preoperative evaluation, operative technique, and post-operative care. A mainstay of postoperative care is pelvic and lower extremity immobilization. A wide variety of techniques of postoperative immobilization have been employed to include external fixation with skin traction and spica casts with or without external fixation. This study reports the findings from a high volume exstrophy center comparing outcomes and complications of primary and reoperative bladder closures between patients immobilized with spica casts, spica casts with external fixation, or external fixation and skin traction.
METHODS: A prospectively-maintained institutional exstrophy-epispadias complex database of 1300 patients was reviewed for patients with CBE born after 1975 who underwent primary or reoperative bladder closure. Demographic, operative, and outcomes data were collected and compared between patients immobilized with spica cast only, spica with external fixation, or external fixation with skin traction.
RESULTS: A total of 215 patients with 251 bladder closures met inclusion criteria. There were 151 males and 64 females. Median follow-up time was 7.9 years. There were 182 primary closures and 69 reoperative closures, with 112 performed at the authors' institution and 139 from outside hospitals. Pelvic osteotomy was undertaken in 186 (74.1%) of closures. Postoperative immobilization was achieved with spica casts in 112 closures and external fixation with skin traction in 133. Only 6 cases utilized spica casts with external fixation. For all closures, there were 53 failures (47.3%) amongst those immobilized with spica cast alone versus 10 failures (7.5%) for those immobilized with external fixation and skin traction (p<0.005). When restricted only to closures performed with osteotomy, the failure rates were 30.2% and 7.9%, respectively (p<0.005). This trend persisted for subanalysis of primary closures alone (respective failure rates 47.6% and 4.1%, p<0.005) and for primary closures only with osteotomy (respective failure rates 29.8% and 4.4%, p<0.005). There were no differences in complication rates between spica casts and external fixator groups (11.4% versus 20.3%, p=0.104). Of the six patients immobilized with spica casts and external fixation, there were 2 (33.3%) failures.
CONCLUSIONS: Failure of bladder closure can occur with any form of pelvic and lower extremity immobilization. However, it appears that external fixation with lower extremity skin traction offers a more secure manner in which to protect a well done exstrophy closure in this select group on patients.
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