Society For Pediatric Urology

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3D Real Time MRI-Guided Intraoperative Navigation of the Pelvic Floor During Primary Exstrophy Closure
Heather N. Di Carlo, M.D., Eric Z. Massanyi, M.D., Aylin Tekes, M.D., John P. Gearhart, M.D..
Johns Hopkins School of Medicine, Baltimore, MD, USA.

BACKGROUND: Radical dissection of the urogenital fibers and the thickened smooth and striated muscle fibers connecting the posterior urethra and bladder plate to the diastatic pubic rami is crucial for adequate placement of the posterior vesicourethral unit deep within the pelvis during primary bladder exstrophy closure, as well as ensuring successful outcomes. Intraoperative MRI guided navigation of the pelvic floor offers a novel technique for identification of these structures and improving safety while mentoring and ensuring optimal outcomes.
METHODS: Institutional review board and Food and Drug Administration approval was obtained for use of Brainlab® (Munich, Germany) intraoperative MRI-guided navigation of the pelvic floor anatomy during primary closure of exstrophy at the authors’ institution. Pre-operative pelvic MRI was obtained one day prior to primary exstrophy closure in patients necessitating pelvic osteotomies. Intraoperative registration was performed after pre-operative planning with a pediatric radiologist utilizing five anatomic landmarks immediately prior to initiation of surgery. Accuracy of identification of pelvic anatomy was assessed by two pediatric urologic surgeons and one pediatric radiologist.
RESULTS: 24 patients with CBE and 2 patients with CE closed at the authors’ institution have successfully utilized Brainlab® technology to navigate and guide the dissection of the pelvic floor intraoperatively (9 newborn, 15 delayed CBE patients; 2 delayed CE patients). All patients had 100% accuracy in correlation of gross anatomic landmarks with MRI identified landmarks intraoperatively, and all have had successful closure without any complication.
CONCLUSIONS: Brainlab® intraoperative MRI-guided pelvic floor navigation and dissection is an effective way to accurately identify pelvic anatomy during primary exstrophy closure. This allows for improved safety, both inter- and intra-institutional telementoring and improved outcomes in this most important first step of exstrophy reconstruction.

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