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The Bladder Exstrophy Surgical Training (BEST) Model: The Role of the Co-Surgeon
Timothy Baumgartner, MD, Rachel Davis, MD, Matthew Kasprenski, MD, Peter Stuhldreher, MD, Mahir Maruf, MD, Heather Di Carlo, MD, Paul Sponseller, MD, John Gearhart, MD.
Johns Hopkins School of Medicine, Baltimore, MD, USA.

BACKGROUND: Bladder and cloacal exstrophy are rare congenital malformations of the genitourinary system. A successful primary closure is paramount in establishing a foundation for bladder growth and the establishment of future continence. This study describes a novel teaching model in bladder exstrophy - BEST: Bladder Exstrophy Surgical Training - wherein the referring pediatric surgeon or pediatric urologist travels to participate as a co-surgeon in the case at a high volume exstrophy center of excellence. The surgical outcomes using the BEST model are also described. METHODS: A prospectively-maintained institutional exstrophy-epispadias complex database of 1,387 patients was reviewed for patients with exstrophy, including all variants, who underwent primary or reoperative closure after 1997 at our institution with the referring pediatric surgeon or pediatric urologist participating as the co-surgeon in the case alongside a senior surgeon. Demographic, operative, and outcomes data were collected and analyzed. In addition, each physician completed a 14-question survey regarding their experience. RESULTS: There were 23 participating co-surgeons in the BEST Model: 2 general urologists, 13 pediatric urologists, and 8 pediatric surgeons. 100% of the co-surgeons stated the BEST model enhanced patient relationships and follow-up care once the patient returned home. Within their practices, 83% of the co-surgeons reported diagnosing one or fewer cases of exstrophy a year, yet 58% of the co-surgeons have gone on to close an exstrophy at their home institution following participation in the BEST model. A total of 31 patients met the inclusion criteria and underwent closure using the BEST model; 25 patients had bladder exstrophy and six patients had cloacal exstrophy. All patients underwent an osteotomy. There were no failures in either group. 12% of the patients experienced complications ranging from surgical site infections to penile skin separation.
CONCLUSIONS: The use of the Bladder Exstrophy Surgical Training (BEST) Model, or a co-surgeon training model, provides renewed familiarity of bladder closure in exstrophy to the referring surgeon with the support of a senior surgeon. The BEST model subsequently enhances continuity of care as the patient transitions back to their local area.


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