Complications of Delayed and Newborn Primary Closures of Classic Bladder Exstrophy: Is There a Difference?
Christian C. Morrill, MD1, Roni Manyevitch, MD2, Ahmad Haffar, MD1, Wayland J. Wu, MD1, Kelly T. Harris, MD1, Mahir Maruf, MD1, Chad Crigger, MD1, Heather N. Di Carlo, MD1, John P. Gearhart, MD1.
1Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA, 2Albany Medical Center, Albany, NY, USA.
BACKGROUND:Treatment of classic bladder exstrophy (CBE) has steadily evolved over the decades, moving from urinary diversion to surgical reconstruction. The classical management of bladder exstrophy advocates for early neonatal closure yet many patients are unsuitable for closure at this time due to competing medical comorbidities, small bladder template, or late referral. Delayed primary closure in these patients have demonstrated unique advantages that have led to its growing popularity in all children with exstrophy. However, recent concerns regarding higher complication rates in delayed vs neonatal repairs challenge its popularity. In this study, authors compare 30-day complication rates between delayed and neonatal closure of CBE patients at a single high-volume exstrophy institution.
Methods: An institutional database of 1415 exstrophy-epispadias patients was reviewed retrospectively for CBE patients who underwent primary closures at the authors' institution between 1990 and 2020. Patients were identified as having received either neonatal or delayed (at age >28 days) closures. All 30-day complications were recorded, including wound infection and dehiscence, genitourinary and non-genitourinary infections, bowel obstruction, blood transfusions, and others. Descriptive statistics were performed to summarize patient level data. Categorical variables were reported by count and percentages and were compared using Exact Cochran-Armitage trend analysis by decade, or with Fisher's Exact Test and Chi-square test when directly comparing categories and outcomes. Continuous variables were analyzed via Mann Whitney U and one-way ANOVA as appropriate.
Results: The cohort included 145 patients: 50 delayed and 95 neonatal closures. The total complication rate was 58% in delayed closures compared to 48.4% for neonatal closures (p = 0.298), with the majority being Clavien-Dindo grade I or II. Excluding blood transfusion, complication rates fell to 26% and 34.7% in delayed and neonatal closures, respectively (p = 0.349). The most common single complication was unplanned post-operative blood transfusion (38% delayed; 26.3% neonatal; p = 0.34), followed by pyelonephritis (2% delayed; 8.4% neonatal), and urinary fistula (6% delayed; 1.1% neonatal). Grade III Clavien-Dindo complications occurred in 2% delayed and 7.4% neonatal groups (n = 1; n = 7 respectively; p = 0.263). A single delayed patient had grade IV complications compared to three neonatal patients (p = 0.66).
CONCLUSIONS:
Delayed primary closure has become a frequently performed alternative in the modern treatment of bladder exstrophy for patients who do not undergo newborn closure because of prohibitive circumstances or surgeon's discretion. The majority of the complications associated with delayed closure are a low Clavien-Dindo grade and easily managed during the postoperative inpatient hospital stay. Families should be counseled about the possibility of minor, conservatively managed complications and likelihood of a blood transfusion with osteotomy. 
Back to 2023 Abstracts