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Newborn Exstrophy Closure without Osteotomy: Is There a Role?
Brian M. Inouye, M.D., Mahmoud Abdelwahab, M.B.B.Ch., Heather N. DiCarlo, M.D., Ezekiel E. Young, M.D., Ali Tourchi, M.D., John P. Gearhart, M.D..
Johns Hopkins Hospital, Baltimore, MD, USA.

BACKGROUND: A successful primary closure of classic bladder exstrophy (CBE) is the most important predictor of subsequent bladder capacity and future continence. At times, closure is accompanied by pelvic osteotomy to provide a tension-free approximation of the pubic symphysis and abdominal wall. Recent studies suggest a potential for closure without osteotomy. Still, many patients require osteotomy if they have a large bladder template, excessive pubic diastasis, or non-malleable pelvis. The authors seek to understand the outcomes of newborn bladder closure with and without pelvic osteotomy.
METHODS: An institutional database of 1208 exstrophy complex patients was reviewed for CBE patients closed at the authors’ institution by the modern staged approach within 1 month of life. Patient demographics, closure history, diastasis distance, bladder capacity, and outcomes were recorded and compared for statistical significance. Variables were analyzed using Student’s T-Test, Chi-Squared Test, and ANOVA with a significant p-value cut-off of 0.05. Failure was defined as wound and bladder dehiscence, prolapse, or bladder outlet obstruction requiring re-operation. A bladder capacity greater than 100 cc was deemed sufficient for bladder neck reconstruction (BNR).
RESULTS: Of 848 CBE patients, 100 met inclusion criteria: 38 closed with osteotomy (26 male, 12 female), and 62 closed without (42 male, 20 female). Patients undergoing osteotomy had a significantly wider pre-closure diastasis than patients who did not receive osteotomy (3.85 vs. 3.22 cm; p = 0.006). There was no difference in the length of stay between the two groups. There were 4 failed closures in the osteotomy group (2 dehiscence, 2 prolapse) and 4 failed closures in the non-osteotomy group (2 dehiscence, 2 prolapse). There was no significant difference in failed closures between the two groups (11% vs. 7%, p = 0.466). There was no difference between the groups’ bladders being of sufficient capacity for BNR (82% vs. 71%, p = 0.234).
CONCLUSIONS: With thoughtful and careful planning, newborn CBE patients may be closed safely without a pelvic osteotomy by experienced exstrophy surgeons. However, if the combined surgical team has any doubt concerning the diastasis width or pelvic malleability, an osteotomy is mandatory.

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