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Delayed Versus Conventional Closure for Classic Bladder Exstrophy: A 18 year experience
Dana A. Weiss, MD1, Matthew S. Christman, MD2, Michael C. Carr, MD, PhD1, Douglas A. Canning, MD1.
1The Children's Hospital of Philadelphia, Philadelphia, PA, USA, 2Naval Medical Center San Diego, San Diego, CA, USA.

BACKGROUND: Closure of classic bladder exstrophy is a long and challenging operation with multiple key maneuvers and thus requires prolonged intense concentration for optimal outcomes. While traditionally these operations were done immediately after birth, regardless of the time of day or night, in 2006 we began a new program that incorporated delayed closure of bladder exstrophy with pelvic osteotomy for all babies. The delay in closure has allowed us the luxury of a consistent, experienced, and well-rested team. We now report our results using this new approach compared with our historic series of babies who were closed in the immediate newborn period.
METHODS: 18 newborns with classic bladder exstrophy have been followed after closure using a modified complete repair of bladder exstrophy since 1996. Two of these were initially closed at other institutions, the rest here. We performed a retrospective chart review to document age at time of closure, whether osteotomy was performed, initial results of the bladder closure, subsequent surgeries, and ultimate continence status (when available). Because many of our children are managed with “fine tuning” with Deflux into late childhood, we have defined “social continence” as the ability to void with dry intervals in between, and the use of no more than one pad per day in children older than 10. We have defined “potential for continence” as voiding with dry intervals of one to two hours in children under 10. All others are defined as “wet”.
RESULTS: 16/18 children were closed at our institution, and 6 (4 boys, 2 girls) had newborn closure (NC) while 10 (7 boys, 3 girls) had delayed closure (DC). Of the 6 with NC (days 0 - 2) there were two early dehiscences, one penile injury, and one vesicovaginal fistula. 2 patients have required secondary continence surgeries, and 2 have been augmented. 3 children (2 girls and 1 boy) are socially continent, 2 were wet and have been augmented, and one is wet awaiting definitive treatment. Of the 10 with DC days (6 - 123), there were no complications of the initial closure. 2 girls are socially continent without secondary continence procedures, 1 boy is dry during the day but wet at night, and 2 boys are still infants so have the potential to be dry. 2 boys have had secondary continence procedures and one is socially continent, and one is damp but voiding with dry intervals. 3 (2 boys who have had secondary procedures and 1 girl who has not) are wet and awaiting definitive treatment.
CONCLUSIONS: The delayed closure appears to result in fewer early complications including dehiscence and penile injury. The numbers are still too small to determine if there is a definite benefit in continence rates, although the trend appears to be so. Since the first closure gives the best change for continence, having fewer significant complications in the delayed group may ultimately provide the best chance for a successful first closure, and ultimately continence.

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