An International Survey of Classic Bladder Exstrophy Management
Ezekiel E. Young, MD1, Christopher A. Hesh, MD2, Paul D. Sponseller, MD2, Heather N. Di Carlo, MD2, John P. Gearhart, MD2.
1Stony Brook University School of Medicine, Stony Brook, NY, USA, 2The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Introduction
While evaluation and management options for classic bladder exstrophy patients are numerous and varied, relatively little is known regarding the relative utilization of different methods, either within any one country, or on an international scale. This project surveyed a large group of exstrophy surgeons throughout the world, seeking to document the methods they currently employ.
Materials & Methods
Using a combination of professional email lists, personal contacts and referral networking, a list of e-mail addresses of international surgeons who care for exstrophy patients was compiled. An online survey was sent out to each e-mail address on this list. Trainees and surgeons who had not performed classic bladder exstrophy closure within the previous 5 years were excluded from participation. Survey questions addressed the respondents' surgical practice and years since training, as well as their preferred methods of preoperative evaluation, operative management, and postoperative management. Survey invitations were sent out starting in December 2014 and responses were collected and data compiled for approximately 3 months.
Results
1,152 valid e-mail addresses were invited resulting in 293 respondents representing 39 countries and every AUA section, a 25.43% response rate. 76 respondents were excluded due to current trainee status or lack of experience closing a CBE patient in the last 5 years, leaving 217 respondents. Respondents reported a median of 17 years since finishing their surgical training (IQR 8-25 years). The practice makeup of the respondents included pediatric urology (n = 209), general urology (n = 9), general pediatric surgery (n = 59), and other practice makeup (n = 3). The results of each question are reported in the following table:
| Phase of Care | MODALITY | % of Surgeons Reporting Current Utilization |
| Preoperative Evaluation | ||
| Renal Ultrasound | 97.70 | |
| Plain film X-ray | 77.88 | |
| Exam Under Anesthesia | 35.49 | |
| MRI | 10.60 | |
| Other methods | 0.03 | |
| Operative Management | ||
| SURGICAL METHOD OF CLOSURE | ||
| Modern Staged Repair of Exstrophy | 58.10 | |
| Complete Primary Repair of Exstrophy | 38.71 | |
| Radical Soft Tissue Mobilization (Kelly) | 0.01 | |
| Other methods | 0.02 | |
| IDEAL TIMING OF INITIAL CLOSURE | ||
| Within first 24 Hours of Life | 5.10 | |
| 24 - 72 Hours or Life | 53.46 | |
| 72 Hours - 28 Days of Life | 20.28 | |
| Beyond 28 Days of Life | 21.20 | |
| USE OF PELVIC OSTEOTOMIES FOR NEWBORN CLOSURES | ||
| Always Use | 29.96 | |
| Use in More Than Half of Cases | 13.36 | |
| Use in Less Than Half of Cases | 24.89 | |
| Never Use | 20.28 | |
| Do Not Perform Closure in Newborn Period | 11.52 | |
| USE OF PELVIC OSTEOTOMIES FOR PRIMARY CLOSURES BEYOND NEWBORN PERIOD | ||
| Always Use | 61.76 | |
| Use in More Than Half of Cases | 15.21 | |
| Use in Less Than Half of Cases | 11.10 | |
| Never Use | 7.37 | |
| Do Not Perform Primary Closures Beyond Newborn Period | 4.56 | |
| USE OF PELVIC OSTEOTOMIES FOR REVISION (SECONDARY) CLOSURES | ||
| Always Use | 58.06 | |
| Use in More Than Half of Cases | 14.75 | |
| Use in Less Than Half of Cases | 11.52 | |
| Never Use | 9.21 | |
| Do Not Perform Revision (Secondary) Closures | 6.46 | |
| OSTEOTOMY TECHNIQUE | ||
| Bilateral Innominate | 54.19 | |
| Vertical Iliac | 17.24 | |
| Posterior | 23.65 | |
| Other methods | 4.93 | |
| Do Not Know | 9.85 | |
| PUBIC SYMPHYSEAL FIXATION MATERIAL | ||
| Suture | 93.10 | |
| Wire | 4.61 | |
| Plate | 2.30 | |
| None | 5.10 | |
| Postoperative Management | ||
| METHOD OF IMMOBILIZATION | ||
| Cast (Spica or other) | 35.02 | |
| Bryant''s Traction | 31.33 | |
| Wrap | 26.27 | |
| External Fixation | 22.12 | |
| Buck''s Traction | 7.83 | |
| Padded Self-Adhesive Tape | 6.45 | |
| None | 4.61 | |
| LENGTH OF IMMOBILIZATION (AMONG THOSE WHO IMMOBILIZE) | ||
| Less Than 2 Weeks | 11.06 | |
| 2-4 Weeks | 45.62 | |
| 4-6 Weeks | 39.63 | |
| Greater Than 6 Weeks | 3.23 | |
| TUBES AND DRAINS | ||
| Externalized Ureteral Stents | 93.10 | |
| Suprapubic Tube | 88.48 | |
| Urethral Catheter | 58.99 | |
| Internal Ureteral Stents | 2.30 | |
| Surgical Drain | 22.11 | |
| METHODS OF PAIN CONTROL | ||
| Intravenous Opioids | 60.82 | |
| Oral Opioids | 23.04 | |
| Oxybutynin or Other Anticholinergics | 44.24 | |
| Diazepam or Other Benzodiazepines | 12.44 | |
| Dedicated Pain Management Consultants | 39.63 | |
| Epidural Catheters | 41.94 | |
| Tunneled Epidural Catheters | 13.36 | |
| Other Forms | 9.22 | |
Conclusions
There appears to be a great deal of variation among the practices of current surgeons performing classic bladder exstrophy closure. The wide range of methods demonstrated by this survey suggest the need for more conclusive comparative studies to eluciate 'gold standard' practices, and improved consensus and communication of such 'gold standard' practices where and when they can, in fact, be determined.
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