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The Impact of Bladder Surgery on Successful Bladder Neck Closure in Classic Bladder Exstrophy: The Role of Mucosal Violations
Chad Barrett Crigger, MD, MPH, Tamir N. Sholklapper, MD, Thomas GW Harris, MD, John P. Gearhart, MD.
Johns Hopkins University, Baltimore, MD, USA.

Abstract  Purpose Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. 
Materials and Methods CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression.   
Results  A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider diastasis at time of primary exstrophy closure (4.4 vs 4.0, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0004). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). 
Conclusions This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more MVs may benefit from a pedicled muscle flap to prevent fistula development. 


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