BACKGROUND- Primary bladder exstrophy (BE) closure was, except in rare circumstances, historically performed within 72 hours of birth. However, over the last 15 years, the age at primary BE closure has been increasing, in part due to the formation of multi-institutional BE consortia. This may have led to the re-evaluation of the need for immediate BE closure at other institutions as well. This study aimed to determine the age at primary BE closure from 2012 through 2023. We hypothesized that the age at primary BE closure increased from early postnatal closure in 2012 to closure at 2 months in 2023.
METHODS- A retrospective, cross-sectional analysis was performed using the Epic Cosmos database, a de-identified dataset containing information from 246 million distinct patients extracted from 1,415 participating Epic hospitals. The study timeframe was Jan 1, 2012 to Dec 31, 2023. BE patients were identified using a combination of International Classification of Diseases (ICD)-9 (753.5 and 57.86) and -10 (Q64.10, 0TQB0ZZ, and 0TSB0ZZ) diagnostic and procedure codes in combination with the Current Procedural Terminology (CPT) code 51940. Potential subjects were excluded if a BE closure was not performed, if they had any bowel surgery within the first month of life (i.e., had cloacal exstrophy), or if there was a diagnostic (ICD-9 (752.62) or -10 (Q64.0)) and/or procedure code (CPT 54380, 54385, and 54390) for epispadias without any BE code(s). The use of pelvic osteotomies was also noted.
The primary outcome was the age at the primary BE closure. Secondary outcomes were whether epispadias repair and/or a pelvic osteotomy occurred synchronously with BE closure. Measures of central tendency and the sample’s distribution for the primary outcome stratified by year are displayed using box-and-whisker plots.
RESULTS- 149 total patients (77 (52%) male) were identified as having a BE closure within the database. Of these, 10 (2%) had an epispadias closure and 52 (35%) had pelvic orthopedic procedures at the same time as their BE closure. The majority (44/52) (85%) of pelvic osteotomies occurred in patients whose BE closures were performed at >7 days of age.
In 4 of the first 5 years of the study, the median age at BE closure was within 1 week of birth. Conversely, in 3 of the last 5 years of the study, the median age at BE closure was at or after 3 months of birth (Figure 1).
CONCLUSIONS-These data suggest a shift from immediate postnatal to delayed primary BE closure over the last decade. Importantly, only one-third of patients underwent pelvic osteotomy synchronous with BE closure. If osteotomies occurred, they were more likely to be in patients with delayed BE closures. If confirmed in other studies, these findings underscore the evolving surgical approach to primary BE closure and emphasize the importance of further research to compare modern outcomes in bladder exstrophy management with those from earlier eras.
