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Abstract
Keywords:
Anatomy
Bladder exstrophy
Osteotomy
Staged repair
The role of the pelvic osteotomy at the time of bladder exstrophy closure
has been better defined over the past three decades. Modern radiographic imaging provides greater insight into the pelvic bony and muscular defects encountered with these children and has forced surgeons
to reconsider the importance of reconstructive efforts beyond the genitourinary tract. Surgical series from several of the worlds specialist
centers clearly identify the use of osteotomy as a positive predictor
for overall success of the management provided to these patients.
Osteotomies decrease the tension placed on the soft tissues at the time
of initial closure, thereby decreasing the risk of early dehiscence or
prolapse. Long-term studies have discovered benefits with respect to
urinary continence and orthopedic function when efforts have been
made to restore the anatomic integrity of the pelvic muscles and bones.
This review summarizes the most current knowledge of anatomy in
classic bladder exstrophy and suggests the indications, methods, and
expected outcomes for the use of pelvic osteotomies during bladder
exstrophy closure. Most of this report derives from the authors experience with the modern staged repair of exstrophy at the Johns Hopkins
Hospital. However, the benefits of pelvic osteotomies at the time of
closure should extend to all patients, regardless of the specific genitourinary reconstructive strategy chosen.
# 2007 European Association of Urology and European Board of Urology.
Published by Elsevier B.V. All rights reserved.
* Corresponding author. Johns Hopkins Hospital, 149 Marburg, 600 North Wolfe Street,
Baltimore, MD 21287, USA. Tel. +1 410 955 5358; Fax: +1 410 955 0833.
E-mail address: jgearhart@jhmi.edu (J.P. Gearhart).
1.
Introduction
1871-2592/$ see front matter # 2007 European Association of Urology and European Board of Urology. doi:10.1016/j.eeus.2007.07.002
Published by Elsevier B.V. All rights reserved.
189
2.
190
3.
4.
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5.
Staged pelvic reconstruction in exstrophy
with extreme diastasis
Ideally, a complete osteotomy should be performed
at the time of the primary closure. However, when
the anatomy is unfavorable due to severe pubic
diastasis or a paucity of soft tissue, this may not
always be possible. Patients with cloacal exstrophy
present a particular problem due to the frequent
presentation of pelvic asymmetry, malformation of
the sacroiliac joints, and hip dislocation. A solution
to this problem is to perform the osteotomy in a
staged fashion prior to attempting closure [17]. This
approach involves performing the initial osteotomy
and then placing an external fixator that is gradually
tightened over a period of several weeks, followed by
an attempt at closure.
In the most recent update of a series of patients
undergoing staged closure at our institution, Mathews and colleagues [18] reported on 15 patients, all
but one of whom had cloacal exstrophy. All patients
were found to have a pubic diastasis of at least 8 cm
and all were over the age of 12 mo. The latter point
must be emphasized because children younger than
1 yr have inadequate bone strength to permit stable
pin placement. All patients underwent combined
anterior innominate and vertical iliac osteotomies
with placement of interfragmentary pins, followed
by placement of an external fixator and positioned
in modified Bucks traction. Pin size was dependent
on the size of the child, with infants receiving
2.5-mm pins, young children receiving 4.0-mm pins,
and adolescents receiving 5.0-mm pins. Gradual
reduction of the pelvis was performed at the bedside
under appropriate analgesia and sedation, 4872 h
postoperatively for infants and 1 wk after osteotomy
in older children. Final closure was performed when
the diastasis was reduced to <1 cm. An interpubic
stainless steel plate was used (Fig. 4) to maintain the
193
6.
Reoperative osteotomy in bladder and
cloacal exstrophy
7.
Immobilization and traction with pelvic
osteotomy
After a successful osteotomy and soft-tissue closure
one must not overlook the importance of postoperative pelvic and lower extremity immobilization. Meldrum and associates [22] compared the
different immobilization techniques in primary
closures for children younger and older than 72 h
of age, as well as for secondary closures after
194
patients had suffered prior, failed attempts. Successful closure was defined as cases in which
dehiscence and prolapse were avoided. Children
closed primarily with osteotomy before 3 d of age
had a success rate of 93% when immobilized 68 wk
with an external fixator and modified Bucks
traction (Fig. 5). Success rates using 46 wk of
modified Bryants traction (Fig. 6), spica casting, or
mummy wrapping were all 0%. For children closed
primarily with osteotomy after 3 d of age, the
success rates for Bucks traction and Bryants
traction were 98% and 50%, respectively, whereas
spica casting, mummy wrapping, and no immobilization yielded 0% success rates. Finally, closures
after prior failed attempts were investigated and
found to be 97% successful when the modified
Bucks was used and slightly less so, 87%, when
modified Bryants was used. Spica casting and
mummy wrapping were significantly less effective
with success rates at 33% and 0%, respectively. It is
worth noting that all three subgroups had much
8.
Conclusion
Conflicts of interest
Fig. 6 Modified Bryants traction in an infant closed
without pelvic osteotomies.
None declared.
References
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CME questions
Please visit www.eu-acme.org/europeanurology
to answer these CME questions on-line. The
CME credits will then be attributed automatically.
1. Of the three major common exstrophy closure
strategies, which could benefit from concurrent
performance of pelvic osteotomies?
A. Complete primary repair of exstrophy (CPRE).
B. Modern staged repair of exstrophy (MSRE).
C. Radical soft tissue mobilization (Kelly repair).
D. All of the above.
2. Which musculoskeletal defect is characteristic of
classic bladder exstrophy?
A. Internal rotation of the posterior pelvis.
B. More narrow levator hiatus than normal.
C. Flattening of the levator ani muscles.
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