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Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery

Published:December 25, 2021DOI:https://doi.org/10.1016/j.jpedsurg.2021.12.017

      Highlights

      • What is currently known about this topic?
      • Primary bladder closure in patients with CBE is mainly performed in specialist centers. There is still an ongoing debate on the time and type of closure and on the need of pelvic osteotomy for successful bladder closure. Especially osteotomy is associated with long hospital stays.
      • What new information is contained in this article?
      • Delayed primary closure in patients with CBE is safe procedure, which can be routinely performed without osteotomy. The major advantage of continuous epidural blockage could be confirmed.

      Abstract

      Background

      Successful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management.

      Material and Methods

      We reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay.

      Results

      66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13–34 d).

      Conclusion

      Delayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE.

      Level of Evidence

      Level III.

      Keywords

      Abbreviations:

      bw (bodyweight), CBE (classic bladder exstrophy), CPRE (primary complete reconstruction bladder), ICU (intensive care unit), MRSE (modern staged repair), RSTM (radical soft tissue mobilization), UC (urethrocystoscopy), VCUG (voiding cysturethrogramm)
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