Osteotomy in the newborn classic bladder exstrophy patient: A comparative study. Issue 4 (August 2021) - Khandge, Preeya
Summary: Introduction: Pelvic osteotomy is indicated in classic bladder exstrophy (CBE) patients with a wide pubic diastasis or non-malleable pelvis. While the safety of pelvic osteotomy in delayed and failed closures is established, there remains less clarity on their safety in newborns. The authors herein sought to present their experience with CBE patients who underwent pelvic osteotomy for assistance with bladder closure during both the newborn and delayed time periods. Objective: The authors hypothesize that pelvic osteotomy during exstrophy closure may be performed safely in newborns with few perioperative or post-operative negative sequelae. Study design: A prospectively maintained IRB-approved database was reviewed for CBE patients who underwent osteotomy during primary closure. Patient demographics, performing institution (authors' or outside), closure outcome, diastasis width, and post-operative complications were noted. Patient subgroups included newborn and delayed (>28 days of life) closures. Failure was defined as bladder dehiscence, prolapse, outlet obstruction, or vesicocutaneous fistula requiring reoperation. Orthopedic complications included nerve palsies, superficial pin-site infection, and bladder neck erosion by orthopedic hardware. Analyses were performed using a Chi-square test. Results: 286 patients were included: 186 newborn and 100 delayed closures. The authors' institution performed 109 cases (44 newborn and 65 delayed). Within the overall newborn closure cohort, no significant differences were found in outcomes among the osteotomy types with success rates of 80%, 60.8%, and 71.4% in the combined, posterior iliac, and anterior innominate groups, respectively (p = 0.24). In the delayed group, success rates were significantly different with rates of 100%, 72.4%, and 93.8% in the combined, posterior iliac, and anterior innominate groups, respectively (p < 0.001). Febrile urinary tract infection (UTI) was the most common complication at 8% (23/286). Only 1.7% (5/286) of patients had orthopedic complications with 3 patients in the newborn cohort, 2 patients in the delayed cohort, and only one patient requiring reoperation. Discussion: Orthopedic complications are rare in CBE patients who undergo osteotomies regardless of the closure period. No clinically significant difference in orthopedic complication rate was found between newborn and delayed closure periods. Conclusions: While current trends have moved toward delayed primary closures, there remains a role for osteotomy during exstrophy closure in select newborn patients and can be performed safely with few complications. Summary Table closure outcome and post-operative complications. Summary Table Variable, n (%) Newborn Closure Delayed Closure Overall (Newborn + Delayed) Overall Success Rate 127 (68.3%) 88 (88.0%) 215 (75.2%) Location AH OH AH OH AH OH Success Rate 40 (90.9%) 87 (61.3%) 65 (100%) 23 (65.7%) 105 (96.3%) 110 (62.1%) Blood Transfusion Rate 17 (38.6%) 9 (36%) 26 (42.6%) 3 (42.9%) 43 (41%) 12 (37.5%) Overall Clavien I-II Complication Rate 15 (34.1%) 8 (5.6%) 23 (35.4%) 6 (17.1%) 38 (36.2%) 14 (12.7%) Febrile UTI 8 (53.3%) 3 (37.5%) 10 (43.5%) 2 (33.3%) 18 (47.4%) 5 (35.7%) Abdominal Wound Infection 4 (26.6%) 0 (0%) 2 (8.7%) 0 (0%) 6 (15.8%) 0 (0%) Urinary Fistula 0 (0%) 2 (25%) 3 (13%) 2 (33.3%) 3 (7.9%) 4 (28.6%) Bladder Outlet Obstruction 0 (0%) 1 (12.5%) 1 (4.3%) 1 (16.7%) 1 (2.6%) 2 (14.2%) Orthopedic Complications 2 (13.3%) 1 (12.5%) 2 (8.7%) 0 (0%) 4 (10.5%) 1 (7.1%) Other Complications 1 (6.7%) 1 (12.5%) 0 (0%) 1 (16.7%) 1 (2.6%) 2 (14.2%) (Abbreviations: AH, Author's Hospital; OH, Outside Hospital).