Complications of the radical soft tissue mobilisation procedure as a primary closure of classical bladder exstrophy

Abstract

Purpose The radical soft tissue mobilisation procedure was developed as a component of the staged closure of classical bladder exstrophy to improve continence rates without having to perform pelvic osteotomies. We describe complications following this procedure and discuss possible aetiologies and subsequent management. Material and methods We extracted from an institutionally approved exstrophy database the records of patients evaluated for complications following radical soft tissue mobilisation repair (Kelly Procedure)from 1999 to 2002. Results Four patients were referred to our institution following closure of exstrophy with the radical soft tissue mobilization technique; two boys and two girls. Both boys experienced ischemic damage of the penile tissue requiring multiple reconstructions. One of the boys had deterioration of his left upper tract and incontinence which necessitated transection of his bladder neck, augmentation and creation of a catheterizable stoma. A female patient had deterioration of a solitary right kidney and wide pubic diastasis requiring an osteotomy. Due to bladder neck fibrosis she ultimately underwent diversion. The other female patient had failure of closure due to dehiscience and required re-closure with osteotomy. She also required diversion as bladder neck reconstruction was prevented by her fibrotic bladder neck. Conclusions Despite the perception that this method obviates pelvic osteotomies, complications secondary to omission of this component of closure are seen. Additionally, the complex dissection during radical mobilisation has great potential to injure the pelvic structures and genitalia, as has been seen with the cases presented herein. Surgeons investigating this technique should be mindful of the potential pitfalls.