EDITORIAL COMMENT

Abstract

This is an interesting offering that adds to our knowledge of the problems that can be incurred in managing an exstrophy female during pregnancy. The most interesting vignette is in the lack of uterine prolapse in those patients who had an old fashioned posterior iliac osteotomy. The newer combined transverse innominate and anterior iliac osteotomies with pelvic fixation do a much better job of transferring the major pelvic musculature from behind the anus to a more anterior position to better support the anterior pelvic compartment seen on three-dimensional magnetic resonance imaging (3D MRI). 1 Stec AA Tekes A Ertan G et al. Evaluation of pelvic floor muscular redistribution after primary closure of classic bladder exstrophy by 3-dimensional magnetic resonance imaging. J Urol. 2012; 188: 1535-1542 Crossref PubMed Scopus (23) Google Scholar Also, we have seen very few post Cesarean section prolapses in this group regardless of whether they void from below or have a continent reservoir. We tell these ladies they usually can have one delivery without prolapse but afterwards the risk does increase regardless of having a prior osteotomy. That being said we have performed sacroculpopexies for these women to have subsequent pregnancies if they desire. Although pelvic osteotomies is a morbid procedure in adults, the authors have performed pelvic osteotomies to facilitate uterine suspension in patients with failed prior attempts at repairing uterine prolapse. 2 Ansari MS Gearhart JP Cervellione RM Sponseller PD. The application of pelvic osteotomy in adult female patients with exstrophy: applications and outcomes. BJU Int. 2011; 108: 908-912 PubMed Google Scholar Recently reported 3D MRI-guided surgery combined with pelvic osteotomy may allow for better recapitulation of the pelvic floor thus decreasing the rate or prolapse in adult life. 3 Di Carlo HN Maruf M Massanyi EZ Shah B Tekes A Gearhart JP. 3-Dimensional magnetic resonance imaging guided pelvic floor dissection for bladder exstrophy: a single arm trial. J Urol. 2019; 202: 406-412 Crossref PubMed Scopus (5) Google Scholar More data in the future like this paper is needed as modern exstrophy surgery along with better pelvic reconstructive osteotomies will hopefully decrease the complication rate in this interesting group of patients.