Plastic Repair of Exstrophy of Bladder Combined with Bilateral Osteotomy of Ilia

Abstract

So far as I am aware, this combination of procedures has never been attempted. One case does not prove a rule, but the end result has been so successful that I must report it, in order that others of you who have had more experience with such patients may give it a trial, add improvements to the technique and develop procedures that will increase the number of satisfactory functional results. I had the good fortune to observe one of the excellent urologists in the country perform a plastic repair on such a case. He severed the right arm of urethral sphincter muscle at its attachment to the right pubic bone, and brought this end over the to be constructed urethra, suturing it to the base of the left arm of urethral sphincter muscle. He was tempted to perform the same procedure on the left, but did not do so because he believed that severing the attachment interfered with blood and nerve supply sufficiently that it might be responsible for failure to obtain a functioning urethral sphincter. He then did a beautiful construction of the urinary bladder as well as a fascial sliding closure of the abdominal muscles over it. The immediate end result was excellent but the future functional result was not. Therefore it occurred to me that if some procedure could be devised to bring the pubic bones together, the undesirable separation of the sphincter muscles from their pubic attachments could be avoided, and the fascial sliding closure of the abdominal muscles would likewise be unnecessary, resulting in marked simplification of both procedures and the possibility of a much more satisfactory end result. When the case herewith reported (fig. 1) was referred to me by the Crippled Childrens Clinic, a local orthopedic surgeon, Dr. John R. Schwartzmann, was rendering orthopedic care. When he learned that the patient was to be hospitalized by me for repair of the bladder exstrophy, he requested that I let him know when I had completed my surgical procedure, as he was desirous of performing an orthopedic surgical procedure and thus avoid readmission. It was his intention to perform osteotomy of the ilia to correct external rotation of both hips and legs as well as correct the gait which was quite unstable. When I inquired if this procedure would permit fairly close approximation of the two pubic bones he said that it would, and I suggested that he perform the osteotomy before I did any procedure and that, at the time of the bladder repair, a suitable interval after this osteotomy, we might be able to combine fixation of the pubic bones at a suitable point during the bladder reconstruction. Such a procedure was decided upon.