The Utility of Repeat Pelvic Osteotomy in Facilitating Closure of the Exstrophy Patient

Abstract

Introduction Failed primary closure of the exstrophic bladder is a serious complication with significant impact on the continence outcomes and stability of the urinary tract. Pelvic ostetomy is a critical component of repeat closure as it facilitates a tension-free approximation of the pubis and abdominal wall, and gives the best chance for a successful outcome. This study examines the success rates and complications of repeat pelvic osteotomy(RPO) following failed closure of patients with classic bladder and cloacal exstrophy. Methods The authors analyzed patient data from our institutionally-approved exstrophy database and identified all bladder and cloacal exstrophy patients who have undergone RPO in conjuction with repeat exstrophy closure. Within this select group we analyzed patient history, complications, and orthopedic outcomes. Results 75 patients who underwent RPO were identified from the database, 56% male and 44% female. In 83% of patients, RPO was performed prior to 36 months of age. Mean time from initial to repeat osteotomy was 20 months. Anterior inominate osteotomy was utilized in 41% of cases, while combined transverse-anterior inominate/vertical iliac comprised 40% of cases. All cloacal exstrophy patients remain closed, while 5(7%) of the bladder exstrophy patients required repeat bladder closure. Minor complications, such as pin site infections or loose hardware, were observed in 10 patients. 3 patients had major infections of the hardware, and 3 patients had non-union of their pelvic bones after osteotomy. 63 patients now walk with a normal gait, 10 ambulate with assistance or with a limp, while only 2 are non-ambulatory. Conclusions A failed exstrophy closure is a serious complication which significantly affects the functional outcome of the child. When performed in conjunction with repeat pelvic osteotomy and proper immobilization, secondary closure can be successful and safely performed, and major post-osteotomy complications are uncommon.