Bilateral Posterior Iliac Osteotomy Research Articles

Bladder exstrophy closure using anterior pelvic osteotomy of superior pubic rami

Background: Bladder exstrophy is a rare and complex urogenital malformation. The current surgical approach consists of early closure followed by other procedures later on aiming for continence. Primary closure usually requires some form of osteotomy to facilitate successful bladder and abdominal wall repair. For decades, bilateral posterior iliac osteotomy has been the most commonly used technique. A new osteotomy technique, consisting of anterior pelvic ostecotomy of the superior pubic ramus, seems to be a safe and quick alternative method to obtain tension-free approximation of the symphysis pubisPatients and methods: A prospective study between 2006 and 2013, were 10 (9 males and 1 female) newborns underwent surgery for bladder exstrophy closure in the pediatric surgery department, using anterior pelvic osteotomy of superior pubic rami to achieve tension-free approximation of the symphysis pubis and successful repair.Results: Successful closure was achieved in 90% of the patients operated upon. Only 1 patient had wound dehiscence and failure of the repair. The procedure was safe, quick with minimal blood loss and was performed by the pediatric surgeon without the need to an orthopedic surgeon.Conclusion: Anterior pelvic osteotomy of superior pubic rami in an effective alternative measure to obtain tension-free approximation of the symphysis pubis, and hence successful bladder exstrophy repair. It provides further advantages namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or patient’s repositioning.

Exstrophy anomalies: Preliminary review of 18 cases in Maiduguri, North-eastern Nigeria

Exstrophy anomalies, although rare, pose a tremendous challenge to both surgeons and surrogates. Management is intricate and experience with large members is restricted to a few centres worldwide. This report is a review of 18 cases of these anomalies managed in University of Maiduguri Teaching Hospital (UMTH) over 8 years, highlighting the intricacies of management, and contributes to the existing data bank on this subject matter in our environment. We reviewed the records of all cases of anomalies that were managed in the index hospital from December 2002 to December 2010. Eighteen cases were studied. The youngest was a 2-day-old neonate and the oldest was 6 years at repair, with a median age of 4 months. There were 7 boys and 9 girls with bladder exstrophy, and the remaining two were girls with cloacal exstrophy, giving a male-female ratio of 7:11 for the exstrophy anomalies. Eight patients (33.5%) had associated congenital anomalies; 16.7% had undescended testes (UDT), anorectal malformation (ARM) and patent processus vaginalis (PPV); and duplicate bladder occurred in 5.6% of the patients. All but one patient had bilateral posterior iliac osteotomy at bladder closure. Out of the 17 patients that had osteotomy, 76.5% had satisfactory bladder closure (no complication), 5.9% had superficial wound dehiscence, 11.8% had bladder neck dehiscence and 5.9% had complete disruption. The lone patient that did not undergo osteotomy had complete bladder dehiscence. Postoperative immobilization was done for 3 weeks for 16 cases; one was discontinued after 1 week because of complication. The longest follow-up was for 2 years and the shortest for 2 weeks. Four patients (22.2%) did not turn up for follow-up. Exstrophy anomalies although rare remain a major challenge in paediatric surgery. Iliac osteotomy, among other technical considerations, remains a cornerstone for successful bladder closure.

One-Stage External Iliac Fixation Device and Bilateral Fascial and Groin Flaps Facilitate Abdominal Wall Closure after Posterior Sagittal Iliac Osteotomy in Cloacal Exstrophy

Repairing abdominal wall defects after cloacal exstrophy reconstruction always poses a challenge. Our proposal for repair consists of bilateral posterior iliac osteotomy and external iliac fixation with Schanz pins, together with abdominoplasty through bilateral groin flaps of skin and muscular aponeuroses, in a single staged procedure. 7 patients (5 male and 2 female; mean age 3.1 years) with cloacal exstrophy underwent reconstructive surgery at our institution. Cloacal exstrophy reconstruction was performed in 3 stages, whenever possible. In Stage 1, the intestinal tract is separated from the hemi-bladders; the small colon is tubularized (colorrhaphy) with an opening on the left flank. The hemi-bladders are joined and the pathology is converted into classic bladder exstrophy, followed by primary repair (cystorraphy). At this stage, closure of the abdominal wall is made by groin flap plasty, following bilateral posterior iliac osteotomy with an external iliac fixator. Stage 2 consists of bladder augmentation and the management of urinary continence. Stage 3 is genitoplasty. The aim of this study was to demonstrate our results for the first stage. After a mean follow-up of 7 years, closure of abdominal wall was found to be excellent and successful in all 7 patients. Their abdominal walls are strong and solid, with no retraction, fistula or eventration. The association, in a single stage, of a posterior osteotomy with an external iliac bone fixator and bilateral groin flaps for the closure of soft tissue defects of the abdominal wall in cloacal exstrophy appears to be a safe and cosmetically acceptable alternative technique.

Salvage Procedures to Achieve Continence After Failed Bladder Exstrophy Repair

We assessed the results from a single exstrophy center of salvage continence surgery after failed staged reconstruction for bladder exstrophy. A total of 32 patients with bladder exstrophy had undergone salvage continence procedures. Indications for surgery included incontinence due to poor bladder capacity or failed bladder neck repair, and upper tract deterioration. Continence was defined according to the International Children's Continence Society as continent, intermittently incontinent and continuously incontinent. A total of 29 patients (91%) are continent, 3 (9%) are intermittently incontinent and none is continuously incontinent. One patient is continent after bladder augmentation and urethral clean intermittent catheterization. Two patients are continent and 1 is intermittently incontinent after bladder augmentation and modified Young-Dees bladder neck repair using urethral clean intermittent catheterization. One patient is continent using clean intermittent catheterization through a continent cutaneous diversion into a bladder substitution. A total of 19 patients are continent after bladder neck closure, bladder augmentation and continent cutaneous diversion using clean intermittent catheterization. Four patients are continent after cutaneous urinary diversion. Two are continent and 2 are intermittently incontinent after a Mainz II pouch. The majority of patients can still achieve continence following failed staged repair. Patients who have a low bladder leak pressure and who tolerate urethral catheterization can be consistently dry with bladder augmentation and bladder neck repair, which is a viable alternative to bladder neck closure, bladder augmentation and continent cutaneous diversion. Cutaneous urinary diversion has a role in selected patients. Mainz II pouch has not yielded consistent results. With better patient selection and increasing experience within specialist exstrophy centers fewer patients should require salvage continent surgery in the future.

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success.

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Factors responsible for successful primary closure in bladder exstrophy.

To assess the important factors for successful primary closure in staged reconstruction of bladder exstrophy, 25 patients (18 males, 7 females) underwent primary bladder closure during the years 1993-1997. Twenty-one were more than 72 h old; all of these underwent bilateral posterior iliac osteotomies followed by primary bladder closure during the same anesthetic. Bladder closure was done in a double layer. The ureteric catheters were removed after 2 weeks and the bladder catheter after 3.5-4 weeks. Only 1 patient had a bladder dehiscence on the 10th postoperative day due to infection; 3 had partial wound dehiscences but no bladder dehiscence. One had a partial bladder prolapse. The osteotomies needed no drainage, and no complications occurred. One patient needed a urinary diversion 3 years after surgery as the bladder capacity did not increase. Eleven important factors play a pivotal role for successful primary bladder closure: (1) Proper patient selection; (2) A staged approach; (3) Anterior approximation of the pubic bones with placement of the bladder and urethra in the true pelvis; (4) Posterior bilateral iliac osteotomies in all indicated cases; (5) Double-layered closure of the bladder; (6) Two weeks' proper ureteric catheter drainage; (7) Prevention of infection; (8) Prolonged and proper postoperative immobilization; (9) Prompt treatment of bladder prolapse; (10) Prevention of abdominal distension postoperatively; and (11) Ruling out bladder-outlet obstruction before removing the bladder catheter.

Bilateral posterior pelvic resection osteotomies in patients with exstrophy of the bladder.

This paper describes a modification of bilateral posterior iliac osteotomies for bladder exstrophy, in which a strip of ilium is resected subperiosteally lateral to the sacroiliac joints, allowing easier anterior closure with less breakdown compared with traditional osteotomies. Thirty-one children underwent repair of bladder exstrophy between 1974 and 1994. Orthopaedic procedures included: closed reduction and cast application in the newborn period (four patients), classic bilateral posterior iliac osteotomies (12 patients), and bilateral posterior resection osteotomies (15 patients). Dehiscence occurred after one closed reduction, five classic osteotomies, and one resection osteotomy. Urinary continence was obtained in four patients who underwent closed reduction, nine patients who underwent classic posterior osteotomies, and nine patients who underwent posterior resection osteotomies.

Iliac Osteotomy: A Model to Compare the Options in Bladder and Cloacal Exstrophy Reconstruction

Bladder exstrophy and cloacal exstrophy present challenging reconstructive problems. Traditionally, bilateral posterior iliac osteotomy has been performed in the majority of patients undergoing primary closure for these abnormalities. Recently, 2 anterior osteotomy approaches have been proposed: 1) incision of the ilium transversely above the acetabulum (transverse osteotomy) and 2) incision of the superior ramus of the pubis (superior ramus osteotomy). We devised a new anterior mid-iliac diagonal osteotomy that provides a more functional pelvic closure. To provide a fair comparison of the procedures we developed a pelvic exstrophy model based on data from a 3-dimensional computerized tomogram of a 3-year-old patient with classical bladder exstrophy. The different osteotomies were then performed on the model and the results were compared. Our new anterior mid-iliac diagonal osteotomy correction allowed the best surgical approach, provided the best correction of the flattened ilia bony deformities, was performed in the thinnest area of marrow bone and resulted in the best pelvic symmetry.

Anatomic basis for the orthopedic treatment of bladder exstrophy: anatomic study of the sacrosciatic ligaments in the newborn.

Anatomic study of the pelvis of 30 fetuses and newborn children, yielded a precise relationship between the sacrotuberous ligaments and size of the gluteal region. At birth, the distance between the posterior superior iliac spine and the ischium is 40 mm. Closure of the anterior defect in bladder exstrophy sometimes requires an orthopedic surgical procedure. Bilateral posterior iliac osteotomy and section of these ligaments can be easily done by a single medial posterior approach herein described.

Fecal continence following an anterior-sagittal ano-enteroplasty in a patient with cloacal exstrophy

A two-year-old Latin American female was referred for treatment of what appeared to be a straightforward case of cloacal exstrophy. At operation, incision along the superior margin of the exstrophic bladder allowed identification of an unusual variant of exstrophy which consisted of bladder exstrophy; erminal colon duplication, the common medial wall of which protruded 8 cm beyond the end of the bowel lumen, and which exited ventrally and immediately caudad to the exstrophic bladder; an enteric diverticulum at the superior rim of the bladder; and two small vaginae, existing laterally on either side, at the junction between the bladder and the terminal bowel. The terminal bowel was mobilized, the duplications were excised, and a tapering enteroplasty was performed. Despite a flat-appearing bottom, a posterior muscle complex was identified which extended anterolaterally and attached to the pubis on either side. Following observation of an appropriate response to electrical stimulation, the muscle complex was partially divided in the midline, from anterior to posterior, just enough to make room for the tapered bowel. The muscle was then reapproximated in the midline anteriorly, surrounding the bowel, and an anoplasty was constructed. The bladder was closed, and the pubic rami were wired together (bilateral posterior iliac osteotomies were performed at the beginning of the operation). One and 1/2 years following this procedure, the child has a normal "rectal" exam with a palpable sphincter. She has 3 to 4 solid bowel movements daily without soiling, and she awaits genitourinary reconstruction.

Exstrophy of the Bladder

One hundred cases of exstrophy of the bladder treated with bilateral posterior iliac osteotomies to facilitate anterior closure of the pelvis and soft tissues were reviewed. Sixty-nine cases followed 5 to 18 years were evaluated in terms of: success of anterior closure (95%); degree of urinary continence (45% with near normal continence); incidence of chronic urinary tract infection, dilation of upper urinary tract and need for ileal diversion (30%); the effect of bony reconstruction on hip and pelvic development. Modifications of the technique of pelvic stabilization anteriorly and a previously unreported complication of asymmetrical pelvic closure are presented. Closure of the bony pelvis appears to increase the success of repair of both in terms of soft-tissue closure and attainment of urinary continence. Follow-up examinations of the patients throughtout the growing years with special attention to possible development of pelvic obliquity or scoliosis are important.

Posterior iliac osteotomy for fixed pelvic obliquity.

In nine children with a myelomeningocele and fixed pelvic obliquity due to uncorrectable lumbosacral scoliosis, a bilateral posterior iliac osteotomy was done and a wedge of bone was transferred form the low side to the high side of the pelvis. This produced a mean correction of 14 degrees (41 per cent) of the pelvic obliquity and a mean correction of the trunk list from the midline of seven centimeters (69 per cent). Two to seven-year follow-ups showed that the correction was permanent, without tendency for the obliquity to return as long as the scoliosis did not progress. The procedure resulted in several complications, including fracture of the pelvis and transient sciatic-nerve palsy; however, it provided a means of correcting pelvic obliquity that could not be corrected by standard procedures.