Posterior Iliac Osteotomy Research Articles

The true pelvic volume change with various corrective osteotomy techniques for exstrophy-epispadias complex spectrum: the value of computer-assisted virtual surgery.

Pelvic osteotomies are essential to approximate widened symphysis pubis in the exstrophy-epispadias complex, yet it is unknown which osteotomy type has the greatest effect on pelvic volume. We therefore used virtual surgery to study pelvic volume change with anterior, oblique, and posterior iliac osteotomies. Preoperative CT scans of two cloacal and one classic bladder exstrophy patients were used. Simulations were free-hand or constrained to keep minimal strain in the sacrospinous SSL and sacrotuberous STL ligaments. Changes in inter-pubic distance, pelvic volume, SSL and STL strains were measured. Mean pelvic volume decreased by 10% with free hand compared to 23% with constrained simulations ( P = 0.171) and decreased by 7% with posterior, 17% with diagonal and 26% with horizontal osteotomies ( P = 0.193). SSL and STL were strained by 20% and 26%, respectively, with free-hand simulations. A statistically significant moderate positive correlation was found between the decrease in inter-pubic distance and reduction in pelvic volume (r = 0.6, P = 0.004). Mean pelvic volume decreased 0.05, 0.37 and 0.62% for each mm of pubic symphysis approximation with posterior, diagonal and horizontal osteotomies, respectively. Differences in effect on pelvic volume were identified between the osteotomies using virtual surgery which predicted residual diastasis in actual cloacal exstrophy surgical reconstructions. Oblique osteotomies are a compromise, avoiding difficulties with posterior osteotomies and excessive pelvic volume reduction with horizontal osteotomies. Understanding how osteotomy type affects pelvic morphology with virtual surgery may be an effective adjunct to pre-operative planning in exstrophy spectrum.

Fixation with lower limb immobilization in primary and secondary exstrophy closure: A saving grace

A pivotal factor in the success of bladder closure in patients with classic bladder exstrophy (CBE) is the postoperative immobilization of the pelvis and lower extremities after pelvic osteotomy. This study investigates the outcomes of closure among patients with lower limb immobilization using many techniques. The authors hypothesize that the addition of external fixation (pelvic immobilization) in patients with any form of limb immobilization will be associated with improved outcomes. A prospectively maintained institutional exstrophy-epispadias complex database of 1415 patients was reviewed for patients with CBE who had undergone closure with available immobilization and osteotomy data. Association between closure outcomes and immobilization techniques were determined. Univariate analysis was performed using Chi-Square or Fischer-Exact test as appropriate for categorical variables. Multivariate analysis via binomial logistic regression was used to identify factors leading to successful closure. A total of 747 closure events matching the inclusion criteria were identified. Patients included 508 males and 239 females. There were 597 primary closures (79.9%) with 150 reclosure events (20.1%). Limb immobilization was used in 627 (83.9%) of closure events. Successful closures were associated with osteotomy use (p<0.0001) and limb immobilization (p<0.0001); specifically, the combined anterior innominate with posterior vertical iliac osteotomy and modified Buck's traction with external fixation (p<0.0001, p<0.0001). Among the group of 33 patients who received external fixation alone and no other type of immobilization, the failure rate was 33.3%, comparatively, patients with any form of combined immobilization (external fixation with lower limb immobilization) had a failure rate of 7.1% ( Table 1). Among patients immobilized with mummy wrap, spica casting, or knee immobilizers, external fixation was associated with 3.76 increased odds of successful closure (p=0.0005, 95% CI 1.79-7.90). In a unique group of 67 patients without pelvic osteotomy or any form of pelvic or limb immobilization, the failure rate was 74.6%. This study confirms, in a larger series, previous findings of improved outcomes when patients are immobilized with modified Buck's traction and external fixation. The authors apply this technique in most all closures and recommend this technique be utilized whenever feasible. However, regardless of the manner of lower limb immobilization, external fixation is a critical factor to optimize closures and ensure success. The results of this study clearly suggest the use of external fixation can be protective against bladder closure failure. The use of pelvic immobilization, in addition to post-operative lower limb immobilization should be strongly considered.

The Y-Pelvic Osteotomy in Treating Bladder Exstrophy: A Surgical Technique.

Bladder exstrophy (BE) is a rare congenital anomaly caused by an embryological defect in the closure of the abdominal wall.It comprises a spectrum of defects about severity, including epispadias in the mildest form and cloacal exstrophy in the worst. Surgical correction is required to achieve urinary continence, maintain normal renal function, achieve secured abdominal wall closure, and create cosmetically and functionally satisfactory genitalia. Iliac bone osteotomy is considered essential to achieve the above goals in most patients by reducing the tension of the closed abdominal walllayers, particularly when present late in infancy. Several types of pelvic iliac bone osteotomy have been described to aid bladder and cloacal exstrophy closure. They can be grouped into posterior iliac osteotomy, anterior iliac osteotomy, oblique (also called diagonal) iliac osteotomy, and a combination of posterior and anterior iliac osteotomy. We described here the Y-pelvic osteotomy, which was developed by the Manchester Orthopaedic Group in the United Kingdom. It has the advantage of anterior and posterior osteotomiesbut also has less risk to the neurovascular structures, less blood loss, and ease of surgical technique. The osteotomy was named the Y-pelvic osteotomy due to the morphological shape it resembles.

EDITORIAL COMMENT

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.

AUTHOR REPLY

In his editorial comment, he proposes an interesting reflection in which he highlights the importance of carrying out a long term follow up on this group of patients with this pathology to determine the long-term effectiveness of the techniques we use. Our series is about historical retrospective. Our patients underwent a posterior iliac osteotomy technique that is no longer performed because innominate anterior and transverse iliac osteotomy offers considerable advantages: shorter operating time and greater decrease in pubic diastasis.

Mesane Ekstrofisi Tedavisinde Ortopedik Cerrahi Yaklaşımlar

Bladder exstrophy is an embryologic malformation that affects urogenital and skeletal systems. Non-operative treatment of this rare problem is impossible. Urogenital reconstructions can be facilitated by orthopedic procedures. These reconstructions can be performed in a single stage as a complete repair or multi-stage approaches. The goal of the treatment is closure of the bladder and abdominal wall for the achievement of continence, preservation of renal functions, and cosmetic and functional reconstruction of genital organs. Orthopedic procedures are performed to decrease the tension that complicates the bladder and abdominal wall closure by approximating the pubic rami to achieve a secure closure and a low recurrence rate. Surgical interventions consist of the approximation of the pubic rami with different materials such as suture materials and plaque or the application of different osteotomy types such as posterior iliac, anterior pelvic (pubic), diagonal iliac, horizontal iliac and posterior pelvic resection osteotomies. The age of the patient, the amount of pubic diastasis and history of previous operations that the patient has undergone should be considered during the operation planning. Pubic rami can be approximated without performing pelvic osteotomy in patients who are operated within the first 72 hours after birth. But, osteotomy is required in children older than 2 years of age with severe pubic diastasis, concomitant cloacal exstrophy and unsuccessful operation history. The surgical team should have enough knowledge and experience to perform different osteotomy types in case of need to combine anterior and posterior iliac osteotomies. With these multidisciplinary approaches, much more successful outcomes could be achieved.

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.

PEDIATRIC UROLOGY Complications after primary bladder exstrophy closure – role of pelvic osteotomy

IntroductionBladder exstrophy is the most common form of the exstrophy – epispadias complex. It is observed in 1:30 000 life births, about four times more often in boys than in girls. Iliac osteotomy is used to facilitate bringing together pubic bones and to minimize the tension of fused elements. To analyze complications after primary bladder exstrophy closure with a special consideration of the role of pelvic osteotomy.Material and methodIt is a retrospective study evaluating 100 patients (chosen by chance out of 356) with bladder exstrophy (65 boys and 35 girls), treated in Pediatric Urology Department of the Children's Memorial Health Institute in Warsaw, Poland between 1982 and 2006. All children underwent primary bladder exstrophy closure, among them 32 elsewhere. Primary bladder exstrophy closure with contemporary iliac osteotomy was done in 36 children. In the rest 64 patients bladder was closed without osteotomy, regardless child's age.ResultsDehiscence after primary closure followed with bladder prolaps occurred in 31 patients, among them 13 out of 68 (19%) operated in our department and 18 out of 32 (56%) operated in another hospital. Primary bladder exstrophy closure with contemporary iliac osteotomy was done in 32 infants above 72 hours of life.ConclusionsOsteotomy performed at primary bladder exstrophy closure diminishes the risk of wound dehiscence independently of patient's age. Posterior iliac osteotomy is sufficient and safe and could be repeated if necessary.

Author's replay

Looking for bladder exstrophy as a diagnosis, we found 356 cases in our database, which makes us one of the biggest centers of exstrophy-epispadias complex treatment in the world. Some patients are treated at our institution from the beginning while others are coming for further treatment after primary bladder exstrophy closure or because of complications and poor results of surgery performed at another institution. From the technical point of view it was not possible to include all 356 patients into our study, because we felt that a group of 100 cases was large enough to function as a representative group. All of the cases were chosen randomly from the database. Bladder exstrophy is treated with staged reconstruction, which begins with primary closure, followed by urethral and penile reconstruction, and finally bladder neck creation. The primary closure is crucial because it involves not only bladder closure but also the necessity to rearrange the pelvic bones, pelvic floor muscles, and anterior abdominal wall layers. In newborns up to the third day of life, the primary bladder closure could be performed without osteotomy. At this age, the pelvic bones are elastic and it is possible to connect the pubic symphysis without osteotomy. However, we learned, that in case of a diastasis of 4 cm or more, it is better to perform osteotomy even if the baby is less than three days old. In older children, however, osteotomy is recommended independently of the distance of the pubic bones. Unfortunately, there are doctors who do not understand the role of osteotomy and they still perform exstrophy closure without this procedure. As a consequence of the wide diastasis of the symphysis, the results of primary closure are bad. Most often wound dehiscence is observed with re-exstrophy of the bladder. In other cases, the cicatricial hernia develops or extensive scarring occurs. Moreover, wide standing pubic bones make the proper reconstruction of external genitalia impossible and predispose to vaginal prolapse in adulthood. That is why we decided to call attention to primary bladder exstrophy closure and the value of osteotomy in this procedure. Pelvic osteotomy combined with bladder exstrophy closure has only one aim – to connect the pubic bones. The reconstruction of the symphysis allows the pelvic floor muscles and abdominal rectus muscles to close up. Approximation of the pubic bones is achieved with iliac osteotomy independently of the method of osteotomy. The most popular is posterior iliac osteotomy, which was described for the first time in 1958 by Schulz and practically unchanged until today. In some cases with big diastasis of the symphysis, even if the osteotomy is performed, the pubic bones are connected with tension, which predisposes to wound dehiscence and bladder prolapse. That is why re-exstrophy may occur in all centers even those doing osteotomy in all patients. However, closure without osteotomy always gives tension. The discrepancy between the results achieved in our center and in the others (failure rate 19% to 56%, respectively), derives evidently from the osteotomy that was, or was not, performed together with bladder closure (Tables 2, 3, 4, & 5). Our experience and results push us to conclude that it is better to close the exstrophy together with iliac osteotomy in all age groups, even in the newborn less than three days old – and this is a new message. Furthermore, if we should perform osteotomy regardless child's age, let us postpone the surgery for about one month to let the baby stay with the mother and allow the rest of family to develop emotional relations. Although the delay of operation should not be longer because of epithelialization of the bladder mucosa.

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.

The role of osteotomy in surgical repair of bladder exstrophy

Classic bladder exstrophy (CBE) patients are born with a pubic diastasis that increases steadily with age from a mean value of 4 cm at birth to a mean of 8 cm at age 10, compared with a mean normal width of the pubic symphysis of 0.6 cm at all ages. The width of the sacrum and length of the posterior (iliac) segment of the pelvis in CBE patients are normal; however, the anterior (ischiopubic) segment of the pelvis is a mean 30% shorter and both the anterior and posterior segments are externally rotated compared to controls. The main role of osteotomy in treatment of CBE appears to be to relax tension on the bladder and repaired abdominal wall during wound-healing. Anterior innominate osteotomy with optional posterior vertical iliac osteotomy presents several advantages over the prior conventional technique of posterior iliac osteotomy. These include (a) less intraoperative blood loss, (b) better apposition and mobility of the pubic rami at the time of closure, (c) allowance for placement of an external fixator under direct vision, (d) allowance for secure external fixation in children over 6 months old, and (e) no requirement to turn the patient during the operation.

The Modified Invance Perineal Sling in the Treatment of Incontinence in Boys with the Exstrophy-Epispadias Complex

Purpose The surgical management of incontinence in boys with the exstrophy-epispadias complex has challenged surgeons for many decades. We present a modification of our previously described sling for the treatment of neurogenic incontinence to permit the treatment of these patients. Material and Methods Two boys aged 11 and 18 with the exstrophy-epispadias complex were treated for severe urinary incontinence. The 11 year old was status post a Mitchell single stage repair with an anterior iliac osteotomy. The 18 year old had undergone a staged Cantwell –Ransley repair with a posterior iliac osteotomy. Both patients underwent the placement of an AMS InVance sling modified with the creation of a midline polypropylene bolster to permit adequate urethral compression while obviating corporal compression. Both procedures were discharged home the day of surgery. Results Both patients immediately had an improvement in continence and were able to volitionally void without CIC. With a follow-up ranging to 26 months, both patients maintain a significant clinical improvement. The 18 year old has minor spotting with valsalva but is otherwise dry both day and night. The younger boy required the placement of a larger bolster 7 months following his initial repair but remains largely dry with occasional daytime pad use for mild stress incontinence. Both patients are on oxybutynin and have not undergone bladder augmentation. Conclusions The modified bone-anchored perineal sling is a simple out-patient option in the treatment of this difficult problem. Long-term studies with larger number of patients will be required to determine the ultimate role of this new procedure.

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.

PAEDIATRIC UROLOGY: The Failed Exstrophy Closure: Strategy for Management

In the last 7 years, 29 boys and 11 girls have been referred with failure of their exstrophy closure; 38 patients had classic bladder exstrophy and 2 had cloacal exstrophy. Reclosure was performed for complete bladder dehiscence in 28 cases and for significant bladder prolapse in 10. Two patients underwent revision of the posterior urethra after primary closure due to a severe urethral stricture secondary to the use of para-exstrophy skin flaps. Six patients underwent posterior iliac osteotomy at the time of initial bladder closure and in 34 no osteotomy was performed. Thirty-seven patients underwent either posterior iliac osteotomy (15) or anterior innominate osteotomy (22). Epispadias repair together with reclosure of bladder exstrophy was done in 20 boys. The upper tract has remained normal in all patients. Fourteen have undergone subsequent bladder neck reconstruction. Seven patients have undergone simultaneous bladder neck reconstruction and augmentation cystoplasty and 1 has undergone augmentation cystoplasty and Mitrofanoff procedure; all are dry on intermittent self-catheterisation. The failed exstrophy reconstruction represents a formidable dilemma. However, a well planned reconstruction including osteotomy (even if previously performed), reclosure with or without epispadias repair or revision of the urethra can be performed with an excellent chance of proceeding with staged reconstruction.

Hypertension following primary bladder closure for vesical exstrophy

Since the initiation of staged reconstruction for bladder exstrophy, hypertension has been a known complication of the procedure. The etiology of the elevation in blood pressure was presumably secondary to ureteral dysfunction caused by edema at the ureterovesical junction and secondary renal obstruction. This report details the clinical course of three patients who developed significant hypertension following primary bladder closure with posterior iliac osteotomies and bony immobilization by skin traction. None of the patients had urinary obstruction and all had their hypertension alleviated by removal of the traction. The presumed etiology of the elevated blood pressure within these patients is similar to that experimentally produce by inappropriately applied traction resulting in tension on the sciatic nerve and reflex induced vasoconstriction. The need to maintain appropriately applied traction and the necessity of monitoring the postoperative blood pressure is stressed.