Radical Soft-tissue Mobilization Research Articles

Bilateral Obturator Osteotomy: A Novel Osteotomy for Bladder Exstrophy Closure

BackgroundAbdominal and pelvic closure remains a challenge during bladder exstrophy initial repair. We aimed to report on the feasibility and results of a novel technique of bilateral obturator osteotomy. MethodsRetrospective study of prospective collected data of children who underwent single-stage delayed bladder exstrophy closure combined with RSTM (Radical Soft Tissue Mobilization) for BEEC (Bladder Exstrophy Epispadias Complex) by the same team at different institutions between December 2017 and May 2021. When pubic approximation was not feasible at the end of the procedure, bilateral obturator osteotomy was performed through the same approach, consisting in bilateral divisions of the ilio-pubic rami, ischio-pubic rami, obturator membrane, and detachment of the internal obturator muscle. Pubic bone fragments were approximated together on the midline. Immobilization in a thermoformed posterior splint was indicated for 3 weeks. The main outcome criterion was the bladder dehiscence rate at 6 months, assessed by physical inspection. Secondary outcome criteria included neurovascular obturator pedicle injury, analyzed during orthopedic physical examination, wound or bone infections, gait acquisition, reported by parents and evaluated during medical examination, and vascular penile impairment, judged by penile and glans coloration. Results17 children (11 males, 6 females) were included, at a median age of 2 months [1–33]; and representing 29% (17/58) of the children with bladder exstrophy who underwent the same surgical approach during the time of study. There was no postoperative bladder dehiscence with a median follow-up of 34 months [6–47]. No complication was observed. Pelvic X-rays showed bilateral normal ossification process. Neither gait abnormality, nor clinical indication of obturator nerve deficiency was observed during follow-up. ConclusionWhen pubic bones approximation is not possible, bilateral obturator osteotomy is a useful adjunct in bladder exstrophy closure, feasible by the pediatric urologist through the same approach, and not requiring external fixator. Level of EvidenceIV.

Recent Trends in the Management of Bladder Exstrophy: The Gordian Knot Has Not Yet Been Cut.

Although enormous effort has been made to further improve the operative techniques worldwide, the management of bladder exstrophy (BE) remains one of the most significant challenges in pediatric urology. Today it is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome with regard to bladder capacity, renal function and continence. Due to a number of reasons, including a lack of comparable multicenter studies, a range of concepts is currently used to achieve successful primary closure. We review the literature of the last 15 years on the current concepts of bladder exstrophy repair with regard to the time of primary closure (initial vs. delayed closure), the concepts of primary closure (single-stage vs. staged approach; without osteotomy vs. osteotomy) and their outcomes. There is a worldwide lack of multicenter outcome studies with adequate patient numbers and precisely defined outcome parameters, based on the use of validated instruments. The modern staged repair (MRSE) in different variations, the complete primary reconstruction of exstrophy (CPRE), and the radical soft-tissue mobilization (RSTM) had been the most extensively studied and reported procedures. These major concepts are obligatory stable now for more than 20 years. Nevertheless, there are still a lot of open-ended questions e.g., on the potential for development of the bladder template, on continence, on long-term orthopedic outcome, on sexuality and fertility and on quality of life. Management of BE remains difficult and controversial. Further, clinical research should focus on multi-institutional collaborative trials to determine the optimal approach.

Commentary to ‘One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results’

The authors present data from a retrospective review of 27 bladder exstrophy patients operated in a modified technique of the radical soft tissue mobilization (RSTM). According to their concept, they combined delayed bladder closure and RSTM as a single-stage procedure. Focussing on the safety of this modified concept, the main outcome criterion was the rate of bladder dehiscence. Secondary outcome criteria were UTI, urethral stenosis urethrocutaneous fistula and parietal hernia. Important technical details are keenly described and complemented by coherent drawings and video clips. After a follow-up of 12 months, there was no case of bladder dehiscence, but a number of complications occurred such as urethral stenosis and urethrocutaneous fistula. The authors concluded that early single-stage RSTM combined with bladder closure is a feasible and attractive option in the management of classical bladder exstrophy.

One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results

The radical soft-tissue mobilization (RSTM, or Kelly repair) is an anatomical reconstruction of bladder exstrophy generally performed as a second part of a two-step strategy, following successful neonatal bladder closure. The objective of this study is to determine the feasibility of a combined procedure of delayed bladder closure and RSTM in one stage without pelvic osteotomy, in both primary and failed initial closure. From 11/2015 to 01/2018, 27 bladder exstrophy patients underwent combined bladder closure with RSTM by the same surgical team at four cooperating tertiary referral centers for bladder exstrophy, including 20 primary repairs (delayed bladder closure, median age 3.0m [0.5-37m])and seven secondary repairs after failed attempt at neonatal closure, median age 10m [8-33m]. RSTM included full mobilization of the bladder plate, urogenital diaphragm, and corpora cavernosa from the medial pelvic walls, followed by anatomical reconstruction with antireflux procedure, bladder closure, urethrocervicoplasty, muscle sphincter approximation, and penile/clitoral reconstruction. The main criteria were bladder dehiscence or prolapse. Secondary outcomes included bladder neck fistula or urethral fistula, urethral stenosis, and parietal hernia. Continence and voiding have not been addressed at this stage. All bladder exstrophy cases were successfully closed without osteotomy, with no case of bladder dehiscence after 12 m[3-30]follow-up. Urethral fistula or stenosis occurred in eight patients: 4/5 fistulae closed spontaneously in less than 3 months; four urethral stenoses were successfully treated with 1-3 sessions of endoscopic high-pressure balloon dilatation or meatoplasty; one patient with persistent bladder neck fistula is currently awaiting repair. Although the follow-up is short, it does allow examination of the main outcome criterion, namely bladder dehiscence, which is usually expected to happen very early after surgery. The Kelly RSTM can be safely combined with delayed bladder closure without osteotomy in both primary and redo cases in classic bladder exstrophy.

Primary female epispadias: Perineal approach or Kelly repair?

Primary female epispadias encompasses a spectrum of disease, presenting with a variable degree of incontinence. We hypothesized that although perineal urethrocervicoplasty can be a successful first-line procedure in patients with normal bladder, a more radical reconstruction was necessary to achieve continence in cases lying at the most severe end of the spectrum. Our aim was to assess the results of a surgical management using perineal approach in girls with normal bladder capacity, and Kelly radical soft-tissue mobilization (RSTM) in patients with inadequate bladder, based on the assumption that bladder capacity (BC) is a reliable marker of epispadias severity. Prospective inclusion of incontinent girls with female epispadias referred to a single institution. Patients with normal BC were treated with perineal urethrocervicoplasty (PUCP, group 1). Patients with small bladder underwent RSTM (group 2). Follow-up was at 1, 3, 6, and 12 months postoperatively, then annually, including physical examination, renal ultrasound at each visit, continence status, and estimation of functional/maximal BC. The main study outcome was continence status at the age of 5 years or later, if postoperative follow-up was >12 months. From 2006 to 2017, 16 consecutive children were prospectively included in this study, at a median age of 39 months (5-102 months). Seven girls were included in group 1 and underwent PUCP; at the last follow-up, five out of seven were dry by day (4/5 day and night), although three out of five required bladder-neck injection after perineal reconstruction due to stress incontinence. Two patients with persistent incontinence and absence of BC increase after PUCP subsequently underwent RSTM. Eleven patients with low BC (56% [10-94%] of expected BC) were included in group 2 (9 without prior surgery, 2 after PUCP failure). Among the eight evaluable patients, eight out of eight achieved diurnal continence, and 3/8 were fully continent. One girl with obstructive micturition required clean intermittent catheterization. The traditional approach of female epispadias based on staged reconstruction (urethroplasty followed by bladder-neck reconstruction) raised concerns regarding the risk of non-physiological obstructive micturition. The perineal approach was suggested as an alternative, with reported diurnal continence rates of 60-80%, but less than 50% of nocturnal continence, presumably in relation with limited bladder capacity. In cases selected within the most severe end of the epispadias spectrum, the Kelly RSTM seems to offer excellent continence rates. A tailored approach to female epispadias, based on perineal reconstruction in favorable cases, and radical soft-tissue mobilization in severe cases, seems to yield good continence outcomes in the long term.

The radical soft-tissue mobilization (Kelly repair) for bladder exstrophy

The radical soft-tissue mobilization (RSTM) technique has been proposed as an alternative for staged reconstruction of bladder exstrophy. In this video, we demonstrate the successive steps of this technique. A newborn male with classic bladder exstrophy underwent bladder closure without pelvic osteotomies at birth; he then underwent RSTM at 1 year of age. Mobilization: The RSTM involved simultaneous intra-pelvic and perineal dissection, aiming at full mobilization of potential urethral sphincter striated structures, levatores ani muscles, pudendal pedicles and corpora cavernosa from their attachment on the pubic bones. From the perineal approach, a periosteum incision was performed on the antero-medial aspect of the pubic bones, and the periosteum was peeled from the ischio-pubic ramus, lifting the corpora from the bone and providing control on the pudendal pedicles. The attachments of all striated muscular structures on the lower aspects of the posterior corpora (transverse perinei, bulbo-spongiosus, ischio-cavernosus muscles) were released to allow adequate re-approximation around the reconstructed urethra. Reconstruction: After ureteric reimplantation, a funnel-shaped cervicoplasty was performed and continued by urethroplasty over an 8-Fr catheter. The muscular structures mobilized from the corpora and the bones were wrapped around the neo-urethra, which was transposed ventrally in the scrotal position, creating a temporary hypospadiac urethrostomy. After abdominal wall closure, the corpora were then de-rotated, and secured to the neo-symphisis with non-absorbable sutures, and the penile skin shaft was reconstructed. At the 12-month follow-up, the boy was asymptomatic, still in nappies, with non-dilated upper-tracts on renal ultrasound, and dryness intervals of 90min. Radical soft-tissue mobilization allows a tension-free bladder-neck reconstruction, and may favour development of physiological continence mechanisms independent of the inevitable pubic symphisis re-enlargement. Creation of temporary hypospadias is most often needed to maximize penile length. This technically demanding procedure requires thorough knowledge of detailed anatomy of the bladder exstrophy pelvis, as demonstrated in this video.

Multiple failed closure of bladder in children with vesical exstrophy: Safety and efficacy of temporary ileal patch augmentation in assisting bladder closure.

Objective:The surgical approach to small bladder template in exstrophy bladder is difficult. Previously, many of these children underwent ureterosigmoidostomy and in recent times, the trend is to do a delayed primary closure. We have used ileal patch as a temporary cover for these small bladders with a view to encourage bladder growth and early results are encouraging.Materials and Methods:In five of the 45 children with bladder exstrophy managed by radical soft-tissue mobilization over 10 years, primary bladder closure was not possible due to repeated failed closures. A detubularized ileum was used to patch the bladder initially and after 4 months the patch was excised and bladder closure with sphincter repair was done in second stage.Results:In five children (three girls and two boys) the mean age at initial bladder closure was 14 months and mean age at ileal patch was 22 months. In four patients, the bladder grew facilitating closure and in one patient it failed. There were no complications with the use of gut in patch.Conclusion:A temporary ileal patch seems promising in managing failed bladder closure in exstrophy patients. Long-term studies are needed before such a technique can be used in all patients with failed primary bladder closures.

Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms

Partial or complete penile loss following bladder exstrophy and/or epispadias repair has been reported in the literature progressively more frequently. The authors report new cases of penile injury following bladder exstrophy and/or epispadias repair referred to their centers and not previously published. They review the literature on this subject and offer an explanation as to the likely mechanism for the penile injury and recommendations to avoid this complication. Seven new cases of partial or complete penile loss following bladder exstrophy or epispadias repair have been recently referred to the authors' institutions. Twenty-one patients have previously been reported in the literature. Altogether, 24 cases occurred after bladder exstrophy closure: 23 after complete primary repair of exstrophy (Mitchell repair) and one after first-stage radical soft-tissue mobilization (Kelly repair). Nineteen of 24 patients did not have a pelvic osteotomy at the time of primary closure. Four cases occurred after epispadias repair: two following the second-stage radical soft-tissue mobilization (Kelly repair) and two following penile disassembly epispadias repair (Mitchell repair). Exstrophy closure combined with epispadias repair can be followed by ischemic penile injury, particularly when osteotomy is not performed. Compression of the pudendal vessels after pubic apposition and/or direct injury to the pudendal vessels play an important role in the pathogenesis of this complication.

The Kelly Technique of Bladder Exstrophy Repair: Continence, Cosmesis and Pelvic Organ Prolapse Outcomes

The Kelly technique of radical soft tissue mobilization, an alternative to osteotomy and modern staged repair, has been used extensively at our tertiary referral center for bladder exstrophy in the last 2 decades. We present what is to our knowledge the first long-term followup of the Kelly technique in 31 patients treated at our institution. Patients admitted for bladder exstrophy at our institution since 1980 were identified and the medical charts were reviewed. Continence questionnaires were completed during followup appointments or by mail. Continence was defined as complete-dry greater than 3 hours during the day and night with 2 or fewer night wets per month and partial-dry 2 hours or more during the day and 3 or greater night wets per month, and/or stress incontinence. The degree of pelvic organ prolapse was assessed in females older than 12 years. Data were available on 31 Kelly patients, including 14 females, 4 to 25 years old and 13 patients, including 4 females, 2 to 29 years old treated with another staged technique. Of 30 Kelly patients without urinary diversion 21 (70%) were completely or partially continent. Of the 30 patients 17 voided spontaneously without clean intermittent catheterization or augmentation, of whom 12 (71%) were continent. Lower abdominal appearance was graded as abnormal in 11 of 12 male Kelly patients vs in 2 of 7 nonKelly males with pubic approximation (p = 0.01). Of the 12 females assessed none of 9 Kelly patients had prolapse, whereas 2 of 3 nonKelly patients had prolapse (p <0.05). The continence rate after the Kelly operation compares favorably with that in recent series. The abnormal appearance of the lower abdomen and bony pelvis in Kelly males may result from a lack of pubic approximation. Importantly pelvic organ prolapse may be decreased in women after the Kelly technique.

Radical soft tissue mobilization and reconstruction (Kelly procedure) for bladder exstrophy repair in males: initial experience with nine cases

to report the early experience with the Kelly procedure for the treatment of bladder exstrophy (BE) in males. Nine boys with BE were treated at our institute. One had an untouched BE, four had epispadias after neonatal bladder closure, and four were secondary phalloplasties. Data on surgical complications, continence status, presence of erections and parental satisfaction with penile appearance and length are reported. Mean patient age was 4.7 (1-8.9) years. No intra-operative complications occurred. Two secondary cases experienced formation of a bladder-neck fistula and glans ischemia, respectively. The latter led to glans loss. All the patients had some residual degree of hypospadias after surgery. After a median follow-up of 18.1 (10-22) months, one patient developed chronic bladder outlet obstruction. Overall, five patients are dry (including two on clear intermittent catheterization and one with a Minz II pouch). The other four are still younger than 3 years, all have spontaneous micturitions and dry interval between 30 and 120 min. Of the eight patients without phalloplasty complications, all had erections, and parents judged the penile length and appearance as being satisfactory in six cases. The Kelly procedure is feasible in a vast array of BE patients, but may be formidable, especially in secondary phalloplasties. It allows for complete reconfiguration and lightening of the penis, but exposes to potentially catastrophic complications, such as partial or complete penile loss. Longer follow-up is needed to assess the results in terms of continence.

Complications of radical soft-tissue mobilization procedure as a primary closure of exstrophy

Purpose The radical soft-tissue mobilization procedure was developed as a component of the staged closure of classical bladder exstrophy to improve continency rates without having to perform pelvic osteotomies. The authors describe complications following this procedure and discuss possible etiologies and subsequent management. Materials and methods We extracted from an institutionally approved exstrophy database the records of patients evaluated for complications following radical soft-tissue mobilization repair from 1999 to 2002. Results Four patients were referred to our institution following closure of exstrophy with the radical soft-tissue mobilization technique; two boys and two girls. Complications included ischemic penile injuries in both males, failed exstrophy closure in one female, incontinence with need for bladder neck transection and diversion in two patients, and upper tract deterioration in two patients of whom one required cystectomy and incontinent diversion. Conclusions Omission of osteotomies when employing the radical soft-tissue mobilization repair appears to result in complications that could otherwise be prevented. Additionally, the complex dissection of the pelvic musculature, innervation and vasculature performed during radical mobilization has great potential to injure the pelvic structures and genitalia, as has been seen with the cases presented herein.

Complications of the radical soft tissue mobilisation procedure as a primary closure of classical bladder exstrophy

Purpose The radical soft tissue mobilisation procedure was developed as a component of the staged closure of classical bladder exstrophy to improve continence rates without having to perform pelvic osteotomies. We describe complications following this procedure and discuss possible aetiologies and subsequent management. Material and methods We extracted from an institutionally approved exstrophy database the records of patients evaluated for complications following radical soft tissue mobilisation repair (Kelly Procedure)from 1999 to 2002. Results Four patients were referred to our institution following closure of exstrophy with the radical soft tissue mobilization technique; two boys and two girls. Both boys experienced ischemic damage of the penile tissue requiring multiple reconstructions. One of the boys had deterioration of his left upper tract and incontinence which necessitated transection of his bladder neck, augmentation and creation of a catheterizable stoma. A female patient had deterioration of a solitary right kidney and wide pubic diastasis requiring an osteotomy. Due to bladder neck fibrosis she ultimately underwent diversion. The other female patient had failure of closure due to dehiscience and required re-closure with osteotomy. She also required diversion as bladder neck reconstruction was prevented by her fibrotic bladder neck. Conclusions Despite the perception that this method obviates pelvic osteotomies, complications secondary to omission of this component of closure are seen. Additionally, the complex dissection during radical mobilisation has great potential to injure the pelvic structures and genitalia, as has been seen with the cases presented herein. Surgeons investigating this technique should be mindful of the potential pitfalls.