The Giessen-Mainz-Frankfurt procedure: a new method for complex pelvic reconstruction for bladder exstrophy

In bladder exstrophy primary reconstruction remains the gold standard worldwide. Despite various types of osteotomies the permanent correction of pubic diastasis remains a challenge. In maxillofacial surgery callus distraction is a routine treatment for hypoplastic mandibles. Originally described by Ilizarov, this method provides stable and true bone lengthening after gradual distraction of an osteotomy site as long as the periosteum remains intact. In cooperation with the departments of maxillofacial surgery and orthopedics we used this technique to correct pubic diastasis and facilitate phallic reconstruction in a 4 1/2-year-old boy with bladder exstrophy who had previously undergone continent diversion.

Three-dimensional computerized tomography was used to create a stereolithography model and mock surgery was performed. Based on this model bilateral osteotomies of the superior and inferior segments of the pubic bones were done, preserving the periosteum. Pins were inserted and a multidirectional external fixation device was mounted. Distraction was started on day 5 postoperatively. The distraction rate was 1 mm. daily and immobilization time was 28 days. The distraction progress was monitored by sonography. The device was removed 6 weeks postoperatively.

Radiography of the pelvis 2 years postoperatively revealed that the distance between the pubic bones had decreased from 6 to 3 cm. (50%). Simultaneously the slanting angle normalized from 24 to 35 degrees due to upward rotation of the inferior pubic rami. Mineralization in the newly formed bones was excellent. Visible penile length had increased significantly.

To our knowledge we describe the first use of the basic Ilizarov principle of callus distraction for permanent complex pelvic reconstruction for bladder exstrophy in a 4 1/2-year-old boy. After subperiostial osteotomies approximation of the symphysis and rotation of the inferior pubic rami were achieved with a device commonly used in maxillofacial surgery. Approximation of 1 mm. daily for 28 days resulted in significant penile lengthening. At a followup of 2 years there were stable pelvic ring reconstruction and normal mineralization of the newly formed bones. In contrast to the standard techniques of osteotomies for correcting pubic diastasis, the Giessen-Mainz-Frankfurt procedure provides true bone growth with a stable decrease in diastasis. Successful penile reconstruction was facilitated 1 year postoperatively. This method may also be useful in primary and secondary bladder reconstruction.