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The role of osteotomy in surgical repair of bladder exstrophy
Aaron T Wild1, Paul D Sponseller, Andrew A Stec
1Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA.
Insights
Classic bladder exstrophy (CBE) involves significant pubic bone widening. Anterior innominate osteotomy offers advantages over traditional methods for treating CBE, improving surgical outcomes and patient recovery.
Area of Science:
- Pediatric Urology
- Orthopedic Surgery
- Developmental Biology
Background:
- Classic bladder exstrophy (CBE) is a congenital condition characterized by abnormal development of the pelvic bones.
- CBE patients exhibit progressive pubic diastasis, with mean widths increasing from 4 cm at birth to 8 cm by age 10, contrasting sharply with the normal 0.6 cm.
- Pelvic structural abnormalities in CBE include a 30% shorter anterior (ischiopubic) segment and external rotation of both anterior and posterior pelvic segments.
Purpose of the Study:
- To evaluate the role of osteotomy in managing Classic bladder exstrophy (CBE).
- To compare the advantages of anterior innominate osteotomy with optional posterior vertical iliac osteotomy against conventional posterior iliac osteotomy in CBE treatment.
Main Methods:
- The study focuses on the biomechanical and surgical aspects of pelvic osteotomy in CBE patients.
- Comparison of anterior innominate osteotomy (with optional posterior vertical iliac osteotomy) versus posterior iliac osteotomy.
Main Results:
- Osteotomy in CBE primarily serves to reduce tension on the bladder and abdominal wall during healing.
- Anterior innominate osteotomy demonstrates advantages including reduced blood loss, improved pubic rami apposition and mobility, direct visualization for external fixator placement, secure fixation in older children, and elimination of patient repositioning.
Conclusions:
- Anterior innominate osteotomy with optional posterior vertical iliac osteotomy is a superior surgical technique for managing pelvic abnormalities in Classic bladder exstrophy.
- This approach offers significant benefits in terms of surgical efficiency, patient safety, and post-operative recovery compared to traditional methods.
Abstract:
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.
