Failed exstrophy closure
1Department of Surgery, Division of Urology, Brooke Army Med Center, San Antonio, TX 78234, USA. Thomas.novak@amedd.army.mil
Insights
Failed bladder exstrophy closure is a significant complication. Repeat closure with pelvic osteotomy and immobilization can be successful, but long-term bladder growth and reconstruction outcomes are less favorable.
Area of Science:
- Pediatric Urology
- Reconstructive Surgery
- Congenital Anomalies
Background:
- Bladder exstrophy presents a complex surgical challenge, with initial repair success being critical for long-term outcomes.
- Failed exstrophy closure is a major complication impacting the urinary tract's ultimate fate and requiring further intervention.
Purpose of the Study:
- To evaluate the outcomes of repeat exstrophy closure in pediatric patients.
- To compare the long-term results of failed exstrophy closure followed by repeat closure versus primary successful closure.
Main Methods:
- Review of surgical approaches for failed bladder exstrophy closure, including staged repair, complete primary repair, and immediate continent urinary diversion.
- Analysis of outcomes associated with repeat exstrophy closure, particularly in conjunction with pelvic osteotomy and postoperative immobilization.
Main Results:
- Repeat exstrophy closure can be successful in most cases when combined with pelvic osteotomy and proper immobilization.
- Children undergoing repeat closure have significantly reduced likelihood of achieving adequate bladder growth for bladder neck reconstruction.
- Success rates for bladder neck reconstruction are lower in patients with a history of failed exstrophy closure, even when candidates.
Conclusions:
- While acceptable dryness can be achieved after repeat exstrophy closure, it often necessitates intermittent catheterization and continent diversion.
- Failed bladder exstrophy closure negatively impacts long-term bladder capacity and reconstructive potential, underscoring the importance of primary repair success.
Abstract:
Children with bladder exstrophy present a formidable surgical challenge. Like all major reconstructive surgeries, the best hope for a favorable outcome lies in achieving success in the first operative attempt. Regardless of the surgical approach, however, complications do occur. A failed exstrophy closure is a major complication with significant implications on the long-term surgical outcome and ultimate fate of the urinary tract. Successful repeat exstrophy closure can be accomplished in most cases when performed in conjunction with pelvic osteotomy and proper postoperative immobilization. Modern staged repair of exstrophy, complete primary repair of exstrophy, and immediate continent urinary diversion have been advocated by different groups in the management of a failed exstrophy closure. It is apparent that compared with children who undergo successful primary closure, a failed closure with subsequent successful repeat closure makes the child much less likely to achieve sufficient bladder growth to be considered for bladder neck reconstruction, and furthermore, makes them less likely to have a successful bladder neck reconstruction even when they are an acceptable candidate. Although acceptable dryness rates after repeat closure can ultimately be obtained, they are typically at the expense of a commitment to intermittent catheterization and continent diversion.
