Use of human acellular dermal matrix during classic bladder exstrophy repair

The extent of the abdominal wall defect in people with classic bladder exstrophy (CBE) varies, and can be extensive. In this study, human acellular dermis (HAD) was used to bridge the fascial gap, as an alternative to osteotomy, to support a fascial repair of the abdominal wall, and as a filler in selected cases of CBE.

To demonstrate the efficacy of the employed techniques of using HAD within the bladder exstrophy population.

The medical records of six males, born with CBE, and who had abdominal wall defects were reviewed. Two children, aged 6 and 8 years old, were referred from overseas with unrepaired bladder exstrophy plates and large abdominal wall defects (8 cm and 12 cm wide). Both had their bladders reconstructed, placed within the pelvis, and HAD was used to replace the absent abdominal wall (bridged repair) without the use of pelvic osteotomy. In three other patients, HAD reinforced the native fascial repair (bolster repair). In three patients, HAD also served as a filler for the abdominal depression that was present following initial staged repair. Where HAD was used for bridged or bolster repair, the edges of the allograft were extended 2-3 cm circumferentially beyond the perimeter of the abdominal wall defect.

All six patients healed well, without evidence of abdominal wall hernias at 1-3 years postoperatively. Functionally, each patient regained an appropriate level of abdominal wall strength. Two children successfully underwent a secondary procedure through the bridged allograft repair, as each required bladder neck reconstruction and bilateral ureteral reimplantation through the reconstructed abdominal wall. Continence was achieved in these two patients, with one child voiding at 2-hourly intervals and the second at 3-hourly intervals. One patient developed a urethral-cutaneous fistula, distant to location of the allograft. There were no associated wound complications.

In this series of patients born with classic bladder exstrophy, HAD acted as a biologic scaffold and allowed native cellular ingrowth and tissue remodeling. It served as an alternative to pelvic osteotomy in older patients with unrepaired CBE. The material reinforced a weak or potentially suboptimal fascial repair and filled a tissue gap, resulting in improved aesthetics. Given its ease of preparation and the lack of significant morbidity associated with its use, combined with the functional and esthetic results in the present series, HAD may be considered during delayed reconstruction of abdominopelvic tissues in people born with CBE.