Peri-operative transfusion risk in classic bladder exstrophy closure: Results from a national database review

Classic bladder exstrophy (CBE) is one of the most complex pediatric urologic conditions, with patients often requiring multiple procedures throughout their lives. Patients undergoing these complex surgeries may require blood transfusion, exposing them to the risks of transfusion including antibody reactions, transmission of infectious diseases, and transfusion-related immunomodulation. We sought to determine the prevalence of and risk factors for peri-operative transfusion in patients undergoing closure for CBE. Because of the complexity of CBE management, we hypothesized that a significant number of patients undergoing closure of CBE would require peri-operative transfusion.

Patients undergoing CBE closure between 2012 and 2014 were retrospectively identified by Current Procedure Terminology codes from The National Surgical Quality Improvement Program Pediatric database, which includes data from 64 participating hospitals. Patient demographics, pre-operative characteristics including comorbidities, intra-operative characteristics, and post-operative outcomes were analyzed for associations with transfusion requirement intra-operatively or in the first 72 h post-operatively.

Seventy-eight patients met our criteria, of whom 45 (57.7%) underwent transfusion. Patient characteristics and outcomes are noted in the Table. There was no difference between the groups in terms of age or gender. Patients who underwent transfusion were more likely to be over 3 days of age than those who did not (93.3% versus 75.8%; p = 0.046). Transfused patients were also more likely to have undergone osteotomy (82.2% versus 48.5%; p = 0.002), had an external fixation (46.7% versus 6.1%; p < 0.001), had longer median operative times (447 versus 295 min; p < 0.001), and had longer median post-operative lengths of stay (LOS) (35 versus 17 days; p = 0.003). There was no difference between the groups in terms of pre-operative risk factors or post-operative complications.

A significant number of patients undergoing CBE closure required transfusion in the peri-operative period (57.7%). Patient characteristics found to have a higher rate of transfusion included osteotomy, external fixation, increased operative times, and longer post-operative LOS. In children undergoing closure for CBE, a large number require transfusion. The rate of transfusion is greater in older children and children undergoing osteotomy. Although osteotomy has a potentially important clinical role, especially in older patients, this study emphasizes the need for proper family counseling to include the increased likelihood of a blood transfusion and the risks associated with blood transfusion if osteotomies are performed.