Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older
Karl S Benz1, John Jayman1, Mahir Maruf1
1Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
Insights
External fixation with skin traction significantly reduces bladder closure failure in cloacal exstrophy (CE) compared to spica casting. This technique offers a more secure postoperative management for children with CE.
Area of Science:
- Pediatric Surgery
- Urology
- Orthopedics
Background:
- Cloacal exstrophy (CE) closure requires meticulous technique and multidisciplinary care.
- Postoperative immobilization is critical for successful bladder closure in CE.
- Previous methods like spica casting have shown variable success rates.
Purpose of the Study:
- To compare the outcomes of bladder closures in CE patients immobilized with spica cast versus external fixation with skin traction.
- To identify the optimal postoperative management strategy for CE bladder closure.
Main Methods:
- Retrospective comparative study of 71 CE patients with 94 bladder closures (1975-2015).
- Patients were immobilized using spica cast alone or external fixation with skin traction.
- Outcomes, including closure failure and complication rates, were compared between immobilization groups.
Main Results:
- Bladder closure failure rates were significantly lower with external fixation and skin traction (9.3%) compared to spica cast alone (71.7%) (p<0.001).
- Even with pelvic osteotomy, external fixation showed a lower failure rate (9.3%) versus spica cast (50.0%) (p=0.002).
- Complication rates showed minimal difference between groups (8.7% vs 23.3%, p=0.059).
Conclusions:
- External fixation with skin traction is a superior technique for postoperative management of CE bladder closure.
- This method demonstrates a low failure rate (3.8%) and is recommended for older children (1-2 years).
- While any immobilization can fail, external fixation offers enhanced security.
Introduction:
Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction.
Methods:
The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction.
Results:
Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p<0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p=0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p=0.059).
Conclusion:
Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years).
Level Of Evidence:
Level III, Retrospective comparative study STUDY TYPE: Therapeutic study.
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