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How to close classic bladder exstrophy: Are subspecialty training and technique important?
Brian M Inouye1, J Todd Purves1, Jonathan C Routh1
1Duke University School of Medicine, Department of Surgery, Division of Pediatric Urology, USA.
Journal of Pediatric Urology
|April 9, 2018
Summary
Successful closure of classic bladder exstrophy (CBE) is crucial for continence. This study found that closure by pediatric urologists, rather than general pediatric surgeons, significantly reduces the risk of failed CBE closure.
Area of Science:
- Pediatric Urology
- Surgical Outcomes
- Congenital Abnormalities
Background:
- Classic bladder exstrophy (CBE) closure is vital for achieving continence in affected patients.
- Despite advancements, primary closure failures remain a significant challenge in CBE management.
- Understanding factors influencing closure success is essential for improving patient outcomes.
Purpose of the Study:
- To investigate the impact of surgical training and technique on the success rates of primary classic bladder exstrophy closure.
- To identify specific factors associated with failed CBE closures.
- To provide evidence-based recommendations for optimizing CBE surgical management.
Main Methods:
- Retrospective cohort study utilizing the world's largest single-institution database of CBE patients.
- Analysis of 722 patients undergoing primary or re-closure for CBE.
- Multivariable logistic regression to assess associations between patient/surgical factors and closure success, adjusting for comorbidities and closure location.
Main Results:
- Multivariable analysis revealed increased odds of closure failure when performed by pediatric surgeons compared to pediatric urologists (OR 4.32).
- Closure by surgeons with unknown credentials and specific closure types (Complete Primary Repair of Exstrophy - CPRE) were also associated with higher failure rates.
- Factors like gestational age, time of closure, and concomitant osteotomy showed associations on bivariate analysis but were adjusted for in the multivariable model.
Conclusions:
- Primary classic bladder exstrophy closure should be performed by specialized pediatric urologists.
- Centralization of care at high-volume centers with expertise in pediatric urology is recommended.
- Further research may elucidate the nuances of different surgical techniques and their impact on long-term continence.
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