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Bilateral Obturator Osteotomy: A Novel Osteotomy for Bladder Exstrophy Closure
Sebastien Faraj1, Cyrille Decante2, Hortense Alliot1
1Pediatric Surgery and Urology Department, Nantes University Hospital, Nantes, France.
Insights
Bilateral obturator osteotomy is a feasible and safe technique for challenging bladder exstrophy closures when pubic approximation is not possible. This method avoids complications and external fixators, improving outcomes for bladder exstrophy patients.
Area of Science:
- Pediatric Urology
- Orthopedic Surgery
- Developmental Biology
Background:
- Abdominal and pelvic closure presents significant challenges in initial bladder exstrophy repair.
- Existing methods for pubic approximation can be difficult to achieve in certain cases of bladder exstrophy.
Purpose of the Study:
- To evaluate the feasibility and outcomes of a novel bilateral obturator osteotomy technique.
- To assess the safety and efficacy of this osteotomy as an adjunct for bladder exstrophy closure.
Main Methods:
- Retrospective analysis of prospectively collected data from children undergoing single-stage delayed bladder exstrophy closure with Radical Soft Tissue Mobilization (RSTM) for Bladder Exstrophy Epispadias Complex (BEEC).
- Bilateral obturator osteotomy (division of ilio-pubic and ischio-pubic rami, obturator membrane, and internal obturator muscle) was performed when pubic approximation was not feasible.
- Outcomes assessed included bladder dehiscence rate, neurovascular obturator pedicle injury, infections, gait acquisition, and penile vascular impairment.
Main Results:
- 17 children (29% of total BEEC cases) underwent the procedure; no postoperative bladder dehiscence was observed at 6 months.
- Median follow-up was 34 months with no reported complications, including normal ossification on pelvic X-rays.
- No gait abnormalities or clinical signs of obturator nerve deficiency were noted during follow-up.
Conclusions:
- Bilateral obturator osteotomy is a feasible and effective adjunct for bladder exstrophy closure when pubic approximation is not achievable.
- The technique can be performed by pediatric urologists within the same surgical approach.
- This method obviates the need for an external fixator, simplifying post-operative management.
Background:
Abdominal and pelvic closure remains a challenge during bladder exstrophy initial repair. We aimed to report on the feasibility and results of a novel technique of bilateral obturator osteotomy.
Methods:
Retrospective study of prospective collected data of children who underwent single-stage delayed bladder exstrophy closure combined with RSTM (Radical Soft Tissue Mobilization) for BEEC (Bladder Exstrophy Epispadias Complex) by the same team at different institutions between December 2017 and May 2021. When pubic approximation was not feasible at the end of the procedure, bilateral obturator osteotomy was performed through the same approach, consisting in bilateral divisions of the ilio-pubic rami, ischio-pubic rami, obturator membrane, and detachment of the internal obturator muscle. Pubic bone fragments were approximated together on the midline. Immobilization in a thermoformed posterior splint was indicated for 3 weeks. The main outcome criterion was the bladder dehiscence rate at 6 months, assessed by physical inspection. Secondary outcome criteria included neurovascular obturator pedicle injury, analyzed during orthopedic physical examination, wound or bone infections, gait acquisition, reported by parents and evaluated during medical examination, and vascular penile impairment, judged by penile and glans coloration.
Results:
17 children (11 males, 6 females) were included, at a median age of 2 months [1-33]; and representing 29% (17/58) of the children with bladder exstrophy who underwent the same surgical approach during the time of study. There was no postoperative bladder dehiscence with a median follow-up of 34 months [6-47]. No complication was observed. Pelvic X-rays showed bilateral normal ossification process. Neither gait abnormality, nor clinical indication of obturator nerve deficiency was observed during follow-up.
Conclusion:
When pubic bones approximation is not possible, bilateral obturator osteotomy is a useful adjunct in bladder exstrophy closure, feasible by the pediatric urologist through the same approach, and not requiring external fixator.
Level Of Evidence:
IV.
