Cloacal Exstrophy Closure Without Osteotomy and Immobilization: A Recipe for Failure

Cloacal exstrophy (CE) remains one of the most severe birth defects compatible with life with a constellation of anomalies involving the bladder, genitalia, hindgut, and spinal cord. Pelvic osteotomy and immobilization have been utilized to facilitate bladder closure, yet their role as adjuncts remains a topic of debate. The authors sought to evaluate the outcomes of CE closure without the use of osteotomy or lower extremity (LE)/pelvic immobilization.

An institutional database of 173 CE patients was reviewed for patients closed without osteotomy and/or limb immobilization. Patient records were reviewed for continence procedures, reclosure operations, and continence outcomes.

A total of 59 closure surgeries that met inclusion criteria were identified in 56 unique patients. Thirty-seven closure procedures developed eventual failure (63%) with secondary closure events also resulting in failure. Most closures did not use an osteotomy, 93.2%. LE immobilization-only was used in most closures (43/59), of which only 37% were successful. Failures were attributed to dehiscence (14/37), bladder prolapse (19/37), or both dehiscence and prolapse (4/37). The median age at closure was 3 days old (1-18.5 IQR) with the majority of closure events (47) closure events taking place in the newborn period. Median diastasis prior to primary closure was 6 cm (4.8-8 cm IQR). The median number of closure attempts needed to close the bladder was 2 (1-2 IQR). Of the 56 patients, 31 have >3 h of daytime continence, with the entirety of these patients catheterizing a stoma or below.

These results highlight the critical role of osteotomy and lower limb immobilization in successful closure of the bladder and abdominal wall in CE.

Treatment Study.

Level III.