One-Stage Delayed Bladder Exstrophy Closure Combined With Kelly Repair: Early Outcomes Following the 100-Case
Hortense Alliot1,2, Sajid Sultan3, Alice Faure1,4
1MARVU National Rare Diseases Reference Centre, Hôpital Universitaire Robert-Debré, Paris, France.
Insights
Single-stage delayed closure for bladder/cloacal exstrophy using the Kelly procedure resulted in no bladder dehiscence. This effective technique showed low early complication rates, primarily wound-related issues.
Area of Science:
- Pediatric Surgery
- Urology
- Congenital Abnormalities
Background:
- Bladder exstrophy and cloacal exstrophy are complex congenital anomalies requiring specialized surgical management.
- One-stage delayed closure aims to improve outcomes by allowing for growth and development before reconstruction.
Purpose of the Study:
- To evaluate the incidence of bladder dehiscence after a one-stage delayed closure of bladder/cloacal exstrophy.
- To assess early complications associated with this surgical approach, combining bladder plate closure with the Kelly procedure.
Main Methods:
- A multicenter retrospective study included 123 children with bladder or cloacal exstrophy undergoing single-stage closure with Kelly mobilization.
- The primary endpoint was bladder dehiscence within 3 months post-surgery; secondary endpoints included early complications.
- Outcomes were analyzed for primary repairs and complex cases, with a median follow-up of 54 months.
Main Results:
- No cases of bladder dehiscence were observed in the 123 patients.
- Early complications occurred in 19% of patients, predominantly wound-related (12%) and urinary fistulas (7%).
- Abdominal closure using rectus abdominis muscle transposition was identified as an independent risk factor for wound complications (OR 4.47, p=0.02).
Conclusions:
- Single-stage delayed closure combined with Kelly mobilization provides reliable bladder closure for bladder/cloacal exstrophy with no early dehiscence.
- The overall early morbidity rate was less than 20%, with most complications being low-grade.
- For challenging pubic approximations, osteotomies or fascial flaps may yield better early parietal outcomes than rectus muscle transposition.
Purpose:
We evaluated bladder dehiscence after 1-stage delayed closure of bladder/cloacal exstrophy combining bladder plate closure with Kelly procedure, with or without osteotomy.
Materials And Methods:
We conducted a multicenter retrospective study of children with bladder exstrophy or cloacal exstrophy who underwent single-stage closure with Kelly mobilization (October 2015-October 2025), by one surgical team, in France and tertiary centers abroad. The primary end point was bladder dehiscence within 3 months. Secondary end points were early (<3 months) complications. Outcomes were analyzed separately for primary repairs and complex cases.
Results:
A total of 123 patients were included (110 bladder exstrophy [89%], 13 cloacal exstrophy [11%]; 76 men [62%]). The median age at surgery was 7.1 months (2.9-15.8); median follow-up 54 months (25-82). The reconstruction was a primary repair in 106 children (86%) and redo closure after failed repair in 17/123 (14%). No bladder dehiscence occurred. Early complications arose in 23/123 children (19%), mainly wound-related (15/123, 12%) including infection/dehiscence (n = 6, 5%) and urinary fistula (9/123, 7%). Complications were Clavien-Madadi grade IV (n = 3, 2.4%) III-B (n = 4, 3.3%), III-A (n = 4, 3.3%), and I-B or II (n = 12, 10%). In multivariate analysis, abdominal closure with rectus abdominis muscles midline transposition was the only independent prognostic factor of wound complications (odds ratio 4.47 [1.22-16.37], P = .02).
Conclusions:
Single-stage delayed closure combined with Kelly mobilization allows reliable bladder closure with no early dehiscence in bladder/cloacal exstrophy. Early morbidity rate was < 20%, with predominantly low-grade complications. When pubic approximation was difficult, osteotomies or fascial flaps appeared to offer better early parietal outcomes than rectus muscles transposition.