Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique
Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique
Elsayed, Ehab R.; Alam, Mohamed N.; Sarhan, Osama M.; Elsayed, Diab; Eliwa, Ahmed M.; Khalil, Salem
2011-09-01 00:00:00
Arab Journal of Urology (2011) 9, 203–207 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique a, a b a Ehab R. Elsayed , Mohamed N. Alam , Osama M. Sarhan , Diab Elsayed , a a Ahmed M. Eliwa , Salem Khalil Urology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt Urology and Nephrology Centre, Faculty of Medicine, Mansoura University, Mansoura, Egypt Received 20 June 2011, Received in revised form 18 August 2011, Accepted 25 August 2011 Available online 15 November 2011 KEYWORDS Abstract Objective: To evaluate the results of simple closure using bilateral anterior pubic oste- otomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with Bladder; Exstrophy; bladder exstrophy. Osteotomy; Patients and methods: A prospective study carried out between 2006 and 2009 included 15 patients Anterior pelvic osteotomy; (13 boys and 2 girls; age range 3–47 months). Of these patients, three had recurrent exstrophy while Safety 10 were operated primarily. An elective surgical technique was used for all patients, which included dissection of the exstrophic bladder from the abdominal wall, closure of the bladder and reconstruc- tion of the urethra, then dissection of the rectus muscle and sheath lateral to the attachment of muscle to pubic bone, which makes osteotomy of the superior pubic ramus easy, thus facilitating closure. Results: For closure of the bladder and anterior abdominal wall the results were excellent for all patients soon after surgery, but there was soft-tissue infection in two patients. Of all 15 patients, one had incomplete bladder dehiscence and another had a vesico-cutaneous fistula; both needed surgical intervention later. Conclusions: Simple closure with anterior pubic osteotomy is a feasible and effective means to facil- itate both bladder and abdominal closure for patients with bladder exstrophy. It is advantageous in being a rapid procedure, and can be completed by the paediatric urologist. ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction Corresponding author. Tel.: +20 14 6044499. Classic bladder exstrophy is a birth defect mainly involving the E-mail address: Dr_ihabraafat@yahoo.com (E.R. Elsayed). musculoskeletal system and genitourinary tracts; it occurs at a 2090-598X ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.08.004 204 Elsayed et al. rate of 1 in 10 000–50 000 live births [1–4]. During the past two decades, the operative treatment of bladder exstrophy has advanced considerably, with various techniques and ap- proaches described to achieve successful closure and the best functional outcomes [5–9]. The initial goal of exstrophy closure is a tension-free approximation of the pubic bones and soft tis- sue in the midline. Osteotomy provides closure of the bony ring and muscles of the pelvic floor to support the bladder and surround the urethra. Many types of osteotomy have been described to obtain a tension-free approximation of the pubic bones and soft tissues in the midline [10–17]. A successful osteotomy technique consisting of anterior pel- vic osteotomy of the superior pubic ramus was first described by Frey and Cohen in 1989 [15]. This technique seems to be a safe and quick adjunct for pubic bone approximation, so that this approach would preclude the need for a paediatric ortho- paedic surgeon [16,17]. The aim of the present study was to Figure 2 Anterior pelvic osteotomy lateral to the rectus muscle evaluate the feasibility and outcome of simple closure of from the same incision on the left side. exstrophy, using bilateral anterior pubic osteotomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with bladder exstrophy. inferior pubic wing. The technique of anterior pelvic osteotomy was the same as described by Frey and Cohen [15]. To begin anterior pubic osteotomy, both rectus muscles and Patients and methods sheath are identified and dissection is continued between the rectus sheath and the subcutaneous tissue laterally until the This prospective study, carried out between January 2006 and lateral boarder of the rectus abdominis muscle is reached. February 2010, included 15 patients (age range 3–47 months; The rectus sheath is incised at this point and the superior pubic 13 boys and 2 girls). Three patients had recurrent exstrophy ramus is exposed. The periosteum of the superior pubic ramus while 12 were operated primarily; an elective surgical is incised at the superior half of the pubic ramus medial to the technique was used for all patients, of any age once osteotomy insertion of the inguinal ligament. A bone retractor is inserted is indicated. After general anaesthesia was established, the ure- in the obturator foramen below the superior pubic ramus teric orifices were cannulated (Fig. 1), the skin around the before starting the pubic osteotomy, to protect the obturator exstrophic bladder was incised and the exstrophic bladder nerve and vessels. Pubic osteotomy is then performed using a was dissected from the abdominal wall extraperitoneally, with chisel and mallet (diathermy was sometimes used), with partic- generous bladder dissection and any inter-symphyseal bands ular care taken not to tear the inferior periosteum or injure the resected. The bladder was closed in two layers with insertion obturator nerve (Fig. 2). After completing the pubic osteotomy of a suprapubic catheter, and the epispadiac urethra recon- bilaterally, both pubic bones are tilted medially and approxi- structed over 10 F urethral catheter using the Cantwell–Ransley mated using one or two polyglactin-1 or -2 sutures (Fig. 3). technique [18]. In girls the bladder was separated from the The proposed bladder neck and urethra are positioned deep anterior vaginal wall to help in female urethral reconstruction. to the approximated pubic bones before securing the polyglac- Attention was directed after that to the pelvic osteotomy, in tin sutures. Two drains are inserted at the site of both pubic which both crura were dissected from their attachment to the Figure 1 Preoperative view of a 7-month-old boy with failed Figure 3 Easy approximation of the two recti in the midline after exstrophy closure after fixation of two ureteric stents. osteotomy. Closure of bladder exstrophy 205 were soft-tissue infections in two patients; they were treated conservatively by frequent wound dressing and appropriate antibiotics. Of the 15 patients, one had complete wound dehis- cence and another had a vesico-cutaneous fistula; both were treated by a later simple repair. The mean (range) operative duration was 165 (135–190) min and only one patient required a blood transfusion. No intraoperative repositioning was needed, and there was no need for orthopaedic surgeons. Discussion The main goal of initial exstrophy repair is to close the pubic bones and soft tissue of the anterior abdominal wall without tension, so it is apparent that any type of osteotomy seems to prevent dehiscence of the reconstructed bladder and abdominal wall. Pelvic osteotomies have been described by many authors, Figure 4 Final postoperative picture of the same case with a tube and there are many different techniques that can be chosen drain, suprapubic catheter and two ureteric stents passing through according to the surgeon’s preference and experience [10–17]. the neourethra. In 1958, Schultz [10] described a bilateral posterior iliac osteot- omy, which became a well-known technique for closure of cases with bladder exstrophy. However, it is a time-consuming major operation, usually performed by orthopaedic surgeons. Fur- thermore, this procedure requires repositioning the patient to complete the operation, which considerably increases the dura- tion of the operation and of anaesthesia. In the late 1980s, Sponseller et al. [11] used the technique of anterior innominate osteotomy and approximated the pubic bones using an external fixator. It is an efficient procedure with none of the drawbacks of posterior osteotomy. However, it remains a major procedure and is usually done by orthopaedic surgeons. Other drawbacks of this type of osteotomy include increased blood loss and post- operative pain. Furthermore, in 1995 the combined anterior innominate with a posterior iliac osteotomy was used from an anterior approach [13]. Other approaches, including an oblique iliac wing osteotomy, have been described, and some promising clinical results reported [14]. Anterior pelvic osteotomy was first described by Frey and Cohen [15], when they used this type of osteotomy for children with bladder exstrophy. They documented complications in two of these patients; one had partial bladder prolapse while Figure 5 A drawing of the osteotomy procedure. the other had a severe deep wound infection with complete breakdown of the repair. This type of osteotomy has many osteotomy and one more is inserted at the site of the recon- advantages; it is a versatile technique that could be used for structed bladder. Wound closure is started by approximating both primary and re-do cases, regardless of patient age; the both rectus muscles which, after completing the osteotomy, operative duration is reasonable, with no need to change the are easily approximated using interrupted absorbable sutures. patient’s position, and thus reduced anaesthetic exposure. Finally, the skin is closed, with reconstruction of the umbilicus Blood loss was minimized and blood transfusion was rarely (Fig. 4). Fig. 5 shows a diagram of the procedure. A hip spica needed. Anterior pubic osteotomy also has the advantage of cast was used as fixation in recurrent cases only for 2–3 weeks, being performed by the paediatric urologist, with no need while in the other cases simple closure was by a plaster and for an orthopaedic surgeon. Two other reports on the same pressure bandage for 2 weeks. All patients were kept on bed approach were published in early 1990s by Perovic et al. [17] rest during the period of hip spica, and movement was allowed and Schmidt et al. [12], which confirmed that there was no dif- thereafter. ference between bilateral iliac osteotomy and superior pubic ramotomy in terms of bladder exstrophy closure. Results Following these reports, again Frey [16], who proposed this technique, documented further experience on 16 cases after exstrophy closure. He found that the abdominal wall closure The mean (range) follow-up was 14 (6–36) months; we evalu- was excellent in all patients except two, in whom major compli- ated the anterior pubic osteotomy for closure of the bladder cations developed in the form of soft-tissue infection and blad- and anterior abdominal wall. The results were excellent for der dehiscence in one, and transient obturator nerve palsy in all patients in which a tension-free anterior abdominal wall the other. The latest experience of anterior pelvic osteotomy and bladder reconstruction was used. Soon after surgery there 206 Elsayed et al. [10] Shultz WG. Plastic repair of exstrophy of bladder combined with was reported by Chiari et al. [19] in which all procedures were bilateral osteotomy of ilia. J Urol 1958;79:453–8. successful. Tension-free complete approximation of the sym- [11] Sponseller PD, Gearhart JP, Jeffs RD. Anterior innominate physis and uncomplicated healing was achieved in all five osteotomies for failure or late closure of bladder exstrophy. J Urol cases, without palsy of the obturator nerve or postoperative 1991;146:137–40. haemorrhage. In our practice we used to use anterior innomi- [12] Schmidt AH, Keenen TL, Tank ES, Bird CB, Beak RK. Pelvic nate osteotomy to close bladder exstrophy. However, this osteotomy for bladder exstrophy. J Ped Orthoped procedure was lengthy (4–6 h), was only done by paediatric 1993;13:214–9. orthopaedic surgeons, and needed two separate incisions, with [13] Gearhart JP, Forschner DC, Jeffs RD, Ben-Chaim J, Sponseller more blood loss. For these reasons we tried to use the anterior PD. A combined vertical and horizontal pelvic osteotomy pubic osteotomy technique for a consecutive group of patients approach for primary and secondary repair of bladder exstrophy. J Urol 1996;155:689–93. and compare the results with the previous group who under- [14] Jones D, Parkinson S, Hosalkar HS. Oblique pelvic osteotomy in went innominate osteotomy. We evaluated the feasibility of the exstrophy/epispadias complex. J Bone Joint Surg Br bilateral anterior osteotomy of the superior pubic ramus for 2006;88:799–806. closure of the abdominal wall, bladder and urethral recon- [15] Frey P, Cohen SJ. Anterior pelvic osteotomy: a new operative struction, operative time and technical difficulty. The opera- technique facilitating primary bladder exstrophy closure. Br J tion was significantly quicker and the success rate was Urol 1989;64:641–3. comparable with the other techniques. Anterior osteotomy of [16] Frey P. Bilateral anterior pubic osteotomy in bladder exstrophy the superior pubic ramus allowed symphyseal approximation closure. J Urol 1996;156:812–5. and abdominal wall closure in all patients in the present study, [17] Perovic S, Brdar R, Scepanovic D. Bladder exstrophy and and there was no greater tension for pubic approximation than anterior pelvic osteotomy. Br J Urol 1992;70:678–82. [18] Ransley PG, Duffy PG, Wollin M. Bladder exstrophy closure and in the other technique. This is in accordance with the previ- epispadias repair. In: Operative surgery: paediatric surgery. 4th ously published reports about this type of osteotomy, which ed. Edinburgh: Butterworths; 1989. p. 620. reported that it is an efficient procedure. [19] Chiari G, Avolio L, Bragheri R. Bilateral anterior pubic osteot- The importance of osteotomy for exstrophy repair is to omy in bladder exstrophy repair. Report of increasing success. achieve a tension-free closure of the bladder and abdominal Pediatr Surg Int 2001;17:160–3. wall [20]. A comparison of anterior pubic osteotomy with [20] Wild AT, Sponseller PD, Stec AA, Gearhart JP. The role of other types of osteotomy for continence and pelvic dimension osteotomy in surgical repair of bladder exstrophy. Semin Pediatric has not yet been reported. Surg 2011;20:71–8. In conclusion, simple closure with anterior pubic osteotomy is a feasible and effective means to facilitate both bladder and abdominal closure for patients with bladder exstrophy. This Editorial comment technique has the advantage of being reproducible, quicker, with less blood loss and easily performed by the paediatric The authors of this article should be congratulated for urologist. reporting their experience of pubic osteotomy in children with exstrophy, which seems relatively straightforward and References ‘orthopaedist-free’, although not adopted by many surgical teams. I wondered why, and the answer might be in the roles [1] Rickham PP. The incidence and treatment of ectopia vesicae. of pelvic osteotomy in the child with exstrophy. There is no Proc Roy Soc Med 1961;54:389–92. doubt that the bilateral anterior pubic osteotomy, like several [2] Lattimer JK, Smith MJ. Exstrophy closure. A followup on 70 other techniques, is suitable for achieving a tension-free clo- cases. J Urol 1966;95:356–9. sure and filling the lower abdominal midline depression. Con- [3] Stec AA, Pannu HK, Tadros YE, Sponseller PD, Wakim A, Fishman EK, et al. Evaluation of the bony pelvis in classic trary to the anterior oblique iliac osteotomy, the reported bladder exstrophy by using 3D-CT. Further insights. Urology technique does not change the depth of the pelvis, which is 2001;58:1030–5. classically flattened in patients with exstrophy. This is an [4] Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, important point for relocating the bladder and bladder neck Gearhart JP. Pelvic floor anatomy in classic bladder exstrophy inside the pelvis, and possibly to restore some bladder func- using 3-dimensional computerized tomography: initial insights. J tion. Pubic osteotomy also fails to bring together the corpora Urol 2001;166:1444–9. cavernosa to reconstruct the epispadiac penis, except if it is [5] Jeffs RD, Charrios R, Mnay M, Juransz AR. Primary closure of combined with the Kelly soft-tissue mobilization. As far as I the exstrophied bladder. In: Scott R, editor. Current controversies know, there is no report of a combination of these two proce- in urologic management. Philadelphia: Saunders; 1972. p. 135–43. dures. It would be interesting to know if this type of osteotomy [6] Grady R, Mitchell ME. Complete primary repair of exstrophy. J remains stable in the long term and avoids the progressive sep- Urol 1999;162:1415–20. [7] Baka-Jakubiack M. Combined bladder neck, urethral and penile aration of the two hemi-pelves seen with other types of reconstruction in boys with exstrophy-epispadias complex. BJU osteotomy. Int 2000;86:513–8. The inward displacement of the nerves and vessels passing [8] Gearhart JP, Mathews RI, Taylor S, Jeffs RD. Combined bladder through the obturator foramen might be an issue when the exstrophy closure and epispadias repair in the reconstruction of gap between the two hemi-pelves is large. Transient paresis bladder exstrophy. J Urol 1998;160:1182–5. of the quadriceps is a common adverse effect of pelvic osteot- [9] Baird AD, Nelson CP, Gearhart JP. Modern staged repair of omy, and is particularly symptomatic in older children. This bladder exstrophy: a contemporary series. J Pediatr Urol aspect has not been contemplated in the present study, nor 2007;3:311–5. the place of this technique in the newborn, when many of these
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Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique
Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique
Abstract
AbstractObjective:To evaluate the results of simple closure using bilateral anterior pubic osteotomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with bladder exstrophy.Patients and methods: A prospective study carried out between 2006 and 2009 included 15 patients (13 boys and 2 girls; age range 3–47 months). Of these patients, three had recurrent exstrophy while 10 were operated primarily. An elective surgical technique was used for all patients,...
Arab Journal of Urology (2011) 9, 203–207 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com PEDIATRIC UROLOGY ORIGINAL ARTICLE Closure of bladder exstrophy with a bilateral anterior pubic osteotomy: Revival of an old technique a, a b a Ehab R. Elsayed , Mohamed N. Alam , Osama M. Sarhan , Diab Elsayed , a a Ahmed M. Eliwa , Salem Khalil Urology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt Urology and Nephrology Centre, Faculty of Medicine, Mansoura University, Mansoura, Egypt Received 20 June 2011, Received in revised form 18 August 2011, Accepted 25 August 2011 Available online 15 November 2011 KEYWORDS Abstract Objective: To evaluate the results of simple closure using bilateral anterior pubic oste- otomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with Bladder; Exstrophy; bladder exstrophy. Osteotomy; Patients and methods: A prospective study carried out between 2006 and 2009 included 15 patients Anterior pelvic osteotomy; (13 boys and 2 girls; age range 3–47 months). Of these patients, three had recurrent exstrophy while Safety 10 were operated primarily. An elective surgical technique was used for all patients, which included dissection of the exstrophic bladder from the abdominal wall, closure of the bladder and reconstruc- tion of the urethra, then dissection of the rectus muscle and sheath lateral to the attachment of muscle to pubic bone, which makes osteotomy of the superior pubic ramus easy, thus facilitating closure. Results: For closure of the bladder and anterior abdominal wall the results were excellent for all patients soon after surgery, but there was soft-tissue infection in two patients. Of all 15 patients, one had incomplete bladder dehiscence and another had a vesico-cutaneous fistula; both needed surgical intervention later. Conclusions: Simple closure with anterior pubic osteotomy is a feasible and effective means to facil- itate both bladder and abdominal closure for patients with bladder exstrophy. It is advantageous in being a rapid procedure, and can be completed by the paediatric urologist. ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction Corresponding author. Tel.: +20 14 6044499. Classic bladder exstrophy is a birth defect mainly involving the E-mail address: Dr_ihabraafat@yahoo.com (E.R. Elsayed). musculoskeletal system and genitourinary tracts; it occurs at a 2090-598X ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.08.004 204 Elsayed et al. rate of 1 in 10 000–50 000 live births [1–4]. During the past two decades, the operative treatment of bladder exstrophy has advanced considerably, with various techniques and ap- proaches described to achieve successful closure and the best functional outcomes [5–9]. The initial goal of exstrophy closure is a tension-free approximation of the pubic bones and soft tis- sue in the midline. Osteotomy provides closure of the bony ring and muscles of the pelvic floor to support the bladder and surround the urethra. Many types of osteotomy have been described to obtain a tension-free approximation of the pubic bones and soft tissues in the midline [10–17]. A successful osteotomy technique consisting of anterior pel- vic osteotomy of the superior pubic ramus was first described by Frey and Cohen in 1989 [15]. This technique seems to be a safe and quick adjunct for pubic bone approximation, so that this approach would preclude the need for a paediatric ortho- paedic surgeon [16,17]. The aim of the present study was to Figure 2 Anterior pelvic osteotomy lateral to the rectus muscle evaluate the feasibility and outcome of simple closure of from the same incision on the left side. exstrophy, using bilateral anterior pubic osteotomy to achieve a tension-free approximation of the pubis and abdominal wall in patients with bladder exstrophy. inferior pubic wing. The technique of anterior pelvic osteotomy was the same as described by Frey and Cohen [15]. To begin anterior pubic osteotomy, both rectus muscles and Patients and methods sheath are identified and dissection is continued between the rectus sheath and the subcutaneous tissue laterally until the This prospective study, carried out between January 2006 and lateral boarder of the rectus abdominis muscle is reached. February 2010, included 15 patients (age range 3–47 months; The rectus sheath is incised at this point and the superior pubic 13 boys and 2 girls). Three patients had recurrent exstrophy ramus is exposed. The periosteum of the superior pubic ramus while 12 were operated primarily; an elective surgical is incised at the superior half of the pubic ramus medial to the technique was used for all patients, of any age once osteotomy insertion of the inguinal ligament. A bone retractor is inserted is indicated. After general anaesthesia was established, the ure- in the obturator foramen below the superior pubic ramus teric orifices were cannulated (Fig. 1), the skin around the before starting the pubic osteotomy, to protect the obturator exstrophic bladder was incised and the exstrophic bladder nerve and vessels. Pubic osteotomy is then performed using a was dissected from the abdominal wall extraperitoneally, with chisel and mallet (diathermy was sometimes used), with partic- generous bladder dissection and any inter-symphyseal bands ular care taken not to tear the inferior periosteum or injure the resected. The bladder was closed in two layers with insertion obturator nerve (Fig. 2). After completing the pubic osteotomy of a suprapubic catheter, and the epispadiac urethra recon- bilaterally, both pubic bones are tilted medially and approxi- structed over 10 F urethral catheter using the Cantwell–Ransley mated using one or two polyglactin-1 or -2 sutures (Fig. 3). technique [18]. In girls the bladder was separated from the The proposed bladder neck and urethra are positioned deep anterior vaginal wall to help in female urethral reconstruction. to the approximated pubic bones before securing the polyglac- Attention was directed after that to the pelvic osteotomy, in tin sutures. Two drains are inserted at the site of both pubic which both crura were dissected from their attachment to the Figure 1 Preoperative view of a 7-month-old boy with failed Figure 3 Easy approximation of the two recti in the midline after exstrophy closure after fixation of two ureteric stents. osteotomy. Closure of bladder exstrophy 205 were soft-tissue infections in two patients; they were treated conservatively by frequent wound dressing and appropriate antibiotics. Of the 15 patients, one had complete wound dehis- cence and another had a vesico-cutaneous fistula; both were treated by a later simple repair. The mean (range) operative duration was 165 (135–190) min and only one patient required a blood transfusion. No intraoperative repositioning was needed, and there was no need for orthopaedic surgeons. Discussion The main goal of initial exstrophy repair is to close the pubic bones and soft tissue of the anterior abdominal wall without tension, so it is apparent that any type of osteotomy seems to prevent dehiscence of the reconstructed bladder and abdominal wall. Pelvic osteotomies have been described by many authors, Figure 4 Final postoperative picture of the same case with a tube and there are many different techniques that can be chosen drain, suprapubic catheter and two ureteric stents passing through according to the surgeon’s preference and experience [10–17]. the neourethra. In 1958, Schultz [10] described a bilateral posterior iliac osteot- omy, which became a well-known technique for closure of cases with bladder exstrophy. However, it is a time-consuming major operation, usually performed by orthopaedic surgeons. Fur- thermore, this procedure requires repositioning the patient to complete the operation, which considerably increases the dura- tion of the operation and of anaesthesia. In the late 1980s, Sponseller et al. [11] used the technique of anterior innominate osteotomy and approximated the pubic bones using an external fixator. It is an efficient procedure with none of the drawbacks of posterior osteotomy. However, it remains a major procedure and is usually done by orthopaedic surgeons. Other drawbacks of this type of osteotomy include increased blood loss and post- operative pain. Furthermore, in 1995 the combined anterior innominate with a posterior iliac osteotomy was used from an anterior approach [13]. Other approaches, including an oblique iliac wing osteotomy, have been described, and some promising clinical results reported [14]. Anterior pelvic osteotomy was first described by Frey and Cohen [15], when they used this type of osteotomy for children with bladder exstrophy. They documented complications in two of these patients; one had partial bladder prolapse while Figure 5 A drawing of the osteotomy procedure. the other had a severe deep wound infection with complete breakdown of the repair. This type of osteotomy has many osteotomy and one more is inserted at the site of the recon- advantages; it is a versatile technique that could be used for structed bladder. Wound closure is started by approximating both primary and re-do cases, regardless of patient age; the both rectus muscles which, after completing the osteotomy, operative duration is reasonable, with no need to change the are easily approximated using interrupted absorbable sutures. patient’s position, and thus reduced anaesthetic exposure. Finally, the skin is closed, with reconstruction of the umbilicus Blood loss was minimized and blood transfusion was rarely (Fig. 4). Fig. 5 shows a diagram of the procedure. A hip spica needed. Anterior pubic osteotomy also has the advantage of cast was used as fixation in recurrent cases only for 2–3 weeks, being performed by the paediatric urologist, with no need while in the other cases simple closure was by a plaster and for an orthopaedic surgeon. Two other reports on the same pressure bandage for 2 weeks. All patients were kept on bed approach were published in early 1990s by Perovic et al. [17] rest during the period of hip spica, and movement was allowed and Schmidt et al. [12], which confirmed that there was no dif- thereafter. ference between bilateral iliac osteotomy and superior pubic ramotomy in terms of bladder exstrophy closure. Results Following these reports, again Frey [16], who proposed this technique, documented further experience on 16 cases after exstrophy closure. He found that the abdominal wall closure The mean (range) follow-up was 14 (6–36) months; we evalu- was excellent in all patients except two, in whom major compli- ated the anterior pubic osteotomy for closure of the bladder cations developed in the form of soft-tissue infection and blad- and anterior abdominal wall. The results were excellent for der dehiscence in one, and transient obturator nerve palsy in all patients in which a tension-free anterior abdominal wall the other. The latest experience of anterior pelvic osteotomy and bladder reconstruction was used. Soon after surgery there 206 Elsayed et al. [10] Shultz WG. Plastic repair of exstrophy of bladder combined with was reported by Chiari et al. [19] in which all procedures were bilateral osteotomy of ilia. J Urol 1958;79:453–8. successful. Tension-free complete approximation of the sym- [11] Sponseller PD, Gearhart JP, Jeffs RD. Anterior innominate physis and uncomplicated healing was achieved in all five osteotomies for failure or late closure of bladder exstrophy. J Urol cases, without palsy of the obturator nerve or postoperative 1991;146:137–40. haemorrhage. In our practice we used to use anterior innomi- [12] Schmidt AH, Keenen TL, Tank ES, Bird CB, Beak RK. Pelvic nate osteotomy to close bladder exstrophy. However, this osteotomy for bladder exstrophy. J Ped Orthoped procedure was lengthy (4–6 h), was only done by paediatric 1993;13:214–9. orthopaedic surgeons, and needed two separate incisions, with [13] Gearhart JP, Forschner DC, Jeffs RD, Ben-Chaim J, Sponseller more blood loss. For these reasons we tried to use the anterior PD. A combined vertical and horizontal pelvic osteotomy pubic osteotomy technique for a consecutive group of patients approach for primary and secondary repair of bladder exstrophy. J Urol 1996;155:689–93. and compare the results with the previous group who under- [14] Jones D, Parkinson S, Hosalkar HS. Oblique pelvic osteotomy in went innominate osteotomy. We evaluated the feasibility of the exstrophy/epispadias complex. J Bone Joint Surg Br bilateral anterior osteotomy of the superior pubic ramus for 2006;88:799–806. closure of the abdominal wall, bladder and urethral recon- [15] Frey P, Cohen SJ. Anterior pelvic osteotomy: a new operative struction, operative time and technical difficulty. The opera- technique facilitating primary bladder exstrophy closure. Br J tion was significantly quicker and the success rate was Urol 1989;64:641–3. comparable with the other techniques. Anterior osteotomy of [16] Frey P. Bilateral anterior pubic osteotomy in bladder exstrophy the superior pubic ramus allowed symphyseal approximation closure. J Urol 1996;156:812–5. and abdominal wall closure in all patients in the present study, [17] Perovic S, Brdar R, Scepanovic D. Bladder exstrophy and and there was no greater tension for pubic approximation than anterior pelvic osteotomy. Br J Urol 1992;70:678–82. [18] Ransley PG, Duffy PG, Wollin M. Bladder exstrophy closure and in the other technique. This is in accordance with the previ- epispadias repair. In: Operative surgery: paediatric surgery. 4th ously published reports about this type of osteotomy, which ed. Edinburgh: Butterworths; 1989. p. 620. reported that it is an efficient procedure. [19] Chiari G, Avolio L, Bragheri R. Bilateral anterior pubic osteot- The importance of osteotomy for exstrophy repair is to omy in bladder exstrophy repair. Report of increasing success. achieve a tension-free closure of the bladder and abdominal Pediatr Surg Int 2001;17:160–3. wall [20]. A comparison of anterior pubic osteotomy with [20] Wild AT, Sponseller PD, Stec AA, Gearhart JP. The role of other types of osteotomy for continence and pelvic dimension osteotomy in surgical repair of bladder exstrophy. Semin Pediatric has not yet been reported. Surg 2011;20:71–8. In conclusion, simple closure with anterior pubic osteotomy is a feasible and effective means to facilitate both bladder and abdominal closure for patients with bladder exstrophy. This Editorial comment technique has the advantage of being reproducible, quicker, with less blood loss and easily performed by the paediatric The authors of this article should be congratulated for urologist. reporting their experience of pubic osteotomy in children with exstrophy, which seems relatively straightforward and References ‘orthopaedist-free’, although not adopted by many surgical teams. I wondered why, and the answer might be in the roles [1] Rickham PP. The incidence and treatment of ectopia vesicae. of pelvic osteotomy in the child with exstrophy. There is no Proc Roy Soc Med 1961;54:389–92. doubt that the bilateral anterior pubic osteotomy, like several [2] Lattimer JK, Smith MJ. Exstrophy closure. A followup on 70 other techniques, is suitable for achieving a tension-free clo- cases. J Urol 1966;95:356–9. sure and filling the lower abdominal midline depression. Con- [3] Stec AA, Pannu HK, Tadros YE, Sponseller PD, Wakim A, Fishman EK, et al. Evaluation of the bony pelvis in classic trary to the anterior oblique iliac osteotomy, the reported bladder exstrophy by using 3D-CT. Further insights. Urology technique does not change the depth of the pelvis, which is 2001;58:1030–5. classically flattened in patients with exstrophy. This is an [4] Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, important point for relocating the bladder and bladder neck Gearhart JP. Pelvic floor anatomy in classic bladder exstrophy inside the pelvis, and possibly to restore some bladder func- using 3-dimensional computerized tomography: initial insights. J tion. Pubic osteotomy also fails to bring together the corpora Urol 2001;166:1444–9. cavernosa to reconstruct the epispadiac penis, except if it is [5] Jeffs RD, Charrios R, Mnay M, Juransz AR. Primary closure of combined with the Kelly soft-tissue mobilization. As far as I the exstrophied bladder. In: Scott R, editor. Current controversies know, there is no report of a combination of these two proce- in urologic management. Philadelphia: Saunders; 1972. p. 135–43. dures. It would be interesting to know if this type of osteotomy [6] Grady R, Mitchell ME. Complete primary repair of exstrophy. J remains stable in the long term and avoids the progressive sep- Urol 1999;162:1415–20. [7] Baka-Jakubiack M. Combined bladder neck, urethral and penile aration of the two hemi-pelves seen with other types of reconstruction in boys with exstrophy-epispadias complex. BJU osteotomy. Int 2000;86:513–8. The inward displacement of the nerves and vessels passing [8] Gearhart JP, Mathews RI, Taylor S, Jeffs RD. Combined bladder through the obturator foramen might be an issue when the exstrophy closure and epispadias repair in the reconstruction of gap between the two hemi-pelves is large. Transient paresis bladder exstrophy. J Urol 1998;160:1182–5. of the quadriceps is a common adverse effect of pelvic osteot- [9] Baird AD, Nelson CP, Gearhart JP. Modern staged repair of omy, and is particularly symptomatic in older children. This bladder exstrophy: a contemporary series. J Pediatr Urol aspect has not been contemplated in the present study, nor 2007;3:311–5. the place of this technique in the newborn, when many of these
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