Summary
Purpose
A pivotal factor in the success of bladder closure in patients with classic bladder
exstrophy (CBE) is the postoperative immobilization of the pelvis and lower extremities
after pelvic osteotomy. This study investigates the outcomes of closure among patients
with lower limb immobilization using many techniques. The authors hypothesize that
the addition of external fixation (pelvic immobilization) in patients with any form
of limb immobilization will be associated with improved outcomes.
Methods
A prospectively maintained institutional exstrophy–epispadias complex database of
1415 patients was reviewed for patients with CBE who had undergone closure with available
immobilization and osteotomy data. Association between closure outcomes and immobilization
techniques were determined. Univariate analysis was performed using Chi-Square or
Fischer–Exact test as appropriate for categorical variables. Multivariate analysis
via binomial logistic regression was used to identify factors leading to successful
closure.
Results
A total of 747 closure events matching the inclusion criteria were identified. Patients
included 508 males and 239 females. There were 597 primary closures (79.9%) with 150
reclosure events (20.1%). Limb immobilization was used in 627 (83.9%) of closure events.
Successful closures were associated with osteotomy use (p < 0.0001) and limb immobilization
(p < 0.0001); specifically, the combined anterior innominate with posterior vertical
iliac osteotomy and modified Buck's traction with external fixation (p < 0.0001, p < 0.0001).
Among the group of 33 patients who received external fixation alone and no other type
of immobilization, the failure rate was 33.3%, comparatively, patients with any form
of combined immobilization (external fixation with lower limb immobilization) had
a failure rate of 7.1% ( Table 1). Among patients immobilized with mummy wrap, spica
casting, or knee immobilizers, external fixation was associated with 3.76 increased
odds of successful closure (p = 0.0005, 95% CI 1.79–7.90). In a unique group of 67
patients without pelvic osteotomy or any form of pelvic or limb immobilization, the
failure rate was 74.6%.
Discussion
This study confirms, in a larger series, previous findings of improved outcomes when
patients are immobilized with modified Buck's traction and external fixation. The
authors apply this technique in most all closures and recommend this technique be
utilized whenever feasible. However, regardless of the manner of lower limb immobilization,
external fixation is a critical factor to optimize closures and ensure success.
Conclusion
Summary Table 1Failure rate among all closures (to be used in the extended summary if possible).
| Total closures | Closures with osteotomy | Closures without osteotomy | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Method of Immobilization | Total no. (n = 597) | No. failed | % Failed | Total no. (n = 411) | No. failed | % Failed | Total no. (n = 186) | No. failed | % Failed |
| External fixation with no lower limb immobilization | 33 | 11 | 33.3 | 31 | 10 | 32.3 | 2 | 1 | 50 |
| External fixation with any form of lower limb immobilization | 184 | 13 | 7.1 | 174 | 11 | 6.3 | 10 | 2 | 20 |
| External fixation with spica casting/mummy wrapping | 42 | 14 | 33.3 | 39 | 12 | 30.8 | 3 | 2 | 67 |
| Spica casting with no external fixation | 148 | 81 | 54.7 | 74 | 30 | 40.5 | 74 | 51 | 68.9 |
| No form of Immobilization | 87 | 60 | 69.0 | 20 | 10 | 50 | 67 | 50 | 74.6 |
Keywords
Abbreviations:
CBE (Bladder Exstrophy), CE (Cloacal Exstrophy), AH (Authors' institution), OSH (Outside hospitals)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: December 27, 2022
Accepted:
December 20,
2022
Received in revised form:
December 15,
2022
Received:
October 12,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
