Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success

Abstract

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Anterior Pelvic Osteotomy of Superior Pubic Rami as Adjunctive Measure to Repair the Primary and Recurrent Cases with Bladder Extrophy

“…This result is comparable to what is reported by Elsayed et al [16] . It is slightly lower than what is reported 100% by Chiari et al [5] , which may be due to the small sample size in the later study [table 2and graph 2]. Graph 2: Comparison of present study (no., sex, success rate) to other studies The operative time for both osteotomies ranged from 30 to 45 minutes.…”

“…As comparison to Chiari and Elsayed studies who reported a male incidence of 80% and 86.6% respectively [5], [16] , in present study 85.7% of the patients were males. Successful repair using bilateral anterior pelvic osteotomy of superior pubic rami in this study was achieved in 92.8% of the patients operated on.…”

“…Chiari et al reported in his study using anterior pelvic osteotomy [5] , that all five procedures were successful, tension-free complete approximation of the symphysis and uncomplicated healing without palsy of the obturator nerve or postoperative hemorrhage. Elsayed et al reported simple closure with anterior pubic osteotomy is a feasible and effective adjunctive means to facilitate both bladder and abdominal closure for patients with bladder exstrophy and with success rate; 93% [16] .…”

“…Primary closure with approximation of the pubic bones is generally regarded as the initial procedure of choice for patients with this malformation. Even if this is accomplished during the first few days of life, primary closure usually requires some form of osteotomy if the pubic bones are to be brought together without undue tension [5] . Fusion of the symphysis with reconstruction of all layers of the anterior abdominal wall is the basic element of the surgical procedure.…”

“…Another osteotomy technique, first described by Frey and Cohen in 1988 and consisting of anterior pelvic osteotomy of the superior pubic ramus, seems to be a safe and quick alternative method to obtain tension-free approximation of the symphysis pubis [5], [9] . In this study we evaluate the feasibility of the bilateral anterior pubic osteotomy as adjunctive measure to simple closure of the bladder exstrophy and achieving a tension-free approximation of the symphysis pubis and abdominal wall.…”