Bladder neck reconstruction in classic bladder exstrophy: the role of osteotomy in the development of continence

Abstract

Objective To assess the role of osteotomy at the time of bladder neck reconstruction (BNR) for continence in classic bladder exstrophy, in which closure of the pelvic ring and reconstitution of the pelvic diaphragm may affect eventual continence. Patients and methods The results of using osteotomy at the time of BNR in 29 children were reviewed. The mean bladder capacity before BNR was 76 mL. The indications for osteotomy were a wide pubic diastasis and a soft intersymphyseal bar. After osteotomy, all children were maintained in external ®xation and lower-extremity traction for 6±8 weeks. Results Complications of osteotomy were limited to a partial femoral nerve palsy (one patient) and delayed union of fragments (one patient). Complications of BNR included urethral stricture (®ve patients) and bladder calculi (six patients). Continence results were modest, with 11 of 29 children (38%) dry during the day (dry interval >3 h) and eight of 29 (28%) dry at night. Eight children had daytime dry intervals of <3 h. The mean preoperative bladder capacity in children who were dry both day and night was 101 mL. Conclusions The preoperative bladder capacity remains a key determinant for the attainment of continence after BNR in the reconstruction of classic bladder exstrophy. Osteotomy allows pelvic closure and thus improves cosmesis of the mons and stabilizes the BNR in patients with a soft intersymphyseal bar, but seems to have no effect on continence when performed at the time of bladder neck plasty.

Long‐term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias

“…Successful initial bladder closure [25], sufficient bladder capacity [26,27] at the time of BNR, pelvic osteotomy [27] to relocate pelvic organs inside the pelvic ring and the intraoperative measurement of bladder outlet resistance have been reported to be important factors in successfully achieving social urinary dryness. Even with this wide experience, we remain unable to predict the outcome of bladder outlet surgery and, moreover, cannot identify the adequate balance between urine storage (which requires a large bladder reservoir with low pressures and high bladder outlet resistance to keep the child dry) and bladder emptying (which requires a transient increase in bladder pressure to overcome the bladder outlet resistance, and reduced bladder outlet resistance).…”

Contemporary outcomes in bladder exstrophy

“…Gender seems to play a role with several studies showing a higher rate of eventual continence in girls compared with boys [15,30]. Others have emphasized that pelvic osteotomies are vital in establishing continence [38].…”

PEDIATRIC UROLOGY Complications after primary bladder exstrophy closure – role of pelvic osteotomy

“…An example of a good cosmetic result is shown in Figure 7. Putting together the pubic bones is essential for pelvic diaphragm closure, which prevents vaginal and anal prolapse [12, 13]. The pelvic diaphragm is also important for further functional reconstruction and the achievement of the continence [11, 14, 15].…”

“…There are two types of iliac osteotomy mostly used: posterior and anterior [2, 7, 8, 12, 16]. However, a group from Baltimore has advocated performing these two procedures together as a combined transverse innominate and vertical iliac osteotomy [9].…”