The role of osteotomy in surgical repair of bladder exstrophy

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Classic bladder exstrophy (CBE) patients are born with a pubic diastasis that increases steadily with age from a mean value of 4 cm at birth to a mean of 8 cm at age 10, compared with a mean normal width of the pubic symphysis of 0.6 cm at all ages. The width of the sacrum and length of the posterior (iliac) segment of the pelvis in CBE patients are normal; however, the anterior (ischiopubic) segment of the pelvis is a mean 30% shorter and both the anterior and posterior segments are externally rotated compared to controls. The main role of osteotomy in treatment of CBE appears to be to relax tension on the bladder and repaired abdominal wall during wound-healing. Anterior innominate osteotomy with optional posterior vertical iliac osteotomy presents several advantages over the prior conventional technique of posterior iliac osteotomy. These include (a) less intraoperative blood loss, (b) better apposition and mobility of the pubic rami at the time of closure, (c) allowance for placement of an external fixator under direct vision, (d) allowance for secure external fixation in children over 6 months old, and (e) no requirement to turn the patient during the operation.

Section snippets

Defects in the bony pelvic anatomy

Because the pelvis arises from sclerotomal components of the mesenchyme, the altered mesenchymal migration seen in CBE produces abnormal pelvic development. This leads to important aberrations in the bony anatomy, such as wide diastasis of the pubic rami and, consequently, an open pelvic ring.15 The first detailed study of the bony pelvic deformities in the exstrophy-epispadias complex uses 2-dimensional (2D) transpelvic computerized tomography scans.3 Although not all patients with CBE have

Defects in the muscular pelvic anatomy

Having elucidated the anatomical differences in the passive support mechanisms of the pelvic floor (sacrum, coccyx, pubic ramus, ischium), we turn now to the active support mechanisms in CBE patients. The chief component of active support of the pelvic floor is the pelvic diaphragm, which separates the pelvis above from the perineum below and consists of the striated muscles obturator internus, obturator externus, and levator ani. These muscles, along with their upper and lower fascial layers,

Posterior iliac osteotomy

Before 1958, no attempt had been reported to correct the bony abnormalities of the pelvis in CBE patients; rather, plastic repair of only the soft tissues was performed.5, 20, 24, 25, 26 Despite reconstructive success in several patients, numerous postoperative complications were reported, including poor wound healing and bladder dehiscence, fistula formation, wound infections, incontinence, and recurrence of the exstrophic defect.25 Many, if not all, of these complications were related to

Anterior osteotomy of the superior pubic rami

In the late 1980s, an alternative method of osteotomy in CBE repair was proposed by Frey and Cohen involving a bilateral anterior osteotomy of the superior pubic rami.34, 38, 39, 40, 42 The aim of this method is to simplify the procedure through which reapproximation of the pubic symphysis is achieved so that it may be performed by a pediatric urologist rather than an orthopedic surgeon while achieving the same outcome sought in bilateral posterior osteotomy of a tension-free abdominal wall

Anterior diagonal iliac osteotomy

In the mid-1990s, McKenna et al proposed an additional alternative osteotomy procedure to correct the pelvic deformities observed in CBE patients.43 Various osteotomies were performed in the setting of a computerized model with a 3-dimensional computed tomography scan from a 3-year-old patient with CBE and it was found that an anterior midiliac diagonal osteotomy provided more functional pelvic closure than contemporary osteotomy techniques.43 Anterior diagonal iliac osteotomy is performed

Anterior innominate osteotomy with optional vertical posterior iliac osteotomy

Although no absolute consensus exists regarding the optimal osteotomy type to be used in surgical correction of CBE, a procedure commonly used in the modern era is the anterior innominate osteotomy proposed by Sponseller et al.14 The anterior osteotomy derives its inspiration from the Salter innominate osteotomy, which was devised in 1961 to correct congenital dislocation and subluxation of the hip. Salter found that if the innominate bone was divided completely just above the acetabulum, the

Conclusions

CBE is accompanied by a well-classified array of bony and muscular abnormalities in pelvic anatomy that factor prominently into effective surgical repair. The use of osteotomy in surgical treatment of CBE has evolved during the past 50 years as more of the anatomy has been elucidated and as outcomes studies have provided new guidelines for the use of osteotomy in conjunction with soft tissue and urological repair. A variety of osteotomies have been shown to be effective adjuncts in the

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      In our study, the surgical procedure was bilateral vertical pelvic osteotomies with external fixation and one case with anterior innominate osteotomy and external fixation. These surgical techniques have shown to be beneficial in correcting pelvic diastasis and managing bladder exstrophy and showed a low failure rate [9,10]. Stabilised pelvic osteotomy with a plaster or traction, which has the benefit of preventing infectious complications described with external fixators [11].

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