The dual-staged pathway for closure in cloacal exstrophy: Successful evolution in collaborative surgical practice

IntroductionA successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures.MethodsA prospective database of 1332 Exstrophy–Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected.ResultsThere are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011).ConclusionThe standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes.Level of evidenceLevel III, retrospective comparative study.     

Predictors of a successful primary bladder closure in cloacal exstrophy: A multivariable analysis

Purpose

To investigate the factors affecting primary bladder closure in cloacal exstrophy (CE). A successful primary closure is important for optimizing reconstructive outcomes, and it is a critical first-step in the reconstruction of CE. The authors' hypothesize that a smaller diastasis and use of an osteotomy are independent predictors of a successful closure.

Complex abdominal wall reconstruction combined with bladder closure in OEIS complex

PurposeDue to the large abdominal defect from the omphalocele and extreme pubic diastasis in cloacal exstrophy (CE), bioprosthetic material may be used to bridge this gap during abdominal closure in CE. This study examined presurgical factors associated with the use of bioprosthetic materials in CE closure and complications in these patients.MethodsAn institutional database of exstrophy-epispadias complex patients was reviewed for CE. Inclusion criteria included CE and primary closure performed at the host institution from 1998 to 2018. Data collection included demographics, presurgical factors, use of bioprosthetic material, complications, and outcomes.ResultsAll 32 patients had a staged closure and pelvic osteotomy prior to bladder closure. Ten of the 32 patients incorporated a bioprosthetic material during abdominal wall closure. There is at least 3 months follow up for all patients, all had successful bladder closure without any postoperative hernias. Those who underwent closure without bioprosthetic material were younger at the time of closure (565 vs 693 days, p = 0.043). The differences in complication rates and mean pubic diastasis was not statistically significant, p = 0.079 and p = 0.457 respectively.ConclusionsThe use of bioprosthetic material is associated with older age at abdominal wall and bladder closure. The use of bioprosthetic material is a useful adjunct for secure abdominal wall closure in the reconstruction of CE.Type of StudyPrognostic.Level of EvidenceIII.     

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

Introduction

Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction.

Repeat pelvic osteotomy in patients with failed closure of bladder exstrophy: applications and outcomes

Background/Purpose

In patients with failed primary or secondary closure of bladder exstrophy, repeat osteotomy is useful in facilitating reconstruction. The clinical consequences of repeated surgical disruption of the pelvic ring have not been carefully described, however.

Methods

We reviewed our experience with exstrophy patients who had undergone repeat pelvic osteotomy (RPO) and analyzed patient history, complications, and orthopedic outcomes.

Results

Fifty-six patients who underwent RPO were identified. All had previously failed at least one attempted bladder closure. The patients underwent RPO at a mean age of 23.2 months. The mean time from initial osteotomy to RPO was 20.5 months. Anterior innominate or combined iliac/innominate approaches comprised 80% of RPO procedures. Of the patients, 95% had a normal gait after RPO; all 3 patients with an abnormal gait had osteotomy site nonunion, which was treated with bone grafting. Five patients had local fixator pin site infections, which were managed with local care and oral antibiotics, and 1 patient had late osteomyelitis requiring incision and drainage. No patient had femoral or sciatic nerve palsy after RPO at our institution.

Conclusions

Orthopedic complications after RPO are uncommon, and most patients have a normal gait postoperatively. Repeat pelvic osteotomy is useful in the complex reconstruction of failed exstrophy closures, and few cases fail reclosure when the reconstruction is combined with RPO.     

Pelvic osteotomy in cloacal exstrophy: A changing perspective

BackgroundThe type of osteotomy and pelvic fixation in the management of primary cloacal exstrophy (CE) closure is variable. The purpose of this study was to evaluate primary CE closure outcomes with osteotomy, immobilization, and multi-staging procedure trends over time.MethodsAn institutional database was retrospectively reviewed for patients who underwent primary CE closure from 1960 to 2020. Demographics, osteotomy, fixation, and outcomes were noted. Subanalyses by location of primary closure (AH=author's hospital; OH=outside hospital).ResultsOut of 122 patients, multi-stage became more common than single-stage procedures (p = 0.019), with multi-stage associated with higher success rates (77.4% v 45.7%; p = 0.001). The use of any osteotomy increased over time (p = 0.007), with a posterior approach falling out of favor and increasing prevalence of a combined osteotomy (p<0.001). The use of any osteotomy compared to no osteotomy was associated with successful closure (77.6% v 41.7%; p = 0.007). The combined, posterior, and anterior approaches were associated with 90%, 76.2%, and 60.9% successful primary closure rates, respectively (p<0.001). Fixation modalities changed over time as Buck's traction (p<0.001) and external fixation (p<0.001) became more prevalent. Spica casting has become less common (p = 0.0002). Immobilization type was associated with success rates with Buck's (92.1%; p<0.001) and external fixation (86.0%; p<0.001) performing best.ConclusionsThe use of osteotomy and fixation in the CE spectrum has changed markedly. In this cohort, a staged approach with combination osteotomy was associated with better outcomes when using a multidisciplinary team approach.Level of EvidenceThis is a retrospective comparative study (Type of Study: Treatment; Evidence Level: III)     

Urogynaecological and obstetric issues in women with the exstrophy-epispadias complex

OBJECTIVE: To review of the sexual and urogynaecological issues faced by a large cohort of women with the exstrophy-epispadias complex (EEC). PATIENTS AND METHODS: The study comprised 83 women and girls with EEC; a confidential survey was mailed to identify their social and sexual concerns. Fifty-six women had classical bladder exstrophy (CBE), 13 had female epispadias (FE) and 14 had cloacal exstrophy (CE). Data on the initial method of reconstruction and urogynaecological problems were obtained from a review of the hospital records. Information on continence, infection and sexual function was obtained from 34 completed surveys. RESULTS: The bladder was closed in 51 patients with CBE and 13 with CE. Urinary calculi developed in 10 patients with CBE, two with FE and three with CE. Vaginal and uterine prolapse occurred an earlier age in patients with EEC. Eight women had 13 pregnancies, eight of which resulted in normal healthy children. Overall continence was achieved in 85% of the women surveyed. Urinary tract infections remained a frequent problem for women with EEC; only 27% of respondents indicated that they were infection-free. Women aged > 18 years (24) who responded indicated that they had appropriate sexual desire; 16 were sexually active and the mean age for commencing sexual activity was 19.9 years. Six patients had dyspareunia and 10 indicated that they had orgasms. However, five additional patients indicated that they had restricted intercourse, as they were dissatisfied with the cosmesis of their external genitalia. CONCLUSIONS: Sexual and gynaecological issues become increasingly important in patients with EEC as they become adults. Understanding these issues faced by patients with EEC as they mature will permit better counselling of future patients.     

Initial bladder closure of the cloacal exstrophy complex: Outcome related risk factors and keys to success

Purpose

This study examines a large single-institution experience with cloacal exstrophy patients, analyzing patient demographics and surgical strategies predictive of bladder closure outcomes.

Methods

One hundred patients with cloacal exstrophy were identified. Complete closure history including demographics, operative history, and outcomes was available on 60 patients. Twenty-six patients with a history of failed initial bladder closure were compared to 34 with a history of successful initial bladder closure. Univariate logistic regression analysis was used to compare the two groups.

Results

Median follow up time after initial closure was 9 years (range: 13 months-29 years). A 1 cm increase in pre-closure diastasis resulted in a 2.64 increase in the odds of initial closure failure (p = 0.004). Protective strategies against failure included delaying closure (per month) (OR = 0.894, p = 0.009), employing pelvic osteotomies (OR = 0.095, p < 0.001), and applying external fixation (OR = 0.024; p = 0.001). Among patients who underwent osteotomy (31% of patients in the failed group, 82% in the successful group), a longer delay between osteotomy and closure (OR = 0.033; p = 0.005) was also protective against failure.

Conclusion

Patients with a large diastasis are more likely to fail initial closure. Delaying initial closure for at least 3 months, performing pelvic osteotomy, and using an external fixation device post-operatively are strategies that improve closure success.     

Impact of pelvic osteotomy on the incidence of inguinal hernias in classic bladder exstrophy

Background/purpose

The high prevalence of inguinal hernias in the bladder exstrophy population is well documented. The authors' aim is to determine whether pelvic osteotomy reduces the incidence of primary and recurrent inguinal hernias in patients with classic bladder exstrophy.

Methods

Using an institutionally-approved database, patients who underwent immediate or delayed primary bladder closure between 1974 and 2012 were identified and stratified by the use of pelvic osteotomy at the time of closure. Data were analyzed using Fisher's exact test and multivariate logistic regression analysis.

Results

One hundred thirty-six patients were identified with a median follow up of 8 years. The incidence of inguinal hernias following closure was 25% in the osteotomy group versus 46% in the non-osteotomy group (p = 0.017). Osteotomy was associated with a significant decrease in recurrence of inguinal hernias amongst patients who underwent previous repair (17% versus 47%, osteotomy versus non-osteotomy, p = 0.027) and the development of primary inguinal hernias in whom initial groin exploration was negative (20% versus 39%, p = 0.029). Osteotomy and female sex were associated with a decreased rate of inguinal hernia development after bladder closure while age at closure was not.

Conclusions

Pelvic osteotomy at the time of exstrophy closure decreases the likelihood of primary or recurrent inguinal hernia development.     

Achieving urinary continence in cloacal exstrophy: The surgical cost

Introduction

Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence.

Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery

BackgroundSuccessful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management.Material and MethodsWe reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay.Results66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13–34 d).ConclusionDelayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE.Level of EvidenceLevel III.     

Anterior innominate osteotomies for failure or late closure of bladder exstrophy

The bony pelvis was analyzed in 12 patients undergoing a further operation after initial bladder closure. Of the patients 5 had undergone a prior posterior osteotomy. All patients had wide diastasis of the pubis (average 5.5 cm.). In 9 of these patients late closure or reclosure of a failed initial bladder repair was done and 3 underwent a repeat bladder neck reconstruction. In all patients a new procedure, anterior iliac osteotomy with internal or external fixation, was performed. This procedure provides increased mobility of the pubis and increased correction. It avoids turning of the patient while under anesthesia for repeat preparation and in most cases postoperative traction is not needed. There were no instances of dehiscence, nonunion or infection. Three cases of transient femoral palsy were noted. All patients had a normal gait 4 months postoperatively. The mobility obtained after anterior osteotomy allows for excellent approximation. In view of evidence that approximation of the pubis improves closure and eventual continence results, we believe that osteotomies, even when repeated, are useful in revision surgery if there is bony diastasis.     

Injectable polydimethylsiloxane for treating incontinence in children with the exstrophy-epispadias complex: long-term results

OBJECTIVE: To present our experience with the use of injectable polydimethylsiloxane (Macroplastique, Uroplasty, Minneapolis, MI, USA) for treating incontinence in children with the exstrophy-epispadias complex (EEC), as incontinence continues to be a challenging problem in such children, and although the primary management of EEC has developed over the last few decades, with early closure and reconstruction of the penis, achieving satisfactory continence status remains elusive. PATIENTS AND METHODS: We retrospectively reviewed the hospital records of 52 patients (41 boys and 11 girls, mean age at first injection 6.6 years, range 3.6-16.7) with EEC who had injections with Macroplastique between January 1991 and February 2004; 34 had bladder exstrophy and 18 primary epispadias. For this study we defined success as complete dryness with no use of pads or nappies. Improvement was defined as being occasionally wet but with dry intervals lasting >or= 4 h. RESULTS: The mean (range) follow-up was 4.6 (0.5-9) years. Twenty patients had one injection, 10 had two, 13 had three, six had four, two had six and one had seven injections. In most patients a maximum of three injections predicted the outcome. The injection of Macroplastique was successful in nine patients (17%; with an annual follow-up, two at 1-2 years, three at 2-5 years and four at >5 years), whilst 17 (33%) improved significantly (one at <1 year, two at 1-2 years, eight at 2-5 years and six at >5 years). Those patients comprised five of 18 (27%) with epispadias and four of 34 (12%) with exstrophy. A history of previous surgery and gender had no significant effect on the outcome. Overall half the patients benefited from the procedure. CONCLUSIONS: This series confirms that injection with Macroplastique is minimally invasive, durable in significantly many patients and has a reasonable success rate. A history of previous surgery and gender had no significant effect on the outcome. Patients with epispadias are more likely to benefit from an injection with Macroplastique than those with bladder exstrophy. A maximum of three injections is predictive with reasonable certainty of any benefit from the procedure.     

Pelvic Floor Reconstruction in Female Exstrophic Complex Patients: Different Results from Males?

OBJECTIVES: To present the surgical, functional, and cosmetic results of anterior pelvic floor reconstruction in female exstrophic patients who underwent single-stage surgical repair. To verify differences in outcome from male exstrophic patients. METHODS: Among the 31 exstrophy-epispadias complex (EEC) patients treated in 10 yr, 13 (42%) were females. We studied 10 of them (9 classic exstrophies and 1 prolapsing epispadia), aged 2 d to 6 yr, who received one-stage repair with pelvic floor reconstruction. The reconstructive steps were posterior pelvic osteotomy, en bloc mobilisation of bladder neck-urethra/vagina within the midline pelvic floor, symmetrical reassembly of the muscular complex that constitutes the pelvic diaphragm (using a bipolar stimulator), tubularisation and elongation of the bladder neck and urethra, and genitoplasty. At 2- to 3-yr follow-up, bladder capacity and dry intervals were evaluated by cystogram and urodynamic study, respectively. Surgical complications and cosmetic appearance were also assessed. Results were compared with a group of 18 male EEC patients treated in the same period with similar technique. Fisher exact test and chi-square test were used for statistical analysis. RESULTS: No bladder/urethra dehiscence, exstrophy relapse, or uterine procidentia were observed. Cosmesis was fully satisfying in all. Bladder capacity ranged from 35 to 137 ml (mean: 87). Cyclic voiding with 45- to 90-min dry intervals was achieved in 7 patients (70%), but stress incontinence was present in 5 patients. Volitional micturition control was achieved in 5 of 6 (83.3%) girls aged 4-8 yr. In the male group, we observed two surgical complications (glans disruption and urethrocutaneous fistula) and one poor cosmetic outcome. Mean bladder capacity was 70 ml (range: 25-140). Dry intervals were present in 6 patients (33%). Volitional voiding was achieved in 5 of 12 (40%) male exstrophic patients older than 4 yr, with little stress incontinence. Female and male EEC patients presented significantly different outcomes (p<0.05) regarding both surgical complications and functional bladder behaviour. CONCLUSIONS: Pelvic floor reconstruction and its correct relationship with the lower genitourinary tract may facilitate the development of volitional micturition control. Female patients behaved slightly better than males concerning dry intervals and coordinated bladder activity achievement.     

The exstrophy‐epispadias complex: is aesthetic appearance important?

OBJECTIVE: To show the relevance of cosmetic appearance in the adequate treatment of patients with exstrophy-epispadias complex (EEC), and to indicate that surgery by experienced teams can improve the long-term treatment forecast and the patient's body image. PATIENTS AND METHODS: From 1978 to 2002, 71 patients diagnosed with EEC were treated in the authors' institution; 24 (aged 2-23 years) were selected to undergo different surgical procedures. The criterion for surgery considered interviews conducted by the psychology team with the parents and children. The plastic surgery and paediatric urology teams carried out the procedures jointly; the follow-up was 0.33-7 years. RESULTS: Five female patients and six male had abdominoplasty to treat multiple scars; eight had intermittent catheterization conduits repositioned from the right iliac fossa to the umbilicus. Six female patients had plastic surgery of the external genitalia and three had a broad mobilization of the urogenital sinus. Thirteen male patients had a small penis and had the corpora cavernosa fully mobilized and the penis reconstructed. Five female patients and one male had anterior osteotomy. One patient with no left testis had it replaced and one patient with uterine prolapse had the uterus fixed to the posterior abdominal wall. Six patients had a second procedure, in two because the outcome of the initial operation was poor and in the others to complement the initial treatment. In all but one patient there was an improvement in the objective criteria, e.g. school absences, difficulty in establishing long-lasting social relationships and refusal to participate in sports activities. However, none of the patients would attempt sexual intercourse. CONCLUSIONS: Body image, self-esteem, sexuality, sexual function and fertility are deemed crucial by adolescents; in patients with EEC customised surgical procedures can give a satisfactory aesthetic outcome, and be a further reason for adequately following occasional urinary complications and renal function, to avoid loss to follow-up.     

Staged closure of the pelvis in cloacal exstrophy: first description of a new approach

PURPOSE: We describe a staged approach for pelvic closure in patients with cloacal exstrophy, and evaluate the technique for functional and cosmetic results. MATERIALS AND METHODS: Staged closure of the pelvis was performed in 5 patients 12 months to 14 years old with cloacal exstrophy at our institution, including some referred with a history of failed closure. The technique involves initial pelvic osteotomy followed by soft tissue and pelvic ring closure 2 to 3 weeks later. Clinical information is reviewed to assess the effectiveness of the technique. RESULTS: At a mean followup of 3.2 years (range 1 to 9) closure was successful in all 5 patients without technical problems or surgical complications, and with excellent functional and cosmetic results. CONCLUSIONS: This technique of staged pelvic closure may provide reliable initial or secondary repair in patients with cloacal exstrophy in whom 1-stage pelvic closure is unfeasible even with pelvic osteotomy.     

The importance of a successful initial bladder closure in the surgical management of classical bladder exstrophy: analysis of 144 patients treated at the Johns Hopkins Hospital between 1975 and 1985

The staged functional closure of classical bladder exstrophy has produced improved results for many urologists involved in the surgical management of this congenital anomaly. To determine which factors are most important for achieving a successful outcome (urinary continence with preservation of normal renal function) the 144 patients treated at The Johns Hopkins Hospital between 1975 and 1985 were reviewed. Of these patients 51 were managed entirely at our institution, while 93 had had the initial surgical treatment elsewhere. All patients who had undergone primary bladder closure and bladder neck reconstruction were divided into 2 groups: group 1--patients who had a successful initial bladder closure (an exstrophied bladder that is converted into a complete epispadias without wound infection, dehiscence or any degree of bladder prolapse on the first attempt) and group 2--children whose initial bladder closure was not successful. Both groups were analyzed with respect to bladder capacity at the time of bladder neck reconstruction, time required for the bladder to become sufficiently large for bladder neck reconstruction, urinary continence rate, and interval between bladder neck reconstruction and achievement of urinary continence. Patients in group 1 had the largest bladders at the time of bladder neck reconstruction (mean capacity 79 cc, p equals 0.03), shortest intervals between primary closure and bladder neck reconstruction (mean 3.5 years, p equals 0.006), highest urinary continence rate (92 per cent, p equals 0.002), and the shortest interval between bladder neck reconstruction and achievement of urinary continence (mean 1.5 years, p equals 0.18). These findings suggest that a successful initial bladder closure is an important factor for obtaining a larger bladder more quickly and for achieving a high urinary continence rate in patients with classical bladder exstrophy undergoing the staged functional bladder closure.     

Coping with bladder exstrophy: diverse results from early attempts at functional urinary tract surgery

OBJECTIVES: To report the long-term surgical outcome in a group of patients with bladder exstrophy treated from 1960 to 1982, and to assess physical health, social integration and sexual function, as attempts at functional closure during the development of this surgery resulted in patients with differing surgical status of the genitourinary organs. PATIENTS AND METHODS: A review of medical record archives revealed 36 patients; of these, seven had died, six were untraceable and six declined to participate, leaving 15 evaluable subjects (seven men and eight women, mean age at follow-up, 35 years). Data were collected from medical records and direct interviews were conducted using a semi-structured questionnaire, after obtaining informed consent. The Short Form-36 (SF-36) v2 Health Survey instrument was used to assess health and well-being. RESULTS: Three patients have retained the use of their bladder, and 11 had initial bladder closure but required (at a mean age of 3.1 years) various urinary diversions. Eight patients had a pelvic osteotomy. Of 27 functioning renal units, 25 are in reasonable to good condition. Six men and six women had genital reconstruction. Four men are capable of penetrative intercourse and ejaculate; six women manage penetrative intercourse and five have orgasms. All patients attended mainstream school and 13 achieved examination success. Nine patients took vocational training and 11 work full-time. Five patients are married and five are in long-term relationships. Two men have achieved three pregnancies and one women has had a child. The mean total SF-36 score (maximum 3600) was 2763 in men and 2235 in women. CONCLUSIONS: Surgery for bladder exstrophy has been developing for more than 40 years and the legacy of early attempts at functional closure is a population of adults who have a diversity of lower urinary tracts, good preservation of renal function overall and acceptable sexual function. They are usually robust, healthy and well-adjusted individuals functioning well in society, often in full-time employment and long-term relationships. Adolescent follow-up must be clearly focused, incorporating a multidisciplinary team approach to facilitate a seamless transition into adulthood.     

A new suture fixation technique for the Akin Osteotomy of the Proximal Phalanx: You don’t need any implant

BackgroundVarious fixation methods have been described for Akin osteotomy, based on using metal implants or transosseous sutures. The aim of this study was to evaluate radiological outcomes and complications of closing wedge Akin osteotomy based on a crossed suture configuration of the joint capsule rather than using implants. The null hypothesis is that a crossed suture has comparable radiological results to other techniques, with no additional complications.MethodsIt’s a retrospective study. Patients who underwent Akin osteotomy fixed either with implant or joint capsule suture between 2015 and 2018 were included. Distal articular set angle corrections in pre- and postoperative anteroposterior foot x-rays were calculated by 2 observers. Complications, such as pain, infection, non-union and need of surgery revision, was compared at 1 year follow-up.Results89 patients, 30 in the implant group and 59 in the suture group. Mean distal articular set angle corrections were 6.43 (SD 5.54) and 7.36 (SD 5.48) degrees in the implant and suture groups, respectively, without statistically significant differences (p 0.454). Complications were 2 local pain and 1 wound infection cases in the suture and implant groups, respectively (p 0.138, p 0.197).ConclusionAkin osteotomy with suture fixation yields comparable radiological results to metal implant fixation methods without increasing the associated complications.     

The fate of the upper urinary tract in exstrophy

PURPOSE: We evaluated the impact of reconstructive bladder procedures on the upper urinary tract in bladder/cloacal exstrophy. MATERIALS AND METHODS: A total of 57 patients underwent bladder neck procedures for urinary incontinence due to bladder exstrophy between 1988 and 2001. We correlated evidence of renal injury to urinary continence and type of surgery. Renal scarring and moderate/severe hydronephrosis were considered significant upper tract changes. RESULTS: Overall 27 patients (47%) underwent bladder neck closure, 38 (67%) augmentation cystoplasty and 44 (77%) a Mitrofanoff procedure. Mean interval since last continence procedure was 4.5 years and mean patient age at last followup was 11.7 years. Hydronephrosis was noted in 18 patients (32%) at last followup (after bladder neck reconstruction in 15). Renal scarring in 14 cases on dimercapto-succinic acid scan was evenly distributed regardless of the type of bladder neck procedure or presence of augmentation. Of 6 patients with grade 3 to 4 hydronephrosis 5 had renal scarring versus only 1 in the 39 without hydronephrosis (p <0.0001). Serum creatinine remained normal in 55 patients, mild renal insufficiency developed in 1 and renal transplantation was performed in 1. Two patients with persistent incontinence are anticipating an augmentation. CONCLUSIONS: Of our 57 patients with exstrophy 14 (24%) had significant upper tract damage in the form of renal scarring and/or moderate or severe hydronephrosis. The surgical method of achieving continence was not predictive of hydronephrosis or scarring. Bladder neck closure appears to provide better urinary continence and was equally safe with respect to hydronephrosis or scarring compared to patent forms of bladder neck reconstruction.