title: Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex.
abstract: OBJECTIVE
  Staged pelvic closure has been shown to be beneficial in achieving pubic approximation in children with the exstrophy-epispadias complex. We have continued to use this procedure in children with extreme pelvic diastasis and have updated our experience.
  
  
  METHODS
  We performed closure of the pelvis in 15 patients 12 months to 14 years old presenting with a pubic diastasis of at least 8 cm (range 8 to 16). Of the patients 14 had cloacal exstrophy and 1 had classic exstrophy. Two patients with cloacal exstrophy and the patient with classic exstrophy had prior complete dehiscence at primary closure, and 1 patient with cloacal exstrophy had partial dehiscence. The technique involved bilateral innominate and vertical iliac osteotomy, and placement of a bony fixator with interfragmentary pins. The fixator was gradually closed, and soft tissue and pelvic ring closure occurred 2 to 3 weeks later. In 9 of the 15 patients an interpubic stainless steel plate was used to keep the pubis in apposition at the time of bladder closure.
  
  
  RESULTS
  At a mean followup of 5.5 years (range 6 months to 14 years) closure was successful in all 15 patients. One patient (age 12 months) had loosening of the pin between stages, which was salvaged with pin replacement. One patient had ureteral obstruction from hematoma after pin placement without direct pressure from the pins or bone. None of the patients had dehiscence or prolapse.
  
  
  CONCLUSIONS
  This technique of staged pelvic closure can be used in the setting of primary or secondary pelvic reconstruction in patients presenting with extreme pelvic diastasis. The gradual reduction in diastasis allows gradual stretching of the soft tissues. It converts a major reconstruction challenge into 2 well tolerated components. However, the procedure is not recommended in children younger than 1 year due to the possibility of the pins loosening during diastasis reduction.
authors.affiliation: Division of Pediatric Urology, Johns Hopkins School of Medicine, Baltimore, Maryland 21287-2101, USA. rmathews@jhmi.edu
authors.forename: Ranjiv
authors.initials: R
authors.lastname: Mathews
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
authors.forename: Rishi
authors.initials: R
authors.lastname: Bhatnagar
authors.forename: Paul
authors.initials: P
authors.lastname: Sponseller
mesh_terms: D000293:Adolescent; D001746:Bladder Exstrophy / Q000150:complications*; D002648:Child; D002675:Child, Preschool; D004842:Epispadias / Q000150:complications*; D006801:Humans; D007223:Infant; D008297:Male; D046548:Pubic Symphysis Diastasis / Q000209:etiology* / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods