title: Delayed primary closure of bladder exstrophy: immediate postoperative management leading to successful outcomes.
abstract: OBJECTIVE
  To present the critical features of our postoperative plan for children undergoing delayed primary bladder closure because appropriate postoperative management is crucial to successful exstrophy repair.
  
  
  METHODS
  Using an institutionally approved database, patients with bladder exstrophy whose primary bladder closure was performed at least 1 month after birth were identified. All aspects of the postoperative management were reviewed.
  
  
  RESULTS
  A total of 20 patients (18 boys) were identified: 19 with classic bladder extrosphy and 1 with an exstrophy variant. The patients underwent closure at a mean age of 9.9 months. All patients underwent pelvic osteotomy and immobilization for an average of 34.8 days. Analgesia was administered by way of a tunneled epidural catheter in 90% of patients for an average of 18.8 days, and 12 patients (60%) required adjunct intravenous analgesia. Bilateral ureteral catheters and suprapubic tubes were used in all patients. Total parenteral nutrition was administered to 10 (83%) of 12 patients who underwent closure after 2000. All patients received preoperative antibiotics and 2 weeks of postoperative intravenous antibiotics that was followed by oral prophylaxis. The mean hospital stay was 6.3 weeks. With an average follow-up of 7.4 years, delayed closure was 100% successful.
  
  
  CONCLUSIONS
  Successful delayed primary closure of bladder exstrophy requires a multidisciplinary approach. The keys to success include osteotomy, pelvic immobilization, analgesia, nutritional support, maximal bladder drainage, and infection prophylaxis.
authors.affiliation: Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins School of Medicine, Baltimore, Maryland 21287, USA.
authors.forename: Nima
authors.initials: N
authors.lastname: Baradaran
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Stec
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Schaeffer
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
authors.forename: Ranjiv I
authors.initials: RI
authors.lastname: Mathews
mesh_terms: D058107:Abdominal Wound Closure Techniques; D019072:Antibiotic Prophylaxis; D001746:Bladder Exstrophy / Q000601:surgery*; D019468:Disease Management; D005260:Female; D006801:Humans; D007103:Immobilization; D007223:Infant; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010027:Osteotomy; D010289:Parenteral Nutrition, Total; D010384:Pelvic Bones / Q000601:surgery; D011182:Postoperative Care / Q000379:methods*; D020127:Recovery of Function; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014546:Urinary Catheterization