title: Primary bladder exstrophy closure in neonates: challenging the traditions.
abstract: OBJECTIVE
  We describe a novel approach to neonatal bladder exstrophy closure that challenges the role of postoperative immobilization and pelvic osteotomy.
  
  
  METHODS
  We reviewed the primary management of bladder exstrophy at our institutions between 2007 and 2011. In particular we compared postoperative management in the surgical ward using epidural analgesia to muscle paralysis and ventilation in the intensive care unit. Clinical outcome measures were time to full feed, length of stay, postoperative complications and redo closure. Cost-effectiveness was also evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t-test.
  
  
  RESULTS
  A total of 74 patients underwent primary closure without osteotomy. Successful closure was achieved in 70 patients (95%). A total of 48 cases (65%) were managed on the ward (group A) and 26 (35%) were transferred to the intensive care unit (group B). The 2 groups were homogeneous for gestational age (median 39 weeks, range 27 to 41) and age at closure (3 days, 1 to 152). Complications requiring surgical treatment were noted in 4 patients (8.3%) in group A and 3 (11.5%) in group B (p = 0.609). Length of stay was significantly shorter for the group managed on the ward (11 vs 18 days, p <0.0001). Median costs were $42,732 for patients admitted to the intensive care unit and $16,214 for those admitted directly to the surgical ward (p <0.0001).
  
  
  CONCLUSIONS
  Primary closure of bladder exstrophy without lower limb immobilization and osteotomy is feasible. Postoperative care on the surgical ward using epidural analgesia results in shorter hospitalization.
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: I
authors.initials: I
authors.lastname: Mushtaq
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom; Department of Pediatric Surgery, UCL Institute of Child Health, London, United Kingdom.
authors.forename: M
authors.initials: M
authors.lastname: Garriboli
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: N
authors.initials: N
authors.lastname: Smeulders
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: A
authors.initials: A
authors.lastname: Cherian
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: D
authors.initials: D
authors.lastname: Desai
authors.affiliation: Department of Pediatric Surgery, UCL Institute of Child Health, London, United Kingdom.
authors.forename: S
authors.initials: S
authors.lastname: Eaton
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Duffy
authors.affiliation: Department of Pediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
authors.forename: P
authors.initials: P
authors.lastname: Cuckow
mesh_terms: D001746:Bladder Exstrophy / Q000191:economics / Q000601:surgery*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D017063:Outcome Assessment, Health Care; D011182:Postoperative Care; D019651:Plastic Surgery Procedures / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies
keywords: BE; CBEX; ICU; bladder exstrophy; classic bladder exstrophy; intensive care unit; osteotomy; urologic surgical procedures