title: Initial bladder closure of the cloacal exstrophy complex: outcome related risk factors and keys to success.
abstract: OBJECTIVE
  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 9years (range: 13months-29years). A 1cm 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.
  
  
  CONCLUSIONS
  Patients with a large diastasis are more likely to fail initial closure. Delaying initial closure for at least 3months, performing pelvic osteotomy, and using an external fixation device post-operatively are strategies that improve closure success.
authors.affiliation: University of South Florida Morsani College of Medicine, Department of Urology, South Tampa Center of Advanced Health Care, Tampa FL 33606, USA. Electronic address: bshah52@gmail.com.
authors.forename: Bhavik B
authors.initials: BB
authors.lastname: Shah
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: Heather
authors.initials: H
authors.lastname: Di Carlo
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Surgery, Charlotte Bloomberg Children's Hospital, 1800 Orleans St., Baltimore, MD 21287, USA.
authors.forename: Seth D
authors.initials: SD
authors.lastname: Goldstein
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Pierorazio
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Inouye
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: Eric Z
authors.initials: EZ
authors.lastname: Massanyi
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: Adam
authors.initials: A
authors.lastname: Kern
authors.affiliation: The Johns Hopkins University School of Medicine, Department of Diagnostic Radiology, 600N. Wolfe Street, Baltimore, MD 21287, USA.
authors.forename: June
authors.initials: J
authors.lastname: Koshy
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Orthopaedics, The Johns Hopkins Outpatient Center, 601N. Caroline St., Room 5152, Baltimore, MD 21287, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Sponseller
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7302, Baltimore, MD 21287, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D001746:Bladder Exstrophy / Q000601:surgery*; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D001743:Urinary Bladder / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*
keywords: Bladder closure; Cloacal exstrophy; Exstrophy; Failure; Osteotomy