title: Safety and efficacy of staged pelvic osteotomies in the modern treatment of cloacal exstrophy.
abstract: OBJECTIVE
  Staged pelvic osteotomy (SPO) prior to bladder closure has been shown to be a safe and effective method for achieving pubic approximation in cloacal exstrophy (CE) patients with extreme diastasis. However, SPO outcomes have never been compared to those for combined pelvic osteotomy (CPO) at the time of closure in CE patients.
  
  
  METHODS
  A prospectively maintained database of 1208 exstrophy-epispadias complex patients was reviewed for CE patients treated with pelvic osteotomies. Inclusion criteria were osteotomy at the authors' institution and closure within two months of osteotomy. After inclusion, patients were separated into four groups depending on osteotomy procedure (SPO vs. CPO) and whether their osteotomy occurred with primary closure or re-closure. Patient demographics, closure history, pre-operative diastasis measurement, most recent post-operative diastasis measurement, and outcomes were recorded and compared by chi-squared tests and ANOVA.
  
  
  RESULTS
  Among 116 CE patients reviewed, 46 met inclusion criteria. With primary closure or re-closure, 27 had SPO and 19 had CPO. No SPO re-closure patients had previous osteotomy; 4 CPO re-closure patients had a previous osteotomy with closure. Median time between osteotomy and closure in SPO patients was 14 days. Median follow-up after SPO and CPO were 4 and 11 years, respectively. SPO significantly reduced the pre-operative diastasis compared to CPO on most recent diastasis measurement (3.5 cm vs. 0.4 cm, p=0.003). There were no significant differences in the overall complication rate, or the rates of each specific complication, between the SPO and CPO groups. No patients had wound dehiscence or prolapse. One CPO patient was able to intermittently catheterize per urethra while all other patients required continent urinary diversion to achieve continence.
  
  
  CONCLUSIONS
  To the authors' knowledge, this is the first study comparing SPO and CPO outcomes in CE patients. SPO reduces pre-operative diastasis more than CPO, and does not appear to incur increased rates of complication, closure failure, or incontinence. Due to its apparent safety and greater efficacy, SPO should be considered in all CE patients with extreme diastases undergoing primary closure or re-closure.
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St. Suite 7204, Baltimore, MD, 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, 1800 Orleans St. Suite 7204, Baltimore, MD, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Tourchi
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St. Suite 7204, Baltimore, MD, USA.
authors.forename: Heather N
authors.initials: HN
authors.lastname: Di Carlo
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St. Suite 7204, Baltimore, MD, USA.
authors.forename: Ezekiel E
authors.initials: EE
authors.lastname: Young
authors.affiliation: The Johns Hopkins University School of Medicine, The Russell H. Morgan Department of Radiology and Radiological Sciences, Division of Pediatric Radiology, Baltimore, MD, USA.
authors.forename: Joyce
authors.initials: J
authors.lastname: Mhlanga
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 1800 Orleans St. Suite 7204, Baltimore, MD, USA.
authors.forename: Joan S
authors.initials: JS
authors.lastname: Ko
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Orthopaedics, Charlotte Bloomberg Children's Hospital, Baltimore, USA.
authors.forename: Paul D
authors.initials: PD
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, 1800 Orleans St. Suite 7204, Baltimore, MD, USA. Electronic address: Jgearha2@jhmi.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D000293:Adolescent; D001746:Bladder Exstrophy / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D008297:Male; D010027:Osteotomy / Q000379:methods*; D046548:Pubic Symphysis Diastasis / Q000601:surgery*; D012086:Reoperation; D013521:Urologic Surgical Procedures, Male / Q000379:methods*
keywords: Cloacal exstrophy; Pelvic osteotomy; Pubic symphysis diastasis