title: Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast.
abstract: OBJECTIVE
  Secure closure of the pubic diastasis during bladder exstrophy and epispadias repair decreases the abdominal wall tension at the time of reconstruction. Pelvic osteotomies are routinely performed at the time of abdominal wall and bladder reconstruction in order to more easily facilitate pubic symphyseal diastasis approximation. Postoperative pelvic immobilization is performed by methods that include modified Buck's traction, modified Bryant's traction, and spica casting. People undergoing closure often require inpatient hospitalization for 2-8 weeks because of the pelvic immobilization. The present study examined the findings from a clinical pathway for early discharge after complete primary repair of exstrophy (CPRE) and proximal epispadias repair with spica casting.
  
  
  METHODS
  The present study is a retrospective review of patients that underwent pelvic osteotomies with spica casting at the time of CPRE or proximal epispadias repair from November 2006 to March 2013. All patients had anterior innominate osteotomies and spica cast pelvic immobilization.
  
  
  RESULTS
  Pelvic osteotomies and spica cast pelvic immobilization were performed on 17 children. The median postoperative stay was 6.0 days and the subdivided results are in Table. No children experienced an abdominal or orthopedic complication. A few children required minor cast adjustments to relieve pressure. After cast removal, no skin breakdown, pressure necrosis, or nerve palsy were found. The median length of casting without pinning was 31 (26-48) days.
  
  
  CONCLUSIONS
  The use of spica cast pelvic immobilization after exstrophy and epispadias repair is safe and allows for earlier discharge when compared to other methods of pelvic immobilization. However, although the family appreciates early discharge and additional bonding, the priority is the success of the closure. The present findings demonstrate, and are corroborated by other spica cast publications, that spica casting is as effective as modified Bryant's traction or modified Buck's traction. The success rates for CPRE with spica casting are similar to published staged repairs and have the benefit of allowing for bladder cycling, which potentially enables better bladder growth and development. If success and complication rates are comparable amongst the different pelvic immobilization groups, then variables including hospital length of stay and cost become appropriate comparisons.
  
  
  CONCLUSIONS
  The shortened discharge time, along with a significant decrease in acuity of care leads to significant decreases in hospital costs. Additional hospital stay when using modified Bryant's traction or modified Buck's traction with external fixation will accrue significant hospital costs.
authors.affiliation: Medical College of Wisconsin, Department of Urology C4248, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA. Electronic address: bsack@mcw.edu.
authors.forename: Bryan S
authors.initials: BS
authors.lastname: Sack
authors.affiliation: Children's Hospital of Wisconsin, Pediatric Urology, 999 North 92nd St., Suite 330, Milwaukee, WI 53226, USA. Electronic address: jkryger@chw.org.
authors.forename: John V
authors.initials: JV
authors.lastname: Kryger
authors.affiliation: Children's Hospital of Wisconsin, Pediatric Urology, 999 North 92nd St., Suite 330, Milwaukee, WI 53226, USA. Electronic address: memitchell1@gmail.com.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Mitchell
authors.affiliation: Children's Hospital of Wisconsin, Pediatric Urology, 999 North 92nd St., Suite 330, Milwaukee, WI 53226, USA. Electronic address: cdurkee@chw.org.
authors.forename: Charles T
authors.initials: CT
authors.lastname: Durkee
authors.affiliation: Children's Hospital of Wisconsin, Pediatric Orthopedics, 999 North 92nd St, Milwaukee, WI 53226, USA. Electronic address: rlyon@chw.org.
authors.forename: Roger
authors.initials: R
authors.lastname: Lyon
authors.affiliation: Children's Hospital of Wisconsin, Pediatric Urology, 999 North 92nd St., Suite 330, Milwaukee, WI 53226, USA. Electronic address: tgroth@chw.org.
authors.forename: Travis W
authors.initials: TW
authors.lastname: Groth
mesh_terms: D001746:Bladder Exstrophy / Q000601:surgery*; D002370:Casts, Surgical; D002675:Child, Preschool; D019091:Critical Pathways; D004842:Epispadias / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010027:Osteotomy / Q000379:methods; D010351:Patient Discharge / Q000639:trends*; D046548:Pubic Symphysis Diastasis / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome; D013520:Urologic Surgical Procedures / Q000379:methods*
keywords: Bladder exstrophy; Epispadias; Osteotomy