title: Newborn exstrophy closure without osteotomy: Is there a role?
abstract: BACKGROUND
  Recent articles document successful classic bladder exstrophy (CBE) closure without osteotomy. Still, many patients require osteotomy if they have a large bladder template and pubic diastasis, or non-malleable pelvis.
  
  
  OBJECTIVE
  To understand the indications and outcomes of bladder closure with and without pelvic osteotomy in patients younger than 1 month of age.
  
  
  METHODS
  An institutional database of 1217 exstrophy-epispadias patients was reviewed for CBE patients closed at the authors' institution within the first month of life. Patient demographics, closure history, pubic diastasis distance, bladder capacity, and outcomes were recorded and compared using chi-square tests between osteotomy and non-osteotomy patients. Failure was defined as bladder dehiscence, prolapse, vesicocutaneous fistula, or bladder outlet obstruction requiring reoperation. Bladder capacity >100 mL was deemed sufficient for bladder neck reconstruction (BNR).
  
  
  RESULTS
  One hundred CBE patients were included for analysis: 38 closed with osteotomy (26 male, 12 female), and 62 closed without osteotomy (42 male, 20 female). There were four failed closures in the osteotomy group (2 dehiscence, 2 prolapse) and four failed closures in the non-osteotomy group (2 dehiscence, 2 prolapse). This corresponded to statistically equivalent rates of failure between the osteotomy and non-osteotomy groups (10.5% vs. 6.5%, p = 0.466). There was no statistically significant difference between the groups' ability to achieve bladder capacity sufficient for BNR (82% vs. 71%, p = 0.234).
  
  
  CONCLUSIONS
  A successful primary bladder closure, regardless of the use of osteotomy, has been shown to be the single most important predictor of eventual continence. Because of the complexity of exstrophy manifestations, a multidisciplinary team approach is of the utmost importance. Based on our institutional experience, closure without osteotomy is considered when patients are <72 h of life, have a pubic diastasis <4 cm, malleable pelvis, and pubic apposition without difficulty. Rates of successful closure and attaining sufficient capacity for BNR were both statistically equivalent across groups. This retrospective study is limited by selection bias and the significant difference in follow-up time between groups. Nevertheless, as a high-volume exstrophy center this study draws from one of the largest cohorts available.
  
  
  CONCLUSIONS
  Regardless of the type of closure undertaken, there clearly is a role for newborn CBE closure without pelvic osteotomy in patients considered suitable for closure by both the pediatric urologist and orthopedic consultant. However, if there is any doubt concerning pubic diastasis width, pelvic malleability, or ease of pubic apposition, an osteotomy is highly recommended.
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 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, Baltimore, MD, USA.
authors.forename: Kathy
authors.initials: K
authors.lastname: Lue
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Abdelwahab
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 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, Baltimore, MD, USA.
authors.forename: Ezekiel E
authors.initials: EE
authors.lastname: Young
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, 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, Baltimore, MD, USA.
authors.forename: Mehnaj
authors.initials: M
authors.lastname: Grewal
authors.affiliation: The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Hesh
authors.affiliation: The Johns Hopkins University School of Medicine, Division of Pediatric Orthopaedics, Charlotte Bloomberg Children's Hospital, Baltimore, MD, 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, Baltimore, MD, USA. Electronic address: Jgearha2@jhmi.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D001746:Bladder Exstrophy / Q000601:surgery*; D000075202:Contraindications; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D010027:Osteotomy; D010384:Pelvic Bones; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods*
keywords: Classic bladder exstrophy; Pelvic osteotomy; Pubic symphysis diastasis