title: Failed Primary Bladder Exstrophy Closure with Osteotomy: Multivariable Analysis of a 25-Year Experience.
abstract: Successful primary bladder exstrophy closure provides the best opportunity for patients to achieve a functional closure and urinary continence regardless of the method of repair. Use of osteotomy during initial closure has significantly improved success rates. However, failures can still occur. We identify factors that contribute to a failed primary exstrophy closure with osteotomy.
  
  
  
  We reviewed a prospectively maintained institutional database for classic bladder exstrophy cases primarily closed with osteotomy at our institution or referred after primary closure between 1990 and 2015. Data were collected regarding patient gender, closure, osteotomy, immobilization, orthopedics and perioperative pain control. Univariate and multivariable analyses were performed to determine predictors of failure.
  
  
  
  A total of 156 patients met inclusion criteria. Overall failure rate was 30% (13% from our institution and 87% from referrals). On multivariable analysis use of Buck traction (OR 0.11, 95% CI 0.02-0.60, p = 0.011) and immobilization time greater than 4 weeks (OR 0.19, 95% CI 0.04-0.86, p = 0.031) had significantly lower odds of failure. Osteotomy performed by general orthopedic surgeons had significantly higher odds of failure (OR 23.47, 95% CI 1.45-379.19, p = 0.027). Type of osteotomy and use of epidural anesthesia did not significantly impact failure rates.
  
  
  
  Proper immobilization with modified Buck traction and external fixation, immobilization time greater than 4 weeks and undergoing osteotomy performed by a pediatric orthopedic surgeon are crucial factors for successful primary closure with osteotomy.
authors.affiliation: Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Pokket
authors.initials: P
authors.lastname: Sirisreetreerux
authors.affiliation: Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Kathy M
authors.initials: KM
authors.lastname: Lue
authors.affiliation: Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Thammasin
authors.initials: T
authors.lastname: Ingviya
authors.affiliation: Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Friedlander
authors.affiliation: Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Heather N
authors.initials: HN
authors.lastname: Di Carlo
authors.affiliation: Division of Pediatric Orthopaedics, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Paul D
authors.initials: PD
authors.lastname: Sponseller
authors.affiliation: Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address: jgearhart@jhmi.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D001746:Bladder Exstrophy / Q000601:surgery*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D015999:Multivariate Analysis; D010027:Osteotomy; D011446:Prospective Studies; D013997:Time Factors; D017211:Treatment Failure
keywords: bladder exstrophy; bladder exstrophy and epispadias complex; osteotomy