Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

Karl S. Benz, John Jayman, Mahir Maruf, Timothy Baumgartner, Matthew C. Kasprenski, Daniel A. Friedlander, Heather DiCarlo, Paul David Sponseller, John Phillip Gearhart

Research output: Contribution to journalArticle

Abstract

Introduction: Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. Methods: The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. Results: Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p. <. 0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p = 0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p = 0.059). Conclusion: Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years). Level of Evidence: Level III, Retrospective comparative study. Study Type: Therapeutic study.

Original languageEnglish (US)
JournalJournal of Pediatric Surgery
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Bladder Exstrophy
Immobilization
Lower Extremity
Newborn Infant
Traction
Urinary Bladder
Skin
Osteotomy
Epispadias
Retrospective Studies
Demography
Databases

Keywords

  • Cloacal exstrophy
  • Immobilization
  • Outcomes
  • Pediatric urology
  • Pelvic osteotomy

ASJC Scopus subject areas

  • Surgery
  • Pediatrics, Perinatology, and Child Health

Cite this

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children. / S. Benz, Karl; Jayman, John; Maruf, Mahir; Baumgartner, Timothy; Kasprenski, Matthew C.; Friedlander, Daniel A.; DiCarlo, Heather; Sponseller, Paul David; Gearhart, John Phillip.

In: Journal of Pediatric Surgery, 01.01.2018.

Research output: Contribution to journalArticle

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abstract = "Introduction: Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. Methods: The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. Results: Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2{\%}) of all closures, and in 36 (97.3{\%}) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9{\%}) closures, external fixation and skin traction in 43 (45.7{\%}), and spica cast and external fixation in 5 (5.3{\%}) closures. For all closures, there were 33 failures (71.7{\%}) among those immobilized with spica cast alone versus 4 failures (9.3{\%}) for those immobilized with external fixation and skin traction (p. <. 0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0{\%} and 9.3{\%} respectively (p = 0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7{\%} versus 23.3{\%}, p = 0.059). Conclusion: Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8{\%} failure rate) for postoperative management in an older child (1-2 years). Level of Evidence: Level III, Retrospective comparative study. Study Type: Therapeutic study.",
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AU - S. Benz, Karl

AU - Jayman, John

AU - Maruf, Mahir

AU - Baumgartner, Timothy

AU - Kasprenski, Matthew C.

AU - Friedlander, Daniel A.

AU - DiCarlo, Heather

AU - Sponseller, Paul David

AU - Gearhart, John Phillip

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N2 - Introduction: Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction. Methods: The authors reviewed an institutionally approved and daily updated database of 1311 patients with exstrophy-epispadias complex and identified patients with cloacal exstrophy born between 1975 and 2015 who had undergone primary or reoperative bladder closures. Only the closures that used spica casting or external fixation were included for analysis. Demographic, operative, and outcomes data were compared between patients with spica cast only and patients with external fixation and skin traction. Results: Out of 140 patients with CE or a CE variant, a total of 71 patients with 94 bladder closures (66 primary and 28 reoperative) met inclusion criteria. Median follow-up time was 8.8 years (range 1.5-29.1). There were 37 closures performed at the authors' institution and 58 from outside hospitals. Pelvic osteotomy was undertaken in 66 (70.2%) of all closures, and in 36 (97.3%) of closures at the authors' institution. Postoperative immobilization was achieved with spica cast alone in 46 (48.9%) closures, external fixation and skin traction in 43 (45.7%), and spica cast and external fixation in 5 (5.3%) closures. For all closures, there were 33 failures (71.7%) among those immobilized with spica cast alone versus 4 failures (9.3%) for those immobilized with external fixation and skin traction (p. <. 0.001). When restricted to closures performed with osteotomy, the failure rates were 50.0% and 9.3% respectively (p = 0.002). There was minimal differences in complication rates between spica and external fixation groups (8.7% versus 23.3%, p = 0.059). Conclusion: Failure of CE closure can occur with any form of pelvic and lower extremity immobilization. This study, however, provides continued evidence that external fixation with skin traction is an optimal, secure technique (3.8% failure rate) for postoperative management in an older child (1-2 years). Level of Evidence: Level III, Retrospective comparative study. Study Type: Therapeutic study.

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KW - Cloacal exstrophy

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