Are osteotomies necessary for bladder exstrophy closure?

摘要

One of the most important tenets of surgical technique is approximation of tissue without tension to facilitate healing and successful outcome. It is possible that this surgical principle is bypassed at times during the initial surgical repair of the newborn with bladder exstrophy (BE). The classic teaching has been that osteotomy is not necessary as an adjunct to BE closure performed within 72 hours of life due to the relative malleability of the pelvic bone. Some practitioners challenge this dogma by performing primary closure of BE beyond the neonatal period, absent osteotomy.In this issue of The Journal Mushtaq et al (page 193) present the cost, length of stay and other early postoperative outcomes for patients with BE in whom they performed initial bladder closure.1 As per routine, the bladder and proximal urethra were closed without osteotomy or postoperative immobilization. Age at closure ranged from 1 to 152 days. Of the 74 patients 4 required re-do closure for bladder rupture, bladder prolapse or urethral stenosis. Although not the focus of this report, the second stage, a radical soft tissue (Kelly) procedure, is planned for age 9 to 12 months without osteotomy.The surgical management of BE as described by Mushtaq et al1 prompts the question, "Are. osteotomies necessary for bladder exstrophy closure?" Based on the current report and other successful approaches that do not use osteotomy for primary repair of BE in the neonate or otherwise, the answer would appear to be no. In the well established Erlangen approach for the patient with BE with appropriate anatomy, bladder closure, bilateral ureteral reimplantation, bladder neck reconstruction (BNR), bilateral groin exploration and epi-spadias repair are performed at age 8 weeks without osteotomy.2 In contrast to Mashtaq1 and Ebert2 et al, others have preferred osteotomy in most if not all neonatal bladder exstrophy closures.