Failed Primary Bladder Exstrophy Closure with Osteotomy: Multivariable Analysis of a 25-Year Experience

Pokket Sirisreetreerux, Kathy M. Lue, Thammasin Ingviya, Daniel A. Friedlander, Heather N. Di Carlo, Paul D. Sponseller, John P. Gearhart

A 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. This study aimed to identify factors that contribute to a failed primary exstrophy closure with osteotomy. A prospectively-maintained institutional database was reviewed for classic bladder exstrophy patients who were primarily closed with osteotomy at our institution or referred after primary closure from 1990 to 2015. Data were collected regarding gender, closure, osteotomy, immobilization, orthopaedics, and perioperative pain control. Univariate and multivariable analyses were performed to determine predictors of failure. 156 patients met inclusion criteria. Overall failure rate was 30% (13% from the authors' institution and 87% from outside centers). On multivariable analysis, use of Buck's traction (OR 0.11; 95% CI 0.02-0.60, p=.011) and immobilization time greater than 4 weeks (OR 0.19; 95% CI 0.04-0.86, p=.031) had significantly lower odds of failure. Osteotomy performed by general orthopaedic surgeons had significantly higher odds of failure (OR 23.47; 95% CI 1.45-379.19, p=.027). Type of osteotomy and use of epidural anesthesia did not significantly impact failure rates. Proper immobilization with modified Buck's traction and external fixation, immobilization time greater than 4 weeks, and having the osteotomy undertaken by a pediatric orthopaedic surgeon are crucial factors for a successful primary closure with osteotomy.