Delayed surgical treatment of children with exstrophy without approximation of the pubic bones, the use of displaced flaps and immobilization of the patient

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Abstract

BACKGROUND: Bladder exstrophy is one of the most difficult for the reconstruction of malformations.

AIM: This study aimed to evaluate the outcomes of delayed bladder closure in exstrophy in comparison with procedures in newborns and to test the hypothesis that the reliability of bladder closure does not decrease without closing the fascial defect between the rectus abdominis muscles and that the postoperative period is more favorable.

MATERIALS AND METHODS: Delayed closure of exstrophy without osteotomy, convergence of pubic bones, or flap movement was performed in 46 patients with classic bladder exstrophy. Among them, 34 were primary patients, and the remaining patients, who had a complete relapse of exstrophy as a result of suture divergence, had undergone unsuccessful surgery in other clinics 1–4 times (n = 12). In total, 25 were boys and 21 were girls who underwent surgery from 2006 to 2021.

RESULTS: Delayed bladder closure was successful in all 46 children (100%). No signs of acute pain were noted. Serious complications such as dehiscence of the sutures in the bladder and proximal urethra were not observed. Minor complications occurred in five patients, which resolved promptly.

DISCUSSION: In the treatment of exstrophy, successful primary bladder closure is critical to achieving future urinary continence. The elimination of the defect between the rectus abdominis muscles with the convergence of the pubic bones has significant drawbacks, including an increase in the operating time and trauma, need for blood transfusion, risk of orthopedic and neurological complications, and a more difficult postoperative period. The vast majority of the patients develop rediastasis. The authors proposed a more reliable method of delayed closure of exstrophy.

CONCLUSIONS: The presented method of bladder closure was 100% successful. The procedure was simplified technically, the surgery time was reduced, and the postoperative period proceeded more easily without prolonged pain syndrome, prolonged use of analgesics, and, in most cases, without blood transfusions.

About the authors

Vasily V. Nikolaev

Pirogov Russian National Research Medical University; Clinical and Research Institute of Emergency Pediatric Surgery and Trauma

Email: vasnik@yandex.ru
ORCID iD: 0000-0001-7815-4825

Dr. Sci. (Med.), Professor

Russian Federation, 22, Bolshaya Polyanka st., Moscow, 119180; Moscow

Nikita V. Demin

Clinical and Research Institute of Emergency Pediatric Surgery and Trauma; Peoples’ Friendship University of Russia

Email: doctor@drdemin.ru
ORCID iD: 0000-0001-7508-5019
SPIN-code: 2757-6028

Cand. Sci. (Med.), Leading Researcher

Russian Federation, 22, Bolshaya Polyanka st., Moscow, 119180; Moscow

Elizaveta A. Ladygina

Clinical and Research Institute of Emergency Pediatric Surgery and Trauma

Author for correspondence.
Email: doc.lizaladygina@yandex.ru
ORCID iD: 0000-0002-9916-419X

Postgraduate student

Russian Federation, 22, Bolshaya Polyanka st., Moscow, 119180

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Supplementary files

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2. Fig. 1. Exstrophy in a newborn

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3. Fig. 2. Scheme of closing the bladder and proximal urethra after suturing: a — Retziev’s tissue — the space is pushed cranially; b — the bladder neck is covered with Retziev’s adipose tissue

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4. Fig. 3. Anterior abdominal wall after surgery

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5. Fig. 4. Examples of long-term results of the procedures performed: a — anterior abdominal wall of a 6-year-old boy 2 years after the closure of exstrophy before plastic surgery of the penis and urethra; b — anterior abdominal wall of an 8-year-old girl with full urinary retention 7 years after the closure of exstrophy and 2 years after plastic surgery of the bladder neck

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