Cloacal exstrophy management in a low- and middle-income country (LMIC): comparative outcomes of direct versus staged closure and a multidisciplinary risk-stratified protocol

PurposeCloacal exstrophy represents a significant challenge for pediatric surgeons. A critical component of treatment involves bladder closure and reconstruction of the urethra, genitalia and pubic symphysis. The objective of this study is to describe and compare outcomes of patients with cloacal exstrophy based on the type of closure employed and to propose a multidisciplinary management protocol. MethodsA retrospective descriptive study was conducted on patients with cloacal exstrophy treated between 2008 and 2024. Demographic, clinical, surgical, and immediate post-operative (< 30 days) variables were recorded. The analysis was stratified into two groups based on the surgical approach: staged closure (SC) versus direct closure (DC). ResultsTwelve patients were evaluated. In the DC group (n = 5), three (60%) were male, with a mean birth weight of 2401 (+/- 488) g. The median age at the time of surgery was 9 days [interquartile range (IQR): 5526 days]. Cecal plate rescue was successfully achieved in 80% of cases, and the mean pubic diastasis was 4.65 (+/- 2.84) cm. The most frequent complication observed was surgical wound infection. In the SC group (n = 7), five (71.4%) were female, with a mean birth weight of 2046.67 (+/- 489.8) g. The median age at surgery was 62.5 days (IQR: 1116 days). Cecal plate rescue was successful in six (85.7%) patients, and the mean pubic diastasis was 5.16 (+/- 2.74) cm. The most common complication was surgical wound infection associated with external fixation. No statistically significant differences were observed. ConclusionThe outcomes of both techniques were comparable. In the DC group, males predominated, as this technique achieves greater phalloplasty length and was performed at an earlier age. The staged group included patients with higher risks of bladder closure dehiscence: lower birth weight, larger pubic diastasis, and associated cardiac comorbidities. This approach necessitates a specialized team of orthopedic surgeons for modern closure techniques, involving osteotomies and external fixators, which entail higher costs. Individualizing the surgical technique for bladder closure is critical. We recommend single stage closure for male neonates. A staged approach is advised for patients referred later in life with low birth weight, pubic diastasis > 5 cm, or hemodynamically significant cardiac comorbidities.