Pelvic and extremity immobilization after bladder exstrophy closure: Complications and impact on success

Objectives. A successful initial bladder closure is critical to the development of adequate bladder capacity and ultimate continence among patients with bladder exstrophy. Although secure pelvic fixation is essential to success, the various methods of pelvic and extremity immobilization and their impact on surgical outcome have not previously been examined. Methods. A review of the approved bladder exstrophy database at our institution identified 194 patients for whom data were available regarding initial bladder closure and the method of pelvic immobilization. The records were reviewed with respect to age at bladder closure, use/type of osteotomy, method of pelvic immobilization, complications related to the immobilization technique, and surgical outcome. Results. Of 194 patients identified, initial exstrophy closure failed in 86. Of these 86 patients, the initial closure failed in 80 at another hospital who were referred to our institution for additional treatment. Of the 114 initially closed at this institution, 6 failed. The success rates for initial and second closures were highest after osteotomy (75% versus 38% and 81.5% versus 27%, respectively), and when the patients were immobilized with an external fixator and 6 to 8 weeks of modified Buck's traction with osteotomy (96%) or 4 to 6 weeks of modified Bryant's traction without osteotomy (61%). The Spica cast and "mummy wrapping" immobilization techniques were less effective and were associated with significant complications. Conclusions. These results demonstrate that a successful exstrophy bladder closure depends on the proper use of the osteotomy and effective postoperative immobilization of the pelvis. Our best outcomes have been achieved using lower extremity traction (with or without external fixation of the pelvis).