Complex bladder-exstrophy-epispadias management: causes of failure of initial bladder closure.

The success of the initial closure of the complex bladder-exstrophy remains a challenge in pediatric surgery. This study describes a personal experience of the causes of failure of the initial closure and operative morbidity during the surgical treatment of bladder-exstrophy complex. From April 2000 to March 2014, four patients aged 16 days to 7 years and 5 months underwent complex exstrophy-epispadias repair with pelvic osteotomies. There were three males and one female. Three of them had posterior pelvic osteotomy, one had anterior innominate osteotomy. Bladder Closure: Bladder closure was performed in three layers. Our first patient had initial bladder closure with polyglactin 4/0 (Vicryl ® 4/0), concerning the last three patients, initial bladder closure was performed with polydioxanone 4/0 (PDS ® 4/0). The bladder was repaired leaving the urethral stent and ureteral stents for full urinary drainage for three patients. In one case, only urethral stent was left, ureteral drainage was not possible, because stents sizes were more important than the ureteral diameter. Out of a total of four patients, initial bladder closure was completely achieved for three patients. At the immediate postoperative follow-up, two patients presented a complete disunion of the abdominal wall and bladder despite an appropriate postoperative care. The absorbable braided silk (polyglactin) used for the bladder closure was considered as the main factor in the failure of the bladder closure. The second cause of failure of the initial bladder closure was the incomplete urine drainage, ureteral catheterisation was not possible because the catheters sizes were too large compared with the diameters of the ureters. The failure of the initial bladder-exstrophy closure may be reduced by a closure with an absorbable monofilament silk and efficient urine drainage via ureteral catheterisation.