Sholklapper Tamir N, Crigger Chad, Haney Nora, Khandge Preeya, Wu Wayland, Sponseller Paul D, Gearhart John P
Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
J Pediatr Urol. 2022 Oct;18(5):586.e1-586.e8. doi: 10.1016/j.jpurol.2022.09.005. Epub 2022 Sep 15.
The addition of pelvic osteotomy to the armamentarium of tools for correction of classic bladder exstrophy (CBE) and cloacal exstrophy (CE) has undeniably served as one of the most effective advancements in improving the likelihood of successful primary bladder closure. Osteotomy-related complications have been studied and documented extensively in patients with CBE, yet evaluation remains limited in CE concordant with its relative rarity.
To compare orthopedic complications in patients with CBE and CE who underwent primary bladder closure with osteotomy.
A prospectively maintained, IRB-approved database of 1401 exstrophy-epispadias patients was reviewed for patients with CBE or CE after primary closure and pelvic osteotomy performed at a single institution from 1975 to 2021. Failed closure was defined as dehiscence, bladder prolapse, or vesicocutaneous fistula at any point. Surgery or anesthesia-related complications were captured within 6 weeks of osteotomy or closure.
A total of 146 patients were included in the analysis with 109 and 37 patients with CBE and CE, respectively. Between the CBE and CE cohorts, there were significant differences in median age at primary closure (68 days [IQR 10-260] vs 597 [448-734]; p < 0.001), diastasis width (4 cm IQR [3.8-4.6] vs 6.1 [5.0-7.2]; p < 0.001), osteotomy at time of closure (99.1% vs 75.7%; p < 0.001), and utilization of external hip fixation (67.9% vs 89.2%; p = 0.011). There was no significant difference by gender, osteotomy technique, or hip immobilization technique. Regarding exstrophy closure outcomes, there were 5 failures in the CBE group and 1 in the CE group (p = 1.000). Complications were experienced in 38.5% and 56.8% of CBE and CE patients (p = 0.054) with a significant difference in orthopedic complications (primarily consisting of superficial pin-site infections) between the cohorts (4.6% vs 16.2%, p = 0.031). There was no significant difference in grade 3 or higher complications between cohorts (5.5% vs 13.5%, p = 0.147).
This was the first study comparing orthopedic complications after osteotomy between CBE and CE, providing valuable insight into which factors vary among cohorts and which are associated with increased complication rates. Despite availability of high case numbers for these rare disorders, the analysis continued to be limited sample size and missing data for retrospective analysis.
While exstrophy closure success and overall complications rates are similar in patients with CBE and CE, patients with CE experience more superficial pin-site infections after pelvic osteotomy. External hip fixation may be associated with the increase in orthopedic complications, though further research is required to elucidate the underlying cause of these complications.
在经典膀胱外翻（CBE）和泄殖腔外翻（CE）的矫正工具中增加骨盆截骨术无疑是提高一期膀胱关闭成功率最有效的进展之一。CBE患者的截骨相关并发症已得到广泛研究和记录，但由于CE相对罕见，其评估仍然有限。
比较接受一期膀胱关闭并进行截骨术的CBE和CE患者的骨科并发症。
回顾了一个前瞻性维护、经机构审查委员会批准的数据库，该数据库包含1401例膀胱外翻-尿道上裂患者，这些患者于1975年至2021年在单一机构接受了一期关闭和骨盆截骨术。关闭失败定义为在任何时间出现裂开、膀胱脱垂或膀胱皮肤瘘。手术或麻醉相关并发症在截骨术或关闭术后6周内记录。
共有146例患者纳入分析，其中CBE患者109例，CE患者37例。在CBE组和CE组之间，一期关闭时的中位年龄（68天[四分位间距10 - 260] vs 597[448 - 734]；p < 0.001）、耻骨分离宽度（4 cm四分位间距[3.8 - 4.6] vs 6.1[5.0 - 7.2]；p < 0.001）、关闭时的截骨术（99.1% vs 75.7%；p < 0.001）以及外固定架的使用（67.9% vs 89.2%；p = 0.011）存在显著差异。在性别、截骨技术或髋关节固定技术方面无显著差异。关于膀胱外翻关闭结果，CBE组有5例失败，CE组有1例失败（p = 1.000）。CBE和CE患者的并发症发生率分别为38.5%和56.8%（p = 0.054），两组间骨科并发症（主要为浅表针道感染）有显著差异（4.6% vs 16.2%，p = 0.031）。两组间3级及以上并发症无显著差异（5.5% vs 13.5%，p = 0.147）。
这是第一项比较CBE和CE截骨术后骨科并发症的研究，为各队列之间哪些因素存在差异以及哪些因素与并发症发生率增加相关提供了有价值的见解。尽管这些罕见疾病有大量病例，但分析样本量仍然有限且存在回顾性分析的数据缺失。
虽然CBE和CE患者的膀胱外翻关闭成功率和总体并发症发生率相似，但CE患者在骨盆截骨术后出现更多浅表针道感染。外固定架可能与骨科并发症增加有关，不过需要进一步研究以阐明这些并发症的潜在原因。
