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How to close classic bladder exstrophy: Are subspecialty training and technique important?

Publication ,  Journal Article
Inouye, BM; Purves, JT; Routh, JC; Maruf, M; Friedlander, D; Jayman, J; Gearhart, JP
Published in: J Pediatr Urol
October 2018

INTRODUCTION: Successful primary closure is one of the main factors for achieving continence in a classic bladder exstrophy (CBE) patient. Even with contemporary management, patients still have failed primary closures. We sought to understand the role of training, surgical technique, and their impacts on outcomes of CBE closure. MATERIALS AND METHODS: A retrospective cohort study from the largest single-institution database of primary and re-closure CBE patients in the world was performed. Failed closure was defined as developing bladder outlet obstruction, wound dehiscence, bladder prolapse, or any need for a re-closure operation. Patient demographics and surgical factors were abstracted and analyzed. Multivariable analysis was performed to test for associations with successful exstrophy closure. RESULTS: Data from 722 patients were analyzed. On bivariate analysis, successful closure was associated with gestational age at presentation, time of closure, location of closure, credential of surgeon performing the closure, closure type, concomitant osteotomy, and type of immobilization. Multivariable analysis, adjusting for patient comorbidity and location of closure, demonstrated increased odds of failure for closure by pediatric surgeon compared with pediatric urologist (OR 4.32, 95% CI 1.98-9.43; p = 0.0002), closure by unknown credentialed surgeon (OR 1.86, 95% CI 1.15-2.99; p = 0.011), Complete Primary Repair of Exstrophy (CPRE) closure compared with Modern Staged Repair of Exstrophy (OR 2.05, 95% CI 1.29-2.99; p = 0.0024), and unknown closure type (OR 4.81, 95% CI 2.94-7.86; p < 0.0001) (Table). DISCUSSION: Many factors associated with failure on bivariate analysis can be explained by these patients presenting to a center of excellence or the selection bias of this cohort stemming from a single center database that have been previously published. However, the finding on adjusted multivariable logistic regression analysis that closure by a pediatric surgeon is associated with higher odds of failure is novel. The additional finding that CPRE closure is associated with failure is most likely secondary to these patients being referred to our institution after having been closed with CPRE which falsely increases its impact on closure failure. Nevertheless, as a center with a large exstrophy volume, this study draws from a cohort that is larger than any other. CONCLUSION: Classic bladder exstrophy closure should be performed at a center with pediatric urologists to ensure the best chance of a successful primary closure.

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Published In

J Pediatr Urol

DOI

EISSN

1873-4898

Publication Date

October 2018

Volume

14

Issue

5

Start / End Page

426.e1 / 426.e6

Location

England

Related Subject Headings

  • Urology & Nephrology
  • Urologic Surgical Procedures
  • Treatment Outcome
  • Retrospective Studies
  • Male
  • Infant, Newborn
  • Infant
  • Humans
  • Female
  • Cohort Studies
 

Citation

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Inouye, B. M., Purves, J. T., Routh, J. C., Maruf, M., Friedlander, D., Jayman, J., & Gearhart, J. P. (2018). How to close classic bladder exstrophy: Are subspecialty training and technique important? J Pediatr Urol, 14(5), 426.e1-426.e6. https://doi.org/10.1016/j.jpurol.2018.02.025
Inouye, Brian M., J Todd Purves, Jonathan C. Routh, Mahir Maruf, Daniel Friedlander, John Jayman, and John P. Gearhart. “How to close classic bladder exstrophy: Are subspecialty training and technique important?J Pediatr Urol 14, no. 5 (October 2018): 426.e1-426.e6. https://doi.org/10.1016/j.jpurol.2018.02.025.
Inouye BM, Purves JT, Routh JC, Maruf M, Friedlander D, Jayman J, et al. How to close classic bladder exstrophy: Are subspecialty training and technique important? J Pediatr Urol. 2018 Oct;14(5):426.e1-426.e6.
Inouye, Brian M., et al. “How to close classic bladder exstrophy: Are subspecialty training and technique important?J Pediatr Urol, vol. 14, no. 5, Oct. 2018, pp. 426.e1-426.e6. Pubmed, doi:10.1016/j.jpurol.2018.02.025.
Inouye BM, Purves JT, Routh JC, Maruf M, Friedlander D, Jayman J, Gearhart JP. How to close classic bladder exstrophy: Are subspecialty training and technique important? J Pediatr Urol. 2018 Oct;14(5):426.e1-426.e6.
Journal cover image

Published In

J Pediatr Urol

DOI

EISSN

1873-4898

Publication Date

October 2018

Volume

14

Issue

5

Start / End Page

426.e1 / 426.e6

Location

England

Related Subject Headings

  • Urology & Nephrology
  • Urologic Surgical Procedures
  • Treatment Outcome
  • Retrospective Studies
  • Male
  • Infant, Newborn
  • Infant
  • Humans
  • Female
  • Cohort Studies