Abstract
Background: Classic bladder exstrophy is a developmental defect
presenting at birth with a wide pubic separation and an exposed
bladder; cloacal exstrophy involves, in addition, intestinal prolapse.
Reconstruction requires several surgical procedures. The use of
anterior iliac osteotomies in this process has not been reviewed
in a large series.
Methods: We reviewed the results of eighty-six anterior innominate
osteotomies performed in conjunction with genitourinary repair of
classic and cloacal bladder exstrophy in eighty-two patients. Clinical outcome
measures were successful bladder closure, achievement of continence,
and maintenance of a normal gait. Radiographs of the pelvis were reviewed,
and the pubic intersymphyseal diastasis (a measure of the reduction
in tension on the anterior closure) was measured preoperatively
and at three time-points postoperatively. Children with classic
exstrophy who had undergone osteotomy and bladder neck reconstruction
but not bladder augmentation were divided into four groups on the basis
of the degree of continence. In addition, children with classic
exstrophy were stratified according to age at the time of the osteotomy.
The mean postoperative percent reduction in the amount of the original
diastasis was determined for all groups.
Results: Children with classic exstrophy and those
with cloacal exstrophy had correction of the diastasis after the
osteotomy, with greater correction in those with classic exstrophy,
presumably because of better bone quality. Daytime continence was
achieved with anterior osteotomy and bladder neck reconstruction
in 74% of the children for whom continence was a goal. However,
no difference in the symphyseal diastasis or in the percentage of
pubic reduction was detected among the four continence groups. Children
who were older at the time of the osteotomy maintained better correction
over time. Wound dehiscence or bladder prolapse occurred in 4% of
the patients who had osteotomy and primary closure, and the only
important complication of the osteotomies was transient palsy of
the left femoral nerve in seven children.
Conclusions: Anterior innominate osteotomy is an
effective part of reconstructive repair of bladder exstrophy. The primary
goals of the osteotomy are to reduce the tension in the closed bladder
and the lower abdominal wall and to promote continence by restoring
the sling of the pelvic floor muscles. These goals can be achieved
in the majority of patients.
The bladder exstrophy-epispadias complex is a congenital
disorder that involves the genitourinary tract, the musculoskeletal
system, and sometimes the intestinal tract. Classic bladder exstrophy involves
the first two organ systems, whereas cloacal exstrophy involves
all three. Exstrophy of the bladder results from abnormal anterior
rupture of the cloacal membrane early in the embryonic period. Mesenchymal
ingrowth into the abdominal wall is therefore inhibited. Since the
pelvis is derived from sclerotomal components of the mesenchyme,
the development of the pelvis may be affected by this altered migration
of mesenchyme. Studies of the pathoanatomy of the pelvis in children
with classic exstrophy have shown that, on each side, the posterior
part of the pelvis is externally rotated about 12°, the acetabula
are retroverted, and the pubic rami are 30% shorter than the normal
length1. The prevalence of classic
bladder exstrophy is approximately one per 40,000 children, whereas
the prevalence of cloacal exstrophy is one per 200,000 children2,3. Children born with bladder exstrophy
have an exposed bladder and a wide diastasis of the pubic rami resulting
in an open pelvic ring. The musculoskeletal function appears to
be normal throughout childhood; the gait is characterized by external
foot progression, which lessens with growth1,
even if osteotomy is not performed.
Several types of pelvic osteotomies have been developed to help
to close the pelvic ring and to decrease the stress on the abdominal
wall during initial exstrophy closure and to improve the outcome
of future genitourinary reconstruction2.
Shultz was the first, as far as we know, to describe bilateral posterior
iliac osteotomy as part of a two-stage repair of bladder exstrophy3. The earliest outcome studies of
this osteotomy were done by O'Phelan4 and
by Aadalen et al.5. This osteotomy
has been shown to lower rates of wound dehiscence and to help to
obtain a more secure and better genitourinary reconstruction than is
obtained with reconstruction without osteotomy4,5.
The success in achieving continence has been reported to be related
to the reduction in the diastasis and has been thought to result
from better approximation of the muscles of the pelvic floor around
the urethra5.
The sequence of bladder exstrophy reconstruction involves primary
closure of the bladder and abdominal wall in the newborn period,
epispadias repair around the age of one or two years in boys, and bladder
neck reconstruction around the age of three or four, when the child
is mature enough to maintain dryness. Patients may undergo pelvic
osteotomy at one of these stages if the diastasis prevents attainment
of these urologic goals. In general, we rarely perform osteotomy
on newborns because the laxity of the sacroiliac ligaments allows
closure of the defect without undue tension.
Other types of osteotomies that have been used include bilateral
osteotomy of the superior pubic ramus6-10,
diagonal osteotomy of the iliac wing11,
and anterior innominate osteotomy12,
with or without posterior innominate osteotomy13.
The anterior innominate osteotomy was developed for several reasons.
The osteotomy is performed with the patient in the supine position
as is the urologic repair, thus avoiding the need to turn the patient.
The anterior osteotomy also allows placement of an external fixator
under direct vision12. A greenstick-type
closing-wedge osteotomy of the ilium is also performed adjacent
to the sacrum in most patients who are more than two years old.
We analyzed all pelvic osteotomies performed at our institution
to assess the success of the combined procedure (osteotomy and urologic
reconstruction) in achieving closure and continence and the degree to
which the pubic diastasis was corrected and maintained. Since it
was our impression that the children who had osteotomies early in
life had less correction of the pubic diastasis as they grew, we examined
the effect of age on the amount of final correction. In addition,
we studied the relationship of diastasis correction to continence,
as some surgeons have hypothesized that it is important to achieve
approximation of the pelvic floor muscles to achieve good urinary
continence. Finally, we assessed the complications of the osteotomies
to gain a more complete picture of the costs as well as the benefits
of this approach.
We reviewed the cases of all of the children in whom anterior
innominate osteotomy was performed as part of reconstructive surgery
of the bladder exstrophy complex at our institution from 1988 to
1996. A total of ninety-two bilateral anterior innominate osteotomies
(with or without posterior osteotomies) were performed in eighty-eight
children. Four repeat osteotomies were performed because of failure
of the primary closure and a need for reapproximation at the time
of bladder neck reconstruction in two patients each. Of the eighty-eight
children, four had less than two years of follow-up and two were
lost to follow-up. The remaining eighty-two children were included
in the study. Ten of these children had cloacal exstrophy and seventy-two,
classic exstrophy. The mean age (and standard deviation) at the
time of the operation was 2.9 3.7 years (range, birth to thirteen
years), and all patients had at least two years (mean, 4.8 years) of
clinical follow-up. Thirty-eight procedures (thirty-six in patients
who had classic exstrophy and two in patients who had cloacal exstrophy) consisted
of anterior osteotomies only, and forty-eight (forty in patients
who had classic exstrophy and eight in patients who had cloacal
exstrophy) consisted of anterior and posterior osteotomies. Data
on the bilateral osteotomies in the eighty-two patients were analyzed
as described below.
Twenty-nine children who had had primary closure of the defect
(with a pelvic osteotomy in twenty and without it in nine) had wound
dehiscence and/or bladder prolapse and presented for repeat closure. (In
all cases in which bladder prolapse occurred, the pelvic diastasis
recurred.) Ten of these patients underwent anterior osteotomies
only, and nineteen had combined anterior and posterior osteotomies. We
performed innominate osteotomy with initial exstrophy closure in
twenty-one infants (fourteen had anterior osteotomies only and seven,
anterior and posterior osteotomies) who were first seen at our institution.
Thirty children had osteotomies at the time of reconstruction of
the bladder neck to restore continence because they had a wide diastasis
and they lacked a firm fibrocartilaginous bar from which to suspend
the bladder neck. In addition, three children had anterior osteotomies
as part of an epispadias repair and three had perineal or abdominal
wall reconstruction with anterior and posterior innominate osteotomies.
As four patients required repeat osteotomies, eighty-six procedures were
performed on eighty-two patients.
Technique of Anterior Innominate Osteotomy
Anterior innominate osteotomy is performed by first placing the
patient in the supine position, preparing and draping the lower
part of the body below the costal margin, and placing absorbent
gauze with a sterile barrier drape over the exposed bladder. Oblique
incisions are made inferior to the anterior superior iliac spine
as described for the Salter osteotomy12,14
(Fig. 1-AFigs.
1-A, Fig. 1-B, Fig. 1-C, and Fig. 1-D). The femoral
nerve is exposed by incising the fascia superficial to it. Each
side of the pelvis is exposed subperiosteally from the iliac wings
inferiorly to the pectineal tubercle and posteriorly to the sacroiliac
joint. The periosteum of the sciatic notch is elevated carefully,
and a Gigli saw is used to create a transverse iliac osteotomy,
exiting anteriorly at a point halfway between the anterior superior
and anterior inferior spines. This osteotomy is created at a slightly
more cephalad level than that described for a Salter osteotomy,
in order to allow placement of external fixator pins in the distal
segments.
For patients who are more than two years old or who have cloacal
exstrophy, an additional osteotomy of the posterior part of the
ilium may be performed through the anterior approach to facilitate complete
correction of the deformity. This step is important because anatomical
studies have shown that the posterior portion of the pelvis is externally rotated
in patients with exstrophy, and older patients lose the elasticity
of the sacroiliac ligaments1.
We believe that failure to correct the external rotation of the
iliac wings in these patients results in tightening of the inguinal
ligament over the femoral nerve as the pubic diastasis is narrowed.
This region may be approached by continuing the subperiosteal dissection
of the medial surface of the iliac wing posteriorly to the sacroiliac
joint. Often there is a nutrient vessel to the ilium in the middle
of the wing, and bleeding from this vessel should be controlled
with cautery or bone wax. A rongeur or a burr is then used to create
a closing-wedge osteotomy vertically (longitudinally) by removing
cortical and cancellous bone from the anterior portion of the ilium
just lateral to the sacroiliac joint13.
The osteotomy should be performed at least a centimeter away from
the sacroiliac joint. The sclerotic cortical bone proximal to the
sciatic notch should be divided completely. The more pliable proximal part
of the posterior iliac cortex is left intact and used as a hinge.
This combination of osteotomies corrects the abnormalities in both
the anterior and the posterior part of the pelvis.
Two threaded fixator pins are placed in the inferior pelvic segment,
and two pins are placed in the wing of the ilium superiorly. An
anteroposterior radiograph of the pelvis is made to confirm pin
placement, soft tissues are closed, and the urologic procedure is
then performed. At the end of the procedure, in order to cover the
repaired bladder, the pelvis is closed with a horizontal mattress
suture placed within the pubic bone on each side. In patients who
were more than about eight years old, we recently used supplemental
internal fixation across the diastasis. The fixation device consists
of a two-hole plate, with one screw directed from medial to lateral
in the medullary canal of each superior pubic ramus (Fig. 4-BFig. 4-B).
This helps to achieve and to maintain correction in these most difficult
cases. The lower abdominal wall muscles then are closed, and external
fixator bars are applied between the pins to hold the pelvis in
the corrected position.
Postoperatively, patients remain supine with the lower extremity
in light skin traction for approximately four weeks to prevent dislodgment
of the vesicostomy tubes and destabilization of the pelvis. If radiographs
made seven to ten days postoperatively do not show complete reduction
of the symphyseal diastasis, it can be gradually approximated with
use of the fixator bars over several days. The external fixator
is left in place for approximately six weeks, until adequate callus
is seen at the osteotomy sites12,13.
In newborns, the pelvic bones may be too soft to allow secure pin
fixation, and only skin traction, with the hips flexed to 90 and
adducted to the midline, is used.
Radiographic Analysis
Symphyseal diastasis was measured at four time-points: (1) at
the examination performed a few days before the surgery (preoperative),
(2) on the first radiograph made within one week after the surgery (postoperative),
(3) at three months after the osteotomy (six weeks after removal
of the external fixator), and (4) at the time of the latest follow-up.
The diastasis was determined by measuring the distance between the
two most medial points of the pubic rami. The hips were examined
for any evidence of dysplasia, and the osteotomy sites were examined for
healing.
The percentage of pubic approximation was calculated according
to the following formula:
The denominator in the equation is corrected for the 1-cm symphyseal
diastasis that is present throughout life in normal individuals
(unpublished data, 1990). The measurements of the diastasis at the three-month
and latest follow-up evaluations were used for the "postoperative
diastasis" in the formula. In patients who required repeat osteotomy, only
the results of the last procedure were analyzed because this procedure
had the longest duration of follow-up.
Degree of Continence and Percentage
of Pubic Approximation
Thirty-eight children with classic exstrophy who had undergone
bladder neck reconstruction but not bladder augmentation and/or
stoma construction and thus could voluntarily void through a reconstructed
urethra were stratified, according to the level of continence, into
four categories: excellent (dry during the day and at night, with
occasional stress incontinence), good (dry for more than three hours
during the day and wet at night), fair (dry for two to three hours),
and poor (dry for less than two hours).
The mean percentage of pubic approximation and the mean pubic
diastasis were calculated at three months and at the final follow-up
evaluation for each continence group. In addition, the same analysis
was performed to compare the patients with excellent and good continence
as a combined group with those with fair and poor continence as
a combined group.
Age at the Time of the Osteotomy and
Percentage of Pubic Approximation
Patients with classic exstrophy were stratified into five groups
according to the age at the time of the osteotomy: (1) birth to
six months, (2) more than six months to eighteen months, (3) more
than eighteen months to twenty-four months, (4) more than two years
to five years, and (5) more than five years. The wide spectrum of
ages at the time of the operation reflects the various problems
that were addressed: initial closure, revision of failed closure, bladder
neck reconstruction, or perineal reconstruction. The mean percentage
of pubic approximation (as described above) and the mean diastasis
at three months and at the time of the final follow-up were determined
for each age-group.
Gait and Motor Examination
At the most recent examination, patients were observed while
they were walking to determine whether they had a limp. In addition,
the parents were questioned about whether the child had any pain
in the pelvis or lower extremities, any limitation in running or
playing, or a limp during these activities.
Statistical analysis was done with use of two-sample t tests
for groups with unequal variance. The level of significance was
set at p < 0.05.
Surgical Outcome and Complications
The mean estimated blood loss (and standard deviation) was 120 ± 106 ml for anterior innominate osteotomies alone and
176 ± 114 ml for anterior and posterior osteotomies.
The mean total time that the external fixator was worn was 6.1 ± 1.6 weeks. For the eighty children (eighty-four procedures)
who had traction in addition to external fixation, the mean time
in traction was 4.3 ± 1.3 weeks. For the
two newborns for whom external fixation was not considered appropriate
and who were treated with traction only, the time in traction was
three and four weeks.
Postoperative complications included transient palsy of the left
femoral nerve, which resolved at a mean of twelve weeks postoperatively,
in seven patients. This complication occurred after anterior innominate
osteotomy in five patients and after combined anterior and posterior
innominate osteotomies in two patients. This difference reached
significance (p = 0.04). None of the patients had palsy of the right
femoral nerve, although the same surgeon performed the same technique
on both sides. The palsies all resolved spontaneously and fully. The
patients were managed with bed rest for the first six to eight weeks,
and then they wore a knee-immobilizer for the remaining six to eight
weeks until quadriceps weakness resolved.
Other complications included delayed union of the anterior iliac
osteotomy site (three patients), superficial infection at the site
of the iliofemoral incision that required irrigation and d�bridement
(one patient), transient abductor weakness in the right thigh (one
patient), an infection around a pin in the ilium that required irrigation
and d�bridement (one patient), and transient motor palsy involving
the right peroneal nerve (one patient). In addition, one child had
a persistent, mild left Trendelenburg gait of unknown cause (see
below). Postoperative skin inflammation occurred commonly around
the fixator pins, and it was usually controlled with oral antibiotics.
One child had bladder prolapse after bilateral anterior and posterior
innominate osteotomies and primary closure. Wound dehiscence developed
after primary closure and pelvic osteotomy in another child when
he had a respiratory syncytial virus infection, which caused severe
respiratory distress with labored, abdominal breathing. These were considered
failures of closure with anterior innominate osteotomy. Both patients
had classic exstrophy.
Four patients in our study required repeat osteotomies, which
we performed. All had had the initial osteotomies before the first
year of life. In addition to the two patients in whom the closures
failed (as described above), two others, in whom the defect had
been closed when they were infants, had development of a diastasis
and lacked a firm bar of symphyseal tissue from which to suspend
the bladder neck at the time of bladder neck reconstruction. Therefore,
repeat osteotomies were performed concomitantly at the suggestion
of the urologist. No particular technical difficulties were encountered during
these repeat osteotomies or during those performed after an osteotomy
done at another hospital, except for increased difficulty in isolating
the superficial cutaneous branch of the femoral nerve.
Symphyseal Diastasis
The mean symphyseal diastasis at each time-point in the patients
with classic exstrophy and those with cloacal exstrophy is shown
in Figure 2Figure
2. Both the patients who had classic exstrophy and those who had
cloacal exstrophy had a decrease in the symphyseal diastasis after
the surgery, although those with classic exstrophy obtained greater
correction toward normal (Fig. 3-AFigs. 3-A, Fig. 3-B3-B, and Fig. 3-C3-C). Patients
with classic exstrophy had a mean diastasis (and standard deviation)
of 5.1 ± 1.2 cm preoperatively, which was
corrected to 1.8 ± 0.6 cm postoperatively
and measured 2.5 ± 0.8 cm at three months
postoperatively and 3.7 ± 1.1 cm at the time
of the latest follow-up (mean, 4.8 years). Patients with cloacal
exstrophy had a mean diastasis of 8.1 ± 3
cm preoperatively, which was corrected to 2.7 ± 1.4
cm postoperatively and measured 4.5 ± 1.2
cm at three months postoperatively and 5.8 ± 3.4
cm at the time of the latest follow-up (mean, 4.6 years). The goal
of relaxing the tension on the midline repair and allowing successful
closure of the bladder and lower abdominal wall was achieved in
all of the patients with cloacal exstrophy (Fig. 4-AFigs. 4-A and Fig. 4-B4-B).
Continence and Diastasis
Of the patients with classic exstrophy who had undergone osteotomy
and bladder neck reconstruction but not bladder augmentation, and
therefore for whom continence was a goal, seventeen had excellent
continence; eleven, good; seven, fair; and three, poor. The patients
with excellent continence had a mean correction of the diastasis
(and standard deviation) of 63% ± 18% at
three months and 37% ± 22% at the time of
the latest follow-up. The patients with good continence had a mean
correction of 62% ± 33% at three months and
24% ± 45% at the time of the latest follow-up.
The patients with fair continence had a mean correction of 64% ± 18% at three months and 41% ± 17%
at the time of the final follow-up. The patients who had poor continence
had a mean correction of 79% ± 13% at three
months and 53% ± 29% at the time of the final
follow-up. With the numbers available, there was no significant
difference among any of the groups, stratified according to the
degree of continence, with respect to the mean diastasis or the
percentage of correction of symphyseal diastasis (at either time-point).
In addition, there was no significant difference in the mean diastasis
or the percentage of correction when the patients with excellent
and good continence as a combined group were compared with the patients with
fair and poor continence as a combined group. None of the patients
had increasing reflux of urine into the ureters or more than one
urinary tract infection per year.
Age at the Time of the Osteotomy and
Percentage of Pubic Approximation
The percentage of approximation of the pubic diastasis with respect
to the age of the patient at the time of the operation is presented
in Table ITable
I. At the three-month follow-up examination, there was significantly
less correction in the birth to six-month age-group than in the
two to five-year age-group (p < 0.05). At the time of the latest
follow-up, the group that had the operation between birth and six
months had significantly less correction than the group that had
the operation between six and eighteen months (p < 0.05) and
all other age-groups (p < 0.001); in addition, the group that
had the operation at six to eighteen months had significantly less
correction than the group that was eighteen to twenty-four months
old (p < 0.05), the group that was two to five years old (p < 0.01),
and the group that was more than five years old at the time of the
operation (p < 0.02). There was no difference among the groups
with respect to the duration of follow-up.
Gait and Motor Examination
One patient had a persistent unilateral Trendelenburg gait at
the time of the final follow-up, at three years. He had palpable
contraction of the gluteus medius and minimus muscle group, but
active abduction of the hip against gravity was one-half grade below
normal. This may have been due to an injury to the superior gluteal
nerve, as no osseous abnormality was found. All of the patients
with a femoral nerve palsy and the one patient with a peroneal nerve
palsy had complete restoration of strength within three months.
The parents of two of the children complained of a persistent so-called out-toeing
gait when their children were three and four years old. All children
with classic exstrophy were able to run and to participate in sports
to the same degree as preoperatively. No patient complained of pain
in the pelvis, hips, or lower extremities at the latest follow-up
examination.
Pelvic osteotomy has been widely accepted as a useful adjunct
in the operative treatment of bladder exstrophy. The anterior approach,
used in the present report15,
obviates the need to turn the patient and allows external fixation
to be applied under direct vision.
Both the children with classic exstrophy and those with cloacal
exstrophy had correction of the degree of bone and soft-tissue diastasis
following osteotomy, although the patients with classic exstrophy gained
more correction. Two of forty-nine children who underwent anterior
innominate osteotomy with primary closure had wound dehiscence or
bladder prolapse, resulting in a failure rate of 4%, which is similar
to the results reported with posterior osteotomy5.
When repeat bladder closure was performed with an osteotomy, which
represented 43% of all bladder closures done at our institution,
there were no failures.
The most common complication was transient palsy of the left
femoral nerve, probably resulting from femoral nerve compression
between the iliacus muscle and the inguinal ligament. We believe that
the inguinal ligament becomes stretched and its direction changes
with rotation of the inferior iliac segment, which includes its
pubic insertion. The medial portion of this more taut inguinal ligament also
appears to be translated slightly posteriorly. After we had formulated
this hypothesis, we added a posterior osteotomy to the procedure
in order to allow internal rotation of the iliac wings and to decrease
the stretch of the inguinal ligament. We also now expose the femoral
nerve and carefully incise the taut, cordlike fold of the external
oblique muscle, which forms the inguinal ligament. These two steps
seem to have decreased the rate of femoral nerve palsy. No femoral
arterial or venous compromise was seen. We are unsure why femoral nerve
palsy occurred only on the left.
In a study of posterior iliac osteotomies, Aadelen et al. reported
that asymmetrical closure and vertical migration of one hemipelvis
was an occasional problem, with a functional limb-length inequality of
more than 2 cm seen in 6% of 100 patients5.
With the anterior approach, we have not observed this problem. This
is most likely because the primary plane of the osteotomy is transverse,
with a broad metaphyseal contact area to resist vertical migration.
In older children in whom we add a posterior vertical osteotomy,
it is done in a so-called greenstick fashion, preserving the proximal
part of the posterior iliac cortex to maintain posterior stability.
Aadalen et al. found that the mean interpubic distance in thirty-six
children who underwent primary closure and bilateral posterior iliac
osteotomy before three years of age was substantially less in those
who had an excellent or good result than in those who had a fair
or poor result5. However, the
percentage of excellent or good results in that study (45%) was
less than that in our study. We found no association between the
degree of continence and the pubic diastasis or the percentage of
pubic approximation in children who underwent pelvic osteotomy.
However, of the thirty-eight children in the study who underwent
anterior osteotomy and bladder neck reconstruction only, twenty-eight
(74%) were able to maintain excellent or good continence (dry for
more than three hours during the day). Our working theory was that
pelvic closure by osteotomy promotes continence by bringing the
muscles of the pelvic floor together to help to place the urethra
within the pelvis and thus provide a more acute ureterovesical angle.
It also allows the urethra to be surrounded by the restored sling
of the pelvic floor muscles2.
Our results suggest that the amount of closure achieved with anterior
innominate osteotomy and eventual bladder neck reconstruction is
not associated with continence. Since the correction of the diastasis
by itself was not associated with continence, we cannot determine
whether the osteotomy or the bladder neck reconstruction is responsible
for the high degree of success. Multiple factors, such as the age
at follow-up, bladder size, and number or type of surgical procedures,
may confound the analysis and would require study of a larger number
of patients. On the basis of the results in the present study, we
now perform osteotomy only if the patient lacks a firm symphyseal
bar of bone or fibrocartilaginous tissue from which to suspend the bladder
neck.
The age of the patient plays a role in the amount of correction
that is maintained over time, as older children tend to retain a
greater amount of correction. It is our impression that partial
recurrence of the diastasis occurs by two mechanisms. First, the pelvis
may partially derotate as a result of early loosening of the pin-bone
purchase before the osteotomy site heals; this is seen mostly in
infants. Second, there is long-term undergrowth of the ischiopubic
segment (which has been shown to be 33% smaller than normal in adults
with exstrophy1) as the whole
pelvis grows. The amount of pubic diastasis increased linearly with
growth in patients with uncorrected exstrophy.
We regard the main role of osteotomy to be relaxation of the
tension on the bladder and the repaired abdominal wall during wound-healing.
Therefore, we rarely do an osteotomy in newborns and young infants
whose ligamentous laxity allows the pelvis to be closed without
much tension. In patients with cloacal exstrophy, we often defer
closure until bone density is sufficient to permit good pin fixation
to buttress the closure (when the patient is eighteen to twenty-four
months old). A secondary goal is to improve the appearance of the
widened perineum. In patients for whom improved appearance is the primary
goal, we recommend delaying the osteotomy until the age of about
eight years to minimize the chance of correction being lost.
In summary, the ideal age for osteotomies is related to the urologic
goal to be achieved. An osteotomy is not performed in newborns,
unless there has been failure of primary closure. In all older patients,
it is performed to facilitate primary closure or reclosure, usually
in the three to five-year age-group. We now perform anterior and
posterior osteotomies together in all patients who are more than
two years old. The primary goals of anterior innominate osteotomy
in patients with exstrophy are to reduce the tension in the closed
bladder and the abdominal wall and possibly to promote continence
by restoring the fibrous symphyseal bar and the pelvic floor muscles.
These goals can be achieved in the majority of patients.
Note: The authors thank Hong Cui, MD, for the illustrations.
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