OEIS complex: prenatal ultrasound and autopsy findings

OBJECTIVE

To describe prenatal ultrasound and autopsy findings in fetuses with OEIS (omphalocele, bladder exstrophy, imperforate anus, spina bifida) complex.

METHODS

This was a retrospective study of the nine cases with OEIS complex diagnosed at our center using detailed fetal ultrasound during the last 10 years. We summarized the fetal ultrasound findings that led to the diagnosis and compared them with the autopsy results.

RESULTS

All affected fetuses were diagnosed using detailed fetal ultrasound after 16 weeks' gestation. The main prenatal findings were omphalocele, skin-covered lumbosacral neural tube defect, non-visualized bladder and limb defects. Prenatal sonography failed to detect the abnormal genitalia, bladder exstrophy and anal atresia. All cases had abnormalities in a 'diaper distribution', which helped in making the prenatal diagnosis. Eight of the nine couples chose to terminate the pregnancies following multidisciplinary counseling. The pregnancy that was continued was a case with dizygotic twins discordant for OEIS, and the affected fetus died in utero.

CONCLUSIONS

The combination of the following ultrasound findings: ventral wall defect, spinal defect and a non-visualized bladder with or without limb defects, are characteristic of OEIS complex. Diagnosis can be made with confidence as early as 16 weeks' gestation, although earlier diagnosis may be possible.

The use of refluxing ureter in the creation of a Mitrofanoff channel in children undergoing bladder augmentation: is a formal reimplantation necessary?

To study the fate of a refluxing ureteral stump used as a Mitrofanoff channel (MC) for clean intermittent catheterization (CIC), without reimplantation in augmented bladders. Ten boys and seven girls, 1-14 years old (mean 6.5 years) seen in period 1998-2005, underwent creation of MC using refluxing or potentially refluxing ureters. Concomitant bladder augmentation (BA) was performed for various abnormalities of lower urinary tract, including exstrophy epispadias complex, neurogenic bladder cloaca and posterior urethral valve. The uretero-vesical junction was maintained intact during creation of the MC. Follow-up period ranged from 2-72 months (mean 32.5 months). Satisfactory CIC was possible in 14 children while in two children the stoma became obstructed due to non-usage. Urinary leak via the ureteric MC was seen in only one patient who partially responded to anticholinergic therapy and a shortened CIC interval but this needed to be formally closed subsequently. A refluxing ureter can be used in the creation of a MC without formal reimplantation in the majority of children undergoing BA.

The OEIS complex: two case reports that illustrate the spectrum of abnormalities and a review of the literature

We present two cases of OEIS (omphalocele, exstrophy, imperforate anus, spinal defects) complex -MIM 258040 and a review of the literature. Case 1 was a 14-year-old girl who presented at 30 weeks' gestation. An ultrasound examination showed an omphalocele and spina bifida; the bladder was not visualised. She went into spontaneous labour two weeks later and the baby died shortly after birth. A full post-mortem examination was refused, but the mother did agree to an external examination, skin biopsy for fibroblast culture, X rays and MR imaging. The MR imaging showed a pelvic kidney, a large omphalocele containing the other kidney, liver, bowel and a fluid filled structure thought to represent an exstrophy of the bladder (EB). Case 2 was a 30-year-old woman who had an ultrasound examination at 20 weeks' gestation; this showed an omphalocele, but the bladder was not visualised. The pregnancy was subsequently terminated and a post-mortem examination showed a low set umbilical cord associated with a small omphalocele; there was an imperforate anus; a blind ending rectum terminated in the omphalocele. We conclude that these two cases illustrate the variability of the OEIS complex.

Acetabular coverage in bladder exstrophy: role of 3-dimensional computed tomography

We studied the acetabular coverage in bladder exstrophy patients and normal control children. The study included 13 patients with bladder exstrophy, who were divided according to their ages into group I below 5 years, group II between 5 and 10 years, and group III above 10 years of age. Four normal children served as controls, 2 were below 5 years, one was 7 and one was 12 years old. We measured the acetabular coverage (AC) and the center-edge-angle (CEA) by utilising the reconstructed 3-dimensional CT images. The mean right and left AC angles were 82 +/- 12 and 82 +/- 20 degrees in group-I, 107 +/- 15 and 103 +/- 17 in group-II and 119 +/- 24 and 116 +/- 22 in group-lII, respectively (p < 0.05). The mean right and left CEA angles were 33 +/- 4 and 32 +/- 4 degrees in group-I, 30 +/- 4 and 29 +/- 5 in group-II and 25 +/- 2 and 24 +/- 1 in group-III, respectively (p < 0.05). In controls, the mean right and left AC angles were 151 +/- 2 and 153 +/- 2 degrees for children below 5 years, 166 and 165 degrees in the 7 year-old child and 180 and 180 degrees in the 12 year-old child. The CEA angle ranged from 15 to 25 degrees. Acetabular coverage in bladder exstrophy patients is deficient during the first 5 years of life. Although it gradually improves over time, it does not reach to normal value.

[Prenatal diagnosis of pelvic floor malformations]

Pelvic floor malformations are congenital defects in the pelvic and perineal area, which are derived from a defective development of the cloaca membrane, the uro-rectal septum, the mesonephric and para-mesonephric ducts and the urogenital sinus. These are complex anomalies with a profound emotional impact on parents. The prenatal diagnosis is possible favoring the prenatal counseling for the parents and expediting the post-natal evaluation and management. Aim of the present paper is to review the current criteria for the prenatal diagnosis of the following malformations: anorectal anomalies, cloacal anomalies, persistence of the urogenital sinus, bladder and cloacal exstrophy and ambiguous genitalia.

Prenatal ultrasound diagnosis of cloacal exstrophy associated with myelocystocele complex by the ‘elephant trunk-like’ image and review of the literature

A case of cloacal exstrophy (CE) was detected by ultrasound as early as 22 weeks of gestation in association with myelocystocele complex, an unusual form of occult spinal dysraphism often associated with such a disease. The ultrasonographic diagnosis was made through the detection of a wavy cord-like segment of soft tissue protruding from the anterior abdominal wall, just below the umbilical cord insertion, strongly resembling the trunk of an elephant. Our article enforces the suggestion that the ultrasound elephant trunk-like image should be added to the existing major criteria for making prenatal diagnosis of CE.

Using color Doppler sonography to identify the perivesical umbilical arteries: a useful method in the prenatal diagnosis of omphalocele-exstrophy-imperforate anus-spinal defects complex

OBJECTIVE

To describe the different prenatal sonographic findings in 3 cases of omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex, or cloacal exstrophy.

METHODS

Three patients with OEIS complex were examined by sonography. In 2 (cases 2 and 3) of the 3 cases, color Doppler sonography was applied to the area of cord insertion and the abdominal mass to determine the origin of the abdominal mass.

RESULTS

Three cases of OEIS complex with different sonographic appearances are included in this series. An absent bladder without an abdominal mass but with bowel floating in the amniotic cavity was revealed in case 1; an absent bladder with a lower anterior abdominal mass was found in the second trimester in case 2; and a large cystlike mass located in the anterior abdominal wall was found in case 3. Color Doppler imaging showed that the abdominal mass originated from the urinary bladder in cases 2 and 3; therefore, OEIS complex was presumptively diagnosed antenatally in these cases. In all cases, OEIS complex was confirmed postnatally.

CONCLUSIONS

Omphalocele-exstrophy-imperforate anus-spinal defects complex should be considered in patients with an absent bladder combined with either an anterior abdominal wall mass or defects. Special attention should be given to search for other combined anomalies. We suggest that color Doppler sonography for identifying the perivesical umbilical arteries is a very useful method in establishing of the diagnosis of OEIS complex.

Another case of autosomal dominant exstrophy of the bladder

OBJECTIVE

Exstrophy of the bladder is a rare malformation due to an anterior midline defect. Most cases of this condition with variable expression occur sporadically, but there are some cases indicative of a strong genetic component apart from environmental factors. This is a report about another rare mother-child pair with bladder exstrophy.

METHODS

We present the clinical data of a familial case of bladder exstrophy with an affected mother and her equally affected male fetus.

RESULTS

Prenatal diagnosis of bladder exstrophy in the fetus was assessed by ultrasound at the 19th gestational week and was confirmed after termination of pregnancy at the 21st gestational week.

CONCLUSION

The present case may be additional evidence for an autosomal dominant inherited variant of this malformation complex with implication for counselling of affected patients.

A chicken model to study the embryology of cloacal exstrophy

BACKGROUND/PURPOSE

The embryology of bladder and cloacal exstrophy is a mystery. Reasons for this are the lack of human embryos showing these malformations as well as the scarcity of appropriate animal models. Here, the authors present cases of cloacal exstrophies found in chick embryos subsequent to the application of suramin and trypan blue. This animal model might facilitate insight into the embryology of cloacal exstrophy.

METHODS

Fertilized chicken eggs were incubated at 38 degrees C and 75% humidity. Embryos were treated in ovo on incubation day 3. The egg shell was windowed, and solutions of suramin (stage 13, 2 x 40 microL/0.2%) or trypan blue (stage 14, 2 x 80 microL/0.03%) were injected into the coelomic cavity. The window was closed, and the embryos were reincubated until examination on incubation day 8. Fifty embryos were treated in each group.

RESULTS

Among the surviving embryos, cloacal exstrophy was found in 2 cases in the suramin-treated group (2 of 29, 6.9%) and in 4 cases in the trypan blue-treated group (4 of 20, 20%).

CONCLUSIONS

Suramin and trypan blue can induce cloacal exstrophy in chick embryos. The authors now are modifying their experimental protocols to increase the incidence of this malformation. This model might facilitate studies on the morphogenesis of cloacal exstrophy.

New sonographic finding for the prenatal diagnosis of bladder exstrophy: a case report

Bladder exstrophy is a very rare congenital malformation in which the anterior wall of the bladder is absent, and the posterior wall is exposed externally. Although sonographic findings of bladder exstrophy have been documented, we report a case presenting with a solid mass in the lower fetal abdomen with umbilical arteries running alongside the mass. The relationship between umbilical arteries and bladder exstrophy is a new sonographic finding which may be helpful in the prenatal diagnosis of this condition.

Complete repair of exstrophy: further experience with neonates and children after failed initial closure

PURPOSE

The surgical repair of bladder exstrophy remains challenging for the urologist. Recently, complete primary repair has been used in neonates. We present our experience with this approach in neonates and children after failed initial closure.

MATERIALS AND METHODS

Between November 1998 and November 2000, 17 boys and 2 girls with bladder exstrophy underwent complete repair. Complete primary repair was performed in the first 72 hours of life in 4 boys. Complete repair with osteotomy was at a mean age +/- SD of 23 +/- 21 months (range 1 to 74) in 15 patients including 7 with failed initial closure. The bladder and urethra were closed in continuity with epispadias repair by total penile disassembly. All patients were kept in spica cast for 3 weeks. Ureteral stents and suprapubic tube were removed 10 and 14 days after surgery, respectively. Ultrasound was performed before surgery and 3 months thereafter, and voiding cystourethrography was obtained 3 months postoperatively and then annually in all cases.

RESULTS

Complete closure resulted in hypospadias in 10 boys (59%). There was no major complication. Mean followup +/- SD was 17 +/- 8 months (range 5 to 33). Temporary suprapubic urinary leakage was noted initially in 10 cases (52%) but no patient had persistent fistula. Initial postoperative renal ultrasound revealed hydronephrosis in 11 renal units (29%). However, at last followup only 1 renal unit (2%) showed pelvicaliceal dilatation. Two patients (10%) had a febrile urinary tract infection and were treated conservatively. Reflux was noted in 24 renal units (63%) but did not require surgery. The 4 boys in whom the closure was performed at birth had regular voiding with 60 to 90-minute dry intervals and mean bladder capacity +/- SD was 85 +/- 35 cc. The 15 older children had a mean bladder capacity of 74 +/- 37 cc and 5 (33%) had regular voiding with 30 to 90-minute dry intervals.

CONCLUSIONS

Complete repair of exstrophy is feasible in neonates and older children including, those with failed initial closure with minimal morbidity. There is a short-term evidence of favorable outcome in newborns. Longitudinal followup is required to determine the future need of bladder neck reconstruction and augmentation in older patients.

Connections of the bladder plate and bladder neck with the bony pelvis in a fetus with classic bladder exstrophy

OBJECTIVES

To demonstrate that the bladder plate and bladder neck in classic bladder exstrophy are laying on smooth muscle fibers that extend laterally to the pubic bones.

METHODS

We compared a male fetus of 28 weeks' gestational age with classic bladder exstrophy with a normal fetus of the same age. The specimens were divided into two parts by a midsagittal section, from the bladder neck to the membranous urethra. Thin transverse slices were also obtained on one part, and longitudinal slices on the other part.

RESULTS

The smooth musculature of the bladder is normally differentiated cytologically and extends laterally to the bony structures of the pelvis. The musculature of the bladder neck and urethra are normally present compared with the control.

CONCLUSIONS

The results of this study demonstrate the musculoskeletal organization of the urogenital system in classic bladder exstrophy. They also indicate that these structures should be clearly individualized and repaired in the reconstruction of classic bladder exstrophy.

Classic bladder exstrophy in a nonhuman primate: a comparative analysis

OBJECTIVES

To describe the pelvic floor musculature and bony pelvic anatomy in a case of naturally occurring classic bladder exstrophy in a rhesus monkey, the first reported case in the animal population since 1832, and compare the results to exstrophy seen in human newborns.

METHODS

A 7-day-old male rhesus monkey with classic bladder exstrophy was examined by a pediatric urologist and primate veterinarian before being killed. A multidetector row computed tomography study with three-dimensional reconstruction was obtained, and a comparison computed tomography study of a 17-day-old male human with exstrophy was also reconstructed three dimensionally. The bony pelvis and pelvic floor muscular anatomy of both subjects were then examined and compared.

RESULTS

On gross examination, a similar appearance of classic bladder exstrophy in the rhesus monkey and human newborn were noted, including an open exposed bladder, associated penile epispadias, and widely separated pubic bones. The evaluation of the three-dimensional models showed a similar orientation of the bony pelvis in both the rhesus and the human newborn. The iliac wings were significantly rotated outward, and the sacroiliac joint was 10 degrees wider than that seen in normal children. The exstrophy pelvic floor in both the rhesus and the newborn was markedly flattened, with approximately 33% of the muscle located anterior to the rectum to support the pelvic structures (normal children have 50% of their levator ani anterior to the rectum).

CONCLUSIONS

By using advancements in imaging modalities, this study illustrated that naturally occurring classic bladder exstrophy in the human newborn and rhesus monkey were identical in both external appearance and internal anatomy.

Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights

OBJECTIVES

To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships.

METHODS

Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls.

RESULTS

The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls).

CONCLUSIONS

These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

Non-visualisations of the fetal bladder: aetiology and management

Failure to detect a normally filled fetal bladder on ultrasound scanning can imply the presence of a serious urogenital abnormality. Detailed scanning may elicit the underlying pathology, but there may be complex anomalies present, the full extent of which often has to await the results of postnatal investigations. Management in a combined paediatric urology:fetal medicine clinic is recommended.

Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights

PURPOSE

We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery.

MATERIALS AND METHODS

3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls.

RESULTS

The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls.

CONCLUSIONS

This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.

The AP diameter of the pelvis: a new criterion for continence in the exstrophy complex?

OBJECTIVE

Reconstructive surgery of bladder exstrophy remains a challenge. By using CT of the pelvis, we suggest a new pre- and post-operative investigative procedure to define the AP diameter (APD) as a predictive criterion for continence in this anomaly.

PATIENTS AND METHODS

Three axial CT slices were selected in nine children with exstrophy who had undergone neonatal reconstructive surgery. The three levels selected were the first sacral plate, the mid acetabular plane and the superior pubic spine. We used combined slices to measure: APD = distance between the first sacral vertebra and the pubic symphysis. Pubic diastasis (PD). Three angles defined on the transverse plane of the first sacral vertebra--iliac wing angle, sacropubic angle and acetabular version.

RESULTS

In exstrophy, the angles demonstrate opening of the iliac wings and the pubic ramus, and acetabular retroversion compared to controls. Comparisons between controls, continent and incontinent patients reveal that in continent patients, APD increases with growth and seems to be a predictive criterion for continence, independent of diastasis of the pubic symphysis.

CONCLUSIONS

We believe that CT of the pelvis with measurements of the APD should be performed in all neonates with bladder exstrophy before reconstructive surgery and for better understanding of the malformation. The APD seems to be predictive and may be a major criterion for continence, independent of PD.

Antenatally diagnosed cloacal exstrophy variant with intravesical phallus in a twin pregnancy

We report a rare case of covered cloacal exstrophy variant with a hemiphallus trapped within partially closed bladder halves. The persistence of the cloacal membrane until at least 18 weeks' gestation, confirmed by antenatal ultrasound scanning, is discordant with existing theories of embryogenesis of cloacal exstrophy. The clinical presentation highlights the need for careful assessment, before and during surgery, to obtain a complete understanding of the anatomic defect before gender assignment and appropriate reconstructive efforts. A multispecialty approach and antenatal counseling are important, especially when only one fetus of twins has major birth defects.

Implications of prenatal ultrasound screening in the incidence of major genitourinary malformations

PURPOSE

During the last 3 decades infant mortality has decreased nearly 50%. While neonatal intensive care deserves much of the credit, the recent increase in prenatal ultrasound from 33% of pregnancies in 1980 to 78% in 1987 has improved early detection. We evaluate the impact of prenatal ultrasound on major genitourinary malformations.

MATERIALS AND METHODS

Data obtained from the Malformations Surveillance Program at Brigham and Women's Hospital between 1974 and 1994 tracked 163,431 pregnancies and termination rates of fetuses with spina bifida, bladder exstrophy, the prune belly syndrome and posterior urethral valves.

RESULTS

Hospital data revealed that pregnancy was electively terminated due to spina bifida in 65% of cases, posterior urethral valves in 46%, the prune belly syndrome in 31% and exstrophy in 25%.

CONCLUSIONS

Clearly, surveillance programs and improved accuracy of prenatal ultrasound have allowed early diagnosis of major genitourinary malformations. Many factors influence decision making in these affected fetal cases, including the financial and emotional impact of these major anomalies during lifetime. Future societal decisions and reduction in these anomalies may influence our training programs, manpower needs, medical facility requirements and character of our practices. These findings may have significant implications in the field of pediatric urology.

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Pseudoexstrophy of the bladder: a rare variant

A 15-day-old female presented with a healed omphalocele and a triangular musculoskeletal defect in the hypogastric area similar to the defect seen in classic bladder exstrophy. The bladder was normal on exploration. The defect was successfully closed using a bilateral anterior pubic ramotomy. Only ten cases of pseudoexstrophy have been reported in the world literature.

Anterior innominate osteotomy in repair of bladder exstrophy

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.