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Hofmann A, Haider M, Promm M, Neissner C, Badelt G, Rösch WH. Delayed primary closure of bladder exstrophy without osteotomy: 12 year experience in a safe and gentle alternative to neonatal surgery. J Pediatr Surg 2022; 57:303-308. [PMID: 35000729 DOI: 10.1016/j.jpedsurg.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Successful primary closure of bladder exstrophy is of utmost importance for bladder capacity and urinary continence. We evaluated our concept of delayed primary closure that challenges the role of neonatal surgery, pelvic osteotomy, and perioperative pain management. MATERIAL AND METHODS We reviewed the medical records of patients with classic bladder exstrophy (CBE) who had undergone delayed primary closure without osteotomy at our institution between January 2008 and May 2020. Data to be analyzed included patient demographics, intraoperative pelvic laxity, blood transfusion, postoperative ventilation time, requirement of pain medication, time to full feeds, length of ICU stay, postoperative complications, and total hospital stay. RESULTS 66 patients (44 boys) met the inclusion criteria. Mean age at surgery was 64.8 days (SD±24.7). Pelvic approximation < 5 mm was possible in 66 (100%) patients. Blood transfusion was required by 31 (47%) patients. 14 (21.2%) patients needed postoperative ventilation for a mean time of 2.7 h. 45 (68.2%) children required intravenous opioids in addition to an epidural catheter. Oral feeding started on average 17.6 h after surgery. Mean ICU stay was 1.3 day. The initial success rate of delayed closure was 93.9%. None of the patients had bladder dehiscence. Girls developed more often minor postoperative complications than boys (m/f: 12 [27.3%] vs. 8 [36.4%]. Mean overall time of hospitalization was 19 days (13-34 d). CONCLUSION Delayed primary closure of CBE without osteotomy but with continuous epidural blockage is a safe and promising procedure that has crucial advantages in the pre- and postoperative management of CBE. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Aybike Hofmann
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany.
| | - Maximilian Haider
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Claudia Neissner
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Gregor Badelt
- Department of Pediatric Anesthesiology, Clinic St. Hedwig, Steinmetzstr. 1-3, Regensburg 93049, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Steinmetzstr. 1-3, Regensburg 93049, Germany
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Chalfant V, Riveros C, Elshafei A, Stec AA. An evaluation of perioperative surgical procedures and complications in classic bladder exstrophy patients Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P). J Pediatr Urol 2022; 18:354.e1-354.e7. [PMID: 35341671 DOI: 10.1016/j.jpurol.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Classic bladder exstrophy (CBE) repair report wide variation in success. Given the complexity of CBE care, benefit would be derived from validation of reported outcomes. Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data, this manuscript evaluates surgical complications for bladder closure and advanced urologic reconstruction in CBE patients. AIM The primary aim of this study was to determine complication rates in the CBE population for bladder closure and advanced urologic reconstruction in national studies compared to single-institutional studies. STUDY DESIGN Pediatric cases and complications were identified in the 2012-2019 NSQIP-P database in CBE patients who had either bladder closure or advanced urologic reconstruction. Bladder closure was further defined as early (<7 days) or delayed (>7 days). Differences were assessed using Fisher's exact test and analysis was conducted using SPSS with significance defined as p-value <0.05. RESULTS 302 patients were included; 152 patients underwent bladder closure, and 150 patients underwent advanced urologic reconstruction. The 30-day complication rate for bladder closure is 30.3% and for advanced urologic reconstruction is 24.0% in the CBC cohort. No differences were found in the rates of NSQIP complications between early and delayed bladder closure, though significant differences (p < 0.001) were found in the rates of blood transfusion (17.9 vs 65.3%). This may be due to the different rates of osteotomy (25.0 vs 48.3%) between early and delayed bladder closure. Rates of readmission are 14.7% and rates of reoperation are 8.0% for advanced urologic reconstruction procedures. Both bladder closure and advanced urologic reconstruction had infectious issues in greater than 10% of the population. DISCUSSION CBE surgeries nationally carry a higher risk of complications than is reported in most institutional studies. Infectious complications occur greater than 10% of the time in both bladder closure and advanced urologic reconstruction, which should be the source of additional study given the inverse relationship infections pose to surgical success in BE patients. A limitation of this study is that the data is derived from Children's hospitals that elect to participate and includes only data from 30 days after a procedure. CONCLUSION CBE complication data for both bladder closure and advanced urologic reconstruction may be underrepresented in the literature.
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Affiliation(s)
- Victor Chalfant
- Creighton University School of Medicine, Department of Urology, Omaha, NE, 68108, USA.
| | - Carlos Riveros
- University of Florida Health, Department of Urology, Jacksonville, FL, 32209, USA
| | - Ahmed Elshafei
- University of Florida Health, Department of Urology, Jacksonville, FL, 32209, USA; Cairo University, Department of Urology, Cairo, Egypt
| | - Andrew A Stec
- Nemours Children's Health, Division of Pediatric Urology, Jacksonville, FL, 32207, USA
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Ebert AK, Zwink N, Reutter HM, Jenetzky E, Stein R, Hölscher AC, Lacher M, Fortmann C, Obermayr F, Fisch M, Mortazawi K, Schmiedeke E, Promm M, Hirsch K, Schäfer FM, Rösch WH. Treatment Strategies and Outcome of the Exstrophy-Epispadias Complex in Germany: Data From the German CURE-Net. Front Pediatr 2020; 8:174. [PMID: 32509709 PMCID: PMC7248227 DOI: 10.3389/fped.2020.00174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: To evaluate the impact of reconstructive strategies and post-operative management on short- and long-term surgical outcome and complications of classical bladder exstrophy (CBE) patients' comprehensive data of the multicenter German-wide Network for Congenital Uro-Rectal malformations (CURE-Net) were analyzed. Methods: Descriptive analyses were performed between 34 prospectively collected CBE patients born since 2009, median 3 months old [interquartile range (IQR), 2-4 months], and 113 cross-sectional patients, median 12 years old (IQR, 6-21 years). Results: The majority of included individuals were males (67%). Sixty-eight percent of the prospectively observed and 53% of the cross-sectional patients were reconstructed using a staged approach (p = 0.17). Although prospectively observed patients were operated on at a younger age, the post-operative management did not significantly change in the years before and after 2009. Solely, in prospectively observed patients, peridural catheters were used significantly more often (p = 0.017). Blood transfusions were significantly more frequent in males (p = 0.002). Only half of all CBE individuals underwent inguinal hernia repair. Cross-sectional patients after single-stage reconstructions showed more direct post-operative complications such as upper urinary tract dilatations (p = 0.0021) or urinary tract infections (p = 0.023), but not more frequent renal function impairment compared to patients after the staged approach (p = 0.42). Continence outcomes were not significantly different between the concepts (p = 0.51). Self-reported continence data showed that the majority of the included CBE patients was intermittent or continuous incontinent. Furthermore, subsequent consecutive augmentations and catheterizable stomata did not significantly differ between the two operative approaches. Urinary diversions were only reported after the staged concept. Conclusions: In this German multicenter study, a trend toward the staged concept was observed. While single-stage approaches tended to have initially more complications such as renal dilatation or urinary tract infections, additional surgery such as augmentations and stomata appeared to be similar after staged and single-stage reconstructions in the long term.
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Affiliation(s)
- Anne-Karoline Ebert
- Department of Pediatric Urology, University Hospital for Urology and Pediatric Urology, University Medical Center Ulm, Ulm, Germany
| | - Nadine Zwink
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Heiko M Reutter
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany.,Institute of Human Genetics, University Hospital Bonn, Bonn, Germany
| | - Ekkehart Jenetzky
- Department of Child and Adolescent Psychiatry, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.,Child Center Maulbronn GmbH, Hospital for Pediatric Neurology and Social Pediatrics, Maulbronn, Germany
| | - Raimund Stein
- Department of Pediatric and Adolescent Urology, University Medical Center Mannheim, Mannheim, Germany
| | - Alice C Hölscher
- Department of Pediatric Surgery and Pediatric Urology, Children's Hospital Amsterdamer Straße Köln, Köln, Germany
| | - Martin Lacher
- Department of Pediatric Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Caroline Fortmann
- Center of Pediatric Surgery Hannover, Hannover Medical School and Bult Children's Hospital, Hannover, Germany
| | - Florian Obermayr
- Department of Pediatric Surgery and Pediatric Urology, University Hospital for Child and Adolescent Medicine Tübingen, Tübingen, Germany
| | - Margit Fisch
- Department of Urology and Pediatric Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kiarasch Mortazawi
- Department of Pediatric Surgery, Klinik für Kinderchirurgie, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Pediatric Urology, Center for Child and Youth Health, Klinikum Bremen-Mitte, Bremen, Germany
| | - Martin Promm
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Karin Hirsch
- Department of Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Frank-Mattias Schäfer
- Pediatric Surgery and Pediatric Urology, Cnopfsche Children's Hospital, Nürnberg, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Clinic St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
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Zaman MH, Davis R, Maruf M, DiCarlo H, Gearhart JP. Exploration of Practice Patterns in Exstrophy Closures: A Comparison Between Surgical Specialties Using a National and Institutional Database. Urology 2019; 131:211-216. [DOI: 10.1016/j.urology.2019.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/15/2019] [Accepted: 05/24/2019] [Indexed: 11/16/2022]
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Colaco M, Hester A, Visser W, Rasper A, Terlecki R. Relative to open surgery, minimally-invasive renal and ureteral pediatric surgery offers no improvement in 30-day complications, yet requires longer operative time: Data from the National Surgical Quality Improvement Program Pediatrics. Investig Clin Urol 2018; 59:200-205. [PMID: 29744478 PMCID: PMC5934283 DOI: 10.4111/icu.2018.59.3.200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 03/05/2018] [Indexed: 11/18/2022] Open
Abstract
Purpose Performance of minimally-invasive surgery (MIS) is increasing relative to open surgery. We sought to compare the contemporary rates of short-term complications of open versus laparoscopic renal and ureteral surgery in pediatric patients. Materials and Methods A retrospective cross-sectional analysis of the National Surgical Quality Improvement Program Pediatrics database was performed of all cases in 2014 identified using CPT procedure codes for nephrectomy, partial nephrectomy (PN), ureteroneocystostomy (UNC), and pyeloplasty, and reviewed for postoperative complications. Univariate analysis was performed to determine 30-day complications, with comparison between open and MIS approaches. Receiver operator curve (ROC) analysis was performed to determine differences in body surface area (BSA) and age for open versus MIS. Results Review identified 207 nephrectomies, 72 PN, 920 UNC, and 625 pyeloplasties. MIS was associated with older age and larger BSA except for cases of UNC. Apart from PN, operative durations were longer with MIS. However, only PN was associated with significantly longer length of hospital stay (LOS). There was no difference in incidence of all other 30-day complications. When evaluating BSA via ROC, the area under the curve (AUC) was found to be 0.730 and was significant. Children with a BSA greater than 0.408 m2 were more likely to have MIS (sensitivity, 66.9%; specificity, 69.3%). Regarding age, the AUC was 0.732. Children older than 637.5 days were more likely to have MIS (sensitivity, 72.8%; specificity, 63.3%). Conclusions Pediatric MIS is associated with longer operative time for nephrectomy, but shorter LOS following PN. Surgical approach was not associated with difference in short-term complications.
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Affiliation(s)
- Marc Colaco
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Austin Hester
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - William Visser
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Alison Rasper
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ryan Terlecki
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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