The Pubic Diastasis Measurement, a Key Element for the Diagnosis, Management, and Prognosis of the Bladder Exstrophy

Optimizing prenatal diagnosis and referral of classic bladder exstrophy: Lessons from a single-institution experience

INTRODUCTION

Classic bladder exstrophy (CBE) is a malformation of the genitourinary system that occurs due to failure of abdominal wall closure. Unlike other malformations of similar incidence, prenatal diagnosis of CBE relies on suggested, rather than formal, diagnostic criteria.

OBJECTIVE

This report describes prenatal diagnosis of CBE in the largest single-institutional cohort to date and delineates key sonographic findings and protocols for specialist referral.

MATERIALS AND METHODS

A single-institutional database was reviewed for CBE patients born since 2000. Data on screening ultrasound use, gestational age at ultrasound, and abnormal findings were extracted. Where possible, time of prenatal diagnosis (pre- or postnatal and gestational age), ultrasound findings and other imaging data, specialist referral, institution of birth and closure, and outcome of primary closure attempt were compared.

RESULTS

Of 557 patients born with CBE between 2000 and 2022, 284 met inclusion criteria and complete data were available for 280 (229 born domestically and 51 born internationally) who were included for analysis. Abnormal sonography suggestive of CBE was present for 48% (n = 134) of patients, for whom absent bladder was the most common abnormal finding (76% [102/134]). Of domestic patients, 46% (n = 106) were diagnosed prenatally at a median gestational age of 22 weeks (inter-quartile range [IQR]: 20-24), and 14% (n = 32) underwent confirmatory fetal magnetic resonance imaging. Of domestic patients with abnormal prenatal findings, 75% (n = 80/106) consulted with maternal-fetal medicine and 58% (n = 62/106) consulted with pediatric urology. On univariate analysis, prenatal diagnosis was positively associated with primary repair at Association for the Bladder Exstrophy Community-recognized centers of excellence (54% vs. 38%, p = 0.02) and negatively associated with osteotomy at primary closure (41% vs 59%, p = 0.003) but not success of primary closure (74% vs. 82%, p = 0.07).

DISCUSSION

Rates of prenatal diagnosis in this cohort were similar to previous reports of smaller cohorts. Diagnosis allows for comprehensive pre- and postnatal follow-up with a pediatric urologist, with implications on birth planning and decisions on termination of pregnancy. Because of the previously-reported association between exstrophy and in vitro fertilization, these pregnancies should undergo detailed sonography. Any nonvisualization of the fetal bladder should prompt a detailed exam, and any finding characteristic of bladder exstrophy warrants referral to pediatric urology.

CONCLUSIONS

Although CBE is a rare disorder, it is underdiagnosed during pregnancy. Sonographers and obstetricians should be aware of characteristic findings and best practices following diagnosis. Early referral to pediatric urology and maternal-fetal medicine is important for counseling and postnatal planning.

A case report of single umbilical artery combined with fetal bladder exstrophy in singleton pregnancy and related literature review

BACKGROUND

According to prenatal ultrasonographic studies, single umbilical artery may be present alone or in association with other fetal abnormalities. So far, the exact pathogenesis of bladder exstrophy is unclear. Some scholars believe that bladder exstrophy and cloacal exstrophy should be regarded as a disease spectrum to explore their pathogenesis. If bladder exstrophy and cloacal exstrophy are regarded as the same disease spectrum, then we can speculate that the single umbilical artery should have the probability of being accompanied by bladder exstrophy at the same time.

CASE PRESENTATION

For the first time, we report a rare case of fetal bladder exstrophy with single umbilical artery in single pregnancy. This patient underwent targeted color Doppler ultrasound at 26 weeks of pregnancy which first suspected bladder exstrophy with single umbilical artery and fetal MRI for diagnosis at 38 + 3 weeks of pregnancy which confirmed the suspicion. After the diagnosis was confirmed, the patient was scheduled for a multidisciplinary discussion. Ultimately the patient opted for induced fetal demise at 38 + 5 weeks of pregnancy and the physical appearance of the fetal demise affirmed previous ultrasound and MRI examination results.

CONCLUSIONS

Our report is the first finding of single umbilical artery combined with bladder exstrophy in a singleton pregnancy. Accordingly, our case enhances the evidence that cloacal exstrophy and bladder exstrophy should be treated as the same disease spectrum. In addition, we conducted a literature review on the diagnostic progress of single umbilical artery combined with bladder exstrophy, hoping to provide useful references for the diagnosis of this disease.

Color Doppler evaluation of umbilical arteries in relation to bony landmarks in the fetal pelvis as a clue to the mid-trimester diagnosis of bladder exstrophy: A novel observation

Color Doppler (CD) is an established diagnostic modality for bladder exstrophy. We present two mid-trimester difficult-to-diagnose cases with no obvious infraumbilical mass bulge, assessed by CD in sagittal and axial pelvic views. The first case was a classical bladder exstrophy at 19 weeks nestled under the umbilical-cord and the second case was an omphalocele-exstrophy-imperforate-anus-spinal complex at 18 weeks 4 days gestation with exstrophic bladder embedded under the omphalocele. The altered course of umbilical arteries in relation to pelvic bony landmarks seen in these fetuses could be an objective approach to complement mid-trimester diagnosis of bladder exstrophy regardless of mass bulge.

Total hip arthroplasty in patients with severe hip dysplasia and congenital pubic diastasis: report of two cases

Background

Congenital bladder exstrophy is a rare malformation which is often associated with pubic diastasis and hip dysplasia. We reported the case two patients who underwent total hip arthroplasty (THA) due to advanced osteoarthritis combined with large congenital pubic diastasis (> 10 cm).

Case presentation

The first patient, a 39 years old woman with a pubic diastase and severe hip dysplasia on both sides was treated with a primary two-staged bilateral THA. Both hips were treated with a cementless osteoconductive cup (TM, Zimmer-Biomet) and a cementless stem (Alloclassic SL, Zimmer-Biomet). A 10° elevated rim liner of the cup was used in order to avoid dislocation. The main problem was represented by the fixation of the cup, given the retroverted acetabulum along with the elevated rotation centre due to the dysplastic hips. In the case two, a 52 years woman presented dysplastic osteoarthritis of the left hip. A conventional hemispherical cup (Alloclassic-Allofit, Zimmer-Biomet) was placed in the retroverted acetabulum combined with a cementless stem (Fitmore A, Zimmer-Biomet) attached at the metaphyseal proximal femur bone.

Conclusion

Our results suggest that THA may be a good strategy to manage advanced hip osteoarthritis in patients with dysplasia and congenital pubic diastasis.

Level of evidence

IV, case series.

Isolated bladder exstrophy in prenatal diagnosis

PURPOSE

Isolated classic bladder exstrophy (CBE) is the most common variant of the bladder-exstrophy-epispadias complex (BEEC). The BEEC represents a spectrum ranging from isolated epispadias over CBE to the most severe form, cloacal exstrophy. We report on a series of 12 cases with CBE diagnosed prenatally and illustrate the spectrum of prenatal ultrasound findings with comparison to prior published reports on this entity.

METHODS

This was a retrospective study involving 12 fetuses with CBE at two large tertiary referral centers in Germany over a 14-year period (2004-2018).

RESULTS

Median diagnosis was made with ultrasound in 24 + 5 (IQR_25,75: 21 + 2, 29 + 0) weeks of gestation. All fetuses presented with the pathognomonic findings non-visualization of the fetal bladder and protruding abdominal mass below the umbilical cord insertion. All fetuses showed normal kidney anatomy and normal amniotic fluid throughout pregnancy. Epispadia was visible prenatally on ultrasound in 6/8 male fetuses. 1/12 Parents opted for termination of pregnancy, 11/12 fetuses were live born and received reconstructive surgery.

CONCLUSIONS

Isolated CBE is an extremely rare prenatal sonographic finding. Prenatal diagnostics should exclude additional malformations within the spectrum of cloacal malformations.