V7-04: Multi-Institutional Bladder Exstrophy Consortium: Complete Primary Repair of Exstrophy

Video

Introductions and Objectives
For bladder exstrophy (BE) repair, gaining necessary surgical experience is challenging due to the rarity of BE. We created a multi-institutional collaboration for the purposes of sharing collective expertise, to efficiently maximize surgical proficiency, and to standardize surgical technique and subsequent care of complete primary repair of exstrophy (CPRE). Our objective is to demonstrate the surgical technique adopted by this collaboration.

Methods
Boston Children’s Hospital, Children’s Hospital of Philadelphia and Children’s Hospital of Wisconsin alternately served as host site for scheduled surgeries, with observation, commentary and critique by surgeons from the other sites. Technique was CPRE with bilateral iliac osteotomy performed at 1-3 months of age. Video recording was used for real-time observation both locally and remotely, teaching, future analysis, editing, and review.

Results
From February 2013 through September 2014, CPRE was performed in 23 patients: 12 boys and 8 girls with classic bladder exstrophy; 1 boy and 2 girls with epispadias. Three surgical modifications were adopted by the group. The first concerned approach to the urethral plate dissection in the boy. The current approach uses a ventral dissection along the medial aspect of the corpora cavernosa using bipolar electrocautery. The second was the deliberate attempt to form a bladder neck in an effort to increase continence by elongating the urethra and creating a more acutely angled transition from proximal urethra to bladder neck into bladder. The third was made after urethral obstruction was noted in 3 girls. Preplacement of perineal and urethral meatus sutures prior to approximation of the pubis allowed optimal exposure of the tissue for accurate and precise suture placement. Complications in girls included 4 episodes of pyelonephritis, 3 urethral obstructions (1 resulted in bladder rupture and 2 required temporary clean intermittent catheterization), and 1 partial labial separation. Complications in boys included 3 urethrocutaneous fistula, 1 hypospadias, return to operating room for 1 suprapubic tube removal, and 1 spica cast change. All closures were successful without dehiscence.

Conclusions
We report the surgical method adopted by a multi-institutional collaboration. The increased volume of patients, expert opinions shared, and proficiency gained were immediate benefits observed. This effort increased the annual experience of each institution involved from 3 to 9-fold to ultimately benefit patient care.

Funding: None