Mucosal Violations and Their Effect on Successful Bladder Neck Closure in Cloacal Exstrophy

Chad B Crigger; Thomas G W Harris; Tamir N Sholklapper; Ahmad Haffar; Christian C Morrill; Isam W Nasr; Robin Yang; Richard J Redett; John P Gearhart

doi:10.1016/j.jpedsurg.2023.05.009

Mucosal Violations and Their Effect on Successful Bladder Neck Closure in Cloacal Exstrophy

J Pediatr Surg. 2023 Dec;58(12):2313-2318. doi: 10.1016/j.jpedsurg.2023.05.009. Epub 2023 May 19.

Authors

Chad B Crigger¹, Thomas G W Harris², Tamir N Sholklapper¹, Ahmad Haffar¹, Christian C Morrill¹, Isam W Nasr³, Robin Yang⁴, Richard J Redett⁴, John P Gearhart⁵

Affiliations

¹ James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
² James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
³ Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁴ Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
⁵ James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: Jgearha2@jhmi.edu.

PMID: 37302866
DOI: 10.1016/j.jpedsurg.2023.05.009

Abstract

Background: Cloacal exstrophy (CE) is rare and challenging to reconstruct. In the majority of CE patients voided continence cannot be achieved and so patients often undergo bladder neck closure (BNC). Prior mucosal violations (MVs), a surgical event when the bladder mucosa was opened or closed, significantly predicted failed BNC in classic bladder exstrophy with an increased likelihood of failure after 3 or more MVs. The aim of this study was to assess predictors for failed BNC in CE.

Methods: CE patients who underwent BNC were reviewed for risk factors for failure including osteotomy use, successful primary closure, and number of MVs. Chi-squared and Fisher's exact tests were used for comparing baseline characteristics and surgical details.

Results: Thirty-five patients underwent BNC. Eleven patients (31.4%) failed BNC including a vesicoperineal fistula in nine, vesicourethral and vesicocutaneous fistula in one each. The fistula rate in patients with 2 or more MVs was 47.4% (p = 0.0252). Two patients subsequently developed a vesicocutaneous fistula after undergoing repeated cystolithotomies. A rectus abdominis or gracilis muscle flap were used to close the fistula in 11 and 2 patients, respectively.

Conclusions: MVs have a greater impact in CE with an increased risk of failed BNC after 2 MVs. CE patients are most likely to develop a vesicoperineal fistula while a vesicocutaneous fistula is more likely after repeat cystolithotomy. A prophylactic muscle flap should be considered at time of BNC in patients with 2 or more MVs.

Levels of evidence: Prognosis Study, Level III.

Keywords: Bladder neck closure; Bladder neck transection; Cloacal exstrophy; Fistula; Mucosal violation; Muscle flap.

MeSH terms

Bladder Exstrophy* / surgery
Cutaneous Fistula*
Humans
Retrospective Studies
Urinary Bladder / surgery
Urination
Urologic Surgical Procedures