Modern Management of the Failed Bladder Exstrophy Closure: A 50-yr Experience

Background: A failed closure of classic bladder exstrophy (CBE) has a negative long-term impact on the patient and the health care system. Objective: To investigate the outcomes of CBE patients with failed primary bladder closure. Design, setting, and participants: A database of 1317 exstrophy-epispadias complex patients was retrospectively reviewed for CBE patients with failed primary bladder closure from 1965 to 2017 with subsequent repeat closure. Intervention: Repeat bladder exstrophy closure and subsequent continence procedure. Outcome measurements and statistical analysis: Failed exstrophy closures are defined as occurrence of bladder prolapse, dehiscence, vesicocutaneous fistula, outlet obstruction, or combination of these factors. Successful repeat closures are defined as closures that require no further operative intervention as a consequence of these factors. Kaplan-Meier to determine time to successful repeat closure and receiver operator characteristic curve to determine the optimal time for secondary closure were determined. Results and limitations: In total, 170 CBE patients had at least one repeat closure following a failed primary closure (115 male/55 female). With continued closure attempts, 166/170 (97.6%) patients were successfully closed. The median time to successful closure from birth was 12.9 mo (95% confidence interval: 11.7–15.7). Furthermore, 52/153 (34%) patients had more than one osteotomy. Of 215 total osteotomies, 50 (29.4%) were performed during the 170 failed primary closures, 128 (75.3%) during the 170 second closures, and 27 (64.3%) during the 42 third closures. Of 96 patients with available continence data, 74 (77.1%) achieved urinary continence. Conclusions: A successful repeat closure is possible, especially when used in conjunction with a pelvic osteotomy. Continent urinary diversion yielded the highest continence rate in this cohort. Patient summary: We looked at outcomes of classic bladder exstrophy closure in a large population. Successful repeat closure is possible in the majority of cases when used with pelvic osteotomy. A majority of patients achieved urinary continence using a continent diversion. Especially when performed in conjunction with osteotomy, a successful repeat bladder exstrophy closure is possible following a prior failed attempt. The majority of patients are able to achieve urinary continence after a prior failed closure using a continent diversion.