Orthopaedic management and considerations for classic bladder exstrophy

Abstract

Bladder exstrophy results from an embryological aberration that affects the genitourinary and musculoskeletal systems leading to anterior midline defects. The complex urogenital reconstruction procedure is facilitated by the closure of the bony pelvic ring by the orthopaedic team. There are many orthopaedic considerations in the setting of bladder exstrophy. Therefore, this review aims to present a contemporary overview of orthopaedic management in bladder exstrophy, including osteotomy techniques, intraoperative radiology, pin placement, and repeat pelvic osteotomy (RPO) for failed primary bladder closure. The age of the patient and other comorbidities, such as hip dysplasia, are important orthopaedic considerations during the preoperative evaluation. Several types of osteotomy techniques exist to facilitate bladder closure to alleviate tension, enhance genital reconstruction, and improve appearance and possibly continence. Bilateral anterior pelvic osteotomy offers good approximation and improved mobility of the pubic rami at the time of closure. They allow the surgeon to prevent vertical migration of the hemipelvis through direct visual external fixator placement and postoperative adjustments. There is no need for patient repositioning during surgery. In the setting of bladder prolapse or dehiscence after initial bladder repair, RPO augments the success rates of secondary closure with better closure of the abdominal wall and genitalia. Orthopaedic management is essential in treating bladder exstrophy as the approximation of the pubis with pelvic osteotomies is important to optimise primary and secondary bladder closure outcomes.