Transcript PowerPoint Presentation - Catalyst

Orthopaedic Management of
Bladder Exstrophy
Jessica J. M. Telleria, MD
Resident PYG-1
Department of Orthopaedics and Sports Medicine
University of Washington, Seattle, WA, USA
Pediatric Surgery Weekly Conference
07/07/2011
Disclosures
No disclosures
Outline
• Anatomic anomalies in bladder exstrophy
• Indications & goals for surgery
• Operative approaches
• Complications
• Conclusions
Urology Perspective
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Ortho Perspective
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What do we do with this?
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What is Normal in Exstrophy
• Sacral width
• Iliac segment (posterior Pelvis) length
• Microscopic histology normal
– Boney and cartilaginous differentiation &
development
– Endochondral ossification (cartilage model)
Defects in Boney Anatomy
• Pubic diastasis  incomplete pelvic ring
– Mean ~4 cm (birth)  8 cm (10 yrs)
– Normal 0.6 cm (all ages)
• Ischiopubic segment (anterior pelvis) is 30%
shorter
– Reduced symphyseal tension/mechanical stress
• Anterior segment externally rotated extra 18º
• Posterior segment externally rotated extra 12º
Defects in Boney Anatomy
• Wider hips
– 31% greater distance between triradiate cartilage
• Acetabular retroversion
– 13° retroversion, normal = 0°
Defects in Boney Anatomy
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Defects in Muscular Anatomy
• Obturator internus externally rotated extra 15º
• Obturator externus externally rotated extra 17º
– “Frame” for pelvic diaphragm
• Levator ani
– 15° greater anterosuperior rotation
– 68% of puborectus sling is posterior to rectum
(normal = 52%)
• Further from bladder neck  less support 
incontinence
– Hiatus is 2x wider & 1.3x longer
• Wider/flatter  Greater pelvic organ prolapse
Why Correct Boney Deformity?
• Prior to boney correction well executed softtissue repairs subject to complications:
– Dehiscence/Poor wound healing
– Fistula formation
– Wound infection
– Incontinence
– Recurrence of exstrophic defect
• Many related to excess soft tissue tension on
bladder/urethra/abdominal wall
– Pubic diastasis & innominate external rotation
Goals of Surgery
• Restore stability to pelvic ring
– Close anterior ring
• Reconstitute “scaffold” for pelvic diaphragm
• Provide tension-free closure for bladder/soft
tissues wound healing
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Before
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After
Approaches
• Posterior iliac osteotomy
• Anterior osteotomy of superior pubic rami
• Anterior diagonal iliac osteotomy
• Anterior transverse iliac osteotomy
• Combine posterior vertical and anterior
transverse iliac osteotomy
Combined Vertical/Transverse
• Corrects both anterior & posterior defects
• Transverse osteotomy: ~10mm proximal to
AIIS  most proximal (superior) sciatic notch
• Posterior vertical osteotomy: 2-3 cm lateral to
SI joint  sacral notch.
– Symphysis secured with wire through obturator
foramen
– External table left intact
– Vertical closing wedge (hinged greenstick)
Combined Vertical/Transverse
• Ex-fix to close pubic symphysis, x 4 wks
– Applied under direct visualization
– Adjustable if incomplete reduction
• Better symphyseal approximation and lower
recurrence ( p < 0.05 compared to posterior
alone)
Combined Vertical/Transverse
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Anterior Transverse Osteotomy
Preoperative
Anterior Transverse Osteotomy
Immediate Postoperative
Anterior Transverse Osteotomy
Preoperative
3 Years Postoperative
Posterior Iliac Osteotomy
• Landmark procedure (1958)
• 1st stage: Vertical osteotomy 2-3 cm lateral to
iliosacral joints. Iliac crest  sacral notch.
• 2nd stage: Pubic rami closed/secured with
wire through obturator foramina
– Sturdy anterior ring  prevents prolapse,
infection, dehiscence of bladder
– Soft tissue reconstruction proceeds
• Improved urinary continence 5%  43-69%
Posterior Iliac Osteotomy
Preoperative
Posterior Iliac Osteotomy
Immediately Postoperative
Posterior Iliac Osteotomy
Preoperative
14 Years Postoperative
Post-Operative Management
• Options:
– Bucks traction (4-6 wks)
– External fixator + modified buck traction (4-6 wks)
• Close follow-up, monitor for complications
– Pin-site infection, bladder outlet obstruction, etc
Complications
• Rate of orthopaedic complications 4 - 6%
• Boney
– Delayed union, non-union, SI joint pain, leg length
inequality/asymmetry
• Neurological
– Femoral, sciatic, peroneal, superior gluteal nerves
– Most recover, some with permanent palsy
• Soft tissue
– Pressure sores, compartment syndrome due to
overly tight bandages/traction
– Deep infection, osteo
Complications
• Overall complication rates higher (up to 25%)
• Include urologic complications: bladder
prolapse, dehiscence, bladder outlet
obstruction, ischemic injury to penis, etc.
• Symptomatic non-union (limp) 10 yrs
following vertical osteotomy
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• Vertical migration of ilium following vertical
osteotomy, deficit increased with growth
• 3 cm leg length inequality
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Take Home Points
• Care of these patients requires a
multidisciplinary approach
• Benefits of osteotomy outweigh risks
• Major technical surgery, requires:
– Careful planning
– Creativity
– Experienced hands
– Know your limits
• Success dependent on tension free construct
• Evolution of management, continued research
and reporting
References
1.
Sponseller PD, Bisson LJ, Gearhart JP, et al. The anatomy of the pelvis in the exstrophy complex. J Bone Joint Surg Am 1995;77-A:177-89.
2.
Stec AA, Wakim A, Barbet P, et al. Fetal bony pelvis in the bladder exstrophy complex: Normal potential for growth. J Pediatr Urol 2003; 62:337-41.
3.
Delaere O, Dhem A. Prenatal development of the human pelvis and acetabulum. Acta Orthop Belg 1999;65:255-60.
4.
Stec AA, Pannu HK, Tadros YE, et al. Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: Initial insights. J Urol
2001;166:1444-9.
Thanks!
Ant. Osteotomy Sup. Pubic Ramus
• Goal: simplify process for completion by
pediatric urologist, not ortho (1980s)
– Concurent boney & soft tissue repair
– Faster, no repositioning, fewer incisions
– Tension free closure of abdominal wall
• Bilateral superior pubic ramus osteotomies
between pectineus & adductor insertions
• Medial segments tilted toward midline, suture
secured through cartilagenous symphysis
• Problem: almost always have complete
recurrence of diastasis
Anterior Diagonal Iliac Osteotomy
• Originated from computer modeling (1990s)
• Diagonal osteotomy, greater sciatic notch  12 cm posterior to ASIS
– Optional bone graft in defect
• Pelvis compressed  rami approximated 
symphysis secured with suture
• Best of both worlds:
– Tension free closure, faster, no repositioning
– Lowest wound infection and dehiscence rates
– Failure rate similar to posterior iliac osteotomy