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A Single Institution Experience of Complete Primary Repair of Bladder Exstrophy in Girls: Risk Factors for Urinary Retention
Bryan Sack, MD, Joseph Borer, MD.
Boston Children's Hospital, Boston, MA.

BACKGROUND: Following recent technical modifications, we have observed a high rate of urinary retention in girls post-complete primary repair of exstrophy (CPRE). The aim of this investigation was to identify factors that may be responsible for this observation by reviewing our historical outcomes in comparison to current outcomes. METHODS: A retrospective review of all girls that underwent CPRE from December 1998 through September 2016 from a single institution was performed. Operative age and weight, type of pelvic immobilization, use of pelvic osteotomies, imaging, clinical course, and need for additional surgical procedures were recorded. Patients were deemed in retention if their clinical course was consistent with such, included a procedure or procedures to relieve urinary retention, and/or a requirement for clean intermittent catheterization (CIC). RESULTS: Nineteen girls underwent CPRE in this time period. In the mid-2000s, a change to delaying CPRE to approximately 2-months of age was made and this led us to divide the girls into newborn (<72 hours of age) and delayed (>72 hours of age) repair subgroups. Eight (42%) had newborn and eleven (58%) had delayed repair. None of the newborn and all of the delayed repairs had posterior iliac osteotomies. There were no girls with retention in the newborn group. One delayed repair was complicated by bladder rupture secondary to retention, necessitating surgical exploration and CIC. A second delayed CPRE required CIC. Long-term outcomes greater than nine years are available for six girls in the newborn group and two (33%) required bladder neck procedures for incontinence. CONCLUSIONS: The absolute absence of retention in the newborn group (without osteotomy) is concerning for the delayed (with osteotomy) group incurring a higher risk of retention post-CPRE. The increased risk of retention could be secondary to compression of the urethra at the time of pubic symphysis approximation, which may cause a compartment syndrome-like phenomenon leading to urethral ischemia. Different from the newborn CPRE girls, additional technical revision of CPRE, namely elongation of the urethra and the dissection it involves, may also place the delayed CPRE girls at risk for urinary retention.

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