THE STAGED APPROACH TO BLADDER EXSTROPHY CLOSURE AND THE ROLE OF OSTEOTOMIES

Since the 1970's, the staged reconstruction of bladder exstrophy has y ielded consistent surgical success. The Johns Hopkins Hospital approac h begins with early pelvic ring approximation with abdominal wall. bla dder, and posterior urethral closure. Within the first 72 hours of lif e, the malleable pelvis can sometimes be approximated without osteotom ies. Beyond this age, the author's prefer a combined vertical iliac an d horizontal innominate osteotomy. Second, we typically perform the ep ispadias closure at 1 year of age. A modified Cantwell-Ransley techniq ue is performed, usually yielding an increase in bladder capacity and very satisfactory results. In the last phase, the modified Young-Dees- Leadbetter continence procedure along with transtrigonal/cephalotrigon al ureteroneocystostomies are performed when the urethra is catheteriz able, the bladder capacity is 60cc or greater, and the child will part icipate in a postoperative voiding program (typically 4-5 years of age ). This applied approach usually results in a continent, voiding patie nt with pleasing external genitalia and preserved renal function.