The Giessen-Mainz-Frankfurt procedure: A new method for complex pelvic reconstruction for bladder exstrophy

Purpose: In bladder exstrophy primary reconstruction remains the gold stand ard worldwide. Despite various types of osteotomies the permanent correctio n of pubic diastasis remains a challenge. In maxillofacial surgery callus d istraction is a routine treatment for hypoplastic mandibles. Originally des cribed by Ilizarov, this method provides stable and true bone lengthening a fter gradual distraction of an osteotomy site as long as the periosteum rem ains intact. In cooperation with the departments of maxillofacial surgery a nd orthopedics we used this technique to correct pubic diastasis and facili tate phallic reconstruction in a 4 1/2-year-old boy with bladder exstrophy who had previously undergone continent diversion. Materials and Methods: Three-dimensional computerized tomography was used t o create a stereolithography model and mock surgery was performed. Based on this model bilateral osteotomies of the superior and inferior segments of the pubic bones were done, preserving the periosteum. Pins were inserted an d a multidirectional external fixation device was mounted. Distraction was started on day 5 postoperatively. The distraction rate was 1 mm. daily and immobilization time was 28 days. The distraction progress was monitored by sonography. The device was removed 6 weeks postoperatively. Results: Radiography of the pelvis 2 years postoperatively revealed that th e distance between the pubic bones had decreased from 6 to 3 cm. (50%). Sim ultaneously the slanting angle normalized from 24 to 35 degrees due to upwa rd rotation of the inferior pubic rami. Mineralization in the newly formed bones was excellent. Visible penile length had increased significantly. Conclusions: To our knowledge we describe the first use of the basic Ilizar ov principle of callus distraction for permanent complex pelvic reconstruct ion for bladder exstrophy in a 4 1/2-year-old boy. After subperiostial oste otomies approximation of the symphysis and rotation of the inferior pubic r ami were achieved with a device commonly used in maxillofacial surgery. App roximation of 1 mm. daily for 28 days resulted in significant penile length ening. At a followup of 2 years there were stable pelvic ring reconstructio n and normal mineralization of the newly formed bones. In contrast to the s tandard techniques of osteotomies for correcting pubic diastasis, the Giess en-Mainz-Frankfurt procedure provides true bone growth with a stable decrea se in diastasis. Successful penile reconstruction was facilitated 1 year po stoperatively. This method may also be useful in primary and secondary blad der reconstruction.