Bladder exstrophy: primary closure in the modern staged repair

Operative visualisation

UrOops3D · UroRef · © Nity G

How to use this module. Play the nine steps, or use Back and Next. Watch the plate lift off the wall, the outlet roll into a tube, the bladder close and sink behind the pubis, and the pelvis turn as the bones meet. The triggers show a failed closure, an obstructed ureter, a fistula and continence that fails.

Operative steps

1. Newborn assessment A newborn boy with classic bladder exstrophy is seen by the exstrophy team. The umbilical cord is tied rather than clamped, and the plate is covered with plastic film so that it stays moist and is not rubbed. The size and quality of the plate, the width of the pubic gap, the penis and the hips are assessed, the kidneys are scanned, and the family meets the team that will look after the child for life.
   where it bites: a plate that dries, is rubbed by dressings or is crushed by a cord clamp becomes inflamed and polypoid, and a poor plate closes badly.
2. Circumferential incision The line is marked round the bladder plate, below the umbilicus, and carried down both edges of the urethral plate on the dorsum of the penis. It is incised where the mucosa meets the skin. The paraexstrophy skin lateral to the plate is kept, with its own supply.
   where it bites: the line keeps to the junction: an incision into the plate narrows it, and one wide of it takes skin needed later.
3. Free the plate The plate is lifted and freed from the abdominal wall and the paraexstrophy tissue, with the dissection kept on the side of the wall so that the plate keeps its blood supply. The freeing is carried deep to the bladder neck and the urethral plate, toward the pelvic floor, so that both can be brought back into the pelvis without tension. The ureters enter the plate from behind, low down.
   where it bites: the blood supply of the plate and of the genitalia runs in this tissue; the ureters lie just behind the trigone, and the peritoneum and bowel just above the dome.
4. Tubularise the outlet A fine stent is passed up each ureter. A catheter is laid along the urethral plate into the bladder neck, and the posterior urethra and the bladder neck are rolled into a tube round it. No formal continence procedure is done at this stage: tightening the outlet now would obstruct a bladder that has yet to grow.
   where it bites: the orifices sit close to the neck in an abnormal trigone; a stitch placed low in the tube can take a ureter.
5. Pelvic osteotomy The orthopaedic surgeon makes the pelvic osteotomies, under the same anaesthetic and usually before the urological closure begins. An iliac osteotomy on each side lets the two halves of the pelvis turn forward, so that the pubic bones can be brought together without tension. Many centres use it when the closure is not done in the first days of life or when the pubic gap is wide.
   where it bites: the pelvic vessels and nerves lie close behind the cut; a closure under tension without osteotomy is a common reason for dehiscence.
6. Close the bladder and drop it The plate is rolled into a bladder and closed in layers in the midline, from the neck up to the dome, with the two stents brought out through the dome. A suprapubic tube is placed through the dome to drain it. The bladder and the posterior urethra are then dropped back into the pelvis, behind the pubis.
   where it bites: a bladder closed under tension or with its dome left too high is the bladder that prolapses.
7. Bring the pubis together A stitch is passed round the two pubic bones, in front of the bladder neck, and tied as the halves of the pelvis turn forward and the bones meet. The bladder neck and posterior urethra now lie deep in the pelvis, behind the symphysis.
   where it bites: the bladder neck lies directly behind the stitch; a knot on the urethra causes erosion and fistula.
8. Close the abdominal wall The rectus fascia is closed in the midline over the bladder, then the skin. The two ureteric stents and the suprapubic tube leave through the closed wall. The pelvis is held still afterwards, in traction or with an external fixator, while the bones and the wound heal.
   where it bites: movement of the pelvis in the weeks after closure pulls on the repair; immobilisation and the drains are kept until healing allows.
9. The later stages In the first years of life the epispadias is repaired: the urethral plate is rolled into a tube and the corpora are brought together over it. Once the bladder has grown enough, usually at about school age, the bladder neck reconstruction is done for continence, often with the ureters reimplanted. Follow-up of the kidneys, the bladder, continence, sexual function and cancer risk goes on for life.
   where it bites: a bladder that does not grow, or a neck reconstruction that fails, leads to augmentation, a catheterisable channel and their own long-term risks.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance

Curriculum. Supports learning relevant to the ISCP Urology Curriculum syllabus topic Paediatric urology. Not a workplace-based assessment and not evidence of competence.