Difference between revisions of "Bladder exstrophy repair"
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Zining Chen (talk | contribs) (Created page and finished overview indications and procedure description) |
Zining Chen (talk | contribs) (Finished postop management and references) |
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = | | anesthesia_type = General | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = PIV x2 | ||
| monitors = | Arterial line (often recommended) | ||
| considerations_preoperative = | | monitors = Standard ASA | ||
| considerations_intraoperative = | Temperature | ||
| considerations_postoperative = | Arterial BP (if placed) | ||
| considerations_preoperative = -Neonate/infant physiology | |||
-Associated congenital anomalies | |||
| considerations_intraoperative = -Large fluid shifts and blood loss risk | |||
-Hypothermia prevention | |||
-Pelvic osteotomies need | |||
-Regional analgesia (caudal/epidural) | |||
| considerations_postoperative = -Ventilatory support (neonate or prolonged case) | |||
-Epidural analgesia management | |||
-Wound dehiscence risk | |||
-Electrolyte abnormalities | |||
}} | }} | ||
| Line 25: | Line 35: | ||
Timing | Timing | ||
* Ideally within first year of life, preferably before 9 months | * Ideally within first year of life, preferably before 9 months (now the new norm) | ||
* Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies | * Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies | ||
* Delayed or staged reconstruction can be performed in older infants or failed primary closure | * Delayed or staged reconstruction can be performed in older infants or failed primary closure | ||
| Line 37: | Line 47: | ||
* Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage) | * Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage) | ||
* Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair) | * Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair) | ||
<ref>{{Cite journal|last=Mathews|first=Ranjiv I.|last2=Schaeffer|first2=Anthony J.|last3=Gearhart|first3=John P.|date=2024-06|title=Classic Bladder Exstrophy - Timing of initial closure and technical highlights|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC11649320/|journal=African Urology|volume=4|issue=se1|pages=S11–S15|doi=10.36303/auj.0150|issn=2710-2750|pmc=11649320|pmid=39687281}}</ref> | |||
== Preoperative management == | == Preoperative management == | ||
| Line 47: | Line 58: | ||
|- | |- | ||
|Airway | |Airway | ||
| | | -Neonatal airway considerations | ||
-Syndromic features possible | |||
-Prematurity possible | |||
-Appropriate ETT size | |||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | | -Developmental abnormalities possible | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | | -Congenital heart disease screening | ||
-Neonatal physiology (HR dependence) | |||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | | -Prematurity related lung disease | ||
-Postoperative apnea risk | |||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | | -NPO considerations in neonate | ||
-Aspiration risk | |||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | | -T&C | ||
-Anticipate moderate to significant blood loss | |||
|- | |- | ||
|Renal | |Renal | ||
| | | -Urinary tract anomalies | ||
-Monitor electrolytes | |||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | | -Neonatal glucose (hypoglycemia risk) | ||
|- | |- | ||
|Other | |Other | ||
| | | -Hypothermia risk | ||
-Latex allergy precautions | |||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* T&C | |||
* CBC | |||
* BMP, electrolytes | |||
* Echocardiogram if cardiac anomaly suspected | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Blood products available | |||
* Fluid warmer | |||
* Forced-air warming device | |||
* Pediatric airway equipment | |||
* Consider arterial line setup | |||
* Caudal/epidural kit | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Multidisciplinary planning per institution (urology + orthopedic if osteotomies) | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
Caudal or Lumbar Epidural strongly considered for | |||
* Intra/postoperative opioid-sparing pain control | |||
* Reduction in movement to protect repair | |||
* Sometimes tunneled as epidural will be in place for days to weeks | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* Standard ASA | |||
* Core temperature montoring | |||
* PIV x2 preferred | |||
* Arterial line commonly used | |||
* Foley/suprapubic catheter placed by surgeon with UOP monitoring | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Standard inhalational or IV induction | |||
* Neonatal dosing considerations | |||
* Avoid hypotension | |||
* Standard pediatric airway considerations | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* Balanced anesthesia with volatile or TIVA | |||
* Temperature management (large exposed viscera, long case) | |||
* Blood loss replaced promptly (neonates tolerate anemia poorly) | |||
* Fluid balance (neonates sensitive to hypo and hypervolemia) | |||
* Glucose monitoring (neonates have limited glycogen stores) | |||
* Osteotomies may increase bleeding and stimulation | |||
* Continuous epidural infusions commonly used | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
Extubation if | |||
* Hemodynamically stable | |||
* Normothermic | |||
* Adequate ventilation | |||
Consider postoperative ventilation if | |||
* Premature infants | |||
* Prolonged case | |||
* Significant blood loss | |||
* Severe edema | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
NICU or PICU (PACU uncommon for primary repairs) | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
Pain often significant (especially with osteotomy) and adequate analgesia is critical to prevent movement that compromise repair | |||
* Epidural analgesia | |||
* Scheduled acetaminophen | |||
* Opioids for breakthrough pain | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Wound dehiscence | |||
* Bladder outlet obstruction | |||
* Urinary leakage | |||
* Pelvic instability (if osteotomy) | |||
* Bleeding | |||
* Infection | |||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | == Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ||
{| class="wikitable wikitable-horizontal-scroll" | {| class="wikitable wikitable-horizontal-scroll" | ||
|+ | |+<ref>{{Cite book|title=A practice of anesthesia for infants and children|date=2019|publisher=Elsevier|isbn=978-0-323-42974-0|editor-last=Coté|editor-first=Charles J.|edition=Sixth edition|location=Philadelphia, PA|editor-last2=Lerman|editor-first2=Jerrold|editor-last3=Anderson|editor-first3=Brian J.}}</ref><ref>{{Cite book|last=Davis|first=Peter J.|title=Smith's anesthesia for infants and children|last2=Cladis|first2=Franklyn P.|last3=Motoyama|first3=Etsuro K.|date=2011|publisher=Mosby|isbn=978-0-323-06612-9|edition=8th ed|location=St. Louis, Mo}}</ref><ref>{{Cite book|title=Campbell-Walsh-Wein urology|date=2026|publisher=Elsevier|isbn=978-0-323-88405-1|editor-last=Dmochowski|editor-first=Roger R.|location=Philadelphia, PA|editor-last2=Kavoussi|editor-first2=Louis R.|editor-last3=Peters|editor-first3=Craig A.|editor-last4=Campbell|editor-first4=Meredith F.|editor-last5=Walsh|editor-first5=Patrick C.|editor-last6=Wein|editor-first6=Alan J.}}</ref> | ||
! | ! | ||
! | !Modern staged repair (MSRE) | ||
! | !Complete primary repair (CPRE) | ||
|- | |- | ||
| | |Surgical timing | ||
|Stage 1 (before 9 months for primary closure +/- osteomy) | |||
Stage 2 (before 2 years for epispadias repair in males) | |||
|- | |||
Stage 3 (childhood for bladder neck reconstruction) | |||
|Neonatal period | |||
| | |||
|- | |- | ||
|EBL | |EBL | ||
| | |Moderate | ||
| | |High | ||
|- | |- | ||
| | |Unique consideration | ||
| | |Repeated anesthesia exposure | ||
| | |Prolonged case | ||
High blood loss | |||
More fluid shifts | |||
|} | |} | ||
Latest revision as of 09:44, 23 February 2026
Bladder exstrophy repair
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
PIV x2 Arterial line (often recommended) |
| Monitors |
Standard ASA Temperature Arterial BP (if placed) |
| Primary anesthetic considerations | |
| Preoperative |
-Neonate/infant physiology -Associated congenital anomalies |
| Intraoperative |
-Large fluid shifts and blood loss risk -Hypothermia prevention -Pelvic osteotomies need -Regional analgesia (caudal/epidural) |
| Postoperative |
-Ventilatory support (neonate or prolonged case) -Epidural analgesia management -Wound dehiscence risk -Electrolyte abnormalities |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Bladder exstrophy is a rare congenital anomaly characterized by failure of lower abdominal wall and anterior bladder closure, resulting in exposure of posterior bladder wall through the abdominal wall. The defect results from failure of mesenchymal migration and premature rupture of cloacal membrane during embryologic development.
Surgical repair is typically performed in neonatal period (primary closure) or later in staged reconstruction.
Overview
Indications
Surgical repair indicated in all cases of classic bladder exstrophy with goals to
- Protect exposed bladder mucosa from infection and trauma
- Prevent progressive renal damage
- Restore urinary continence
- Reconstruct genital and abdominal anatomy
Timing
- Ideally within first year of life, preferably before 9 months (now the new norm)
- Immediate closure within first 72 hours of life when pelvic bones are more malleable can help avoid osteotomies
- Delayed or staged reconstruction can be performed in older infants or failed primary closure
Surgical procedure
- Bladder plate mobilization and closure (exposed bladder plate is dissected and mobilized to allow posterior wall approximation)
- Bladder neck and urethra reconstruction (if part of staged repair)
- Abdominal wall closure (rectus muscles and fascia are mobilized and reapproximated)
- Pelvic osteotomies (commonly done to reduce tension and allow pubic approximation, which increase surgical time, blood loss, and postop pain)
- Urinary drainage (suprapubic catheter, urethral stents, urethral catheter depending on stage)
- Postoperative immobilization (e.g. Bryant's traction or Spica cast to protect repair)
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | -Neonatal airway considerations
-Syndromic features possible -Prematurity possible -Appropriate ETT size |
| Neurologic | -Developmental abnormalities possible |
| Cardiovascular | -Congenital heart disease screening
-Neonatal physiology (HR dependence) |
| Pulmonary | -Prematurity related lung disease
-Postoperative apnea risk |
| Gastrointestinal | -NPO considerations in neonate
-Aspiration risk |
| Hematologic | -T&C
-Anticipate moderate to significant blood loss |
| Renal | -Urinary tract anomalies
-Monitor electrolytes |
| Endocrine | -Neonatal glucose (hypoglycemia risk) |
| Other | -Hypothermia risk
-Latex allergy precautions |
Labs and studies
- T&C
- CBC
- BMP, electrolytes
- Echocardiogram if cardiac anomaly suspected
Operating room setup
- Blood products available
- Fluid warmer
- Forced-air warming device
- Pediatric airway equipment
- Consider arterial line setup
- Caudal/epidural kit
Patient preparation and premedication
- Multidisciplinary planning per institution (urology + orthopedic if osteotomies)
Regional and neuraxial techniques
Caudal or Lumbar Epidural strongly considered for
- Intra/postoperative opioid-sparing pain control
- Reduction in movement to protect repair
- Sometimes tunneled as epidural will be in place for days to weeks
Intraoperative management
Monitoring and access
- Standard ASA
- Core temperature montoring
- PIV x2 preferred
- Arterial line commonly used
- Foley/suprapubic catheter placed by surgeon with UOP monitoring
Induction and airway management
- Standard inhalational or IV induction
- Neonatal dosing considerations
- Avoid hypotension
- Standard pediatric airway considerations
Maintenance and surgical considerations
- Balanced anesthesia with volatile or TIVA
- Temperature management (large exposed viscera, long case)
- Blood loss replaced promptly (neonates tolerate anemia poorly)
- Fluid balance (neonates sensitive to hypo and hypervolemia)
- Glucose monitoring (neonates have limited glycogen stores)
- Osteotomies may increase bleeding and stimulation
- Continuous epidural infusions commonly used
Emergence
Extubation if
- Hemodynamically stable
- Normothermic
- Adequate ventilation
Consider postoperative ventilation if
- Premature infants
- Prolonged case
- Significant blood loss
- Severe edema
Postoperative management
Disposition
NICU or PICU (PACU uncommon for primary repairs)
Pain management
Pain often significant (especially with osteotomy) and adequate analgesia is critical to prevent movement that compromise repair
- Epidural analgesia
- Scheduled acetaminophen
- Opioids for breakthrough pain
Potential complications
- Wound dehiscence
- Bladder outlet obstruction
- Urinary leakage
- Pelvic instability (if osteotomy)
- Bleeding
- Infection
Procedure variants
| Modern staged repair (MSRE) | Complete primary repair (CPRE) | |
|---|---|---|
| Surgical timing | Stage 1 (before 9 months for primary closure +/- osteomy)
Stage 2 (before 2 years for epispadias repair in males) Stage 3 (childhood for bladder neck reconstruction) |
Neonatal period |
| EBL | Moderate | High |
| Unique consideration | Repeated anesthesia exposure | Prolonged case
High blood loss More fluid shifts |
References
- ↑ Mathews, Ranjiv I.; Schaeffer, Anthony J.; Gearhart, John P. (2024-06). "Classic Bladder Exstrophy - Timing of initial closure and technical highlights". African Urology. 4 (se1): S11–S15. doi:10.36303/auj.0150. ISSN 2710-2750. PMC 11649320 Check
|pmc=value (help). PMID 39687281 Check|pmid=value (help). Check date values in:|date=(help) - ↑ Coté, Charles J.; Lerman, Jerrold; Anderson, Brian J., eds. (2019). A practice of anesthesia for infants and children (Sixth edition ed.). Philadelphia, PA: Elsevier. ISBN 978-0-323-42974-0.
|edition=has extra text (help) - ↑ Davis, Peter J.; Cladis, Franklyn P.; Motoyama, Etsuro K. (2011). Smith's anesthesia for infants and children (8th ed ed.). St. Louis, Mo: Mosby. ISBN 978-0-323-06612-9.
|edition=has extra text (help) - ↑ Dmochowski, Roger R.; Kavoussi, Louis R.; Peters, Craig A.; Campbell, Meredith F.; Walsh, Patrick C.; Wein, Alan J., eds. (2026). Campbell-Walsh-Wein urology. Philadelphia, PA: Elsevier. ISBN 978-0-323-88405-1.
Top contributors: Zining Chen