Pelvic Osteotomy in the Modern Treatment of the Exstrophy-Epispadias Complex

The role of the pelvic osteotomy at the time of bladder exstrophy closure has been better defined over the past three decades. Modern radiographic imaging provides greater insight into the pelvic bony and muscular defects encountered with these children and has forced surgeons to reconsider the importance of reconstructive efforts beyond the genitourinary tract. Surgical series from several of the world's specialist centers clearly identify the use of osteotomy as a positive predictor for overall success of the management provided to these patients. Osteotomies decrease the tension placed on the soft tissues at the time of initial closure, thereby decreasing the risk of early dehiscence or prolapse. Long-term studies have discovered benefits with respect to urinary continence and orthopedic function when efforts have been made to restore the anatomic integrity of the pelvic muscles and bones. This review summarizes the most current knowledge of anatomy in classic bladder exstrophy and suggests the indications, methods, and expected outcomes for the use of pelvic osteotomies during bladder exstrophy closure. Most of this report derives from the authors’ experience with the modern staged repair of exstrophy at the Johns Hopkins Hospital. However, the benefits of pelvic osteotomies at the time of closure should extend to all patients, regardless of the specific genitourinary reconstructive strategy chosen.