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18041

Primary Closure of Bladder Exstrophy without Osteotomies and Intensive Care Unit Is Safe and Cost-Effective

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Massimo Garriboli, Naima Smeulders, Abraham Cherian, Imran Mushtaq and Peter Cuckow, Paediatric Urology, Great Ormond Street Hospital, London, United Kingdom

Purpose To analyse the clinical and cost effectiveness outcome of two different post-operative regimens following neonatal bladder closure for primary Bladder Exstrophy (BE).

Methods We reviewed our neonatal management of primary bladder exstrophy over the past 5 years, comparing post-operative management on the surgical ward with epidural analgesia to muscle paralysis/ventilation on the intensive care unit (ICU). Clinical outcome measures were: length of stay, postoperative complications and re-do closure. Cost-effectiveness has also been evaluated using hospital financial data. Data are expressed as median (range). Significance was explored by Fisher exact test and unpaired t test.

Results 74 neonates were referred to us between 2007 and 2011 and all underwent closure without osteotomies. 48 babies (65%) were managed on the ward (Group A), 26 transferred to ICU (Group B). The allocation was related to surgeon preference based on tight closure or failed epidural. The two groups were homogeneous for gestational age: 39 weeks (27–41) and age at closure: 3 days (1-152). Re-do closure was required in 2 patients in each group (4.2% and 7.7%, p=0.691). Complications requiring surgical treatment occurred in 4 children in group A and 3 children in group B (8.3% and 11.5%, p=0.609): 1 bladder rupture secondary to a tight urethral opening (group A), 1 prolapse managed by laparoscopic cystopexy (group B) and 5 urethral/meatal stenosis requiring dilatation under general anaesthesia. Epidural-related complications (redness, swelling or positive swab from epidural site) were observed in 6 patients (21%). None required treatment. Sagittal sinus thrombosis was identified on routine brain ultrasound following ICU in 1, without clinical sequelae. Length of stay was significantly shorter for the group cared for on the ward (11 days vs 18 days, p < 0.0001). Costing a representative uncomplicated patient for each group demonstrated a significant difference (£ 13.290 group A vs £ 36.394 group B).

Conclusion Neonatal closure of bladder exstrophy can safely be performed without osteotomies. Routine post-operative management in ICU confers no benefit of outcome and significant longer post-operative stay with major cost implications. Patients managed postoperatively with epidural infusion for analgesia in a urology ward are fed and discharged home earlier.

 

Group A (ward)

n=48

Group B (ICU)

 n=26

 

p

Median Length of stay (days)

11 (6 – 30)

18 (12 -41)

< 0.0001

Complications requiring surgical treatment

4 (8.3%)

3 (11.5%)

0.691

bladder rupture

1

0

-

bladder prolapse

0

1

-

urethral/meatal stenosis

3

2

-

Re-do closure

2 (4.2%)

2 (7.7%)

0.609

Cost for admission (£)

13.290

36.394

-