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1 . Abstract

Is pelvic osteotomy associated with lower risk of pelvic organ prolapse in postpubertal females with classic bladder exstrophy ? Ifeanyi Anusionwu MD, a Nima Baradaran MD, a Bruce J. Trock PhD, a Andrew A. Stec MD, b John P Gearhart MD, a E. James Wright MD a

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1 . Abstract

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  1. Is pelvic osteotomy associated with lower risk of pelvic organ prolapse in postpubertal females with classic bladder exstrophy? • IfeanyiAnusionwuMD,aNimaBaradaranMD,a Bruce J. TrockPhD,aAndrew A. StecMD,b John P Gearhart MD,a E. James Wright MDa • a- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institution, Baltimore, MD • b- Department of Urology, Medical University of South Carolina, Charleston, SC 1. Abstract Objectives: It appears intuitive that closure of the pelvic ring with the use of osteotomy will be associated with decreased risk of pelvic organ prolapse(POP) in patients with bladder exstrophy. The aim of this study is to determine whether osteotomy is associated with a lower risk of POP in females with classic bladder exstrophy. Methods: We queried our institutional review board-approved bladder exstrophy database, and identified 335 females. We excluded patients who were younger than 13 years old, those who had cloacalexstrophy or female epispadias, and those who did not have postpubertal imaging for measurement of pubic diastasis. Our final study population consisted of 67 females. Univariate analysis was performed using t-test or rank sum test for continuous variables and chi-squared test for categorical variables. Logistic regression was used for multivariable analysis. Results: Median patient age was 23.1 years (range 13- 60). Twenty patients (29.9%) developed POP at median age of 20.4 (range 11.0-42.8) years. Twenty-five patients (37.3%) had undergone osteotomy at median age of 6 months (range birth to 9.8 years) and 7patients had at least one pregnancy (range 1-3). On univariate analysis, only diastasis was associated with prolapse, with smaller diastasis associated with lower risk of prolapse. On multivariable analysis including diastasis and osteotomy, only diastasis was statistically significant. Mean diastasis in patients who underwent osteotomy was 7.14cm while for those who did not undergo osteotomy it was 7.98cm (p =0.46). Conclusions: Pelvic osteotomy does not appear to decrease the risk of POP in patients with classic bladder exstrophy. Rather, it is the degree of symphysealdiastasis that is significantly associated with pelvic organ prolapse. 2. Methods • Study population: 67 females with classic bladder exstrophy • Diastasismeasured using the most recent pelvic radiograph, computed tomography or magnetic resonance imaging • POP diagnosed on vaginal exam performed as routine clinical practice by the urologist at onset of puberty • Univariateanalysis performed using t-test for continuous variables (rank sum test when data not normally distributed) and chi-squared test for categorical variables • Osteotomy evaluated both as a dichotomous variable (yes or no) and as a categorical variable stratified by age at osteotomy (no, early osteotomy at age <2 years and late osteotomy at age>2 years) • Logistic regression used for multivariable analysis evaluating factors associated with POP • 3. Results • Median age 23.1 years (range 13-60; inter-quartile range 18-30). • 20 patients (29.9%) developed POP at median age 20.4 (range 11.0-42.8) years • 25 patients (37.3%) had undergone osteotomy at median age of 6 months (range birth to 9.8 years) • 7 patients had at least one pregnancy (range 1-3 pregnancies) • On comparison of age at measurement of pubic diastasis, a significant difference was seen between patients who had POP and those who did not (P = 0.03) with diastasis measured at an older age in patients with prolapse(24.7 versus 19.03 years) • When age at measurement of diastasis was included in the multivariate model, there was still no significant association between osteotomy and POP (p=0.15) Table 1. Mean (standard deviation) and frequencies of variables in patients with and without pelvic organ prolapse Table 2. Logistic regression model to predict pelvic organ prolapse in patients with classic bladder exstrophy • 4. Conclusions • In postpubertal females with bladder exstrophy, osteotomy is not associated with risk of POP, rather, the degree of pubic diastasis was associated with the risk of POP • Thus, osteotomyby itself is not protective against POP, but it is the pelvic floor configuration at time of initial closure and the subsequent development in the postpubertal years that is associated with risk of POP For more information, contact IfeanyiAnusionwu

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