Annals of African Medicine
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Table of Contents
Year : 2011  |  Volume : 10  |  Issue : 3  |  Page : 243-245  

Abdominal wall closure in bladder exstrophy complex repair by rectus flap

1 Department of Surgery, Division of Pediatric Surgery, Shiraz and Hormozgan University of Medical Sciences, Iran
2 Department of Surgery, Semnan University of Medical Science, Iran
3 Department of Forensic Sciences, Iranian Legal Medicine Research Center, Shiraz, Iran

Date of Web Publication9-Sep-2011

Correspondence Address:
S. M. V. Hosseini
Department of Surgery, Division of Pediatric Surgery, Shiraz University of Medical Sciences, Namazi Hospital
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1596-3519.84704

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Background and Objectives: The Exstrophy Complex (EC) is a serious malformation of midline abdominal wall. Wide pubis prevents approximating the lateralized rectus muscle and leads to dehiscence and fistula formation. Our aim was to recommend an easier method for abdominal wall closure in the Bladder Exstrophy (BE) complex repair.
Materials and Methods: From November 2007 to April 2010, we had three case of Cloacal Exstrophy (CE) and 10 BE, in which early bladder closure and coverage were performed by wide mobilization of bladder and rectus muscle flap closure in the midline without pubic closure.
Results: Two cases of CE had only minor wound dehiscence and bladder prolapsed later. One of the 10 BE cases developed vesicocutaneous fistula and the other two had minor wound dehiscence.
Conclusions: Our Technique reconstructed the abdominal wall with less morbidity and hospitalization because of tensionless closure.

   Abstract in French 

Contexte et objectifs: Exstrophy le complexe (EC) est une grave malformation de la paroi abdominale de la ligne médiane. Large pubienne empêche de se rapprocher du muscle rectus latéralisation et conduit à la formation de fistule et de déhiscence. Notre objectif était de recommander une méthode simplifiée de fermeture de la paroi abdominale dans la réparation complexe de la vessie Exstrophy (BE).
Méthodes et matériaux: De novembre 2007 à avril 2010, nous avons eu trois cas de cloacaux Exstrophy (CE) et 10 BE, dont la couverture et la fermeture anticipée de la vessie ont été effectuées par large mobilisation de la vessie et rectus fermeture de Rabat musculaires dans la ligne médiane sans poils pubiens fermeture.
Résultats: Deux cas de CE avaient déhiscence plaies mineures et la vessie prolabées plus tard. L'un des 10 cas BE développé vesicocutaneous fistule et les deux autres avaient une blessure mineure déhiscence.
Conclusions: Notre Technique reconstruit la paroi abdominale avec moins de morbidité et hospitalisation en raison de la fermeture de tensionless.
Mots clés: Fermeture de la paroi abdominale, Exstrophy de la vessie, rectus flap

Keywords: Abdominal wall closure, bladder exstrophy, rectus flap

How to cite this article:
Hosseini S, Sabet B, Zarenezhad M. Abdominal wall closure in bladder exstrophy complex repair by rectus flap. Ann Afr Med 2011;10:243-5

How to cite this URL:
Hosseini S, Sabet B, Zarenezhad M. Abdominal wall closure in bladder exstrophy complex repair by rectus flap. Ann Afr Med [serial online] 2011 [cited 2023 Feb 1];10:243-5. Available from:

   Introduction Top

The Exstrophy Complex (EC) is a serious malformation of the abdominal wall. The main purpose of early surgery is to secure abdominal wall for achieving bladder closure, which subsequently leads to urinary continence with preservation of renal function. [1] Delayed closure leads to further inflammatory or mechanical alterations; meanwhile, not closing the pubic bone by osteotomy may predispose the patients to rectal prolapse, anal incontinence, and uterine prolapses occasionally. [2],[3] The important steps in the repair of EC is a secured closed and growing bladder, without damaging the tiny pelvis of small neonate with improper osteotomy.

   Materials and Methods Top

During November 2007-April 2010, three cases of EC (one boy, two girls) and 10 cases of Bladder Exstrophy (BE) [seven boys, three girls] with median age (range, 3 days to 26 years) were referred to our center. Our method was approved by university ethics committee and written consent was taken from the parents of the children. Bladder closure were performed as earlier methods in all patients. [1],[2] However, we deferred from pubic closure in the abdominal wall closure by incising the inferior attachments of rectus muscles with a slice of pubic bone that was cut with diathermy from the pubis and performing an upper relaxing incision on the fascia of upper parts of both rectus muscles after mobilizing bilateral large skin flaps. Later, relaxed fascia and muscles of the abdominal wall were closed with heavy nonabsorbable suture in the midline over the bladder and posterior urethra.

All patients received local cleansing and antibiotic ointment until full healing occurred along with sufficient pain medication. There was no traction during the care and the infants accessed free movement that gave their mothers better cooperation in caring for them. The ureteral catheter was removed 3-4 weeks after surgery. The patients were followed by sonography for hydronephrosis and size of bladder for 6 months until adequate size of bladder reached for the second stage of operation [Figure 1], [Figure 2] and [Figure 3].
Figure 1: Bladder closed and rectus flap released from attachment

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Figure 2: Rectus flap closed in the midline

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Figure 3: Two months after closure

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   Results Top

A total of 13 patients with median age of 2 months (2 days to 26 years) were followed up during study. Male/female ratio was 1.5/1. Three cases had CE and 10 had BE, while other anomalies were observed in 25% (two myelomeningocele, one clubfoot). The mean operation time was 117±34 min (range, 80-180). The mean healing day was 27.6±13 (range, 14-50). Outcome evaluation showed bladder volume 65.5±18 mm (range, 40-100), without pelvic bone traction in all studied cases. Major complications were seen in four cases.

   Discussion Top

Reconstruction methods have always looked for easier symphyseal approximation, abdominal wall closure, placement of the entire bladder deep into the pelvis and re-approximation of the pelvic floor towards the midline. [1]

Osteotomy has gained importance in the prevention of uterine prolapse and the overall functional outcome; despite this, the reconstructive methods used to close the pelvis in early childhood, the symphysis will always reopen and influence the reconstructive surgery of pelvic soft tissue. [2],[3] Rectus fascial flaps have been used in abdominal closure when wide diastasis of the rectal muscles is present and when the lower abdomen lacks fascial support because lack of support predisposes the bladder to reopening as well as fistula formation. [4],[5],[6]

Our cases had no pubic closure in the first stage and a tension-free closure was possible for restoration of the abdominal wall. But, Hernandez et al. [7] reported that 90% of complications were seen in patients that underwent bladder repair and pubic closure without osteotomy. However, in large series effects of osteotomy in outcome bladder repaired were not mentioned, though we did not have to close the pubic bone, and thus the need of osteotomy was postponed.

Rectus abdominus has been used for reconstruction of the abdominal wall in severe cases of bladder exstrophy. Horton et al. [4] used inferiorly based rectus abdominus muscle flaps for constructing a firm abdominal without osteotomy. Mansour et al. [5] constructed the abdominal wall from the remaining muscular part of bladder wall and coverage of new urinary conduit, while Celayir et al. [6] performed augmentation of the small contracted bladder.

Our experience showed that for abdominal wall closure, there was no need for forceful pubic closure or use of osteotomy for protection of closed bladder and posterior urethra in the first stage of operation and the set goals were achieved successfully.

   References Top

1.Ebert AK, Reutter H, Ludwig M, Rösch WH. The Exstrophy-epispadias complex. Orphanet J Rare Dis 2009;4:23.  Back to cited text no. 1
2.Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, Gearhart JP. Pelvic floor anatomy in classical bladder exstrophy by using 3D computerized tomography: Initial insights. J Urol 2001:166:1444-9.  Back to cited text no. 2
3.Sponseller PD, Bisson LJ, Gearhart JP, Jeffs RD, Magid D, Fishman E. The anatomy of the pelvis in the exstrophy complex. J Bone Joint Surg 1995;77:177-89.  Back to cited text no. 3
4.Horton CE, Sadove RC, Jordan GH, Sagher U. Use of the rectus abdominis muscle and fascia flap in reconstruction of epispadias/exstrophy. Clin Plast Surg1988;15:393-7.  Back to cited text no. 4
5.Mansour AM, Sarhan OM, Helmy TE, Awad B, Dawaba MS, Ghali AM. Management of bladder exstrophy epispadias complex in adults: Is abdominal closure possible without osteotomy? World J Urol 2010;28:199-204.  Back to cited text no. 5
6.Celayir S, Kiliç N, Eliçevik M, Büyükünal C. Rectus abdominis muscle flap (RAMF) technique for the management of bladder exstrophies. late clinical outcome and urodynamic findings. Br J urol 2003;79:276-8.  Back to cited text no. 6
7.Hernandez DJ, Purves T, Gearhart JP. Complications of surgical reconstruction of the exstrophyeepispadias complex. J Pediatr Uro 2008;4:460-6.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]

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