The use of alloderm as an adjunct in the closure of the bladder - Cloacal exstrophy complex

Objective: To decrease the incidence of vesicocutaneous fistulae (VCF), intra-pubic stitch erosion (IPE) and intrasymphyseal plate erosion (ISE) of bladder or cloacal exstrophy in patients undergoing reclosure, we sought additional bulking material to place between the posterior urethral/bladder neck and pubic closures. Material and methods: In 43 patients (2005-2009) undergoing exstrophy/cloacal exstrophy closure or reclosure, we placed human acellular dermis (HAD) between the posterior urethral/bladder neck and pubic closures. The thickest piece of HAD available was placed above the urethra and bladder neck, and attached to the pelvic floor with sutures of 4-0 Vicryl prior to pubic bone apposition. Results: Twenty-three were primary and 20 were reclosures. Of the 23 primary closures, 17 were classic exstrophy and six were cloacal exstrophy. Of the 20 reclosures, 17 were classic exstrophy and three were cloaca' exstrophy. Thirty-four had an osteotomy and nine did not, at the time of closure. No patient experienced failure of closure, a VCF, an IPE or an ISE into the urethra after pubic apposition, or other complication related to the use of HAD. One patient had a superficial wound infection, and one had premature suprapubic tube dislodgement requiring replacement in the operating room. Conclusion: From the success of this novel technique in failed closures, we have begun using HAD as an adjunct in all exstrophy closures. Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.