UroToday - The group from Johns Hopkins reviewed their perioperative management of newborn infants undergoing bladder exstrophy reconstruction between November 1999 and October 2006. They identified 23 newborn infants who underwent reconstructive exstrophy surgery utilizing a combined epidural and general anesthetic technique. They inserted a tunneled caudal epidural catheter in all patients. Local anesthetic without morphine was used, and they sedated the children with Diazepam. Central lines were placed intra-operatively and maintained for the duration of inpatient stay for blood sampling and fluid and drug administration.

The group found that caudal epidural catheters were helpful in their patients. They felt it facilitated mobilization as well as analgesia and sedation. They believed that this helped them achieve an excellent cosmetic repair, and there were no cases of bladder prolapse or wound dehiscence from movement.

The type of immobilization utilized during exstrophy repair is quite variable. Some argue that immobilization with an external fixater is beneficial. Others believe that SPICA casts are also beneficial since patients can be discharged earlier. However, all techniques have drawbacks as well. Those who use SPICA casts feel that epidural catheters have not been useful or beneficial in their patients. The pain management has been well controlled with an epidural catheter. Nonetheless, it is my opinion that whatever you use for exstrophy repairs that gives you the best result should be utilized. Bladder exstrophy reconstruction is extremely challenging, and one should not cut any corners when getting continence results similar to Dr. Gearhart or Dr. Mitchell.

Kost-Byerly S, Jackson EV, Yaster M, Kozlowski LJ, Mathews RI, Gearhart JP
J Pediatr Urol. 2008 Aug;4(4):280-5

Reported by UroToday Medical Editor Pasquale Casale, MD

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