BERKELEY, CA (UroToday Inc.) - Bladder exstrophy remains to be one of the most complex reconstructions faced by pediatric urologists. It seems that the success of these patients depends upon the results of their first attempt at reconstruction. The success is typically defined with continence, functional and adequate bladder and penis, and cosmesis. The aim of this study was to use a large nationwide database to investigate and describe practice patterns in the contemporary management of bladder exstrophy. Nelson et al performed a retrospective analysis utilizing the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (1988 to 2000) to identify infants with bladder exstrophy hospitalized during the first week after birth. Admission and disposition patterns, resource utilization and length of stay, surgical repair trends, and factors associated with in-hospital death were analyzed.

The group identified 426 hospital admissions of newborns with exstrophy. Most patients (75%) were transferred in from, or out to, other facilities; this was a fundamental feature of early exstrophy care. Racial differences were evident, with Hispanics less likely to be transferred (19% versus 60%, P = 0.001). Among newborns that were not transferred, many (46%) were discharged without bladder surgery. Surgical repair was usually done in a hospital other than the birth hospital. The mean hospital charges for surgery were $75,742. Five patients (1%) who died after repair all had undergone surgery at what were termed "low-volume" hospitals. The length of stay did not change significantly during the study period, helping to keep resource utilization high in this population.

The results of this study provide a picture or "snapshot" in bladder exstrophy practice patterns during the newborn period between 1988 and 2000. The group stated that additional research should investigate whether newborns with exstrophy are receiving optimal care, including appropriate timing of surgery, equitable transfers to tertiary centers, and reconstruction at centers with adequate volume and experience. Work is currently underway to create a database that helps centralize and standardize the care and approach in children with exstrophy. I strongly feel that centers of excellence may need to be established with surgeons who perform a few in a year as compared to a few in a career to give these children the best chance possible for a normal bladder function and sexual future.

Urology 66(2): 411-415, August 2005