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Commentary to “Use of human acellular dermal matrix during classic bladder exstrophy repair”
Journal of Pediatric Urology (2016) 12, 115
Commentary to “Use of human acellular dermal matrix during classic bladder exstrophy repair” Earl Y. Cheng Lurie Children’s Hospital of Chicago, Chicago, IL, USA Correspondence to: E.Y. Cheng, Ann and Robert H. Lurie Children’s Hospital of Chicago, Division of Urology, 225 E, Chicago Ave., Chicago, IL 60611, USA [email protected] (E.Y. Cheng)
18 November 2015 Accepted 18 November 2015 Available online 6 January 2016
Successful reconstruction of the bladder and genitalia in patients with bladder exstrophy continues to be one of the biggest challenges that pediatric urologists face today. One aspect of reconstruction that is often not discussed is the technical aspect of abdominal wall closure. In cases where osteotomies are performed, primary fascial closure is usually easily achieved. However, in cases of delayed surgery or re-do surgery where osteotomies are not always performed, the fascial defect may be too large to allow tension-free closure. Historically, one needed to use either crossed fascial flaps or synthetic materials to bridge this gap. In this study [1], the authors report on their preliminary experience using human acellular dermis (HAD) in six patients to either “bridge” fascial closure or “bolster” a fascial repair. HAD performed well in all cases. It appeared to become incorporated into the native tissue and facilitated functional integrity of the abdominal wall. Use of off-the-shelf biologic materials that can be used in this fashion are preferable to synthetic materials due to lessened risk of infection and foreign body reaction. We have used four-layer SIS in a similar fashion, with the same observed success in this series. SIS has also been used as a barrier to reduce the risk of bladder neck fistulas in bladder exstrophy patients following primary bladder closure [2]. Based on the observations in the present study, the authors suggest that use of HAD to facilitate fascial closure should be considered as an alternative to use of osteotomies in select patients. However, as the authors discuss, it is important to recognize that osteotomies have several advantages that are independent of
the ability to facilitate primary fascial/ abdominal wall closure. These include the ability to adequately reposition the bladder in a more anatomic position within the pelvis, better approximation of the pelvic floor musculature anterior to the bladder neck, further lengthening of the penis by proximal approximation of the divergent corporal bodies that are separated by the pubic diastasis. This in turn leads to improvements in continence and sexual function. Thus, in individual patients, one needs to carefully balance the benefits of osteotomies against the morbidity of the procedure itself. Nevertheless, when osteotomies are not felt to be needed, use of HAD and other off-the-shelf biologic materials like SIS are a nice option to have to allow easy functional restoration of the abdominal wall defect. Hopefully, this preliminary report is the tip of the iceberg. As basic science advancements in the field of tissue engineering occur in the future, we will hopefully have more sophisticated biologic materials for use in surgical reconstruction of the urogenital tract and abdominal wall defects in bladder exstrophy patients.
References [1] Bonitz RP, Hanna MK. Use of human acellular dermal matrix during classic bladder exstrophy repair. J Pediatr Urol 2016;12(2):114.e1e5. [2] Alpert SA, Cheng EY, Kaplan WE, Snodgrass WT, Wilcox DT, Kropp BP. Bladder neck fistula after the complete primary repair of exstrophy: a multi-institutional experience. J Urol 2005; 174(Pt 2):1687e9.
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2015.10.005. http://dx.doi.org/10.1016/j.jpurol.2015.11.009 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Commentary to “Use of human acellular dermal matrix during classic bladder exstrophy repair” Earl Y. Cheng Lurie Children’s Hospital of Chicago, Chicago, IL, USA Correspondence to: E.Y. Cheng, Ann and Robert H. Lurie Children’s Hospital of Chicago, Division of Urology, 225 E, Chicago Ave., Chicago, IL 60611, USA [email protected] (E.Y. Cheng)
18 November 2015 Accepted 18 November 2015 Available online 6 January 2016
Successful reconstruction of the bladder and genitalia in patients with bladder exstrophy continues to be one of the biggest challenges that pediatric urologists face today. One aspect of reconstruction that is often not discussed is the technical aspect of abdominal wall closure. In cases where osteotomies are performed, primary fascial closure is usually easily achieved. However, in cases of delayed surgery or re-do surgery where osteotomies are not always performed, the fascial defect may be too large to allow tension-free closure. Historically, one needed to use either crossed fascial flaps or synthetic materials to bridge this gap. In this study [1], the authors report on their preliminary experience using human acellular dermis (HAD) in six patients to either “bridge” fascial closure or “bolster” a fascial repair. HAD performed well in all cases. It appeared to become incorporated into the native tissue and facilitated functional integrity of the abdominal wall. Use of off-the-shelf biologic materials that can be used in this fashion are preferable to synthetic materials due to lessened risk of infection and foreign body reaction. We have used four-layer SIS in a similar fashion, with the same observed success in this series. SIS has also been used as a barrier to reduce the risk of bladder neck fistulas in bladder exstrophy patients following primary bladder closure [2]. Based on the observations in the present study, the authors suggest that use of HAD to facilitate fascial closure should be considered as an alternative to use of osteotomies in select patients. However, as the authors discuss, it is important to recognize that osteotomies have several advantages that are independent of
the ability to facilitate primary fascial/ abdominal wall closure. These include the ability to adequately reposition the bladder in a more anatomic position within the pelvis, better approximation of the pelvic floor musculature anterior to the bladder neck, further lengthening of the penis by proximal approximation of the divergent corporal bodies that are separated by the pubic diastasis. This in turn leads to improvements in continence and sexual function. Thus, in individual patients, one needs to carefully balance the benefits of osteotomies against the morbidity of the procedure itself. Nevertheless, when osteotomies are not felt to be needed, use of HAD and other off-the-shelf biologic materials like SIS are a nice option to have to allow easy functional restoration of the abdominal wall defect. Hopefully, this preliminary report is the tip of the iceberg. As basic science advancements in the field of tissue engineering occur in the future, we will hopefully have more sophisticated biologic materials for use in surgical reconstruction of the urogenital tract and abdominal wall defects in bladder exstrophy patients.
References [1] Bonitz RP, Hanna MK. Use of human acellular dermal matrix during classic bladder exstrophy repair. J Pediatr Urol 2016;12(2):114.e1e5. [2] Alpert SA, Cheng EY, Kaplan WE, Snodgrass WT, Wilcox DT, Kropp BP. Bladder neck fistula after the complete primary repair of exstrophy: a multi-institutional experience. J Urol 2005; 174(Pt 2):1687e9.
DOI of original article: http://dx.doi.org/10.1016/j.jpurol.2015.10.005. http://dx.doi.org/10.1016/j.jpurol.2015.11.009 1477-5131/ª 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.