Analysis of complications after neonatal bladder exstrophy closure, and rationale for an alternative surgical strategy: a case series

BACKGROUND: Although neonatal closure of bladder exstrophy has conventionally been considered the standard surgical approach, accumulated clinical experience indicates a high incidence of severe complications. To date, the pathogenesis of these complications and the role of specific surgical techniques—particularly pubic bone approximation and the extent of bladder mobilization—in the development of adverse outcomes remain insufficiently studied.

AIM: This study aimed to evaluate the spectrum of complications following neonatal bladder exstrophy closure, identify their probable causes, and substantiate an alternative surgical strategy.

METHODS: A retrospective analysis was performed of 33 patients who underwent neonatal bladder exstrophy closure at different institutions and were subsequently referred to our clinic with complications between 2019 and 2024. The timing and nature of complications, as well as the outcomes of reoperations, were analyzed. In most cases, repeat surgery was performed using a modified technique without pubic bone approximation.

RESULTS: The most common complications included complete wound dehiscence (36%), fistula formation (27%), bladder prolapse (18%), and buried penis (12%). In several patients, protrusion of suture material or mesh fixators into the bladder or urethral lumen was identified, accompanied by inflammation and stone formation. Repeat closure with wide bladder mobilization and without pubic bone approximation achieved anatomical integrity in the majority of cases.

CONCLUSION: Neonatal bladder exstrophy closure is associated with a high rate of severe complications, primarily related to tension during pubic bone approximation, insufficient bladder and/or bladder-urethral segment mobilization. Delayed closure at 2–4 months of age without pubic bone approximation demonstrates high anatomical reliability and may be considered a preferable surgical option in specialized centers. Osteotomy should be deferred to a later stage, when the pelvic bones are more robust.