Subperiosteal Tunneled Allograft Reconstruction of the Symphyseal Ligaments (STARS) in Bladder Exstrophy Epispadias Complex.

Background: Because of the lack of symphyseal ligaments, pubic symphysis re-diastasis is the rule after iliac osteotomies for bladder exstrophy reconstruction. Progressive symphyseal diastasis may cause pelvic organ prolapse in females and penile retraction in males. This study assesses the results of tendon allograft symphyseal reconstruction for maintaining pubic approximation with iliac osteotomies in exstrophy repair.

Methods: Eleven consecutive patients had symphyseal reconstruction with delayed exstrophy repair, 7 classic bladder exstrophy, 2 cloacal exstrophy, and 2 exstrophy variants. There were 4 males and the average age at surgery was 14 months (9 to 20 mo). The average preoperative diastasis was 52 mm (43 to 79 mm). After pubic approximation with modified oblique iliac osteotomies, tendon allografts were looped subperiosteally around the pubic bones and through the obturator foramina, and reinforced by suturing anterior chondro-periosteal flaps. With the legs in a mermaid dressing, external fixators were kept for 3 to 4 weeks. All patients had preoperative pelvic computed tomography scans and pelvic x-rays before fixator removal and at the latest follow-up.

Results: All patients had successful urologic closure. The mean postoperative inter-pubic distance was 20.5 mm (8 to 29 mm). The mean postoperative follow-up was 10 months (4 to 19 mo). The mean inter-pubic distance at the latest follow-up was 21.6 mm (3 to 35 mm). We had maintained or even decreased inter-pubic distance in 9 out of 11 cases with the average postoperative interpubic distance of 19.3 mm compared with 18.9 mm at an average 11 months follow-up. In 2 patients, the inter-pubic distance increased from 25 and 26 mm postoperatively to 33 and 35 mm at 4 months follow-up.

Conclusion: The interpubic distance was stable or decreasing in 9 out of 11 patients with average follow-up of 11 months. Further reduction in the interpubic distance was observed due to bone formation medial to the pubic bones caused by the subperiosteal dissection. Longer-term follow-up is required to confirm stable pubic approximation.

Level of evidence: Level III.