Francisco Nicanor Araruna Macedo1 1 Pediatric Surgery Unit, Hospital da Criança, Rio de Janeiro, Brazil; Department of Surgery, Universidade Federal Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil , Eduardo Corrêa Costa2 2 Pediatric Surgery Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Pediatric Surgery Unit, Hospital Moinhos de Vento, Porto Alegre, Brazil , Jovelino Quintino de Souza Leão3 3 Pediatric Urology Unit, Hospital Infantil Darcy Vargas, São Paulo, Brazil , Antônio Carlos Amarante4 4 Pediatric Urology Unit, Hospital Pequeno Príncipe, Curitiba, Brazil , Fernanda Ghilardi Leão5 5 Pediatric Urology Unit, Hospital Infantil Darcy Vargas, São Paulo, Brazil , Hélio Buson Filho6 6 Department of Urology, Hospital da Criança de Brasília José de Alencar, Brasília, Brazil. , et al.
J Pediatr Urol. 2022 Apr 22;S1477-5131(22)00159-0.
COMMENT
Kelly´s Together Project (KTP) is a great initiative. The results of this work may bring very important information to the Pediatric Urologists community.
The opportunity to treat a relatively high number of OIES cases, including complex patients with a single and standardized technique is unique. The number of patients tends to be high because of Brazilian´s territorial scope and big population, where legal abortion is prohibited. The availability of the National Brazilian Health Service facilitates logistics.
KTP is similar to other programs to treat bladder exstrophy going on in India and North America, using other techniques. In due time it may be possible to compare results between big cohorts treated with different techniques at the same time frame.
The idea of professional consortia is a great development in what concerns rare surgical diseases, and the recent availability of online transmission of surgeries in real-time time and of planning online meetings adds to its implementation. Financial support from the government, in the case of countries counting on public health systems, is needed for travel expenses and to allow paid licenses for the professionals to participate in the initiative.
The present paper (11 Macedo FNA, Costa EC, Leão JQS, Amarante AC, Leão FG, Buson Filho H, et al. Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results. J Pediatr Urol. 2022:S1477-5131(22)00159-0.) is the first to be presented by KTP group and deals with one of the most difficult aspects of exstrophy treated without pelvic osteotomy: the closure of the abdomen, especially after the first days of life and in cases exhibiting large pubic diastasis. The authors ingeniously associate techniques of rectus muscle releasing and myofascial compartment mobilization. We wonder whether associating intramuscular pre-operative botox injections would also help (22 de Jesus LE, Leve TC, Fulgencio C, et al. Botulinum toxin abdominal wall injection and post-omphalocele ventral hernia repair: database and proposal of a protocol. Ann Pediatr Surg. 2020;16: 56.). This would be easy to accomplish, as surgeries are usually programmed electively after 3 months of age.
The results described by the authors are great but must be evaluated with a grain of salt, as long-term results are as yet unknown, especially in what concerns genital prolapse in females, late sexual results, and the possibility of dyspareunia and/or penile fracture attaining the released penises, that are fixed on myofascial structures and will not count on the physiologically normal long osseous anchorage of the corpora during coitus in adulthood. To the best of our knowledge, those data are not yet available, either concerning the “classical” Kelly technique (that used radical tissue mobilization to treat the penis and bladder neck AFTER neonatal bladder closure (33 Kumar KV, Mammen A, Varma KK. Multiple failed closure of bladder in children with vesical exstrophy: Safety and efficacy of temporary ileal patch augmentation in assisting bladder closure. J Indian Assoc Pediatr Surg. 2014;19:222-6.)) or the new adaptations being used now, that propose radical tissue mobilization to close the bladder and bladder neck and penile reconstruction simultaneously.
Mr. Justin Kelly has recently suggested that the right term to describe the surgical treatment of bladder exstrophy is to construct, not to reconstruct, as to reconstruct means to put up something together again, while to construct means creating something new (44 Kelly JH. Vesical exstrophy: repair using radical mobilisation of soft tissues. Pediatr Surg Int. 1995;10:298–304.). In OIES cases the surgeon does not “recover” tissues. He/she build something new from scratch, using abnormal tissues. This applies to all techniques described at the moment and probably reflects on the results of any technique.
The authors are to be congratulated for their persistence, resilience, and personal investment in making clinical research. Their effort is at the same time valuable, stimulating and beautiful. This paper is the first from their group, but, for sure, many more will follow.
REFERENCES
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1Macedo FNA, Costa EC, Leão JQS, Amarante AC, Leão FG, Buson Filho H, et al. Anterior component separation technique for abdominal closure in bladder exstrophy repair: Primary results. J Pediatr Urol. 2022:S1477-5131(22)00159-0.
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2de Jesus LE, Leve TC, Fulgencio C, et al. Botulinum toxin abdominal wall injection and post-omphalocele ventral hernia repair: database and proposal of a protocol. Ann Pediatr Surg. 2020;16: 56.
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3Kumar KV, Mammen A, Varma KK. Multiple failed closure of bladder in children with vesical exstrophy: Safety and efficacy of temporary ileal patch augmentation in assisting bladder closure. J Indian Assoc Pediatr Surg. 2014;19:222-6.
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4Kelly JH. Vesical exstrophy: repair using radical mobilisation of soft tissues. Pediatr Surg Int. 1995;10:298–304.
Publication Dates
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Publication in this collection
26 Aug 2022 -
Date of issue
Sep-Oct 2022
