Posterior iliac osteotomy in modern neonatal bladder exstrophy repair: a case report.

Introduction and importance: Pelvic osteotomy remains an important adjunct in selected cases of bladder exstrophy to facilitate tension-free closure. Although posterior iliac osteotomy was widely used in earlier decades, contemporary practice has largely shifted toward anterior osteotomy or selective non-osteotomy approaches. Its role in neonates remains debated, particularly in relation to long-term functional and aesthetic outcomes. Presentation of case: We report the case of a female neonate with classic bladder exstrophy who underwent bilateral posterior iliac osteotomy, followed by primary bladder closure, bilateral inguinal hernia repair, and abdominal wall reconstruction with umbilical reconstruction. Postoperative management included 3 weeks of immobilization, short-term neuromuscular blockade, prophylactic antibiotics, anticholinergic therapy, and structured physiotherapy. At a 17-year follow-up, the patient achieved sustained urinary continence, with dry intervals exceeding three hours, preserved renal function, absence of recurrent urinary tract infections, and excellent cosmetic outcomes of the abdomen and external genitalia. Clinical discussion: Posterior iliac osteotomy allows pelvic realignment and facilitates tension-free abdominal closure in neonates with wide pubic diastasis and rigid pelvic configuration. Although infrequently used in current practice, it may remain a valuable option in anatomically selected cases when alternative reconstructive strategies are unlikely to provide adequate approximation. Conclusion: Posterior iliac osteotomy can be a safe and effective option in selected neonates with bladder exstrophy, providing durable, functional, and aesthetic outcomes, as demonstrated by this long-term follow-up case.