Percutaneous Cystolitholapaxy and Open Cystolithotomy in Exstrophy–Epispadias Complex: A Comparative Approach to Bladder Stone Management

<b><i>Background:</i></b> Patients with exstrophy-epispadias complex (EEC) often present with attenuated fascia. Currently, there is no direct comparison of outcomes between percutaneous cystolitholapaxy and open cystolithotomy in this specific patient population. Thus, we sought to evaluate the therapeutic efficacy and associated morbidity of both surgical approaches in patients with EEC. <b><i>Methods:</i></b> Patients who underwent either their first percutaneous cystolitholapaxy or open cystolithotomy between 2003 and 2023 were identified using an IRB-approved institutional database of 1512 patients with EEC. <b><i>Results:</i></b> Among 66 patients, 8 (12.12%) underwent percutaneous cystolitholapaxy without augmentation, 31 (46.97%) underwent percutaneous cystolitholapaxy with augmentation, 11 (16.67%) underwent open cystolithotomy without augmentation, and 16 (24.24%) underwent open cystolithotomy with augmentation. Compared with the open approach, the percutaneous approach resulted in shorter operative times: 123 (interquartile ranges [IQR]: 81-151) <i>vs</i> 218 minutes (IQR: 142-281) for patients with augmentation, and 131 (IQR: 115.5-141) <i>vs</i> 196 minutes (IQR: 176.5-287.3) for those without augmentation (<i>p</i> = 0.0002). Hospital stays were shorter with the percutaneous approach: 1 (IQR: 1-1) <i>vs</i> 3 days (IQR: 1-4) with augmentation, and 1.5 (IQR: 1-2) <i>vs</i> 3 days (IQR: 1-4) without augmentation (<i>p</i> = 0.0044). Notably, the percutaneous group had smaller stone volumes (7.15 cm³, IQR: 2.73-24.31 <i>vs</i> 31.04 cm³, IQR: 10.77-107.40, <i>p</i> = 0.0011). Both techniques achieved a 100% stone-free rate (<i>p</i> > 0.99). There were no differences in recurrence (<i>p</i> = 0.20) and cumulative incidence (HR 0.76, 95% confidence interval: 0.39-1.48, <i>p</i> = 0.38) between groups. Postoperative complications revealed that vesicocutaneous fistulas were most common in open surgery without augmentation (<i>n</i> = 5, 45.45%), followed by open with augmentation (<i>n</i> = 1, 6.25%), and none in the percutaneous groups (<i>p</i> = 0.0002). <b><i>Conclusion:</i></b> Percutaneous cystolitholapaxy provided significant advantages for patients with EEC, including shorter operative times and reduced hospital stays, with equivalent stone clearance. Moreover, open cystolithotomy carried a higher risk of vesicocutaneous fistula formation. These findings suggest percutaneous approaches may offer a safer and more efficient alternative for managing bladder stones in patients with EEC.