Functional and urodynamic characteristics of bladder substitution with detubularised right colonic segment

A total of 19 patients underwent bladder replacement with a detubularised right colonic segment; 14 males underwent complete substitution after cystoprostatectomy and 5 females had augmentation after subtotal cystectomy. The mean follow-up time was 20 months. Urodynamic evaluation showed a low pressure reservoir with a mean capacity of 580 ml and normal closure pressure. Sensitivity of the bladder to cold was normal in the augmentation group but was lacking in all patients in the total substitution group. In all except 1 patient the neobladder emptied effectively upon straining without significant residual urine. Seventeen patients were completely continent by day and 10 by night; 1 patient developed hyperchloraemic acidosis requiring treatment. Bladder substitution is superior to the standard ileal or colonic conduits with regard to quality of life, and the use of a right colonic segment is functionally comparable with neobladders composed of the ileum or a combination of the right colon and ileum. The latter are more difficult to fabricate and so may have more complications.     

100 cases of Mainz pouch: continuing experience and evolution

The surgical technique for creation of the Mainz pouch uses 10 to 15 cm. of cecum and ascending colon and 2 ileal loops of the same length for construction of a urinary reservoir. Initial applications of the Mainz pouch were for bladder augmentation after subtotal cystectomy and for continent urinary diversion. Current indications have been extended to complete bladder substitution after radical cystoprostatectomy with anastomosis of the pouch to the membranous urethra. For cosmetic reasons the umbilicus is used as a stomal site for continent urinary diversion, and the technique of intussuscepting the continence nipple has been modified accordingly. A total of 100 patients underwent a Mainz pouch procedure since 1983: 34 for bladder augmentation, 15 for total bladder substitution after cystoprostatectomy and 51 for continent urinary diversion. In the bladder augmentation group 1 patient underwent conversion to a continent stoma, 1 has urge and frequency, and the remaining 32 are completely dry day and night. These patients empty the bladder at normal intervals spontaneously except for 3 who rely on intermittent catheterization. In the bladder substitution group 1 patient has grade 1 stress incontinence and the remainder are completely dry during the day. However, at night 4 patients have leakage and they use a condom urinal. In the urinary diversion group all but 2 patients are completely dry and are on intermittent catheterization. The main problem of the initial series was prolapse of the continence nipple, which has been solved by staple fixation of the nipple to the bowel wall and to the ileocecal valve.     

Failed bladder neck reconstruction: options for management

During the last 10 years 17 patients have been seen at this institution for persistent urinary incontinence after Young-Dees-Leadbetter bladder neck reconstruction. Of these patients 16 were born with classical bladder exstrophy and 1 with complete epispadias. Six patients underwent 1, 10 underwent 2 and 1 underwent 3 prior bladder neck procedures. As salvage procedures 8 patients underwent another Young-Dees-Leadbetter procedure, 1 repeat bladder neck reconstruction and augmentation cystoplasty, 3 augmentation alone, 4 bladder augmentation with creation of a continent abdominal stoma and 1 augmentation with implantation of an artificial urinary sphincter. Of the 8 patients who underwent a repeat Young-Dees-Leadbetter procedure 7 are dry for 3 hours or more and 1 is dry for greater than 3 hours on intermittent self-catheterization. All of those who are dry for greater than 3 hours are dry at night and 1 wears pads when engaging in strenuous physical activity. Of the 9 patients who underwent augmentation cystoplasty along with other adjunctive procedures 8 are continent for greater than 3 hours on intermittent catheterization, 6 are dry at night if they perform catheterization at bedtime and 1 remains totally incontinent after removal of the artificial urinary sphincter. Thus, with persistence and creativity a child with a previously failed bladder neck reconstruction or even multiple failed repairs can be made socially continent, providing a satisfactory alternative without resorting to urinary diversion.     

Early experiences with continent bladder substitution

Since January 1987 a total of 14 patients have undergone continent bladder replacement procedure. The bladder substitute was constructed of ileum (ileal neobladder) in three patients, of an ileocaecal segment (Mainz pouch) in five patients while in six patients a segment of ascending colon (Mayo pouch) was used. Nine male patients underwent a complete bladder substitution after cystoprostatectomy. In five patients a bladder augmentation was performed. Four of these patients were female. They were subjected to subtotal cystectomy which left only one cm of the bladder neck, while the ureters were reimplanted into the pouch. Seven of the nine patients with total bladder substitution are continent during the day and seven at night. All patients in the bladder augmentation group are continent day and night, but one of them has to empty his bladder by intermittent catheterization. Because of stenosis at the ureterocolonic anastomosis, reoperation was performed on two patients more than one year after the primary operation. Except for these two patients, who required surgical revision, the initial results are encouraging and patient acceptance has been excellent.     

Long-term followup of patients after redo bladder neck reconstruction for bladder exstrophy complex

PURPOSE: The aim of this study was to determine whether redo bladder neck reconstruction is effective in achieving continence after a failed bladder neck reconstruction procedure. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients with bladder exstrophy who had undergone redo bladder neck reconstruction. There were 30 patients in the study, including 20 boys and 10 girls. Mean patient age at redo bladder neck reconstruction was 9.3 years (range 3.2 to 15.5). The patients were divided into 3 groups on the basis of the preoperative pattern of incontinence--incomplete wetters, complete wetters and those on continuous suprapubic drainage. Of the patients 15 already had undergone bladder augmentation, 12 had undergone a Mitrofanoff procedure and 12 had been treated with bulking agents injected in the bladder neck in an attempt to achieve continence. Four patients had undergone more than 1 bladder neck procedure. The patients were investigated with a combination of noninvasive urodynamics, cystoscopy, cystogram and ultrasound. All patients underwent Mitchell's modification of Young-Dees-Leadbetter bladder neck reconstruction. Additional procedures performed included augmentation cystoplasty and Mitrofanoff formation. RESULTS: Mean followup was 6.9 years (range 1.2 to 15.5). Postoperatively 28 patients were using clean intermittent catheterization to empty the bladder (5 per urethra, 23 via Mitrofanoff). Two patients remained on continuous suprapubic catheter drainage. A total of 18 patients (60%) were dry postoperatively (80% of girls and 50% of boys). Among dry patients only 3 were performing clean intermittent catheterization per urethra and 15 via a Mitrofanoff channel. No patient was able to void per urethra without the need for clean intermittent catheterization. The 2 patients on continuous suprapubic catheter drainage continued to remain so. At night only 50% of the patients were dry (5 on free drainage, 4 on clean intermittent catheterization, 6 not on any drainage). Those patients who did not respond satisfactorily to redo bladder neck reconstruction underwent subsequent additional procedures, which included injection of bulking agents (3 patients), insertion of an artificial urinary sphincter (1), Mitrofanoff formation (2) and bladder augmentation plus Mitrofanoff channel (1). Postoperative complications included difficulty with clean intermittent catheterization (8 patients), perivesical leak (1), recurrent epididymo-orchitis (1), upper urinary tract dilatation (2) and incisional hernia (1). Bladder neck closure was being considered in 5 patients. CONCLUSIONS: In our experience redo bladder neck reconstruction cannot achieve continence with volitional voiding per urethra. Although redo bladder neck reconstruction can render a significant number of patients dry, it is only effective if performed in conjunction with augmentation. Failure of the initial bladder neck reconstruction may be a reflection of a bladder that is of inadequate capacity and/or compliance. Therefore, bladder augmentation should be considered in all patients requiring redo bladder neck reconstruction. Bladder neck closure may be a better alternative to redo bladder neck reconstruction.     

Present status on bladder replacement--colon bladder replacement]

Bladder replacement using a detubularized right colonic segment was successfully performed on 22 male patients with bladder cancer after radical cystectomy. There were 10 early postoperative complications and one of them required reoperation. Urodynamic studies, performed on 16 patients, showed a low pressure reservoir at a large capacity without any involuntary spikes in every case. Of the 16 patients, 4 were nocturnally enuretic and 1 was partially continent. The other 11 patients (68.8%) were totally continent and voiding well, except one who was on intermittent self-catheterization. The incidence of urinary reservoir infections in patients treated with colon bladder replacement was investigated in 18 patients. The incidence rate of bacteriuria was 5.6% and the positive rate of pyuria was 27.8%. The detection rate of bacteriuria and pyuria was significantly low in patients after colon bladder replacement. These findings indicate that colon bladder replacement can be an ideal option for selected patients with bladder cancer.     

The dispute about the external sphincter and the urogenital diaphragm

PURPOSE: We present a modification of bladder neck reconstruction which resulted in improved continence and voiding compared to other techniques of bladder neck repairs in patients with exstrophy and complete incontinence. MATERIALS AND METHODS: The series consisted of 10 patients with the exstrophy-epispadias complex and complete incontinence who previously had undergone multiple operations for bladder closure, bladder neck reconstruction and epispadias repair. This modification combines bladder neck lengthening and narrowing of the distal half of the urethra, and submucosal embedding of the proximal half of the neourethra in the trigonal area. All patients also underwent bladder augmentation with detubularized sigmoid colon concurrent with bladder neck reconstruction. Additionally the appendical Mitrofanoff principle was applied to 5 cases. RESULTS: Of the 10 patients who underwent bladder neck reconstruction with sigmoid cystoplasty 8 are voiding voluntarily without catheterization and are dry for longer than 4 hours day and night. Only 2 patients are partially dry with stress nocturia incontinence and in both we performed a Mitrofanoff procedure as an adjunct to catheterization and to ensure voiding and continence. CONCLUSIONS: Our modified bladder neck reconstruction provides better overall voiding and continence rates than the other bladder neck/urethral reconstruction procedures in patients with exstrophy and complete incontinence.     

Bladder replacement after cystoprostatectomy: efforts to achieve total continence

Total bladder replacement with tubular sigmoid colon and detubularized ileocecal bowel segments was performed on 17 patients after cystoprostatectomy for bladder cancer. There were few complications and patient acceptance was excellent. Daytime continence was achieved in most patients but voiding patterns were superior with detubularized segments. However, enuresis was common with both segment types. Total urinary continence (day and nighttime continence) was achieved in 7 patients with an artificial urinary sphincter that was activated only at night. Total bladder replacement is an acceptable form of urinary diversion after cystoprostatectomy in appropriate patients.     

The ileal neobladder

An ileal neobladder for total bladder replacement was created in 11 patients. To achieve a low pressure system, disruption of directional bowel peristalsis with a longitudinal incision at the antimesenteric border of a 70 cm. ileal segment is performed. A spherical pouch, the neobladder, is fashioned and anastomosed to the urethra. The ureters are implanted according to the method of Le Duc and Camey. Videourodynamic studies during various postoperative phases demonstrate this neobladder to be a urinary reservoir with a capacity approximating that of a normal bladder, good compliance during filling by maintaining pressure lower than 30 cm. water and no reflux. Of the 11 patients with the neobladder 8 are completely dry day and night, while 3 have grade I stress incontinence. All 11 patients had recognizable sensations of bladder distension closely simulating those of normal bladders. The use of this ileal neobladder in male patients undergoing radical cystectomy offers an alternative free of a stoma to urinary diversion, resulting in a highly compliant, low pressure bladder.     

Total bladder replacement in the male and female using the ileocolonic segment (LeBag)

A group of 11 patients, 2 female and 9 male, underwent total bladder replacement using the ileocolonic segment (LeBag technique) with anastomosis of the bowel to the urethra. The diagnosis was invasive bladder cancer in 10 patients and severe intractable interstitial cystitis in 1. The surgical technique in the male patients was modified to simplify the procedure. The 2 female patients underwent insertion of an artificial sphincter around the bowel segment for a continence mechanism. One patient died 6 weeks post-operatively from a severe coagulopathy. Five of the 9 male patients are continent day and night, relying on their own residual sphincter mechanism, but the remaining 4 required insertion of the artificial urinary sphincter to achieve social continence. The surviving female patient is totally continent. All patients have voiding intervals of 4 to 6 h during the day and are thus continent both day and night, but in some cases the artificial sphincter was necessary to achieve this. Loss of the normal bladder-sphincter reflexes following cystectomy may account for the high incidence of nocturnal incontinence observed in most series. Total bladder replacement is now possible in both male and female patients, thus avoiding an abdominal stoma.     

Colon bladder replacement after total cystectomy

Although ileal conduit diversion is widely accepted in the treatment of the patients undergoing radical cystectomy, many patients would prefer other alternatives which allow continence. and urination through the urethra. We describe a new procedure in which a segment of detuburalized right colon is used as a continent reservoir. Eight patients, 7 after radical cystectomy for bladder cancer and one after total exenteration for rectal cancer, have undergone colon bladder replacement. New created bladder had a capacity of 300 to 600 ml. All patients could pass urine through the urethra but one is on self-catheterization. Five of the 8 patients had no residual urine. Three months after operations 4 were totally continent and 3 were satisfactorily dry during daytime but slightly enuretic. Excretory urography showed no abnormalities in their upper urinary tract. Considering the "quality of life' of a patient, this procedure can be an ideal option for selected patients.     

Variants of the exstrophy complex: a single institution experience

PURPOSE: Variants of the bladder/cloacal exstrophy complex are rare. Different presentations and subsequent management and outcome are discussed. MATERIALS AND METHODS: We performed a retrospective review of our database of more than 815 patients with the exstrophy complex. Patients with variants of classic epispadias or bladder or cloacal exstrophy were identified. Anatomical presentation, surgical management, type of continence procedures and final outcome were evaluated. RESULTS: Of the 25 patients with variants 13 were treated primarily at our institution and 12 were referred. Time until primary bladder closure ranged from 1 day to 4 years. Followup after continence procedure ranged from 1 month to 39 years. Seven of the 25 patients are awaiting a continence procedure. Six patients are dry without a continence procedure, of whom 4 have superior vesical fistulas. A total of 11 patients underwent bladder neck reconstruction (BNR), of whom 3 are dry, 2 are dry during the day but are wet at night, 1 had a failed procedure and 5 are dry after continent diversion (CD). One additional patient underwent CD initially and is dry. Referred cases of epispadias with bladder prolapse were not recognized at birth and had delayed closure. Impaired bladder growth or failed BNR required CD in 4 patients, and 2 are awaiting a continence procedure. Skin covered and duplicate exstrophy had comparable outcomes to the classic presentations. Duplicated organs were used for reconstructive procedures. Of the 6 patients with cloacal variant 2 are continent of stool and 2 await a Pena procedure. One of these patients has an ileal stoma and 1 has a colostomy. CONCLUSIONS: The initial presentation of exstrophy variants can be confusing, often delaying initial treatment. Superior vesical fistulas permit continence without BNR due to an intact urinary sphincter. Variants such as epispadias with bladder prolapse and duplicate or skin covered exstrophy should be closed at birth with standardized techniques to promote bladder growth for later BNR. These cases are faced with the same long-term problems as the classic presentation. Cloacal variants can present with intact anal innervation, allowing a later Pena procedure.     

The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion

The surgical technique for construction of the Mainz (mixed augmentation ileum and cecum) ileocecal pouch for bladder augmentation or continent urinary diversion focuses on 3 functional features: creation of a low pressure reservoir of adequate capacity from cecum and 2 ileal loops, which are split open longitudinally, antirefluxing ureteral implantation into cecum or ascending colon, achieved by a standard submucosal tunnel technique, and in cases of bladder augmentation continence depends on competence of the bladder neck and urethral closure mechanisms, while in urinary diversion continent closure of the pouch is achieved by isoperistaltic ileoileal intussusception or implantation of an alloplastic stomal prosthesis. Of 11 patients with Mainz pouch bladder augmentation (5 of which were undiversions) 10 are completely dry day and night with normal intervals of bladder evacuation. Two patients with myelomeningocele are on intermittent catheterization for bladder evacuation, while the remainder void spontaneously without significant residual urine. Of 12 patients with Mainz pouch urinary diversion 6 have an ileoileal intussusception valve and are completely continent, as are 3 of 4 with an alloplastic stomal prosthesis. Two patients still are awaiting implantation of a sphinteric prosthesis.     

Penile reconstruction combined with bladder closure in the management of classic bladder exstrophy: illustration of technique

OBJECTIVES: Interest has increased in combining procedures during reconstruction of bladder exstrophy in an effort to reduce the number of procedures required for reconstruction and to improve results. This study illustrates our technique of reconstruction and summarizes our current experience with the combination of epispadias repair and bladder closure during initial reconstruction or following prior failed bladder closure. METHODS: Twenty-four boys with classic bladder exstrophy underwent combined bladder closure and epispadias repair. The mean patient age was 20 months, and 18 boys had a prior failed closure. Osteotomies were performed in all patients. RESULTS: No instances of bladder prolapse or dehiscence were noted on follow-up. Urethrocutaneous fistula developed in 7 patients. Eventual bladder neck reconstruction has been performed in 11 boys (6 boys are dry day and night, 3 are dry during the day with occasional wet episodes at night, 2 have required follow-up bladder augmentation and continent diversion for persistent incontinence), and 1 boy had augmentation at the same time as bladder neck reconstruction. Twelve boys are awaiting adequate capacity for bladder neck reconstruction, and 1 is awaiting bladder augmentation and continent stoma construction. CONCLUSIONS: Epispadias closure can be safely combined with bladder closure in select patients with classic bladder exstrophy. Complication rates and cosmesis approximate that achieved with staging the two procedures. This achievement represents strict patient selection and attentive follow-up.     

Reconstruction of urinary bladder

Reconstruction of the urinary tract was reviewed. Reconstruction of the ureter dealt with end to end ureteroureterostomy, transureteroureterostomy, bladder flap procedure, psoas hitch procedure, ureterovesiconeostomy, ileal inter position and autotransplantation of the kidney. Bladder augmentation concerned with use of the ileum, ileocecal segment and sigmoid colon, together with artificial material. Reconstruction of the bladder included urinary diversion such as ileal, jejunal, sigmoid, transverse and ileocecal conduit, ureterureterostomy, continent urinary reservoir such as Kock, Mainz and Indiana pouch, and total replacement of the bladder using various segments of intestine anastomosed to the urethra. Surgical endeavor performed by urologists during the past 100 years from 1890 to 1990 was tremendous and it was mainly reviewed from the standpoints of surgical technique and complications.     

Bladder neck reconstruction using an anterior bladder flap in post-prostatectomy incontinence

Bladder neck reconstruction using an anterior bladder flap was used in 10 patients with total diurnal urinary incontinence, persistent 1 year after suprapubic (n = 6) or transurethral (n = 4) prostatectomy. 8 patients achieved symptomatic improvement, 6 of them with excellent or good results. Bladder neck reconstruction is undoubtedly able to correct post-prostatectomy incontinence, provided there is no residual bladder neck obstruction or alteration of the bladder musculature due to previous surgery. These cases should be considered for artificial sphincter implantation.     

The significance of the open bladder neck associated with pelvic fracture urethral distraction defects.

PURPOSE: As a result of pelvic fracture urethral distraction defects, urinary continence relies predominantly on intact bladder neck function. Hence, when cystoscopy and/or cystography reveals an open bladder neck before urethroplasty, the probability of postoperative urinary incontinence may be significant. Unresolved issues are the necessity, the timing and the type of bladder neck repair. We report the outcome of various therapeutic options in patients with pelvic fracture urethral distraction defects and open bladder neck. We also attempt to identify prognostic factors of incontinence before urethroplasty. MATERIALS AND METHODS: We retrospectively reviewed the records of 15 patients with a mean age of 30 years in whom an open bladder neck was identified before posterior urethroplasty between January 1981 and October 1997. RESULTS: Of the 15 patients 6 were continent and 8 were incontinent postoperatively. One patient underwent artificial urethral sphincter implantation simultaneously with pelvic fracture urethral distraction defect repair and was dry postoperatively without sphincter activation. Average bladder neck and prostatic urethral opening on the cystourethrogram before urethroplasty was significantly longer in incontinent (1.68 cm.) than in continent (0.9 cm.) patients. Of the 8 patients who were incontinent 6 underwent bladder neck reconstruction, 1 artificial urinary sphincter and 1 periurethral collagen implant. Five patients with bladder neck reconstruction are totally continent and 1 requires 1 pad daily. The patient who underwent collagen implant requires 2 pads daily and the patient who received an artificial urethral sphincter has minor urge leakage. CONCLUSIONS: Open bladder neck before urethroplasty may herald postoperative incontinence which may be predicted by radiographic and cystoscopic features. Evaluation of the risk of postoperative incontinence may be valuable, and eventually guide the necessity and timing of anti-incontinence surgery, although our preference remains to manage the pelvic fracture urethral distraction defects and bladder neck problem sequentially. Bladder neck reconstruction provides good postoperative continence rates and is our technique of choice.     

Continent urinary diversion and the exstrophy-epispadias complex

PURPOSE: The use of continent urinary reservoirs has gained wide acceptance, particularly in urinary reconstruction in children with a small capacity or neuropathic bladder. When augmentation cystoplasty is combined with clean intermittent catheterization, patients are often able to achieve continence with low intravesical filling pressures and renal preservation. Often this approach requires fashioning a continent cutaneous stoma, which remains the most challenging aspect of continent urinary reservoirs. We analyzed our experience with continent diversion in patients with exstrophy-epispadias to determine complications and long-term results. MATERIALS AND METHODS: We performed a retrospective database review of 704 cases of exstrophy-epispadias. Medical records were then used to identify those patients who had undergone creation of a continent urinary reservoir. Charts were reviewed to determine initial diagnosis, augmentation technique, continence mechanism, age, preoperative and postoperative bladder capacity, continence status and complications. RESULTS: Of the 91 patients identified (68 male, 23 female) who had undergone continent urinary diversion classic bladder exstrophy was present in 80, cloacal exstrophy in 8, complete male epispadias in 2 and female epispadias in 1. The most common techniques for augmentation and continent diversion were ileocystoplasty (41 patients [45%]) and sigmoid cystoplasty (30 [33%]), respectively. Appendix was used in 67 patients (74%) and variants of the Mitrofanoff procedure using segments of tapered ileum or ureter were used to create a continent stoma in 10 (11%). Bladder neck transection was performed in 59 patients (65%). Mean age at augmentation and continent diversion was 8 years (range 2 to 25), with a mean preoperative bladder capacity of 77 cc (15 to 220). Mean followup was 6 years (range 6 months to 12 years). Of the 91 patients 85 (93%) were continent with clean intermittent catheterization per stoma. Of these 85 patients 13 required anticholinergics and alpha-agonists to achieve continence. Six patients (7%) were incontinent after the procedure. Analysis of bladder capacity measurements after augmentation and continent diversion revealed that mean postoperative volume and mean volume increase were 404 cc (range 250 to 640) and 524%, respectively. The most common complications were bladder stone formation (24 patients [26%]) and stomal stenosis (21 [23%]). Bladder stones recurred in 9 patients and stomal stenosis in 3. Other less common complications were vesicourethral fistula (3 patients) and a small bladder perforation (2). CONCLUSION: Augmentation and continent diversion procedures can increase the functional capacity of the small contracted noncompliant exstrophic bladder, and allow the vast majority of patients to achieve continence and preserve renal function. Bladder calculi and stomal stenosis pose the most significant long-term complications in these patients.     

Orthotopic ileocolic neobladder reconstruction following radical cystectomy: history, technique and results of the Johns Hopkins experience, 1986-1998

Reconstruction of the lower urinary tract using intestinal segments has become a standard component of the treatment of patients with bladder cancer. A variety of intestinal segments can be successfully used for this purpose. Between 1986 and 1998, the authors have used a composite ileocolic segment for neobladder reconstruction in patients desiring orthotopic reconstruction of the lower urinary tract. The early and late complication rates are 11% and 30%, respectively. Forty-five percent of men are potent postoperatively. Seventy-six percent of patients are continent both day and night. Three percent of our patients experience nocturnal enuresis, and 15% perform clean intermittent catheterization. Bothersome daytime stress urinary incontinence occurs in 3% of patients evaluated for this report. Although no contemporary studies demonstrate the superiority of a particular bowel segment for lower urinary tract reconstruction, the authors' long-term experience with the ileocolic neobladder suggests that this composite segment provides excellent results for lower urinary tract reconstruction after radical cystectomy.     

The newborn exstrophy bladder inadequate for primary closure: evaluation, management and outcome

PURPOSE: The surgical approach to the small newborn exstrophy bladder inadequate for primary closure remains undetermined. Various methods for long-term management have been implemented. We evaluated our experience with late primary closure of the small exstrophied bladder template. MATERIALS AND METHODS: Our institutional database of patients treated and followed for the exstrophy-epispadias complex was reviewed. Of these patients 19 had a bladder template that was too small to close in the newborn period. The treatment and outcome of these 19 patients were reviewed. RESULTS: Of the 19 children who had delayed closure due to a small bladder template 14 were males and 5 were females. Followup from birth ranged from 2 to 36 years (mean 18 years). Primary closure was performed at a mean patient age of 13 months (range 6 months to 2 years). Pelvic osteotomy was performed in 16 patients. Of the 19 patients 9 achieved continence after gaining a bladder capacity sufficient for bladder neck reconstruction, 4 required enterocystoplasty to augment bladder volume and perform clean intermittent catheterization (2 per stoma and 2 per urethra), 1 required a colon conduit for an extremely small bladder, and 1 underwent cystectomy and ureterosigmoidostomy for rhabdomyosarcoma. Four patients are currently incontinent, including 3 who are awaiting bladder neck reconstruction and 1 who has frequent nighttime incontinence that is medically managed. CONCLUSIONS: Delayed primary closure of the small bladder exstrophy template can allow the native bladder tissue adequate time to grow to a size feasible for successful closure. Epispadias repair can usually be performed at the same time and is facilitated by prior testosterone administration. Bladder neck reconstructive techniques have achieved continence without the need for augmentation or bladder replacement in 47% of the patients in our series. For patients who do not achieve adequate capacity for bladder neck reconstruction, preservation of the native bladder template facilitates future augmentation and ureteral reimplantation, thus requiring use of less bowel in the growing child.