Continent Gastric Tube: New Techniques and Long-Term Followup

Purpose

The successful use of stomach for bladder augmentation and substitution is well documented. Gastric tissue has been used more recently to create continent catheterizable tubes. We describe 2 new techniques of gastric tube construction, and report our long-term followup of catheterizable gastric tubes in children and adults undergoing complex urinary tract reconstruction.

Materials and Methods

A retrospective chart review of 6 male and 4 female patients 5 to 43 years old was done. Primary diagnoses included bladder exstrophy, cloacal exstrophy, rhabdomyosarcoma and neurogenic bladder. Five patients underwent gastrocystoplasty with simultaneous creation of a continent gastric tube from the anterior gastric flap. In 2 patients who had undergone previous gastrocystoplasty a continent gastric tube was created from an anterior flap raised from the existing gastric bladder. Isolated gastric tubes were constructed in 3 patients.

Results

Followup ranged from 2 to 9 years (median 3.5). All patients demonstrated easy reliable catheterization. One patient required revision of the proximal end of the tube for incontinence. At followup all tubes were continent. Complications occurred only in flush or protuberant stomas, and resolved after stomal revision with recessed skin flaps.

Conclusions

Several techniques can be used to create a continent gastric tube. Long-term followup reveals reliable catheterization and good continence rates. Recession of the gastric tube stoma with a skin flap prevents peristomal complications.     

Colonic Conduit in Children: Protection of the Upper Urinary Tract 16 Years Later?

Purpose

Complication rates of up to 86.6 percent have been reported after creation of an ileal conduit. In contrast to others, we construct an antirefluxing isoperistaltic colonic conduit for incontinent diversion in children.

Materials and Methods

Between 1968 and 1989 a colonic conduit was created in 105 patients up to age 20 years for neurogenic bladder (76), bladder exstrophy (16)and other reasons (13). Long-term followup (minimum 5 years, mean 16.3 years, range 5 to 26) was possible in 84 patients (159 renal units).

Results

Early and late stenosis at the ureterocolic anastomosis, and stomal stenosis occured in 7.6 and 15.5 percent of the cases, respectively. Renal calculi developed in 8.2 percent of the renal units. Eight kidneys without function after recurrent pyelonephritis, calculi or stenosis at the ureterocolic anastomosis were removed during followup. Compared to preoperative status 3 of the remaining 151 renal units had increased dilatation of the upper urinary tract at the last followup. A total of 31 patients had complications during followup and 18 underwent conversion to continent urinary diversion.

Conclusions

When incontinent urinary diversion is necessary in children, a colonic conduit with the option of continent conversion should be created before deterioration of the upper urinary tract.     

Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias

In the paediatric section this month several important issues are addressed. The authors from Lyon describe the results of bladder neck reconstruction for incontinence in children with bladder exstrophy and incontinent epispadias. They indicate the unpredictability of bladder neck reconstruction and discuss the results of the other techniques used for urinary continence.

OBJECTIVE

To review the long‐term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve ‘continence’ (which implies active mechanisms) but only ‘dryness’ (which implies passive mechanisms).

PATIENTS AND METHODS

Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young‐Dees‐Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow‐up of 11 years. All patients were treated and followed in the same institution.

RESULTS

In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty‐eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery.

CONCLUSION

We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

     

The Outcome of Patients with Classic Bladder Exstrophy in Adult Life

Purpose

We determined the outcome of 20 adult bladder exstrophy patients regarding urinary continence, sexual function, fertility and psychosocial integration.

Materials and Methods

A total of 16 men and 4 women completed an anonymous questionnaire and the charts were reviewed for medical history.

Results

Of 9 patients who void spontaneously 6 are dry for 4 hours and 3 for 2 hours. Among the remaining 11 patients 5 are dry on clean intermittent catheterization, 3 who had undergone ureterosigmoidostomy are dry for more than 4 hours and 3 had an incontinent stoma. Four men and 2 women are married, including 2 men and 1 woman who had a total of 7 children. Ten of 16 men (63 percent) reported that they ejaculate a few cubic centimeters in volume, 3 ejaculate only a few drops and 3 have no ejaculation (2 of whom underwent cystectomy). Semen was analyzed in 4 patients (3 with azoospermia and 1 with oligospermia) and average volume of ejaculate was 0.4 cc (range 0.2 to 1). All women reported regular and normal menstrual periods. A total of 15 patients experienced normal erections that were described as satisfactory by 8 and not satisfactory by 6 due to a small penis, with dorsal chordee in 1. Of the 16 men 12 (75 percent) experienced satisfactory orgasms while 10 had participated in sexual intercourse with complete partner satisfaction in 9. Half of the men and all women describe intimate relationships as serious and long term. Of the 20 patients 15 (75 percent) achieved a high level of education.

Conclusions

Bladder exstrophy patients generally achieve good results but the fertility of most men is in doubt.     

Ureterosigmoidostomy: an outdated approach to bladder exstrophy?

Long-term results among 46 children with ureterosigmoidostomy are presented. The indication for ureterosigmoidostomy had been bladder exstrophy in 40 patients, incontinent epispadias in 5 and neurogenic bladder dysfunction in 1. Of the 40 patients with bladder exstrophy 8 had undergone ureterosigmoidostomy after failure of other types of urinary tract reconstruction (6 had upper tract dilatation before ureterosigmoidostomy). Three patients with previously damaged upper urinary tracts required early postoperative conversion because of severely increasing kidney dilatation. Three other patients required conversion after a mean of 10 years to preserve kidney function. One patient died after 16 years of a cause not related to ureterosigmoidostomy. The remaining 39 patients were alive with a functioning ureterosigmoidostomy after a mean followup of 14.7 years. The daytime continence rate was 97.4% (38 of 39 patients) and the complete continence rate was 92.3% (36 of 39). Except for 1 tubular adenoma that was removed successfully during routine colonoscopy, no bowel neoplasia has been observed. None of the 45 living patients has renal insufficiency.     

Radical Prostatectony with Preservation of Urinary Continence

Purpose

In an effort to improve postoperative urinary continence after radical retropubic prostatectomy, a new operation to preserve the bladder neck and a significant portion of the prostatic urethra has been developed.

Materials and Methods

The prostatic urethra is dissected in continuity with the bladder away from the lumen of the prostate, which allows for a true urethra-to-urethra anastomosis.

Results

A total of 24 patients who underwent the new continence sparing radical retropubic prostatectomy was compared retrospectively to 80 who previously underwent a nerve sparing procedure. Total continence was noted immediately in 11 patients, within 9 days in 15 and within 7 weeks in 21 of 24 who underwent the new operation, compared to 1, 5 and 33, respectively, of 80 who underwent the standard operation. Microscopic positive margins were noted in 2 of 24 patients with the new continence sparing operation. Early results of cancer control were good.

Conclusions

Early followup of this new technique of radical retropubic prostatectomy suggest that preservation of the continence mechanism at the level of the bladder neck and prostatic urethra results in significantly improved postoperative urinary continence without adversely affecting cancer control.     

The Long-Term Outcome of Posterior Urethral Valves Treated with Primary Valve Ablation and Observation

Purpose

We believe that primary valve ablation with observation is the preferred management for posterior urethral valves. However, debate continues as to the role of high diversion. We examined the long-term outcome of a large series of patients treated with primary valve ablation, and compared it to the outcome of high diversion and vesicostomy.

Materials and Methods

We reviewed the records of 100 patients treated with primary valve ablation (74 percent), vesicostomy (13 percent) or high diversion (9 percent) before 1985. Median followup was 11.2 years.

Results

Overall 13 percent of our patients had end stage renal disease by age 15 years. Three patients initially treated with valve ablation and 3 initially treated with vesicostomy later underwent high diversion but none benefited from the secondary procedure. Four patients initially treated with valve ablation subsequently underwent vesicostomy but only 1 benefited. Bladder storage capacity was well preserved. Diurnal urinary continence developed in 46 percent of patients at age 10 years and only 1 remained incontinent after age 20 years. One patient with diversion who awaits transplantation had a small contracted bladder. Recent urodynamic studies in 10 cases of delayed urinary continence have not shown decreased bladder compliance or capacity. Kaplan-Meier analysis of outcomes of the different treatments indicated no statistical difference in patient age at end stage renal disease development. However, comparing the number of surgical procedures in the different treatment groups revealed a significant increase in the amount of surgery in infants with diversion. Our results were equivalent to those of the best published series, many of which strongly advocate high diversion.

Conclusions

By avoiding diversion in most cases bladder function is preserved and the need for bladder augmentation is decreased.     

MALONE ANTEGRADE CONTINENCE ENEMA FOR ADULTS WITH NEUROGENIC BOWEL DISEASE

Purpose

We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion.

Materials and Methods

Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed.

Results

Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion).

Conclusions

Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.     

Urethral Lengthening With Anterior Bladder Wall Flap (Pippi Salle Procedure): Modifications and Extended Indications of the Technique

Purpose

We report a clinical case series of an innovative method of urethral reconstruction for the treatment of urinary incontinence. Modifications of our original technique are presented.

Materials and Methods

Bladder neck repair was done in 17 patients, mean age 9.3, with neurogenic incontinence (13) or exstrophy (4). Average followup is 25.6 months. Of the patients 9 with neurogenic bladder underwent the original procedure using a midline anterior bladder wall flap. In the 4 patients with exstrophy a modified procedure was done using an anterolateral bladder wall flap. In another 4 patients an extended flap of distal mucosa was used to avoid ureteral reimplantation. Augmentation was performed in 13 of the 17 cases (10 detubularized ileum and 3 detubularized colon).

Results

Continence (greater than 4 hours) was obtained in 12 of the 17 patients (70%), 2 are dry for 1 to 2 hours and 3 are incontinent. A urethrovesical fistula developed in 2 patients (1 closed successfully), and 3 patients have problems with catheterization.

Conclusions

Urethral lengthening with anterior bladder wall flap is a versatile alternative in the surgical treatment of urinary incontinence. Variations of the original technique resulted in an improved vascular supply and decreased the formation of fistula at the base of the flap. The modified technique was successful in patients with exstrophy, including those who had failed bladder neck surgery.     

Outcome Analysis of Mitrofanoff Principle Applications Using Appendix and Ureter to Umbilical and Lower Quadrant Stomal Sites

Purpose

We compared the indications for and results of application of the Mitrofanoff principle using appendix and ureter to umbilical and lower quadrant stomal sites.

Material and Methods

We created continent catheterizable conduits in 60 patients 3 days to 20 years old (mean age 8.8 years). The primary indication was refractory urinary incontinence associated with bladder or cloacal exstrophy, or anomalies in 31 cases. We constructed 38 umbilical (all appendix) and 22 lower quadrant (10 appendix and 12 ureter) stomas. Mean followup was 3 years.

Results

We preferred the umbilicus as a stomal site for its cosmetic value. The most common indication for a lower quadrant stomal site was preservation of the retroperitoneal course of the ureter. The stomal stenosis rate was 13 and 4 percent in patients with umbilical and lower quadrant stomas, respectively. We preferred the appendix as a conduit due to availability. Indications for the ureter as a catheterizable conduit were absence of an adequate appendix or presence of a healthy ureter after nephrectomy. The appendiceal and ureteral conduits were catheterizable in 94 and 84 percent of patients, respectively, and continence was achieved in 97 percent.

Conclusions

In a complex group of patients with incontinence application of the Mitrofanoff principle yielded good results for either combination of stomal site or catheterizable conduit. Appendicovesicostomy to the umbilicus remains our preferred procedure.     

Achieving urinary continence in cloacal exstrophy: The surgical cost

Introduction

Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence.

Post-Prostatectomy incontinence and the Artificial Urinary Sphincter: A Long-Term Study of Patient Satisfaction and Criteria for Success

Purpose

We investigated patient satisfaction with the artificial urinary sphincter and established criteria for a successful outcome by inquiring about patient perceived satisfaction, continence achieved and comparison with the surgeon office records.

Materials and Methods

During 9 years 65 patients with post-prostatectomy incontinence underwent placement of the AMS800^* artificial urinary sphincter. Review of charts and a telephone questionnaire were conducted to determine patient perceived satisfaction.

Results

A total of 50 patients participated in the survey. Median followup was 23.4 months. Preoperative incontinence was severe. Of the patients 90 percent reported continuous leakage, and 70 percent wore an average of 6 diapers and 24 percent wore an average of 7.4 pads daily.The long-term complete continence rate was 20 percent. Of the patients with wetness 55 percent had leakage of a few drops daily and 22 percent had leakage of less than a teaspoon. Of all patients 50 percent had leakage daily, 24 percent had leakage 1 or more times a week and wore an average of 1.5 pads per day, and 6 percent reported changing clothes due to wetness. A total of 90 percent of the patients reported satisfaction with the artificial urinary sphincter and 96 percent stated that they would recommend or had recommended the artificial urinary sphincter to a friend. In retrospect, 92 percent of the patients would have the artificial urinary sphincter placed again, 90 percent of those undergoing revision reported no change in satisfaction and 14 percent reported improved sexual activity.

Conclusions

Patient satisfaction with the artificial urinary sphincter for post-prostatectomy incontinence is uniformly high. Although postoperative continence was not 100 percent, relative improvement in continence was the most significant factor affecting patient perceived outcome. Using these parameters criteria for a successful outcome can be established, and patient concerns regarding the artificial urinary sphincter can be dispelled.     

Early Results with Antegrade Collagen Injection for Post-Radical Prostatectomy Stress Urinary Incontinence

Purpose

Results of retrograde transurethral collagen injection for treatment of stress urinary incontinence have been generally disappointing for men with intrinsic sphinchter deficiency following radical prostatectomy. We described a new technique of antegrade transvesical collagen injection using suprapublic percutaneous bladder access.

Materials and Methods

Between October 1994 and January 1996, 20 patients underwent antegrade collagen injection for post-radical prostatectomy stress urinary incontinence. Evaluation by pad test, urodynamics and subjective scores was performed before and after injections.

Results

At a mean followup of 8.5 months 9 of 20 patients (45 percent) had significant subjective improvement and 5 (25 percent) were totally dry.

Conclusions

Antegrade collagen injection is a promising and simple method of correcting post-radical prostatectomy stress urinary incontinence. Further study and longer followup are necessary to determine its precise role in the treatment of this condition.     

The Le Bag Orthotopic Urinary Diversion

Purpose

We reviewed our experience with Le Bag orthotopic urinary diversion in 38 cases.

Materials and Methods

Between April 1990 and January 1995, 38 men underwent radical cystectomy and Le Bag urinary diversion for treatment of bladder cancer. Approximately 20 cm. each of detubularized ileum and cecum were used to construct the pouch. A total of 22 pouches was fashioned with absorbable staples. In 21 cases freely refluxing Bricker ureterointestinal anastomoses were used.

Results

There was no significant difference in major complication rates in the hand sewn versus stapled anastomosis groups, and there were no complications specifically related to the use of staples. There were 3 episodes of febrile urinary tract infection: 2 in the Bricker group and 1 in the tunneled anastomosis group. There was no significant difference between the 2 groups with respect to ureteral obstruction. The daytime continence rate was 91 percent, and 80 percent of the patients are completely dry or have only mild incontinence at night. Most patients had mild hyperchloremic metabolic acidosis postoperatively as evidenced by a decrease in median serum bicarbonate level (28 versus 24 mmol./l.). This difference appears to be related to pouch length (r = 0.58, p = 0.0002).

Conclusions

We conclude that the Le Bag technique is a technically feasible form of urinary diversion with functional results similar to other forms of orthotopic diversion. Use of absorbable staples simplifies pouch construction without increasing complications. This form of urinary diversion is associated with hyperchloremic metabolic acidosis, which is related to pouch length.     

Decreased Bladder Compliance in Patients With Myelomeningocele Treated With Radiological Observation

Purpose

Recently others advocated frequent radiological surveillance to detect upper urinary tract deterioration in children with neurogenic bladder secondary to spina bifida. We reviewed the consequences of such expectant management on bladder compliance and urinary continence.

Materials and Methods

We retrospectively reviewed the records of 214 children presenting to our spina bifida clinic in a 13-year period. Followup is available for 95 girls and 86 boys. Imaging studies of the kidneys were repeated at 6 to 12-month intervals. Urodynamics were performed when upper urinary tracts deteriorated or in incontinent school age children.

Results

On radiographic study there was evidence of upper urinary tract deterioration in 79 children, including hydronephrosis in 34, hydronephrosis and vesicoureteral reflux in 19, and reflux only in 26. Followup studies performed after clean intermittent catheterization and pharmacological therapy were instituted revealed resolution or improvement of upper tract deterioration in 52 patients (69 percent), while bladder compliance improved in only 42 percent. Surgical intervention was required in 34 children, despite improvement of upper tract changes in many of these patients on followup radiographic studies.

Conclusions

Although radiological surveillance of patients with myelomeningocele allows recognition of upper tract changes, the effects of elevated outlet resistance on bladder compliance are not as readily reversible as the initial radiographic findings. The incidence of enterocystoplasty exceeds that reported for patients treated prospectively based on urodynamic findings, which should be considered in the treatment of these children.     

The Malone Antegrade Colonic Enema Enhances the Quality of Life in Children Undergoing Urological Incontinence Procedures

Purpose

Functional alterations of the gastrointestinal and genitourinary tracts, and physical limitations in children with spina bifida, imperforate anus and spinal cord injury challenge the ability to have independent fecal and urinary continence. Urologists have successfully helped these patients achieve urinary continence. We report our experience with the antegrade colonic enema procedure, which allows select individuals to achieve continence of stool, enhancing quality of life.

Materials and Methods

Since December 1992, 18 antegrade colonic enema procedures were performed in 12 female and 6 male patients 5 to 31 years old of whom 14 had spina bifida, 2 had imperforate anus and 2 had spinal cord injury. Simultaneous urological continence procedures were performed in 8 patients, including appendicovesicostomy in 4, augmentation cystoplasty in 2 and augmentation cystoplasty plus an ileal Mitrofanoff procedure in 2. Four patients previously underwent urological reconstruction.

Results

In 24 months of followup (average 6.6) all patients with a functioning stoma remained continent of stool and 17 were continent of urine. Complications related to the antegrade colonic enema procedure occurred in 4 children (22 percent) of whom 3 required further surgery. Three patients (17 percent) had minor stomal stenosis.

Conclusions

The antegrade colonic enema procedure is easily performed and it should be considered for any child with significant physical limitations and/or refractory fecal incontinence before urological continence promoting procedures are done.     

Neodymium: YAG Laser Coagulation Prostatectomy: 3 Years of Experience with 227 Patients

Purpose

For 3 years we prospectively followed a cumulative cohort of men who underwent neodymium:YAG laser coagulation prostatectomy to relieve bladder outlet obstruction to determine the safety, efficacy and durability of this procedure.

Materials and Methods

A total of 227 men with symptomatic bladder outlet obstruction was treated with the Urolase* side-firing laser fiber between October 15, 1991 and October 15, 1994. Voiding outcomes, including peak urinary flow rates, residual urine volumes and American Urological Association symptom scores, were measured with time, and immediate and long-term complications were assessed.*C. R. Bard, Inc., Covington, Georgia.

Results

Median patient followup was 26 months (maximum 42). Significant improvement occurred in all measured voiding parameters, including 133 percent in peak flow rates and 61 percent in symptom scores 1 year postoperatively. Overall 87 percent of patients noticed improved quality of life as a result of surgery. Minimum postoperative followup was 6 months in all cases. Complications included prostatitis in 2.6 percent of patients, urethral stricture in 1.8 percent, bladder neck contracture in 4.4 percent and reoperation for residual prostate tissue in 5.3 percent.

Conclusions

Neodymium:YAG laser coagulation of the prostate represents an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Voiding outcomes are durable through 3 years.     

The Ileal Ureter Neobladder is Associated with a High Success and a Low Complication Rate

Purpose

Several different methods to construct a bladder substitute after cystectomy have been described. We evaluated our experience with the Studer ileal ureter neobladder during the last 5 years.

Materials and Methods

We reviewed retrospectively the results in 32 patients who underwent construction of a slightly modified ileal neobladder from that originally described. Mean followup was 25 months (range 6 to 68).

Results

Patients experienced few complications and only 1 required reoperation. Daytime and nighttime continence rates were 94 and 74 percent, respectively. One patient sustained a ureteral stricture resulting in hydronephrosis (1 of 64 renal units).

Conclusions

The results reveal the ileal neobladder to be an easily constructed pouch with a low complication rate, and a high success rate in regard to continence and the establishment of adequate capacity at low pressure. Within the study period upper tract preservation was excellent. However, a 10 to 15-year followup is indicated to confirm our initial results.     

SOMATIC FUNCTION, MENTAL HEALTH AND PSYCHOSOCIAL FUNCTIONING IN 22 ADOLESCENTS WITH BLADDER EXSTROPHY AND EPISPADIAS

Purpose

We report the long-term somatic outcome, mental health and psychosocial adjustment in adolescents with bladder exstrophy and epispadias.

Materials and Methods

A total of 22 adolescents 11 to 20 years old (median age 14.5), including 19 with bladder exstrophy and 3 with epispadias, were assessed for urogenital status, stoma, renal and bowel function, anorectal physiology, mental health and psychosocial functioning by physical examinations, semistructured interviews and standardized questionnaires. The parents of 21 patients were interviewed and completed questionnaires. Information was also obtained on control groups.

Results

Of the 22 patients 9 (41%) had no urinary diversion and were urinary incontinent, 6 (27%) had persistent fecal staining and anal canal pressures that were lower than the controls, 10 (59%) were dissatisfied with the penile appearance and 11 (50%) met the criteria for psychiatric diagnoses. The main predictors of mental health were parental warmth and patients genital appraisal in the 11 to 14-year age group, and parental warmth and urinary continence function in the 15 to 20-year age group. Psychosocial dysfunction was predicted by fecal incontinence in the younger group and worries about future sexual relationships in the older group.

Conclusions

The present multimodal outcome study revealed that adolescents with bladder exstrophy and epispadias had significant physical and mental problems. Genital malformation, and urinary and fecal incontinence may have a negative impact on mental health and psychosocial functioning. Our findings emphasize the need to include psychosocial experts on health care teams to reveal the amount of distress caused by these anomalies and to offer psychosocial support.     

Evaluation of Smooth Muscle and Collagen Subtypes in Normal Newborns and Those With Bladder Exstrophy

Purpose

Many patients who undergo bladder exstrophy closure as newborns, subsequent epispadias repair and later bladder neck reconstruction become completely continent yet complications can occur. After successful initial exstrophy closure and later epispadias repair some patients may fail to gain sufficient capacity for bladder neck reconstruction or satisfactory capacity and continence after bladder neck reconstruction. In an attempt to understand the pathogenesis of these failures we compared bladder biopsies from normal neonates and those with exstrophy.

Materials and Methods

Bladder biopsies obtained from the midline of the bladder wall just above the base of the trigone from 12 newborns with exstrophy were compared to bladder sections from 9 neonatal cadavers. All bladder specimens were stained with monoclonal antibodies against type I, III or IV collagen and a subset was further stained with Masson's trichrome to define the extracellular matrix. All specimens were then analyzed using a color digital image analysis system.

Results

At initial examination of the extracellular matrix there was an increase in the collagen-to-smooth muscle ratio from 0.38 in controls to 1.2 in newborns with exstrophy, comprising an increase in collagen and decrease in smooth muscle. The collagen component of the extracellular matrix was then further defined to quantitate the amount of each collagen type (I, III and IV) deposited. We then evaluated the ratio of collagen type-to-total collagen sampled. Compared to control bladders there was no statistical difference in the amount of type I or IV in the bladders of newborns with exstrophy at initial closure. However, there was a 3-fold increase in type III collagen (0.14 plus/minus 0.05 to 0.46 plus/minus 0.2 percent, p less than 0.001) in the bladders of neonatal controls versus newborns with exstrophy.

Conclusions

This alteration in collagen makeup may represent an earlier developmental stage of the exstrophy bladder at birth, which then remodels and changes after successful initial closure. Further studies are underway to examine the collagen composition of bladders at bladder neck reconstruction, failed closures and augmentation.