Bladder-neck repair in urinary bladder exstrophy

A simple modification of an existing technique for bladder-neck reconstruction in exstrophy of the urinary bladder is reported. The technique involves tubularization of the posterior urethra up to just below the ureteric orifices. It differs from other techniques in that no part of the bladder tissue is used for buttressing the repair, but all is utilized for enhancing the bladder volume. Only 2 of 20 patients remained incontinent after bladder-neck reconstruction; the remaining 18 have achieved socially acceptable continence. Accepted: 17 June 1998     

The search for continence in bladder exstrophy: Bladder neck transection and Macedo catheterizable reservoir to augment the nativebladder

IntroductionBladder exstrophy remains one of the most challenging abnormalities in pediatric urology. We propose bladder neck transection and bladder augmentation with a catheterizeable reservoir technique to achieve continence after previous anatomic reconstruction in stages.MethodsAt the age of 5–6 years, we offer the transection of bladder neck and enterocystoplasty to achieve continence. We report on a 6-year-old boy that underwent this procedure. We perform the reservoir from ileum according to Macedo-technique that constructs a catheterizeable channel from the same bowel segment. The continence mechanism of the efferent tube is based on angulation and a serous lined tunnel created with 3.0 prolene sutures. The stoma is placed in the midline.ResultsPatient had an uneventful evolution and is continent performing CIC every 4 h with 9 months of follow up.DiscussionIn spite of continuous development of bladder exstrophy surgery, the urethral continence and voluntary micturition is still not possible in the majority of patients. We discuss with our patients honestly and offer this method as a viable alternative to achieve continence.ConclusionIn our experience, most patients accept urethral transection and suprapubic CIC when educated about results with other alternatives of bladder neck plasty.     

Delayed exstrophy repair (DER) does not compromise initial bladder development

ObjectiveDelayed exstrophy repair (DER) represents an alternative to early neonatal bladder closure. This study aims to define the consequence of DER on bladder growth in bladder exstrophy patients who underwent routine DER, compared with those who underwent immediate postnatal reconstruction.MethodsBetween 2000 and 2005, classic bladder exstrophy patients referred to the authors' institution underwent early neonatal bladder closure (group 1). Subsequently, classic bladder exstrophy patients referred to the authors' institution were treated with an elective DER (group 2). Bladder capacity was assessed between the age of 1 and 4 years with an unconscious cystogram. When dilating VUR was present, the volume of the contrast migrated into the ureter was calculated and subtracted.ResultsSixty patients were treated between 2000 and 2012. Complete follow-up data were available for 45 patients and they were included in the study: 21 in group 1 (11 males) and 24 in group 2 (14 males). The mean (SD) bladder volumes were 72.85 (28.5) ml in group 1 and 72.87 (34.9) in group 2 (p = 0.99).ConclusionIn the authors' experience, DER does not reduce the subsequent bladder capacities compared with neonatal exstrophy closure.     

Factors responsible for successful primary closure in bladder exstrophy

 To assess the important factors for successful primary closure in staged reconstruction of bladder exstrophy, 25 patients (18 males, 7 females) underwent primary bladder closure during the years 1993–1997. Twenty-one were more than 72 h old; all of these underwent bilateral posterior iliac osteotomies followed by primary bladder closure during the same anesthetic. Bladder closure was done in a double layer. The ureteric catheters were removed after 2 weeks and the bladder catheter after 3.5–4 weeks. Only 1 patient had a bladder dehiscence on the 10th postoperative day due to infection; 3 had partial wound dehiscences but no bladder dehiscence. One had a partial bladder prolapse. The osteotomies needed no drainage, and no complications occurred. One patient needed a urinary diversion 3 years after surgery as the bladder capacity did not increase. Eleven important factors play a pivotal role for successful primary bladder closure: (1) Proper patient selection; (2) A staged approach; (3) Anterior approximation of the pubic bones with placement of the bladder and urethra in the true pelvis; (4) Posterior bilateral iliac osteotomies in all indicated cases; (5) Double-layered closure of the bladder; (6) Two weeks' proper ureteric catheter drainage; (7) Prevention of infection; (8) Prolonged and proper postoperative immobilization; (9) Prompt treatment of bladder prolapse; (10) Prevention of abdominal distension postoperatively; and (11) Ruling out bladder-outlet obstruction before removing the bladder catheter. Accepted: 12 July 1999     

Augmentation colocystoplasty in bladder exstrophy

A good bladder capacity and adequate outlet resistance determine success after staged reconstruction of bladder exstrophy (BE). Augmentation cystoplasty (AC) is an established salvage procedure to treat the small, noncompliant bladders of some of these children. In a series of 89 patients with BE treated over the last 12 years, 19 underwent detubularized augmentation colocystoplasty (ACC) as an adjunctive procedure. Nine underwent ACC at the time of bladder-neck reconstruction (BNR) for small bladder capacity and poor compliance; 10 underwent ACC as a secondary procedure after BNR for persistent urinary incontinence or poor bladder compliance and upper-tract deterioration. The follow-up period ranged between 6 months and 12 years (mean 41 months). Complications included symptomatic urinary-tract infection in 4 patients, recurrent epididymo-orchitis in 2, calculi in 3, colonic anastomotic dehiscence in 1, bladder-patch fistula in 2, and secondary coloureteric-junction obstruction in 1. There was no postoperative reservoir perforation or mortality. The upper tract remained normal or stable in all patients. Nine of the 19 patients are dry both day and night; 4 others are dry during the day but have occasional nocturnal wetting. Three patients have nocturnal wetting with stress incontinence and 2 remain incontinent. Seven patients can void effectively using abdominal contractions and 12 require clean intermittent catherization to ensure complete voiding. The indications and results of AC in BE from other series are reviewed. AC is an important and safe adjunctive procedure in a subset of BE patients with small and poorly compliant bladders. Despite the known complications, more liberal use of AC in BE is warranted. Accepted: 21 March 2001     

True duplicate bladder exstrophy: a case report

 True duplicate exstrophy is a rare and interesting congenital anomaly. We are adding a case to the previously reported seven cases in the world literature. Accepted: 2 August 2000     

Covered exstrophy associated with an anorectal malformation: A rare variant of classical bladder exstrophy

We report the case of a male newborn with covered bladder exstrophy, high anorectal malformation, and rectourethral fistula. The child had a split symphysis and diverging rectus muscles in the infraumbilical region. The ventral part of the bladder was covered with thin, fragile skin and some portions of the bladder bulged out as abdominal-wall hernias. Two of these hernias were located just above the penis, and the overlying skin showed a resemblance to scrotal skin. The penis was small and slightly laterally displaced, but otherwise normal; the child also had unilateral reflux into a dysplastic left kidney. The bladder neck and posterior urethra were patulous, but there was no urinary incontinence. The child underwent a singlestage reconstruction of the exstrophic lesion and a staged repair of the anorectal malformation. The clinical significance of this entity is discussed and the literature reviewed.     

Anterior abdominal wall closure in bladder exstrophy

Anterior abdominal wall closure without pelvic osteotomy for bladder exstrophy can be very diffecult and more often than not calls for various reconstructive measures. A technique is described that involves bilateral detachment of the rectus abdominis from the pubic ramus, midline vertical closure, and refixation to the pubic rami after medial and caudal advancement. A relaxing fascial incision may be required. This technique has been used in 15 patients and has obviated the need for pelvic osteotomy, thereby decreasing the postoperative morbidity. It has resulted in good cosmetic repair in all patients in addition to the ease of abdominal wall closure. The healing has been remarkably good. This technique is particularly useful in children coming for primary surgery after the neonatal period. Correspondence to: V. Bhatnagar     

The use of gastrocystoplasty in patients with bladder exstrophy

The authors report the use of a stomach segment vascularized via the right gastroepiploic artery in order to increased bladder capacity in 18 patients with bladder exstrophy. The morphological and functional results were good in 15 patients (83.4%); 13 (72.2%) continue to use intermittent catheterization to empty the bladder, while 5 (27.7%) have spontaneous voiding. Seven patients are completely continent, 8 partially continent (<3 h), and 2 are still incontinent. We encountered no metabolic complications and no patient complained of mucus production. Ten patients had a dysuria-hematuria syndrome, 8 only slight and 2 marked. We believe that even though gastrocystoplasty is a valid alternative compared with other tissues used to date for bladder augmentation, attention should be paid to this new pathological sequela, which has proved to occur quite frequently, as seen from the long- and short-term follow-up of patients who have had this operation.