Bladder exstrophy: vesicoplasty or urinary diversion?

Classic bladder exstrophy and complete rectal prolapse in a 10 year-old child with no previous surgical intervention: what to achieve?

The management of bladder exstrophy (BE) remains one of the most significant challenges encountered by pediatric urologists despite improvements in the operative techniques worldwide. Regardless of surgical technique, timing of primary closure remains a matter of debate. The initial closure may be performed within the first 48–72 hours of life or at ~6–12 weeks of age. Delayed presentation until adolescence is extremely rare. However, due to lack of awareness, and access to healthcare along with poor socioeconomic conditions in developing countries, some patients may not receive treatment during infancy. We present a case of a 10-year-old Syrian male with BE associated with complete rectal prolapse who did not undergo any previous surgical interventions.

Exstrophy-epispadias complex presenting in adulthood: a single-center review of presentation, management, and outcomes

OBJECTIVE

To study the presentation, management, and outcome of patients with exstrophy-epispadias complex, who present in adulthood (aged >18 years).

MATERIALS AND METHODS

A retrospective review of the electronic medical records of patients with exstrophy-epispadias complex managed from January 2001 to December 2010 was undertaken. Patients aged >18 years at presentation, with detailed medical records were selected. They were classified into 2 groups: group A (previously untreated) and group B (residual defects or complications after childhood surgery).

RESULTS

Thirty-nine patients with exstrophy-epispadias complex presented to our institution over this 10-year period. Of these 26 were adults (aged >18 years; range, 18-48 years). Detailed medical records could be obtained for 21 of them and they were included. Group A consisted of 4 patients--2 male and 2 female. All underwent cystectomy; 2 had an ileal conduit and 2 had ureterosigmoidostomy (Mainz II). All had improved quality of life and a stable renal function at follow-up. Group B consisted of 17 patients. Mean number of surgeries attempted previously was 4.4 (range, 2-13). Presentation was varied but primarily involved incontinence of urine (n = 12). Four patients were lost to follow-up, 2 were managed conservatively, and 11 underwent a surgical procedure. All patients returned to normal activity with an improvement in the quality of life postoperatively.

CONCLUSION

Exstrophy-epispadias complex is difficult to manage in resource-poor settings associated with illiteracy and poverty. However, successful rehabilitation and an improved quality of life are possible even in cases presenting in adults.

Management of bladder exstrophy in adulthood: report of 5 cases

OBJECTIVE

To report our experience in the management of adult classic bladder exstrophy.

PATIENTS AND METHODS

During 1977-2006 we treated five adult males presenting with classic exstrophy-epispadias complex. Patient age at presentation ranged from 17 to 30 with a mean age of 23 years. Four patients had received no previous treatment and one underwent previous ureterosigmoidostomy. Work-up included evaluation of upper tract and bladder biopsy. Bladder patch condition was variable. Surgery involved bladder preservation in the three patients who underwent primary repair, including bladder closure, bladder neck reconstruction and epispadias repair; two of them also had augmentation ileocystoplasty. The remaining two patients underwent ureterosigmoidostomy, cystectomy and epispadias repair. Abdominal wall closure was by fasciocutaneous M-plasty. Osteotomy was not done in any case.

RESULTS

In patients with bladder preservation, one patient was continent (>3 h) and voided normally whereas the other two showed day and night continence (2-3 h) with mild stress incontinence. Patients were satisfied with functional outcome. Ultrasound and intravenous pyelography showed preservation of upper tract. Follow-up period ranged from 1 to 8 years.

CONCLUSION

Patients with bladder exstrophy presenting in adulthood should not be denied the opportunity of primary reconstruction with bladder preservation in the absence of significant histological changes in the bladder mucosa.

Bladder exstrophy in adulthood

Background

We report our experience with the treatment of classic exstrophy of the bladder in a small series of seven adult males. There are very few documented cases of adults presenting with exstrophy of bladder in literature.

Materials and Methods

Adult males presenting with classic exstrophy of the bladder and complete epispadias underwent detailed evaluation including psychological assessment and counseling. All were explained regarding the surgical procedure and informed about the need for self-catheterization. Prior to 2002 all patients underwent cystectomy of the existing bladder plate, with creation of catheterizable modified Mainz pouch. Since 2002 patients were assessed for bladder reconstruction with augmentation ileocystoplasty, bladder neck reconstruction, and abdominal wall closure.

Results

Seven adult males with classic exstrophy of the bladder and complete epispadias who had not received any previous treatment presented to us during the period 1991-2006. Five of these underwent cystectomy with continent pouch and the remaining two underwent bladder reconstruction. All have been doing well with improved self-esteem and social interaction. Two of these have married and leading a satisfactory sexual relationship.

Conclusions

Surgical correction in adults with exstrophy of the bladder greatly improves self-esteem, confidence, and social relationship.

Bladder augmentation in a young adult female exstrophy patient with associated omphalocele: an extremely unusual case

We present the case of a 20-year-old woman with uncorrected bladder exstrophy and omphalocele treated with ileocystoplasty and continent urinary stoma. To our knowledge this is the first reported case of a young adult patient presenting with both congenital anomalies. The treatment result suggests that bladder preservation is a safe and feasible therapeutic option in bladder exstrophy.

Bladder preservation in adult classic exstrophy: early results of four patients

OBJECTIVES

To report our experience with the treatment of classic exstrophy of the bladder in a small series of adult patients using ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with flaps. The presentation of exstrophy of the bladder in adulthood is rare. The problems encountered include difficulty in abdominal closure, malignant potential, and upper tract dysfunction. The treatment of choice has been cystectomy with urinary diversion in all reported cases.

METHODS

We treated 4 adult male patients with classic exstrophy of the bladder and complete epispadias. They had not received any previous treatment. Multiple random bladder biopsies revealed nonspecific inflammatory changes with focal areas of keratinization. Three patients were treated in two stages. The first stage included ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with the use of flaps. The epispadias was repaired in the second stage. In 1 patient, the reconstruction was completed in a single stage.

RESULTS

All patients were continent at the last follow-up visit, with three using self-catheterization and one voiding spontaneously. The renal parameters and ultrasound scans were normal at a follow-up of 2 to 48 months. Cystoscopy performed at 6 months postoperatively revealed normal-looking mucosa in 2 patients and mild inflammation in 1 patient. Three patients were satisfied with the cosmetic results and one complained of the small size of his penis. All patients were evaluated by psychiatrists and revealed anxiety disorders preoperatively. After surgery, all demonstrated improved social interaction.

CONCLUSIONS

Vesical preservation with primary reconstruction of bladder exstrophy in adults is safe and feasible in the absence of significant histologic changes in the bladder mucosa. Abdominal closure can be achieved without difficulty with the use of transposition flaps. However, these patients require strict follow-up to detect malignant transformation at an early stage.

Adenocarcinoma development in the trigone 34 years after trigonocolonic urinary diversion for exstrophy of the bladder

A case of adenocarcinoma development in the trigone 34 years after trigonosigmoidostomy for exstrophy of the bladder is presented. The need for lifelong surveillance is emphasized and endoscopy is recommended annually in patients with urinary diversion to a colonic segment.

Association between abdominal wall defects and cryptorchidism

To determine whether intra-abdominal pressure may have a role in the process of testicular descent in man, we reviewed retrospectively the records of all male infants who presented during a 10-year period with severe abdominal wall defects, such as gastroschisis (28), omphalocele (29) and umbilical hernia (53), and calculated the incidence of cryptorchidism in these patients. The incidence of cryptorchidism at birth and at 1 year after birth was 18 and 15 per cent, respectively, in patients with gastroschisis, 52 and 33 per cent, respectively, in those with omphalocele, and 6 and 6 per cent, respectively, in those with umbilical hernia. For all 3 disorders the incidence of cryptorchidism was higher than in documented historical controls. From these data we conclude that in male infants there is an association between these 3 abdominal wall defects and cryptorchidism. The demonstration that intra-abdominal pressure is lowered significantly by these abdominal wall defects would suggest a possible role for intra-abdominal pressure in the process of testicular descent in man.

Exstrophy of bladder: evolution of management

Eighty-nine patients with bladder exstrophy were seen at our institution over the last fifty years. There were 63 males and 26 females. Cloacal exstrophy constituted 9 per cent of our experience. Twenty-seven patients underwent primary urinary diversion with subsequent genital reconstruction early on in our series. Of the 57 children operated on since 1951, 50 were judged eligible for and underwent a planned multistaged reconstruction. We realized a 50 per cent success rate. The majority of failures were diverted into an ileal conduit for persistent incontinence.

Renal function in continent patients after surgical closure of bladder exstrophy

We assessed the upper urinary tracts and renal function in 22 children who had achieved continence after staged correction of bladder exstrophy. All patients had been followed for an average of 8 years after completion of the reconstructive operation. In 15 patients the upper urinary tract was normal and only 1 of the remaining 7 required surgical correction (transureteroureterostomy) of the residual anomaly. Renal function was normal in all children. We attribute these satisfactory results to careful selection of patients, improved surgical techniques and good postoperative care.