Long-term follow up (37-69 years) of patients with bladder exstrophy treated with ureterosigmoidostomy: uro-nephrological outcome

End-stage and chronic kidney disease in classic bladder exstrophy: A retrospective muti-institutional cohort study

INTRODUCTION

While most children with classic bladder exstrophy (CBE) are born with normal kidneys, some experience renal deterioration in adulthood. Little is known about the incidence of end-stage and chronic kidney disease (ESKD and CKD, respectively) in this population. Our group has recently published on surgical outcomes in a multi-institutional cohort of 216 people with CBE. Our aim was to describe the incidence of ESKD and prevalence of CKD in this cohort of people with CBE.

METHODS

We retrospectively reviewed records of patients with CBE followed at five tertiary care centers described previously. The primary outcome was incidence of ESKD, defined as permanent peritoneal/hemodialysis or renal transplantation. The secondary outcome was prevalence of CKD stage 3 or higher (CKD3+, estimated glomerular filtration rate [eGFR]<60 ml/min/1.73 m2) at the last appointment. Creatinine-based eGFRs were calculated using the CKD-EPI Creatinine Equation (adults) and the Schwartz formula (children). Survival analysis and Fisher's exact test were used.

RESULTS

A total of 201 patients (93 % of the original cohort) had renal function data available (63 % male). Four patients who had a primary urinary diversion remained diverted at a median follow-up of 20.1 years. None developed ESKD and one developed CKD3+. The remaining 197 patients had a primary bladder closure. At a median follow-up of 18.8 years old, 12 were diverted, 108 were augmented and 77 were neither. Three patients developed ESKD (1.5 %) at a median age of 23.4 years (1 hemodialysis, 2 transplantation). On survival analysis, the risk of ESKD was 0 % at 10 years, 1 % at 20 years and 5 % at 30 years (Figure 1). This was higher than the risk of 0.003 % at 21 years of age in the general population (p < 0.001). The median age of 141 individuals with eGFR data was 21.6 years old (65 % male). No children, 4 % of adolescents and 8 % of adults had CKD3+ (p = 0.45). On exploratory analyses, prevalence of CKD3+ did not differ by center or birth year (p ≥ 0.99).

CONCLUSIONS

The risk of ESKD and CKD among patients with CBE is not insignificant and appears to be more common than the general population. The potential role of modifiable contributing factors, such as increased bladder outlet resistance, warrants further investigation. Reliable long-term follow up is needed in this population to monitor for ESKD and CKD.

Long term outcomes in classic bladder exstrophy - The adult picture

With continued improvements in medical care and surgical reconstruction, more patients with classic bladder exstrophy (CBE) are living into adulthood, than ever before. With improved survival, a greater emphasis on adult issues and improving quality of life (QOL) for these individuals is of increasing importance. This review aims to summarize data on long-term considerations for the adult with exstrophy and to highlight areas of future research and collaboration. Key conclusions are that continence or dryness are achievable alongside the ability to enjoy sexual relationships and a good quality of life.

Exstrophy-epispadias complex: are the kidneys and kidney function spared?

BACKGROUND

Exstrophy-epispadias complex (EEC) is a complex malformation of the lower abdominal wall, bladder, and pelvic floor, which necessitates multiple successive reconstruction procedures. Surgical and infectious complications are frequent. Our aim was to evaluate kidney function in these patients.

METHODS

This cross-sectional study included patients with EEC, followed since birth in a pediatric urology clinic, who underwent nephrological evaluation (blood pressure (BP) measurement and blood and urine chemistries) and imaging studies (urinary tract ultrasound and DMSA kidney scan) during 2017-2020.

RESULTS

Forty-three patients (29 males), median age 9 years (interquartile range 6-19), were included. Eleven (26%) used clean intermittent catheterization (CIC) for bladder drainage. At least one sign of kidney injury was identified in 32 (74%) patients; elevated BP, decreased kidney function (estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2), and proteinuria/albuminuria were detected in 29%, 12%, and 36% of patients, respectively. Urinary tract dilatation (UTD) was found in 13 (37%) ultrasound examinations. Parenchymal kidney defects were suspected in 46% and 61% of ultrasound and DMSA scintigraphy, respectively. UTD was significantly associated with DMSA-proven kidney defects (p = 0.043) and with elevated BP, 39% vs. 20% in those without UTD. Decreased eGFR and elevated BP were less frequent among patients on CIC than among patients who voided spontaneously: 10% vs. 14% and 18% vs. 36%, respectively. Recurrent UTIs/bacteriuria and nephro/cystolithiasis were reported by 44% and 29% patients, respectively.

CONCLUSION

The high rate of signs of kidney injury in pediatric patients with EEC dictates early-onset long-term kidney function monitoring by joint pediatric urological and nephrological teams. A higher resolution version of the Graphical abstract is available as Supplementary information.

The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults

INTRODUCTION AND OBJECTIVE

The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC.

METHODS

Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p < 0.05.

RESULTS

A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p = 0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p = 0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p = 0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician.

DISCUSSION

Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up.

CONCLUSION

Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.

Long-term Kidney Outcomes in Exstrophy-Epispadias Complex: How Patients Present as Adults

OBJECTIVE

To characterize kidney function in patients with exstrophy-epispadias complex (EEC) at time of presentation for adult urologic care.

MATERIALS AND METHODS

This was a retrospective analysis of 23 patients (ages 18-57) with EEC who presented to a single tertiary care center from 2001-2020. Kidney function was evaluated based on calculated eGFR and presence of hydronephrosis on imaging. UDS data was used to evaluate the bladder.

RESULTS

Patients had undergone a variety of different surgical techniques for exstrophy or epispadias repair prior to presentation to an adult urologist. We found that 10 of the 23 patients had evidence of CKD Stage II or higher at the time of presentation and 7 patients had evidence of hydronephrosis on imaging. There was urodynamics data available for 14 patients, of which 8 patients showed poor (≤15 ml/cmH₂O) or intermediate (15-20 ml/cmH₂O) bladder compliance.

CONCLUSION

In conclusion, some patients with EEC have evidence of kidney dysfunction at time of presentation to an adult urologist. It is important to consider this when caring for patients with EEC as adults.

Long-term sexual outcomes in patients with exstrophy-epispadias complex

Exstrophy-epispadias complex (EEC) is a spectrum of genitourinary malformations that ranges in severity and affects external genitalia and the lower urinary tract. The aim of this study was to determine the long-term sexual outcomes of patients with EEC. Sexual outcomes were hypothesized to be related to those of urinary ones. A retrospective database including all patients with EEC who had surgery at a tertiary referral institution from 1990 to 2019 was created. Data based on patient's charts were collected: demographics, surgeries, sexual outcomes, urinary outcomes. Fifty-eight patients with EEC had surgery at tertiary referral institution and entered our database. For this analysis of sexual outcomes, a sub-set of the whole population was selected: patients being 14 years old and older, having at least one surgery at our institution and having at least 12 months of follow-up. Applying this selection criteria to our database resulted in a series of 29 patients. High rates of sexual activity were observed in pubertal and post-pubertal men (96%) and women (75%). Seventy-nine percent of men and 67% of women reported sexual satisfaction; 63% of men reported normal ejaculation. To achieve these rates, 96% of men required surgery (84% penoplasty, 52% phalloplasty), and 25% of women required introitoplasty. Fertility was achieved in 67% of men and 100% of women. Assisted reproductive technology was needed in one man. Continence rates were high (diurnal continence in 83% and nocturnal continence in 93%). However, 76% required multiple continence procedures. Men and women with EEC can have good long-term sexual and urinary outcomes, but this may require multiple surgeries. Good sexual outcomes seem to be related to good urinary and continence outcome.

The Cologne pouch procedure for continent anal urinary diversion in children with bladder exstrophy-epispadias complex

INTRODUCTION

In children who remain incontinent after reconstruction of bladder exstrophy-epispadias complex (BEEC), continent anal urinary diversion (CAD) is one option to achieve continence. Known problems after CAD are an increased stool frequency and ureterointestinal stenosis. We devised a new surgical technique of CAD that we named the "Cologne pouch procedure" (CPP) that renders the possibility of separate evacuation of urine and feces. Furthermore, we connect the bladder plate to the rectosigmoid pouch instead of performing a ureterosigmoidostomy to reduce the rate of ureterointestinal stenosis. In this study, we want to introduce the CCP and critically evaluate our results.

STUDY DESIGN

In CPP a detubularized sigmoid-bladder pouch is created, which is naturally connected to the rectum. A retrospective study was performed including all patients with BEEC and CPP treated in our hospital between January 1, 2007, and December 31, 2016. Epidemiological and surgical key data, complications, and the need for alkaline supplementation were assessed. At follow-up examinations, we evaluated continence, ability of independent urine and feces evacuation, need for bicarbonate supplementation, status of the upper urinary tract, and complications such as urinary tract infections or urolithiasis.

RESULTS

In total, 29 patients with BEEC and CPP were included. The mean age at surgery was 4.2 ± 3.3 years (range 0.1-12.7 years). Overall, 14 short-term complications occurred in nine patients. Postoperatively, all patients were continent for urine and feces during daytime and only one child occasionally lost small portions of urine at night. An independent evacuation of urine and feces was accomplished in 22 patients (81.5%). Continued bicarbonate supplementation was necessary in 15 patients (55.6%). During the follow-up period six patients (22.2%) had a single urinary tract infection and four patients (14.8%) calculi of the urinary tract. No urinary tract abnormalities-especially no vesicoureteral reflux (VUR) or stenosis-were detected during follow-up ultrasound examination. In two children, a preoperatively known hydronephrosis decreased after CPP.

CONCLUSION

CPP is a novel technique that yields excellent results concerning continence. In contrast to other forms of rectosigmoid urinary diversion, functional separation of defecation and urination can be achieved in most patients.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

Exstrophy Bladder - Reconstruction or Diversion for the Underprivileged

The surgical techniques for management of bladder exstrophy epispadias complex have evolved from staged reconstruction, complete primary repair to radical mobilization. Post-operative complications add to the multiplicity of surgical procedures at each step. The end results are variable with many achieving continence rates of 85-89% only after bladder augmentation and clean intermittent catheterization. The situation is further complicated in resource-poor settings, where illiteracy and poverty are the driving factors for choosing a single operative procedure for creation of low pressure reservoir aiming at upper tract preservation and good primary continence. Thus, primary urinary diversion should be offered as a surgical option to patients with limited access to health care facilities. Yogesh's cystorectostomy is a modification of Heitz-Boyer-Hovelacque procedure, wherein the bladder plate is directly anastomosed to the recto-sigmoid pouch, without mobilizing the ureters from their original location. The short-term follow-ups are encouraging with all achieving total urinary continence over the ensuing months. The upper tract functions are well preserved, along with huge parental and patient satisfaction and overall improvement in the quality of life.

Long-term fate of the upper tracts following complete primary repair of bladder exstrophy

INTRODUCTION

Complete primary repair of bladder exstrophy (CPRE) is widely used for classic bladder exstrophy (CBE) closure. Long-term renal function with or without dilation in these patients is poorly characterized and may be impacted by bladder storage parameters or recurrent urinary tract infections (UTIs).

OBJECTIVE

We sought to assess our long-term experience with CPRE and investigate factors that may influence upper-tract deterioration.

STUDY DESIGN

A retrospective review of patients at our institution with CBE undergoing CPRE from 1990 to 2015 was performed. Patients were considered included if age at the last renal ultrasound was at least 5 years. Renal imaging and renal function were reviewed. The Society of Fetal Urology (SFU) and Upper Tract Dilation (UTD) grades were retrospectively assigned to all available ultrasounds with hydronephrosis (HN). Additionally, outcomes related to vesicoureteral reflux and lower urinary tract function were assessed. Descriptive and comparative statistical analyses were performed to assess factors influencing HN and renal function at follow-up.

RESULTS

Thirty patients (57% male) had a median follow-up of 9.7 (3.9-22.3) years. The table shows the HN status and grade for the entire group, stratified by gender, continence, and surgical reconstruction in. The mean creatinine was 0.50 mg/dL (0.2-1.0) and the mean estimated glomerular filtration rate (eGFR) was 106.8 mL/min/1.73 m². No patient had greater than stage 2 chronic kidney disease. Male gender was associated with worse renal outcomes, including overall rate of HN (p < 0.001), severity of HN (p = 0.004) and worse eGFR (p = 0.05). Lower tract reconstruction, urodynamic parameters, and continence were not associated with differences in upper-tract outcomes. Ureteral reimplantation was performed in 22 patients (73%) at a mean age of 22 months for indications of persistent VUR (10), worsening HN (1), or recurrent UTI (11).

DISCUSSION

HN is common following CPRE, although severe HN is seen infrequently. Overall long-term renal outcomes are similar to those of other techniques presented in the literature. However, male gender portends a higher risk for long-term upper-tract deterioration as measured by HN and eGFR. Ureteral reimplantation and the status of the lower urinary tract were not associated with differences in upper-tract outcomes.

CONCLUSIONS

Prospective, standardized approaches to characterize upper-tract outcomes are needed to follow children with bladder exstrophy into adulthood. We believe higher-risk patients should be assessed early and managed more aggressively with attention paid towards accurately assessing renal function and lower tract anatomy.

Carcinoma arising in enteric diversion or rectal neobladder for bladder exstrophy

Bladder exstrophy is a rare malformation. Ureteral diversion, such as ureterosigmoidostomy or a neorectal bladder, has been described. When the patients reach adulthood, cancer may arise in these reconstructions. Our aim was to perform a systematic review (all languages) of the published literature on neoplasia after urinary diversion and suggested management in cases of cancer. PubMed and Cochrane library were searched for relevant articles published within the last 20 years. All identified articles were reviewed for inclusion. Carcinoma occurring in the bladder and unreconstructed exstrophy were excluded. Out of 47 articles found, 12 matched our search criteria. The outcomes of 23 patients (including 2 from the authors' institution) were reported. Twenty-two patients with adenocarcinoma and 1 with carcinoid tumour were identified. Median age at urinary diversion was 3 (range 1-13) years. There were 20 ureterosigmoidostomies and 2 neorectal bladders. Cancer was diagnosed subsequently at a median of 31 (range 5-55) years after urinary diversion still in place (n = 18) or 21 years (range 1-30) after incomplete excision of ureteric stump when re-diverted (n = 5). The long-term outcomes of 15 patients were available. Ten died due to colorectal adenocarcinoma, and 5 were disease-free at 3 years. Patients with enteric diversion for bladder exstrophy, including those with subsequent reconstruction, are at risk of adenocarcinoma during adulthood. It is important to provide adequate surveillance. If lesions suggestive of carcinoma are seen, complete excision of the receptive bowel and urinary diversion are mandatory.

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.

Preservation of renal function in the modern staged repair of classic bladder exstrophy

OBJECTIVE

To compare the estimated glomerular filtration rate (eGFR) in bladder exstrophy patients with published normative GFR estimates.

PATIENTS AND METHODS

eGFR was calculated using the Schwartz formula at three timepoints, with mean eGFR at each timepoint compared to normative values.

RESULTS

At primary closure (n = 53) the mean eGFR (ml/min/1.73 m(2)) in exstrophy patients was similar to norms at 0-7 days (exstrophy vs norm: 42.5 vs 40.6, p > 0.05) and after 2 years of age (108.8 vs 133, p > 0.05). However, the mean eGFR in exstrophy patients was significantly lower than norms between 8 days (44.8 vs 65.8, p < 0.0001) and 2 years of life (68 vs 95.7, p = 0.01). At bladder neck reconstruction (n = 13) no statistically significant difference existed between the exstrophy and normative eGFR values (137.1 vs 133, p > 0.05). Similarly, among 27 patients with at least 1 year follow-up after bladder neck reconstruction, the mean exstrophy eGFR was no worse or higher than normative values (2-12 years: 124.5 vs 133, p > 0.05; males ≥13 years 175.6 vs 140, p = 0.04; females ≥13 years 128.8 vs 126, p > 0.05).

CONCLUSION

The staged reconstruction of exstrophy does not appear to negatively impact renal function in most patients. As eGFR detects only significant changes, surgical reconstruction may still cause more subtle renal damage.

Exstrophy epispadias complex- Issues beyond the initial repair

Despite advances in the management of exstrophy epispadias complex (EEC), the quality of life of these patients is far from good. The post-operative period is complicated by numerous and variable events - infection, dehiscence, upper tract dilatation with deterioration, fistulas, stone formation and incontinence to name a few of the major complications. Redo surgery for bladder closure, bladder neck reconstruction, epispadias repair and closure of fistulas are frequently required. The current focus is on limiting the frequency and morbidity of the reconstructive procedures. A successful initial closure and early satisfactory cosmetic and functional results are gratifying for the family and the health care team, but this is only the beginning of the lifelong care necessary for bladder exstrophy (BE) patients. In this article, the long-term outcome of various treatment options and the continent procedures in BE has been reviewed, tracing the journey of these patients into adolescence and adulthood.

Half century of followup after ureterosigmoidostomy performed in early childhood

PURPOSE

We studied clinical outcomes, especially regarding colorectal adenocarcinoma, in patients who underwent ureterosigmoidostomy in early childhood between 1944 and 1961.

MATERIALS AND METHODS

A total of 25 consecutive patients underwent ureterosigmoidostomy at a mean age of 3.1 years. The most common indication for ureterosigmoidostomy was bladder exstrophy-epispadias complex. The study period ended in 2010. Patient files were retrospectively evaluated, personal telephone interviews were performed and colorectal histology was reevaluated. One girl who died 4 days postoperatively was excluded.

RESULTS

Of the 24 patients 17 were alive in 2010 with a mean age of 59 years (range 48 to 67), and 2 still had a functioning ureterosigmoidostomy. A total of 20 patients with a mean age of 33 years had undergone re-diversion at a mean of 30 years postoperatively. Invasive colorectal adenocarcinoma developed in 7 patients and colorectal adenocarcinoma in situ in 1. Five patients died due to generalized colorectal adenocarcinoma. Mean time from ureterosigmoidostomy to diagnosis of invasive colorectal adenocarcinoma was 38 years (range 23 to 55). Three cases were diagnosed at 1, 21 and 25 years after re-diversion. One patient with colorectal adenocarcinoma in situ was 22 years old at polyp resection, which was 20 years after re-diversion. A carcinoid tumor developed in 1 patient. Of the 7 cases of invasive colorectal adenocarcinoma 6 were low differentiated.

CONCLUSIONS

After a half century of followup in 25 individuals undergoing ureterosigmoidostomy during childhood 17 were still alive and 20 had undergone re-diversion. Compared to the general Swedish population, the risk of colorectal adenocarcinoma was increased 42 times and the incidence of low differentiation was extremely high.

[Secondary malignancies in urinary diversions]

In contrast to ureterosigmoidostomy no reliable clinical data exist for tumor risk in different forms of urinary diversion using isolated intestinal segments.In 44 German urological departments, operation frequencies, indications, patient age, and operation dates of the different forms of urinary diversion, operated between 1970 and 2007, could be registered. The secondary tumors up to 2009 were registered as well and related to the numbers of the different forms of urinary diversions resulting in tumor prevalences.In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (22-fold) and cystoplasty (13-fold) is significantly higher than in other continent forms of urinary diversion such as neobladders or pouches (p<0.0001). The difference between ureterosigmoidostomy and cystoplasty is not significant, nor is the difference between ileocecal pouches (0.14%) and ileal neobladders (0.05%) (p=0.46). The tumor risk in ileocecal (1.26%) and colonic neobladders (1.43%) is significantly higher (p=0.0001) than in ileal neobladders (0.5%). Of the 16 tumors that occurred following ureterosigmoidostomy, 16 (94%) developed directly at the ureterocolonic borderline in contrast to only 50% following urinary diversions via isolated intestinal segments.From postoperative year 5 regular endoscopic controls of ureterosigmoidostomies, cystoplasties, and orthotopic (ileo-)colonic neobladders are necessary. In ileocecal pouches, regular endoscopy is necessary at least in the presence of symptoms or should be performed routinely at greater intervals. Following neobladders or conduits, only urethroscopies for urethral recurrence are necessary.

Urinary diversion in early childhood: indications and outcomes in the exstrophy patients

OBJECTIVE

To evaluate indications and applicability of continent and incontinent urinary diversion (CUD and IUD, respectively) in early childhood in patients with classic bladder exstrophy (CBE).

METHODS

Using an institutionally approved exstrophy database, patients with CBE born after 1980 who underwent CUD or IUD by 2 surgeons within the first 5 years of life were identified. All aspects of their care and clinical outcomes were studied.

RESULTS

In the CUD group (n = 14), only 21% had successful primary closure. Indications were desire to be dry (7), persistent hydronephrosis (4), urinary tract infections (UTIs) (1), repeat CUD (1), and inaccessible proper follow-up (1). Three patients had neobladder creation, 10 had bladder augmentation with continent stomas, and 2 underwent ureterosigmoidostomy. Currently, all patients are dry with clean intermittent catheterization (CIC). In the IUD group (n = 5), only 1 had successful primary closure. In addition to small, noncontractile bladders, the indications for IUD were severe hydronephrosis (2), recurrent UTIs (2), and noncompliance with catheterization (1). Four patients were re-diverted to CUD after a mean of 9.4 years and 1 has colon conduit. All are socially dry via catheterization. There was no case of renal function loss or malignant transformation.

CONCLUSION

The need for early diversion in CBE is primarily driven by upper tract changes after secondary closure and social factors. Urinary diversion can be safe in younger children with a favorable continence outcome.

[Tumors following urinary diversions. Results of a multicenter study]

BACKGROUND

The risk estimation of secondary tumors after different types of urinary diversion with intestinal segments has as yet been possible only for ureterosigmoidostomy.

METHOD

We analyzed the operative records of 44 German clinics for urinary diversions performed from 1970 to 2007 and registered all reported secondary tumors up to 2009.

RESULTS

In 17,758 urinary diversions 32 secondary tumors occurred. The tumor risk in ureterosigmoidostomy (2.58%) and cystoplasty (1.58%) is significantly higher than in other continent forms of urinary diversion (p<0.0001). The risk in orthotopic (ileo)colonic neobladders (1.29%) is significantly higher (p=0.0001) than in ileal neobladders (0.05%). The difference between ileocecal pouches (0.14%) and ileal neobladders is not significant (p=0.46).

CONCLUSION

Ureterosigmoidostomies, cystoplasties, and orthotopic (ileo)colonic neobladders necessitate regular endoscopic evaluation from at least the fifth postoperative year. After ileal neobladders, conduits, and catheterizable ileocecal pouches regular routine endoscopy is not imperative.

Continent urinary diversion in the epispadias-exstrophy complex

Despite improvements in modern surgical reconstructive techniques, many patients with epispadias-exstrophy continue to experience urinary incontinence. Continent diversion is commonly performed to achieve urinary continence and improve quality of life. In this work we describe the population that can be considered for continent urinary diversion, consider the benefits and implications of concurrent augmentation and bladder neck closure, and review recent literature regarding continence outcomes and common complications. Even in this complex patient population, urinary continence can be reliably achieved by bladder augmentation and the use of intermittent catheterization via a catheterizable cutaneous stoma with or without closure of the bladder neck.

Issues with the external and internal genitalia in postpubertal females born with classic bladder exstrophy: a surgical series

STUDY OBJECTIVE

To report our experience with surgical management of gynecological issues in postpubertal female patients born with classic bladder exstrophy (BE).

DESIGN

Retrospective review of clinical charts.

SETTING

Tertiary pediatric urology unit.

PARTICIPANTS

16 postpubertal female BE patients.

INTERVENTIONS

Cosmetic surgery to the external genitalia, widening of vaginal introitus, and treatment of pelvic organ prolapse.

MAIN OUTCOME MEASURES

patient satisfaction and additional gynecological problems during follow-up.

RESULTS

Eight cases (14-43 years old) underwent cosmetic procedures. All resulted in improved cosmesis, but one case complained of reduced erogenous sensitivity after clitoridoplasty. Five cases (17-20 years old) underwent widening of the vaginal introitus. The modification was as short as possible to avoid any foreshortening of the dorsal vaginal wall. Three cases 33-45 years old presented with pelvic organ prolapse. All were sexually active. One had already given birth. All the three had previously been submitted elsewhere to a posterior vaginal cutback and one to hysterectomy. Two are still awaiting further treatment due to recurrent prolapse.

CONCLUSION

Female BE patients can seek advice to improve the appearance of the external genitalia at any ages. Clitoridoplasty should be considered carefully, because it may harm erogenous sensitivity. Problems with the vaginal introitus typically present at around 20 years of age, probably when BE patients become sexually active. Opening too widely the introitus can cause a foreshortening of the posterior vaginal wall, predisposing to pelvic organ prolapse. Treatment of pelvic organ prolapse is difficult.