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Fahiem-Ul-Hassan M, Jadhav V, Hamid R, Mufti G, Munianjanappa N, Saroja M. Rectus Muscle Flap-augmented Closures in Wide-gap Exstrophy Bladder. Afr J Paediatr Surg 2024; 21:263-266. [PMID: 39279620 DOI: 10.4103/ajps.ajps_142_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/01/2024] [Indexed: 09/18/2024] Open
Abstract
BACKGROUND Wound dehiscence is one of the main complications in complete primary repair of exstrophy (CPRE). In our pediatric urology unit, we have switched to the use of inferior epigastric artery based rectus abdominis flap cover for abdominal wall closure in addition to measures like osteotomy and postoperative hip spica. AIM to assess the efficacy of Recus abdominis flap in prevenion of wound dehisence. METHODS This study was conducted from June 2014 to June 2021 comparing two groups of the patients; group I consisted of thirty patients of CPRE with rectus flap repair of abdominal wall (CPRE-RF) and group II consisted of thirty patients with CPRE without rectus flap. Clinical and surgical details, including the outcome with regards to wound dehiscence and continence, were recorded. RESULTS The mean age of the patients in CPRE-RF was 5 months and that with only CPRE was 4.6 months. Mean pubic diastasis in Group l was 4.8± 1.07 cm and that of Group II was 4.6±1.3 cm. None of the patients in CPRE-RF had wound dehiscence or bladder prolapse while as 6 patients in CPRE alone had wound dehiscence and 1 had bladder prolapse. This difference was statistically significant. Primary bladder continence was achieved in 4 patients in CPRE-RF and 3 patients in CPRE group. Hypospadias had almost similar occurrence in the two groups. One patient in each group had bladder neck fistula. CONCLUSION Use of rectus muscle flap in complete Primary Repair ofExtrophy bladder helps in prevention of wound dehiscence and contributes in achievement of final goal of continence in wide gap pubic diatasis.
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Affiliation(s)
- Mir Fahiem-Ul-Hassan
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Begaluru, Karnataka, India
| | - Vinay Jadhav
- Department of Pediatric Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Raashid Hamid
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Begaluru, Karnataka, India
| | - Gowhar Mufti
- Department of Pediatric Surgery, Indira Gandhi Institute of Child Health, Begaluru, Karnataka, India
| | - Narendrababu Munianjanappa
- Department of Pediatric Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Murali Saroja
- Department of Pediatric Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Hammouda HM, Shahat AA, Oyoun NA, Safwat AS, Elderwy AA, Elgammal MA. Long term evaluation of continence after complete primary bladder exstrophy repair. J Pediatr Urol 2023; 19:696.e1-696.e6. [PMID: 37607850 DOI: 10.1016/j.jpurol.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 07/07/2023] [Accepted: 08/01/2023] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Continence after bladder exstrophy (BE) repair remains a major debatable challenge to pediatric urologists, together with the lack of standard definitions and long-term results in large series. OBJECTIVE We assessed the long-term urinary continence in 142 toilet-trained cases after one (1-) stage of complete primary repair of bladder exstrophy (CPRE) and consequent procedures to achieve this goal in a single tertiary referral center. STUDY DESIGN The current retrospective study included 123 boys and 19 girls with BE that were repaired by (1-) stage CPRE. The Mean age at (BE) repair was 9.5 ± 2.6 weeks. Complete penile disassembly (CPD) was used for epispadias repair in 42 (34.1%) and modified Cantwell-Ransley repair (MCR) was used in 81 (65.9%) boys. Bilateral anterior transverse innominate osteotomies (ATIO) were applied in all. Urinary continence was expressed in terms of the dry interval (DI). Continence procedures were afforded if CPRE failed to achieve DI ≥ 3 h (hrs.), those were in the form of endoscopic bladder neck injection (BNI), bladder neck reconstruction (BNR), and bladder neck closure (BNC) with catheterizable stoma. RESULTS The mean age at follow up was 12.1 ± 5.2 years. DI ≥ 3 h was gained in 23 (16.2%) after CPRE alone, while complementary post-CPRE continence procedures were required to reach this goal in the remaining patients. Deflux injection was reported in 10 (7%), CIC in 8 (5.6%), BNR in 32 (22.5), and BNC with catheterizable stoma alone in 37 (26.1%), or with Charleston pouch in 32 (22.5%). DISCUSSION We think that ≥3 h DI with voiding represents an appropriate definition of continence after BE repair. According to the results in the current series, we think that successful anatomical closure of BE is achievable, but the functional outcome in terms of continence and its evaluation is tricky. Results of continence were reported to change with age of the child, and it is difficult to evaluate both before toilet training age and long-term follow up. CONCLUSIONS Long-term follow up of CPRE with bilateral ATIO alone or with BNI results in ≥3 h DI in a few cases; BNR after CPRE can provide a good chance for continence; otherwise, BNC with catheterizable stoma is a valid option.
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Affiliation(s)
- Hisham M Hammouda
- Urology Department Pediatric Urology Division, Assiut University, Assiut, Egypt.
| | - Ahmed A Shahat
- Urology Department Pediatric Urology Division, Assiut University, Assiut, Egypt
| | - Nariman Abol Oyoun
- Urology Department Pediatric Orthopedic Division, Orthopedic and Traumatology Department, Assiut University, Assiut, Egypt
| | - Ahmed S Safwat
- Urology Department Pediatric Urology Division, Assiut University, Assiut, Egypt
| | - Ahmed A Elderwy
- Urology Department Pediatric Urology Division, Assiut University, Assiut, Egypt
| | - Mohamed A Elgammal
- Urology Department Pediatric Urology Division, Assiut University, Assiut, Egypt
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Esmaeilizadeh AH, Ebrahimisaraj G, Sarafi M, Rouzrokh M, Mohajerzadeh L, Ghoroubi J, Tabari AK, Ebrahimian M. The outcome and complications of modern staged repair surgery in newborns with classic bladder exstrophy in different genders: A retrospective study. Birth Defects Res 2023; 115:1469-1474. [PMID: 37507850 DOI: 10.1002/bdr2.2228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/20/2023] [Accepted: 07/16/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Classic bladder exstrophy (CBE) is a rare anterior midline birth defect that remains a challenge for pediatric surgeons. Despite multiple reconstructive methods, outcomes vary widely in various reports. This study aims to compare the success rate and complications of modern staged repair of exstrophy (MSRE) in each gender and compare together. METHODS This retrospective cross-sectional study included cases of CBE between 2010 and 2020 that underwent MSRE. Short-term follow-up results, including incontinence rate, vesicoureteral reflux (VUR), urinary infections, deformed genitalia, and so on, were measured in each gender, and their differences were reported. RESULTS Among the 40 newborns with CBE who underwent MSRE, 25 (62.5%) were boys, while the others had non-male genitalia. The rates of incontinence, VUR, dehiscence, and fistulas did not differ significantly between genders. However, chronic urinary tract infections (UTIs) were more frequent in girls, and boys were more likely to have malformed genitalia (p < .05). CONCLUSION Our findings indicate a similar rate of complications in each gender. However, chronic UTIs and external genitalia deformities were significantly more common in girls and boys, respectively. Further large-sized controlled trials may be needed to corroborate these findings.
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Affiliation(s)
- Amin Haj Esmaeilizadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Ebrahimisaraj
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Sarafi
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Rouzrokh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leily Mohajerzadeh
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Javad Ghoroubi
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ahmad Khaleghnejad Tabari
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Manoochehr Ebrahimian
- Pediatric Surgery Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Harris TGW, Crigger CB, Sholklapper TN, Haffar A, Yang R, Redett RJ, Gearhart JP. The impact of repeated bladder surgery on successful bladder neck closure in classic bladder exstrophy: The role of mucosal violations. J Pediatr Urol 2023:S1477-5131(23)00151-1. [PMID: 37149474 DOI: 10.1016/j.jpurol.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Restoration of genitourinary anatomy with functional urinary continence is the reconstruction aim is the exstrophy-epispadias complex (EEC). In patients who do not achieve urinary continence or those who are not a candidate for bladder neck reconstruction (BNR), bladder neck closure (BNC) is considered. Interposing layers including human acellular dermis (HAD) and pedicled adipose tissue are routinely placed between the transected bladder neck and distal urethral stump to reinforce the BNC and minimize failure due to fistula development from the bladder. OBJECTIVE The aim of this study was to review classic bladder exstrophy (CBE) patients who underwent BNC to identify predictors of BNC failure. Specifically, we hypothesize that increased operations on the bladder urothelium leads to a higher rate of urinary fistula. STUDY DESIGN CBE patients who underwent BNC were reviewed for predictors of failed BNC which was defined as bladder fistula development. Predictors included prior osteotomy, interposing tissue layer use and number of previous bladder mucosal violations (MV). A MV was defined as a procedure when the bladder mucosa was opened or closed for: exstrophy closure(s), BNR, augmentation cystoplasty or ureteral re-implantation. Predictors were evaluated using multivariate logistic regression. RESULTS A total of 192 patients underwent BNC of which 23 failed. Patients were more likely to develop a fistula with a wider pubic diastasis at time of primary exstrophy closure (4.4 vs 4.0 cm, p=0.0016), have failed exstrophy closure (p=0.0084), or have 3 or more MVs before BNC (p=0.0002). Kaplan-Meier analysis of fistula-free survival after BNC, demonstrated an increased fistula rate with additional MVs (p=0.0004, Figure 1). MVs remained significant on multivariate logistic regression analysis with a per-violation odds ratio of 5.1 (p<0.0001). Of the 23 failed BNC's, 16 were surgically closed including 9 using a pedicled rectus abdominis muscle flap which was secured to the bladder and pelvic floor. CONCLUSION This study conceptualized MVs and their role in bladder viability. Increased MVs confer an increased risk of failed BNC. When considering BNC, CBE patients with 3 or more prior MVs may benefit from a pedicled muscle flap, in addition to HAD and pedicled adipose tissue, to prevent fistula development by providing wellvascularized coverage to further reinforce the BNC.
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Affiliation(s)
- Thomas G W Harris
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chad B Crigger
- James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tamir N Sholklapper
- James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmad Haffar
- James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin Yang
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Gearhart
- James Buchanan Brady Urological Institute, Jeffs Division of Pediatric Urology, Douglas A. Canning M.D. Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Kanabolo D, Cain M, Brown M, Ahn J, Fernandez N, Halbach S, Shnorhavorian M, Merguerian P. Long term renal outcome and risk of elevated blood pressure in children undergoing complete primary repair of bladder exstrophy (CPRE). J Pediatr Urol 2023:S1477-5131(23)00096-7. [PMID: 37002021 DOI: 10.1016/j.jpurol.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Since the initiation of staged reconstruction for bladder exstrophy (BE), hypertension has been a known complication of the procedure. Hypertension is a well-established risk factor for chronic kidney disease (CKD) progression and associated with cardiovascular/cerebrovascular morbidity and mortality. Few studies exist evaluating the risk of developing hypertension among patients with bladder exstrophy who underwent CPRE. We hypothesized that long-term blood pressure levels may be elevated in males vs females, and may be correlated with presence of hydronephrosis, bladder neck reconstruction, or continence status. OBJECTIVE We sought to revisit our long-term experience with CPRE and determine factors associated with incidence of elevated blood pressures. METHODS We reviewed all BE patients undergoing CPRE at our institution from 1999 to 2019. Patients were considered eligible for inclusion if last renal ultrasound was obtained at least 5 years after repair. Upper tract outcomes based on imaging, history of pyelonephritis and renal function tests measured by serum creatinine and estimated glomerular filtration rate (eGFR, Schwartz formula) were reviewed. Systolic/diastolic blood pressures (SBP/DBP) from all encounters were captured. All blood pressure values were age adjusted by percentile. RESULTS A total of 36 patients were considered eligible for review. Median follow-up of this cohort was 10.01 (5.16-21.47) years. The mean creatinine for the patients available was 0.58 mg/dL (SD = 0.20), at mean age of 8.90 years Neither SBP or DBP were significantly elevated in males vs females, but had lower odds of elevation >90th percentile for those with higher eGFR, lower renal length, and reimplantation. Pyelonephritis incidence was 38% (n = 14) with first episode at mean age of 8.8 years, and mean of 3.7 episodes per patient. DISCUSSION At long term follow up, blood pressures following CPRE were not significantly elevated, despite the relatively frequent occurrence of CKD, and hydronephrosis. Male gender does appear to suggest higher risk for long-term deterioration in this regard. Higher eGFR, higher renal length, and presence of ureteral reimplantation were associated with lower likelihood of systolic/diastolic blood pressure elevation. Continence status and bladder neck reconstruction were not associated with likelihood of blood pressure elevation. CONCLUSIONS Blood pressure and upper-tract outcomes for patients undergoing CPRE at birth are positive for the majority of patients. To avoid complications from hypertension, patients should be closely evaluated as the risks associated with elevated blood pressure are significant. Ultimately, larger-scale prospective and multi-institutional studies are further needed to characterize risks of hypertension in this complex patient population.
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Affiliation(s)
- Diboro Kanabolo
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.
| | - Mark Cain
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Marshall Brown
- Seattle Children's Hospital, Biostatistics, Epidemiology and Analytics in Research Core
| | - Jennifer Ahn
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Nicolas Fernandez
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Susan Halbach
- Seattle Children's Hospital, Section of Pediatric Nephrology, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
| | - Paul Merguerian
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA; Seattle Children's Hospital, Section of Pediatric Urology, Seattle, WA, USA
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Demirkan H, Kuzdan MÖ. Bladder augmentation in exstrophy vesicae: Long-term results of a single experienced center. Birth Defects Res 2022; 114:645-651. [PMID: 35703116 DOI: 10.1002/bdr2.2056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/02/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND In this study, we present our long-term treatment outcomes of bladder augmentation (BA), bladder neck closure, and Mitrofanoff clean intermittent catheterization (CIC) in managing bladder exstrophy (BE). METHODS This was a retrospective medical records' review of 33 children diagnosed as born with BE, followed up at a tertiary pediatric urology clinic from 1988 to 2020. Outcomes such as surgical interventions, presence of renal calculi, hydronephrosis, and continence status were extracted. RESULTS The median follow-up of the group was 18.2 (4-26) years. Urinary system stones developed in 10 (30.3%) cases about 8.9 years after BA. Stone development was two times more common in patients who underwent colocystoplasty (33.3%) than those who underwent ileocytoplasty (16.6%). The state of continence of the group was satisfactory in 26 (78.7%; excellent in 23; good in 3 cases) and unsatisfactory (wet) in 6 (18.1%) cases. At the last visit, ultrasonography revealed no hydronephrosis in 23 (69.6%) patients, and the voiding cystourethrogram demonstrated low-grade vesicoureteral reflux in 10 (30.3%) and high-grade vesicoureteral reflux in 2 (6%) patients. CONCLUSIONS An elaborated plan of surgical reconstruction for classic BE can lead to satisfactory long-term urinary continence in most patients. Ultimate predictors of outcome in BE repair are difficult to ascertain. Consistently, BA, bladder neck closure, and Mitrofanoff CIC continue to stand out at a critical point in the management of those patients with classic BE. Our study demonstrated that augmentation is required to achieve acceptable dryness with high satisfactory dryness rates in BE.
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Affiliation(s)
- Hasan Demirkan
- Department of Pediatric Urology, Kanuni Sultan Süleyman Training and Research Hospital/Health Sciences University, İstanbul, Turkey
| | - Mehmet Özgür Kuzdan
- Department of Pediatric Surgery, Başakşehir Çam and Sakura City Hospital/Health Sciences University, İstanbul, Turkey
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Jarosz SL, Weaver JK, Weiss DA, Borer JG, Kryger JV, Canning DA, Groth TW, Lee T, Shukla AR, Mitchell ME, Roth EB. Bilateral ureteral reimplantation at complete primary repair of exstrophy: Post-operative outcomes. J Pediatr Urol 2022; 18:37.e1-37.e5. [PMID: 34774430 DOI: 10.1016/j.jpurol.2021.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND STUDY OBJECTIVE The value of bilateral ureteral reimplant (BUR) at the time of complete primary repair of bladder exstrophy (CPRE) has been suggested, however, outcomes are poorly characterized in current medical literature. We hypothesize that BUR at time of CPRE will decrease the rate of recurrent pyelonephritis, post-operative vesicoureteral reflux (VUR), and the need for subsequent ureteral surgery. STUDY DESIGN We analyzed 64 consecutive patients with a diagnosis of classic bladder exstrophy (BE) who underwent CPRE at three institutions from 2013 to 2019.15 patients underwent cephalotrigonal BUR-CPRE and 49 patients underwent CPRE alone. Our primary outcome was >1 episode of pyelonephritis as documented in the medical record. Secondary outcomes were persistent vesicoureteral reflux (VUR), with a sub-analysis of number of refluxing renal units and presence of dilating VUR, and the need for subsequent ureteral surgery. Descriptive statistics in addition to standard, two tailed univariate statistics, were used to compare the groups where appropriate. RESULTS BUR-CPRE was associated with a significant decrease in the rates of post-operative VUR, number of refluxing renal units, and need for subsequent ureteral surgery (p = 0.002, p = 0.001, and p = 0.048 respectively). There was a reduction in the rates of recurrent pyelonephritis and dilating reflux in patients undergoing BUR-CPRE, though it did not reach significance. Female gender was significantly associated with recurrent pyelonephritis regardless of BUR-CPRE status (p = 0.005). There were no reports of distal ureteral obstruction or other complications following BUR-CPRE. The mean post-operative follow up for the BUR-CPRE group was 46.33 (10.26) months vs. 53.76 (26.05) months for CPRE (p = 0.11). DISCUSSION Recurrent pyelonephritis following bladder closure in patients with BE is a well-documented surgical complication, with centers performing CPRE reporting rates of post-operative pyelonephritis from 22 to 50%. Our series demonstrates similar efficacy of BUR-CPRE compared to other contemporary series and provides additional detail about need for subsequent ureteral surgeries and increased long term follow-up of these complex patients. Limitations of the study include male predominance of the cohort and lack of randomization of BUR-CPRE. CONCLUSIONS BUR-CPRE decreases postoperative VUR and the need for additional ureteral surgery in select BE patients; it should be considered when technically feasible. While results continue to suggest a trend toward decreased recurrent pyelonephritis and dilating reflux, further longitudinal follow-up in our cohort will be needed.
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Affiliation(s)
- Susan L Jarosz
- Department of Urology, Pediatric Urology Division, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI, 53226, USA
| | - John K Weaver
- Department of Urology, Pediatric Urology Division, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Dana A Weiss
- Department of Urology, Pediatric Urology Division, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Joseph G Borer
- Department of Urology, Pediatric Urology Division, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Hunnewell 3, Boston, MA, 02115, USA
| | - John V Kryger
- Department of Urology, Pediatric Urology Division, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI, 53226, USA
| | - Douglas A Canning
- Department of Urology, Pediatric Urology Division, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Travis W Groth
- Department of Urology, Pediatric Urology Division, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI, 53226, USA
| | - Ted Lee
- Department of Urology, Pediatric Urology Division, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Hunnewell 3, Boston, MA, 02115, USA
| | - Aseem R Shukla
- Department of Urology, Pediatric Urology Division, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Michael E Mitchell
- Department of Urology, Pediatric Urology Division, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI, 53226, USA
| | - Elizabeth B Roth
- Department of Urology, Pediatric Urology Division, Medical College of Wisconsin, Children's Wisconsin, 8915 W. Connell Court, Milwaukee, WI, 53226, USA.
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Canalichio KL, Ahn J, Hwang C, Amies AM, Merguerian P, Shnorhavorian M. Long-term urological and gynecological outcomes following complete primary repair in females with bladder exstrophy. J Pediatr Urol 2021; 17:608.e1-608.e8. [PMID: 34391690 DOI: 10.1016/j.jpurol.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/30/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Long-term continence outcomes in patients undergoing complete primary repair of exstrophy (CPRE) have shown that a subset of patients do not achieve continence until after puberty. We aim to update the continence outcomes as well as describe gynecological outcomes for females having undergone CPRE. MATERIALS AND METHODS This was a retrospective review between 1989 and 2019 at a single institution. Inclusion criteria were females with classic bladder exstrophy who underwent CPRE. Exclusion criteria were variant diagnoses and age <4 years. Continence was defined as dry for ≥3 h (volitional voiding or clean intermittent catheterization (CIC)). Partial continence was defined as minor stress incontinence or enuresis. Vaginal stenosis was evaluated in post-pubertal patients. RESULTS Eighteen patients met inclusion criteria. Median age at last follow-up was 15.9 years (IQR 13.1, 18.4). All patients underwent primary closure <30 days of life (n = 18). Subsequent procedures included bladder augmentation (n = 4), continent catheterizable channel (n = 7), bladder neck injections (n = 12) and bladder neck reconstruction (n = 12). Continence and partial continence were achieved in 6/18 (33.3%) and 9/18 (50.0%), respectively, with mean 3.2 ± 2.5 continence procedures at 9.6 years (IQR 7.3, 15.2). Volitional voiding was seen in 11/18 (61.1%) and 7/18 (38.9%) performed CIC, with no significant difference in continence. Mean bladder capacity was 199 ml ± 96 versus 90 ml ± 29 in the volitional voiding versus CIC group (P = 0.0047). Eleven women with median age of 18.0 years (IQR 15.2, 21.4) had recorded menarche: 6/11 (54.5%) patients reported painful/irregular menses, controlled with hormonal therapy. Six of 11 (54.5%) women had vaginal stenosis managed with vaginal dilation (n = 2) or vaginoplasty (n = 4). Three (27.3%) reported tampon use and penetrative intercourse. CONCLUSION Overall, the majority of women who have undergone CPRE achieved complete or partial continence, though most required additional procedures and time to attain it. Additionally, volitional voiding was achievable. Bladder capacity was significantly lower in patients dependent on CIC. Most required medical or surgical interventions for gynecologic concerns post menarche. This study underscores the unique needs of girls and young women with bladder exstrophy and further supports the importance of close long-term urologic and gynecologic management throughout development.
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Affiliation(s)
- Katie L Canalichio
- University of Louisville, 501 East Broadway Suite 270, Louisville, KY, 40202, USA; Norton Healthcare, 4123 Dutchmans Lane Suite 102, Louisville, KY, 40207, USA.
| | - Jennifer Ahn
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Catalina Hwang
- University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Anne-Marie Amies
- University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Paul Merguerian
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Margarett Shnorhavorian
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
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Impact of bilateral ureteral reimplantation at the time of complete primary repair of bladder exstrophy on reflux rates, renogram abnormalities and bladder capacity. J Pediatr Urol 2021; 17:393.e1-393.e7. [PMID: 33583747 DOI: 10.1016/j.jpurol.2021.01.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/11/2021] [Accepted: 01/15/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Bilateral ureteral reimplantation at the time of the complete primary repair of bladder exstrophy (BUR-CPRE) has been proposed and has demonstrated favorable outcomes in the past. However, the potential benefits, including prevention of vesicoureteral reflux (VUR) and renal scarring must be tempered with any risks of reimplantation, persistent VUR, and the potential for overtreatment. We aimed to determine the impact of BUR-CPRE on reflux rates, renogram findings and bladder capacity. METHODS An IRB approved registry of children treated for bladder exstrophy epispadias complex (BEEC) during a long-term international collaboration hosted in a region with high prevalence of BEEC was queried. Children undergoing primary CPRE for bladder exstrophy (BE) were identified. Surgical procedure and outcome measures nuclear medicine dimercaptosuccinic acid (DMSA) scintigraphy scans, voiding cystourethrogram (VCUG), and urodynamic study (UDS) were assessed for presence and degree of VUR, renogram abnormalities, and bladder capacity. RESULTS A total cohort of 147 patients with BEEC was queried; 52 children (37 males, 71%) underwent primary CPRE for BE between 2009 and 2019 at median age of 1.1 years (IQR 0.6-1.9 years) with median follow up 4.4 years (IQR 2.4-6.4 years). BUR-CPRE was performed in 22/52 (42%). After BUR-CPRE, children were less likely to have VUR (any VUR present in 9 of 20 with imaging (45%) compared to 23 of 26 with imaging (82%) in the CPRE alone group (p = 0.007)). VUR in the BUR-CPRE group tended to be unilateral and lower grade in comparison to the CPRE alone group. DMSA abnormalities were less common in the BUR-CPRE group (4/19 (21%) vs.12/27 (44%)), although the difference did not reach statistical significance (p = 0.1). At 4 years follow-up, the BUR-CPRE group had a larger bladder capacity (p = 0.016). DISCUSSION After BUR-CPRE, children had a lower rate of VUR, and when present, VUR was more often unilateral and lower grade compared to the CPRE alone group. Fewer numbers of children in the BUR-CPRE group depicted DMSA abnormalities. No children developed obstruction after BUR-CPRE and none have undergone repeat reimplantation. We documented a larger bladder capacity at the time of maximum follow-up available (4 years)-but further data are needed to confirm this observation. CONCLUSION BUR-CPRE decreases the incidence and severity of VUR after CPRE, but the clinical significance of this remains unclear. We are encouraged by these initial results, but since BUR-CPRE does not uniformly eliminate VUR, we continue to proceed carefully in the well selected patient.
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James Sam C, Kurian JJ, Kishore R, Arunachalam P, Sen S. Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction. J Pediatr Urol 2020; 16:836.e1-836.e8. [PMID: 33067135 DOI: 10.1016/j.jpurol.2020.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/31/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA). AIM The aim of this study is to assess the outcome of dehisced exstrophy, using a RAM flap assisted redo closure (without PBA) with concomitant or subsequent further reconstruction. MATERIALS AND METHODS This is a retrospective analysis of children who presented with dehisced exstrophy after repair in other institutions and who have undergone redo repair using RAM flap in two tertiary care centers from 2001 to 2019. The outcome of the redo closure and subsequent or concomitant further reconstruction as regards dryness, stability of the upper tracts and resolution of vesico ureteric reflux (VUR) was studied. RESULTS Fifty five children (34 boys) underwent redo exstrophy repair for dehisced exstrophy using the RAM flap. Epispadias repair was performed concomitantly in 31 boys. In 26 children (group1) of mean age 12 months further surgery was deferred while in 29 children (group 2) of mean age 69 months underwent concomitant BA. Nine group 1 children underwent BA subsequently. Ureteric reimplantation was done at the time of BA in 54 ureters, 40 into the bladder plate and rest into the bowel segment of BA. 22 ureters were not reimplanted. Bladder neck surgery including 18 bladder neck closure and Mitrofanoff port for Clean Intermittent catheterization (CIC) were done along with BA. The RAM assisted bladder closure was event free and none needed redo operation. 35/38 augmented children are dry on Mitrofanoff CIC and one unaugmented boy voids normally. The upper tracts remain stable on ultrasound and VUR has resolved in 67/76 ureters. At current follow up, after a mean period of 53 months eGFR was normal in all except 3 who had initially presented with severe hydro uretero nephrosis. CONCLUSION We present a simple and reliable method of repair of dehisced exstrophy using RAM flap with the feasibility of concomitant BA. Dryness was achieved with stable upper tracts in 36/39 children, 27 of them with a single reconstructive attempt.
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Affiliation(s)
- Cenita James Sam
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
| | - Jujju Jacob Kurian
- Department of Paediatric Surgery, Christian Medical College, Vellore, Tamilnadu, 632004, India.
| | - Ravi Kishore
- Department of Paediatric Surgery, Christian Medical College, Vellore, Tamilnadu, 632004, India.
| | - Pavai Arunachalam
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India.
| | - Sudipta Sen
- Department of Paediatric Surgery, PSG Institute of Medical Sciences and Research, Coimbatore, Tamilnadu, India
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Taskinen S, Suominen J, Mäkelä E. Development of Late Continence in Bladder Exstrophy and Epispadias Patients. Urology 2020; 144:194-197. [DOI: 10.1016/j.urology.2020.06.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022]
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Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience. Int Urol Nephrol 2020; 53:191-198. [PMID: 32980929 DOI: 10.1007/s11255-020-02648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To represent the 15 years' experience of an academic referral center for the reconstruction of bladder exstrophy-epispadias complex with a modified single-stage approach. Single-staged reconstruction techniques are commonly used for classic bladder exstrophy. However, combined bladder closure and epispadias repair have been taken into great consideration in patients with initially failed reconstruction or delayed primary closure. METHODS A total of 49 boys underwent 1-stage bladder and epispadias repair with pubic bone adaptation and without the application of pelvic osteotomy. The mean ± SD age at surgery was 5.23 ± 2.04 months. Continence and social dryness were assessed in the follow-ups with 3 months intervals for the first year and biannually thereafter. RESULTS The mean ± SD of follow-up was 127.25 ± 71.32 months. Urethrocutaneous fistula, stricture, wound infection, and hemiglans were developed in six distinct patients. However, no other major complications were noted. Three patients (6.1%) remained incontinent; while 32 (65.3%) children were socially continent and 14 (28.6%) children were waiting for toilet training. All the patients without previous failed closure were socially continent, while all incontinent patients had two failed closures in their history. No patient was rendered hypospadiac. CONCLUSION Based on the experience of this institution, the application of single-stage reconstructive techniques can lead to continence, cosmetically pleasing appearance with promising outcomes, and reduction of overall operations, hospital stay and costs in the majority of cases as compared to multiple surgical procedures.
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Di Carlo HN, Manyevitch R, Wu WJ, Maruf M, Michaud J, Friedlander D, Gearhart JP. Continence after BNR in the complete repair of bladder exstrophy (CPRE): A single institution expanded experience. J Pediatr Urol 2020; 16:433.e1-433.e6. [PMID: 32546418 DOI: 10.1016/j.jpurol.2020.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 05/04/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Several surgical methods have been used for primary repair of bladder exstrophy in the newborn. Complete primary repair of exstrophy (CPRE) aims to prevent the need for surgeries beyond the newborn period. Due to the rarity of bladder exstrophy, it has proven difficult in the past to analyze whether use of this method of closure truly does confer acceptable continence outcomes and hence minimizes the requirement for additional surgeries later in life. OBJECTIVE To describe the continence outcomes of CPRE patients who went on to receive bladder neck reconstruction (BNR), and secondarily, to compare clinical features between those patients who were able to receive undergo a BNR compared to those who were not. STUDY DESIGN An IRB approved database of 1330 exstrophy-epispadias patients was used to identify referred patients after successful CPRE for management of continued urinary incontinence. Urinary continence outcomes were assessed in those who underwent modified Young Dees Leadbetter BNR following CPRE. RESULTS Sixty-one patients were referred for treatment after successful CPRE between 1996 and 2016. None developed continence or a dry interval after primary closure. Of these, forty-two (68.9%) underwent BNR by a single surgeon at a mean age of 5.8 years (range 5-8.4). The mean bladder capacity at BNR was 147 mL (range 102-210 mL). Twenty-five (59.5%) achieved day and night continence, 7 (16.7%) gained daytime continence with nocturnal leakage, and 10 (23.8%) remain totally incontinent. Mean follow-up after BNR was 5.9 years. Combined CPRE and pelvic osteotomy were performed in 100% of patients who were continent and 75% of those who were daytime dry. No continent patient had a ureteral reimplantation before BNR, whereas 4 patients with daytime continence and nocturnal leakage and 7 patients who remained continuously incontinent did. DISCUSSION This is the largest known series of BNRs in exstrophy patients closed by CPRE. Previous smaller studies have demonstrated mild to moderate success rates of BNR after CPRE, with many patients still requiring additional continence surgeries. The present study found similar results, with additional indication that successful primary closure and use of pelvic osteotomies may correlate with enhanced continence. This study includes outcomes from a single surgeon, with a maximum length of follow up of 13 years. CONCLUSIONS CPRE alone often does not render patients continent of urine, based on the authors' referral population. However, following BNR continence rates in this subgroup were found to reach 76%. Surgeons who treat this population should keep these factors in mind when planning continence surgeries.
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Affiliation(s)
- Heather N Di Carlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Roni Manyevitch
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Wayland J Wu
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Jason Michaud
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Daniel Friedlander
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Zaman MH, Young EE, Maruf M, Hesh CA, Harris KT, Manyevitch R, Davis R, Wu WJ, Hall SA, DiCarlo H, Gearhart J. Practice patterns in classic bladder exstrophy: A global perspective. J Pediatr Urol 2020; 16:425-432. [PMID: 32299766 DOI: 10.1016/j.jpurol.2020.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 02/28/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While evaluation and management options for classic bladder exstrophy (CBE) patients are numerous and varied, little is known regarding the relative utilization of these different methods throughout the world. A large group of exstrophy surgeons practicing globally was surveyed, seeking to document their methods of care. METHODS A list of international exstrophy surgeons' email addresses was compiled using professional contacts and referral networking. An online survey was sent to each email address. Surgeons who had not performed a CBE closure within the previous 5 years were excluded. Survey questions queried the respondents' surgical practice type, years since training, and their preferred methods of preoperative evaluation, operative management, and postoperative management. Survey invitations were sent out starting in December 2014 and responses were collected for approximately 6 months. RESULTS A total of 1152 valid email addresses were invited, resulting in 293 respondents (25%) from 39 countries and every American Urological Association (AUA) section. Seventy-six were excluded, leaving 217 respondents (Table). Respondents reported a median of 17 years since finishing their surgical training (IQR 8-25 years). Practice types included pediatric urology (n = 209), general urology (n = 9), pediatric surgery (n = 59), and other practice makeup (n = 3). On subgroup analyses, there were no significant regional practice differences, with the exception of complete primary repair of exstrophy (CPRE) and oral opioid prescribing being significantly higher in North America compared to other regions. DISCUSSION Findings indicate that there may be diversity in CBE practice patterns globally. While most responding surgeons from regions outside of North America indicated modern staged repair of exstrophy (MSRE) as their preferred closure technique, a relatively equal distribution of respondents from North America selected CPRE and MSRE. A majority of North American surgeons chose performing osteotomies for both newborn and delayed closures, while an appreciable number of respondents from other regions selected never using osteotomies in their closures. Limitations to this study include a low survey response rate, particularly from surgeons outside of the United States, which may have significantly impacted the ability to draw meaningful global comparisons. CONCLUSIONS Global variation among practices of surgeons performing CBE closures may exist. The wide range of methods demonstrated by this survey suggests the need for more conclusive comparative studies to elucidate whether an optimal standard exists. Local social factors, access to surgical expertise and transportation to referral centers, and finances play a role in what constitutes the best operative approach.
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Affiliation(s)
- Mohammad H Zaman
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Ezekiel E Young
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Christopher A Hesh
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Kelly T Harris
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Roni Manyevitch
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Rachel Davis
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Wayland J Wu
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Saran A Hall
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Heather DiCarlo
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John Gearhart
- Robert D. Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institutions, Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
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Pathak P, Ring JD, Delfino KR, Dynda DI, Mathews RI. Complete primary repair of bladder exstrophy: a systematic review. J Pediatr Urol 2020; 16:149-153. [PMID: 32144016 DOI: 10.1016/j.jpurol.2020.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 01/07/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Complete primary repair of exstrophy (CPRE) was established as a method to reduce numbers of procedures for the reconstruction of bladder exstrophy (BE). Performed since 1989, some suggest it as a replacement for the staged reconstructive procedure, the gold standard. Does CPRE reduce the numbers of procedures for reconstruction of BE? METHODS Literature was reviewed from 1989 to 2016, and articles evaluating outcomes of patients undergoing CPRE, extracted. Effort was made to obtain final data from each reporting institution/group. Eleven articles meeting criteria were evaluated for qualitative systematic review. Age at initial closure, complications, additional procedures, and outcomes were evaluated to provide an overview of CPRE. RESULTS Ten groups reported BE management using the CPRE technique. 236 patients (153 boys; 72 girls; 11 unknown sex) had primary closure ranging from birth to 5.6 years. Osteotomy was favored by most in infants closed beyond the first 72 h of life along with spica cast immobilization. Three groups recommended concomitant augmentation for infants with small bladder capacities. Ureteral reimplantation was required in 58 patients with recurrent urinary tract infections resistant to prophylaxis. Hypospadias repair was required for most boys having complete penile disassembly, and most children eventually required bladder neck reconstruction (BNR) for continence. Overall, voiding without BNR was noted in 16-37% of children in the reported series. CONCLUSIONS Complete primary repair of exstrophy has been suggested as a single procedure for the management of BE. Literature review suggests most patients require multiple procedures to complete reconstruction and attain continence.
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Affiliation(s)
- Piyush Pathak
- Southern Illinois University School of Medicine, Springfield, IL, USA.
| | - Joshua D Ring
- Southern Illinois University School of Medicine, Springfield, IL, USA.
| | - Kristin R Delfino
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Danuda I Dynda
- Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Ranjiv I Mathews
- Southern Illinois University School of Medicine, Springfield, IL, USA
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Sabetkish S, Sabetkish N, Kajbafzadeh AM. Early detection of deep wound infection in bladder exstrophy and hypospadias using a novel intervention. J Wound Care 2019; 27:686-691. [PMID: 30332360 DOI: 10.12968/jowc.2018.27.10.686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To introduce a practical technique for the early detection and prompt management of a probable bladder dehiscence (BD) and glanular dehiscence (GD) in patients with bladder exstrophy epispadias complex (BEEC) and hypospadias. METHOD In this prospective study, paediatric patients with BEEC (group 1) and with proximal hypospadias (group 2) underwent body temperature measurement using a non-contact infrared radiant digital temperature measurement device in four body regions, including the surgical wound, forehead, right hand, and right foot at eight hour intervals, postoperatively. This technique was performed to detect wound temperature rises before whole body temperature rise or visible local wound skin redness, cellulitis or any sign of inflammation or wound dehiscence (WD). RESULTS A total of 24 paediatric patients were recruited. Temperature rise in the surgical wound area was discovered in two patients with BEEC. The temperature reached 39.2°C in the first case (12 days postoperative) and 39.4°C in the second case (16 days postoperative). Urinalysis, urine culture, and clean surgical wound sampling was performed and the presence of Gram-positive microorganisms was detected. Both patients were managed with intravenous imipenem and vancomycin. After changing the antibiotic regimen, wound temperature was gradually decreased to 37.2°C in the first patient by day 16, and to 36.9°C in the second patient by day 21, without rise in body temperature. Other patients in group 1 and all patients in group 2 had normal wound temperature fluctuations within the follow-up period. CONCLUSION Postoperative periodical temperature measurement by a non-contact infrared radiant digital temperature measurement device is a safe and feasible technique that has the ability to detect deep wound infection, and may prevent the occurrence of WD before any visible sign of inflammation.
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Affiliation(s)
- Shabnam Sabetkish
- Nurse; Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
| | - Nastaran Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
| | - Abdol-Mohammad Kajbafzadeh
- Professor of Pediatric Urology; Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran (IRI)
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Sack BS, Borer JG. A single-institution experience of complete primary repair of bladder exstrophy in girls: risk factors for urinary retention. J Pediatr Urol 2019; 15:262.e1-262.e6. [PMID: 31023568 DOI: 10.1016/j.jpurol.2019.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Historically after complete primary repair of exstrophy (CPRE) in girls, it had been more likely to observe urinary incontinence than retention. Following recent technical modifications of elongating the urethra and narrowing the bladder neck, the authors have observed a high rate of urinary retention in girls after CPRE. OBJECTIVE The aim was to identify factors that may be responsible for this observation by reviewing historical and current outcomes. The authors hypothesized that differences in anatomic dimensions at the time of CPRE may contribute to urinary retention. STUDY DESIGN A retrospective review of girls who underwent CPRE from December 1998 through September 2016 from a single institution was performed. Patients were deemed in retention if their clinical course was consistent with such, required a procedure to relieve urinary retention, and/or required clean intermittent catheterization. RESULTS Nineteen girls underwent CPRE during this period. In 2012, a change to delaying CPRE to approximately 2 months of age was made, and this led the authors to divide their experience into CPRE performed as a newborn (<72 h of age, 8 patients) versus delayed (>72 h, 11 patients) subgroups. There were no girls with retention in the newborn group and three (38%) girls with retention in the delayed group. In the delayed group, girls had a longer urethral plate and narrower bladder neck compared with the newborn group. Long-term outcomes greater than 9 years are available for six girls in the newborn group and two (33%) required bladder neck procedures for incontinence. None in the delayed group have required incontinence procedures; however, follow-up is limited at 25 months. DISCUSSION The absence of retention in the newborn group is concerning for the delayed group incurring a higher risk of retention after CPRE. This may be secondary to excessive compression of the urethra at the time of pubic symphysis approximation potentially leading to urethral ischemia. Different from the newborn CPRE girls, additional technical revision of CPRE, namely, elongation of the urethra and the dissection it involves and narrowing of the bladder neck, may increase the risk for retention. CONCLUSIONS The multiple factors that were identified as potential contributors to post-CPRE urinary retention should result in a cautious reevaluation of female bladder exstrophy management at the time of CPRE. The authors now create a gradual tapered transition at the bladder neck and, similar to their previous experience, a more generous (wider) bladder neck and a shorter length for urethral plate.
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Affiliation(s)
- B S Sack
- The Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - J G Borer
- The Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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Dellenmark-Blom M, Sjöström S, Abrahamsson K, Holmdahl G. Health-related quality of life among children, adolescents, and adults with bladder exstrophy-epispadias complex: a systematic review of the literature and recommendations for future research. Qual Life Res 2019; 28:1389-1412. [PMID: 30725391 DOI: 10.1007/s11136-019-02119-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of genitourinary malformations. Children risk long-term urinary and genital dysfunctions. To achieve a comprehensive understanding, this study aimed to review the literature on generic and disease-specific health-related quality of life (HRQOL) in BEEC patients, and methodologies used. METHODS A literature search was conducted in Pubmed/CINAHL/Embase/PsycINFO/Cochrane, from inception to May 2018. A meta-analysis of HRQOL in BEEC patients compared to healthy references was performed. RESULTS Twenty-one articles (published 1994-2018), describing HRQOL of children and adolescents (n = 5) and adults only (n = 5), or integrated age populations (n = 11), were identified (median sample size 24, loss to follow-up 43%, response rate 84%). Overall HRQOL was reduced in BEEC patients compared to healthy references in 4/4 studies. Impaired physical or general health in BEEC patients has been described in 9 articles, diminished mental health in 11, restricted social health in 10, and sexual health/functioning or body perception impairments in 13 articles. Urinary incontinence was the most common factor related to worse HRQOL (12 studies). In six studies, HRQOL was better than healthy norms. In eligible studies (n = 5), the pooled estimate of the effect of BEEC indicated worse HRQOL for children and adults (0 > effect sizes < 0.5). Thirty-six HRQOL assessments were used, none developed and validated for BEEC. CONCLUSIONS HRQOL in BEEC patients may be negatively impacted, particularly considering mental and social HRQOL. Sexual health/functioning or body perception impairments may be present in adolescents and adults. However, HRQOL is heterogeneously assessed and subsequent findings are differently reported. Additional research is warranted and can be improved.
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Affiliation(s)
- Michaela Dellenmark-Blom
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, 416 85, Gothenburg, Sweden. .,Department of Pediatrics, The Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 416 86, Gothenburg, Sweden.
| | - Sofia Sjöström
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, 416 85, Gothenburg, Sweden.,Department of Pediatrics, The Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 416 86, Gothenburg, Sweden
| | - Kate Abrahamsson
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, 416 85, Gothenburg, Sweden.,Department of Pediatrics, The Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 416 86, Gothenburg, Sweden
| | - Gundela Holmdahl
- Department of Pediatric Surgery, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, 416 85, Gothenburg, Sweden.,Department of Pediatrics, The Queen Silvia Children's Hospital, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 416 86, Gothenburg, Sweden
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One-stage combined delayed bladder closure with Kelly radical soft-tissue mobilization in bladder exstrophy: preliminary results. J Pediatr Urol 2018; 14:558-564. [PMID: 30126745 DOI: 10.1016/j.jpurol.2018.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/10/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The radical soft-tissue mobilization (RSTM, or Kelly repair) is an anatomical reconstruction of bladder exstrophy generally performed as a second part of a two-step strategy, following successful neonatal bladder closure. OBJECTIVE The objective of this study is to determine the feasibility of a combined procedure of delayed bladder closure and RSTM in one stage without pelvic osteotomy, in both primary and failed initial closure. DESIGN, SETTING, AND PARTICIPANTS From 11/2015 to 01/2018, 27 bladder exstrophy patients underwent combined bladder closure with RSTM by the same surgical team at four cooperating tertiary referral centers for bladder exstrophy, including 20 primary repairs (delayed bladder closure, median age 3.0m [0.5-37m]) and seven secondary repairs after failed attempt at neonatal closure, median age 10m [8-33m]. INTERVENTION RSTM included full mobilization of the bladder plate, urogenital diaphragm, and corpora cavernosa from the medial pelvic walls, followed by anatomical reconstruction with antireflux procedure, bladder closure, urethrocervicoplasty, muscle sphincter approximation, and penile/clitoral reconstruction. OUTCOME MEASUREMENTS The main criteria were bladder dehiscence or prolapse. Secondary outcomes included bladder neck fistula or urethral fistula, urethral stenosis, and parietal hernia. Continence and voiding have not been addressed at this stage. RESULTS AND LIMITATIONS All bladder exstrophy cases were successfully closed without osteotomy, with no case of bladder dehiscence after 12 m [3-30] follow-up. COMPLICATIONS Urethral fistula or stenosis occurred in eight patients: 4/5 fistulae closed spontaneously in less than 3 months; four urethral stenoses were successfully treated with 1-3 sessions of endoscopic high-pressure balloon dilatation or meatoplasty; one patient with persistent bladder neck fistula is currently awaiting repair. Although the follow-up is short, it does allow examination of the main outcome criterion, namely bladder dehiscence, which is usually expected to happen very early after surgery. CONCLUSION The Kelly RSTM can be safely combined with delayed bladder closure without osteotomy in both primary and redo cases in classic bladder exstrophy.
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Arab HO, Helmy TE, Abdelhalim A, Soltan M, Dawaba ME, Hafez AT. Complete Primary Repair of Bladder Exstrophy: Critical Analysis of the Long-term Outcome. Urology 2018; 117:131-136. [PMID: 29649545 DOI: 10.1016/j.urology.2018.03.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/16/2018] [Accepted: 03/24/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To demonstrate the long-term outcome of a contemporary series of 64 children who underwent complete primary repair of bladder exstrophy (CPRE) in a single tertiary referral center. MATERIALS AND METHODS Between 1998 and 2012, 64 children, 47 boys and 17 girls, were identified. Only 60 of the 64 cases were available for follow-up. The follow-up was done by renal bladder ultrasound and serum creatinine every 3 months and voiding cystourethrogram from 6 to 12 months postoperatively. Continence was defined as dryness ≥3 hours. RESULTS Median (range) follow-up is 14 years (from 5 to 19 years). Voided continence was achieved in 14 children (23%) after CPRE only. Additionally, 6 children were continent after bladder neck reconstruction (BNR) and 2 after bladder neck injection (BNI), raising the percentage of voided continence to 36%. The remaining 38 (64%) patients were using clean intermittent catheterization. All cases were continent at last assessment. The results of BNR or BNI were better in de novo than in redo cases (P <.05). The percentage of cases that needed augmentation ileocystoplasty in combination with multiple bladder neck procedures was lower in both female and de novo cases (P <.05). CONCLUSION The percentage of children with classic bladder exstrophy who underwent CPRE who will achieve continence with volitional voiding via the urethra is 36%. The continence results after BNR and BNI are better in de novo cases than in redo ones. Continence in female and de novo cases is more likely to be achieved with lower number of continence procedures.
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Affiliation(s)
- Hesham O Arab
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
| | - Tamer E Helmy
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed Abdelhalim
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Soltan
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mohamed E Dawaba
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ashraf T Hafez
- Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Ahn JJ, Shnorhavorian M, Katz C, Goldin AB, Merguerian PA. Early versus delayed closure of bladder exstrophy: A National Surgical Quality Improvement Program Pediatric analysis. J Pediatr Urol 2018; 14:27.e1-27.e5. [PMID: 29352663 DOI: 10.1016/j.jpurol.2017.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/01/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Delayed closure of bladder exstrophy has become more popular; however, there is limited the evidence of its success. Existing literature focuses on intermediate and long-term outcomes, and short-term postoperative outcomes are limited by the small number of cases and varying follow-up methods. OBJECTIVE The objectives of the current study were to: 1) compare 30-day complications after early and delayed closure of bladder exstrophy, and 2) evaluate practice patterns of bladder exstrophy closure. STUDY DESIGN The National Surgical Quality Improvement Program Pediatric (NSQIPP) database from 2012 to 2015 was reviewed for all cases of bladder exstrophy closure. Early closure was defined as surgery at age 0-3 days, and delayed closure was defined as age 4-120 days at time of surgery. Demographic, clinical, and peri-operative characteristics were collected, as were postoperative complications, readmissions, and re-operations up to 30 days. Descriptive statistics were performed, and multivariate linear and logistic regression analyses were performed for salient complications. RESULTS Of 128 patients undergoing bladder exstrophy closure, 62 were included for analysis, with 44 (71%) undergoing delayed closure. Mean anesthesia and operative times were greater in the delayed closure group, and were associated with more concurrent procedures, including inguinal hernia repairs and osteotomies. The delayed closure group had a higher proportion of 30-day complications, due to a high rate of blood transfusion (57% vs 11%). Wound dehiscence occurred in 6/44 (14%) delayed closures, as compared with 0/18 (0%) early closures. When compared with prior published reports of national data from 1999 to 2010, delayed closure was performed more frequently in this cohort (71% vs 27%). DISCUSSION The NSQIPP provides standardized reporting of peri-operative characteristics and 30-day complications, allowing a comparison of early to delayed closure of bladder exstrophy across multiple institutions. Assessing short-term risks in conjunction with long-term follow-up is crucial for determining optimal management of this rare but complex condition. CONCLUSION Delayed closure of bladder exstrophy is performed frequently, yet it carries a high rate of 30-day complications worthy of further investigation. This can be useful in counseling patients and families, and to understand practice patterns across the country.
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Affiliation(s)
- J J Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - M Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - C Katz
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - A B Goldin
- Division of Pediatric Surgery, Seattle Children's Hospital, Seattle, WA, USA; Department of Surgery, University of Washington, Seattle, WA, USA
| | - P A Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Tourchi A, Shabaninia M, Stewart M, Miyamoto H, Di Carlo H, Gearhart JP. Complete Penile Disassembly for Repair of Epispadias Causes Erectile Tissue Alteration Through Transforming Growth Factor Beta 1 Overexpression in a Rabbit Model. Urology 2018; 111:151-156. [DOI: 10.1016/j.urology.2017.08.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/18/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
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Ellison JS, Ahn J, Shnorhavorian M, Grady R, Merguerian PA. Long-term fate of the upper tracts following complete primary repair of bladder exstrophy. J Pediatr Urol 2017; 13:394.e1-394.e6. [PMID: 28592391 DOI: 10.1016/j.jpurol.2017.03.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/21/2017] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jonathan S Ellison
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - Jennifer Ahn
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Margarett Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Richard Grady
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
| | - Paul A Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Giron AM, Mello MF, Carvalho PA, Moscardi PRM, Lopes RI, Srougi M. One - staged reconstruction of bladder exstrophy in male patients: long - term follow-up outcomes. Int Braz J Urol 2017; 43:155-162. [PMID: 28124539 PMCID: PMC5293397 DOI: 10.1590/s1677-5538.ibju.2015.0581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/13/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction The surgical correction of bladder exstrophy remains challenging. In our institution, the repair has evolved from a staged repair to one-stage reconstruction. The one-stage reconstruction includes; bladder closure, Cantwell-Ransley neourethroplasty and abdominoplasty using groin flaps, without the need of pelvic ostheotomies. Repair of urinary continence (UC) and vesicoureteral reflux (VUR) is done after development of the infant. Objective To present our experience of our modified one-stage reconstruction of bladder exstrophy in male patients. Materials and Methods Medical records of male patients submitted to one-stage reconstruction of bladder exstrophy were analyzed retrospectively. Fifteen exstrophy bladder patients with mean age 4.2±7 years were treated at our institution between 1999-2013. Results 25 Conclusions One-stage reconstruction minimizes the number of surgical procedures required to achieve UC and potentiates bladder-neck function. The advantages of using groin flaps over current techniques for complete repair are the small risk for penile tissue loss and the avoidance of ostheotomies.
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Affiliation(s)
- Amilcar Martins Giron
- Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
| | | | - Paulo Afonso Carvalho
- Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
| | | | | | - Miguel Srougi
- Divisão de Urologia do Departamento de Cirurgia, Universidade de São Paulo, SP, Brasil
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Short-term outcomes of the multi-institutional bladder exstrophy consortium: Successes and complications in the first two years of collaboration. J Pediatr Urol 2017; 13:275.e1-275.e6. [PMID: 28314702 DOI: 10.1016/j.jpurol.2017.01.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/05/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION/BACKGROUND Bladder exstrophy is a rare diagnosis that presents major reconstructive challenges. To increase experience and proficiency in the care of bladder exstrophy (BE), the Multi-Institutional BE Consortium (MIBEC) was formed, with a focus on refining technical aspects of complete primary repair of bladder exstrophy (CPRE) and subsequent care. OBJECTIVE Outcome measures included successful CPRE (absence of dehiscence), complications, and integrated points of technique and care over the short-term. STUDY DESIGN Boston Children's Hospital, Children's Hospital of Philadelphia and Children's Hospital of Wisconsin alternately served as the host, with observation, commentary and critique by visiting collaborating surgeons. CPRE with bilateral iliac osteotomy was performed at 1-3 months of age. High-definition video capture of the surgery allowed local and distant broadcast to facilitate real-time observation and teaching, and recording of all procedures. RESULTS From February 2013 to February 2015, MIBEC participating surgeons performed CPRE on 27 consecutive patients (22 classic BE, five epispadias). There were no dehiscences in 27 patients (0%, 95% CI 0-12.5%). Thirteen girls and 14 boys underwent CPRE at a median age of 2.3 months (range 0.1-51.6). One boy had a hypospadiac urethral meatus at CPRE completion. Hydronephrosis of mild or moderate grade was present postoperatively in eight girls and two boys. Additional results, per gender, are presented in the Summary table below. DISCUSSION Absence of dehiscence in this cohort was comparable or compared favorably with the literature. However, several girls had significant obstructive complications following CPRE. The rate of bladder outlet obstruction (BOO) in girls was increased compared with published reports. A low complication rate was noted in the boys following CPRE, which was comparable to reports in the literature, and early signs of continence and spontaneous voiding were noted in some boys and girls. Limitations included variation in patient age at presentation, thereby introducing a wide age range at CPRE. Outcome data were limited by short follow-up regarding voiding with continence. CONCLUSION This collaborative effort proved beneficial regarding significantly increased surgeon exposure to CPRE, refinement of CPRE technique, surgeon learning and expertise. Technical refinement of CPRE is ongoing.
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Abstract
BACKGROUND Exstrophy of the bladder is a rare congenital defect seen in 2.15 children out of every 100,000 live births, with the most severe variant, cloacal exstrophy (CE), only occurring in 1 in 200,000. Developmental dysplasia of the hip (DDH) describes a spectrum of disease ranging from mild hip instability to frank dislocation. Underlying malformations, such as myelomeningocele and arthrogryposis, are often associated with the most severe variant of hip dysplasia, teratologic hip dislocation. The varying degrees of severity in DDH have been encountered in classic bladder exstrophy (CBE) patients, but the exact incidence is unknown. We sought to determine the incidence of DDH in CBE and CE patients. METHODS We performed a retrospective review of all children with CBE or CE presenting to a single pediatric center between 1994 and 2014. Each chart was reviewed for correct diagnosis of CBE or CE, patient age and demographics, associated medical conditions, pertinent surgeries performed, and the age at operation. Patient imaging was reviewed to determine whether bilateral hip imaging was available. RESULTS In a 20-year retrospective review, we identified 66 patients who were diagnosed with either CBE or CE and had available hip imaging (38 males and 28 females). Of these, 11 patients were found to have radiographic evidence of DDH, for an incidence of 16.7% (11/66). Five of these patients had CE, whereas 6 presented with CBE. The first radiographic evidence of DDH was noted at a mean age of 5.75 years (range, birth to 22 y). CONCLUSIONS We advocate the use of routine hip screening ultrasound in all infants born with either CBE or CE. Early identification of DDH in these patients may allow additional treatment options to coincide with frequently used osteotomy and orthopaedic interventions. LEVEL OF EVIDENCE Level III-retrospective study.
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Ellison JS, Shnorhavorian M, Willihnganz-Lawson K, Grady R, Merguerian PA. A critical appraisal of continence in bladder exstrophy: Long-term outcomes of the complete primary repair. J Pediatr Urol 2016; 12:205.e1-7. [PMID: 27267990 DOI: 10.1016/j.jpurol.2016.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/20/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Long-term continence outcomes for patients with bladder exstrophy are lacking in the literature. The complete primary repair of exstrophy (CPRE) is a widely adopted approach that seeks to normalize anatomy at the initial repair, thereby allowing early bladder filling and cycling. Previous reports of continence following CPRE, however, are limited by variable follow-up duration and continence definitions. OBJECTIVE To assess continence and factors associated with a positive outcome in a cohort of patients following CPRE with long-term follow-up. STUDY DESIGN A retrospective chart review was conducted of all patients with primary bladder closure using CPRE at the present institution for classic bladder exstrophy from 1990 to 2010. Patients <6 years of age or with an incomplete continence assessment at last follow-up were excluded. Continence was defined as voiding volitionally with dry intervals of ≥3 h, which was consistent with other high-volume series in the literature. RESULTS Twenty-nine of the 52 patients (56%) were eligible for inclusion. Twelve patients were continent at last follow-up, including seven boys and five girls. Mean follow-up for the entire cohort was 148 months. The Summary table displays comparisons between continent and incontinent patients. Of patients achieving continence, 42% did not require further continence operations, while 17% required only one additional continence operation. DISCUSSION Long-term CPRE continence rates were lower than previously reported, but comparable to other series in the literature. Of those achieving continence, 59% will do so with zero or one additional operation. Sex and osteotomy status were not associated with continence outcomes, although age at follow-up was a predictor of continence, favoring older patients in the present series. The study was limited by lack of standardized, patient-reported continence outcomes and by the retrospective nature of the review. However, the data add to the literature of long-term continence outcomes and are important for counseling families both at initial repair and follow-up. CONCLUSIONS Complete primary repair of exstrophy can achieve continence without additional operations in a subset of patients. Some patients, however, may not achieve continence until adolescence, underscoring the need for long-term urologic follow-up in patients with bladder exstrophy.
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Affiliation(s)
- J S Ellison
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA.
| | - M Shnorhavorian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
| | | | - R Grady
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
| | - P A Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
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Impact of concomitant hernia repair at the time of complete primary repair of bladder exstrophy. J Pediatr Urol 2016; 12:211.e1-5. [PMID: 27264049 DOI: 10.1016/j.jpurol.2016.04.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 04/30/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Inguinal hernias are common in the bladder exstrophy population. As these hernias may present with incarceration following bladder closure, several groups recommend inguinal exploration and hernia repair at the time of initial bladder closure. However, the benefits of such an approach are not well defined. In 2006, we modified our approach to this condition by routinely performing concomitant inguinal herniorraphy (CIH) repair at the time of initial exstrophy repair. The aim of this study was to test the hypothesis that simultaneous inguinal hernia repair will be safe and effective in reducing subsequent unplanned inguinal procedures in this high-risk group. METHOD We conducted a retrospective chart review of patients with classic bladder exstrophy managed with complete primary repair (CPRE) from 1990 to 2014, with focus on inguinal hernia repair at the time of bladder closure and subsequent need for inguinal surgery. We excluded patients with follow-up less than 6 months, missing data with regards to the initial inguinal approach at the time of bladder closure, and patients with intra-abdominal testicles. RESULTS A total of 43 patients were included for analysis with 27 (61%) having inguinal hernias identified either at birth or in subsequent follow-up, including 20 of 27 boys and 7 of 16 girls. A summary of comparison groups with and without CIH at the time of CPRE, as well as follow-up and need for subsequent hernia repair, is given in the summary Table. Of 25 patients without concomitant inguinal herniorraphy at CPRE, 10 patients required subsequent inguinal surgeries for inguinal herniorraphy (seven), orchiopexy (one), or inguinal herniorraphy plus orchiopexy (two). CONCLUSION CIH at the time of CPRE is safe, with no significant inguinal complications noted. Subsequent inguinal operations were more often required in the cohort of patients not receiving CIH at the time of CPRE, including one patient presenting with incarceration. Thus, CIH appears to reduce need for subsequent inguinal operations when performed at the time of bladder closure. Our study adds to other authors' claims that CIH should be attempted at the time of bladder closure. This study is limited by the retrospective nature of the review and differences in follow-up times between groups. Simultaneous inguinal hernia repair at the time of initial exstrophy repair is safe and associated with decreased incidence of subsequent inguinal surgery. Such an approach should be undertaken during initial bladder closure.
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Hesh CA, Young E, Intihar P, Gearhart JP. The cost of failure: The economic impact of failed primary closure in classic bladder exstrophy. J Pediatr Surg 2016; 51:1312-6. [PMID: 26706034 DOI: 10.1016/j.jpedsurg.2015.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/13/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Failure of primary closure in classic bladder exstrophy (CBE) is a significant cause of morbidity, and yet its relative economic impact has not been well characterized. The authors aim to determine whether CBE patients who underwent failed primary closure incur greater economic burden in the year following their successful closure than those patients who underwent a successful primary closure. MATERIALS AND METHODS After institutional review board approval CBE patients who were successfully closed between 1993 and 2013 were identified in an institutional exstrophy-epispadias database. Patients who were never closed at the study institution and those who had no documented successful closure were excluded. Inpatient hospital charges, hospital costs, and professional fees were collected for the year following successful closure. RESULTS 162 patients met the inclusion and exclusion criteria and accounted for 312 inpatient admissions in the year following and including their respective successful bladder closures. 62 of the patients failed their primary closure and the remaining 100 succeeded. Adjusting for covariates, patients who underwent successful primary closure experienced a reduction in inpatient hospital charges of $8497, hospital costs of $9046 and professional fees of $11,180 in the year following their successful closure compared to those patients who failed their primary closure. CONCLUSION Apart from the self-evident financial advantages of a successful primary closure, namely the avoidance of reclosure, there appears to be a lasting negative financial impact of failed primary closure even after these patients undergo successful reclosure at the study institution.
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Affiliation(s)
- Christopher A Hesh
- The Johns Hopkins School of Medicine, Department of Urology, Division of Pediatric Urology, Baltimore, MD, United States.
| | - Ezekiel Young
- The Johns Hopkins School of Medicine, Department of Urology, Division of Pediatric Urology, Baltimore, MD, United States
| | - Paul Intihar
- The Johns Hopkins Medical Institutions, Financial Analysis Unit, Baltimore, MD, United States
| | - John P Gearhart
- The Johns Hopkins School of Medicine, Department of Urology, Division of Pediatric Urology, Baltimore, MD, United States
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Alsowayan O, Capolicchio JP, Jednak R, El-Sherbiny M. Long-term functional outcomes after bladder exstrophy repair: A single, low-volume centre experience. Can Urol Assoc J 2016; 10:E94-8. [PMID: 27330586 DOI: 10.5489/cuaj.3104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In this study, we present our experience managing bladder exstrophy (BE) in a low-volume centre over 24 years. METHODS Charts of patients with BE between 1990 and 2014 were retrospectively reviewed. Patients with BE closure and ≥5 years followup were included. BE closure was carried out in the first two days of life using either complete primary repair (CPRE) or modern-staged repair (MSRE). Daytime urinary continence (UC) was evaluated by the age of five years. Patients were considered continent if completely dry for ≥3 hours using no or one pad/day. Incontinent patients with bladder capacity (BC) ≥100 ml underwent bladder neck reconstruction (BNR) and bilateral ureteric reimplantation (BUR), while patients with BC <100ml underwent simultaneous augmentation cystoplasty (ACP). RESULTS Sixteen (16) patients met our inclusion criteria with a mean followup time of 18±5 years. Ten (10) underwent CPRE, while six underwent MSRE. Four surgeons were involved in patients' management. Two surgeons had previous experience in BE surgery while working in other institutions. Complications included dehiscence in five patients, vesicocutanous fistula in three and breakthrough UTI in eight. Continence was achieved in 15/16 patients: two after BE closure only, seven with BNR, and six who required ACP and BNR. CONCLUSIONS Despite the small number of patients and the reterospective nature of the study, some observations are noteworthy. Although continence rate post-primary BE closure was initially low, it rose to 93.8% after auxiliary continence procedures. This might be at the cost of urethral voiding, which was achieved in 60% of patients. Our small cohort did not show clear advantage of CPRE vs. MSRE. Our outcomes may not be different from high-volume centres due to the fact that two exstrophy-experienced surgeons performed most primary or subsequent surgeries. For this reason, we recommend assigning designated centres for BE repair for both new and repeat cases.
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Affiliation(s)
- Ossamah Alsowayan
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University Health Centre, Montreal, QC, Canada;; Department of Urology, College of Medicine and King Fahd Hospital of the University, University of Dammam, Kingdom of Saudi Arabia
| | - John Paul Capolicchio
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University Health Centre, Montreal, QC, Canada
| | - Roman Jednak
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University Health Centre, Montreal, QC, Canada
| | - Mohamed El-Sherbiny
- Department of Pediatric Surgery, Division of Pediatric Urology, Montreal Children's Hospital and McGill University Health Centre, Montreal, QC, Canada
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Carrasco A, Vemulakonda VM. Managing adult urinary incontinence from the congenitally incompetent bladder outlet. Curr Opin Urol 2016; 26:351-6. [PMID: 27096718 DOI: 10.1097/mou.0000000000000296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Treatment of urinary incontinence in adult patients with congenital incompetent bladder outlet (exstrophy-epispadias complex, cloacal anomalies, or neurogenic bladder secondary to myelomeningocele) is a challenging surgical problem. In this review article, we summarize and highlight recent studies in the management of incontinence in this patient population. RECENT FINDINGS The literature regarding management of urinary incontinence in this patient population is scarce. Injection of bulking agents to the bladder neck, artificial/autologous slings, artificial urinary sphincters, bladder neck reconstruction, bladder neck closure, or a combination of these are the cornerstone of management. Augmentation cystoplasty is a major adjunct procedure that can help increase continence rate and success of surgery in select patients. The level of evidence on bladder neck procedures for this patient population is low because of significant limitations, including small sample, heterogeneity of primary diagnosis/surgical techniques, variable definitions of continence, and the retrospective nature of most studies in this field. SUMMARY Standard options for treatment of urinary incontinence in the congenitally incompetent bladder outlet procedure remain unchanged. There is no single reproducible procedure to accomplish the goal of renal preservation and continence in these patients, and often patients require multiple procedures to achieve continence. Most importantly, the pediatric and adult urologist should continue to work toward achieving a well tolerated and efficient transition of care. There is a need to standardize data acquisition and reporting of outcomes. Although randomized control studies would be ideal, because of the small number of patients with these conditions, this may not be practical. Collaboration and continued discussion among experts in the field is needed to gain a better understanding of the optimal management strategy in this growing patient population.
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Affiliation(s)
- Alonso Carrasco
- Department of Pediatric Urology, Children's Hospital Colorado, Aurora, Colorado, USA
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Borer JG, Vasquez E, Canning DA, Kryger JV, Mitchell ME. An initial report of a novel multi-institutional bladder exstrophy consortium: a collaboration focused on primary surgery and subsequent care. J Urol 2015; 193:1802-7. [PMID: 25813562 DOI: 10.1016/j.juro.2014.10.114] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE For bladder exstrophy repair it is universally accepted that successful initial surgery is paramount to achieve the optimal outcome. Gaining the necessary surgical experience is challenging due to the rarity of bladder exstrophy. We report preliminary findings of a multi-institutional collaboration created to increase experience and proficiency with the care of bladder exstrophy. MATERIALS AND METHODS Our 3 institutions alternatively served as the host site for scheduled surgeries with observation, commentary and critique by visitors from the other sites. The technique was complete primary repair with bilateral iliac osteotomy. The timing of complete primary repair at age 1 to 3 months facilitated collaboration. We recorded patient demographics and outcomes, and the impact of this collaboration on our technique and experience. Video recording was used for real-time observation and teaching, and future analysis, editing and review. RESULTS A total of 16 site visits occurred from February 2013 through May 2014. Complete primary repair was performed in 9 males and 7 females with bladder exstrophy. Median age at complete primary repair was 2 months (range 0.1 to 28.8). Median followup was 8.9 months (range 2.8 to 18.2). All closures were successful with no dehiscence. Complications included urethrocutaneous fistula in 2 patients, 1 episode of pyelonephritis in 3 each and urethral obstruction in 2 females, of whom 1 required clean intermittent catheterization. CONCLUSIONS We report a multi-institutional collaboration to standardize the surgical management of bladder exstrophy. This effort increased the annual experience of each institution involved from threefold to ninefold and it has accelerated the physician knowledge base to ultimately benefit patient care.
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Affiliation(s)
- Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts.
| | - Evalynn Vasquez
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | | | - John V Kryger
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Anwar AZM, Mohamed MAH, Hussein A, Shaaban AM. Response to Editorial Comment to Modified penile disassembly technique for boys with epispadias and those undergoing complete primary repair of exstrophy: long-term outcomes. Int J Urol 2014; 21:941. [PMID: 24913700 DOI: 10.1111/iju.12520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sub-urothelial polyp enucleation resection and urothelial auto-augmentation cystoplasty: a simple method for bladder exstrophy-epispadias complex reconstruction in bladder plate polyposis. Pediatr Surg Int 2014; 30:669-76. [PMID: 24802675 DOI: 10.1007/s00383-014-3510-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To report the results of a novel technique of sub-urothelial polyp enucleation resection (SUPER) and urothelial auto-augmentation cystoplasty (UAAC) in patients with bladder exstrophy and polyposis plate. METHODS Twenty-eight patients with bladder exstrophy covered by plate polyposis were referred for further management. From these, 12 patients had undergone SUPER, UAAC technique, and subsequent bladder closure. In this technique, the urothelium covering the polyps was utilized as tissue for auto-augmentation cystoplasty. Sixteen patients had been operated by simple polyps' excision and bladder closure. Biopsies of polyps were obtained in both groups at the time of closure for pathological evaluations. The bladder plate was measured pre-and post-bladder plate augmentation. The patients were evaluated every 3 months for 1 year and biannually thereafter for urinary continence and social dryness. Dry period of >3 h during the day with or without nocturnal incontinence was defined as social dryness. RESULTS All patients experienced an uneventful postoperative period. No sign of metaplasia or dysplasia was observed in the histological and cystoscopy evaluations. These findings suggest that neither polyp recurrence nor bladder tumor development has occurred in any of the groups. The urinary continence improved significantly in the polyp's urothelial coverage augmentation cystoplasty technique (66.7%), while 31.3% of patients in simple closure technique achieved continence. Significantly higher mean bladder capacity was obtained in the augmentation group (190 ± 38 ml) and (119 ± 21 ml), respectively. Postoperative mild hydronephrosis and vesicoureteral reflux were significantly lower in auto-augmentation technique. CONCLUSION The final clinical outcome of children with bladder exstrophy polyposis is promising. The combined SUPER and UAAC technique is feasible, safe and reproducible option for bladder exstrophy-epispadias complex (BEEC) patients with bladder plate polyposis. However, it will add one supplementary operation to the single or staged bladder reconstruction. These patients may warrant further surveillance with histopathological evaluations during the adult life.
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Borer JG, Strakosha R, Bauer SB, Diamond DA, Pennison M, Rosoklija I, Khoshbin S. Combined Cystometrography and Electromyography of the External Urethral Sphincter Following Complete Primary Repair of Bladder Exstrophy. J Urol 2014; 191:1547-52. [DOI: 10.1016/j.juro.2013.10.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Joseph G. Borer
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - Ruth Strakosha
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - Stuart B. Bauer
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - David A. Diamond
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - Melanie Pennison
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - Ilina Rosoklija
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
| | - Shahram Khoshbin
- Departments of Urology, Boston Children's Hospital and Brigham and Women's Hospital (SK), Boston, Massachusetts
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Schaeffer AJ, Johnson EK, Logvinenko T, Graham DA, Borer JG, Nelson CP. Practice patterns and resource utilization for infants with bladder exstrophy: a national perspective. J Urol 2014; 191:1381-8. [PMID: 24300484 PMCID: PMC4130705 DOI: 10.1016/j.juro.2013.11.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Substantial variability exists in bladder exstrophy care, and little is known about costs associated with the condition. We define the care patterns and first year cost for patients with bladder exstrophy at select freestanding pediatric hospitals in the United States. MATERIALS AND METHODS We used the Pediatric Health Information System database to identify patients with bladder exstrophy born between January 1999 and December 2010 who underwent primary closure in the first 120 days of life. Demographic, surgical, postoperative and cost data for all encounters were assessed. Multivariate linear regression was used to examine the association between patient, surgeon and hospital characteristics and costs. RESULTS Of the 381 patients who underwent primary closure within the first 120 days of life 279 (73%) did so within the first 3 days of life. A total of 119 patients (31%) underwent pelvic osteotomy, including 51 of 279 (18%) who underwent closure within the first 3 days of life, 38 of 67 (56%) who underwent closure between 4 and 30 days of life, and 30 of 35 (86%) who underwent closure between 31 and 120 days of life (p = 0.0017). Median inflation adjusted, first year cost in United States dollars per patient was $66,577 (IQR $45,335 to $102,398). Presence of nonrenal comorbidity and completion of primary closure after 30 days of life increased first year costs by 24% and 53%, respectively. Increased post-closure length of stay was associated with greater costs. CONCLUSIONS At select freestanding United States pediatric hospitals the majority of bladder exstrophy closures are performed within the first 3 days of life. Most, but not all, patients undergoing closure after the neonatal period undergo osteotomy. The presence of nonrenal comorbidity and increased postoperative length of stay are associated with greater costs.
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Affiliation(s)
| | - Emilie K Johnson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Tanya Logvinenko
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Dionne A Graham
- Clinical Research Center, Boston Children's Hospital, Boston, Massachusetts
| | - Joseph G Borer
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital, Boston, Massachusetts
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Modified penile disassembly technique for boys with epispadias and those undergoing complete primary repair of exstrophy: Long-term outcomes. Int J Urol 2014; 21:936-40. [DOI: 10.1111/iju.12469] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/19/2014] [Indexed: 11/26/2022]
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Dickson AP. The management of bladder exstrophy: the Manchester experience. J Pediatr Surg 2014; 49:244-50. [PMID: 24528959 DOI: 10.1016/j.jpedsurg.2013.11.031] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/09/2013] [Indexed: 10/26/2022]
Abstract
AIM Bladder exstrophy (BE) is a severe congenital malformation with life-long implications. This article discusses the current surgical management and describes the development of the nationally commissioned bladder exstrophy service in Manchester, UK. METHODS Outcome of BE surgery in Manchester was retrospectively reviewed. A Medline search was also undertaken and the published outcomes reviewed for the Modern Staged Repair of Bladder Exstrophy (MSRE), the Complete Primary Repair of Exstrophy (CPRE), and Radical Soft-Tissue Mobilisation (RSTM). RESULTS Sixty-seven infants with BE were treated in the period 2000-2012. Twenty-six infants underwent primary closure during the neonatal period, and in twenty-one this was successful. The remaining forty-one infants underwent delayed closure, and all were successful. Twenty-six children underwent MSRE, and continence with urethral micturition was achieved in sixteen (62%) (ten alone and six with urethral clean intermittent catheterisation). A further five (19%) are continent following bladder neck closure, cystoplasty, and continent diversion. Seven (26%) of the twenty-six patients are completely dry overnight. Twenty infants underwent primary ureteric reimplantation, and none have renal scarring. By contrast, renal scarring (unilateral n=fourteen; bilateral n=five) was found in nineteen of thirty-seven infants who did not undergo reimplantation. CONCLUSIONS Specialised experience has allowed demonstrable improvement in bladder exstrophy outcomes throughout the period of the study.
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Affiliation(s)
- Alan P Dickson
- Department of Paediatric Urology, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, United Kingdom.
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Kurbet SB, Prashanth GP, Patil MV, Mane S. A retrospective analysis of early experience with modified complete primary repair of exstrophy bladder (CPRE) in neonates and children. Indian J Plast Surg 2014; 46:549-54. [PMID: 24459348 PMCID: PMC3897103 DOI: 10.4103/0970-0358.122015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Objective: To study the problems faced during the surgery and follow-up of modified complete primary repair of exstrophy (CPRE) technique. Initial experience with CPRE and its short- and long-term outcomes with respect to continence status and psychosocial impact are reported. Materials and Methods: A retrospective review of the hospital case records from March 2008 to September 2012 was performed. Data of patients with bladder exstrophy managed by a single paediatric surgeon using modified CPRE technique were analysed. Quality of life and psychosocial impact of the surgery were assessed using Pediatric Quality of Life Inventory (PedsQL 4.0) and compared with those of typical peers. Results: Eight children (age 4 days-12 years) underwent CPRE using modified Mitchell's technique. Two patients (25%) experienced early postoperative complications, with infection and fistula developing in one each. All the patients were doing well on follow-up, with variable continence rates and good cosmesis. Mean duration of follow-up was 18.5 months (range 6 months-4 years). Five out of seven (71%) children were continent or partially continent. One case was lost to follow-up. PedsQL scores were comparable with those of age-matched peers in all domains except the social functioning domain in 8-12 years age group (83.53 ± 9.70 vs. 77.86 ± 10.22, P < 0.05). Conclusion: Our preliminary results with modified CPRE in neonates and children have been encouraging. No major complications were observed. Continence rate was satisfactory and cosmetic results were good. Though the technique is being practiced at several Indian centres, there is a paucity of comprehensive Indian data on CPRE.
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Affiliation(s)
- Santosh B Kurbet
- Department of Pediatric Surgery, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Gowda P Prashanth
- Department of Pediatrics, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Mahantesh V Patil
- Department of Pediatrics, Dr. Prabhakar Kore Hospital and Medical Research Centre and KLE University's Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Shivaji Mane
- Department of Pediatric Surgery, Grant Medical College and Sir JJ Group of Hospitals, Byculla, Mumbai, Maharashtra, India
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Modern management of the exstrophy-epispadias complex. Surg Res Pract 2014; 2014:587064. [PMID: 25374956 PMCID: PMC4208497 DOI: 10.1155/2014/587064] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/28/2013] [Accepted: 12/09/2013] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications.
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Massanyi EZ, Shah B, Schaeffer AJ, DiCarlo HN, Sponseller PD, Gearhart JP. Persistent vesicocutaneous fistula after repair of classic bladder exstrophy: a sign of failure? J Pediatr Urol 2013; 9:867-71. [PMID: 23246077 DOI: 10.1016/j.jpurol.2012.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/26/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the potential predisposing clinical characteristics at initial closure, the treatments of and outcomes associated with vesicocutaneous fistula (VCF) after primary bladder closure. MATERIALS AND METHODS Eighteen patients were referred for VCF after primary bladder exstrophy closure. Aspects from the primary closure such as gender, timing of diagnosis and repair, osteotomies, pelvic immobilization, layers of closure, use of tissue adjuncts, and complications in addition to details from their required treatment of VCF were retrospectively extracted from the medical record. RESULTS A diagnosis of failed closure was made at the time of evaluation in 13 of 18 patients who presented with VCF. All 13 patients underwent delayed single-layer closures and had a widened pubic diastasis. Five patients with secure closures who underwent successful simple fistula repairs were all closed early in life, had multi-layered closures with pelvic osteotomies, and had minimal change in pubic diastasis. CONCLUSION VCF may represent a failed bladder closure. Factors which may suggest failure are a fistula tract in the lower abdominal midline between the pubic rami, a pubic diastasis increased from pre-closure measurement, and cystoscopic evidence of an anteriorly positioned bladder.
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Affiliation(s)
- Eric Z Massanyi
- The Johns Hopkins University School of Medicine, James Buchanan Brady Urological Institute, Division of Pediatric Urology, Charlotte Bloomberg Children's Hospital, Suite 7308, Baltimore, MD 21201, USA.
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Surgical management of pediatric urinary incontinence. Curr Urol Rep 2013; 14:342-9. [PMID: 23832825 DOI: 10.1007/s11934-013-0333-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The surgical management of pediatric urinary incontinence secondary to neurogenic bladder and congenital anomalies is challenging, and continues to evolve with new surgical innovations. The goal of these surgical procedures is to achieve complete and socially acceptable urinary dryness, while preserving volitional voiding where possible, without causing damage to the upper tracts. This review focuses on recent studies and highlights the pros and cons of these advances, based on our experience. The short-term success in achieving urinary continence has to be tempered with the long-term implications of these reconstructive procedures, about which our knowledge is limited.
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Wallis MC, Oottamasathien S, Wicher C, Hadley D, Snow BW, Cartwright PC. Padded self-adhesive strap immobilization following newborn bladder exstrophy closure: the Utah straps. J Urol 2013; 190:2216-20. [PMID: 23810641 DOI: 10.1016/j.juro.2013.06.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Several methods have been described for immobilization of the pelvis following bladder exstrophy closure, which can be challenging to manage. We hypothesized that immobilization can be significantly simplified using a modified mermaid wrap with padded Velcro® straps around the thigh and lower leg. MATERIALS AND METHODS We retrospectively reviewed all patients who underwent bladder exstrophy closure in the newborn period at our institution from 1990 through 2010. Patients with cloacal exstrophy and those who underwent delayed closure due to other medical conditions were excluded. We collected data on closure technique, length of stay and complications of the primary closure as outcomes. RESULTS A total of 20 boys and 7 girls underwent closure of classic bladder exstrophy. Followup ranged from 2 to 22 years. Seven boys underwent complete primary repair and 13 underwent staged repair. All patients had the legs stabilized with a modified wrap technique using 2 lengths of Velcro straps lined with self-adhering open cell foam pads for 3 weeks. Complications of exstrophy closure included bladder dehiscence in 1 patient (4%) and incisional hernia in 2 (7%). Following complete primary repair urethrocutaneous fistula developed in 2 patients and urethral stricture in 2. Average length of stay for patients without significant prematurity was 15 days. CONCLUSIONS Padded Velcro strap immobilization simplifies postoperative care, provides secure fixation, decreases length of stay, and enables parents to hold and bond with the child shortly after repair. We advocate this simplified technique, which can be applied with a rate of complications that is comparable to other procedures.
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Affiliation(s)
- M Chad Wallis
- Division of Pediatric Urology, University of Utah School of Medicine, Salt Lake City, Utah.
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Abstract
AIM Outcomes of bladder exstrophy patients were studied in numerical terms using scoring systems for continence and health-related quality of life (HRQOL), along with renal function, in short-term follow up. PATIENTS AND METHODS Patients who had undergone bladder-preserving exstrophy repairs, either staged or as a single procedure, and those who had been managed by bowel augmentation were included. Continence was assessed according to five variables (max. score 15) and HRQOL assessment was by means of a structured modified questionnaire scored on a Likert-scale model (max. score 150). RESULTS A total of 39 patients were followed. Mean age was 8.3 years and mean follow up duration 3 years. Mean HRQOL score was 107.55 (83-133, SD ± 19.31). Mean continence score was 8.73 (6-11, SD ± 1.544). CONCLUSIONS Evaluation of bladder exstrophy outcomes should not be done merely by reporting the length of dry intervals. If performed in numerical terms as outlined in this series, patients across centres will be comparable over a common assessment protocol. Continence score achieved in this series was low in comparison to the literature due to the strict evaluation protocol.
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Inouye BM, Massanyi EZ, Di Carlo H, Shah BB, Gearhart JP. Modern Management of Bladder Exstrophy Repair. Curr Urol Rep 2013; 14:359-65. [DOI: 10.1007/s11934-013-0332-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Schaeffer AJ, Stec AA, Baradaran N, Gearhart JP, Mathews RI. Preservation of renal function in the modern staged repair of classic bladder exstrophy. J Pediatr Urol 2013; 9:169-73. [PMID: 22365973 PMCID: PMC3378802 DOI: 10.1016/j.jpurol.2012.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 01/25/2012] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Anthony J Schaeffer
- Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA.
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Massanyi EZ, Gearhart JP, Kost-Byerly S. Perioperative management of classic bladder exstrophy. Res Rep Urol 2013; 5:67-75. [PMID: 24400236 PMCID: PMC3826855 DOI: 10.2147/rru.s29087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The exstrophy-epispadias complex is a rare congenital malformation of the genitourinary system, abdominal wall muscles, and pelvic structures. Modern surgical repairs focus on reconstruction of the bladder and its adjacent structures, with the goal of achieving urinary continence, a satisfactory cosmetic result, and a high quality of life. Complex surgery in neonates and young children, as well as a prolonged postoperative course require close collaboration between surgeons, anesthesiologists, intensivists, pediatricians, and an experienced nursing staff. This article will review the spectrum of bladder exstrophy anomalies, the surgical repair, and the perioperative interdisciplinary management.
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Affiliation(s)
- Eric Z Massanyi
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - John P Gearhart
- Division of Pediatric Urology, Department of Urology, James Buchanan Brady Urological Institute, Baltimore, Maryland, USA
| | - Sabine Kost-Byerly
- Division of Pediatric Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
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Abstract
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.
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Affiliation(s)
- Jai K Mahajan
- Department of Paediatric Surgery, Institute- Advanced Paediatric centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Giron AM, Passerotti CC, Nguyen H, Cruz JASD, Srougi M. Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies. Int Braz J Urol 2012; 37:605-10. [PMID: 22099272 DOI: 10.1590/s1677-55382011000500006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2011] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE. MATERIALS AND METHODS All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies. RESULTS Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2%) resulted in healthy babies, while four patients (18.1%) had a spontaneous abortion due to genital prolapse, and there was one case (4.7%) of death due to a pneumopathy one week after delivery. There was also one case (5.8%) of premature birth without greater repercussions. During pregnancy, three patients (21.4%) had urinary tract infections and one patient (7.14%) presented urinary retention. After delivery, three patients (21.4%) presented temporary urinary incontinence; one patient (7.14%) had a vesicocutaneous fistula and seven patients (50%) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population. CONCLUSIONS BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle.
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Affiliation(s)
- Amilcar Martins Giron
- Urology Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Resultant hypospadias after epispadias repair in bladder exstrophy patients: a difficult surgical task with high complication rate. J Pediatr Surg 2011; 46:1965-9. [PMID: 22008335 DOI: 10.1016/j.jpedsurg.2011.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 04/19/2011] [Accepted: 05/22/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to analyze the complication rate in male bladder exstrophy (BE) patients undergoing flap or graft urethroplasty for the repair of resultant hypospadias after epispadias repair. METHODS We retrospectively reviewed the charts of 22 male BE patients who underwent 24 urethroplasties for resultant hypospadias between 2000 and 2009. Median patient age was 4.2 (range, 1.5-26.5) years, and median follow-up was 7.5 (range, 0.8-10.3) years. Meatal location after epispadias repair was midshaft in 6 cases and proximal shaft in 15. Complications were compared in relation to meatal position, type of urethroplasty (no graft vs graft), use of second-layer coverage of the urethroplasty, and use of suprapubic diversion. RESULTS Overall, complications developed in 12 (50%) patients, including 10 urethrocutaneous fistulas and 2 urethroplasty dehiscence. Univariate analysis failed to show any differences between complicated and uncomplicated cases in all the variables. Only the 3 cases undergoing a 2-stage repair had fully successful outcomes. CONCLUSIONS Urethroplasty in patients with BE has a high complication rate. Quality of local tissue and presence of scarring are possibly the 2 major determinants of a poor outcome. A staged repair seems the safest, although this commits the patient to 2 procedures.
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