Use of Biodegradable Plates and Screws for Approximation of Symphysis Pubis in Bladder Exstrophy: Applications and Outcomes

Insights and outcomes of single-staged repair of female bladder exstrophy-epispadias complex without osteotomy: 15 Years experience of a single institution

INTRODUCTION

Female exstrophy-epispadias complex (BEEC) has been considered as a rare malformation of the genito-urinary tract affecting. Combining procedures during the reconstruction of bladder exstrophy-epispadias complex to reduce the number of procedures and improve the outcomes has evoked great interest.

OBJECTIVE

we tried to describe the application and results of a single-stage approach for reconstruction of female BEEC during initial reconstruction or following prior failed bladder closure (FBC).

STUDY DESIGN

The records of 37 female patients referred for the repair of BEEC without the application of pelvic osteotomies were extracted from an institutionally approved database from September 2002 to August 2018. The mean patient age was 7.24 and 26 patients had a prior FBC. All patients underwent pelvic floor electrical stimulation and toilet training for 1 year after the closure. Complete continence was defined as having the ability to stay dry for more than 3 h without leakage during the day and night. Partial continence has traditionally been defined as retaining urine for 1-3 h or having some stress incontinence. Incontinence was defined as a continence interval of less than 1 h.

RESULTS

None of the patients presented bladder prolapse or dehiscence on follow-up; while stricture developed in 2 patients (5.4%). A total of 25 (67.6%) children were dry during the day and night. However, 9 (24.3%) were dry during the day but wet at night; while 3 (8.1%) were totally incontinent. The patients were followed up for a mean of 112.56 months.

DISCUSSION

Although earlier reports of this technique seem encouraging, it should be mentioned that postoperative complications are possible and difficult to manage. However, none of our patients were presented with severe postoperative complications in the follow-ups.

CONCLUSION

The single-stage technique provides satisfactory outcomes in selected patients with classic bladder exstrophy. The majority of patients attained social dryness without bladder augmentation and intermittent catheterization accompanied with minimum complication rate and best cosmetic results.

Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience

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.

Early detection of deep wound infection in bladder exstrophy and hypospadias using a novel intervention

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.

Preoperative care of Polypoid exposed mucosal template in bladder exstrophy: the role of high-barrier plastic wraps in reducing inflammation and polyp size

Objective

To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstro- phy cases, and to compare the results with the application of low-barrier wrap.

Materials and Methods

Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps.

Results

The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC.

Conclusion

Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more “exstrophy-friendly”.

Ureteric-urethral engraftment as a new surgical technique for management of incontinence in bladder exstrophy complex: A retrospective cohort

OBJECTIVES

To report the results of a novel surgical technique for achieving urinary continence in patients with bladder exstrophy complex (BEC) by ureteric-urethral engraftment (UUE) technique.

PATIENTS AND METHODS

Sixteen female patients with BEC and a mean ± SD age of 3.48 ± 1.75 years were referred for primary exstrophy repair from 2009 to 2012. From these, 9 patients were operated by single-stage bladder closure (group I); while 7 patients underwent the novel technique of UUE to compare the continence achievement (group II). In UUE technique, distal ureter was applied for total urethral replacement while the lower part of engraft was fixed in external genitalia. No osteotomy was performed in none of the groups. Continence and upper urinary tract evaluation were performed in the follow-ups with 3 months intervals for the first year and biannually thereafter. The patients were followed-up for a mean ± SD duration of 72 ± 6 months.

RESULTS

All patients in both groups experienced an uneventful postoperative period. In group II, 5 patients were continent day and night and voided per urethra without need for augmentation or intermittent catheterization technique (71.42%); while 55.55% of patients in group I achieved total continence (n = 5). Partial continence was achieved in 4 (44.44%) and 2 (28.57%) patients in group I and II, respectively. However, 3 patients in UUE group had postoperative vesicoureteral reflux that was successfully managed by Deflux injection.

CONCLUSION

The eventual clinical outcomes of BEC children undergoing the UUE technique were promising. This practicable, safe, and reproducible option will add one complementary stage to the previously used reconstruction techniques. These patients would necessitate further surveillance with upper urinary tract evaluations during the adult life.

Comparing the bulking effect of calcium hydroxyapatite and Deflux injection into the bladder neck for improvement of urinary incontinence in bladder exstrophy-epispadias complex

OBJECTIVES

The aim of this study was to evaluate the efficacy of the endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck (BN) region of patients with urinary incontinence and bladder exstrophy-epispadias complex (BEEC).

PATIENTS AND METHODS

We designed a retrospective cohort study in which we retrospectively studied medical charts of female and male patients of BEEC who had undergone CaHA or Deflux injection for continence improvement between 2009 and 2014. Sixteen incontinent patients with a mean ± SD age of 8.09 ± 3.5 years received an endoscopic submucosal injection of 5.4 ml of pure CaHA powder with autologous plasma (group A). Patients in group B (N = 21), control group, with a mean ± SD age of 7.51 ± 2.8 years received Deflux injection (5.1 ml). The mean follow-up after injection was 38 ± 5.2 and 33 ± 4.1 months in groups A and B, respectively.

RESULTS

No post-injection complication was detected in none of the patients during the follow-up. Eleven patients (68.75%) in group A became socially dry following 1-2 injections, the degree of incontinence was improved in 4 patients (25%), and there was no change in one patient (6.25%). However, Deflux injection resulted in complete dryness in 14 (66.66%), improvement in the degree of incontinence in 5 (23.81%) and no change in 2 patients (9.52%), leading to no significant difference in continence achievement between CaHA and Deflux groups (p = 0.9). The statistical analysis was not significantly different in terms of bladder capacity (p = 0.7) or Q max (p = 0.8).

CONCLUSION

The preliminary results of this study revealed that CaHA may be applied as an affordable bulking agent in treatment of urinary incontinence in BEEC.

Sub-urothelial polyp enucleation resection and urothelial auto-augmentation cystoplasty: a simple method for bladder exstrophy-epispadias complex reconstruction in bladder plate polyposis

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.