PERIURETHRAL MUSCLE COMPLEX REASSEMBLY FOR EXSTROPHY-EPISPADIAS REPAIR

Repurposing tools: A peña stimulator as a tool to map the limits of dissection and continence zone during bladder exstrophy repair

INTRODUCTION

The complete primary repair of bladder exstrophy (CPRE) aims to restore normal anatomy through complete mobilization and reapproximation of the bladder neck and proximal urethra.

METHODS

The Peña stimulator has previously been used to identify musculature in the pelvis. The device is now used to distinguish intersymphyseal bands from pelvic floor and urethral sphincteric musculature during CPRE. The ability to distinguish the levator ani muscles from fibrotic bands assists the surgeon in identifying the appropriate extent of deep pelvic dissection during CPRE.

RESULTS

During the anatomic bladder neck recreation, the muscle stimulator demonstrated the striated muscle at the level of the bladder neck and urethral sphincter.

CONCLUSION

Localization of the muscles at the bladder neck and proximal urethra corroborates the concept that pelvic floor physical therapy could enhance the strength of the pelvic floor in children with bladder exstrophy.

Treatment Strategies and Outcome of the Exstrophy-Epispadias Complex in Germany: Data From the German CURE-Net

Introduction: To evaluate the impact of reconstructive strategies and post-operative management on short- and long-term surgical outcome and complications of classical bladder exstrophy (CBE) patients' comprehensive data of the multicenter German-wide Network for Congenital Uro-Rectal malformations (CURE-Net) were analyzed. Methods: Descriptive analyses were performed between 34 prospectively collected CBE patients born since 2009, median 3 months old [interquartile range (IQR), 2-4 months], and 113 cross-sectional patients, median 12 years old (IQR, 6-21 years). Results: The majority of included individuals were males (67%). Sixty-eight percent of the prospectively observed and 53% of the cross-sectional patients were reconstructed using a staged approach (p = 0.17). Although prospectively observed patients were operated on at a younger age, the post-operative management did not significantly change in the years before and after 2009. Solely, in prospectively observed patients, peridural catheters were used significantly more often (p = 0.017). Blood transfusions were significantly more frequent in males (p = 0.002). Only half of all CBE individuals underwent inguinal hernia repair. Cross-sectional patients after single-stage reconstructions showed more direct post-operative complications such as upper urinary tract dilatations (p = 0.0021) or urinary tract infections (p = 0.023), but not more frequent renal function impairment compared to patients after the staged approach (p = 0.42). Continence outcomes were not significantly different between the concepts (p = 0.51). Self-reported continence data showed that the majority of the included CBE patients was intermittent or continuous incontinent. Furthermore, subsequent consecutive augmentations and catheterizable stomata did not significantly differ between the two operative approaches. Urinary diversions were only reported after the staged concept. Conclusions: In this German multicenter study, a trend toward the staged concept was observed. While single-stage approaches tended to have initially more complications such as renal dilatation or urinary tract infections, additional surgery such as augmentations and stomata appeared to be similar after staged and single-stage reconstructions in the long term.

Urethral duplication in male epispadias: a very uncommon association

BACKGROUND

Urethral duplication associated with epispadias is a rare malformation. Few cases are described in Literature. We report the experience of two centers to add to the literature.

METHODS

A retrospective study was conducted in two Italian Centers. All patients with urethral duplication associated with epispadias, treated from 1997 to 2017 were included. The preoperative work-up included renal-urinary ultrasonography and voiding cystourethrogram. All patients underwent surgery according to the Mitchell-Caione technique. Cosmetic result, urinary continence and satisfaction degree of patients at the last follow-up were evaluated as outcomes. Six male patients with urethral duplication in epispadias were included. Two patients presented penile epispadias and four penopubic epispadias. Only one patient had urinary incontinence as presenting symptomatology. The diagnosis of urethral duplication was accidental during preoperative evaluation in the remaining five patients.

RESULTS

At last follow-up (mean 8.3 years) all patients but one presented good cosmetic result, one patient presented mild stress urinary incontinence, one presented nocturnal enuresis. The physical genital appearance was improved in all patients. Urethral duplication in association with epispadias is a rare urogenital abnormality. No classification is universally accepted.

CONCLUSIONS

Based on our experience, we believe that the presence of any duplication should be carefully searched during surgery for male epispadias.

Mobilization of pelvic musculature and its effect on continence in classical bladder exstrophy: a single-center experience of 38 exstrophy repairs

Soft tissue mobilization of pelvic musculature in bladder exstrophy repair and its effect on continence. A single-center experience of 38 exstrophy repairs in children.

INTRODUCTION/BACKGROUND

Bladder exstrophy is characterized by infra-umbilical abdominal wall defects, evaginated bladder plate of varying size, epispadias, abnormality of genitalia and bony pelvis. The goal of repair is to provide satisfactory continence, which should preferably be done in specialized centers dedicated to exstrophy management. The concept of functional reconstruction rather than urinary diversion is the gold standard worldwide, which can be accomplished by staged or one-stage procedures. Our technique of mobilization of pelvic musculature is based on the concept that continence in bladder exstrophy can be achieved by repairing the disorganized/splayed tissues involved in normal continence (as first advocated by J.H. Kelly) without osteotomy.

OBJECTIVES

A systematic review of outcomes of neonatal bladder closure followed by mobilization of pelvic musculature in bladder exstrophy repair in children.

STUDY DESIGN

A retrospective chart review of all exstrophy repairs conducted over a 10-year period (between 2001 and 2011). Repairs were done in two stages: bladder closure in the neonatal period (stage 1); and mobilization of pelvic musculature and epispadias repair (stage 2), preferably done between 4 and 6 months of age. The data on complications and continence were evaluated.

RESULTS

Thirty-eight patients had completed all the stages of repair. Mean follow-up was 4.5 years (range 2.5-8 years). The following complications were noted: bladder dehiscence in eight patients after stage 1 repair, penopubic fistula occurred in four patients following stage 2 repair. Vulval scarring and vulval dehiscence (2 patients) were complications seen in girls. Twenty-four of the 38 patients (63.5%) achieved complete continence. Functional continence was attained by 31 of the 38 patients (82%). Older age at bladder closure affected continence, while the number of attempts at closure did not affect outcome. The age at pelvic mobilization was not a significant factor in outcome.

DISCUSSION

The pelvic floor musculature and urethral sphincters are essential for voluntary control of micturition. In bladder exstrophy, these components are splayed out and our technique is based on reorganizing these components in the second stage. The voluntary urethral sphincter is a delicate complex of musculature located dorsal to the opened urethral plate and spread over the corpora. These are identified using a muscle stimulator and repaired around the tubularized urethra. Normally the levator ani muscle, by its attachment to the pubic bone, forms a loop, by which it compresses the urethra, providing additional aid in continence. In bladder exstrophy with wide pubic diastasis, this loop configuration is lost and becomes a hammock configuration and in fact becomes a pushing force. By mobilizing the pelvic musculature and repairing it in front of the bladder neck, this loop configuration is re-established and further aids in continence. After a successful second stage, patients may have increased frequency and dribbling initially, which improves with age as bladder capacity increases. Perineal exercises aimed at strengthening the pelvic floor musculature are an integral part of our bladder exstrophy management, which begins once the child can understand the technique. The results of our technique are shown in comparison with other series employing the original Kelly's technique (see Table). None of our patients have undergone additional bladder neck repair or permanent augmentation.

CONCLUSIONS

Neonatal bladder closure followed by mobilization and repair of the pelvic musculature, produce satisfactory continence in exstrophic children. Proper identification and repair of the external sphincter and levatorplasty correct the altered anatomy by relocating the bladder neck and posterior urethra deep in the pelvis, simulating normal micturition. Early neonatal bladder closure improves outcome. The results are reproducible if basic principles governing continence are followed and when done in a specialized centers.

Long-term outcome of male genital reconstruction in childhood

Hypospadias, epispadias with or without exstrophy, and disorders of sex development are among the most common anomalies of genitalia that occur during childhood. Considering the tremendous effect of genitourinary reconstruction on adult life, the evaluation of the long-term results of different techniques of genitoplasty in pediatrics is of the utmost importance. After reviewing the literature, the authors summarize the available long-term outcomes of genitoplasty in childhood, specifically focusing on the cosmetic, psychosocial, psychosexual and functional results, and emphasize that, contrary to the widely available data on early outcomes of genital reconstruction in the pediatric population, very few well described controlled studies have evaluated the long-term effect of genitoplasty in puberty and adulthood, in the sense that the surgeon should describe the peroperative findings in more detail and also be more structured in evaluating the postoperative result at follow-up visits. Finally, the authors conclude that more attention should be paid to the impact of these techniques on cosmetic aspects and psychosexual development in these patients after puberty, as they play a crucial role in their adult quality of life.

Penile repair in patients with epispadias-exstrophy complex-can we prevent resultant hypospadias?

PURPOSE

Male genitalia reconstruction in patients with exstrophy-epispadias complex often leads to secondary hypospadias, thus requiring additional surgery and resulting in possible complications. We describe a technique of male epispadias repair to prevent resultant hypospadias.

MATERIALS AND METHODS

The complete penile disassembly technique is modified by multiple Z-plasties, which enable creation of a funnel-like bladder neck and urethral plate lengthening. A total of 29 patients 2 months to 12 years old presenting with pure epispadias and bladder exstrophy were treated with this technique between 2004 and 2011. These patients were compared to 19 patients 1 day to 11 years old with exstrophy-epispadias treated with the standard penile disassembly technique between 2000 and 2004.

RESULTS

Outcome measures were urethral orifice position, penile length and complications. There was no statistically significant difference between the 2 groups regarding penile length or complications. In the study group the urethra reached the tip of the glans in all patients, whereas the creation of intentional hypospadias was necessary in 6 patients (31.5%) in the control group (p <0.05).

CONCLUSIONS

The modified technique was effective in obtaining appropriate meatal location without decreasing the penile length. The complication rate was not changed. Creation of resultant hypospadias at genitalia reconstruction in male epispadias should strongly be prevented.

A novel midline scroto-perineal approach facilitating innervation preserving sphincteroplasty and radical corporal detachment for reconstruction of exstrophy-epispadias

OBJECTIVE

To report a novel surgical approach for single-stage repair of exstrophy-epispadias, with the specific aim of innervation, preserving sphincteroplasty corporal detachment for penile lengthening and ischio-pubic ramotomy for Linia-alba approximation.

MATERIAL AND METHODS

Twenty-five classic exstrophy with compliant bladder plate and 10 incontinent epispadias patients were selected. Preoperative magnetic resonance angiogram of urogenital diaphragm showed triangular space between ischio-cavernosus, bulbo-spongiosus, and transverse-perinei muscles containing sphincteric branch of perineal artery indicating the course of sphincteric nerve. Bladder plate was mobilized. Through a midline scrotal septal and transverse incision along the base of urogenital triangle, the urogenital diaphragm was exposed. Corpora were separated from the urethral plate while preserving the glanular continuity and innervation to striated urethral sphincter, using muscle stimulator and nerve integrity monitor. In the subperiosteal plane along the ischio-pubic rami, the corpora were detached. Repair included ureteric reimplantation; anatomic reconstruction of bladder, bladder neck, urethra, and striated sphincter; corporo-glanuloplasty; ischio-pubic ramotomy; and abdominal closure. Assessment included surgical problems, cosmetic satisfaction, erectile function, continence, and upper tract status at 2-year follow-up.

RESULT

There was no corporal loss. Postoperative complications included 4 perineal suture line infections, 11 peno-pubic fistula, and 1 adhesive intestinal obstruction. Erectile function was good in 33 patients. Penile length was gratifying in 25. Of 28 patients, 20 (71.4%) had dry interval of two hours. Dimercaptosuccinic acid study demonstrated upper tract scarring in 2 patients.

CONCLUSION

This approach facilitates innervation preserving sphincteroplasty and precise restoration of anatomy to near normal without operative accidents because of wide exposure gained, improving the functional and cosmetic results.

Surgical anatomy of urogenital diaphragm and course of its vessels in exstrophy-epispadias

OBJECTIVES

To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias.

METHODS

A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography.

RESULTS

A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm.

CONCLUSIONS

First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the triangular space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora.

Comparison of musculoskeletal and urological functional outcomes in patients with bladder exstrophy undergoing repair with and without osteotomy

It is controversial as to whether osteotomy, by restoring a more normal pelvic anatomy, might improve the final outcome of bladder exstrophy (BE) repairs. We compared the functional orthopaedic and urological outcomes in BE patients treated with and without osteotomy. Orthopaedic and urological outcomes were compared in eight BE patients treated with osteotomy and six BE patients treated without osteotomy. Orthopaedic evaluation included an assessment of pubic bones dissymmetry, bending of the spine, presence of Trendelenburg or Thomas sign, and presence of out-toeing. Pubic diastasis was ruled out on a plain X-ray of the pelvis. A Pediatric Orthopedic Society of North America (POSNA) questionnaire was administered to every child or his/her caregiver to assess functional outcome. Urological evaluation included an assessment of required continence surgeries and of contemporary continence status. All patients presented a pubic diastasis. This was in median 49 (24-66) mm in patients treated without osteotomy and 42 (25-101) mm in those treated with osteotomy (p = 0.3). There was no difference either in the orthopaedic outcome or in any features of the POSNA questionnaire between groups. Neither was there a difference in the final continence rate nor in the number of additional continence procedures required. Although osteotomy is an essential step in the treatment of many BE patients in order to achieve a tension-free closure of the abdominal wall and bladder, our preliminary results suggest that it does not improve the eventual orthopaedic or urological outcomes of BE.

Pelvic Floor Reconstruction in Female Exstrophic Complex Patients: Different Results from Males?

OBJECTIVES

To present the surgical, functional, and cosmetic results of anterior pelvic floor reconstruction in female exstrophic patients who underwent single-stage surgical repair. To verify differences in outcome from male exstrophic patients.

METHODS

Among the 31 exstrophy-epispadias complex (EEC) patients treated in 10 yr, 13 (42%) were females. We studied 10 of them (9 classic exstrophies and 1 prolapsing epispadia), aged 2 d to 6 yr, who received one-stage repair with pelvic floor reconstruction. The reconstructive steps were posterior pelvic osteotomy, en bloc mobilisation of bladder neck-urethra/vagina within the midline pelvic floor, symmetrical reassembly of the muscular complex that constitutes the pelvic diaphragm (using a bipolar stimulator), tubularisation and elongation of the bladder neck and urethra, and genitoplasty. At 2- to 3-yr follow-up, bladder capacity and dry intervals were evaluated by cystogram and urodynamic study, respectively. Surgical complications and cosmetic appearance were also assessed. Results were compared with a group of 18 male EEC patients treated in the same period with similar technique. Fisher exact test and chi-square test were used for statistical analysis.

RESULTS

No bladder/urethra dehiscence, exstrophy relapse, or uterine procidentia were observed. Cosmesis was fully satisfying in all. Bladder capacity ranged from 35 to 137 ml (mean: 87). Cyclic voiding with 45- to 90-min dry intervals was achieved in 7 patients (70%), but stress incontinence was present in 5 patients. Volitional micturition control was achieved in 5 of 6 (83.3%) girls aged 4-8 yr. In the male group, we observed two surgical complications (glans disruption and urethrocutaneous fistula) and one poor cosmetic outcome. Mean bladder capacity was 70 ml (range: 25-140). Dry intervals were present in 6 patients (33%). Volitional voiding was achieved in 5 of 12 (40%) male exstrophic patients older than 4 yr, with little stress incontinence. Female and male EEC patients presented significantly different outcomes (p<0.05) regarding both surgical complications and functional bladder behaviour.

CONCLUSIONS

Pelvic floor reconstruction and its correct relationship with the lower genitourinary tract may facilitate the development of volitional micturition control. Female patients behaved slightly better than males concerning dry intervals and coordinated bladder activity achievement.

Single-stage repair of bladder exstrophy in older children and children with failed previous repair

AIM

Evaluation of cosmetic and functional outcome of single-stage exstrophy-epispadias complex repair in older children and those with previously failed repair.

MATERIALS AND METHODS

This study comprised 15 children (12 boys and 3 girls) with classic bladder exstrophy and a mean age at repair of 8.6 months (range 2-24 months). Eight children had a previously failed repair. All children underwent complete primary repair using the single-stage Mitchell technique. Half of the boys had complete penile disassembly, while in the others a modified Cantwell-Ransley technique for epispadias repair was used. Anterior iliac osteotomy was performed and hip spica used for immobilization in all children.

RESULTS

One child had urethral stricture treated by endoscopic visual urethrotomy. Three children had penopubic fistulae that closed spontaneously. No bladder dehiscence or prolapse was encountered. Vesicoureteral reflux was present in 20 renal units but ureteral reimplantation was not performed. Average bladder capacity after closure was 134 cm(3) (range 110-160 cm(3)) with only two partially continent and six incontinent children. Mean follow-up period is 2 years (range 1-3 years).

CONCLUSIONS

Single-stage repair was performed in children with previously failed repair and those presenting at an older age with satisfactory results. Acceptable bladder and genital anatomy and function were achieved together with preservation of renal function. The impact of this technique on continence is not encouraging, but needs to be determined in a longer follow-up period.

Recent advances in external genitalia

In the last decade, significant progress in the knowledge and management of external genital anomalies has been achieved, including an improved understanding of epidemiology and pathophysiology of these anomalies, the identification of etiologic genetic defects, and significant improvements in surgical approaches that have decreased complications and improved cosmetic outcomes. We highlight the most clinically important advances of the commonly encountered external genital anomalies.

Surgery Insight: advantages and pitfalls of surgical techniques for the correction of bladder exstrophy

Staged reconstruction repair of bladder exstrophy results in hydronephrosis or renal scarring in 15-25% of patients. A cosmetically acceptable and functional phallus can be achieved in 85% of patients, 20-30% of whom will require more than one operation for penile reconstruction. Episodes of penile glans loss or corporal loss are rarely reported with this technique. Widely disparate results relating to complete urinary continence and volitional voiding have been published, with urinary continence reported to occur in 7-85% of patients. The need for bladder augmentation to obtain urinary continence also varies, with reports that somewhere between 10% and 90% of patients require an augmentation procedure to gain urinary continence. Complete primary repair of bladder exstrophy using the penile disassembly technique results in hydronephrosis or renal scarring in 0-30% of patients, and hypospadias, as a consequence of this repair, will occur in 30-70% of patients. Loss of the glans and corpora appear more frequently with penile disassembly than in staged reconstruction of bladder exstrophy, however, the exact incidence of this complication is unknown. Reported complete urinary continence and volitional voiding rates are also varied following penile disassembly, ranging from 25-65%. A modified bladder-neck reconstruction to gain urinary continence is reportedly required in 15-90% of patients, with 5-10% requiring both bladder augmentation and bladder-neck reconstruction. Experience with complete primary repair of bladder exstrophy, using the penile disassembly approach, seems promising but is not a panacea. To outline the risks and benefits regarding the various surgical techniques for bladder exstrophy, we would recommend the establishment of a national registry for patients with this disorder.

Komplizierte Harnröhrenrekonstruktionen bei Erwachsenen und Kindern

The urethral reconstruction is a challenge in the adult, but even more in infant and young male patients. Good knowledge of the anatomy of the penis (blood supply and the course of the nerve fibers) with the availability of microsurgery suturing and instruments improved the outcome significantly. The growing knowledge opened the possibility to reconstruct complicate strictures with grafts. The buccal mucosa flap is one of those improvements, which made a tremendous impact to have a successful outcome. Recently we looked into the outcome of urethral reconstruction of long urethral strictures by using a buccal mucosa only flap. We used a modified technique for hypospadias repair to reconstruct coronar or subcoronar defects by meatal mobilization (MEMO). In cases with a long urethral stricture the success rate was over 90% with a mean follow up of 16 months. In all children the outcome with the MEMO-technique was successful without any major complication with a mean follow-up of 12.5 months.

Anterior Perineal Reconstruction in Exstrophy-epispadias Complex

OBJECTIVES

To assess the role of correct anatomical reconfiguration of the anterior perineal musculature in exstrophy-epispadias (E-E) patients. To stress the use of a bipolar stimulator to detect the perineal muscular complex intraoperatively, and to increase the functional results of reconstruction in E-E patients.

METHODS

A total of 22 patients with E-E complex were treated in a 7-year period: 17 patients presenting classic bladder extrophy (aged 3 days to 6 years) and 5 incontinent male epispadias (aged 9 months to 16 years). An electric bipolar stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. Outcome was evaluated at 24 months from surgery, considering bladder capacity, dry intervals, urinary infections (UTI's), upper tract deterioration and surgical complications (fistula, obstruction, dehiscence). Results were compared with a matched group of 19 E-E patients treated in the previous 5-year period, without the presented technique (control group). Student T-test was used for statistical analysis, considering p<or=0.05 as significant.

RESULTS

No bladder neck or urethral dehiscence was observed. Mean bladder capacity at 2-year follow-up was 80 cc in the exstrophic patients and 120 cc in the male epispadias. Mean dry interval increased to 75 minutes in the exstrophy patients and to 130 minutes in the male epispadias. Full daytime continence was achieved in 3 exstrophic and in all the epispadic patients. The difference with the control group of patients was significant (p<0.05).

CONCLUSIONS

Proper identification of the anterior perineal muscular complex, using a bipolar stimulator, and its reapproximation at the posterior urethra on the midline was demonstrated to be effective in increasing bladder cycling and in developing adequate bladder volume, anticipating coordinated micturition.

The place of pelvic osteotomy in the modern era of bladder exstrophy reconstruction

BACKGROUND

The place of pelvic osteotomy in reconstructing bladder/cloacal exstrophy has been debated for some time; the experience with 'combined' osteotomy in primary and re-operative exstrophy closure at this institution is presented, with a discussion of the historical and scientific place of osteotomy in managing this condition.

PATIENTS AND METHODS

Sixty-eight patients had bilateral vertical and transverse iliac osteotomy between 1992 and 2003, and with outcome data available. Of 58 patients with classic exstrophy, eight were newborns, eight were deliberately delayed primary closures, 36 were re-operative after previous failed closure and six were bladder neck reconstructions where the bladder outlet was very wide, such that bony closure was felt necessary for successful bladder neck coaptation. Of 10 patients with cloacal exstrophy, nine were primary closures and one was a re-operative closure. Data were collected relating to age at closure, complications and continence outcome.

RESULTS

The mean (range) age (months) was 41 (5-179) for re-operative closures, 12.5 (3-32) for delayed primary closures, 64.1 (38-79) for bladder neck reconstruction, 51.4 (6-165) for cloacal exstrophy closure, and 15 (2-45) days for newborn exstrophy closure. There was a superficial wound infection in two patients, pin-site infection in one, loose pins in two, and two had transient femoral nerve palsy. In two patients the procedure failed and they required further re-operative closure with osteotomy. Sixteen patients are dry urethrally day and night, 12 have had and four are awaiting bladder augmentation, one has a colon conduit, and 35 are awaiting a definitive continence procedure.

CONCLUSIONS

Osteotomy has a proven track record in the field of exstrophy reconstruction, and the benefit especially in re-operative closure is emphasized by the present results. The surgical morbidity with the 'combined osteotomy' is low, cosmetic results are excellent and the effect on success of closure is clearly advantageous.

The management of urinary incontinence in the exstrophy complex, posterior urethral valves, and infrasphincteric ureters

Urinary incontinence is a debilitating problem that requires careful evaluation. Causes of incontinence in children are numerous, and once the mechanism of incontinence has been identified, management can be planned carefully. The management and outcome in children born with the exstrophy-epispadias complex, posterior urethral valves, and children who have an infrasphincteric ureteric orifice are discussed in this article.

The endoscopic treatment of incontinence in children

The achievement of urinary continence in children may be very difficult with some congenital malformations of the lower urinary tract, such as bladder exstrophy, or in some neurogenic dysfunctions, such as neuropathic bladder. Endoscopic injection of bulging substances into the bladder neck or posterior urethra may be regarded as a minimally invasive procedure that may provide a better dry interval in these patients. Endoscopic treatment can be performed as either a primary or adjunctive procedure after open bladder neck surgery. It is also of use to increase the functional bladder capacity in some children. Although longer follow-up is wise, results so far are encouraging. The search for a safe and reliable substance to use is still ongoing, and the new available biodegradable implants seem adequate.

Evolution of male epispadias repair: 16-year experience

PURPOSE

We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs.

MATERIALS AND METHODS

From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis.

RESULTS

Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042).

CONCLUSIONS

The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

Evolution of male epispadias repair: 16-year experience

PURPOSE

We review our experience during the last 16 years, adopting different surgical approaches for epispadias repair, and compare the results of complete penile disassembly technique with perineal muscular complex reassembly since 1995 with previous repairs.

MATERIALS AND METHODS

From 1984 to 1999, 58 epispadias repairs were performed in 53 male patients 3 days to 13 years old, including 18 with primary penopubic epispadias, 35 with bladder exstrophy and 5 treated with secondary genito-urethroplasty after previous repairs of the exstrophic complex. Cases were divided into 2 periods of the surgical procedure. Different techniques succeeded in 41 patients in the first decade (group 1) while the complete penile disassembly with perineal muscular complex reassembly technique was used in 17 patients during the last 5-year period (group 2). Results of both groups were compared, and Fisher's exact test was used for statistical analysis.

RESULTS

Of the 41 group 1 cases complications (mostly fistula and/or urethral stenosis) in 21 (51%) required 1 or multiple operations. Continence was never achieved with urethroplasty alone. Cosmetic appearance of the phallus was not satisfactory in 23 cases (29%) and urethral catheterization was difficult in 8 (19%). Of the 17 group 2 cases only 2 complications (11%) occurred (1 fistula and 1 distal urethral stenosis). Dry intervals or voluntary continence was achieved in 6 of the 10 patients with exstrophy and in all but 1 with epispadias without bladder neck surgery. The penis had a satisfactory cosmetic appearance and no dorsal chordee with an easily catheterizable urethra was noted. The complication rate was significantly different in the 2 groups (Fisher's exact test p = 0.0042).

CONCLUSIONS

The complete penile disassembly with perineal muscular complex reassembly technique, with deeper positioning of the urethra in the perineal musculature, seems to guarantee a significant step forward in functional epispadias repair.

Urethral reconstruction in children

For hypospadias repair tubularized incised plate urethroplasty provides excellent cosmetic and functional results. It appears to provide equivalent or even better outcomes than other standard procedures. However, long-term results are still lacking. Free grafts show similar complication rates to those with pedicled flaps, and onlays appear to be superior to tubes. By respecting the anatomy and with the use of a few surgical tricks, the fistula rate can be significantly reduced. For epispadias repair, the modified Cantwell-Ransley repair and the complete disassembly technique show good postoperative results, the latter being able to restore the normal anatomical relationship of the male genital components.