New basic science concepts in the treatment of classic bladder exstrophy

Low-dose Human Chorionic Gonadotropin Stimulation Test as a Prognostic Incontinent Indicator in Boys With Bladder Exstrophy-epispadias Complex

OBJECTIVE

To investigate the effect of low-dose human chorionic gonadotropin (HCG) administration on structural changes in the lower urinary tract in boys with urinary incontinence in the setting of bladder exstrophy-epispadias complex (BEEC).

PATIENTS AND METHODS

We prospectively evaluated 30 patients (median age 7.5 years) with BEEC and randomly divided them into 2 groups. Patients in the HCG group were administered 250 IU HCG intramuscularly 3 times per week during a 4-week period. The other 15 patients served as the control group. The patients were followed up for a mean duration of 4 years. Incontinence rate, hormonal changes, penile length, prostate size, and bladder capacity were evaluated using 3D sonography or pelvic magnetic resonance imaging and uroflowmetry studies before and after HCG administration.

RESULTS

The incontinence score improvement was significantly higher in the HCG group (P = .01). A significant increase was detected in the health-related quality of life score of both patients and parents at the final follow-up (P < .001). The total prostate size (P < .0001) and bladder capacity (P < .0001) increased significantly in all patients of the HCG group. Basal serum testosterone level increased significantly after the first (P = .001) and last (P < .001) injections with no significant increase 3 months after the last injection (P > .05). No major side effect was found following the administration of HCG, with no need for open surgical bladder neck reconstruction.

CONCLUSION

Our preliminary results suggest the role of low-dose HCG in boys with BEEC suffering from urinary incontinence. The data also reveal the role of prostate enlargement in the improvement of urinary incontinence. Chronic treatment with HCG increases bladder capacity that may facilitate future reconstructive surgery.

New advances in the pathophysiologic and radiologic basis of the exstrophy spectrum

The exstrophy-epispadias complex is a rare spectrum of anomalies affecting the genitourinary system, anterior abdominal wall, and pelvis. Recent advances in the repair of classic bladder exstrophy (CBE) and cloacal exstrophy (CE) have resulted in significant changes in outcomes of surgical management (including higher continence rate, fewer surgical complications, and better cosmesis) and health-related quality of life in these patients. These noteworthy changes resulted from advances in the pathophysiological and genetic backgrounds of this disease and better radiologic assessment of the three-dimensional anatomy of the bony pelvis and its musculature. A PubMed search was performed with the keyword exstrophy. The resulting literature pertaining to genetics, stem cells, imaging, tissue engineering, epidemiology, and endocrinology was reviewed. The following represents an overview of the advances in basic science understanding and imaging of the exstrophy-epispadias spectrum and discusses their possible and future effects on the management of CBE and CE.

Pelvic osteotomy and symphysis reconstruction in bladder exstrophy: Early (2-6 years) results with a new (Double Door) symphysis reconstruction

OBJECTIVES

To describe the 2-6-years follow up of a combination of oblique pelvic osteotomies and a new method for symphysis reconstruction, with the aim of creating a stable pelvic ring that will not widen during growth.

MATERIALS AND METHODS

Five children were operated on between 1998 and 2003 at the age of 2 days to 8 months. One child had a cloacal exstrophy. A 'Double Door' plasty was performed from hinged cartilaginous flaps at either side of the symphysis diastasis. This was followed by primary fixation with heavy resorbable sutures and 6 weeks in vertical traction for the younger ones and a pelvic external fixator (for 3 months) for the older (>6 months).

RESULTS

One child had a deep infection at 2 weeks postoperatively and healed with gradually increasing diastasis (39 mm at 3 years+2 months). All the others healed uneventfully and the symphysis stabilized after a few weeks. All had a stable symphysis diastasis of only 15-25 mm during the observation period.

CONCLUSIONS

A stable, narrow symphysis can be created by combining oblique pelvic osteotomies with a Double Door plasty, allowing uro-genital reconstruction without interfering with pelvic growth or hip function.

The exstrophy-epispadias complex: is aesthetic appearance important?

OBJECTIVE

To show the relevance of cosmetic appearance in the adequate treatment of patients with exstrophy-epispadias complex (EEC), and to indicate that surgery by experienced teams can improve the long-term treatment forecast and the patient's body image.

PATIENTS AND METHODS

From 1978 to 2002, 71 patients diagnosed with EEC were treated in the authors' institution; 24 (aged 2-23 years) were selected to undergo different surgical procedures. The criterion for surgery considered interviews conducted by the psychology team with the parents and children. The plastic surgery and paediatric urology teams carried out the procedures jointly; the follow-up was 0.33-7 years.

RESULTS

Five female patients and six male had abdominoplasty to treat multiple scars; eight had intermittent catheterization conduits repositioned from the right iliac fossa to the umbilicus. Six female patients had plastic surgery of the external genitalia and three had a broad mobilization of the urogenital sinus. Thirteen male patients had a small penis and had the corpora cavernosa fully mobilized and the penis reconstructed. Five female patients and one male had anterior osteotomy. One patient with no left testis had it replaced and one patient with uterine prolapse had the uterus fixed to the posterior abdominal wall. Six patients had a second procedure, in two because the outcome of the initial operation was poor and in the others to complement the initial treatment. In all but one patient there was an improvement in the objective criteria, e.g. school absences, difficulty in establishing long-lasting social relationships and refusal to participate in sports activities. However, none of the patients would attempt sexual intercourse.

CONCLUSIONS

Body image, self-esteem, sexuality, sexual function and fertility are deemed crucial by adolescents; in patients with EEC customised surgical procedures can give a satisfactory aesthetic outcome, and be a further reason for adequately following occasional urinary complications and renal function, to avoid loss to follow-up.

Fetal bony pelvis in the bladder exstrophy complex: normal potential for growth?

OBJECTIVES

To provide the first look at the bony histologic features of fetuses with the exstrophy complex, specifically evaluating the endochondral ossification, stage of development, and microscopic potential for normal growth.

METHODS

Three fetuses between 28 and 30 weeks of gestation, one with classic bladder exstrophy, one with cloacal exstrophy, and one control, were obtained from France. The bony pelves were dissected and preserved in formalin, and multiple representative sections were sliced from all pelvic areas: pubis, ischium, ilium, and sacrum. These slices were sequentially processed as slides, stained with hematoxylin-eosin, and evaluated microscopically for histologic changes, developmental stage, and degree of endochondral ossification.

RESULTS

All slides from the three specimens showed cartilage analogue with endochondral ossification. Histologically the exstrophy specimens were identical to the control and appeared completely normal; bone development was occurring at an expected rate with the potential for continued normal growth.

CONCLUSIONS

These new findings illustrate that fetal bone in the exstrophy complex displays normal microscopic growth patterns and unhindered endochondral ossification at 28 weeks of gestation, well beyond the embryologic period. With no evident microscopic bony defect, the gross bony anomalies in exstrophy should be surgically correctable, leading us to conclude that early reapproximation of the physiologic shape of the pelvis could lead to more normal gross bone growth, decreased shortage of bone, and a more appropriate distribution of the mechanical and developmental forces on a closed, normally functioning pelvic ring.