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Cleper R, Blumenthal D, Beniamini Y, Friedman S, Yosef YB, Chaim JB. Exstrophy-epispadias complex: are the kidneys and kidney function spared? Pediatr Nephrol 2023; 38:2711-2717. [PMID: 36745252 DOI: 10.1007/s00467-023-05889-y] [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: 04/20/2022] [Revised: 01/09/2023] [Accepted: 01/09/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Exstrophy-epispadias complex (EEC) is a complex malformation of the lower abdominal wall, bladder, and pelvic floor, which necessitates multiple successive reconstruction procedures. Surgical and infectious complications are frequent. Our aim was to evaluate kidney function in these patients. METHODS This cross-sectional study included patients with EEC, followed since birth in a pediatric urology clinic, who underwent nephrological evaluation (blood pressure (BP) measurement and blood and urine chemistries) and imaging studies (urinary tract ultrasound and DMSA kidney scan) during 2017-2020. RESULTS Forty-three patients (29 males), median age 9 years (interquartile range 6-19), were included. Eleven (26%) used clean intermittent catheterization (CIC) for bladder drainage. At least one sign of kidney injury was identified in 32 (74%) patients; elevated BP, decreased kidney function (estimated glomerular filtration rate (eGFR) < 90 ml/min/1.73 m2), and proteinuria/albuminuria were detected in 29%, 12%, and 36% of patients, respectively. Urinary tract dilatation (UTD) was found in 13 (37%) ultrasound examinations. Parenchymal kidney defects were suspected in 46% and 61% of ultrasound and DMSA scintigraphy, respectively. UTD was significantly associated with DMSA-proven kidney defects (p = 0.043) and with elevated BP, 39% vs. 20% in those without UTD. Decreased eGFR and elevated BP were less frequent among patients on CIC than among patients who voided spontaneously: 10% vs. 14% and 18% vs. 36%, respectively. Recurrent UTIs/bacteriuria and nephro/cystolithiasis were reported by 44% and 29% patients, respectively. CONCLUSION The high rate of signs of kidney injury in pediatric patients with EEC dictates early-onset long-term kidney function monitoring by joint pediatric urological and nephrological teams. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Roxana Cleper
- Pediatric Nephrology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 14 Weizman St, 64239, Tel Aviv, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Danith Blumenthal
- Pediatric Nephrology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 14 Weizman St, 64239, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Beniamini
- Pediatric Urology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shiran Friedman
- Pediatric Nephrology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 14 Weizman St, 64239, Tel Aviv, Israel
- Pediatric Urology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yuval Bar Yosef
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Urology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jacob Ben Chaim
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Urology Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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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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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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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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Palacios-Palacios L, Salazar-Ramirez KJ. Anestesia y analgesia para corrección de extrofia vesical. Reporte de 3 casos. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2015.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Anaesthesia and analgesia for bladder exstrophy correction. Case reports. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2015.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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7
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Prenatal Diagnosis of Cloacal Exstrophy: A Case Report and Differential Diagnosis with a Simple Omphalocele. J Med Ultrasound 2015. [DOI: 10.1016/j.jmu.2014.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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8
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Anaesthesia and analgesia for bladder exstrophy correction. Case reports☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543030-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Pierre K, Borer J, Phelps A, Chow JS. Bladder exstrophy: current management and postoperative imaging. Pediatr Radiol 2014; 44:768-86; quiz 765-7. [PMID: 24939762 DOI: 10.1007/s00247-014-2892-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 12/01/2013] [Accepted: 01/20/2014] [Indexed: 11/30/2022]
Abstract
Bladder exstrophy is a rare malformation characterized by an infra-umbilical abdominal wall defect, incomplete closure of the bladder with mucosa continuous with the abdominal wall, epispadias, and alterations in the pelvic bones and muscles. It is part of the exstrophy-epispadias complex, with cloacal exstrophy on the severe and epispadias on the mild ends of the spectrum. Bladder exstrophy is the most common of these entities and is more common in boys. The goal of this paper is to describe common methods of repair and to provide an imaging review of the postoperative appearances.
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Affiliation(s)
- Ketsia Pierre
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA,
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10
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Mesrobian HGO. Complete primary repair of bladder exstrophy is associated with detrusor underactivity type of neurogenic bladder. Urology 2014; 83:1139-44. [PMID: 24485361 DOI: 10.1016/j.urology.2013.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/04/2013] [Accepted: 11/09/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To test the hypothesis that complete primary repair of bladder exstrophy (CPRE) is associated with detrussor underactivity. For this purpose, we review (1) our experience, (2) the results of the published literature as it pertains to bladder function, and (3) the known anatomic basis on which the mechanism of the observed outcome can be understood. METHODS The medical records of all patients who underwent CPRE by the author between 2004 and 2010 were reviewed. Attention was focused on the clinical, imaging, and urodynamic findings. RESULTS Four men and 2 women underwent CPRE. Follow-up ranges from 2 to 8 years. Four underwent bilateral ureteral reimplantation combined with bladder neck repair in 3. Detrusor activity (or overactivity) was not recorded in the 5 patients who underwent urodynamic studies. Four patients achieved short periods of urinary continence. The percent predicted bladder capacity, adjusted for age, ranged from 25 to 70, with a median of 60. Of the 68 publications on CPRE since 1999, none reports the presence of detrusor activity. A description of the pelvic plexus anatomy by Walsh and Donker provides a basis for the mechanism of injury resulting in the previously mentioned results: (1) complete penile disassembly eliminates the distal fixation point of the bladder-urethral plate, (2) the subsequent dissection and mobilization result in shearing injury to the microscopic pelvic plexus branches to the bladder, external sphincter, and prostatic urethra. CONCLUSION CPRE results in disruption of the branches of the pelvic plexus and a neurogenic bladder (detrussor underactivity).
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11
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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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12
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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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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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Abstract
Children with bladder exstrophy present a formidable surgical challenge. Like all major reconstructive surgeries, the best hope for a favorable outcome lies in achieving success in the first operative attempt. Regardless of the surgical approach, however, complications do occur. A failed exstrophy closure is a major complication with significant implications on the long-term surgical outcome and ultimate fate of the urinary tract. Successful repeat exstrophy closure can be accomplished in most cases when performed in conjunction with pelvic osteotomy and proper postoperative immobilization. Modern staged repair of exstrophy, complete primary repair of exstrophy, and immediate continent urinary diversion have been advocated by different groups in the management of a failed exstrophy closure. It is apparent that compared with children who undergo successful primary closure, a failed closure with subsequent successful repeat closure makes the child much less likely to achieve sufficient bladder growth to be considered for bladder neck reconstruction, and furthermore, makes them less likely to have a successful bladder neck reconstruction even when they are an acceptable candidate. Although acceptable dryness rates after repeat closure can ultimately be obtained, they are typically at the expense of a commitment to intermittent catheterization and continent diversion.
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Affiliation(s)
- Thomas E Novak
- Department of Surgery, Division of Urology, Brooke Army Med Center, San Antonio, TX 78234, USA.
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15
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Evaluation of need for salvage continence procedures after failed modern staged repair. Urology 2010; 76:39-42. [PMID: 20451966 DOI: 10.1016/j.urology.2008.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 10/30/2008] [Accepted: 11/06/2008] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess our experience with salvage continence procedures in patients with bladder exstrophy. METHODS We retrospectively reviewed our surgical records of patients with bladder exstrophy who had undergone failed modern staged repair elsewhere and underwent salvage continence operations at our institute from 1996 to 2008. RESULTS A total of 16 patients had undergone salvage continence operations. Bladder augmentation was performed in 11 patients (68.8%); 14 children (87.5%) received a continent, catheterizable stoma. In 6 children (37.5%) bladder neck injections were done. Three patients (18.8%) underwent bladder neck closure combined with other reconstructive procedures. A total of 49 continence procedures were performed, with an average of 3.06 per patient. We included all 16 children >5 years. After these operations, 13 of 16 (81.3%) became continent. Two children were able to void spontaneously and were dry day and night (12.5%). Of the remaining 14 patients, all of whom used clean intermittent catheterization, 11 (68.7%) were continent during the day and night with augmentation and/or a catheterizable stoma. Three patients were incontinent (18.7%). CONCLUSIONS Although the need to perform salvage continence procedures after failed bladder modern staged repair is high, when patients are appropriately selected, continence can be achieved eventually.
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16
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Penile loss following complete primary repair of bladder exstrophy. J Pediatr Urol 2009; 5:519-20. [PMID: 19427815 DOI: 10.1016/j.jpurol.2009.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Accepted: 03/22/2009] [Indexed: 11/24/2022]
Abstract
The complete penile disassembly technique is increasingly employed during the surgical repair of classic bladder exstrophy. We describe the complication in a newborn boy of loss of the glans penis following complete primary exstrophy repair. The possible causes and prevention of this injury are discussed.
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El-Hout Y, Salle JLP, Al-Saad T, Bägli DJ, Lorenzo AJ, Neilson B, Farhat WA. Do patients with classic bladder exstrophy have fecal incontinence? A web-based study. Urology 2009; 75:1166-8. [PMID: 19914696 DOI: 10.1016/j.urology.2009.06.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 05/29/2009] [Accepted: 06/30/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To explore the occurrence of fecal incontinence in patients with classic bladder exstrophy (CBE) by administering a web-based pilot study. METHODS A questionnaire assessing fecal continence status was devised. Questions included demographics, age to achieve toilet training for bowels, and the patient perception of the degree of fecal soiling during day and night, if present. The CBE contact list of our institution's social worker was addressed (324 patients) and directed to fill the survey posted at the website http://www.SurveyMonkey.com. RESULTS There were 94 responders (29%) to the survey. They were analyzed as 2 groups: pediatric (age up to 18 years, n = 69, 9 excluded for not achieving toilet training) and adult (age >18 years, n = 25). In the pediatric group, fecal incontinence was reported in 57% of patients during the day and 32% during night. In the adult group, fecal incontinence was reported in 44% of patients during the day and 40% during night. Seven patients reported having undergone ureterosigmoidostomy (US) diversion. Stratifying patients based on US diversion showed fecal incontinence of 100% vs 22% during the day (P <.001), and 86% vs 22% during the night (P <.01), for the US vs non-US subgroups, respectively. CONCLUSIONS Our preliminary survey suggests that fecal incontinence in CBE may be a significant overlooked issue that may persist into adulthood of CBE patients. With the potential functional and psychological burden, clinical awareness and management of this issue is crucial. Further exploration of this issue, with detailed attention to surgical procedure(s) involved and degree of quality of life impairment, needs to be initiated.
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Affiliation(s)
- Yaser El-Hout
- Division of Urology, Hospital for Sick Children, Toronto, ON, Canada
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Dichorionic diamniotic twin pregnancy discordant for bladder exstrophy. Adv Urol 2009:186483. [PMID: 19753322 PMCID: PMC2742653 DOI: 10.1155/2009/186483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 08/05/2009] [Indexed: 11/17/2022] Open
Abstract
A 38 year-old woman presented with a dichorionic diamniotic twin pregnancy at gestational age of 32 weeks concerning for an abdominal wall mass in one of the twins. Initial ultrasound evaluation was suspicious for an omphalocele, but the affected twin was found to have bladder exstrophy at birth. This illustrates the difficulties of accurate prenatal diagnosis of bladder exstrophy in a twin pregnancy at a late gestation.
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Kibar Y, Roth CC, Frimberger D, Kropp BP. Our initial experience with the technique of complete primary repair for bladder exstrophy. J Pediatr Urol 2009; 5:186-9. [PMID: 19329363 DOI: 10.1016/j.jpurol.2008.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 11/13/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We reviewed our initial results with complete primary repair of exstrophy in regard to continence status and the need for subsequent continence procedures. PATIENTS AND METHODS We performed a retrospective review of our surgical records from 1996 to 2008 to identify all patients with bladder exstrophy managed at our center. RESULTS Sixteen children were closed successfully. Six patients (37.5%) experienced complications: umbilical hernias in two, transient penopubic fistula in three, and subcoronal fistula due to meatal stenosis in one. Of the 12 males, seven (58.3%) were left with a hypospadias at the time of primary closure. Two (22.2%) children required a formal bladder neck reconstruction to achieve continence. Bladder augmentation and continent catheterizable stoma was performed in four cases (44.4%), and bladder neck injection in one case (11.1%). Bladder neck closure was also performed in another child following primary closure. Three of these children are continent and void spontaneously (33.3%). The remaining six require clean intermittent catheterization four to six times a day, resulting in four (44.4%) being continent. The number of continence procedures and mean number per patient were 15 and 1.66, respectively. CONCLUSION Our early experience with this technique has been encouraging, with few major complications, a highly successful closure rate and a cosmetically normal result.
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Affiliation(s)
- Yusuf Kibar
- Department of Pediatric Urology, University of Oklahoma Health Science Center, 920 Stanton L. Young Blvd. WP 3150, Oklahoma City, OK 73104, USA.
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Long-Term Results of Penile Disassembly Technique for Correction of Epispadias. Urology 2009; 73:510-4. [DOI: 10.1016/j.urology.2008.09.072] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 08/29/2008] [Accepted: 09/06/2008] [Indexed: 11/24/2022]
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Kost-Byerly S, Jackson EV, Yaster M, Kozlowski LJ, Mathews RI, Gearhart JP. Perioperative anesthetic and analgesic management of newborn bladder exstrophy repair. J Pediatr Urol 2008; 4:280-5. [PMID: 18644530 DOI: 10.1016/j.jpurol.2008.01.207] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 01/09/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Reconstruction of bladder exstrophy in newborn infants requires immobilization, sedation and pain management to prevent distracting forces from compromising the repair. We present a 6-year review of our experience. SUBJECTS AND METHODS We reviewed the perioperative management of newborn infants undergoing reconstruction between November 1999 and October 2006. Data are presented as means+/-SD. RESULTS Twenty-three newborn infants underwent surgery under a combined epidural and general anesthetic technique. Tunneled caudal epidural catheters were inserted in all patients and intermittently injected with 0.25% bupivacaine with 1:200,000 epinephrine. Postoperatively, a continuous infusion of 0.1% lidocaine, 0.8-1mg/kg/h was administered for 15+/-8 (range 4-30) days. Children were sedated with diazepam for 20+/-13 (range 2-40) days. Central venous catheters were maintained for 20+/-9 (range 1-34) days for fluids, drug administration and blood sampling. No patient experienced bladder prolapse or wound dehiscence. CONCLUSION Perioperative management with tunneled epidural and central venous catheters in newborn infants with bladder exstrophy facilitates immobilization, analgesia and sedation, resulting in an excellent cosmetic repair with no case of bladder prolapse or wound dehiscence.
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Affiliation(s)
- Sabine Kost-Byerly
- Department of Pediatrics, the Johns Hopkins Hospital, Johns Hopkins University, School of Medicine, Baltimore, MD 21287, USA.
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Bibliography. Current world literature. Female urology. Curr Opin Urol 2007; 17:287-90. [PMID: 17558274 DOI: 10.1097/mou.0b013e3281fbd54d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bibliography. Current world literature. Reconstructive surgery. Curr Opin Urol 2006; 16:460-3. [PMID: 17053527 DOI: 10.1097/mou.0b013e328010dc58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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