The gynaecology of exstrophy

Patient-Reported Impact of Pelvic Organ Prolapse on Continence and Sexual Function in Women With Exstrophy-Epispadias Complex

OBJECTIVE

This study aimed to characterize long-term urogynecologic issues of women with a history of bladder exstrophy and pelvic organ prolapse (POP) and to assess the impact of POP repair on continence and sexual function.

DESIGN

Patient demographics and surgical history related to exstrophy and POP were collected through chart review. Patient perceptions regarding sexual function, urinary continence, and quality of life were assessed through Web-based administration of validated questionnaires: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and POP-Urinary Incontinence Sexual Questionnaire.

SETTING

Maryland, United States.

PARTICIPANTS

Review of a single-institution exstrophy-epispadias complex database resulted in 25 adult female patients with a history of POP treated at the authors' institution. Eleven patients participated and were included in the analysis.

MAIN OUTCOME MEASURES

Urinary continence and sexual function.

RESULTS

All participants underwent surgical repair for prolapse, with 7 (63.6%) experiencing unsuccessful initial repair and subsequent recurrence. Median total number of POP repairs was 2.5 (1-4). After correction of POP, patients reported a median improvement in International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form scores of 11 (21 to -1) of 21 and in POP-Urinary Incontinence Sexual Questionnaire scores of 9.5 (6.5-33.0) of 48.0. With regard to urinary continence, 6 (54.5%) patients presently reported no incontinence, 3 (27.3%) reported mild incontinence, and 2 (18.2%) reported continuous incontinence.

CONCLUSIONS

Pelvic organ prolapse poses significant reductions in quality of life for women born with exstrophy, with effects on urinary continence and sexual function. Identification and correction of prolapse seems to result in notable improvements in the lives of these patients.

Contemporary issues relating to transitional care in bladder exstrophy

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Pelvic Organ Prolapse and Pregnancy in the Female Bladder Exstrophy Patient

PURPOSE OF REVIEW

Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health.

RECENT FINDINGS

Contemporary data suggest 30-50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery. This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.

Successful pregnancy outcome in a woman with untreated ectopia vesicae: a case report and review of literature

We report the case of a pregnancy in a 25-year-old woman who was born with ectopia vesicae and split pelvis, but had not undergone any reconstructive or diversion surgery in childhood. Her antenatal period was uneventful and the infant was delivered by cesarean section at term due to breech presentation. The baby had no congenital anomalies. The postoperative period was uneventful and they were discharged from the hospital in a good general condition.

Reproductive outcomes in women with classic bladder exstrophy: an observational cross-sectional study

OBJECTIVE

We sought to examine the reproductive outcomes of 52 women with classical bladder exstrophy.

STUDY DESIGN

This was an observational study with cross-sectional and retrospective arms.

RESULTS

The average age of the sample was 33 years (range, 17-63). Of those who had tried, 19/38 (66%) had conceived. A total of 57 pregnancies (3 sets of twins) were reported for the 19 patients and resulted in 34/57 live births (56%), 21/57 miscarriages (35%), 1/57 (2%) termination, and 4/57 (7%) stillbirths or neonatal deaths. Four deliveries resulted in major complications including 1 transection of the ureter (4%), 1 fistula formation (4%), and 2 postpartum hemorrhages (8%). There were 2 admissions to intensive care, one for urinary sepsis and another for massive obstetric hemorrhage.

CONCLUSION

Fertility is impaired in women with bladder exstrophy. Pregnancy is high risk both for the mother and baby. Delivery should be at a tertiary referral obstetric unit with urology cover. In the majority of cases planned cesarean section is the most appropriate mode of delivery.

Adolescent urology: A challenge for adult urologists

The medical care of adolescents has become a growth area in many disciplines. There are two major aspects. Firstly, adolescents have specific medical and emotional needs which are not fulfilled either by paediatric or by adult specialists. Secondly, some childhood problems, particularly the congenital deformities, have no equivalent in adult life and so lifelong care is mandatory. Renal damage, especially dysplasia and scarring, leads to a substantial risk of early onset hypertension and, occasionally, to renal failure. Bladder outlet obstruction in utero, such as from a posterior urethral valve, causes irreversible changes to the wall that will act adversely on the kidneys in adolescence or early adulthood. The incidence of renal failure in early adulthood is about 36%. Bladder reconstruction with bowel has been very beneficial in preventing renal failure and improving continence. Life long follow-up is needed because of the high incidence of complications. These include stones, hyperchloraemic acidosis, perforation, anastomotic stenosis and, possibly, cancer. Patients have a normal expectation of sexuality and fertility. Their desires cannot always be achieved but they require considerable emotional and surgical support.

Aesthetic aspects of abdominal wall and external genital reconstructive surgery in bladder exstrophy-epispadias complex

Long-term follow-up of patients born with classical bladder exstrophy-epispadias complex (EEC) reveals that many of them suffer from poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. In this article, we review the aesthetic outcomes in performing puboplasty, umbilicoplasty, and genitoplasty in patients born with EEC. Retrospective review of the cosmetic and functional outcomes in 116 patients born with EEC treated by puboplasty, umbilicoplasty, or genitoplasty was performed. Satisfaction with the cosmetic and functional outcomes of these three reconstructive surgeries was high following initial reconstructive efforts (> 90%). Attention to cosmesis during abdominal wall and genital reconstruction for EEC helps to improve a patient's perception of body image and self-esteem. Our experience with these procedures over the past 25 years demonstrated that the efforts directed toward aesthetics have been well worthwhile.

Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature

Management of gynecologic issues in women with bladder exstrophy is challenging. Congenital pelvic organ prolapse and prolapse-associated pregnancy and delivery are common. The management of prolapse is complicated by the anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina. A case of recurrent pelvic organ prolapse successfully managed with a sacral colpopexy and a review of the literature are presented.

Prospects for fertility in patients born with genitourinary anomalies

PURPOSE

The effect of congenital genitourinary anomalies on fertility and the impact of current therapies are reviewed.

MATERIALS AND METHODS

The literature of each of the 2 components was used to define the present status and to make proposals for future management.

RESULTS

Infertility may be caused by gonadal failure (intersex states), failure of sperm transport (exstrophy) or both (bilateral undescended testes). In some conditions it is uncertain whether there are any fertility problems despite an identifiable genital problem. In cases of unilateral undescended testis the fertility rate may be unaffected by surgery and be no different from that in the normal population. Techniques of in vitro fertilization, particularly intracytoplasmic sperm injection, have allowed previously untreatable patients to become parents. Successful pregnancies in patients who had the prune belly syndrome and Klinefelter's syndrome have been reported in the last year.

CONCLUSIONS

Prospects for fertility with current techniques and those that might be discovered in the next 20 years should strongly influence decisions about the treatment of infants and children.

Total urogenital complex mobilization in female patients with exstrophy

PURPOSE

Female bladder exstrophy/epispadias has traditionally been approached in a staged fashion. This approach results in a vagina that remains in an abnormal position on the anterior abdominal wall. We present a surgical correction of the female exstrophy/epispadias urogenital complex with total mobilization that returns the vagina to its proper anatomical position.

MATERIALS AND METHODS

Since 1997, 7 female patients presenting with variants of the exstrophy/epispadias complex have undergone surgical repair using total urogenital complex mobilization. Of the patients 1 newborn and 2 school-age children had classic bladder exstrophy, 2 school-age children had cloacal exstrophy and 2 school-age children had primary epispadias. Total urogenital complex mobilization involved treatment of the urethra and vagina as a single unit. Complete disassembly of the pelvic diaphragm or floor anterior to the rectum was required to reposition the urethra and vagina to their proper anatomical positions in the perineum. The pelvic diaphragm was then reconstructed anterior to the urogenital complex to recapitulate the normal female pelvic floor anatomy.

RESULTS

All patients have an anatomically correct position of the urogenital complex. All the vaginas reached the perineum without the need for skin flaps. All patients have adequate vaginal caliber without evidence of stenosis.

CONCLUSIONS

The female with exstrophy/epispadias has unique anatomical defects in the urogenital complex that require special attention. Anterior displacement of the bladder, urethra and vagina with concomitant lack of development of the anterior pelvic floor musculature make a single stage, total urogenital complex mobilization repair ideal for this population. The results of this technique have been functionally and cosmetically pleasing. Whether repositioning the urogenital complex into the normal anatomical position will improve bladder dysfunction and urinary continence rates, and decrease or eliminate the need for future surgery will only be known after further long-term followup has been completed.

Pediatric reconstructive surgery

The field of reconstructive pediatric urologic surgery is constantly changing. Recent changes in pediatric urologic reconstructive surgery are discussed in the present review. Surgical techniques for treating patients with hypospadias, exstrophy, incontinence, and ambiguous or variant genitalia are also discussed.