VARIANTS OF THE EXSTROPHY COMPLEX: A SINGLE INSTITUTION EXPERIENCE

Prenatal Presentation of a Covered Cloacal Exstrophy Variant; Early Diagnostic Challenges Within the Broad Spectrum of the Exstrophy-Epispadias Complex

There is a broad range of variant phenotypes that can occur within the bladder exstrophy and epispadias complex spectrum. Accurate prenatal detection helps prepare families and to coordinate subspecialty resources. Here, we present the case of a patient with prenatally diagnosed patient with covered cloacal exstrophy variant along with four additional cases illustrating the nonlinear spectrum from isolated epispadias to cloacal exstrophy. Given the rarity of these variants overall and of each subtype within the spectrum, there is a need for long-term multi-institutional outcomes data to improve detection, characterization, and prognostication for these patients.

Inferior Vesical Fissure-A Rare Variant of Exstrophy Bladder: Case Report With Literature Review

Exstrophy variants are uncommon developmental anomalies of the bladder; the variants involving only the bladder neck are extremely rare. There are only three case reports of inferior vesical fissure (IVF) to date, and usually it's uncommonly associated with other malformations. A combination of inferior vesical fistula (IVF) as an exstrophy variant with urethral atresia and anorectal malformation has not been described previously. We report a case of IVF in a 4-year-old male previously operated for anorectal malformation who was managed with fistula closure with bladder neck reconstruction of lay open of stenosed urethra. Recognition of the exstrophy variant is important because the treatment and prognosis are very different.

A Triplicated Bladder with Diphallia; Rare Variant of Duplicate Exstrophy

Background

Exstrophy variants are well described urologic anomalies. They are characterized by atypical anatomical and physical findings than those found in patients with classic bladder exstrophy and epispadias malformation. The combination of these anomalies with duplicated phallus is a rare occurrence. Here we present a neonate with a rare form of exstrophy variant associated with penile duplication.

Case Summary

One day old male neonate who was born at term was admitted to our neonatal intensive care unit. He had lower abdominal wall defect and open bladder plate with no visible ureteric orifices. There were two completely separate phalluses with penopubic epispadias and urethral orifices draining urine. Both testes were descended. Abdominopelvic ultrasound showed normal upper urinary tract. He was prepared and operated with intra operative finding of complete bladder duplication in the sagittal plane and each bladder has its own ureter. The open bladder plate which had no connection with both ureters and urethras was excised. The pubic symphysis was approximated without osteotomy and abdominal wall was closed. He was immobilized with mummy wrap. He had uneventful post-operative course and was discharged on the 7th post-operative day. He was evaluated on the 3rd month post operatively and he was thriving well with no complications.

Conclusion

The occurrence of a triplicated bladder along with diphallia is an exceptionally rare urologic anomaly. As a number of variations are possible in this spectrum, the management of neonates with this anomaly should be individualized.

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

INTRODUCTION

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Prenatal ultrasound findings of covered bladder exstrophy and persistent cloaca

Unlike classic exstrophy, covered bladder exstrophy is a rare variant characterized by a cycling bladder and intact abdominal wall. We present a case of covered bladder exstrophy diagnosed prenatally and associated persistent cloaca (PC) noted only after delivery. This case report demonstrates that prenatal diagnosis of covered bladder exstrophy is possible and PC can present without any abdominal cysts, bowel, or renal findings. Covered bladder exstrophy should be considered in the differential of cystic protrusion of the bladder to the abdominal wall.

Pubic Diastasis in Polytrauma Patients: Traumatic or Congenital?: A Report of 2 Cases

CASE

We report 2 patients who were involved in high-velocity road traffic accidents. Both these patients had congenital pubic diastasis with very subtle clinical and radiological signs that were misdiagnosed as posttraumatic diastasis on initial radiographic evaluation.

CONCLUSION

Trauma surgeons should be aware of this anomaly because congenital pubic diastasis could present without any major clinical signs and could easily be mistaken for a traumatic diastasis.

Exstrophy-Epispadias Complex Variants: A Hybrid Case

The term exstrophy-epispadias complex refers to a group of midline defects ranging from epispadias to cloacal exstrophy. Bladder exstrophy is the most frequent malformation of this spectrum and it can present as a classical or a variant form. We report a case of a hybrid bladder exstrophy variant having some characteristics of both a duplicate bladder exstrophy and a superior vesical fistula.

Variant of Bladder Exstrophy With an Intact Penis: Surgical Options and Approach

Variants of bladder exstrophy are a rare but diverse spectrum of bladder exstrophy-epispadias complex. This case series describes a group of 4 unique exstrophy variant cases who had an intact phallus, but a completely open bladder plate. These patients underwent exstrophy repair and concomitant umbilicoplasty at the Civil Hospital, Ahmedabad as part of the US-India Multi-institutional Bladder Exstrophy Collaboration and were followed at the same institution. We believe that a detailed assessment of bladder neck prior to reconstructive repair and bladder closure would be beneficial in these cases as the extent of bladder neck involvement would affect reconstructive approach.

Anteroposterior Duplicated Exstrophy: A Case Report

Duplicated bladder exstrophy is an extremely rare variant of the exstrophy/epispadias complex. Duplicated exstrophy defines an exstrophic mucosal plate in hypogastric area with a normal closed bladder. We present a unique case of an anteroposterior duplicated exstrophy in a female newborn.

Variant Presentations of the Exstrophy-Epispadias Complex: A 40-Year Experience

OBJECTIVE

To investigate the diagnosis, surgical management, and outcomes in patients with variant EEC. Variant presentations of the exstrophy-epispadias complex (EEC) span a wide range of abnormalities. The rarity and diversity of EEC variants can lead to challenges in the diagnosis and subsequent management of this population.

METHODS

The authors reviewed an institutional database of 1336 EEC patients from 1975 to 2018 for variant presentations of EEC. Variant presentations included those with skin covered bladder exstrophy (BE), duplicate bladders, superior vesical fistula, and epispadias with major bladder prolapse. Surgical management and outcomes were assessed.

RESULTS

In total, 44 EEC variants were identified. Nineteen (43%) presented with a skin-covered BE variant. Five patients presented with duplicate BE, while 6 presented with superior vesical fistula. Fourteen patients (32%) presented with epispadias with major bladder prolapse. Overall, 36 (82%) EEC variants underwent primary bladder closure, at a median of 135 days after birth (range 1-2010), with 21 (58%) undergoing pelvic osteotomy. Primary closures were successful in 89% of cases. Continence procedures were performed in 17 patients. This includes 5 patients who underwent bladder augmentation. However even without a continence procedure, continence with volitional voiding was found in 8 patients.

CONCLUSION

The most common EEC variant is the skin-covered form of BE. In order to expedite appropriate management, accurate diagnosis upon initial presentation is crucial. Still, successful surgical reconstruction often results in continence that is similar to, or better than, nonvariant EEC presentations.

Achieving urinary continence in cloacal exstrophy: The surgical cost

INTRODUCTION

Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night.

RESULTS

In total, 140 CE and CE variant patients have been managed at the authors' institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2-10). This included 1 bladder closure (range 1-3), 2 urinary continence procedures (range 1-4), and 1 (range 0-4) "other" genitourinary procedures. The median time to urinary continence was 11.0 years (95% CI [9.2-14.2]).

CONCLUSIONS

A majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

The intravesical phallus in patients with cloacal exstrophy: An embryologic conundrum

BACKGROUND

Phalluses present inside the extrophied bladder of cloacal exstrophy (CE) newborns have been sporadically reported in the literature; this clinical entity has largely unknown origins and may represent an extremely rare anomaly of CE.

OBJECTIVE

Along with nearly doubling the number of reported intravesical phalluses in the literature, this study aims to outline the common anatomic features and discuss the implications for theories of CE embryogenesis.

STUDY DESIGN

The authors retrospectively identified patients with CE and a potential intravesical phallus between 1997 and 2017 at two high-volume centers. Information was obtained about karyotype, age at closure, neurologic and renal anomalies, diastasis, phallus anatomy, and phallus biopsy pathology.

RESULTS

Six genotypic males met the inclusion criteria. Five of six had a diastasis greater than 6 cm. Four of six had paired corporal bodies in the intravesical phallus, one had a single corporal body, and one had a corporal-like structure. Five of six patients had a phallus located midline in the caudal aspect of the bladder; one was located midline in the bladder dome. Phallic biopsies were obtained in three of six patients. Two showed glanular and corporal tissue while the other showed vascular proliferation morphologically similar to that of erectile tissue.

DISCUSSION

Previous reports suggested that a superior vesicle fissure configuration, fusion of the corporal bodies, and fused bladder plates were common findings with an intravesical phallus. With the addition of new cases, the only consistent variable between patients is a phallus located anywhere along the bladder plate that can comprise a corporal-like structure, a single corporal body, or fused corporal bodies. These findings have implications for several embryologic theories. Although this is a retrospective review with a limited number of patients, the condition is exceedingly infrequent making it only observable retrospectively over decades at high volume centers.

CONCLUSIONS

The study outlined common anatomic features of the intravesical phallus in cloacal exstrophy and discussed the subsequent embryologic implications. In cloacal exstrophy newborns with presumed aphallia, meticulous inspection of the bladder plate and biopsy of any potential phallic structures can prevent resection of phallic tissue.

Laparoscopic excision of complete bladder duplication in a 1-year-old male

OBJECTIVE

Complete bladder duplication is a male predominant rare congenital malformation usually diagnosed at birth. Owing to the rarity of this anomaly, only few reports have discussed the surgical approach for this condition, with the open approach for excision being the most common. We hereby present a video of a laparoscopic resection of complete bladder and urethral duplication in a 1-year-old male.

METHODS

The patient presented to our clinic with a red mucosal tissue protruding from a cutaneous opening at the dorsal base of the penis that has been present from birth. A normally located and functioning bladder and urethra were present. During work-up, a cystic mass located above the bladder was discovered in imaging examinations. No other anomalies were found. After a shared decision process, we performed a laparoscopic transperitoneal bladder duplication excision during which the accessory urethra and duplicated bladder were removed with preservation of the adjacent normal urethra. The patient had an uneventful recovery with excellent cosmetic results.

CONCLUSION

The minimally invasive approach can be utilized for treatment of complex urinary anomalies in young children.

Late presentation of ectopia vesica with malignant transformation. A case report and review

INTRODUCTION

Exstrophy of the bladder is a rare congenital anomaly usually treated in neonatal or childhood period. When combined with renal agenesis and presents for the first time in the adulthood with malignant transformation, is an extreme rarity.

CASE PRESENTATION

We present a case of 65 years single male who presented with a right irreducible inguinal hernia and an unreconstructed Ectopia Vesicae with fungating tumor. He was anemic with impaired renal function, left renal agenesis and right sided hydronephrosis, hydroureter and distal ureteric stricture. He underwent palliative excision of Ectopia Vesicae and urinary diversion via ureterosegmoidostomy after his condition was optimized. Histopathology showed metaplastic squamous mucosa and a moderately differentiated mucinous adenocarcinoma. Three weeks later he had good continence and normal renal function. He was sent to a distant radio-oncology center for further management.

DISCUSSION

In 1851 the first ureterosegmoidostomy for ectopia vesicae was done. Later on it becomes more popular. Some people preferred deferring it until the age of 4 years while others advocates earlier reconstruction. Plastic operation, during neonatal life was also described. In the majority of cases, the fibrotic nature of the bladder and the absence of the sphincter make the reconstruction almost impossible. We performed the only possible option in our setting as our patient had a complex congenital anomalies which present late in life complicated with advanced malignant transformation.

CONCLUSION

Despite the plethora of congenital malformation and advanced malignancy, surgical excision and diversion with adjuvant chemo-radiation provided a good palliation for this patient.

Image of the Month: Clinical Features in a Newborn with Covered Cloacal Exstrophy

Cloacal exstrophy is the most severe type of anorectal malformations that belongs to the bladder–exstrophy–epispadias complex of genitourinary malformations. Interestingly, its variant, the covered cloacal exstrophy, is often missed. The clinical findings of this variant may include an imperforate anus, low lying umbilicus, thick pubic bone, and pubic diastasis but with an intact abdominal wall. We present an interesting case of covered cloacal exstrophy with a side-by-side duplicated bladder and discuss important considerations for the time of colostomy creation in the newborn period.

Pseudo-Exstrophy of Bladder with Unilateral Renal Agenesis: A Rare Combination of two Anomalies

Pseudo-exstrophy of bladder is an uncommon condition characterized by the major musculoskeletal defects without urinary system defects. A two-day-old female neonate was presented with pseudo-exstrophy of the bladder and unilateral renal agenesis- A rare combination of two anomalies. She was born at 37 weeks gestational age with caesarean section delivery. The X-ray of hip revealed pubic diastasis. Ultrasonography clearly showed absence of the left kidney with a normal right kidney. The patient was treated successfully with proper surgical management. We, hereby, report a rare variant case of pseudo-exstrophy of bladder with lower set umbilicus and infra-umbilical midline of lower anterior abdominal wall defect in a neonate who was born in Shahid Sadoughi Hospital, Yazd, Iran.

Antero-posterior Duplicate Exstrophy with a Wet Bladder Plate: A Diagnostic Dilemma

Variants of exstrophy are rare anomalies seen in the spectrum of bladder exstrophy-epispadias complex. We present a rare case of duplicate exstrophy with a wet bladder plate. This is a deviation from the classical description of antero-posterior duplicate exstrophy that is associated with a dry bladder plate.

Management of Urinary Incontinence in Complete Bladder Duplication by Injection of Bulking Agent at Bladder Neck Level into the Proximal Urethra

Bladder duplication is a rare entity in children. The term encompasses a wide spectrum of anomalies from isolated bladder duplication in coronal or sagittal planes to duplicated bladder exstrophy and associated musculoskeletal and visceral anomalies. Given this wide variability, the treatment of these patients is not standardized. We hereby present a female patient with chief complaint of long-standing urinary incontinence who had complete bladder and urethral duplication and pubic diastasis. The patient was treated with bulking agent injection at the incompetent bladder neck and proximal urethra with resolution of incontinence, obviating the need for extensive surgeries.

Covered cloacal exstrophy--a poorly recognized condition: hints for a correct diagnosis

INTRODUCTION

Covered cloacal exstrophy requires a high index of suspicion for its diagnosis. Low implantation of the umbilical cord, separated pubic bones, and anorectal malformation are the most common signs.

METHODS

Thirty-one patients with this defect were retrospectively analyzed.

RESULTS

Besides the anorectal malformation, the patients had important unique anatomic findings, including a colon shorter than 20 cm (17 patients) and absent bladderneck (27 patients). Twenty-four patients underwent a colonic pullthrough; of those, only 5 of them have voluntary bowel movements. Twelve patients underwent a urinary reconstruction. Eleven of them are dry with catheterization, and one leaks in between catheterization. Two patients are urinary continent.

CONCLUSIONS

Covered exstrophy is a serious condition. Externally, the patients may look like having a rather simple malformation. However, the intra-abdominal findings are similar to those seen in cloacal exstrophy. An early correct diagnosis is important to plan a reconstructive strategy and to adjust the parent's expectations concerning bowel and urinary function. In addition to the traditional prognostic factors for bowel and urinary control (sacral ratio, tethered cord, and level of the rectum) these patients have other anatomic defects (absent bladderneck and short colon) that negatively affect the functional prognosis.

Cloacal exstrophy variant with intravesical phallus: further description of anatomy and implications for gender reassignment

Variant presentations of cloacal exstrophy are exceedingly rare. Historically, genetic males with cloacal extrophy were re-assigned to the female gender due to phallic inadequacy. Early recognition of intravesical phallic structures in cloacal exstrophy cases may impact gender reassignment discussions and long-term gender outcomes. We report the case of a male infant with cloacal exstrophy presenting with an intravesical phallus, review and compare the presenting anatomical features of the three previously reported cases, and discuss the potential impact of these findings on gender reassignment in these complex children.

Unusual duplicate bladder exstrophy in a female newborn: a case report

The authors report a rare variant of exstrophy-epispadias complex, a duplicate bladder with normal bladder communicating with an exstrophic bladder by a fistula, in a girl with no genital malformation except for a duplicated clitoris. This variant could be a hybrid form of duplicate bladder exstrophy and superior vesical fistula. It seems easier to repair and has a better prognosis than classic bladder exstrophy.

Complete bladder and urethral duplication with normal urodynamic function associated with visceral sequestration

Complete bladder and urethra duplication is an extremely rare condition. It can occur in the sagittal or coronal plane, depending on the axis of the septum. Most cases are associated with other congenital defects. We present a case of complete duplication of the bladder and urethra in the sagittal plane with normal urodynamic function associated with bowel sequestration.

Covered exstrophy with ectopic intestinal tissue and bifid phallus: one-stage repair of a complex abnormality

Variant presentations of the exstrophy-epispadias complex are rare congenital malformations, such as covered exstrophy with bifid phallus. We describe a male neonate with covered exstrophy with an intestinal remnant and epispadiac bifid phallus. We report this case to emphasize the simultaneous successful repair of bifid phallus and exstrophy in this rare complex abnormality.

An unusual form of duplicate bladder exstrophy

Duplicate bladder exstrophy is a rare variant of the exstrophy/epispadic lesions in which an external patch of exstrophic bladder presents in addition to a closed bladder in a more normal anatomical position, diastasis of the pubis and rectus muscles, and often a form of epispadias. We describe an anomaly of this variant with a fistula to the closed bladder. Careful examination with fluoroscopy and cystoscopy is helpful in defining the anatomy in these variants.

Common ("classical") and covered cloacal exstrophy: a histopathological study and a reconstruction of the pathogenesis

Current opinion about structure and pathogenesis of cloacal exstrophy was challenged by histopathological findings and new insights into the normal development. Autopsy specimens of common (n = 3) and covered cloacal exstrophy (n = 4) with single intraexstrophic and -perineal phallic structures and perineo-exstrophic canals have been analyzed histopathologically. The findings were correlated to normal development to reconstruct the pathogenesis. By identifying a specific cloaca-derived urethra field as distinct from allantois-derived bladder fields, the exstrophic area is found to reflect the original hindgut configuration in embryos of approximately 26-29 postovulatory days gestational age (2-4 mm). Correlation to normal development suggests malfunctioning of the primitive streak/caudal eminence as a primary fault that leads to a defective cloacal region in the hindgut disturbing cloacal-intestinal-allantoic dissociation and also causes lengthening of the intestinal region into a blind-ending colon, teratoma-like lesions, and vertebral and muscular anomalies. The current idea that membranes in "covered cloacal exstrophy" represent persisting cloacal membranes is dismissed by finding an amnion-like structure, which suggests dysfunction of an umbilical ring placode as a simultaneous 2nd fault. This malfunctioning may cause omphalocele by defective demarcation of the umbilical cord and may replace midline stroma of the infraumbilical abdominal wall by extraembryonic tissue that stretches into a weak temporary membrane, may leave a perineo-extrophic canal, and may allow the formation of a single perineal or intraexstrophic phallus. Malfunctioning without replacement may result in a purely epithelial "allantoic" membrane, which by disintegrating in combination with the cloacal membrane will expose common cloacal exstrophy.

Complete duplication of bladder and urethra in a sagittal plane in a male infant: case report and literature review

Complete duplication of the bladder and urethra is a rare entity. It may occur in the coronal and sagittal planes, and is often associated with other organ system anomalies, in particular of the gastrointestinal tract. We report an unusual variant of sagittal duplication of the bladder, in a male, associated with rudimentary hindgut duplication, and review the literature pertaining to this unusual anomaly.

Congenital pouch colon with duplicate bladder exstrophy

Congenital pouch colon, an unusual high anorectal malformation, is rarely associated with exstrophy variants. We describe a case of congenital pouch colon associated with duplicate bladder exstrophy, never reported before in literature. The relevant literature is reviewed, and the possible embryogenesis of this complex anomaly is suggested.

Duplicate bladder exstrophy: a unique variant

Duplicate bladder exstrophy is an extremely rare congenital malformation. Two forms have been described, the anteroposterior form and the collateral form, which is the less common. We report a case of bladder exstrophy in association with a duplicated lower urinary tract, omphalocele, colic duplication and diphallia. Fewer than 30 cases of duplicate bladder exstrophy have been described previously, emphasizing the embryologic significance of this case. To our knowledge it is the first reported case of such an association of anomalies with the exstrophy-epispadias complex.