["Epidemiology, diagnosis, treatment and follow-up of the bladder exstrophy-epispadias complex"]

The development of the new S3 guideline "Epidemiology, diagnosis, treatment and follow-up of the bladder exstrophy-epispadias complex" was funded by the German Innovation Fund of the Federal Joint Committee (G-BA). Despite the relatively low level of evidence of the identified literature, a systematic approach and consistent evaluation of the literature enabled the formulation of a large number of evidence-based recommendations across a variety of topics. In addition, a patient guideline is under development in order to disseminate the guideline recommendations and to enhance self-management and understanding among patients and their relatives. A needs analysis had been carried out in order to adequately assess the topics that are most important for patients and relatives. Upon completion of the German guideline, an English translation in cooperation with the e‑UROGEN network is planned.

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.

LUMBAR Syndrome and Bladder Exstrophy: A Case Report

LUMBAR syndrome is rare with a multitude of features that requires a high index of suspicion for timely diagnosis and appropriate management. We present on a newborn female whose untreated segmental infantile hemangioma lead to poor healing of her bladder exstrophy closure. The objective of this report is to describe bladder exstrophy as a urogenital anomaly in patients with LUMBAR syndrome and the importance of balancing management of infantile hemangioma and time to surgery.

Presentations of bladder exstrophy in a resource-limited setting and the role of Mainz II continent diversion for late referrals or failed primary closures: a multicentric report

Primary closure techniques that have been updated and longterm follow-up for CBE (classic bladder exstrophy) may be out of reach for many patients living in resource-limited settings. Late referrals to medical care and primary closures that lack the necessary skills and facilities for comprehensive treatment are still common. Alternative and long-term surgical solutions may improve the lives of these unfortunate patients. During surgical outreach missions, patients with CBE, either non-operated or with a previous unsuccessful bladder closure, who were referred from vast under-resourced rural areas to three Eastern African hospitals, were studied. The following information is provided: mode of presentation, clinical history, diagnostic workout, management, and outcome. There were 25 cases (M/F ratio 17/8) ranging in age from two days to twenty years. Five of the seventeen patients who were not treated (35%) were under 120 days old and eligible for primary closure in a qualified tertiary center when one was available in the country. There were twelve late referred cases (ranging from 120 days to 20 years). Between the ages of ten months and twelve years, eight children arrived following a failed primary closure. In all of them, the bladder plate was too altered to allow closure. Following a preoperative diagnostic workout, a Mainz II continent internal diversion was proposed to fourteen patients with acceptable bowel control and postponed in the other three. Three cases were lost before treatment because parents refused the procedure. Twelve cases ranging in age from three to twenty years (mean seven years) were operated on. Eight people were followed for a total of 53.87 months (range: 36-120). Except for three people who complained of occasional night soiling, day and night continence were good. The average voiding frequency during the day was four and 1.3 at night. There was no evidence of a metabolic imbalance, urinary infection, or significant upper urinary tract dilatation. Two fatalities could not be linked to urinary diversion. Four patients were not followed up on. Due to the limited number of specialist surgical facilities, CBE late referral or failed closure is to be expected in a resource-limited context. In lieu of the primary closure, a continent internal diversion will be proposed and encouraged even at the level of a non-specialist hospital to improve the quality of life of these unfortunate patients. It is recommended that patients be warned about the procedure's potential long-term risks, which will necessitate a limited but regular follow-up.

Prenatal Diagnosis of Bladder Exstrophy and OEIS over 20 Years

OBJECTIVE

To examine the prenatal diagnosis rates of bladder exstrophy (BE) and Omphalocele-Exstrophy-Imperforate anus-Spinal Defect Syndrome (OEIS) in a large cohort of patients over a 20-year period. We hypothesized that prenatal diagnosis rates improved over time due to evolving techniques in fetal imaging.

METHODS

A multi-institutional database was queried to identify BE or OEIS patients who underwent primary closure between 2000 and 2020. We retrospectively determined prenatal or postnatal diagnosis. Those with unknown prenatal history were excluded. Multivariable logistic regression was used to investigate temporal pattern in rate of prenatal diagnosis while adjusting for sex and treating institution.

RESULTS

Among 197 BE and 52 OEIS patients, 155 BE and 45 OEIS patients had known prenatal history. Overall prenatal diagnosis rates of BE and OEIS were 47.1% (73/155) and 82.2% (37/45), respectively. Prenatal diagnosis rate was significantly lower in BE compared to OEIS (P <.0001). The prenatal diagnosis rate for BE significantly increased over time (OR 1.10; [95%CI: 1.03-1.17]; P = .003). Between 2000 and 2005, the prenatal diagnosis rate of BE was 30.3% (10/33). Between 2015 and 2020, prenatal diagnosis rate of BE was 61.1% (33/54). Prenatal diagnosis rate for OEIS did not change over time. Rates of prenatal diagnosis did not differ by sex or treating institution.

CONCLUSION

Rates of prenatal diagnosis of BE and OEIS are higher than previously reported. Prenatal diagnosis rate of BE doubled in the last 5 years compared to the first 5 years of the study period. Nonetheless, a significant proportion of both BE and OEIS patients remain undiagnosed prior to delivery.

Isolated bladder exstrophy in prenatal diagnosis

PURPOSE

Isolated classic bladder exstrophy (CBE) is the most common variant of the bladder-exstrophy-epispadias complex (BEEC). The BEEC represents a spectrum ranging from isolated epispadias over CBE to the most severe form, cloacal exstrophy. We report on a series of 12 cases with CBE diagnosed prenatally and illustrate the spectrum of prenatal ultrasound findings with comparison to prior published reports on this entity.

METHODS

This was a retrospective study involving 12 fetuses with CBE at two large tertiary referral centers in Germany over a 14-year period (2004-2018).

RESULTS

Median diagnosis was made with ultrasound in 24 + 5 (IQR_25,75: 21 + 2, 29 + 0) weeks of gestation. All fetuses presented with the pathognomonic findings non-visualization of the fetal bladder and protruding abdominal mass below the umbilical cord insertion. All fetuses showed normal kidney anatomy and normal amniotic fluid throughout pregnancy. Epispadia was visible prenatally on ultrasound in 6/8 male fetuses. 1/12 Parents opted for termination of pregnancy, 11/12 fetuses were live born and received reconstructive surgery.

CONCLUSIONS

Isolated CBE is an extremely rare prenatal sonographic finding. Prenatal diagnostics should exclude additional malformations within the spectrum of cloacal malformations.

Bladder Exstrophy from Childhood into Adult Life

Exstrophy of the bladder is rare and the incidence of bladder exstrophy is calculated to be from 1 per 30 000 to 50 000 live births with male to female ratio ranging from 1.5-5 to 1 1-4 It was found that persistence or overgrowth of the cloacal membrane on the lower anterior abdominal area, prevents normal mesenchymal ingrowth. This causes divergence of the lower abdominal muscular structures and forces the genital ridges to fuse caudal to the cloacal membrane. The stage of ingrowth of the urorectal septum at the time of rupture determines whether one will produce an exstrophic urinary tract alone (classic bladder exstrophy or epispadias) or cloacal exstrophy with the hindgut interposed between the hemibladders5,6.

A Borderline Ovarian Tumour in a Patient with Classic Bladder Exstrophy; a Case Report

A 37-year-old Romanian lady presented with a large pelvic mass, urosepsis and deteriorating renal function. She had undergone separation from her conjoined twin. Imaging revealed grossly abnormal anatomy and a suspicious pelvic mass. Examination was consistent with classic bladder exstrophy. Postoperative histology showed borderline ovarian tumour (BTO).

Evaluation of sexual function in females with exstrophy-epispadias-complex: A survey of the multicenter German CURE-Net

OBJECTIVE

Standardized knowledge about genital function in adult female individuals with exstrophy-epispadias complex (EEC) is scarce. The aim of this study was to investigate sexual function using the standardized Female Sexual Function Index (FSFI), and to assess the influence of bladder and vaginal reconstruction and the presence of incontinence on FSFI results.

METHOD

Sixty-one females (aged ≥18 years) recruited by the German multicenter network for congenital uro-rectal malformations (CURE-Net) were asked to complete the FSFI and a self-designed semi-structured questionnaire assessing comprehensive medical data, gynecological, and psychosocial items. Twenty-one eligible females (34%) returned both questionnaires (mean ± standard deviation [SD] age of 26 ± 5.1 years).

RESULTS

In 43% of participants, a staged or single-staged approach had been used for reconstruction, and these had their bladder in use. A primary or secondary urinary diversion (UD) after cystectomy had been performed in 38% of participants. Of the participants, 57% lived in a committed partnership, and 62% had sexual intercourse on a regular basis, with a further 19% experiencing pain or discomfort thereby. Introitus plasty was done in 43%. Mean total FSFI for all participants was 21.3 (SD 1.9). Most domain scores of patients after introitus plasty were similar compared with those without an operative vaginal approach, except for satisfaction (p = 0.057) and pain (p = 0.024). Comparing incontinent with continent patients, significant differences were found for desire (mean 4.6 vs. 3.5, p = 0.021), lubrication (mean 3.1 vs. 4.2, p = 0.049), and satisfaction (mean 1.6 vs. 3.6, p = 0.0065). In contrast pain was not significant between groups.

CONCLUSIONS

Sexual activity rate in the present study was similar to that reported in the literature (81% vs. 89%), whereas dyspareunia rate was lower in our cohort (19% vs. 24%). The risk for sexual dysfunction seems to be lower in patients reconstructed with primary or secondary UD than patients with bladder in use. It is surprising that lubrification was better after UD than after bladder neck surgery. Incontinence and in some parts the history of an introitus plasty may play an additional role in development of sexual dysfunction in EEC. Although most of the female EEC patients lived in a committed partnership and had sexual intercourse, total FSFI values <26.55 clearly indicate a risk of sexual dysfunction. Although continence itself played a major role, females reconstructed with UD seem to have better sexual function. Further evaluation of sexual outcome and improvement of care for these patients is mandatory.

Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years

INTRODUCTION

Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty.

METHODS

After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen.

RESULTS

Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p = 0.06) did not reach statistical significance (Table).

CONCLUSIONS

SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.

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.

[Bladder exstrophy: Quality of primary care and long-term prognosis]

BACKGROUND

It is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome. Due to a number of reasons, including a lack of comparable multicenter studies, there are numerous concepts for initial exstrophy closure.

DISCUSSION

Therefore, we describe our concept of delayed, staged reconstruction without osteotomy in classical bladder exstrophy, while taking into considerion the available literature on long-term follow-up as well as on own clinical and research data.

CONCLUSION

Most notably there are multiple medical but also psychological advantages of a delayed procedure. Primary closure without osteotomy is feasible and has no disadvantages in the long-term follow-up when compared to the invasive procedure of osteotomy. Due to high intravesical pressure, initial bladder neck surgery might have negative effects on bladder development and on the upper urinary tract.

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.

[Treatment of exstrophy of bladder in adults]

Exstrophy of bladder in adults is extremely rare, since such anomalies are usually underwent surgery in early childhood. Difficulties in the treatment of adult patients are associated with severe long-term changes of the mucosa and surrounding tissues, chronic urinary infection, as well as a large diastasis between pubic bones and inefficiency of osteotomy. The article describes the methodology and results of the surgery in a patient 33 years old with exstrophy-epispadias after failed previous interventions. During the follow-up period of more than 5 years, there were no complications related to continent reservoir, reconstruction of the anterior abdominal wall, and urinary infection. Decrease in renal function was not observed. Thus, the cystectomy with formation of continent reservoir from the ileum is accompanied by a good functional and cosmetic results. Resection of vesical plate is justified due to severe long-term changes of the mucosa and the surrounding skin, as well as a high risk of malignancy. The use of polypropylene ? allows to reconstruct the anterior abdominal wall without osteotomy and provides a sufficient degree of its strengthening.

[Advances in pediatric urology]

Urogenital disorders in children include congenital malformations affecting the urinary system and the genital organs, as well as disorders acquired during childhood. They require medical and surgical treatment by a dedicated team, notably a paediatric urologist, nurse and psychologist. Significant advances have been made in this discipline over the last ten years.

Squamous cell carcinoma in bladder exstrophy: a rare entity

Carcinomas arising from an exstrophic urinary bladder are rare entities, and only seven such cases have been reported in the literature. We present the eighth case of advanced squamous cell carcinoma arising from an exstrophic bladder, with a pertinent review of the literature. The mean age of the patients was 54.9 years, with a male to female ratio of 3:1. The average duration of symptoms was 18.6 months. The appearance of a new growth was the most common symptom. Three patients had stage I disease, one patient each had stage II and III disease, two patients had stage IV disease, and the disease stage was not known in one patient. Five out of these eight patients underwent surgery. Four patients in the treatment group remained disease-free, with a mean survival period of 30 months. In conclusion, regular surveillance with cystoscopy is advised in all cases that had primary closure of the exstrophic bladder.

Squamous cell carcinoma in exstrophic unreconstructed urinary bladder in an adult

Bladder exstrophy is rare and associated with an increased incidence of bladder cancer. Unreconstructed bladder extrophy presenting in an adult is very rare as most of the patients undergo repair in childhood. Most of the cancers are adenocarcinomas. We report a rare case of squamous cell carcinoma occurring in exstrophic unreconstructed bladder in a 58-year-old male patient.

Cloacal exstrophy: a case report and literature review

Cloacal exstrophy is an extremely rare congenital malformation resulting in an exstrophy of the urinary, intestinal, and genital organs and associated with anomalies of other organ systems. We present a complicated case of cloacal exstrophy and the recent progress in the management of this probably most complicated anomaly in pediatric urology and surgery.

Cloacal exstrophy: a comprehensive review of an uncommon problem

OBJECTIVE

To provide a comprehensive overview of the clinical features, diagnosis, current management strategies, and outcomes of cloacal exstrophy.

METHODS

A PUBMED/Medline search of the literature was performed on cloacal exstrophy focusing on associated anomalies, treatment, and quality of life issues.

RESULTS

The incidence of cloacal exstrophy is between 1 in 200,000 and 400,000 live births. Survival rates now approach 100% secondary to improved understanding of underlying abnormalities and advances in neonatal care and surgical technique. Important principles of initial management include proper nutritional support, early closure of exstrophy, and preservation of intestinal length. The achievement of urinary and fecal continence remains a challenge. Data for long-term outcomes are now emerging which provide new insight into issues of gender identity, function, and psychosocial development of these patients.

CONCLUSION

Cloacal exstrophy remains a rare and complex congenital anomaly, characterized by an array of anatomical defects affecting multiple organ systems. A multidisciplinary approach to management is advocated with a focus on optimization of patient function and quality of life.

First-trimester prenatal sonographic diagnosis of omphalocele-exstrophy-imperforate anus-spinal defects complex

We describe a case of omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) diagnosed at 13 weeks' gestation by ultrasound detection of a large multilocular ventral wall mass into which inserted the umbilical cord, and thoracic hemivertebrae with kyphoscoliosis. Subsequent sonographic examinations at 16 and 19 weeks revealed evolution of the ventral wall mass into a classic omphalocele. Clinicians should recognize the significance of a large multicystic ventral wall mass, which should lead to a search for other anomalies suggestive of OEIS complex.

Prenatal 3-dimensional sonographic and MRI findings in omphalocele-exstrophy-imperforate anus-spinal defects complex

We describe the second-trimester 3D sonographic and MRI findings of omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex. We suggest that fetal 3-dimensional sonography with tomographic ultrasound imaging and MRI are useful adjuncts to conventional 2-dimensional sonography in the prenatal diagnosis of OEIS complex.

Bladder augmentation: Complications in the pediatric population

Bladder augmentation is an invaluable tool for the pediatric urologist, for both the protection of the upper urinary tract and attainment of urinary continence. However, it remains a major surgical undertaking with significant morbidity. This review examines the incidence and pathophysiology of some of the most common and serious complications, which include surgical complications, such as malignancy, bowel obstruction, and bladder perforation, and medical complications including urinary tract infections and gastrointestinal dysfunction. We review the most current and pertinent literature to provide a comprehensive and practical overview of complications from bladder augmentation in the pediatric population.

Syndromes and Disorders Associated with Omphalocele (II): OEIS Complex and Pentalogy Of Cantrell

Omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex is characterized by a combination of omphalocele, exstrophy of the bladder, an imperforate anus, and spinal defects. Pentalogy of Cantrell is characterized by a combination of a midline supraumbilical abdominal wall defect, a defect of the lower sternum, a defect of the diaphragmatic pericardium, a deficiency of the anterior diaphragm, and congenital cardiac anomalies. This article provides a comprehensive review of OEIS complex and pentalogy of Cantrell, including the pathogenesis, prenatal diagnosis, differential diagnosis, and associated malformations. Omphalocele is an important sonographic marker for OEIS complex and pentalogy of Cantrell. Prenatal detection of an abdominal wall defect associated with multiple midline defects should alert one to the possibility of OEIS complex and pentalogy of Cantrell and prompt the genetic investigation and counseling of the disorders.

Cloacal exstrophy: a case study

Cloacal exstrophy is a complex congenital anomaly that affects both the gastrointestinal and genitourinary systems. It is characterized by an omphalocele, an exstrophied bladder, abnormal genitalia, and imperforate anus. Prior to 1960, there were no reported cases of survival, but because of advancements in neonatology, surgery, and anesthesiology, the survival rate has improved drastically. This case presentation of an infant born with cloacal exstrophy includes discussion of etiology, diagnosis, treatment, ethical issues, and nursing care.

Prenatal ascertainment of OEIS complex/cloacal exstrophy—15 new cases and literature review

Omphalocele-exstrophy of the bladder-imperforate anus-spinal defects (OEIS) complex or cloacal exstrophy (EC), describes a rare grouping of more commonly occurring component malformations [Carey et al., 1978]. The etiology is unknown, but likely heterogeneous. While postnatal identification of its associated gastrointestinal, spinal, and genitourinary systems delineates the extent and natural history of OEIS complex, prenatal findings may provide additional information regarding early detection, possible causative factors, and outcome. The purposes of this study were to: (1) present the prenatal ascertainment of OEIS complex in this series of 15 cases identified through several different sources compared to the literature, and (2) discuss the relationship of these prenatal findings to possible abnormal developmental mechanisms causing OEIS complex. These 15 cases indicate that OEIS complex may be difficult to diagnose prenatally, and that the full extent of abnormalities may not be clear until postnatal exam. Confusion with limb-body wall complex (two of our cases) and pentalogy of Cantrell (one of our cases) can occur. Anal/gastrointestinal malformations and genital ambiguity are under-ascertained. Conversely, prenatal defects may resolve postnatally, yet may provide clues for pathogenetic mechanisms. For instance, the finding of nuchal thickening in our three cases (one reported) suggests vascular/hemodynamic compromise early in embryologic development, or intrathoracic compression leading to jugular lymphatic obstruction may play a role. The association of twinning and OEIS complex suggests they may occur as early as blastogenesis. Our three sets of discordant twins also suggest a non-genetic etiology for OEIS complex of uteroplacental insufficiency. This study also indicates that OEIS complex may be more common than previously thought.

Cloacal exstrophy

Cloacal exstrophy is an extremely rare and devastating complex of congenital abnormalities resulting in multiple debilitating morbidities. Infants with this disorder require numerous surgical interventions to repair gastrointestinal, genitourinary, spinal, and orthopedic malformations. Treatment involves the combined efforts of many medical and nursing specialists. This article discusses the embryology, clinical presentation, and management (both early and long term) of cloacal exstrophy, with emphasis on gender reassignment issues and quality of life.

The OEIS complex: two case reports that illustrate the spectrum of abnormalities and a review of the literature

We present two cases of OEIS (omphalocele, exstrophy, imperforate anus, spinal defects) complex -MIM 258040 and a review of the literature. Case 1 was a 14-year-old girl who presented at 30 weeks' gestation. An ultrasound examination showed an omphalocele and spina bifida; the bladder was not visualised. She went into spontaneous labour two weeks later and the baby died shortly after birth. A full post-mortem examination was refused, but the mother did agree to an external examination, skin biopsy for fibroblast culture, X rays and MR imaging. The MR imaging showed a pelvic kidney, a large omphalocele containing the other kidney, liver, bowel and a fluid filled structure thought to represent an exstrophy of the bladder (EB). Case 2 was a 30-year-old woman who had an ultrasound examination at 20 weeks' gestation; this showed an omphalocele, but the bladder was not visualised. The pregnancy was subsequently terminated and a post-mortem examination showed a low set umbilical cord associated with a small omphalocele; there was an imperforate anus; a blind ending rectum terminated in the omphalocele. We conclude that these two cases illustrate the variability of the OEIS complex.

Genetische und molekularbiologische Aspekte des Blasenekstrophie-Epispadie-Komplexes (BEEK)

The bladder exstrophy and epispadias complex (BEEC) is an anterior midline defect with variable expression involving the infraumbilical abdominal wall including the pelvis, urinary tract, and external genitalia. The incidence varies with regard to ethnical background, sex, and phenotypic expression, and an incidence of 1:20,000 to 1:80,000 has been observed in the middle European population. No gene defect has been attributed to BEEC thus far and chromosomal aberrations or genetic syndromes associated with BEEC have only rarely been reported. According to epidemiological data, a complex genetic as well as a multifactorial mode of inheritance could underlie BEEC. However, no single teratogenic agent or environmental factor has been identified, which could play a dominant role in the expression of the BEEC.A risk of recurrence of 0.5-3% has been described in families with one affected subject. These values correspond to an increased recurrence risk estimated to be as high as 200- to 800-fold when compared to the common population. Due to the paucity of affected sib pairs and suitable multiplex families, conventional linkage analysis to identify candidate genes causally related with BEEC appears to be unfeasible. Large association studies and consecutive linkage disequilibrium mapping should therefore lead to the identification of candidate genes. Also new methods including matrix-based comparative genomic hybridization (CGH) are promising and have successfully been used in the past (e.g., CHARGE association). Moreover, the low incidence of the BEEC requires close cooperation between clinicians in the operative and nonoperative specialties as well as geneticists for successful gene search.

SURGICAL REPAIR OF BLADDER EXSTROPHY IN THE MODERN ERA: CONTEMPORARY PRACTICE PATTERNS AND THE ROLE OF HOSPITAL CASE VOLUME

PURPOSE

Bladder exstrophy is a rare condition, and data are lacking regarding practice patterns in its surgical management. We used a large nationwide database to investigate practice patterns of bladder exstrophy repair.

MATERIALS AND METHODS

We used the Nationwide Inpatient Sample (1988 to 2000) to identify patients who underwent surgical repair of bladder exstrophy (International Classification of Disease-9 code 578.6). We analyzed factors affecting practice patterns and outcomes. Hospital volume was based on caseload during the highest volume year of study participation (high volume 5 or more, mid volume 3 to 4 and low volume less than 3 cases).

RESULTS

We identified 407 cases. Approximately half of the patients (53.2%) were hospitalized within 24 hours of birth, although 28% of patients were older than 1 year. Of the patients 54% were male. Exstrophy repair is extremely resource intensive. In this series mean length of hospital stay (LOS) was 24.6 +/- 22.8 days, and mean inflation adjusted hospital charges were 62,302 dollars (median 39,978 dollars). High volume hospitals (HVHs) had lower hospital charges (37,370 dollars) than mid volume (51,778 dollars) or low volume hospitals (LVHs, 50,474 dollars, p = 0.0095). On multivariate regression HVHs had lower charges even after controlling for other significant predictors, including LOS (p <0.0001). Patients at HVHs were more likely to undergo osteotomy (p = 0.007). Six patients died after exstrophy repair (1.5%), all of whom had been born prematurely (p <0.0001). Although death was more likely at LVHs, this was due to the fact that more patients at LVHs were born prematurely (4.2% at HVHs vs 5.9% at mid volume hospitals and 11.1% at LVHs, p = 0.027).

CONCLUSIONS

Bladder exstrophy repair carries a high risk of morbidity and is resource intensive. Variations between high and low volume hospitals in practice patterns and case mix may contribute to observed differences in resource use, LOS and clinical outcomes.

3-DIMENSIONAL MAGNETIC RESONANCE IMAGING MODELING OF THE PELVIC FLOOR MUSCULATURE IN CLASSIC BLADDER EXSTROPHY BEFORE PELVIC OSTEOTOMY

PURPOSE

We provide a 3-dimensional (3D) model of the pelvic floor musculature in patients with classic bladder exstrophy using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Five male infants 1 day to 12 months old underwent MRI of the pelvis, which was compared to pelvic MRI of 1 male infant without pelvic floor abnormalities. Of the patients 3 were studied before primary closure and 2 before reclosure. None of the patients had a prior pelvic osteotomy. While the entire pelvic floor was imaged, special attention was paid to the contours of the levator ani muscle group which were drawn on T1-weighted axial and coronal images. The overlap of contours in these 2 planes was used to construct a 3D model of this muscle group. The diastasis of the pubic symphysis was also measured for all patients on a plain pelvic radiograph.

RESULTS

The levator ani muscle group conformed to an elliptical dome shape in the control. For the patients the 3D shape was somewhat irregular with an apparent kink in the ellipse. The elliptical shape of the group was described by a shape factor, s, which equals the ratio of the maximum height-to-the length of the base of the ellipse. The shape factor was equal to 0.176 in the control compared to a mean of 0.448 for the patients. There was no relationship between diastasis of the pubic symphysis and the extent of disproportionate curvature of the levator group.

CONCLUSIONS

To our knowledge this is the first qualitative description of the pelvic floor anatomy in bladder exstrophy using MRI. Our model gives further insights into the true pelvic floor anatomy in exstrophy cases and is the first to suggest that abnormalities in the pelvic floor may not correlate with abnormalities of the bony pelvis.

Another case of autosomal dominant exstrophy of the bladder

OBJECTIVE

Exstrophy of the bladder is a rare malformation due to an anterior midline defect. Most cases of this condition with variable expression occur sporadically, but there are some cases indicative of a strong genetic component apart from environmental factors. This is a report about another rare mother-child pair with bladder exstrophy.

METHODS

We present the clinical data of a familial case of bladder exstrophy with an affected mother and her equally affected male fetus.

RESULTS

Prenatal diagnosis of bladder exstrophy in the fetus was assessed by ultrasound at the 19th gestational week and was confirmed after termination of pregnancy at the 21st gestational week.

CONCLUSION

The present case may be additional evidence for an autosomal dominant inherited variant of this malformation complex with implication for counselling of affected patients.

Current management of bladder exstrophy

Bladder exstrophy is a complex anomaly involving the urinary, genital, and intestinal tracts and the musculoskeletal system. The diagnosis is made typically at the newborn examination or on fetal ultrasonography that is performed by an experienced observer. Management of bladder exstrophy presents several challenges, beginning with initial repair using the more conventional staged approach or the recently re-popularized complete primary repair technique. Major goals in the management of bladder exstrophy are preservation of normal kidney function, close observation for development of adequate bladder function including urinary continence, and provision of acceptable cosmesis and function of the external genitalia. This article provides a brief overview of bladder exstrophy and a detailed description of modern management.

Exstrophy variants: should they be considered malformation complexes separate from classic exstrophy?

PURPOSE

Exstrophy variants are very rare and have a better prognosis than classical exstrophy. The authors came across a case of superior vesical fissure (SVF) together with esophageal atresia and tracheoesophageal fistula (EATEF) and a case of SVF with gross limb anomalies. These associated malformations have not been reported so far in the literature and hence we reviewed all the cases of exstrophy variants presented to us with particular emphasis on the associated malformations.

METHODS

Records (n=9) of patients who were diagnosed as exstrophy variants at our institution between 1989 and 2000 were evaluated retrospectively.

RESULTS

Out of 9 cases, 7 cases had associated malformations: EATEF, urethral atresia, absent radius, large umbilical hernia, low anorectal malformation, true diphallus with bifid scrotum, or high anorectal malformation.

CONCLUSION

The high incidence of associated congenital malformations, noted in our exstrophy variant series, raises doubts about the clubbing together of the exstrophy variants with classical exstrophy. Further investigation of such cases may elucidate shared or unique causes of the dysembryogenic mechanisms in the etiologies of variants of bladder exstrophy.

[Anesthetic management for a radical operation in an infant with cloacal exstrophy]

We report the anesthetic management for a radical operation in an infant with cloacal exstrophy. Diagnosis of cloacal exstrophy with meningocele was made at the 26th week of gestation. Cesarian section was performed under general anesthesia in order to keep the infant in a state of apnea to prevent aerophagia, the so-called "sleeping baby", at the 38th week of gestation. As soon as the infant was born, she was intubated orotracheally and a radical operation (abdominal closure, removal of meningocele, and vesico-intestinal-pelvioplasty) was performed. Some complications occurred during the operation including hypotension, oliguria, hypothermia, hypoproteinemia, hyponatremia and hyperpotassemia. The operation time was 10 hours and 30 minutes. Mechanical ventilation was continued for 4 days in the NICU and the infant was discharged 37 days after the operation. Early prenatal diagnosis and simulation of the operation enabled an effective surgical procedure allowing us to minimize these intraoperative complications.

[Bladder exstrophy-epispadias complex: management and preliminary results]

PURPOSE

Retrospective evaluation of operative techniques and perioperative management as related to the primary anatomical and functional situation as well as analysis of the preliminary postoperative results regarding kidney function, continence and complications.

MATERIALS AND METHODS

From October 1992 to April 2003, 21 patients with bladder exstrophy-epispadias complex were treated, consisting of 12 children with untreated exstrophy and 9 who had undergone unsuccessful previous operations. Single-stage complete repair using the Erlangen concept was done during the first weeks of life in 8 infants and before school age in 3 children. One 13 year old girl had received a primary Mainz pouch II. The 9 unsuccessfully operated patients required a variety of different operations. The mean follow-up of 17 regularly controlled children was 62 months (range 3 to 129 months).

RESULTS

In all children global kidney function remained stable, while reflux or obstruction was responsible for impaired unilateral split function ranging between 31 % and 45 % in 5. Four children were continent day and night after complete single-stage repair, 4 after ureterosigmoidostomy or Mainz pouch II and 5 after augmentation.

CONCLUSIONS

In the newborn with previously untreated exstrophy-epispadias, we recommend single-stage complete functional reconstruction within the first weeks of life. Continence without loss of kidney function can be achieved in 50 % of these children. If adequate bladder capacity and continence cannot be achieved, an augmentation procedure or Mainz pouch II is our method of choice.

True duplicate bladder exstrophy: a case report

True duplicate exstrophy is a rare and interesting congenital anomaly. We are adding a case to the previously reported seven cases in the world literature.

Life-threatening hypokalaemia and quadriparesis in a patient with ureterosigmoidostomy

We report quadriparesis as a result of severe hypokalaemia and acidosis in a 50-year-old man who had undergone ureterosigmoidostomy for bladder extrophy 48 years earlier. Aggressive suppletion with intravenous potassium and bicarbonate combined with potassium-sparing diuretics and ACE inhibitors resulted in complete restoration of the serum potassium and resolution of the neurological symptoms. The underlying mechanism as well as the treatment of hypokalaemia and hyperchloraemic metabolic acidosis after ureterosigmoidostomy are briefly discussed.

[Functional anatomy and semiology of the bladder]

Continence and micturition result from an inversely related evolution of urethra and bladder pressures. On filling, the bladder pressure remains low and the urethral pressure is high: filling bladder pressure mainly depends on its visco-elastic properties while urethral pressure is actively kept high by the tonic activity of smooth and striated urethral sphincters. It is the other, way round when the bladder empties: bladder pressure rises and urethral pressure lower, because the parasympathetic impulses; in the adult, the reflex loop passes through the pontine center. The volitional control of this micturitional reflex implies an ability to recognize a specific feeling: the desire to urinate. Physical examination and investigations enables to assess bladder and sphincter function, through a rich semiology.

Association of bladder exstrophy with congenital pathology of the hip and lumbosacral spine: a long-term follow-up study of 13 patients

The authors evaluated, clinically and radiographically, 13 of 28 patients with bladder exstrophy treated at their institution between 1964 and 1982. All had been treated with bilateral iliac osteotomies and pelvic rami reapproximation to assist in urologic repair. At skeletal maturity, the diastasis had partially recurred and the patients had short stature and were living normal lives. Mild acetabular dysplasia and other pelvic abnormalities were common, as were abnormal radiographic findings in the lumbosacral spine. Despite these findings, most did not affect function. These results support the need for pelvic reconstruction for urologic repair, as well as the need for periodic radiographic evaluation of the pelvis and lumbosacral spine. If present, these have the potential to adversely affect function as an adult.

The newborn exstrophy bladder inadequate for primary closure: evaluation, management and outcome

PURPOSE

The surgical approach to the small newborn exstrophy bladder inadequate for primary closure remains undetermined. Various methods for long-term management have been implemented. We evaluated our experience with late primary closure of the small exstrophied bladder template.

MATERIALS AND METHODS

Our institutional database of patients treated and followed for the exstrophy-epispadias complex was reviewed. Of these patients 19 had a bladder template that was too small to close in the newborn period. The treatment and outcome of these 19 patients were reviewed.

RESULTS

Of the 19 children who had delayed closure due to a small bladder template 14 were males and 5 were females. Followup from birth ranged from 2 to 36 years (mean 18 years). Primary closure was performed at a mean patient age of 13 months (range 6 months to 2 years). Pelvic osteotomy was performed in 16 patients. Of the 19 patients 9 achieved continence after gaining a bladder capacity sufficient for bladder neck reconstruction, 4 required enterocystoplasty to augment bladder volume and perform clean intermittent catheterization (2 per stoma and 2 per urethra), 1 required a colon conduit for an extremely small bladder, and 1 underwent cystectomy and ureterosigmoidostomy for rhabdomyosarcoma. Four patients are currently incontinent, including 3 who are awaiting bladder neck reconstruction and 1 who has frequent nighttime incontinence that is medically managed.

CONCLUSIONS

Delayed primary closure of the small bladder exstrophy template can allow the native bladder tissue adequate time to grow to a size feasible for successful closure. Epispadias repair can usually be performed at the same time and is facilitated by prior testosterone administration. Bladder neck reconstructive techniques have achieved continence without the need for augmentation or bladder replacement in 47% of the patients in our series. For patients who do not achieve adequate capacity for bladder neck reconstruction, preservation of the native bladder template facilitates future augmentation and ureteral reimplantation, thus requiring use of less bowel in the growing child.

Pseudoexstrophy in a female child

A six-year-old female patient presenting with a swelling in the infraumbilical part of the abdomen, bulging out on straining, was diagnosed to have pseudoexstrophy bladder. The urinary tract was normal. The patient had bifid clitoris. There was no other associated malformation. Surgical repair of abdominal wall defect was done successfully. A new classification of exstrophy variants is proposed.