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.

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.

Gender identity outcome in female-raised 46,XY persons with penile agenesis, cloacal exstrophy of the bladder, or penile ablation

This review addresses the long-term gender outcome of gender assignment of persons with intersexuality and related conditions. The gender assignment to female of 46,XY newborns with severe genital abnormalities despite a presumably normal-male prenatal sex-hormone milieu is highly controversial because of variations in assumptions about the role of biological factors in gender identity formation. This article presents a literature review of gender outcome in three pertinent conditions (penile agenesis, cloacal exstrophy of the bladder, and penile ablation) in infancy or early childhood. The findings clearly indicate an increased risk of later patient-initiated gender re-assignment to male after female assignment in infancy or early childhood, but are nevertheless incompatible with the notion of a full determination of core gender identity by prenatal androgens.

Twin pregnancy achieved through TESE in an adult male exstrophy

Bladder exstrophy is a rare anomaly, it compromises bladder functions, and in males it occurs with an impairment of reproductive functions, because of erectile and ejaculatory deficit. Advancements in the surgical treatment of bladder exstrophy have allowed an improvement of the bladder functions while spontaneous conception is still impaired. This is a case report of a pregnancy and subsequent birth of twins following testicular sperm extraction, on a man born with classical bladder exstrophy with infertility due to an ejaculation.

New methods of bladder augmentation

Gastrointestinal segments are commonly used for bladder replacement or repair. However, when gastrointestinal tissue is in contact with the urinary tract, several complications may ensue. Recent surgical approaches have relied on native urological tissue for reconstruction. These are based on sound surgical principles, allowing for the exclusion of tissue that is not urological. De-epithelialized bowel segments, either alone or over native urothelium, have also been used. An experimental system of progressive dilatation for ureters and bladders has been proposed. This appears promising, although it has yet to be attempted clinically. There has been a resurgence of interest in the use of acellular collagen-based matrices as scaffolds for bladder regeneration; experimental work is currently underway. Recently, functional bladder tissue has been engineered using selective cell transplantation. This technique uses autologous cells, so avoiding rejection. Tissue is obtained from the host, the cells then dissociated and expanded in vitro, re-attached to a matrix and implanted into the same host. Clinical trials are currently being arranged. Even though the use of bowel for bladder tissue replacement was first proposed over 100 years ago, it remains the gold standard, despite its associated problems. It is evident that urothelial-urothelial anastomoses are preferable functionally. Experience is currently being gained with the recent clinical and experimental approaches to augmentation cystoplasty. It is hoped that this will result in more technologies and methods for bladder augmentation.

Hip configuration and function in bladder exstrophy treated without pelvic osteotomy

Nine children with congenital bladder exstrophy treated without pelvic osteotomy were analyzed clinically and radiologically at a mean age of 13 years (range 9-16 years). The acetabular and femoral version angles were measured by computed tomography (CT) imaging. Two of the children had a slight waddling gait, but none of them had any pain and they could participate in sports without problems. They had a normal range of hip movements and a normal foot progression angle. The acetabulum was retroverted by an average of 5 degrees, but was balanced by an increased anteversion of the femur which on the average was 10 degrees-20 degrees higher than normal. The femoral head in all hips was spherical, and no hip showed dysplasia. In bladder exstrophy, retroversion of the acetabulum was balanced by an increased anteversion of the femur, resulting in a normal range of hip movements and a normal gait in later childhood.

Female genito-urethroplasty and submucosal periurethral collagen injection as adjunctive procedures for continence in the exstrophy-epispadias complex. Preliminary results

Continence is the main goal in the treatment of patients with bladder exstrophy and prognosis is necessarily long-term. Over an 8-year period, 44 patients presented with bladder exstrophy and/or incontinent epispadias. Twenty-five bladder closures (7 secondary), 23 male urethroplasties, 19 bladder neck (BN) reconstructions and 6 bladder augmentations were performed in these patients. In 18 children 2 additional procedures were employed in the last 3 years: female genito-urethroplasty (15) and submucosal periurethral collagen injection (11). Eight children underwent both procedures. Genito-urethroplasty and collagen injection were performed before BN reconstruction in 6 and 5 cases respectively, in order to increase bladder outlet resistance. The submucosal injection was performed at 3, 9 and 12 o'clock in the BN or sphincteric urethra, using 0.75 to 2.5 ml of cross-linked bovine collagen. Continence in the children who underwent the complete staged reconstruction was good in 58%, fair in 32% and poor in 11%. Following female genito-urethroplasty and periurethral collagen injection, bladder capacities increased by 25%. These complementary procedures are effective in increasing outlet resistance and bladder capacity in patients with exstrophy and/or epispadias; they may improve continence and lessen the need for further bladder augmentation.

A comparison of renal function in the exstrophy patient treated with staged reconstruction versus urinary diversion

To assess the preservation of renal function in bladder exstrophy 91 patients with classical bladder exstrophy managed with either staged reconstruction or urinary diversion were reviewed. Renal damage was defined as the development of a renal scar or a persistent elevation in serum creatinine. Of the patients 72 have completed the bladder reconstruction; 51 (71 per cent) are continent and renal damage occurred in 10 (13 per cent) of the reconstructed patients. Median followup was 12.7 years. In a comparable group of 23 exstrophy patients managed by urinary diversion the occurrence of renal damage was notably higher: 82 per cent for ileal conduits, 22 per cent for nonrefluxing colonic conduits and 33 per cent for ureterosigmoidostomy. Based on these results we believe that staged reconstruction of the patient with classical bladder exstrophy offers a low risk for renal injury, an excellent chance for urinary continence and a more acceptable cosmetic appearance.

Perforation of the augmented bladder in patients undergoing clean intermittent catheterization

During urological reconstructive surgery small or large bowel is used to increase bladder capacity or to create a urinary reservoir. In most patients clean intermittent catheterization is necessary for urinary drainage. We report on 4 patients with a sigmoid cystoplasty who perform clean intermittent catheterization and who have experienced a serious long-term complication, urinary reservoir perforation, which was fatal in 1. Two were adolescent girls with myelodysplasia and 2 were prepubertal boys with bladder exstrophy. One patient experienced 2 separate reservoir perforations. Rupture occurred 15 to 48 months (mean 30.2 months) after reconstruction. Diagnosis was made by a static cystogram, which demonstrated extravasation in 2 of 4 patients, and ultrasound. In 2 patients the cystogram was normal. Management included intravenous antibiotics and open abscess drainage in all patients. In patients who have undergone augmentation cystoplasty or continent diversion and in whom abdominal pain and distension develop reservoir perforation should be considered in the differential diagnosis.

Intestinocystoplasty in combination with clean intermittent catheterization in the management of vesical dysfunction

Intestinocystoplasty in combination with clean intermittent catheterization has been used in the management of 60 young patients with bladder dysfunction. Of the patients 39 (65 per cent) had the primary diagnosis of myelomeningocele, 8 had sacral agenesis, 3 had spinal cord tumors and 1 had spinal cord trauma. The remaining 9 patients had either congenital, surgical or traumatic loss of all or a large portion of the bladder. Of the 60 patients 30 had undergone prior urinary diversion, while the remaining 30 were considered failures with management by clean intermittent catheterization and medication. A total of 16 patients underwent ileocecocystoplasty, while 44 had augmentation with either cecum (8), sigmoid (18) or ileum (18). Mean followup was 4 years (range 16 months to 7 years). Fifty-nine patients have stable or improved renal function and the excretory urogram is stable or improved in all 60. Of the patients 38 (63 per cent) were considered dry after the initial bladder augmentation, while an additional 14 were rendered dry by a second procedure consisting of bladder neck reconstruction or placement of the artificial urinary sphincter, for a total of 52 (87 per cent) currently considered to be dry. Eleven patients have had at least 1 symptomatic urinary tract infection (18 per cent) and 21 had a positive urine culture but remained asymptomatic. In contrast to earlier beliefs, intestinocystoplasty can be applied effectively and appropriately to patients with bladder and urethral dysfunction. Intestinocystoplasty combined with clean intermittent catheterization offers a significant alternative to diversion in such patients.

The exstrophy support team: a new concept in the care of the exstrophy patient

The concept of the exstrophy support team is reported. It has extended the care of children with exstrophy into a lifelong continuum of effective assistence, not just by way of medical and surgical interaction but through knowledgeable and sympathetic coordination. There has been a spectacular improvement in over-all lifetime survival and much greater patient interest and appreciation with better followup and maintenance so that we can help quickly and effectively when problems arise. Now that we have achieved an increased longevity for these patients, we must be able to assure them the best possible quality of life.