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RECONSTRUCTIVE
UROLOGY
Bladder
growth and development after complete primary repair of bladder exstrophy
in the newborn with comparison to staged approach
Borer JG, Gargollo PC, Kinnamon DD, Bauer SB, Khoshbin S, Hendren WH,
Peters CA, Diamond DA, Atala A, Chin S, Retik AB
Department of Urology, Children’s Hospital Boston, Boston, Massachusetts,
USA
J Urol. 2005; 174 (4 Pt 2): 1553-7; discussion 1557-8
- Purpose:
We assessed bladder growth and dynamics following complete primary repair
of bladder exstrophy (CPRE) compared to the staged approach.
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Materials and Methods:
We reviewed the records of 16 boys and 7 girls who underwent CPRE within
3 days of life from 1996 to 2004 and compared them to the records of
8 boys and 6 girls treated with a staged repair from 1979 to 1996. Screening
methods included voiding cystourethrogram, radionuclide cystogram and
urodynamic study. We estimated growth curves for bladder capacity following
repair in each group, and compared percent predicted bladder capacity
(PPBC), compliance and detrusor overactivity between the CPRE and staged
repair groups following bladder neck reconstruction.
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Results: Bladder
capacity in the staged repair group was 69.8 ml (95% CI 46.7-104.4)
immediately after bladder neck reconstruction and increased by 15.0%
per year thereafter (95% CI 6.2-24.5, p = 0.002). In the CPRE group
bladder capacity was 29.0 ml (95% CI 21.3-39.5) initially and increased
by 28.9% per year thereafter (95% CI 17.4-41.5, p <0.001). PPBC started
at 45.6% (95% CI 35.7-55.5) and increased 1.2% per year (95% CI -1.1-3.5,
p = 0.29) following repair for all genders and surgery groups. Compliance
was 124.4% (95% CI 22.6-310.7, p = 0.01) greater in the CPRE group at
all times following repair. Detrusor overactivity was present in 0 of
19 patients in the CPRE group and 6 of 13 (46%) in the staged group
(exact p = 0.002).
- Conclusions:
Within the CPRE group bladder stability was universal, and
sphincter electromyography was normal suggesting no neuromuscular compromise
of the pelvic floor. At early followup, our results suggest that PPBC
is equivalent irrespective of gender or management. Further objective
evaluation is needed in both groups.
Magnetic
resonance imaging of pelvic musculoskeletal and genitourinary anatomy
in patients before and after complete primary repair of bladder exstrophy
Gargollo PC, Borer JG, Retik AB, Peters CA, Diamond DA, Atala A, Barnewolt
CE.
Department of Urology and Radiology, Children’s Hospital Boston,
Harvard Medical School, Boston, Massachusetts, USA
J Urol. 2005; 174 (4 Pt 2): 1559-66; discussion 1566
- Purpose:
We characterize pelvic soft tissue and bony anatomy of patients before
and after complete primary repair of exstrophy (CPRE).
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Materials and Methods:
We evaluated 15 measurements on pelvic magnetic resonance imaging (MRI)
in patients who underwent CPRE without osteotomy at our institution
from 1996 to 2004. MRI protocols included axial, sagittal and coronal
fast spin echo proton density sequences. Measurements were compared
before and after CPRE using a paired t test, and between patients after
CPRE, and age and gender matched controls using linear regression adjusting
for the matched case-control groups. Patients older than 3 years with
continent intervals longer than 3 hours after CPRE were compared to
age and gender matched controls using linear regression.
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Results:
A total of 29 MRIs in 18 patients with exstrophy were available for
analysis. Median patient age at postoperative MRI was 25 months (range
4 to 36). The configuration of the post-CPRE pelvis was significantly
different from that of controls in all parameters measured including
wider symphyseal diastasis (34.5 mm vs less than 1 mm) and more obtuse
iliac wing (121 degrees vs 98 degrees), puborectalis (94 degrees vs
49 degrees) and ileococcygeus angles (111 degrees vs 98 degrees). The
anatomy of continent patients after CPRE was not significantly different
from that of controls in most parameters measured.
-
Conclusions:
Comparison of the pelvic anatomy in patients before and after CPRE suggests
that after CPRE patients have parameters that more closely approximate,
but are still significantly different, from those of control patients.
Patients with greater than 3-hour continent intervals after CPRE have
anatomic parameters most similar to those of age matched controls.
- Editorial
Comment
The authors compared their data regarding lower urinary tract function
as well as renal function in 16 boys and 7 girls treated with a complete
primary repair of bladder exstrophy. Early primary repair is defined
as repair within the first 3 days of life; these patients were compared
to a group of 8 boys and 6 girls treated with a staged repair in bladder
exstrophy. Furthermore the same authors studied MRI findings in 18 of
these patients at various intervals after complete primary repair (and
in some patients also prior to surgery).
Bladder capacity, compliance and detrusor overactivity were surrogates
for detrusor function in both primary and staged repair groups. The
“percent predicted bladder capacity” per individual patient
was not different between neither surgical groups nor gender. The conclusion
was therefore that bladder capacity is more dependent on intrinsic factors
than surgical technique. 72% of female and 86% of male patients did
require a bladder neck reconstruction in the long-term follow up after
complete primary repair in order to achieve continence. It is therefore
speculated that the better results after early primary repair regarding
overactivity (none of the patients in the primary repair group did show
detrusor overactivity versus 46% in the staged group) may be the result
of a decreased bladder outlet resistance.
The results concerning compliance were also better in the primary repair
group, which can be partially explained by decreased outlet resistance.
It is a fact that in both groups male patients showed a decline in compliance,
which supports the speculation about the role of resistance and bladder
function in the long term.
Apart from bladder function, complete voiding and continence are additional
important long-term outcome parameters and it is only partially resolved.
Among the anatomical landmarks seen upon endoscopy in adolescence and
adults, location of the verumontanum and length and width of the urethral
sphincteric segment are important. Even for the most experienced surgeons
it is extremely difficult to adequately reconstruct the sphincteric
structures within the first few days of life. Good functionality of
the earliest possible reconstruction is here hampered by what the surgeon
can do with only partially developed and in times invisible structures.
In an attempt to predict continence in patients with complete primary
repair with the same group studied an array of measurements in pelvic
MRI using various bone and soft tissue landmarks and angles. It is not
surprising that the measurements performed were significantly different
from age for most parameters. However, the closer the landmarks and
angles of the treated exstrophy patients were compared to normal age-
and gender matched controls, the better were the results with regards
to continence and bladder capacity. Whether all these measurements can
be reduced for practicality e.g. symphyseal diastases and the puborectalis
sling angle will have to be proven in larger studies with more patients.
These 2 papers nicely demonstrate that early reconstruction seems to
improve the physiological function of the exstrophy bladder smooth muscle
cell. However, some of the sphincteric structures are not sufficiently
developed to allow a satisfactory reconstruction in most patients. Furthermore
we need to include the reconstruction of the entire bony and muscular
pelvis to achieve success with storage, emptying and continence. The
liberal and sophisticated use of new imaging techniques can be helpful
as in many other parts of reconstructive surgery.
Dr.
Arnulf Stenzl &
Dr. Karl-Dietrich Sievert
Department of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany |