RECONSTRUCTIVE UROLOGY

Complete primary repair of bladder exstrophy: initial experience with 33 cases
Hammouda HM, Kotb H
Urology (Pediatric Urology Division) Department, Assiut University, Assiut, Egypt
J Urol. 2004; 172(4 Pt 1): 1441-4; discussion 1444

• Purpose: We evaluated our initial experience with complete primary repair of bladder exstrophy in 33 children.
• Materials and Methods: Between 1998 and 2001, 33 children with classic bladder exstrophy were treated with 1-stage primary repair for the first time in all except 4, who had undergone previous failed initial bladder closure. Our series included 26 boys and 7 girls with a mean age of 2 months (range 3 weeks to 14 months). The bladder was closed in continuity with the urethra and complete penile disassembly was used for epispadias repair. Anterior transverse innominate osteotomy was performed in all cases. Combined general and caudal anaesthesia were applied in all cases with an indwelling epidural caudal catheter in 7.
• Results: Median followup was 42 months (range 24 to 62). Enterocystoplasty was needed in 3 cases during primary repair of a small bladder plate. Wound dehiscence was not recorded. Bladder neck fistula was reported in 2 children, while urethral fistula was recorded in 1 boy. Abdominal ultrasound detected no hydronephrosis in all except 3 patients. Voiding cystourethrogram showed vesicoureteral reflux in 6 patients. No loss of renal function or febrile urinary tract infection was recorded. A dry interval of 3 hours or greater was reported in 24 children (72.7%), while 9 who were incontinent of urine after failed toilet training needed other procedures to achieve continence.
• Conclusions: Complete primary repair with penile disassembly provides a good approach to achieve this purpose without the need for bladder neck reconstruction in some cases. Selection of the proper surgical technique together with adjunctive procedures such as osteotomy and a pain-free early postoperative period can maximize the chance of successful exstrophy repair.
  
  
• Editorial Comment
  Reconstruction of the bladder, bladder neck and urethra in bladder exstrophy patients is still a major challenge for a reconstructive urologist. The series presented here with 33 children out of whom 29 underwent a 1-stage primary repair for the first time is probably the largest series to date. All operations were done in boys and girls less than 14 months old. Preoperative assessment was simple with an intravenous pyelography or abdominal ultrasound. All surgical interventions were done by the same pediatric urologist in all cases. Apart from a well documented surgical technique, meticulous surgical handling was probably the most important factor for having better results than in many other series. There was a 76% continence rate in all children at a toilet trained age. Only three patients - those that underwent enterocystoplasty - were only continent on clean intermittent catheterization.
  It is remarkable that incision of the muscular bladder wall is a possible way to increase bladder capacity in those children where the bladder template is too small. It is here that tissue engineering at some time may become useful when earlier (maybe in utero) biopsy harvests may be expanded in the laboratory to be used to increase the detrusor. The bulging or expanding mucosa usually is not the problem especially not in very young children.

Dr. Arnulf Stenzl
Professor and Chairman of Urology
Eberhard-Karls-University Tuebingen
Tuebingen, Germany