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ORIGINAL ARTICLE |
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| Year : 2002 | Volume
: 18
| Issue : 2 | Page : 117-119 |
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Total correction of bladder exstrophy - our experience in 37 patients
AK Ray, NN Mukherjee, S Mukherjee, P Mukherjee
Division of Paediatric Surgery and Departments of Surgery & Anaesthesiology Medical College; Burdwan Medical College and NRS Medical College, Kolkata, India
Correspondence Address:
A K Ray
"Ray Villa", 59, Ray Bahadur Road, Kolkata - 700 034
India
 Source of Support: None, Conflict of Interest: None  | Check |
 Abstract | | |
All cases of exstrophy epispadias complex carried out in our centre between the period from February 1990 to December 1999. Total 37 cases of exstrophy epispadias complex were dealt with. Out of these, 30 cases underwent primary closure of bladder with or without osteotomy. 7 babies had very small fibrotic patch bladder primarily or secondary to failed primary closure and they went on forpermanent diversion in the form of ileocaecal bladder
Out of 30 cases, 20 underwent Jeffs' closure with osteotomy and in 10 cases primary closure was done without osteotomy.
In 19 patients we have completed all the stages of operation, that is, primary closure, epispadias repair and bladder neck reconstruction.
The main problems in exstrophy bladder repair remained the, failure of bladder to heal, vesical fistula formation, development of inguinal hernia in postoperative stage.
The dry interval period, following total correction of exstrophy bladder remains I to 2 hours with growing age. The children are in follow-up for 10 years now.
Keywords: Exstrophy Epispadias Complex; Primary Closure of Bladder; Total Correction of Exstrophy
How to cite this article:
Ray A K, Mukherjee N N, Mukherjee S, Mukherjee P. Total correction of bladder exstrophy - our experience in 37 patients. Indian J Urol 2002;18:117-9 |
| Materials and Methods | |  |
Bladder exstrophy remains one of the most challenging problems in paediatric urology. Recent efforts have focussed more on primary reconstruction rather than diversion.
We have repaired 37 babies born with exstrophy epispadias complex, who attended our outpatients department during the period from February 1990 to December 1999. [Figure - 1],[Figure - 2],[Figure - 3],[Figure - 4]
There were 4 females and 33 male babies; age of presentation varied from neonate (2 weeks) to 8 years of age. 10 babies reported within 2 weeks of birth, 25 babies presented to us at the age of 1 to 6 months and 2 children presented at the age of 8 years [Table - 1].
The symphyseal gap varied between 2.5 cm and 4 cm. The associated inguinal hernia were present with retractile testes in 10 patients. Another 12 patients presented with inguinal hernia after repair of the exstrophy bladder in whom we did the herniotomy later on.
Out of the total 37 cases, we have so far done the total correction of exstrophy epispadias complex in 19 patients (both staged and single stage).
In the last 10 babies, we did the repair of exstrophy bladder and epispadias in the single stage.
The problems encountered were mostly the nonhealing of exstrophy bladder. In 16 babies, there were vesical fistulas, which were subsequently repaired.
Of the 19 patients so far repaired, dry interval time is gradually increasing from I to 2 hours with age. They are in follow-up for last 10 years.
Primary reconstruction of bladder was done following Jeffs' technique [8] with bilateral iliac osteotomy in 20 babies and without osteotomy in 10 babies. It seems that fascial flap repair of anterior abdominal wall without osteotomy gives better results and successes than with bilateral iliac osteotomy. Epispadias repair was done following Cantwell & Ransley technique.
| Discussion | | |
In 1869, Thiersch [1] raised neighbouring skin flaps in order to close the anterior wall of bladder. Urine was retained by an external appliance.
In 1906, Trendelenberg attempted to achieve urinary continence by sacroiliac osteotomy and bladder closures with narrowing of patulous urethra.
Young [2] reported the first successful functional closure of exstrophy bladder. The bladder was inverted and closed and the anterior abdominal wall defect was closed with fascia] flaps. The patient eventually developed a 3-hour continent interval. However no mention was made regarding the renal function.
Marshall and Muecke [3] reviewed 329 functional bladder closures reported in literature between 1906-1966 and described that urinary continence with preservation of renal function was achieved only in 16 patients (5%).
Over the past 20 years, modifications in the management of functional bladder closure have contributed to dramatic increase in the success rate following this procedure. [4] The four most significant changes in the management of exstrophy bladder were reconstructing a competent bladder neck, performing bilateral iliac osteotomies/anterior/ without osteotomies, staging the reconstruction procedures and defining the criteria for selection of cases suitable for functional closure, as discussed by Jeffs. [5],[6],[8]
In our patients we have found that doing osteotomy and keeping the symphysis in the midline in the postoperative period is more successful when we did anterior osteotomy (10 cases) and total correction of exstrophy bladder along with bladder neck wrapping with urogenital band. Epispadias repair was done in a single sitting rather than staging the procedure, as discussed by Ransley et al. [9]
In 19 cases where we have done 10 total corrections in single sitting with anterior osteotomy, results are good in the sense that the bladder capacity grew well in these babies with less number of wound dehiscences. However, small vesical fistulas occurred in 5 out of 10 babies which were subsequently repaired. [4],[9],[10]
In staged procedures in other 9 babies there were problems of vesical fistula, [6],[9],[10] subsequent hernias' developed while keeping the symphysis in midline with posterior osteotomy.
| Conclusion | | |
So in conclusion, we would like to highlight the following facts :
- At least 10cc capacity bladder with good detrusor compliance gives successful closure.
- Anterior osteotomy gives better results than bilateral iliac osteotomy and/or primary closure without osteotomy and anterior abdominal fascial flap repair.
- Total correction, that is, primary closure of exstrophy bladder with repair of epispadias in single sitting is more successful in our series than staging the procedure.
- Small fibrotic patch bladder needs permanent diversion.
| Acknowledgement | | |
Authors are thankful to Principal and Superintendent of Medical College, Kolkata for kindly allowing them to send the manuscript for publication.
| References | | |
| 1. | Kenneth JW. Exstrophy of urinary bladder. In : Paediatric Surgery. 4`' ed. Chicago. 1986: 2: 1223.  |
| 2. | Young HH. Exstrophy bladder: The first case in which a normal bladder and urinary control have been obtained by plastic operation. Surg Gynaecol Obstet 1942: 74: 729. |
| 3. | Marshall VF. Muecke EC. Functional closure of typical exstrophy of the bladder. J Urol 1970; 104: 205-212. |
| 4. | Anscll JS. Surgical treatment of exstrophy of the bladder with emphasis on neonatal primary closure : Personal experience with 28 consecutive cases treated at the University of Washington Hospitals from 1962 to 1977: techniques and results. J Urol 1979: 121: 650-653. |
| 5. | Borzi PA. Thomas DFM. Cantwell-Ransley epispadias repair in male epispadias and bladder exstrophy. J Urol 1994; 151: 457-459. |
| 6. | DeLa Hunt MN. O'Donnell B. Current management of bladder exstrophy : a BAPS collection review from eight centres of 81 patients born between 1975 and 1985. J Pediatr Surg 1989: 24: 584. |
| 7. | Husmann DA. McLorie GA. Churchill MB. Inguinal pathology and its association with classical exstrophy bladder. J Pediatr Surg 1990: 25: 352. |
| 8. | Jeffs RD. Exstrophy of urinary bladder. In : Paediatric Surgery. 4"' ed. Chicago. 1986. |
| 9. | Ransley PG. Duffy PG, Woolin M. Bladder exstrophy closure and epispadias repair. In : Spitz L, Nixon HH. eds. Paediatric Surgery. 4"ed. Butterworths, London, 1988. |
| 10. | Mollard P. Mouriquand PDE, Buttin X. Urinary continence after reconstruction of classical bladder exstrophy (73 cases). Br J Urol 1994: 73: 298-302. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
[Table - 1]
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