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ORIGINAL ARTICLE
Year : 2002  |  Volume : 18  |  Issue : 2  |  Page : 117-119
 

Total correction of bladder exstrophy - our experience in 37 patients


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
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Source of Support: None, Conflict of Interest: None


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   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

How to cite this URL:
Ray A K, Mukherjee N N, Mukherjee S, Mukherjee P. Total correction of bladder exstrophy - our experience in 37 patients. Indian J Urol [serial online] 2002 [cited 2020 Oct 1];18:117-9. Available from: http://www.indianjurol.com/text.asp?2002/18/2/117/37399



   Materials and Methods Top


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 Top


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 Top


So in conclusion, we would like to highlight the fol­lowing facts :

  1. At least 10cc capacity bladder with good detrusor compliance gives successful closure.
  2. Anterior osteotomy gives better results than bilat­eral iliac osteotomy and/or primary closure without osteotomy and anterior abdominal fascial flap repair.
  3. 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.
  4. Small fibrotic patch bladder needs permanent diver­sion.



   Acknowledgement Top


Authors are thankful to Principal and Superintendent of Medical College, Kolkata for kindly allowing them to send the manuscript for publication.

 
   References Top

1.Kenneth JW. Exstrophy of urinary bladder. In : Paediatric Surgery. 4`' ed. Chicago. 1986: 2: 1223.  Back to cited text no. 1    
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.  Back to cited text no. 2    
3.Marshall VF. Muecke EC. Functional closure of typical exstrophy of the bladder. J Urol 1970; 104: 205-212.  Back to cited text no. 3    
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.  Back to cited text no. 4    
5.Borzi PA. Thomas DFM. Cantwell-Ransley epispadias repair in male epispadias and bladder exstrophy. J Urol 1994; 151: 457-459.  Back to cited text no. 5    
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.  Back to cited text no. 6    
7.Husmann DA. McLorie GA. Churchill MB. Inguinal pathology and its association with classical exstrophy bladder. J Pediatr Surg 1990: 25: 352.  Back to cited text no. 7    
8.Jeffs RD. Exstrophy of urinary bladder. In : Paediatric Surgery. 4"' ed. Chicago. 1986.  Back to cited text no. 8    
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.  Back to cited text no. 9    
10.Mollard P. Mouriquand PDE, Buttin X. Urinary continence after reconstruction of classical bladder exstrophy (73 cases). Br J Urol 1994: 73: 298-302.  Back to cited text no. 10    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1]



 

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    Abstract
    Materials and Me...
    Discussion
    Conclusion
    Acknowledgement
    References
    Article Figures
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