Complete repair of bladder exstrophy: preliminary experience with neonates and children with failed initial closure.

PURPOSE

The surgical repair of bladder exstrophy remains challenging for the pediatric urologist. We present our preliminary experience with complete primary repair of exstrophy in neonates and children with failed initial closure.

MATERIALS AND METHODS

Between November 1998 and April 1999, 9 boys and 2 girls with bladder exstrophy underwent complete repair. This procedure was performed in the first 72 hours of life in 4 boys and at age 3 months in 1 girl. Complete repair with osteotomy was performed after failed initial closure in 5 boys and 1 girl at a mean age of 28 months (range 15 to 36). The bladder and urethra were closed in continuity and epispadias was repaired by total penile disassembly. All patients were kept in a spica cast for 3 weeks. Ureteral stents and suprapubic tube were removed 10 and 14 days, respectively, after surgery. Ultrasound was performed preoperatively and every 3 months postoperatively, voiding cystourethrography was done 6 to 12 months after surgery.

RESULTS

Mean followup is 14 months (range 12 to 17). All repairs were successful including 1 case of penile scrotal duplication. Concomitant augmentation was done in 2 girls due to a small bladder plate. Complete closure resulted in hypospadias in 3 of the 9 boys. No patient had dehiscence or fistula. Serial followup ultrasound revealed no hydronephrosis and normal renal growth. Febrile urinary tract infection occurred in 1 case 2 months after surgery and was managed conservatively. Bladder capacity was 200 and 270 ml., at 6 months, respectively, in the 2 patients with an augmented bladder and both are dry on intermittent catheterization. The 4 patients in whom the closure was performed at birth are voiding with dry intervals with mean bladder capacity of 75 cc at 1 year (range 60 to 90). The 5 older children had a mean bladder capacity of 120 cc (range 70 to 150) at 6 months, of whom 2 are completely continent and 3 have 1 to 3 hours of dry intervals.

CONCLUSIONS

Complete repair of bladder exstrophy is feasible in neonates and children after failed initial closure with minimal morbidity. There is no short-term evidence of worsening reflux or hydronephrosis. Longitudinal followup with adequate recording is required for continence evaluation. This technique may minimize the future need of bladder neck reconstruction and augmentation in patients with exstrophy.