Pelvic floor reconstruction in female exstrophic complex patients: different results from males?

OBJECTIVES

To present the surgical, functional, and cosmetic results of anterior pelvic floor reconstruction in female exstrophic patients who underwent single-stage surgical repair. To verify differences in outcome from male exstrophic patients.

METHODS

Among the 31 exstrophy-epispadias complex (EEC) patients treated in 10 yr, 13 (42%) were females. We studied 10 of them (9 classic exstrophies and 1 prolapsing epispadia), aged 2 d to 6 yr, who received one-stage repair with pelvic floor reconstruction. The reconstructive steps were posterior pelvic osteotomy, en bloc mobilisation of bladder neck-urethra/vagina within the midline pelvic floor, symmetrical reassembly of the muscular complex that constitutes the pelvic diaphragm (using a bipolar stimulator), tubularisation and elongation of the bladder neck and urethra, and genitoplasty. At 2- to 3-yr follow-up, bladder capacity and dry intervals were evaluated by cystogram and urodynamic study, respectively. Surgical complications and cosmetic appearance were also assessed. Results were compared with a group of 18 male EEC patients treated in the same period with similar technique. Fisher exact test and chi-square test were used for statistical analysis.

RESULTS

No bladder/urethra dehiscence, exstrophy relapse, or uterine procidentia were observed. Cosmesis was fully satisfying in all. Bladder capacity ranged from 35 to 137 ml (mean: 87). Cyclic voiding with 45- to 90-min dry intervals was achieved in 7 patients (70%), but stress incontinence was present in 5 patients. Volitional micturition control was achieved in 5 of 6 (83.3%) girls aged 4-8 yr. In the male group, we observed two surgical complications (glans disruption and urethrocutaneous fistula) and one poor cosmetic outcome. Mean bladder capacity was 70 ml (range: 25-140). Dry intervals were present in 6 patients (33%). Volitional voiding was achieved in 5 of 12 (40%) male exstrophic patients older than 4 yr, with little stress incontinence. Female and male EEC patients presented significantly different outcomes (p<0.05) regarding both surgical complications and functional bladder behaviour.

CONCLUSIONS

Pelvic floor reconstruction and its correct relationship with the lower genitourinary tract may facilitate the development of volitional micturition control. Female patients behaved slightly better than males concerning dry intervals and coordinated bladder activity achievement.