Commentary to “Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms”

Abstract

The authors should be commended for this paper, which emphasizes an important yet under-reported pediatric urological issue; namely, penile tissue loss following the surgical treatment of classic bladder exstrophy. They report data from 28 patients who suffered this complication after bladder exstrophy or epispadias repair, and were transferred to their institution, described in the literature or presented in scientific meetings. Understandably some details are missing since the report incorporates cases from other centers, presented at various meetings or collected from limited data provided in the literature. Noticeably, 19 of 20 patients with enough information (as presented in the table) underwent repair in the newborn period and three had the Kelly procedure, which mandates extensive softtissue mobilization. The majority of these children did not undergo concurrent pelvic osteotomies, leading the authors to conclude that this is one of the major factors associated with the development of penile tissue loss. Whereas we agree that osteotomies are an important adjuvant procedure to improve wound closure with less tension, other potential factors are equally or perhaps even more relevant. For instance, in cases with large pubic diastasis significant pelvic tension is produced during approximation, generating high pressures in the underlying structures, with or without osteotomies. Additionally, with primary bladder closure and epispadias simultaneous repair (CPRE), extensive penile and pelvic soft-tissue mobilization is carried out. This dissection is likely to induce reflex vasoconstriction and edema, factors that predispose to ischemia, especially when associated with some degree of hypotension. One can imagine the result of such manipulation when performed in the neonate, who is recognized to be more prone to hypothermia and hemodynamic instability. Therefore, it comes with no surprise that the vast majority of patients in this paper were newborns undergoing CPRE. However, there are unquestionable benefits associated with CPRE performed in the neonatal period. Improved bladder capacity and continence have been observed after CPRE and are likely related to the increased urethral resistance generated by the deep pelvic positioning of the proximal urethra during this repair. This has been considered a good reason to perform this extensive repair in the newborn period. However, it carries an increased risk of developing penile tissue loss, as demonstrated in this series. In order to maintain some of the advantages of CPRE we developed an alternative strategy for the primary closure of bladder exstrophy. Aiming to increase urethral resistance, but without concomitant epispadias repair, we have been performing bladder neck tailoring and concurrent bilateral ureteral reimplantations during the primary closure of exstrophy [1]. In this way, urethral resistance and early bladder cycling can be safely achieved, factors that ultimately may be relevant to improving bladder capacity and possibly urinary continence. Another aspect explored by the authors is the grade of expertise of the surgeons performing CPRE. Although this speculation is appealing, only 5 out of 28 surgeons did not have fellowship training, implying that the surgeon’s