COMPLETE PRIMARY REPAIR OF BLADDER EXSTROPHY IN CHILDREN PRESENTING LATE AND THOSE WITH FAILED INITIAL CLOSURE: SINGLE CENTER EXPERIENCE

Abstract

Complete primary repair (CPR) of bladder exstrophy using Mitchell's technique gained wide popularity. We present a single center experience with CPR in 30 children with bladder exstrophy presenting late or after failed initial closure. Between November 1998 and November 2003, 45 patients underwent CPR of bladder exstrophy using Mitchell's technique. All 22 boys and 8 girls presenting beyond the age of 1 year were evaluated. Of the 30 patients 19 (63%) had a history of failed exstrophy closure. Mean patient age at surgery was 3.2 years (range 1 to 8). Bilateral anterior iliac osteotomies were performed in all children. Ultrasound was performed before surgery and 3 months thereafter in all patients. Voiding cystourethrography was obtained at 3 months and then annually. Continence was defined as dry intervals of 3 hours or more. Mean followup is 40 months (range 5 to 64). Concomitant intestinal bladder augmentation was performed in 5 children (17%). The repair resulted in hypospadias in 17 of 22 boys (77%). Following catheter removal 7 patients (23%) had suprapubic urine leakage that ceased spontaneously in all. Early postoperative hydronephrosis was present in 19 of the 30 children (63%) and resolved spontaneously in all. Six patients (20%) had febrile urinary tract infection that was treated conservatively. Vesicoureteral reflux was present in 23 children (68%). Of the 5 patients treated with concomitant bladder augmentation 2 are continent, 2 underwent bladder neck closure and 1 underwent bladder neck reconstruction (BNR). All 5 patients are currently dry. The remaining 25 patients had a mean bladder capacity of 90 ml (range 30 to 200) with continence in 6 children (24%). Continence was achieved in 3 of 6 girls (50%) versus 3 of 19 boys (16%). Five patients underwent BNR with ileocystoplasty in 4. The remaining 14 patients are awaiting BNR with or without bladder augmentation. CPR of bladder exstrophy is feasible in children presenting late or after failed initial closure. Concomitant intestinal bladder augmentation was required in 17% of our patients. The procedure resulted in hypospadias in 77% of the boys. Continence was achievable in 50% of the girls without subsequent bladder neck surgery. On the other hand, most boys (84%) will require BNR with or without augmentation.