Correspondence Re: “Garat JM, de la Peña E, Caffaratti J, Villavicencio H. Prevention of Vesicoureteral Reflux at the Time of Complete Primary Repair of the Exstrophy-epispadias Complex. Int Urol Nephrol. 2004; 36: 211–2”.

Abstract

This letter is in reference to the recently published paper ‘‘Prevention of vesicoureteral reflux at the time of complete primary repair of the exstrophy– epispadias complex’’ [1] to which we would like to add some comments. The paper presents for the second time in a PubMed indexed journal [2] one case of total neonatal exstrophy reconstruction associated to theGil-Vernet antireflux technique [3]. Unfortunately, Garat et al. disregard the fact that the association of the ureteral advancement designed by Gil-Vernet with the one step exstrophy closure, had already been published in the BJU Int [4] after being presented in 2002 at the European Society for Pediatric Urology (ESPU). In that paper, the authors, leaded by De Castro (with a solid reputation and experience in bladder exstrophy), hypothesized that the Gil-Vernet procedure could add a certain antireflux effect. Three exstrophy patients of their series were treated in that fashion and none of them presented vesicoureteral reflux in the follow-up. Furthermore, it seems exceeding to conclude that the procedure is ‘‘very successful’’ when only one patient, in the authors’ hands, underwent the procedure. Besides, we miss in Garat et al. [1] case report a critical appraisal of the possible limitations that the incorporation of this surgical step could imply. No doubt the proposal of adding the Gil-Vernet trigonoplasty to the one-stage complete neonatal exstrophy closure is appealing. However, the text does not mention the differences that this antireflux technique presents in cases of bladder exstrophy as opposed to conventional vesicoureteral refluxing bladders. Anatomical issues such as pubic diastasis, the defect in the bladder floor reinforcement or the existence of an incompetent bladder neck as well as the possible variation in the intramural course of the ureter are some of the subjects that could have been addressed when evaluating the potential effectiveness of this antireflux mechanism in these patients. Moreover, as De Castro et al. [4] state: ‘‘more experience and a longer follow-up is required to assure if this technique will be of interest’’. Finally, Garat el al. [1] report’ missreferences the first report(s) of Grady and Mitchell [5, 6] on the complete one-stage exstrophy closure and instead makes reference to the penile disassembly technique for the epispadias reconstruction developed by Mitchell and Bagli [7]. We believe the authorship of Grady and its’ contribution to this innovative technique should be acknowledged.