Radical soft tissue mobilization for persistence of epispadias in previously closed bladder exstrophy with persistent incontinence

Abstract

Objective: The radical soft tissue mobilization (RSTM) technique has been utilized as an alternative to staged reconstruction of bladder exstrophy, with purported benefits of social continence and increased phallic length due to corporal body mobilization. In this video, we demonstrate the successive steps of this technique. Patient and surgical procedure: A 5-year-old male with a history of classic bladder exstrophy underwent bladder closure with bilateral pelvic osteotomies at birth. He subsequently underwent epispadias repair at 18-months and revision at 24-months, complicated by urethrocutaneous fistula formation and buried penis. He was continuously incontinent and unable to toilet train. Cystoscopy and cystogram showed a wide, incompetent bladder neck with small bladder capacity and bilateral VUR. After counseling regarding various management options, he underwent RSTM with bilateral pelvic redoosteotomies and penile reconstruction at 5 years of age.RSTM involved full mobilization of pelvic floor musculature, corpora cavernosa, and pudendal pedicles from their attachments on the pubic bones. Bilateral periosteal incisions were made on the antero-medial aspect the ischio-pubic ramus, peeling the corporal bodies off the periosteum and providing control of the pudendal pedicles. Attachments of all striated pelvic floor muscles were released along the white line to allow for mobilization and approximation around the reconstructed bladder neck.Bilateral cross-trigonal ureteral reimplantation and bladder neck repair were performed. The corpora cavernosa were separated from the corpora spongiosum, which was then brought ventrally, creating a temporary proximal hypospadias urethrostomy for staged repair. The bulbospongiosus muscle was wrapped around the proximal urethra to create the external sphincter continence mechanism. The separated corpora were apposed – avoiding torsion or chordee. A pubic symphistomy was performed to gain access to the bladder neck; however, following this repair it was not possible to approximate with sutures. Hence, bilateral pelvic redoosteotomies were performed and an external fixation device was applied to facilitate pubic symphysis closure. Corporal bodies were then anchored proximally to the pubic symphysis dorsally. The abdominal wall was then closed, Z-plasty skin arrangement was performed at penopubic junction, while the penile shaft skin from the ventral aspect was brought dorsally and reconstructed. A circumcised appearance to penis obtained. Results: RSTM combined with bilateral pelvic osteotomies improves cosmesis and continence by supporting the sphincter complex with pelvic musculature and lengthening the penis. Conclusion: The video demonstrates radical pelvic floor mobilization for bladder exstrophy epispadias complex in a male child. An expert level knowledge of pelvic anatomy is critical, and only surgeons experienced in this technique should perform surgery.