RESULTS OF UMBILICOPLASTY FOR BLADDER EXSTROPHY

Abstract

The umbilicus is an important aesthetic landmark and its absence or deformity may be associated with poor self-image. In patients born with bladder exstrophy the umbilicus is attached to the upper margin of the bladder and reconstructive surgery often removes the navel. The umbilicus marks the waistline and serves to complete the harmony of the curved lines above and below the waist. We present our experience with children born with exstrophic anomalies during the last 2 decades. Our database included 61 children born with classic bladder and 8 born with cloacal exstrophy treated between 1980 and 1998. We performed primary reconstruction in 35 children, while 34 children and young adults were referred for secondary surgical repair, including bladder augmentation, continent diversion, genitoplasty and so forth. Neoumbilicoplasty was done in all of the former and in 30 of the 34 latter cases. Early in the series a V-shaped flap was raised and buried subcutaneously. The flap eventually became a tube around the cystotomy tube and the cicatrix formed the umbilical dimple. This method necessitated packing with iodoform gauze for 4 weeks with weekly dressing. The technique evolved into a tubularized U-shaped flap. A rubber tube was placed indwelling as a stent to maintain inward projection of the neoumbilicus. In 66 of the 69 cases the early results of umbilicoplasty were described by the surgeon as excellent or satisfactory. In 3 cases the neoumbilicus appeared flat, lost depth and was described as unsatisfactory. Long-term followup of more than 1 year was available in 48 patients, of whom 2 underwent umbilical repositioning for an off center or low umbilicus and 3 underwent repeat umbilicoplasty for a flat umbilicus that had lost depth. The best cosmetic results were achieved in patients with a relatively thick layer of subcutaneous fat, whereas cosmesis was suboptimal in thin children. Nevertheless, the patients and parents were generally pleased with the umbilical appearance even when the surgeon was not. Although the navel is a functionless depressed scar, it represents an important and pleasing landmark. Umbilical construction should be attempted early during functional closure or urinary diversion.