Surgical Treatment of Exstrophy of The Bladder With Emphasis on Neonatal Primary Closure: Personal Experience With 28 Consecutive Cases Treated at the University of Washington Hospitals From 1962 to 1977: Techniques and Results

Abstract

Of 28 consecutive previously untreated cases of exstrophy of the bladder seen from 1962 to 1977, 20 presented in the classical form, 3 had complete epispadias, 2 were cloacal, 1 had a superior vesical fissure and 2 were variants. Primary closure was attempted in all patients except a 1-year-old child with a tiny metaplastic bladder and 1 with cloacal exstrophy who died during the neonatal period. Closure was attempted as early as possible. Osteotomies were not required in 9 cases in which closure was done within 48 hours after birth. All older children had iliac osteotomies with simultaneous bladder closure. Complete epispadias is the goal of the initial stage in this multistage procedure. An attempt is made to swing the separated abdominal-perineal midline structures together, after dissection has freed the edge of the bladder and urethra from the skin and muscles. A key in the dissection is palpation of the medial edges of the symphyses pubes. Once these are exposed rectus fascia and muscle, and perineal structures are traced from them. I use 5F infant feeding tubes as ureteral stents brought out through the urethra. A feeding tube is anchored in the bladder and brought out per urethram for drainage. The bladder is closed with interrupted permanent non-reactive materials. Currently, 5-zero and 4-zero polypropylene is placed extramucosally in neonates. The same sutures close the recti and fascia. Symphyses are brought together in neonates with 2, 3-zero figure-of-8 polypropylenes. Subsequent stages, starting when the patient is about 1 year old, usually are required to correct epispadias. Most cases also require ureterovesicoplasties, herniorrhaphies and release of chordee. Of 26 patients 12 are continent, including 6 of the 19 classical cases, 2 complete epispadiacs, 2 variants and the 1 fissure. Of the classical types 9 patients are diverted and 3 are too young to evaluate. The upper tracts are better in closed than in diverted systems.