The fate of the upper urinary tract in exstrophy.

Abstract

We evaluated the impact of reconstructive bladder procedures on the upper urinary tract in bladder/cloacal exstrophy. A total of 57 patients underwent bladder neck procedures for urinary incontinence due to bladder exstrophy between 1988 and 2001. We correlated evidence of renal injury to urinary continence and type of surgery. Renal scarring and moderate/severe hydronephrosis were considered significant upper tract changes. Overall 27 patients (47%) underwent bladder neck closure, 38 (67%) augmentation cystoplasty and 44 (77%) a Mitrofanoff procedure. Mean interval since last continence procedure was 4.5 years and mean patient age at last followup was 11.7 years. Hydronephrosis was noted in 18 patients (32%) at last followup (after bladder neck reconstruction in 15). Renal scarring in 14 cases on dimercapto-succinic acid scan was evenly distributed regardless of the type of bladder neck procedure or presence of augmentation. Of 6 patients with grade 3 to 4 hydronephrosis 5 had renal scarring versus only 1 in the 39 without hydronephrosis (p <0.0001). Serum creatinine remained normal in 55 patients, mild renal insufficiency developed in 1 and renal transplantation was performed in 1. Two patients with persistent incontinence are anticipating an augmentation. Of our 57 patients with exstrophy 14 (24%) had significant upper tract damage in the form of renal scarring and/or moderate or severe hydronephrosis. The surgical method of achieving continence was not predictive of hydronephrosis or scarring. Bladder neck closure appears to provide better urinary continence and was equally safe with respect to hydronephrosis or scarring compared to patent forms of bladder neck reconstruction.