Primary Bladder Closure Research Articles

MODIFIED YOUNG-DEES-LEADBETTER BLADDER NECK RECONSTRUCTION IN PATIENTS WITH SUCCESSFUL PRIMARY BLADDER CLOSURE ELSEWHERE: A SINGLE INSTITUTION EXPERIENCE

Achievement of urinary continence in patients with the exstrophy-epispadias complex remains a challenge. We reviewed our experience with the modified Young-Dees-Leadbetter bladder neck repair in patients with bladder exstrophy who underwent primary bladder closure elsewhere. We retrospectively reviewed exstrophy charts and database of 57 male and 11 female with classic bladder exstrophy who underwent bladder neck repair at our institute and successful primary bladder closure elsewhere during the last 2 decades. Osteotomy was performed at primary closure in 14 (20%) cases and 9 (13%) patients at bladder neck repair in 9 (13%) to aid in stabilizing the urethra and pelvic ring, and to help reapproximate the pelvic floor musculature facilitating urinary continence. Primary closure was done within 72 hours of life elsewhere in 41 (60%) patients, and between ages 72 hours and 5 years (most during the first month of life) in 27. Paraexstrophy skin flaps were used in 33 (48%) cases, and the most common complication was bladder outlet obstruction of the posterior urethra secondary to the skin flaps. Of the 68 patients 57 (83%) are continent and voiding per urethra without need for augmentation or clean intermittent catheterization, 9 (13%) required clean intermittent catheterization including 7 who underwent continent urinary diversion after failed bladder neck repair, and 2 are still incontinent due to a severe posterior urethral stricture. Urinary retention was the most common symptom after bladder neck repair which resolved following catheter dilation or prolonged suprapubic catheter drainage. Successful early primary closure of a good bladder template is the most important determinant of eventual bladder capacity and compliance.

THE NEWBORN EXSTROPHY BLADDER INADEQUATE FOR PRIMARY CLOSURE: EVALUATION, MANAGEMENT AND OUTCOME

The surgical approach to the small newborn exstrophy bladder inadequate for primary closure remains undetermined. Various methods for long-term management have been implemented. We evaluated our experience with late primary closure of the small exstrophied bladder template. Our institutional database of patients treated and followed for the exstrophy-epispadias complex was reviewed. Of these patients 19 had a bladder template that was too small to close in the newborn period. The treatment and outcome of these 19 patients were reviewed. Of the 19 children who had delayed closure due to a small bladder template 14 were males and 5 were females. Followup from birth ranged from 2 to 36 years (mean 18 years). Primary closure was performed at a mean patient age of 13 months (range 6 months to 2 years). Pelvic osteotomy was performed in 16 patients. Of the 19 patients 9 achieved continence after gaining a bladder capacity sufficient for bladder neck reconstruction, 4 required enterocystoplasty to augment bladder volume and perform clean intermittent catheterization (2 per stoma and 2 per urethra), 1 required a colon conduit for an extremely small bladder, and 1 underwent cystectomy and ureterosigmoidostomy for rhabdomyosarcoma. Four patients are currently incontinent, including 3 who are awaiting bladder neck reconstruction and 1 who has frequent nighttime incontinence that is medically managed. Delayed primary closure of the small bladder exstrophy template can allow the native bladder tissue adequate time to grow to a size feasible for successful closure. Epispadias repair can usually be performed at the same time and is facilitated by prior testosterone administration. Bladder neck reconstructive techniques have achieved continence without the need for augmentation or bladder replacement in 47% of the patients in our series. For patients who do not achieve adequate capacity for bladder neck reconstruction, preservation of the native bladder template facilitates future augmentation and ureteral reimplantation, thus requiring use of less bowel in the growing child.

Bilateral anterior pubic osteotomy in bladder exstrophy repair: report of increasing success.

Bilateral posterior iliac osteotomy is performed in most patients undergoing primary closure of an exstrophic bladder; the aims are to facilitate abdominal-wall closure, prevent postoperative wound dehiscene, and possibly, to achieve better urinary control in older age. A new technique, anterior pelvic osteotomy of the superior pubic ramus, seems to obtain tension-free symphysis approximation safely and quickly. We report our initial experience with this osteotomy. Five neonates, four males and one female from 1 to 4 days old, all underwent closure surgery for bladder exstrophy (BE) and subsequent bilateral osteotomy of the superior pubic ramus (SPRO). Postoperatively, Bryant's traction was applied. Tension-free, complete approximation of the symphysis and uncomplicated healing were achieved in all five cases without palsy of the obturator nerve or postoperative hemorrhage. Follow-up revealed partial rediastasis with a stable anterior pelvic ring. Tension-free closure and immobilization are important factors in both initial and subsequent closure of BE. Several osteotomy techniques are currently in use. SPRO presents numerous advantages, namely, ease and rapidity, minimal blood loss, and no requirement for an extra skin incision or need to turn the patient on the operating table. A certain degree of rediastasis with growth was subsequently observed: although undesirable, this complication is common to all osteotomy techniques. We believe that SPRO is a valid and uncomplicated method to facilitate BE closure.

Urinary diversion in children with mainly exstrophy and epispadias: alternative to primary bladder closure.

To review the long term outcome of children who underwent urinary diversion for various non-malignant conditions and to assess the suitability of urinary diversion as an alternative treatment to primary bladder closure in cases of bladder exstrophy epispadias complex. A retrospective study. Institute of Urology, Moshi, Tanzania. Fifteen children who underwent urinary diversion for various non-malignant conditions between 1985 and 1997. Fifteen children underwent urinary diversion for: exstrophy epispadias complex (n = 12) neurogenic bladder (n = 2) and trauma (n = 1). Seven children underwent Mainz pouch II diversion, six had classical ureterosigmoidostomy and two had appendicovesicostomy. One patient with a solitary kidney developed ureteral stenosis at the implantation site and was undiverted. Metabolic acidosis was well compensated with none of the patients requiring sodium bicarbonate supplements. All the patients except one were continent. We conclude that continent urinary diversion in children offers a viable alternative method for children with bladder exstrophy epispadias complex.

Factors responsible for successful primary closure in bladder exstrophy.

To assess the important factors for successful primary closure in staged reconstruction of bladder exstrophy, 25 patients (18 males, 7 females) underwent primary bladder closure during the years 1993-1997. Twenty-one were more than 72 h old; all of these underwent bilateral posterior iliac osteotomies followed by primary bladder closure during the same anesthetic. Bladder closure was done in a double layer. The ureteric catheters were removed after 2 weeks and the bladder catheter after 3.5-4 weeks. Only 1 patient had a bladder dehiscence on the 10th postoperative day due to infection; 3 had partial wound dehiscences but no bladder dehiscence. One had a partial bladder prolapse. The osteotomies needed no drainage, and no complications occurred. One patient needed a urinary diversion 3 years after surgery as the bladder capacity did not increase. Eleven important factors play a pivotal role for successful primary bladder closure: (1) Proper patient selection; (2) A staged approach; (3) Anterior approximation of the pubic bones with placement of the bladder and urethra in the true pelvis; (4) Posterior bilateral iliac osteotomies in all indicated cases; (5) Double-layered closure of the bladder; (6) Two weeks' proper ureteric catheter drainage; (7) Prevention of infection; (8) Prolonged and proper postoperative immobilization; (9) Prompt treatment of bladder prolapse; (10) Prevention of abdominal distension postoperatively; and (11) Ruling out bladder-outlet obstruction before removing the bladder catheter.

COMPLETE PRIMARY REPAIR OF EXSTROPHY

The surgical correction of bladder exstrophy to achieve continence with voiding remains a challenging problem for the urologist. Since 1989 we have performed complete primary repair for exstrophy based on the concept that the primary defect of bladder and cloacal exstrophy is anterior herniation. Thus, the bladder and urethra must be treated as a single unit to move them posteriorly into the pelvis. We present this technique. From 1989 to 1997, 18 patients with bladder exstrophy and 6 with cloacal exstrophy underwent complete primary repair of exstrophy. This procedure was done on day 1 of life in 18 patients. Mean followup is 44 months (range 4 months to 8 years). At a median followup of 48 months 4 boys and 4 girls have volitional voiding after complete primary repair of bladder exstrophy, 21 patients have continent intervals and 2 boys void with continent intervals after complete primary repair of cloacal exstrophy. No patient has had a loss of renal function in this series. Postoperative complications included urethrocutaneous fistula formation in 2 cases. No patient had primary closure dehiscence. The rate of urinary continence achieved with complete primary repair compares favorably to that of staged repair for exstrophy. Complete primary repair also minimizes the number of surgical procedures required to achieve urinary continence and potentiates bladder neck function that permits bladder cycling in year 1 of life. The complication rates of these techniques are significantly lower than those reported in previous series of primary closure of exstrophy.

STRATEGIES FOR RECONSTRUCTION AFTER UNSUCCESSFUL OR UNSATISFACTORY PRIMARY TREATMENT OF PATIENTS WITH BLADDER EXSTROPHY OR INCONTINENT EPISPADIAS

Purpose Following unsuccessful or unsatisfactory primary treatment in patients with the epispadias/exstrophy complex, the options for a surgical solution to preserve the upper urinary tract, to achieve complete continence, and to reconstruct the external and female internal genitalia are limited. We reviewed the records of the patients treated at our institution to determine a surgical compromise between ingenious operative constructions and patient desires, both of which are secondary to stabilization of renal function. Materials and Methods From 1967 to December 1997, 128 patients with bladder exstrophy/epispadias complex were treated, of 80 whom had received previous unsuccessful or unsatisfactory treatment. Of these patients 72 were followed for an average of 22.4 years after the first surgical intervention. There were 40 patients referred to our institution after primary bladder closure and bladder neck reconstruction, 10 after rectal bladder, 7 after ureterosigmoidostomy and 5 after incontinent diversion. Results At the latest followup 19 patients had a rectal reservoir, 38 an ileocecal pouch, 12 a conduit diversion and 3 an augmented Young-Dees procedure. The upper urinary tract remained stable in 95% of the renal units with rectal reservoir, 95% with ileocecal pouch, 96% with a colonic conduit and 100% with an augmented Young-Dees procedure. Day and night continence was achieved in 95% of the patients with a rectal reservoir and 97% of those with an ileocecal pouch were continent, whereas only 2 of the 3 patients with an augmented Young-Dees procedure were continent. Of the women 16 were satisfied with the cosmetic results and 6 delivered 8 children by cesarean section. Only 1 man was dissatisfied with the final cosmetic result. All adults but 1 engaged in sexual intercourse. Conclusions The first operative intervention in patients with bladder exstrophy/epispadias complex determines their fate. After failure of primary treatment, the upper urinary tract must be stabilized. In patients with severely impaired renal function the colonic conduit is our method of choice while in those with a normal or slightly dilated upper urinary tract and intact anal sphincter we performed a rectal reservoir. In the remaining patients an ileocecal pouch guarantees continence day and night. The results of genital reconstruction are satisfactory.

Long-Term Results of Ureterosigmoidostomy in Children With Bladder Exstrophy

Purpose We evaluated long-term results of patients with bladder exstrophy who underwent ureterosigmoidostomy. Materials and Methods Of 4 women and 23 men monitored at our institution 16 (59 percent) underwent primary diversion by ureterosigmoidostomy, while 11 (41 percent) underwent primary bladder closure or an ileal conduit procedure before conversion to ureterosigmoidostomy. Average followup after ureterosigmoidostomy was 17 years. Results Significant upper urinary tract changes developed in 18 percent of the patients. Metabolic acidosis was well compensated in most patients but 2 had problems with urinary retention leading to hyperammonemia and acidosis. Of the 19 patients monitored with biennial colonoscopy benign polyps were removed in 4. Daytime continence was achieved in 92 percent of cases and nighttime continence in 58 percent. Conclusions Our experience with ureterosigmoidostomy in children with bladder exstrophy has been favorable through long-term followup. With proper imaging, metabolic surveillance, biennial colonoscopy and nonsteroidal anti-inflammatory drugs we offer ureterosigmoidostomy as a viable alternative for patients with small bladders.

Social integration, sexual behavior and fertility in patients with bladder exstrophy--a long-term follow up.

After primary bladder closure or urinary diversion, other factors apart from the reconstruction itself gain importance for individuals with the exstrophy-epispadias complex: social integration and, after reaching puberty, sexuality and fertility. Between 1968 and July 1994 115 patients with bladder exstrophy or incontinent epispadias underwent surgery at our institution. A total of 104 patients could be followed, 2 of whom died in the meantime. Of the remaining 102 patients 48 attend school, 4 are in college, 40 have completed or are currently undergoing vocational training, 3 are unemployed, 1 lives in a therapeutic centre and 6 are younger than 6 years of age. A total of 95% of the patients with continent urinary diversion are continent day and night, whereas only three of five patients with a sling plasty (incontinent epispadias) or with primary bladder closure followed by a Young-Dees procedure are continent. None of the patients showed deterioration or renal function. In 25 females the external genitalia were reconstructed. Fixation of the uterus was done in 13 to correct or prevent uterine prolapse. Of the 17 women older than 18 years of age with genital reconstruction, 16 are satisfied with the cosmetic result. All adults engage in sexual intercourse. Five women have delivered seven children by Caesarean section. Of the 35 male adults 32 underwent reconstruction of the external genitalia and 34 males achieve erection. One developed necrosis of the penis early in life following primary bladder closure performed at an outside hospital. Penile deviation was present in 11 of the 32 patients with genital reconstruction, which is distressing in only 2. Thirty patients are satisfied with the cosmetic result. After genital reconstruction 9 males developed epididymitis, necessitating two orchiectomies and three vasectomies. No patients with reconstruction of the external genitalia can ejaculate normally or has fathered children, whereas ejaculation was normal in the three men who did not undergo genital reconstruction and in two patients prior to post-pubertal reconstruction. Furthermore, two of these three men have fathered four children. Education, occupation and social development of patients with urinary diversion are uneventful. The cosmetic results achieved by genital reconstruction are satisfactory. In female patients, antefixation of the uterus should be performed before or together with an introitusplasty to prevent uterine prolapse. In male patients, however, surgery is performed at the expense of fertility. Detailed discussions with the patients and their patients should include not only the question of primary bladder closure versus urinary diversion, but also the pros and cons of correction of the external and-in females-the internal genitalia.

Hypertension following primary bladder closure for vesical exstrophy

Since the initiation of staged reconstruction for bladder exstrophy, hypertension has been a known complication of the procedure. The etiology of the elevation in blood pressure was presumably secondary to ureteral dysfunction caused by edema at the ureterovesical junction and secondary renal obstruction. This report details the clinical course of three patients who developed significant hypertension following primary bladder closure with posterior iliac osteotomies and bony immobilization by skin traction. None of the patients had urinary obstruction and all had their hypertension alleviated by removal of the traction. The presumed etiology of the elevated blood pressure within these patients is similar to that experimentally produce by inappropriately applied traction resulting in tension on the sciatic nerve and reflex induced vasoconstriction. The need to maintain appropriately applied traction and the necessity of monitoring the postoperative blood pressure is stressed.

Results of surgical treatment in children with bladder exstrophy.

A series of 42 children (30 boys and 12 girls) underwent surgery for bladder exstrophy between 1972 and 1989. Primary bladder closure was performed in 11 patients and was successful in 6. Four of these children are about 2 years old and so it is not yet possible to assess their continence. Ureterosigmoidostomy was performed in 35 children, one of whom was converted to cutaneous ureterostomy. Follow-up ranges from 2 to 20 years (average 9 years 3 months) and 50% of the patients are symptom-free. The most frequent problems were acidosis and urinary tract dilatation. Other complications, such as hypokalaemia and pyelonephritis, were seldom seen. Although ureterosigmoidostomy has some disadvantages, our patients have adapted well and lead a normal life.

Long-Term Followup of 207 Patients with Bladder Exstrophy: An Evolution in Treatment

Between 1945 and 1985 a total of 207 patients (male-to-female ratio 2:1) was treated at our institution for exstrophy of the bladder. Primary anatomical bladder closure was performed in 137 patients, of whom 42 (31 per cent) eventually required urinary diversion. Primary urinary diversion was the initial treatment in 70 patients, including ureterosigmoidostomy in 40, ileal conduit in 17, colon conduit in 11 and cutaneous ureterostomy in 2. Secondary urinary diversion was necessary in 35 patients and included continent diversion in 7. Primary anatomical bladder closure, done within 72hours of birth and followed by staged reconstruction of the bladder neck, was the most successful surgical regimen for the treatment of bladder exstrophy. Acceptable urinary continence was achieved in 82 per cent of our patients with this approach. However, multiple procedures often were required to achieve continence.

Primary closure of bladder exstrophy: Long-term functional results in 137 patients

Between 1945 and 1985, 207 patients were treated at our institution for exstrophy of the urinary bladder. Primary anatomical bladder closure was performed in 137 patients. In 97 patients treated prior to 1975, bladder closure was performed at a median age of 1 year and continence in this group was only 16%. Forty patients treated after 1975 underwent closure at a median age of 72 hours followed by staged reconstruction of the bladder neck. Continence in this group was 82%; however, the average number of surgical procedures was five as compared with two in the first group. Early bladder closure and staged reconstruction can achieve acceptable urinary continence, but multiple surgical procedures may be required.

Long-Term Followup of 103 Patients with Bladder Exstrophy

We reviewed 103 patients with exstrophy of the bladder. Followup was more than 15 years in 51 patients. Initial management consisted of primary bladder closure in 32 patients and urinary diversion in 71. Urinary continence, renal function, urinary tract infections and development of malignant lesions were evaluated. Factors leading to success or failure were analyzed. Although the highest continence rate (83 per cent) was achieved in 40 patients with ureterosigmoidostomy, renal functional deterioration was highest in this group, with 70 per cent of the evaluable renal units being abnormal. Furthermore, 10 per cent of this group died of renal failure and 23 per cent lost 1 kidney each. In 26 patients with an ileal conduit 69 per cent of the renal units evaluated were abnormal. Only 1 patient died of renal failure but 27 per cent lost 1 kidney each. Of 32 patients with primary bladder closure 31 had preservation of renal function. Twelve of 18 patients (67 per cent) in whom vesical neck reconstruction had been completed had total urinary continence and 3 (17 per cent) had partial continence. The incidence of significant urinary tract infections was highest in the ureterosigmoidostomy group (63 per cent) and next to the highest in the ileal conduit ileal conduit group (48 per cent). Malignant lesions developed in 8 patients (8 per cent).

Pediatric Urinary Diversion and Undiversion

Many things have changed in our management of the urinary tract of children and young adults. Important contributions from many sources have resulted in the refinement of therapy and the progression from diversion to undiversion and reconstruction. Primary urinary diversion is now uncommon. Patients with exstrophy, for example, are treated with primary bladder closure as newborns, and newborns with valves often are treated with primary valve ablation. Children with neurogenic bladder dysfunction resulting from myelodysplasia are rarely diverted, but are started at an early age with ICC. It is hoped that in future the contents of this article on diversion techniques and undiversion will be of historical interest, however. Note: The editors also have found the use of the Mitrofanoff procedure, utilizing a nonrefluxing tunnel and a catheterizable stoma made out of the ureter or appendix, to be a very valuable addition to the reconstructive surgeon's armamentarium. We also feel that use of detubularized bowel for either bladder augmentation or replacement provides more efficient storage capability. Occasional reports of extremely significant diarrhea after removal of the ileocecal segment from the intestinal tract have been reported in children with myelodysplasia.

Urinary incontinence in epispadias and bladder exstrophy with special reference to free autologous muscle transplantation

This is a report on 16 patients with epispadias of grades II to IV and on 35 patients with exstrophy of the bladder, grades III and IV. The following surgical treatment was carried out: in children with epispadias, simple closure of the urethra in one case, neck of the bladder plasty according to Young-Dees in two cases, the method after Thiersch-Duplay in three cases, whereas four patients were treated after Williams, five after Johnston and one patient after Ombrédanne in reverse. Seven additional operations were done mainly for prepuce correction and closure of fistula after urethroplasty. Three of the 16 patients were continent already before the operation. 4 children were partially continent. Two of these showed improved continence, thus achieving prolonged periods of dryness. 9 children remained incontinent. Hence, free muscle transplantation to the bladder was performed in four patients. A total of 45 operations were performed on children with exstrophy of the bladder. Of these, 12 concerned primary closure of bladder; in 13 cases, an ileum bladder was constructed, whereas cystosigmoideostomy was done in 5 times, uretersigmoideostomy 5 times, cutaneous ureterostomy once, rectum bladder once, and a colon conduit once. The postoperative continence performance of the 12 patients with primary bladder closure was unsatisfactory. Three children only attained periods of dryness up to two hours; 5 remained completely incontinent, whereas in 4 it was subsequently necessary to construct a urinary passage into the intestine by means of an ileum bladder in 2 cases, a colon conduit in one case, and ureterosigmoideostomy in one case. Free muscle transplantation to the bladder was performed in two patients. Free muscle transplants were also performed on 2 children, in one case after traumatic tearoff of the urethra and in one case after iatrogenic lesion of the musculus sphincter vesicae externus in adrenogenital syndrome (AGS) according to Prader III and IV. This means that a total of eight free muscle transplants were performed. All children were primarily incontinent. Postoperatively, complete continence could be achieved in four cases, once an improvement with dry periods up to 2 hours. The two patients with bladder exstrophy remain incontinent, in one patient with epispadias the postoperative interval has been too short so far to arrive at a final judgement. It follows from the examinations that free muscle transplantation is a good method for treating urinary incontinence, the suspension effect playing an important part. However, in patients with bladder exstrophy the indication should be considered with caution.

The Importance of a Successful Initial Bladder Closure in the Surgical Management of Classical Bladder Exstrophy: Analysis of 144 Patients Treated at the Johns Hopkins Hospital Between 1975 and 1985

The staged functional closure of classical bladder exstrophy has produced improved results for many urologists involved in the surgical management of this congenital anomaly. To determine which factors are most important for achieving a successful outcome (urinary continence with preservation of normal renal function) the 144 patients treated at The Johns Hopkins Hospital between 1975 and 1985 were reviewed. Of these patients 51 were managed entirely at our institution, while 93 had had the initial surgical treatment elsewhere.All patients who had undergone primary bladder closure and bladder neck reconstruction were divided into 2 groups: group 1—patients who had a successful initial bladder closure (an exstrophied bladder that is converted into a complete epispadias without wound infection, dehiscence or any degree of bladder prolapse on the first attempt) and group 2—children whose initial bladder closure was not successful. Both groups were analyzed with respect to bladder capacity at the time of bladder neck reconstruction, time required for the bladder to become sufficiently large for bladder neck reconstruction, urinary continence rate, and interval between bladder neck reconstruction and achievement of urinary continence. Patients in group 1 had the largest bladders at the time of bladder neck reconstruction (mean capacity 79cc, p equals 0.03), shortest intervals between primary closure and bladder neck reconstruction (mean 3.5 years, p equals 0.006), highest urinary continence rate (92 per cent, p equals 0.002), and the shortest interval between bladder neck reconstruction and achievement of urinary continence (mean 1.5 years, p equals 0.18).These findings suggest that a successful initial bladder closure is an important factor for obtaining a larger bladder more quickly and for achieving a high urinary continence rate in patients with classical bladder exstrophy undergoing the staged functional bladder closure.

Primary bladder closure and bladder neck reconstruction in classical bladder exstrophy: H. Lepor and R. D. Jeffs. J Urol 130:1142–1145, (December), 1983

Primary bladder closure and bladder neck reconstruction in classical bladder exstrophy: H. Lepor and R. D. Jeffs. J Urol 130:1142–1145, (December), 1983

Urethral Reconstruction in Boys with Classical Bladder Exstrophy

A total of 24 boys with classical bladder exstrophy underwent initial urethral reconstruction at our hospital between 1975 and 1982. Penile reconstruction in male patients with classical bladder exstrophy includes penile lengthening, release of the dorsal chordee and reconstruct10n of the urethra. The former 2 procedures are performed during the primary bladder closure and urethroplasty usually follows bladder neck reconstruction. A modified Young urethroplasty was done in 22of the 24 patients. Preputial pedicle grafts of free full thickness skin grafts were used for urethroplasty in 2 boys with insufficient penile skin. Fistulas requiring surgical revision developed after urethroplasty in 21 per cent of the patients. A prior osteotomy was associated with a decreased fistula rate. The cosmetic and preliminary functional results of the penile reconstruction were assessed by parental interviews. The definitive assessment of the penile reconstruction will be determined when these boys reach sexual maturity.

Primary bladder closure and bladder neck reconstruction in classical bladder exstrophy.

The surgical results of 28 consecutive initial bladder closures and 25 consecutive initial bladder neck reconstructions performed for classical bladder exstrophy at our hospital between 1975 and 1982 are presented. Partial bladder prolapse occurred in 2 cases and complete wound dehiscence never occurred following the initial primary bladder closure. Urinary continence following bladder neck reconstruction was assessed from parental interviews. An excellent surgical result was defined either as achievement of a daytime dry interval for more than 3 hours or less than 1 incontinent episode per day. According to these parameters, an excellent surgical result was achieved in 86 and 80 per cent of children, respectively. In 21 children evaluated with excretory urograms between 1/2 and 6 years after bladder neck reconstruction 10 per cent of the renal units showed significant hydronephrosis and deterioration of function. The 2 patients who had upper tract deterioration were not followed postoperatively at our institution and the diagnosis of bladder outlet obstruction was delayed when excretory urograms were not obtained during the first postoperative year. This review of the surgical results following primary bladder closure and bladder neck reconstruction for classical bladder exstrophy demonstrates that secure abdominal wall closure and urinary continence can be achieved with minimal morbidity and with infrequent deterioration of renal function following staged functional bladder closure.