Surgery Insight: Advantages and Pitfalls of Surgical Techniques for the Correction of Bladder Exstrophy

Douglas A Husmann

Disclosures

Nat Clin Pract Urol. 2006;3(2):95-100. 

In This Article

Summary and Introduction

Summary

Staged reconstruction repair of bladder exstrophy results in hydronephrosis or renal scarring in 15-25% of patients. A cosmetically acceptable and functional phallus can be achieved in 85% of patients, 20-30% of whom will require more than one operation for penile reconstruction. Episodes of penile glans loss or corporal loss are rarely reported with this technique. Widely disparate results relating to complete urinary continence and volitional voiding have been published, with urinary continence reported to occur in 7-85% of patients. The need for bladder augmentation to obtain urinary continence also varies, with reports that somewhere between 10% and 90% of patients require an augmentation procedure to gain urinary continence. Complete primary repair of bladder exstrophy using the penile disassembly technique results in hydronephrosis or renal scarring in 0-30% of patients, and hypospadias, as a consequence of this repair, will occur in 30-70% of patients. Loss of the glans and corpora appear more frequently with penile disassembly than in staged reconstruction of bladder exstrophy, however, the exact incidence of this complication is unknown. Reported complete urinary continence and volitional voiding rates are also varied following penile disassembly, ranging from 25-65%. A modified bladder-neck reconstruction to gain urinary continence is reportedly required in 15-90% of patients, with 5-10% requiring both bladder augmentation and bladder-neck reconstruction. Experience with complete primary repair of bladder exstrophy, using the penile disassembly approach, seems promising but is not a panacea. To outline the risks and benefits regarding the various surgical techniques for bladder exstrophy, we would recommend the establishment of a national registry for patients with this disorder.

Introduction

Before surgical treatments were introduced in 1850, patients with bladder exstrophy had to cope with the life-long problems of chronic urinary incontinence, sexual inadequacy, increased risk of adenocarcinoma of the bladder and renal deterioration.[1] Attempts to improve the social and physical problems of this congenital abnormality by simple cystectomy and urinary diversion with ureterosigmoidostomy were initiated at the turn of the 20th century, and rapidly exploded in popularity following the development of antibiotics.[1] From 1935 until the late 1960s, simple cystectomy, ureterosigmoidostomy and genital reconstruction were the main treatments used. The popularity of ureterosigmoidostomy, however, declined in the 1960s when its associated complications, including metabolic derangements, chronic pyelonephritis, and urocolonic tumors, became known.

From the historical treatment of classical bladder exstrophy, urologists learned two important tenets. Firstly, the success of any genitourinary-tract reconstructive procedure should meet the following three goals: to preserve kidney function; to provide urinary continence; and to maintain or create functionally normal external genitalia. Secondly, complications of reconstructive techniques can take decades to become apparent. The purpose of this review is, therefore, to address how well the current surgical techniques for bladder exstrophy are meeting the goals for genitourinary reconstruction and to examine the associated complications of this reconstructive surgery.

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