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Bladder Neck Reconstruction After Failed Exstrophy Closure: Is It Justified?

Saturday, October 20, 2012
Grand Ballroom A/B (Hilton Riverside)
Eric Z. Massanyi, MD, Nima Baradaran, MD, Bhavik Shah, MD and John P. Gearhart, MD, Pediatric Urology, Johns Hopkins University School of Medicine, Baltimore, MD

Purpose: Successful primary closure of bladder exstrophy ultimately plays an important role in the status of long-term urinary continence.  When applying the techniques of modern staged repair of exstrophy, bladder neck reconstruction results in volitional voiding and dryness in up to 75% of patients after successful primary closure with a good template.  Failed closures represent an extremely challenging subset of patients where urinary continence is often achieved at the expense of intermittent urethral catheterization or urinary diversion.

Methods: The authors performed a retrospective review of operative notes and medical records of patients who underwent a bladder neck reconstruction with a history of one or more failed exstrophy closures between 1970-2007.  Surgical endpoints measured for each patient included: number of failures, time between surgical procedures, whether or not an osteotomy was performed, bladder capacity at the time of bladder neck reconstruction, need for additional continence procedures, and final continence status.  Continence was defined as achieving a dry interval of >3 hours and voiding through the urethra.

Results: We identified 137 patients who underwent a repeat closure following one or more failed closures.  Of the 58 patients who underwent bladder neck reconstruction, 24 (41%) were continent.  Of the remaining patients, 3 (5%) achieved dryness by intermittent urethral catheterization and 22 (38%) by urinary diversion.  An additional 9 (16%) patients were awaiting a definitive continence procedure.  The mean bladder capacity at the time of bladder neck reconstruction differed between those who achieved continence (101 cc.) and those who did not (75 cc.) (p = 0.03). 

Conclusion: A failed exstrophy closure has significant long-term implications on the fate of urinary continence.  The majority of patients who undergo bladder neck reconstruction will require additional procedures to achieve dryness.  Bladder capacity has been used to determine which patients are candidates for bladder neck reconstruction after successful primary closure of exstrophy.  Our data suggest that bladder capacity may also have predictive value in the success of bladder neck reconstruction after failed exstrophy closure.