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Protocol of Delayed Bladder Exstrophy Management: The Bengali Scenario

Monday, October 22, 2012: 1:30 PM
Grand Ballroom B (Hilton Riverside)
Claudia Gatti, M.D1, Carmine Del Rossi1, Alberto Attilio Scarpa1, Francesca Caravaggi, M.D1, Giovanni Casadio1, Giovanni Mosiello2, Akanksha Mehta, M.D.3 and Anthony A. Caldamone, MD3, (1)Paediatric Surgery, Maggiore Hospital, Parma, Italy, (2)Urology, Bambino Gesł Children's Hospital, Rome, Italy, (3)Pediatric Urology, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, RI

Purpose:

Bladder exstrophy (BE)-epispadias complex represent a challenge in paediatric urology. Approaching these patients in a missionary hospital confront us with additional problems. We report our 20-years experience in Bangladesh.

Methods:

In 20 years a paediatric surgical/urological team has cared patients with BE evaluating them for continence, upper tract status and cosmesis. The approach in all primary cases was the staged Jeff's technique. Cantwell-Ransley and Mitchell epispadias repair  were used. Endoscopic Bladder neck (BN) bulking procedures and bladder augmentation with BN reconstruction and continent derivation were considered.

Results:

We treated 44 patients [males 30 (68%), females 14 (32%)] with BE, mean age 11,5 years (range 0,5-25). BE repair and epispadias repair data are showed in the table. One boy (2%) was completely dry after repair alone. Twentysix (59%) patients  [males 18 (41%), females 8 (18%)] had endoscopic BN bulking procedures with a mean of 3 treatments per patients. Relating results on urinary incontinence (UI) are showed in the table. Eight (18%) patients [males 4 (9%), females 4 (9%)] with persistence of UI underwent bladder augmentation with BN reconstruction (Young-Dees) and continent derivation (Mitrofanoff channel). Six (14%) were augmented with caecum, 2 (6%, all females) with ureter and all (16%) are now completely dry with intermittent catheterization. Ten (23%) patients  [males 9, female 1] underwent endoscopic treatment for concomitant vesico-ureteric reflux. Four males (13%) required surgery for cosmetic problems.

Conclusion:

Our experience demonstrates that management of BE in a limited-resources country is challenging, but possible, with regular patient follow-up. We report a low rate of BE relapse. A higher rate of female patients  were completely continent compared to males. Despite widespread use of endoscopic treatment few patients benefit from these. A good management of exstrophic complex can have a significantly impact on quality of life.

Bladder exstrophy repair data

Males

Females

Total

Primary closure (Jeff's technique)

22 (50%)

10 (23%)

32/44 (73%)

BE repaired elsewhere

8 (18%)

4 (9%)

12/44 (27%)

Failure primary closure

0 (0%)

1 (3%)

1/32 (3%)

Redo bladder closure after BE repair elsewhere

5 (83%)

1 (17%)

6/12 (50%)

Failure after redo bladder closure

1 (16%)

1 (16%)

2/6 (33%)

Epispadias repair data

details

number of patients (percentage)

Number of patient

27/30                      (90%)

Cantwell-Ransley repair

24                           (80%)

Mitchell repair

3                             (20%)

Failure Cantwell-Ransley repair

2                             (7%)

Failure Mitchell repair

0                             (0%)

Fistula after epispadias repair

9/27                        (33%)

Closure of fistula

8/9                          (89%)

Redo fistula closure

3/9                          (33%)

Results after endoscopic BN bulking procedures

Males

Females

Dry

1     (5,5%)

3     (37,5%)

Completely wet

10   (55,5%)

3     (37,5%)

Intermediate

7     (39 %)

2     (25%)