Urinary continence after reconstruction of classical bladder exstrophy (73 cases)

Abstract

Objective: To evaluate urinary continence in children after reconstruction of classical bladder exstrophy.

Patients and methods: Seventy-three children were treated between 1966 and 1990 at Debrousse Hospital in Lyon, France. Reconstruction involved a three-stage repair including bladder closure (with posterior iliac osteotomy), bladder neck reconstruction and penile reconstruction.

Results: Of 73 children with bladder exstrophy, seven underwent an initial urinary diversion and 66 a successful bladder closure at birth combined with posterior iliac osteotomy, 55 of whom underwent a bladder neck reconstruction and anti-reflux procedures. The Young-Dees procedure was performed in four cases, combined with the Jeff's technique in two cases and the Mollard technique in 49. Fifty-four of 55 (22 girls and 32 boys) were followed up for between 1 and 17 years. Results were classified as excellent (37 cases), good (11 cases) or failed (six cases), following assessment of continence, voiding capabilities, residual urine volume, urinary tract infection and urinary tract dilatation. Of these patients 69% had normal continence with transurethral voiding (girls, 77%; boys, 63%). Persistent incontinence after bladder neck reconstruction was related to insufficient outlet resistance, an abnormal bladder or a combination of the two. Repeated bladder neck reconstruction (seven patients), bladder augmentation (five patients), bladder neck suspension (one patient) and bladder neck reconstruction combined with augmentation (five patients) were performed. These operations were coupled with a Mitrofanoff procedure if further complications occurred.

Conclusion: The outcome of bladder neck reconstruction was unpredictable. Achievement of a balance between intravesical pressure and outlet resistance was difficult and often required secondary endourethral procedures. Persistent incontinence after bladder neck reconstruction was related to insufficient outlet resistance, an abnormal bladder or a combination of the two. Repeated bladder neck reconstruction, bladder augmentation, bladder neck suspension and reconstruction combined with augmentation were performed. These operations were coupled with a Mitrofanoff procedure, which offered catheterization as a safe alternative if further complications occurred.