Management of bladder exstrophy and incontinent epispadias: 25 years of experience with urinary diversion

Abstract

Objectives: Achieving complete urinary continence with preservation of the upper urinary tract in the exstrophy-epispadias complex must be the primary aim. To determine the optimal surgical approach, we reviewed the records of patients treated at our institution.

Methods: During the last 26 years, 95 patients with bladder exstrophy and 20 with incontinent epispadias were operated upon at our department. For this retrospective study a total of 102 patients could be interviewed. Mean followup after the first operation was 16.7 years. Of the 102 patients, in 43 primary treatment was performed at our institution (urinary diversion n = 39, modified Young Dees n = l, sling plasty n = 3). A further 59 patients were referred to our institution for secondary treatment, 34 of whom after primary bladder closure and/or bladder neck reconstruction (urinary diversion n = 27, modified Young Dees n = 7).

Results and conclusion: Of the 8 patients with modified Young Dees, 5 required conversion to a Mainz Pouch I due to obstruction of the reconstructed bladder neck or incontinence. Continence rates are 96% for the rectal reservoirs, 97% for the Mainz Pouch I and 67% for the modified Young Dees procedure. Presently, none of the 102 patients has deterioration of the upper urinary tract or has renal insufficiency; none has developed severe metabolic complications or bowel neoplasms. The physical, social and psychological development of the patients treated at our institution appears to be comparable to that of the general population. All children over 6 years of age attend elementary school, most of the adults are, well-educated, only three are unemployed and one lives in a therapeutic center as a result of multiple physical problems. Rectal reservoirs are the urinary diversion of choice at our institution in patients with bladder exstrophy or incontinent epispadias. When the upper urinary tract has deteriorated, a colon conduit is created with the option of conversion to a continent form of diversion as soon as renal and ureteral functions have recovered. In patients with failed urinary tract reconstruction/insufficient anal sphincter function, we prefer the Mainz Pouch 1.