Posterior iliac osteotomy in ischiopagus tetrapus twins

Eight hemipelvises in ischiopagus tetrapus conjoined twins were assessed retrospectively to determine whether posterior iliac osteotomy is appropriate to reconstruct pelvic symmetry. Although clinical and radiological similarity exists with classic bladder exstrophy, axial and three-dimensional computed tomography showed the pelvic deformity to be very different. In classic bladder exstrophy, the deformity is one of shortening and external rotation of the anterior segment, and external rotation of the posterior segment. The deformity in the ischiopagus tetrapus pelvis is purely one of external rotation of the posterior segment. Posterior iliac osteotomy alone was therefore able to restore pelvic symmetry in seven of the eight hemipelvises, and prevented rediastasis of the symphysis pubis in all patients.

The hip in adults with classic bladder exstrophy: a biomechanical analysis

We studied the untreated pelvic deformity in 14 adult patients with bladder exstrophy to determine the relative hip-joint force and stress and their effects on the clinical status of the hip. Pelvic radiographs were used for biomechanical analysis to calculate joint force and joint stress (force/area) relative to partial body weight, which allowed comparison between patients and age-matched controls. IOWA hip ratings were used for clinical evaluation, and hips were scored radiographically for degenerative joint disease. The mean relative joint force and joint stress was significantly higher for exstrophy patients (p < 0.001). In addition, the mean distance from the body center to the center of the femoral head was significantly increased (p < 0.001) in bladder exstrophy patients. An increase in diastasis correlated with an approximate 30% increase in the distance from the center of the femoral head to the body midline. The mean distance from the greater trochanter to the femoral head center was significantly less (p < 0.02) and the center-edge angle was significantly decreased in exstrophy patients (p < 0.05). Two patients' hips showed significant subluxation, and one of these showed degenerative hip disease in association with poor IOWA and radiographic scores. The force and stress on the hip joint are increased in untreated adult bladder exstrophy patients. Further longitudinal study is indicated to validate these findings and to determine whether clinically important degenerative changes are occurring. This could affect treatment recommendations in childhood.

New methods of bladder augmentation

Gastrointestinal segments are commonly used for bladder replacement or repair. However, when gastrointestinal tissue is in contact with the urinary tract, several complications may ensue. Recent surgical approaches have relied on native urological tissue for reconstruction. These are based on sound surgical principles, allowing for the exclusion of tissue that is not urological. De-epithelialized bowel segments, either alone or over native urothelium, have also been used. An experimental system of progressive dilatation for ureters and bladders has been proposed. This appears promising, although it has yet to be attempted clinically. There has been a resurgence of interest in the use of acellular collagen-based matrices as scaffolds for bladder regeneration; experimental work is currently underway. Recently, functional bladder tissue has been engineered using selective cell transplantation. This technique uses autologous cells, so avoiding rejection. Tissue is obtained from the host, the cells then dissociated and expanded in vitro, re-attached to a matrix and implanted into the same host. Clinical trials are currently being arranged. Even though the use of bowel for bladder tissue replacement was first proposed over 100 years ago, it remains the gold standard, despite its associated problems. It is evident that urothelial-urothelial anastomoses are preferable functionally. Experience is currently being gained with the recent clinical and experimental approaches to augmentation cystoplasty. It is hoped that this will result in more technologies and methods for bladder augmentation.

Prenatal diagnosis of cloacal exstrophy before rupture of the cloacal membrane

We describe a case of cloacal exstrophy what was diagnosed prenatally by ultrasound and confirmed at birth. We also review the literature on 15 previous prenatally diagnosed cloacal extrophy cases.

Bilateral posterior pelvic resection osteotomies in patients with exstrophy of the bladder

This paper describes a modification of bilateral posterior iliac osteotomies for bladder exstrophy, in which a strip of ilium is resected subperiosteally lateral to the sacroiliac joints, allowing easier anterior closure with less breakdown compared with traditional osteotomies. Thirty-one children underwent repair of bladder exstrophy between 1974 and 1994. Orthopaedic procedures included: closed reduction and cast application in the newborn period (four patients), classic bilateral posterior iliac osteotomies (12 patients), and bilateral posterior resection osteotomies (15 patients). Dehiscence occurred after one closed reduction, five classic osteotomies, and one resection osteotomy. Urinary continence was obtained in four patients who underwent closed reduction, nine patients who underwent classic posterior osteotomies, and nine patients who underwent posterior resection osteotomies.

Prenatal diagnosis of bladder exstrophy: what counseling?

PURPOSE

Bladder exstrophy has recently become one of the several congenital malformations detectable prenatally by fetal ultrasonography, which implies the necessity of a correct prognostic evaluation of quality of life on which therapeutic termination of pregnancy may depend within the temporal limits stated by the law. While maintaining a preeminently informative role, prenatal counseling has gained increasing relevance for the quality of life long-term prognosis in adults affected by bladder exstrophy, particularly in regard to urinary continence, and sexual and reproductive problems in male and female individuals. We report a case of bladder exstrophy diagnosed at 22 week of gestation, and comprehensively review the literature on prenatal diagnostic tools and procedures as well as long-term followup in such cases.

MATERIALS AND METHODS

At week 22 of gestation a woman underwent prognostic counseling due to the diagnosis of fetal bladder exstrophy made by prenatal ultrasound. After counseling the parents elected pregnancy termination. In addition, literature data were analyzed in regard to quality of life and bladder exstrophy.

RESULTS

We believe that the rarity of the prenatal diagnosis of this abnormality has resulted in the lack of a comprehensive review of necessary counseling criteria.

CONCLUSIONS

We suggest what we consider to be a valid counseling approach for parents after a prenatal diagnosis of bladder exstrophy.

Successful pregnancy in a patient with previous bladder exstrophy

Bladder exstrophy is an unusual congenital anomaly. Patients becoming pregnant with such anomaly after surgical repair are even rarer. The present case reports a lower segment Caesarean section delivery of a living healthy baby in a woman who had been operated on for bladder exstrophy at the age of 18 years. This is the first case of this type seen in our institution in 35 years.

The pelvis of fetuses in the exstrophy complex

By using a three-dimensional computed tomography (CT) scanner, we compared the anatomic features of the pelvis of three fetuses of same gestational age, one with a normal pelvis representing the reference model, one with classic bladder exstrophy, and one with cloacal exstrophy. The tomography slices were selected at the same levels for each case. Three angles expressing external opening of the pelvis were defined. Comparing normal and abnormal pelvises allowed definition of three criteria for the correction of the malformation: (a) the sum of the differential angles gives the amplitude of the correction needed; (b) a supraacetabular osteotomy appears to allow best closure of the pelvic ring; (c) only three slices of a CT scan are needed, which cannot be harmful, especially for neonates. Therefore, we believe that a CT scan of the pelvis should be performed whenever an osteotomy is planned in the surgical reconstruction of bladder and cloacal exstrophy.

Prenatal diagnosis and management of abdominal wall defects

The widespread use of fetal ultrasonography in routine antenatal care now allows the majority of abdominal wall defects to be identified prenatally, with subsequent opportunities for parental counseling, fetal intervention, and optimal perinatal management. Outcome is significantly affected by the presence of additional structural or chromosomal malformations; appropriate multidisciplinary counseling and management is dependent on the early identification of such anomalies in addition to accurate delineation of the abdominal wall defect itself. In cases with associated lethal or multiple severe abnormalities, parents may opt for elective termination of the pregnancy. Serial sonography is of particular value in gastroschisis, but there is little evidence that fetal manipulation or premature delivery confers any significant benefit. For all types of abdominal wall defect, optimal perinatal management is achieved in centers where neonatal medical, surgical, and anesthetic expertise is immediately available; cases diagnosed in units without these services should be considered for in utero transport to the nearest perinatal center.

Prenatal diagnosis of fetal bladder and cloacal exstrophy by ultrasound. A report of three cases

BACKGROUND

Bladder and cloacal exstrophy can be diagnosed with prenatal ultrasound.

CASES

Three cases of bladder and cloacal exstrophy were diagnosed prenatally by ultrasound and confirmed at birth. The ultrasound findings were a soft tissue mass in the lower abdominal wall (which appeared larger and more heterogeneous in cloacal exstrophy than in bladder exstrophy), absent bladder, malformation of the external genitalia and normal kidneys along with normal amniotic fluid volume.

CONCLUSION

Prenatal diagnosis of these defects will allow appropriate referrals prior to birth.

Hip configuration and function in bladder exstrophy treated without pelvic osteotomy

Nine children with congenital bladder exstrophy treated without pelvic osteotomy were analyzed clinically and radiologically at a mean age of 13 years (range 9-16 years). The acetabular and femoral version angles were measured by computed tomography (CT) imaging. Two of the children had a slight waddling gait, but none of them had any pain and they could participate in sports without problems. They had a normal range of hip movements and a normal foot progression angle. The acetabulum was retroverted by an average of 5 degrees, but was balanced by an increased anteversion of the femur which on the average was 10 degrees-20 degrees higher than normal. The femoral head in all hips was spherical, and no hip showed dysplasia. In bladder exstrophy, retroversion of the acetabulum was balanced by an increased anteversion of the femur, resulting in a normal range of hip movements and a normal gait in later childhood.

Gastrocystoplasty in the treatment of bladder exstrophy

A wedge-shaped segment of stomach based on the right gastroepiploic artery was used for bladder augmentation in 11 patients. Initial diagnosis in these 11 patients was bladder exstrophy. Indications for the use of stomach in bladder reconstruction were important bilateral upper tract deterioration in 10 patients, dederivation in 1. A continent appendicostomy (Mitrofanoff) has been performed in all patients. In post-operative follow-up (average 24 months), all patients have stable upper tract X-rays and stable or improved renal function. All patients require intermittent clean catheterization, 8 are totally continent, 2 are partially continent, 1 patient is still incontinent. No serious digestive problem was encountered. The increase in bladder capacity was 300 to 500% after 6 months. Mucus production is reduced relative to other intestinal segments and the patients require no bladder irrigation. The authors recommend the use of stomach for urinary tract reconstruction in compromised patients.

Criteria for the prenatal diagnosis of classic bladder exstrophy

OBJECTIVE

To define ultrasonographic criteria for the prenatal diagnosis of classic bladder exstrophy.

METHODS

Forty-three prenatal ultrasound scans were studied from 25 pregnancies in which live delivery of an infant with classic bladder exstrophy occurred. The diagnosis of bladder exstrophy could be made retrospectively in 29 prenatal studies from 17 pregnancies. The time of the fetal ultrasound varied from 14-36 weeks' gestation (mean 23). The diagnosis of bladder exstrophy was made before delivery in only three cases.

RESULTS

Five factors associated with bladder exstrophy were identified: 1) The bladder was not visualized on ultrasound in 12 of 17 cases (71%); 2) a lower abdominal bulge representing the exstrophied bladder was seen in eight of 17 cases (47%); 3) a small penis with anteriorly displaced scrotum was identified in eight of 14 males (57%); 4) the umbilical insertion was low set in five of 17 cases (29%); and 5) abnormal widening of the iliac crests was seen in three of 17 cases (18%).

CONCLUSION

The prenatal diagnosis of bladder exstrophy should be considered any time the bladder is not visualized or any of the aforementioned factors are noted.

Prenatal detection of anterior abdominal wall defects with US

The size and position of an anterior abdominal wall defect, its contents, and its association with other anomalies are features that can be diagnosed in utero with ultrasound and that allow a differential diagnosis to be made. The correct prenatal diagnosis is extremely important for patient management. The key feature for sonographically distinguishing these conditions is the position of the defect in relation to the umbilical cord insertion. Omphaloceles and pentalogy of Cantrell usually involve a midline defect at the umbilical cord insertion. Gastroschisis most frequently consists of a small, right-sided paraumbilical defect. Eccentric, large lateral defects are typically present in limb-body wall complex or amniotic band syndrome. Bladder and cloacal exstrophy involve the infraumbilical region. In addition, the size of the defect, the organs eviscerated, the presence of membranes or bands, and any associated abnormalities help determine the correct diagnosis. Increased knowledge of these uncommon fetal conditions should result in better detection, more accurate diagnosis, and improved management of anterior abdominal wall defects.

The anatomy of the pelvis in the exstrophy complex

We compared computerized tomography scans of the pelvis of twenty-four patients who had exstrophy of the bladder with scans of age-matched controls in order to analyze the pelvic deformity that accompanies the variably severe manifestations of this condition. The patients who had classic exstrophy of the bladder were found to have a mean of 12 degrees of external rotation of the posterior aspect of the pelvis on each side, retroversion of the acetabula, a mean additional 18 degrees of external rotation and 30 per cent shortening of the pubic rami, and progressive diastasis of the symphysis pubis. The foot-progression angle demonstrated 20 to 30 degrees of external rotation beyond the normal limits seen in early childhood, but this improved with age. The patients who had exstrophy of the cloaca and the bladder not only had all of these pelvic deformities to a greater degree but also had asymmetry of measured parameters between the right and left sides of the pelvis, malformation of the sacro-iliac joints, and occasional dislocation of the hip. An understanding of the pelvic anatomy that accompanies exstrophy is essential when corrective approaches are planned. Such an understanding will improve the rate of success of both closure of the bladder and control of urinary continence postoperatively.

[Reconstructive-plastic surgery in bladder exstrophy]

Among 234 children with exstrophy of the urinary bladder 112 were subjected to reconstructive-plastic operation after G. A. Pair. A good result was produced in 71 cases. In 27 children a satisfactory result was attained only after repeated operations. Reconstructive-plastic interventions had no positive effect in 14 children. By means of electrophysiological and morphological methods three degrees of underdevelopment of the muscular coat of an urinary bladder affected by exstrophy were distinguished. In I degree plastics of the bladder with local tissues is indicated, in II degree the indications are relative, in III degree a plastic operation is not indicated. Choice of the operative method on basis of the morphofunctional condition of the bladder with exstrophy, the use of microsurgical techniques, the formation of a closed pelvic ring, and antireflux operations on the ureters improve the immediate and late-term results of reconstructive-restorative surgical interventions.

Four cases of bladder exstrophy in two families

Bladder exstrophy is a rare congenital anomaly, caused by abnormal development of the cloacal membrane. To our knowledge, 18 familial patients with this malformation have been described. Two sets of familial cases with bladder exstrophy are reported here: two cousins and a mother and son and the published reports of the 18 familial cases among 682 index patients with bladder exstrophy are reviewed. Ultrasonography is advocated as the investigation of choice for early prenatal diagnosis.

Indications for bladder augmentation in the exstrophy-epispadias complex

OBJECTIVE

To determine whether bladder augmentation has a role in avoiding urinary diversion in patients with exstrophy-epispadias complex (EEC), whether it can improve the lifestyle in patients who have previously undergone diversion or improve the result of any single surgical step in the staged functional reconstruction of the bladder in these patients.

PATIENTS AND METHODS

From 1970 to 1991, 85 patients were treated for EEC. Between 1981 and 1991, 12 bladder augmentations were performed in 11 patients (seven girls and four boys) with bladder exstrophy, male epispadias (one case) and cloacal exstrophy (one case).

RESULTS

No significant early surgical complications were reported. Follow-up ranged from 18 months to 11 years. Late complications included bowel obstruction in one patient, a partial left ureteric stenosis at the level of the anastomosis with the gastric patch wall in one patient and bladder lithiasis in five patients (sigmoidocystoplasty in one and ileocystoplasties in four). No metabolic problems, no bladder perforations or malignancies were observed. The results on continence were good and, with the one exception reported, the condition of the upper urinary tract following surgery was satisfactory in all patients.

CONCLUSION

Augmentation cystoplasty is of use in the treatment of patients with bladder exstrophy when staged functional reconstruction is unsuccessful. This technique greatly reduces the indications for urinary diversion and can be used in the surgical treatment of EEC. The only disadvantage is that clean intermittent catheterization must be performed, sometimes only temporarily, but patient acceptance is usually high.

Cloacal exstrophy: prenatal diagnosis before rupture of the cloacal membrane

Embryologically, cloacal exstrophy is thought to result from persistence and subsequent rupture of the infraumbilical cloacal membrane during the fifth embryonic week. We report a case of cloacal exstrophy in which a prenatal diagnosis was made prior to rupture of the cloacal membrane. A routine ultrasound at 17 weeks' gestation demonstrated monoamniotic twins. One twin was normal, but the other was found to have a sacral myelomeningocele, "rocker-bottom" feet, splaying of the pubic rami, and a large cystic mass protruding from the infraumbilical anterior abdominal wall. A repeat ultrasound was performed at 22 weeks, with the same findings. At 26 weeks, further examination showed disappearance of the abdominal cyst, a small omphalocele, no demonstrable bladder, and the suggestion of prolapsed bowel inferior to the umbilical cord insertion. After delivery at 34 weeks, the abnormal twin was found to have the typical findings of cloacal exstrophy, myelomeningocele, bilateral lower limb anomalies, and extremely foreshortened small bowel. Rupture of the presumed cloacal membrane after 22 weeks in this case is inconsistent with our current understanding of the embryology of this anomaly, and should stimulate a reexamination of the current concepts. If the characteristic features are recognized, cloacal exstrophy can be diagnosed by prenatal ultrasound, permitting prenatal counseling and appropriate perinatal management.