The Cantwell-Ransley technique for repair of epispadias

Application of Tunica Vaginalis Flap for Epispadias Repair in the Epispadias-Exstrophy Complex

OBJECTIVE

To describe long-term outcomes and experience with the tunica vaginalis flap (TVF) as a tissue augment for complex epispadias repair.

METHODS

A prospectively maintained institutional database was reviewed for patients who underwent epispadias repair with TVF from 2010 to 2021. Evaluation of patient characteristics between those who developed dehiscence or UCF and those who did not was performed via Mann-Whitney U, Kruskal-Wallis, or Fisher's exact test, as appropriate.

RESULTS

A total of 47 male patients were identified, of whom, 1 (2.1%) had cloacal exstrophy, 38 (80.9%) had classic bladder exstrophy or a variant, and 8 (17.0%) had epispadias as their primary exstrophy-epispadias complex diagnosis. The median age at epispadias repair was 13 months (IQR 11 - 19). The overall rate of fistula or dehiscence development was 19.1% (9 patients), of whom, 7 developed urethrocutaneous fistulae, 1 dehiscence, and 1 both. Notably, 0 of the 5 patients who had undergone prior epispadias repair and 0 of the 8 patients with a diagnosis of isolated epispadias developed a UCF or dehiscence after repair with TVF. Differences in age at repair, primary EEC diagnosis, prior epispadias repair, pre-repair testosterone, fibrin sealant utilization, closure layers, stent removal time, and bladder capacity at repair were not statistically significant (P>.05) CONCLUSION: Our expanded evaluation indicates that utilization of the tunica vaginalis as an adjunct to epispadias repair may provide durable protection against fistula development in EEC patients who have undergone prior epispadias repair and in primary repair of patients with isolated epispadias.

Bladder augmentation in exstrophy vesicae: Long-term results of a single experienced center

BACKGROUND

In this study, we present our long-term treatment outcomes of bladder augmentation (BA), bladder neck closure, and Mitrofanoff clean intermittent catheterization (CIC) in managing bladder exstrophy (BE).

METHODS

This was a retrospective medical records' review of 33 children diagnosed as born with BE, followed up at a tertiary pediatric urology clinic from 1988 to 2020. Outcomes such as surgical interventions, presence of renal calculi, hydronephrosis, and continence status were extracted.

RESULTS

The median follow-up of the group was 18.2 (4-26) years. Urinary system stones developed in 10 (30.3%) cases about 8.9 years after BA. Stone development was two times more common in patients who underwent colocystoplasty (33.3%) than those who underwent ileocytoplasty (16.6%). The state of continence of the group was satisfactory in 26 (78.7%; excellent in 23; good in 3 cases) and unsatisfactory (wet) in 6 (18.1%) cases. At the last visit, ultrasonography revealed no hydronephrosis in 23 (69.6%) patients, and the voiding cystourethrogram demonstrated low-grade vesicoureteral reflux in 10 (30.3%) and high-grade vesicoureteral reflux in 2 (6%) patients.

CONCLUSIONS

An elaborated plan of surgical reconstruction for classic BE can lead to satisfactory long-term urinary continence in most patients. Ultimate predictors of outcome in BE repair are difficult to ascertain. Consistently, BA, bladder neck closure, and Mitrofanoff CIC continue to stand out at a critical point in the management of those patients with classic BE. Our study demonstrated that augmentation is required to achieve acceptable dryness with high satisfactory dryness rates in BE.

Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex

BACKGROUND

Male epispadias is a rare congenital urogenital anomaly in which the meatus is ectopically located along the dorsal midline of the penile shaft. In cases associated with severe curvature, functional and cosmetic outcomes could be accomplished by lengthening the shorter dorsal surface with the use of corporal grafting. Various graft materials have been used in the past for hypospadias repair including tunica vaginalis, dermis, and small intestinal submucosa (SIS). The use of SIS grafting for corporoplasty during epispadias repair has rarely been described in the literature.

OBJECTIVE

To report the experience in the management of dorsal corporal body grafting using SIS in children with severe penile curvature due to epispadias.

STUDY DESIGN

The authors retrospectively reviewed the charts of all patients with epispadias or bladder exstrophy/epispadias complex and severe dorsal chordee (>40°) who underwent epispadias repair with single-layer SIS for corporal body grafting. Clinical variables, surgical technique, and outcomes were analyzed.

RESULTS

A total of nine consecutive patients underwent staged epispadias repair with dorsal corporal single-layer SIS grafting (summary figure). Of these, four (44.4%) had primary penopubic epispadias, one (11.1%) had mid-shaft epispadias, and four (44.4%) had bladder exstrophy/epispadias complex. The mean age at surgery was 13.4 ± 6 months. After phalloplasty with SIS grafting, there were no reported complications related to the graft during the post-operative period or follow-up visits.

DISCUSSION

Although traditional techniques for epispadias repair allow some degree of corporal lengthening, they also result in abrupt medial rotation of the corporal bodies leading to torqueing and potential unsatisfactory cosmetic results. In contrast, the authors use single-layer SIS for corporal body grafting, and this study technique results in a more gradual inward rotation thus allowing more anatomical accuracy. Furthermore, an advantage of the use of SIS over other grafting materials is that there is no need to harvest an autologous graft such as tunica vaginalis or dermis.

CONCLUSION

Epispadias repair using single-layer SIS corporal body grafting is an effective, safe, and feasible method, which provides satisfactory cosmesis and correction of dorsal curvature in congenital epispadias in children. Furthermore, a more normal penis appearance, without a decrease in the corporal length or diameter, is achieved with this technique.

Recent Trends in the Management of Bladder Exstrophy: The Gordian Knot Has Not Yet Been Cut

Although enormous effort has been made to further improve the operative techniques worldwide, the management of bladder exstrophy (BE) remains one of the most significant challenges in pediatric urology. Today it is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome with regard to bladder capacity, renal function and continence. Due to a number of reasons, including a lack of comparable multicenter studies, a range of concepts is currently used to achieve successful primary closure. We review the literature of the last 15 years on the current concepts of bladder exstrophy repair with regard to the time of primary closure (initial vs. delayed closure), the concepts of primary closure (single-stage vs. staged approach; without osteotomy vs. osteotomy) and their outcomes. There is a worldwide lack of multicenter outcome studies with adequate patient numbers and precisely defined outcome parameters, based on the use of validated instruments. The modern staged repair (MRSE) in different variations, the complete primary reconstruction of exstrophy (CPRE), and the radical soft-tissue mobilization (RSTM) had been the most extensively studied and reported procedures. These major concepts are obligatory stable now for more than 20 years. Nevertheless, there are still a lot of open-ended questions e.g., on the potential for development of the bladder template, on continence, on long-term orthopedic outcome, on sexuality and fertility and on quality of life. Management of BE remains difficult and controversial. Further, clinical research should focus on multi-institutional collaborative trials to determine the optimal approach.

Bladder Exstrophy from Childhood into Adult Life

Exstrophy of the bladder is rare and the incidence of bladder exstrophy is calculated to be from 1 per 30 000 to 50 000 live births with male to female ratio ranging from 1.5-5 to 1 1-4 It was found that persistence or overgrowth of the cloacal membrane on the lower anterior abdominal area, prevents normal mesenchymal ingrowth. This causes divergence of the lower abdominal muscular structures and forces the genital ridges to fuse caudal to the cloacal membrane. The stage of ingrowth of the urorectal septum at the time of rupture determines whether one will produce an exstrophic urinary tract alone (classic bladder exstrophy or epispadias) or cloacal exstrophy with the hindgut interposed between the hemibladders5,6.

Isolated Male Epispadias: Anatomic Functional Restoration Is the Primary Goal

Background. Isolated male epispadias (IME) is a rare congenital penile malformation, as often part of bladder-exstrophy-epispadias complex (BEEC). In its isolated presentation, it consists in a defect of the dorsal aspect of the penis, leaving the urethral plate open. Occurrence of urinary incontinence is related to the degree of dorsal displacement of the meatus and the underlying underdevelopment of the urethral sphincter. The technique for primary IME reconstruction, based on anatomic restoration of the urethra and bladder neck, is here illustrated. Patients and Methods. A retrospective database was created with patients who underwent primary IME repair between June 1998 and February 2014. Intraoperative variables, postoperative complications, and outcomes were assessed. A descriptive statistical analysis was performed. Results and Limitations. Eight patients underwent primary repair, with penopubic epispadias (PPE) in 3, penile epispadias (PE) in 2, and glandular epispadias (GE) in 3. Median age at surgery was 13.0 months [7–47]; median follow-up was 52 months [9–120]. Complications requiring further surgery were reported in two patients, while further esthetic surgeries were required in 4 patients. Conclusion. Anatomical restoration in primary IME is safe and effective, with acceptable results given the initial pathology.

Results of Epispadias Repair Using the Modified Cantwell-Ransley Technique

OBJECTIVE

To evaluate our results of epispadias repair with a modified Cantwell-Ransley (MCR) technique.

METHODS

A retrospective Institutional Review Board-approved chart review of all patients who underwent an MCR epispadias repair was conducted between 1998 and 2015. Procedures were performed at birth or after the age of 8 months as part of the modern staged repair of exstrophy-epispadias complex (EEC) in patients with bladder exstrophy treated since birth, at presentation for older patients, and after the age of 6 months in isolated epispadias patients. Twenty-two children underwent MCR epispadias repair in our institute during the study period. Sixteen of them had EEC and 6 had isolated epispadias. Four patients underwent exstrophy and epispadias repair at the same session. Twelve children underwent epispadias repair as a second stage of modern staged repair at a mean age of 21 months (range 8-60). The procedures involved dissection of the corporeal bodies and urethral plate from the penile base to the tip of the penile glans.

RESULTS

After a mean follow-up of 6.9 years (range 0.5-18), there were no complications in the isolated epispadias group and 4 complications in the bladder exstrophy group: urethrocutaneous fistula (n = 1), residual dorsal curvature (n = 1), and excess of penile skin (n = 2). The meatal location was orthotopic in all cases. All of the complications were successfully addressed in a single subsequent surgical session.

CONCLUSION

MCR technique continues to be a reliable, reproducible option for epispadias repair in EEC patients and in cases of isolated epispadias.

The Tunica Vaginalis Flap as an Adjunct to Epispadias Repair: A Preliminary Report

OBJECTIVE

To report our preliminary institutional experience of incorporating a tunica vaginalis flap (TVF) as an adjunct into primary or secondary epispadias repair.

PATIENTS AND METHODS

A prospectively maintained institutionally approved database of exstrophy-epispadias complex patients was used to identify and retrospectively review male patients who underwent epispadias repair from September 2010 to October 2014 at the authors' institution. Patients who underwent epispadias repair with TVF were identified and their clinical outcomes were measured.

RESULTS

A total of 49 male patients were identified as meeting inclusion criteria, of which 15 (2 isolated epispadias, 13 classic bladder exstrophy) underwent epispadias repair incorporating a TVF. Median age at time of repair was 12 months (interquartile range [IQR] 10-15.5). A median of 4 layers (IQR 4-5) was incorporated into each repair closure, applying EVICEL Fibrin Sealant as an additional layer in all patients. All patients received preoperative testosterone injection therapy of 2 mg/kg 5 and 2 weeks before surgery for penile growth. There were no intraoperative complications. Median follow-up of 19 months (IQR 12-23) revealed 5 patients who underwent epispadias revision, 3 (20%) of which developed a urethrocutaneous fistula. All patients had a successful repair without recurrence.

CONCLUSION

The authors have found the utilization of a TVF with epispadias repairs to be beneficial but no better than the repair with our routine soft-tissue coverage in primary epispadias repair. However, in patients presenting with complex anatomy and limited tissue reserves, a TVF is an important adjunct to epispadias repair and/or revision and may lead to improved outcomes.

Sexual Health Outcomes in Adults with Complete Male Epispadias

PURPOSE

Complete male epispadias is a rare congenital anomaly characterized by failed closure of the entire penopubic dorsal urethra. Epispadias repair is typically performed during infancy, and resultant genitourinary abnormalities can have a marked impact on adult life. We assess long-term post-reconstruction sexual health and fertility outcomes in adults with complete male epispadias.

MATERIALS AND METHODS

A total of 132 patients 18 years or older with complete male epispadias who had undergone reconstruction were identified from a prospectively maintained, institutionally approved database. Patients who could be contacted were asked to complete a telephone survey regarding sexual function. Reconstructive history and clinical details were obtained by chart/database review.

RESULTS

Of 132 patients with complete male epispadias 74 met inclusion criteria and 15 (20%) completed the questionnaire. Seven patients (47%) reported currently being in a relationship. Although 12 patients (80%) reported overall satisfactory sexual intercourse, 11 (73%) admitted to 1 or more problems with sexual function, including abnormal ejaculation (53%), diminished sensation (20%) and difficulty maintaining an erection (20%). When questioned regarding the importance of fertility on a scale of 0 to 5 using a Likert-type item the response of 10 patients (67%) was 4 points or greater. Five patients (33%) reported having impregnated a sexual partner. Although 4 patients (27%) had suspicion of fertility problems, only 2 (13%) reported having abnormal semen analyses.

CONCLUSIONS

This is one of few studies examining post-reconstruction sexual health and function in adults with complete male epispadias. Although small, our study demonstrates that patients are able to engage in relationships, participate in sexual intercourse and impregnate their partners. These results highlight sexual concerns and outcomes that may be of use when counselling patients with complete male epispadias and their families.

Modern management of the exstrophy-epispadias complex

The exstrophy-epispadias complex is a rare spectrum of malformations affecting the genitourinary system, anterior abdominal wall, and pelvis. Historically, surgical outcomes were poor in patients with classic bladder exstrophy and cloacal exstrophy, the two more severe presentations. However, modern techniques to repair epispadias, classic bladder exstrophy, and cloacal exstrophy have increased the success of achieving urinary continence, satisfactory cosmesis, and quality of life. Unfortunately, these procedures are not without their own complications. This review provides readers with an overview of the management of the exstrophy-epispadias complex and potential surgical complications.

Phalloplasty for the genetic male

The goal of total phallic reconstruction in the genetic male is the creation of a sensate and cosmetically acceptable phallus with an incorporated neo-urethra that allows the patient to void while standing, engage in penetrative sexual intercourse with confidence and ejaculate in the vagina.

Use of forearm free-flap phalloplasty in bladder exstrophy adults

OBJECTIVE

To assess the long-term outcome and cosmetic results of forearm free-flap phalloplasty for correcting micropenis associated with bladder exstrophy in men.

PATIENTS AND METHODS

From 1992 to 2000, six men with bladder exstrophy and unsatisfactory penile appearance underwent phalloplasty at our institution. The mean (range) follow-up was 113 (62-153) months. The surgical procedure consisted of a modified radial free-flap phalloplasty and prosthesis implantation. One-stage urethroplasty was electively performed according to the patient's voiding pattern. Early and late complications were recorded and quality of life after phalloplasty was assessed.

RESULTS

The mean (range) age was 21.2 (17-26) years and flap survival was 100%. Two incontinent patients underwent immediate perineal urethrostomy. One sepsis occurred, requiring the removal of the penile prosthesis and a cutaneous continent urinary diversion; this patient was the only one to complain about the outcome. Two anastomotic urethral strictures were conservatively treated by endoscopic urethrotomy and only one patient underwent subsequent urethral self-dilatations. Five patients were very satisfied with the cosmesis of the neophallus and three patients reported having regular sexual intercourse.

CONCLUSIONS

Although short, this series indicates the low incidence of early complications and the excellent long-term satisfaction with forearm free-flap phalloplasty in bladder exstrophy. Phalloplasty has potential indications when adult exstrophy patients are dissatisfied with the cosmetic appearance of their external genitalia or have unsatisfactory sexual intercourse.

Applications of the modified Cantwell-Ransley epispadias repair in the exstrophy-epispadias complex

OBJECTIVE

The Cantwell-Ransley technique is the most popular and widely used approach to epispadias repair. This is an evaluation and update of the long-term results of using the modified Cantwell-Ransley technique for epispadias repair.

PATIENTS AND METHODS

The modified Cantwell-Ransley epispadias repair technique was performed on 129 boys of which 97 had classic bladder exstrophy and 32 complete epispadias. For 106 boys this was primary urethral repair (82 with classic exstrophy, 24 with epispadias) and for the other 23 boys it was a repeat repair (15 with exstrophy, eight with epispadias).

RESULTS

At a mean follow-up of 88 months, 120 had a penis that was inclined downward or horizontally while standing. In patients with exstrophy, fistulae were noted in 16% and 33% after primary and repeat urethral repair, respectively. In patients with epispadias, fistulae were noted in 13% and 25% after primary and secondary repair, respectively. In total, five boys with a fistula appearing in the immediate postoperative period following primary urethral repair demonstrated spontaneous healing by 3 months' follow-up. Urethral stricture requiring treatment developed in nine patients. Minor wound infection and skin separation occurred in nine with exstrophy and three with epispadias. Endoscopic examination or catheterization in 120 cases revealed an easily manipulated neourethra. Of 15 sexually active patients, all reported orgasms and ejaculation with a straight penis on erection, although one has complained that his penis is shorter since surgery.

CONCLUSIONS

The modified Cantwell-Ransley technique for epispadias repair produces durable functional and cosmetic results, and fewer major complications than seen with other repairs. Fistulae occurring after primary urethral repair may close spontaneously, but all those occurring after repeat closure will require further surgery.

Results of Complete Penile Disassembly for Epispadias Repair in 42 Patients

PURPOSE

We evaluated the Mitchell complete penile disassembly technique for epispadias repair.

MATERIALS AND METHODS

A total of 42 males 1 month to 22 years old presented for repair of epispadias between 1998 and 2002. Cases were divided into 2 groups. Group 1 included 29 cases of complete epispadias as a component of bladder exstrophy, 8 with previous continent urinary diversion. Group 2 included 13 cases of epispadias alone (10 primary and 3 secondary). Of the 29 patients in group 1, 21 underwent complete penile disassembly as part of 1-stage primary closure of bladder exstrophy.

RESULTS

Mean followup was 37.5 months (range 6 to 52). Ischemic changes at the glans penis were observed in 5 cases during our initial experience. Ventral orthotopic meatus was observed in all 42 patients, conical glans in 40 (95.2%), straight shaft in 34 (81%) and urethral fistula in 1 (2.4%). There were no cases of dehiscence, meatal stenosis or urethral stricture. Erectile function was preserved in all patients.

CONCLUSIONS

Complete penile disassembly is a safe procedure that can provide normalization of the urethra and penis together with satisfactory cosmetic and functional outcome.

[Surgical treatment of the extrophy-epispadias complex. Review and current concepts]

Since earlier descriptions the surgical management of the bladder exstrophy and epispadias complex (BEEC) has experimented gradual changes in the search for good aesthetic and functional results. The initial urinary diversion and bladder plate removal has evolved under various authors either by improving or supplementing the above described advances, until reaching the staged functional closure and more recently the complete primary BEEC closure. These later techniques allow to obtain encouraging continence indexes and successful aesthetic results; the low incidence and complexity of this condition however, advises both in terms of early management and later complications that this should be managed in reference centres. Sharing on this spirit of technique combination in search for a satisfactory result for exstrophic newborns and inspired by Leadbetter's contribution to Young-Dees's procedure for vesicoureteral reflux (VUR) correction, we have added a new step to the complete primary BEEC closure known as the Mitchell's technique by performing Gil-Vernet's trigonoplasty to prevent VUR, closely associated to bladder exstrophy. We believe VUR can be prevented right from the first surgical approach in the exstrophic newborn.

Management of epispadias

Although epispadias is considered to be the least severe defect of the exstrophy-epispadias complex, the treatment of this anomaly is far from trivial. Epispadias does not involve the body of the bladder or the hindgut but does affect the urethra and can affect the bladder neck. As a consequence, it presents with a spectrum of severity that can affect urinary continence if the epispadias anomaly is proximal enough to affect the urinary sphincter mechanism.

The modified Cantwell-Ransley repair for exstrophy and epispadias: 10-year experience

PURPOSE

We evaluate our experience with the modified Cantwell-Ransley epispadias repair technique to determine the complications and long-term results.

MATERIALS AND METHODS

The modified Cantwell-Ransley epispadias repair was performed during the last 10 years in 93 males of whom 79 had classic bladder exstrophy and 14 had complete epispadias. Primary repair was performed in 65 boys with classic bladder exstrophy and 12 with epispadias, and secondary repair was done after prior failed reconstruction in 14 boys with classic exstrophy and 2 with complete epispadias.

RESULTS

At mean followup of 68 months 87 patients had a horizontal or downward angled penis while standing. The incidence of urethrocutaneous fistulas was 23% in the immediate postoperative period and 19% at 3 months. A urethral stricture at the proximal anastomotic area developed in 7 patients and 5 (4 with exstrophy and 1 with epispadias) had minor skin separations of the dorsal penile skin closure. Catheterization or cystoscopy in 77 cases revealed an easily negotiable neourethral channel.

CONCLUSIONS

The modified Cantwell-Ransley epispadias repair produces an excellent functional and cosmetic result.

Combined bladder neck, urethral and penile reconstruction in boys with the exstrophy-epispadias complex

OBJECTIVE

To describe a one-stage combined bladder neck, urethral and penile reconstruction for achieving urinary continence and creating a penis with good cosmesis and function in boys with the exstrophy-epispadias complex.

PATIENTS AND METHODS

Seventy-three boys underwent the combined procedure, including 36 after classic bladder exstrophy closure and 37 with epispadias. All were completely incontinent at the time of combined reconstruction. The bladder capacity just before surgery was 70-180 mL and was greater in those with epispadias. The boys were 2.5-11 years old, with those in the exstrophy group being slightly older.

RESULTS

Thirty-three boys (89%) with epispadias were completely continent during the day but 15 had episodes of nocturnal enuresis. Of boys with classic exstrophy, 27 (75%) were continent during the day but nine had occasional nocturnal enuresis. Eleven boys required intermittent catheterization, which they found easy to perform. In seven boys (10%) a urethrocutaneous fistula or urethral stricture developed.

CONCLUSIONS

Combined bladder neck, urethral and penile reconstruction can be carried out as a one-stage procedure in selected patients with adequate bladder capacity. Reconstruction of the whole length of the urethra facilitates intermittent catheterization.

Penile reconstruction combined with bladder closure in the management of classic bladder exstrophy: illustration of technique

OBJECTIVES

Interest has increased in combining procedures during reconstruction of bladder exstrophy in an effort to reduce the number of procedures required for reconstruction and to improve results. This study illustrates our technique of reconstruction and summarizes our current experience with the combination of epispadias repair and bladder closure during initial reconstruction or following prior failed bladder closure.

METHODS

Twenty-four boys with classic bladder exstrophy underwent combined bladder closure and epispadias repair. The mean patient age was 20 months, and 18 boys had a prior failed closure. Osteotomies were performed in all patients.

RESULTS

No instances of bladder prolapse or dehiscence were noted on follow-up. Urethrocutaneous fistula developed in 7 patients. Eventual bladder neck reconstruction has been performed in 11 boys (6 boys are dry day and night, 3 are dry during the day with occasional wet episodes at night, 2 have required follow-up bladder augmentation and continent diversion for persistent incontinence), and 1 boy had augmentation at the same time as bladder neck reconstruction. Twelve boys are awaiting adequate capacity for bladder neck reconstruction, and 1 is awaiting bladder augmentation and continent stoma construction.

CONCLUSIONS

Epispadias closure can be safely combined with bladder closure in select patients with classic bladder exstrophy. Complication rates and cosmesis approximate that achieved with staging the two procedures. This achievement represents strict patient selection and attentive follow-up.

Male epispadias repair: surgical and functional results with the Cantwell-Ransley procedure in 40 patients

PURPOSE

We present our experience using the Cantwell-Ransley epispadias technique, particularly focusing on postoperative anatomical and functional complications.

MATERIALS AND METHODS

Between 1989 and 1997, 40 patients 1 to 28 years old underwent the Cantwell-Ransley technique for epispadias at our institution. The condition was isolated in 17 cases and associated with exstrophy in 23. Surgery involved a primary and secondary procedure in 29 and 11 patients, respectively. Cavernocavernostomy was performed in only 16 cases.

RESULTS

At a mean followup of 3 years 18 patients (45%) had complications and needed further procedures, and 3 (7.5%) had major wound dehiscence. The complication rate was higher in the exstrophy than in the isolated epispadias group (65 versus 28%) and urethral complications were consistently associated with previous urethral plate sectioning. In 1 patient major and persistent loss of continence was probably related to prolonged transurethral bladder drainage. All 17 patients in the postpubertal group report erections, although 1 who did not undergo cavernocavernostomy still complains of dorsal curvature. In 36 patients (90%) a fully satisfactory anatomical and functional result was achieved.

CONCLUSIONS

The Cantwell-Ransley technique of epispadias repair allows successful reconstruction in most patients. However, postoperative complications, some of which are serious, may develop that are more associated with previous procedures that compromise the blood supply to the urethral plate than the Cantwell-Ransley technique.

Low-dose desmopressin in the treatment of nocturnal urinary incontinence in the exstrophy-epispadias complex

OBJECTIVE

To report our experience of the use of desmopressin to improve nocturnal dryness in patients who have undergone a staged reconstruction of the exstrophy-epispadias complex (EEC), who although continent by day, have nocturnal incontinence because their nocturnal urinary output exceeds their bladder capacity.

PATIENTS AND METHODS

Seven children (aged 8-12 years) who had undergone a staged reconstruction for EEC (six with classical bladder exstrophy, one with incontinent epispadias) were treated with intranasal desmopressin for persistent nocturnal incontinence despite daytime dryness. Previous additional procedures for continence had been self-augmentation in one and periurethral collagen injection in three others. The criteria for inclusion in the study were: normal renal function, no upper tract deterioration, no urinary tract infections, spontaneous voiding during the day with dry intervals between micturitions, a postvoid residual volume of <10% of bladder capacity and night-time incontinence for 7 nights/week. Desmopressin was administered at bedtime at increasing dosages from 10 to 30 microg until effective. Body weight, arterial blood pressure, and serum electrolytes were measured, and all patients assessed using renal ultrasonography, a voiding diary and a nocturnal pad-test.

RESULTS

Desmopressin at doses of 10-30 microg was successful in keeping all the patients dry. The nocturnal urinary output was decreased so that it did not exceed bladder capacity. There was only one minor side-effect (nose bleeding).

CONCLUSIONS

In selected patients with EEC, desmopressin is effective in improving nocturnal dryness, with no significant side-effects.

Epispadias repair using the Mitchell technique

PURPOSE

The results of epispadias repair using Mitchell's technique in nine patients is analyzed and the advantages of the procedure discussed.

METHODS

Nine boys aged between 6 weeks and 6 years underwent epispadias repair between November 1996 and March 1998 (Penopubic epispadias, inferior vesical fissure, and midpenile epispadias, one patient each; exstrophy epispadias complex, six patients). Eight patients had first attempt at repair of epispadias. Two patients had closure of exstrophy and epispadias at one stage.

RESULTS

At a mean follow-up of 10 months, all children had a conical glans, eight patients had ventral orthotopic meatus, and one had coronal hypospadiac meatus. Minor penopubic fistula developed in one patient. Six patients had downward angled penis, and three had horizontal penis in a flaccid state. All children were observed to have good erections during sleep.

CONCLUSIONS

Mitchell's technique of epispadias repair allows an anatomic reconstruction of the penis with superior cosmetic and functional results. Long-term follow-up studies are necessary to evaluate the genital functions.

Penopubic flaps technique for the repair of epispadias with or without exstrophy: a preliminary report

Six patients (average age, 2 1/2 years; range, 4 months to 8 years) with the exstrophy-epispadias complex and isolate epispadias were treated using an alternative method. An inverted U-shaped incision (with a length of approximately 3 to 5 cm and a width of approximately 0.7 to 1.0 cm) was prepared, extending from the penopubic urethral meatus toward the umbilicus. The two incisions were extended along the urethral plate toward the ventral face of the glans. The pubic flap was prepared from the skin or scar tissue on the pubic area. The neourethra was reconstructed using penopubic flaps. A fistula occurred in one patient, which healed spontaneously. The penopubic flaps enabled us to form a wide-enough urethral tube and to perform a better dissection on the pubic area.

The Cantwell-Ransley epispadias repair in exstrophy and epispadias: lessons learned

OBJECTIVES

We evaluated our experience with the Cantwell-Ransley epispadias repair to determine the lessons that have been learned with the increased experience and follow-up.

METHODS

A total of 75 boys (60 with bladder exstrophy and 15 with complete epispadias) underwent a Cantwell-Ransley epispadias repair at our institute in the last 6 years. Primary repair was performed in 58 boys (45 with exstrophy and 13 with epispadias), and secondary repair was performed after prior failed closure in 17 boys (12 at the secondary exstrophy closure, 3 with exstrophy, and 2 with complete epispadias).

RESULTS

At a mean follow-up of 28 months, all patients had a horizontal or downward angled penis while standing. The incidence of urethrocutaneous fistulas in the immediate postoperative state was 21% and at 3 months was 15%. The incidence of urethrocutaneous fistulas was no more in those patients in whom paraexstrophy skin flaps were used at anterior closure than in those in whom the urethral plate was left intact. Two patients developed a urethral stricture at the proximal anastomotic area, and 4 patients had minor skin separation of the dorsal penile skin closure. Catheterization or cystoscopy, or both, has been performed in 60 patients and revealed an easily negotiable urethral channel in all.

CONCLUSIONS

The Cantwell-Ransley epispadias repair offers a straighter urethra, better correction of chordee and cosmesis, and a lower fistula rate in the exstrophy or epispadias patient.

Complete male epispadias: genital reconstruction and achieving continence

We report on 15 patients who were primarily treated for complete male epispadias at our institution since 1975. Repair of epispadias was performed using a modified Young urethroplasty in 13 patients and a Cantwell-Ransley urethroplasty in 2. In addition, 2 patients underwent a Cantwell-Ransley urethroplasty with chordee repair after a previous Young urethroplasty failed. Bladder capacity increased from a mean of 50 cc before repair to 92 cc after urethroplasty. A urethrocutaneous fistula developed in 6 cases, including 5 Young repairs and 1 Cantwell-Ransley. Three fistulas resolved spontaneously and there were no urethral strictures. Bladder neck reconstruction was performed in 11 patients. Time to initial continence ranged from 21 days to 6 months (mean 3 months) postoperatively. All patients attained daytime continence in a mean of 9 months (range 21 days to 24 months) after bladder neck reconstruction, including 9 of 11 (82%) who achieved total day and night continence. Mean followup was 7 years (range 1 to 10). Modern treatment of complete male epispadias allows for an excellent genital appearance and achievement of urinary continence.

Improved glanuloplasty in epispadias repair: technical aspects

An improved surgical approach to glanuloplasty in male epispadias repair is reported. The 3 essential steps of this repair include 1) reverse meatal advancement and glanuloplasty, 2) excision of redundant glans wing tissue bilaterally and 3) creation of a glandular urethra with a 2-layer glans closure. In more than 200 cases this technique has proved successful in producing a cosmetically satisfactory glans with a low rate of fistula formation (less than 5%).

Complications of paraexstrophy skin flaps in the reconstruction of classical bladder exstrophy

We reviewed the cases of the exstrophy/epispadias complex treated at our institution between July 1976 and April 1992. A total of 78 patients was identified who had paraexstrophy skin flaps used in the bladder closure, of whom 31 (40%) had a complication as a result of the flaps. The main complication encountered was a urethral stricture where the paraexstrophy skin flaps joined the urethral plate area. Multiple maneuvers were undertaken to correct these problems, including direct vision internal urethrotomy (12 cases), multiple urethral dilations (4), open revision (3) and full thickness skin grafts (5). Seven patients had such a complex stricture situation that they required either continent urinary diversion (5), colon conduit diversion (1) or cutaneous ureterostomy (1), the latter 2 patients having undergone vesicostomy elsewhere before referral. Of the remaining 24 patients who did not undergo a diversionary procedure 12 have undergone an epispadias repair and bladder neck reconstruction, 7 underwent an epispadias repair and 5 await further treatment. Freedom from complications in the initial closure of exstrophy significantly improves the chances of successful reconstruction. The avoidance of problems leading to obstruction, infection, hydronephrosis and reflux nephropathy will provide better kidneys regardless of bladder suitability for function or augmentation. Our use of paraexstrophy flaps has decreased but when they are required, special care in design, placement and followup is advised to avoid complicating strictures and their sequelae.