A comparison of renal function in the exstrophy patient treated with staged reconstruction versus urinary diversion

Long-term follow up (37-69 years) of patients with bladder exstrophy treated with ureterosigmoidostomy: uro-nephrological outcome

OBJECTIVE

To describe the urological and nephrological long-term outcome of patients born with classical bladder exstrophy treated with bilateral ureterosigmoidostomies in early childhood.

PATIENTS AND METHOD

Out of 42 patients born with bladder exstrophy in Switzerland between 1937 and 1968, 25 participated in this study; seven had died, seven were lost to follow up and three refused consent. Assessment included chart review, clinical examination, and assessment of renal function and morphology.

RESULTS

After a follow-up period of 37-69 years ((mean 50 years), 13 of the 25 participants (52%) had their ureterosigmoidostomy still in place. All others had different forms of urinary diversions. Fifteen (60%) patients had normal renal function or mild chronic kidney disease as assessed by estimated glomerular filtration rate. Three patients were on renal replacement therapy. MRI (n=16) showed 10 morphologically normal kidneys. One patient suffered from adenocarcinoma of the colon, five had benign colonic polyps, one urethral papillary carcinoma and 18 no evidence of tumor.

CONCLUSION

The majority of our patients have normal or mildly impaired renal function and a well functioning ureterosigmoidostomy. This is remarkable, given the fact that ureterosigmoidostomies are considered to be refluxing high-pressure reservoirs at risk of renal injury and malignancy.

Surgery Insight: advantages and pitfalls of surgical techniques for the correction of bladder exstrophy

Staged reconstruction repair of bladder exstrophy results in hydronephrosis or renal scarring in 15-25% of patients. A cosmetically acceptable and functional phallus can be achieved in 85% of patients, 20-30% of whom will require more than one operation for penile reconstruction. Episodes of penile glans loss or corporal loss are rarely reported with this technique. Widely disparate results relating to complete urinary continence and volitional voiding have been published, with urinary continence reported to occur in 7-85% of patients. The need for bladder augmentation to obtain urinary continence also varies, with reports that somewhere between 10% and 90% of patients require an augmentation procedure to gain urinary continence. Complete primary repair of bladder exstrophy using the penile disassembly technique results in hydronephrosis or renal scarring in 0-30% of patients, and hypospadias, as a consequence of this repair, will occur in 30-70% of patients. Loss of the glans and corpora appear more frequently with penile disassembly than in staged reconstruction of bladder exstrophy, however, the exact incidence of this complication is unknown. Reported complete urinary continence and volitional voiding rates are also varied following penile disassembly, ranging from 25-65%. A modified bladder-neck reconstruction to gain urinary continence is reportedly required in 15-90% of patients, with 5-10% requiring both bladder augmentation and bladder-neck reconstruction. Experience with complete primary repair of bladder exstrophy, using the penile disassembly approach, seems promising but is not a panacea. To outline the risks and benefits regarding the various surgical techniques for bladder exstrophy, we would recommend the establishment of a national registry for patients with this disorder.

Ureteral reimplantation before bladder neck plasty in the reconstruction of bladder exstrophy: indications and outcomes

OBJECTIVES

After initial closure, all exstrophy patients have vesicoureteral reflux. This reflux is usually managed with antimicrobial prophylaxis, surveillance, and ureteral reimplantation concurrent with bladder neck plasty. Patients with recurrent urinary tract infections or worsening hydronephrosis may require earlier correction of reflux. This subset of patients was reviewed to determine the ability to correct reflux adequately, the difficulty with subsequent bladder neck plasty, and the long-term continence results.

METHODS

We reviewed an exstrophy database of more than 700 patients and identified 19 who underwent ureteral reimplantation independent of bladder neck plasty. All had undergone bladder closure in infancy. Eleven had since undergone modified Young-Dees-Leadbetter bladder neck plasty. Five patients were awaiting bladder neck reconstruction, 2 girls were continent without bladder neck plasty, and one had undergone augmentation.

RESULTS

Indications for early ureteral reimplant were recurrent febrile infections despite adequate prophylaxis (n = 15) or worsening hydronephrosis on follow-up (n = 4). In the 11 patients who had undergone subsequent bladder neck repair, prior reimplantation did not increase the operative difficulty or complications. The continence results among these 11 were comparable with those in patients without prior reimplantation. In 1 patient, reflux recurred and was corrected at the time of bladder neck plasty. None had further urinary tract infections, and hydronephrosis improved in three and stabilized in one.

CONCLUSIONS

In patients who present with recurrent infections or worsening hydronephrosis after initial exstrophy closure, early reimplantation can be undertaken. If performed with later bladder neck plasty in mind, the surgical treatment of incontinence is not compromised and recurrent infections and upper tract changes will be abated.

The management of urinary incontinence in the exstrophy complex, posterior urethral valves, and infrasphincteric ureters

Urinary incontinence is a debilitating problem that requires careful evaluation. Causes of incontinence in children are numerous, and once the mechanism of incontinence has been identified, management can be planned carefully. The management and outcome in children born with the exstrophy-epispadias complex, posterior urethral valves, and children who have an infrasphincteric ureteric orifice are discussed in this article.

Evaluation of the functional significance of the colorectal valve used in rectal urinary diversion in children: a comparative study between cases with and without the valve

OBJECTIVES

To study the long-term impact of functional isolation of rectal reservoirs on the blood chemistries and acid-base balance of children who underwent this type of urinary diversion.

METHODS

A retrospective evaluation of 63 children with rectal reservoirs was performed. Of these, 40 had a colorectal valve and 23 had double-folded rectal reservoirs without a functional isolation valve. Evaluation included serum chemistry and arterial blood sample analysis to verify the impact of the created valve on homeostasis.

RESULTS

There was a statistically significant difference between the two groups relative to the value of pH, P(CO2), bicarbonate, base excess, and chloride in favor of those having a colorectal valve. Reduction of the absorptive surface area of the colon is presumably the cause in view of the functional isolation created by the colorectal valve.

CONCLUSIONS

In children, the long life expectancy and the benign condition for which they have diversion require the incorporation of the colorectal valve in any form of continent rectal diversion. Prophylactic alkalinization with strict follow-up is a must in those having no valve.

Outcome analysis of the psychosexual and socioeconomical development of adult patients born with bladder exstrophy

Since sonographic evaluation of the fetus became routine, prenatally established diagnosis of multiple or severe malformations raises the question of whether a pregnancy should be terminated. To answer this question properly, all aspects concerning the life of a child born with a serious malformation, such as exstrophy of the bladder, must be considered. Therefore, more than ever an evaluation of the quality of life of these patients is necessary to be able to make a solid based decision. We studied the psychosexual and socioeconomic development of 22 adult exstrophy patients (11 men and 11 women) by a standardized personal interview, evaluation of a standard performance test SCL-90 (symptom checklist 1990) and an adapted personality score test. The latter 2 tests are well established and provide reproducible results. Based on several large scale investigations, standard scores are available. Nine women (82%) and 10 men (91%) scored better or in accordance with the standard scores. Exstrophy of the bladder does influence the psychosexual and socioeconomic development. The quality of life is hardly ever considered so poor that termination of pregnancy is a realistic alternative.

Continence in bladder exstrophy: determinants of success

We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61% were continent based on a significantly higher urethral continence length (25.8 +/- 6.4 mm., mean plus or minus standard error) and a higher urethral closing pressure (69.4 +/- 5.8 cm. water) compared to the incontinent male population (11.4 +/- 3.1 mm. and 43.4 +/- 4.6 cm. water). No significant difference was noted in the bladder capacity of these 2 groups. Of the female population 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 +/- 4.4 mm.) and a higher urethral closing pressure (62.7 +/- 10.2 cm. water) compared to the incontinent female subjects (8.4 +/- 2.5 mm. and 32.7 +/- 6.9 cm. water). Moreover, those who were continent had a significantly higher bladder capacity (201.2 +/- 39.5 ml.) compared to those who were incontinent (84.3 +/- 23.6 ml.). These findings support a multifactorial mechanism in achieving continence but they suggest that of all the factors urethral length may be the most important.

Nonrefluxing colonic conduits: a long-term life-table analysis

We evaluated 25 patients undergoing urinary diversion with a nonrefluxing colonic conduit. Renal scarring developed in 10% of the kidneys during a median followup of 12.7 years. In 11 renal units (22%) deterioration of the ureteroenteric anastomosis occurred due to the development of reflux or stricture. Of these kidneys 45% had scarring; no renal unit in which the anastomosis remained intact had renal scars (p less than 0.001). Of our patients 96% had bacterial colonization of the colonic conduit but this was not associated with renal scarring if the urinary diversion was anatomically intact.