Classic bladder exstrophy in a nonhuman primate: a comparative analysis

Surgical and endoscopic treatment of bladder exstrophy-epispadias complex in a female dog

CASE DESCRIPTION A 14-week-old 7.7-kg (16.9-lb) sexually intact female Golden Retriever was evaluated because of urine dripping from the caudoventral aspect of the abdomen. CLINICAL FINDINGS Ultrasonography, radiography, excretory CT urography, and vaginocystourethroscopy were performed. Results indicated eversion of the bladder through the ventral abdominal wall with exposure of the ureterovesicular junctions, pubic diastasis, and an open vulva and clitoral fossa. Clinical findings were suggestive of bladder exstrophy, a rare congenital anomaly. TREATMENT AND OUTCOME The dog was anesthetized and bilateral ileal osteotomies were performed. Two ureteral catheters were passed retrograde into the renal pelves under fluoroscopic guidance. The lateral margins of the bladder, bladder neck, and urethra were surgically separated from the abdominal wall, and the bladder was closed, forming a hollow viscus. The symphysis pubis was closed on midline with horizontal mattress sutures. The defects in the vestibule and clitoral fossa were closed. Lastly, the iliac osteotomies were stabilized. The dog was initially incontinent with right hind limb sciatic neuropraxia and developed pyelonephritis. Over time, the dog became continent with full return to orthopedic and neurologic function, but had recurrent urinary tract infections, developed renal azotemia likely associated with chronic pyelonephritis, and ultimately was euthanized 3.5 years after surgery because of end-stage kidney disease. CLINICAL RELEVANCE Bladder exstrophy and epispadias is a treatable but rare congenital abnormality. The procedure described could be considered for treatment of this condition, but care should be taken to monitor for urinary tract infections and ascending pyelonephritis.

Genetische und molekularbiologische Aspekte des Blasenekstrophie-Epispadie-Komplexes (BEEK)

The bladder exstrophy and epispadias complex (BEEC) is an anterior midline defect with variable expression involving the infraumbilical abdominal wall including the pelvis, urinary tract, and external genitalia. The incidence varies with regard to ethnical background, sex, and phenotypic expression, and an incidence of 1:20,000 to 1:80,000 has been observed in the middle European population. No gene defect has been attributed to BEEC thus far and chromosomal aberrations or genetic syndromes associated with BEEC have only rarely been reported. According to epidemiological data, a complex genetic as well as a multifactorial mode of inheritance could underlie BEEC. However, no single teratogenic agent or environmental factor has been identified, which could play a dominant role in the expression of the BEEC.A risk of recurrence of 0.5-3% has been described in families with one affected subject. These values correspond to an increased recurrence risk estimated to be as high as 200- to 800-fold when compared to the common population. Due to the paucity of affected sib pairs and suitable multiplex families, conventional linkage analysis to identify candidate genes causally related with BEEC appears to be unfeasible. Large association studies and consecutive linkage disequilibrium mapping should therefore lead to the identification of candidate genes. Also new methods including matrix-based comparative genomic hybridization (CGH) are promising and have successfully been used in the past (e.g., CHARGE association). Moreover, the low incidence of the BEEC requires close cooperation between clinicians in the operative and nonoperative specialties as well as geneticists for successful gene search.