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Ostertag-Hill CA, Delaplain PT, Lee T, Dickie BH. Updates on the Care of Cloacal Exstrophy. CHILDREN (BASEL, SWITZERLAND) 2024; 11:544. [PMID: 38790539 PMCID: PMC11120324 DOI: 10.3390/children11050544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
Cloacal exstrophy is the most severe congenital anomaly of the exstrophy-epispadias complex and is characterized by gastrointestinal, genitourinary, neurospinal, and musculoskeletal malformations. Individualized surgical reconstruction by a multidisciplinary team is required for these complex patients. Not infrequently, patients need staged surgical procedures throughout childhood and adolescence. Following significant improvements in medical care and surgical reconstructive techniques, nearly all patients with cloacal exstrophy now survive, leading to an increased emphasis on quality of life. Increased attention is given to gender identity and the implications of reconstructive decisions. Long-term sequelae of cloacal exstrophy, including functional continence and sexual dysfunction, are recognized, and many patients require ongoing complex care into adulthood.
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Affiliation(s)
- Claire A. Ostertag-Hill
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
| | - Patrick T. Delaplain
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
| | - Ted Lee
- Department of Urology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
| | - Belinda H. Dickie
- Department of Surgery, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (C.A.O.-H.); (P.T.D.)
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Harris KT, Namdarian B, Gearhart JP, Wood D. Long term outcomes in classic bladder exstrophy - The adult picture. J Pediatr Urol 2024; 20:157-164. [PMID: 37451916 DOI: 10.1016/j.jpurol.2023.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
With continued improvements in medical care and surgical reconstruction, more patients with classic bladder exstrophy (CBE) are living into adulthood, than ever before. With improved survival, a greater emphasis on adult issues and improving quality of life (QOL) for these individuals is of increasing importance. This review aims to summarize data on long-term considerations for the adult with exstrophy and to highlight areas of future research and collaboration. Key conclusions are that continence or dryness are achievable alongside the ability to enjoy sexual relationships and a good quality of life.
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Affiliation(s)
- Kelly T Harris
- Division of Urology, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16 Ave. Aurora, CO 80045, USA.
| | - Benjamin Namdarian
- Department of Urology, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dan Wood
- Division of Urology, Department of Surgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 E 16 Ave. Aurora, CO 80045, USA
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Hosiani A, Smet ME, Nayyar R. A road map for the management of a pregnancy complicated by maternal bladder exstrophy. BMC Pregnancy Childbirth 2024; 24:195. [PMID: 38475706 DOI: 10.1186/s12884-024-06316-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 02/03/2024] [Indexed: 03/14/2024] Open
Abstract
Bladder exstrophy (BE) is a congenital genito-urinary malformation where there is a defect in the abdominal wall resulting in a protruding open bladder with exposed mucosa (Resnik R.P. et al. Creasy and Resnik's maternal-fetal medicine: principles and practice. Elsevier, 2019). Several reconstructive procedures are required to correct the anomalies, resulting in an ileal conduit which is an alternate urinary reservoir reconstructed from the terminal ileum (Madersbacher S, et al. J Urol 169(3):985-90, 2003). We describe the care of a pregnant woman with BE and outline the principles of management of her pregnancy with a multidisciplinary team. Timely pre-operative planning is advised to minimise intraoperative complications in the event of a caesarean section. The woman went on to have an uncomplicated classical caesarean section at term by midline laparotomy with a good outcome for both mother and baby.
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Affiliation(s)
- A Hosiani
- Department of Obstetrics and Gynaecology Blacktown Hospital, Blacktown, Australia.
| | - M E Smet
- Westmead Institute for Maternal Fetal Medicine, Westmead, Australia
| | - R Nayyar
- Westmead Institute for Maternal Fetal Medicine, Westmead, Australia
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Haney NM, Morrill CC, Haffar A, Crigger C, Gabrielson AT, Galansky L, Gearhart JP. Long-Term Management of Problems in Cloacal Exstrophy: A Single-Institution Review. J Pediatr Surg 2024; 59:26-30. [PMID: 37838618 DOI: 10.1016/j.jpedsurg.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 10/16/2023]
Abstract
INTRODUCTION Cloacal exstrophy (CE) is the most severe malformation of the exstrophy-epispadias complex. This study aims to discuss long-term sequela in a single major institution with a high volume of CE patients. MATERIALS AND METHODS A prospectively maintained database of 1490 patients on the exstrophy epispadias spectrum (145 cloacal exstrophy) from 1974 to 2023. The patient database was reviewed for CE patients >10 years of age for genitourinary, gastrointestinal, orthopedic, and psychosocial outcomes. RESULTS A total of 63 patients (43.4%) with ≥10 years of follow up were included for analysis. Thirty-nine (61.9%) patients were 18 years or older. Twenty-two (34.9%) patients were female and 39 (61.9%) male, 14 of whom were gender converted at birth. Two female patients conceived naturally and delivered via cesarean section. No male born CE patients had biological children. Catheterizable channels were common (45/63, 71.4%) and most (88.9%) were continent. Gastrointestinal diversion was managed mostly by colostomy (37/63, 58.7%). Three out of five (60.0%) patients who underwent PSARP were continent of stool. Twenty-two (34.9%) patients were wheelchair-bound. Psychosocial diagnoses included 52.4% (33/63) patients with anxiety/depression and 27.0% with chronic pain. Out of 56 patients evaluated by physical therapy, 75% were independent in ADL performance. Of patients older than 18, 79.5% (31/39) had attended college and 82.1% (32/39) were gainfully employed. CONCLUSION Advances in critical care, nutrition, gastrointestinal, orthopedic, and urologic management have resulted in survival rates approaching 100% among patients with CE. While these children face long-term sequela spanning various organ systems, many lead independent and fully-functional lives. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Nora M Haney
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
| | - Christian C Morrill
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmad Haffar
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Chad Crigger
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Andrew T Gabrielson
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Logan Galansky
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - John P Gearhart
- James Buchanan Brady Urological Institute, Division of Pediatric Urology, Douglas A. Canning MD Exstrophy Database Center, Charlotte Bloomberg Children's Hospital, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Schrey-Petersen S, Lacher M, Stepan H. Course of an unplanned and unexpected pregnancy in a 39 year-old patient with Complex bladder extrophy: a case report. J Med Case Rep 2023; 17:450. [PMID: 37898815 PMCID: PMC10613355 DOI: 10.1186/s13256-023-04181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 09/15/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND With improved operative techniques pregnancy rates have been rising in patients with anomalies of the extrophy-epispadias-complex, including also female patients with bladder extrophy. Specific risks around pregnancy need to be addressed sufficiently beforehand. CASE PRESENTATION An unplanned pregnancy was detected at 34 weeks in a 39-year old White female patient with former complex bladder extrophy. Decades after her operation she had not received any follow-up medical care and believed to be unable to conceive due to her anomaly. Thus no contraceptive matters were taken. The patient had lived in a stable relationship with regular sexual intercourse for many years. Until 34 weeks the pregnancy was uncomplicated, but then uterine prolapse and signs of beginning pre-eclampsia appeared, and a healthy girl was born with cesarean section. CONCLUSION As patients with bladder extrophy and other anomalies from the extrophy-epispadias-complex reach adolescence/adulthood, they need continuous medical follow-up and transition of care to adult surgery and gynecology in order to address specific aspects of sexual health, reproduction, contraception, and also cancer screening. In the presented case lack of transition of care resulted in an unplanned and complicated pregnancy.
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Affiliation(s)
| | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
| | - Holger Stepan
- Department of Obstetrics, University of Leipzig, Liebigstr. 20A, 04103, Leipzig, Germany
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Lee T, Borer J. Exstrophy-Epispadias Complex. Urol Clin North Am 2023; 50:403-414. [PMID: 37385703 DOI: 10.1016/j.ucl.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Exstrophy-epispadias complex encompasses a spectrum of disorders with lower abdominal midline malformations, including epispadias, bladder exstrophy, and cloacal exstrophy, also known as Omphalocele-Exstrophy-Imperforate Anus-Spinal Anomalies Complex. In this review, the authors discuss the epidemiology, embryologic cause, prenatal findings, phenotypic characteristics, and management strategies of these 3 conditions. The primary focus is to summarize outcomes pertaining to each condition.
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Affiliation(s)
- Ted Lee
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue Boston, MA 02115, USA; Department of Surgery (Urology), Harvard Medical School, Boston, MA, USA.
| | - Joseph Borer
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue Boston, MA 02115, USA; Department of Surgery (Urology), Harvard Medical School, Boston, MA, USA
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Taira Y, Yara N, Kinjo Y, Kinjo T, Mekaru K, Aoki Y. Low-set umbilicus in a pregnant woman with bladder pseudoexstrophy: A case report. Case Rep Womens Health 2022; 36:e00467. [PMID: 36406178 PMCID: PMC9667195 DOI: 10.1016/j.crwh.2022.e00467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Bladder pseudoexstrophy is a rare form of bladder exstrophy. Bladder exstrophy occurs in 1 in every 30,000 to 50,000 live births. Because bladder pseudoexstrophy is asymptomatic, it may be undiagnosed even in adulthood. A 31-year-old woman with uterus bicornis unicollis and a low-set umbilicus underwent emergency cesarean delivery during the 37th week of pregnancy for chorioamnionitis. Perioperatively, asymptomatic anatomical abnormalities were identified, which included separated rectus abdominis muscles and diastasis of the symphysis pubis. The urinary tract was normal. The patient was diagnosed with bladder pseudoexstrophy. A low-set umbilicus may be a potential marker for the diagnosis of bladder pseudoextrophy. Pseudoexstrophy should be diagnosed and managed to improve a woman's health. A low-set umbilicus would be a good marker for diagnosis of pseudoexstrophy. Pseudoexstrophy is associated with perinatal risks and women's health care.
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Pelvic Organ Prolapse in Patients with Congenital Genitourinary Conditions. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Seat M, Boxwalla M, Hough A, Goodwin G. A case of congenital cloacal exstrophy/omphalocele-exstrophy-imperforate anus-spinal defects syndrome and a successful pregnancy. Clin Exp Reprod Med 2022; 49:215-218. [PMID: 36097738 PMCID: PMC9468692 DOI: 10.5653/cerm.2021.05148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
Herein, we report an exceptionally rare case of a 25-year-old woman with cloacal exstrophy/omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) syndrome achieving a viable pregnancy despite many gastrointestinal and genitourinary malformations and multiple respective corrective operations. The patient was born with two vaginas, two uteruses, four ovaries, an imperforate anus, a large omphalocele including bowel and bladder exstrophy, and diaphysis of the pubic rami. This patient is the only documented OEIS patient not to have tethered spinal cord as an anomaly, perhaps contributing to her successful pregnancy. After experiencing preeclampsia with severe features at 35 weeks, the baby was born via cesarean section.
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Affiliation(s)
- Mara Seat
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
- Corresponding Author: Mara Seat Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, 3200 S University Dr, Fort Lauderdale, FL 33328, USA Tel: +1-94-1330-6938 E-mail:
| | - Munira Boxwalla
- Department of Obstetrics and Gynecology, Staten Island University Hospital, Staten Island, NY, USA
| | - Arielle Hough
- Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, FL, USA
| | - Glenn Goodwin
- Department of Emergency Medicine, Aventura Hospital and Medical Center, Miami, FL, USA
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Musleh L, Privitera L, Paraboschi I, Polymeropoulos A, Mushtaq I, Giuliani S. Long-term active problems in patients with cloacal exstrophy: A systematic review. J Pediatr Surg 2022; 57:339-347. [PMID: 34563362 DOI: 10.1016/j.jpedsurg.2021.08.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/08/2021] [Accepted: 08/27/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cloacal exstrophy (CE) is the most severe end of the Exstrophy-Epispadias Complex malformations spectrum. Improvements in postnatal management and well-established operative techniques have resulted in survival rates approaching 100%. This systematic review aims to define the prevalence of long-term active medical problems affecting CE patients after the first decade of life. METHODS PubMed/Medline, Embase, Scopus, and ISI Web of Knowledge databases were used for the literature search. Original articles related to medical, surgical, and psychosocial long-term problems in CE patients >10 years of age were included in the study. Quality assessment of the articles was performed through the Newcastle-Ottawa Scale. Prevalence estimates and 95% CI were assessed for each outcome. RESULTS Twelve studies were included. The most common long-term active problems identified were: urinary incontinence with a prevalence ranging from 9.1% to 85%; sexual function issues related to vaginal anomalies with a prevalence ranging from 8.3% to 71.3%, and uterine anomalies, with a prevalence from 14.3% to 71%; gender identity issues in 46, XY patients raised female had a prevalence from 11.1% to 66.7%. There is no documented history of paternity. Impairment of ambulatory capacity was recorded in 13.8% of patients. Only one paper studied psychological well-being, reporting significantly higher levels of depression among gender reassigned patients. CONCLUSIONS Teenagers and adults born with CE have well defined long-term problems compared to the general population. Recognition and expert management are crucial to improve care and quality of life during and after the transition into adulthood.
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Affiliation(s)
- Layla Musleh
- Great Ormond Street Hospital for Children NHS Foundation Trust, Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street, London WC1N 3JH, United Kingdom; San Camillo Forlanini Hospital. Department of Pediatric Surgery, Circonvallazione Gianicolense, 87, Rome 00152, Italy
| | - Laura Privitera
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College of London, 43 - 45 Foley Street, London W1W 7TS, United Kingdom; UCL Great Ormond Street Institute of Child Health, Developmental Biology and Cancer Research Department, 30 Guilford Street, London WC1N 1EH, United Kingdom
| | - Irene Paraboschi
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College of London, 43 - 45 Foley Street, London W1W 7TS, United Kingdom; UCL Great Ormond Street Institute of Child Health, Developmental Biology and Cancer Research Department, 30 Guilford Street, London WC1N 1EH, United Kingdom
| | - Alexios Polymeropoulos
- University of Milano-Bicocca, Department of Statistics ad Quantitative Methods, 1 Piazza dell'AteneoNuovo, Milan 20126, Italy
| | - Imran Mushtaq
- Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Stefano Giuliani
- Great Ormond Street Hospital for Children NHS Foundation Trust, Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street, London WC1N 3JH, United Kingdom; Wellcome / EPSRC Centre for Interventional and Surgical Sciences (WEISS), University College of London, 43 - 45 Foley Street, London W1W 7TS, United Kingdom; UCL Great Ormond Street Institute of Child Health, Developmental Biology and Cancer Research Department, 30 Guilford Street, London WC1N 1EH, United Kingdom.
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Bey E, Perrouin-Verbe B, Reiss B, Lefort M, Le Normand L, Perrouin-Verbe MA. Outcomes of pregnancy and delivery in women with continent lower urinary tract reconstruction: systematic review of the literature. Int Urogynecol J 2021; 32:1707-1717. [PMID: 34125241 DOI: 10.1007/s00192-021-04856-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/09/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of this systematic review of the literature was to pool all the existing data regarding pregnancy and delivery in women with neurogenic bladder or bladder exstrophy who had undergone previous lower urinary tract reconstruction (LUTR). METHODS We conducted a systematic review of the literature from PubMed/MedLine, ClinicalTrials.gov and the Google Scholar database, from 1972 to July 2020. Fifty articles were included, of which 25 contained data that could be pooled (229 women representing 292 pregnancies). RESULTS Ninety-eight women had bladder exstrophy (43%), 58 had spinal dysraphism (25%), 14 had spinal cord injury (6%), and 59 presented other pathological conditions. Of these, 138 have had an augmentation cystoplasty (61%), 42 (18%) had a continent cutaneous urinary diversion, and 31 had an artificial urinary sphincter (14%). During their pregnancy, 97 women (33%) experienced at least one febrile urinary tract infection. Thirty-one women (11%) required ureteral stenting or nephrostomy placement for upper urinary tract dilatation. Forty-six pregnancies ended with premature delivery (16%). Delivery mode was by C-section for 108 patients (62%) and vaginal delivery for 104 (36%). Twenty complications were reported during delivery (mainly urological), of which 19 occurred during C-section. Nine women experienced postpartum urinary incontinence (4%); in 5 of then this was due to urinary fistulae secondary to complicated C-section. CONCLUSIONS Pregnancy and vaginal delivery are possible for women with LUTR who have no obstetric or medical contraindications, except for some particular cases of bladder exstrophy. However, these high-risk pregnancies and deliveries should be managed by a specialist multidisciplinary team.
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Affiliation(s)
- Elsa Bey
- Department of Urology, CHU-Université de Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France.
| | - Brigitte Perrouin-Verbe
- Physical Medicine and Rehabilitation Department, CHU-Université de Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
| | - Bénédicte Reiss
- Physical Medicine and Rehabilitation Department, CHU-Université de Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
| | - Marc Lefort
- Physical Medicine and Rehabilitation Department, CHU-Université de Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
| | - Loïc Le Normand
- Department of Urology, CHU-Université de Nantes, 1 place Alexis Ricordeau, 44000, Nantes, France
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Cai B, Guan Y. Case Report: Recurrent Placental Abruption During Pregnancy in a Patient With Pseudoexstrophy. Front Med (Lausanne) 2021; 8:619322. [PMID: 33575266 PMCID: PMC7870684 DOI: 10.3389/fmed.2021.619322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Pseudoexstrophy is a rare variant of the exstrophy-epispadias complex, which comprises musculoskeletal defects associated with bladder exstrophy without any urinary tract defects. However, only a few pregnancy complications have been reported in patients with pseudoexstrophy. Case Presentation: This report presents the case of a woman with pseudoexstrophy, who survived recurrent placental abruption during the second trimester of her pregnancy. The patient presented with a bicornuate uterus and survived placental abruption twice, which may have resulted from the malformation of the uterus. Placental abruption occurred at 20 weeks during her first pregnancy, and because she was already in labor, uterine contraction was augmented until vaginal delivery was achieved. The second pregnancy, however, could not be terminated quickly enough; therefore, a cesarean section was performed to save the patient's life. Conclusions: Our study makes a significant contribution to the literature although pregnancy complications have been reported in patients with pseudoexstrophy. Our findings show that in female patients with pseudoexstrophy who are or wish to become pregnant, detailed imaging studies must be performed to identify any deformities of the pelvis or reproductive organs, in order to make a pregnancy-related risk assessment. Our experience also indicates that if surgery is inevitable, the obstetrician must be more careful when entering the abdominal cavity during the surgery to avoid secondary injury. Furthermore, the peritoneum and fascia layers must be sutured more firmly when closing the abdomen to avoid an abdominal wall hernia, because of the lack of abdominal muscle and fat tissue in such patients.
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Affiliation(s)
- Benshuo Cai
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuheng Guan
- Department of Radiology, The First Hospital of China Medical University, Shenyang, China
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Fertility and sexuality issues in congenital lifelong urology patients: female aspects. World J Urol 2020; 39:1021-1027. [PMID: 32989556 DOI: 10.1007/s00345-020-03461-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 09/14/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE With advances in treatment modalities and medical knowledge, girls with congenital urologic disorders are living well into adulthood. Although, sexual and reproductive function in this population is still poorly understood. The aim is to review existing literature about fertility and sexuality in women with congenital genitourinary disorders, including spina bifida (SB), bladder exstrophy-epispadias complex (BEEC) and congenital adrenal hyperplasia (CAH). METHODS This review represents the joint SIU-ICUD (Société Internationale d'Urologie-International Consultation on Urological Disease) consultation on congenital lifelong urology. The results of this analysis were first presented at a joint consultation of the SIU and ICUD at the 2018 SIU annual conference in Seoul, South Korea. Appropriate experts were asked to write specific sections regarding sexuality and reproductive function in female patients with these complex congenital urogenital disorders. Each expert performed their own literature review which was reviewed by GDW, AFS, Hadley M. Wood and Dan Wood. Expert opinion was obtained where data are non-existent. RESULTS Only about half of the individuals with SB express a satisfactory sex life. In women with BEEC, cosmetic concerns surrounding genital appearance and function may increase psychological distress, including severe depression, suicide and sexual dysfunction. Professional health care is key for improving self-esteem and to interact in the biopsychosocial model of the quality of life. Patients with SB and BEEC should be informed about all the potential risks and difficulties before, during and after pregnancy. Screening for pelvic organ prolapse is important as it can exacerbate their already existing sexual dysfunction, difficulties achieving pregnancy and challenges with clean intermittent catheterization. CONCLUSIONS Lifelong multidisciplinary follow-up and management are complex but necessary. As these patients grow into their adolescence, they may have the desire to become involved in personal relationships and have sexual interactions. Their healthcare team needs to be increasingly sensitive to these aspects.
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Single-staged male bladder exstrophy-epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience. Int Urol Nephrol 2020; 53:191-198. [PMID: 32980929 DOI: 10.1007/s11255-020-02648-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To represent the 15 years' experience of an academic referral center for the reconstruction of bladder exstrophy-epispadias complex with a modified single-stage approach. Single-staged reconstruction techniques are commonly used for classic bladder exstrophy. However, combined bladder closure and epispadias repair have been taken into great consideration in patients with initially failed reconstruction or delayed primary closure. METHODS A total of 49 boys underwent 1-stage bladder and epispadias repair with pubic bone adaptation and without the application of pelvic osteotomy. The mean ± SD age at surgery was 5.23 ± 2.04 months. Continence and social dryness were assessed in the follow-ups with 3 months intervals for the first year and biannually thereafter. RESULTS The mean ± SD of follow-up was 127.25 ± 71.32 months. Urethrocutaneous fistula, stricture, wound infection, and hemiglans were developed in six distinct patients. However, no other major complications were noted. Three patients (6.1%) remained incontinent; while 32 (65.3%) children were socially continent and 14 (28.6%) children were waiting for toilet training. All the patients without previous failed closure were socially continent, while all incontinent patients had two failed closures in their history. No patient was rendered hypospadiac. CONCLUSION Based on the experience of this institution, the application of single-stage reconstructive techniques can lead to continence, cosmetically pleasing appearance with promising outcomes, and reduction of overall operations, hospital stay and costs in the majority of cases as compared to multiple surgical procedures.
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Irfan O, Ladiwala ZFR, Zaidi Z. Long-term Follow-up of Exstrophy-epispadias Complex from a Lower-middle Income Country: A Case Report and Review of the Literature. Cureus 2020; 12:e7723. [PMID: 32432001 PMCID: PMC7234001 DOI: 10.7759/cureus.7723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Bladder exstrophy-epispadias complex (EEC) is a rare congenital defect where the abdominal muscles and bones fail to close in the mid-pelvis. It is crucial to understand the health-related quality of life (QOL) of exstrophy patients who have undergone multiple correctional surgeries. We herein discuss a case of bladder EEC that was repaired through a series of procedures at a resource-limited hospital in Karachi, Pakistan. A 21-year-old male, who was born with EEC, underwent bladder augmentation, Mitrofanoff procedure, bladder neck reconstruction, ureter implantation and a right nephrectomy in a single one-stage procedure during late childhood for urinary incontinence. However, this required a further revision because the urinary incontinence persisted, with difficulty in catheterizing the Mitrofanoff channel. On follow-up after 10 years, our patient currently describes normal QOL with near-normal sexual function. Validated questionnaires for QOL, erectile dysfunction, incontinence and prostatic function were used to assess the patient's post-operative status in these domains. Through our report, we conclude that such patients can have a normal QOL by means of a holistic multidisciplinary management, which includes timely surgical corrections along with an additional focus on the psycho-social and sexual aspects of this condition.
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Affiliation(s)
- Omar Irfan
- Pediatrics, Centre for Global Child Health, Hospital for Sick Children, Toronto, CAN
| | | | - Zafar Zaidi
- Urology, The Indus Hospital, Indus University of Health Sciences, Karachi, PAK
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Treatment guidelines for persistent cloaca, cloacal exstrophy, and Mayer–Rokitansky–Küster–Häuser syndrome for the appropriate transitional care of patients. Surg Today 2019; 49:985-1002. [DOI: 10.1007/s00595-019-01810-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/26/2019] [Indexed: 11/30/2022]
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Novel Observations of Female Genital Anatomy in Classic Bladder Exstrophy Using 3-Dimensional Magnetic Resonance Imaging Reconstruction. J Urol 2018; 200:882-889. [DOI: 10.1016/j.juro.2018.04.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2018] [Indexed: 11/23/2022]
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Patient-Reported Impact of Pelvic Organ Prolapse on Continence and Sexual Function in Women With Exstrophy-Epispadias Complex. Female Pelvic Med Reconstr Surg 2018; 23:377-381. [PMID: 28277470 DOI: 10.1097/spv.0000000000000414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to characterize long-term urogynecologic issues of women with a history of bladder exstrophy and pelvic organ prolapse (POP) and to assess the impact of POP repair on continence and sexual function. DESIGN Patient demographics and surgical history related to exstrophy and POP were collected through chart review. Patient perceptions regarding sexual function, urinary continence, and quality of life were assessed through Web-based administration of validated questionnaires: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and POP-Urinary Incontinence Sexual Questionnaire. SETTING Maryland, United States. PARTICIPANTS Review of a single-institution exstrophy-epispadias complex database resulted in 25 adult female patients with a history of POP treated at the authors' institution. Eleven patients participated and were included in the analysis. MAIN OUTCOME MEASURES Urinary continence and sexual function. RESULTS All participants underwent surgical repair for prolapse, with 7 (63.6%) experiencing unsuccessful initial repair and subsequent recurrence. Median total number of POP repairs was 2.5 (1-4). After correction of POP, patients reported a median improvement in International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form scores of 11 (21 to -1) of 21 and in POP-Urinary Incontinence Sexual Questionnaire scores of 9.5 (6.5-33.0) of 48.0. With regard to urinary continence, 6 (54.5%) patients presently reported no incontinence, 3 (27.3%) reported mild incontinence, and 2 (18.2%) reported continuous incontinence. CONCLUSIONS Pelvic organ prolapse poses significant reductions in quality of life for women born with exstrophy, with effects on urinary continence and sexual function. Identification and correction of prolapse seems to result in notable improvements in the lives of these patients.
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Abstract
PURPOSE OF REVIEW Classic bladder exstrophy (BE) remains one of the most demanding reconstructive challenges encountered in urology. In female BE patients, the long-term sequela of both primary and revision genitoplasty, as well as intrinsic pelvic floor deficits, predispose adult women to significant issues with sexual function, pelvic organ prolapse (POP), and complexities with reproductive health. RECENT FINDINGS Contemporary data suggest 30-50% of women with BE develop prolapse at a mean age of 16 years. Most women will require revision genitoplasty for successful sexual function, although in some series over 40% report dyspareunia. Current management for pregnancy includes elective cesarean section with involvement of high-risk obstetrics and urologic surgery. This review encapsulates contemporary concepts of etiology, prevalence, and management of POP and pregnancy in the adult female BE patient.
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Affiliation(s)
- Melissa R Kaufman
- Department of Urologic Surgery, Vanderbilt University Medical Center, A-1302 Medical Center North, Nashville, TN, 37232-2765, USA.
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Bonner S, Mohammed Y. Complex maternal congenital anomalies - a rare presentation and delivery through a supra-umbilical abdominal incision. J OBSTET GYNAECOL 2018; 38:874-875. [PMID: 29433356 DOI: 10.1080/01443615.2017.1394282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Samantha Bonner
- a Department of Obstetrics , St Mary's Hospital , Manchester , UK
| | - Yara Mohammed
- a Department of Obstetrics , St Mary's Hospital , Manchester , UK
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Ebert AK, Lange T, Reutter H, Jenetzky E, Stein R, Boemers TM, Hirsch K, Rösch WH, Zwink N. Evaluation of sexual function in females with exstrophy-epispadias-complex: A survey of the multicenter German CURE-Net. J Pediatr Urol 2017; 13:183.e1-183.e6. [PMID: 27480467 DOI: 10.1016/j.jpurol.2016.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/13/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Standardized knowledge about genital function in adult female individuals with exstrophy-epispadias complex (EEC) is scarce. The aim of this study was to investigate sexual function using the standardized Female Sexual Function Index (FSFI), and to assess the influence of bladder and vaginal reconstruction and the presence of incontinence on FSFI results. METHOD Sixty-one females (aged ≥18 years) recruited by the German multicenter network for congenital uro-rectal malformations (CURE-Net) were asked to complete the FSFI and a self-designed semi-structured questionnaire assessing comprehensive medical data, gynecological, and psychosocial items. Twenty-one eligible females (34%) returned both questionnaires (mean ± standard deviation [SD] age of 26 ± 5.1 years). RESULTS In 43% of participants, a staged or single-staged approach had been used for reconstruction, and these had their bladder in use. A primary or secondary urinary diversion (UD) after cystectomy had been performed in 38% of participants. Of the participants, 57% lived in a committed partnership, and 62% had sexual intercourse on a regular basis, with a further 19% experiencing pain or discomfort thereby. Introitus plasty was done in 43%. Mean total FSFI for all participants was 21.3 (SD 1.9). Most domain scores of patients after introitus plasty were similar compared with those without an operative vaginal approach, except for satisfaction (p = 0.057) and pain (p = 0.024). Comparing incontinent with continent patients, significant differences were found for desire (mean 4.6 vs. 3.5, p = 0.021), lubrication (mean 3.1 vs. 4.2, p = 0.049), and satisfaction (mean 1.6 vs. 3.6, p = 0.0065). In contrast pain was not significant between groups. CONCLUSIONS Sexual activity rate in the present study was similar to that reported in the literature (81% vs. 89%), whereas dyspareunia rate was lower in our cohort (19% vs. 24%). The risk for sexual dysfunction seems to be lower in patients reconstructed with primary or secondary UD than patients with bladder in use. It is surprising that lubrification was better after UD than after bladder neck surgery. Incontinence and in some parts the history of an introitus plasty may play an additional role in development of sexual dysfunction in EEC. Although most of the female EEC patients lived in a committed partnership and had sexual intercourse, total FSFI values <26.55 clearly indicate a risk of sexual dysfunction. Although continence itself played a major role, females reconstructed with UD seem to have better sexual function. Further evaluation of sexual outcome and improvement of care for these patients is mandatory.
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Affiliation(s)
| | - Theresa Lange
- Department of Urology and Pediatric Urology, Ulm University, Ulm, Germany
| | - Heiko Reutter
- Institute of Human Genetics, University of Bonn, Bonn, Germany; Department of Neonatology, Children's Hospital, University of Bonn, Bonn, Germany
| | - Ekkehart Jenetzky
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Child Center Maulbronn, Hospital for Pediatric Neurology and Social Pediatrics, Maulbronn, Germany; Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Mainz, Germany
| | - Raimund Stein
- Department of Pediatric and Adolescent Urology, University of Mannheim, Mannheim, Germany; Department of Pediatric Urology, University of Mainz, Mainz, Germany
| | - Thomas M Boemers
- Department of Pediatric Surgery and Urology, University Hospital Cologne, Cologne, Germany
| | - Karin Hirsch
- Department of Pediatric Urology, University Hospital Erlangen, Erlangen, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, Klinik St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Nadine Zwink
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
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Continent Anal Urinary Diversion in Classic Bladder Exstrophy: 45-Year Experience. Urology 2016; 100:249-254. [PMID: 27890681 DOI: 10.1016/j.urology.2016.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/12/2016] [Accepted: 11/15/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the long-term outcomes in patients with classic bladder exstrophy and continent anal urinary diversion (CAD) for continence, upper urinary tract status, secondary malignancies, and sexual function. PATIENTS AND METHODS The medical records of 82 exstrophy patients having undergone CAD in our department between 1970 and 2015 were reviewed. Patients were invited for follow-up examinations and asked to complete validated questionnaires relating to sexual function. RESULTS Thirty-two of 57 eligible patients with a median follow-up of 23.9 years were included in the study. Ninety-seven percent of patients were fully continent during daytime. Upper urinary tract and renal function remained stable in 75% and 87%, respectively. Five patients developed secondary malignancies originating from the rectal reservoir. Forty-one percent received prophylactic alkaline substitution. Sexual function as measured by the Female Sexual Function Index and the International Index on Erectile Function was negatively affected in all domains in both genders. Eighty-six percent of patients had a stable relationship and 35% were married. Five women conceived a total of 6 healthy children. Paternity rate was 40%. CONCLUSION CAD constitutes an effective treatment option with acceptable long-term outcomes in exstrophy patients in whom all attempts at restoring the lower urinary tract have failed. Long-term follow-up of the upper urinary tract, assessment of acid-base balance, and endoscopy of the rectosigmoid reservoir are paramount for the safety of this type of management. Evaluation of sexual dysfunction should be an active part of follow-up.
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Higuchi T, Holmdahl G, Kaefer M, Koyle M, Wood H, Woodhouse C, Wood D. International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence. Urology 2016; 94:288-310. [DOI: 10.1016/j.urology.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Sexual Function and Fertility of Women with Classic Bladder Exstrophy and Continent Urinary Diversion. J Urol 2016; 196:140-5. [DOI: 10.1016/j.juro.2015.12.099] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2015] [Indexed: 11/21/2022]
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Dy GW, Willihnganz-Lawson KH, Shnorhavorian M, Delaney SS, Amies Oelschlager AM, Merguerian PA, Grady R, Miller JL, Cheng EY. Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience. J Pediatr Urol 2015; 11:213.e1-6. [PMID: 26092092 DOI: 10.1016/j.jpurol.2015.04.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. OBJECTIVES We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. STUDY DESIGN/RESULTS This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. DISCUSSION Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.
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Affiliation(s)
- Geolani W Dy
- Department of Urology, University of Washington, Seattle, WA, USA
| | | | | | - Shani S Delaney
- Department of Obstetrics/Gynecology, University of Washington, Seattle, WA, USA
| | | | - Paul A Merguerian
- Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard Grady
- Department of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
| | - Jane L Miller
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Edith Y Cheng
- Department of Obstetrics/Gynecology, University of Washington, Seattle, WA, USA.
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Park W, Zwink N, Rösch WH, Schmiedeke E, Stein R, Schmidt D, Noeker M, Jenetzky E, Reutter H, Ebert AK. Sexual function in adult patients with classic bladder exstrophy: A multicenter study. J Pediatr Urol 2015; 11:125.e1-6. [PMID: 25986209 DOI: 10.1016/j.jpurol.2015.02.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 02/11/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The bladder exstrophy-epispadias complex (BEEC) comprises a spectrum of congenital anomalies that represents the severe end of urorectal malformations, and has a profound impact on continence as well as sexual and renal functions. OBJECTIVE The relation between severity of BEEC and its associated functional impairments, on one hand, and the resulting restrictions in quality of life and potential psychopathology determine the patients' outcome. It is important for improving further outcome to identify BEEC-related sources of distress in the long term. Genital function and sexuality becomes an important issue for adolescent and adult BEEC individuals. Hence, the present study focused on sexual function and psychological adaption in patients with BEEC. STUDY DESIGN In a multicenter study 52 patients (13 females, 39 males) with classic bladder exstrophy (BE) with their bladders in use were assessed by a self-developed questionnaire about sexual function, and psychosexual and psychosocial outcome. The patients were born between 1948 and 1994 (median age 31 years). RESULTS Twelve of 13 (92%) females and 25 of 39 (64%) males with classic BE had answered the questions on sexual function. Of these, 50% females and 92% males answered that they masturbated. Females had sexual intercourse more frequently. Six (50%) females affirmed dyspareunia whereas only two (8%) males reported pain during erection. Eight (67%) females specified having orgasms. Eighteen (72%) males were able to ejaculate. Two males and none of the females lived in a committed partnership (Figure). Two (15%) females and 13 (33%) males answered all psychosocial questions. The majority of these patients had concerns about satisfactory sexuality and lasting, happy partnerships. A minority of patients of both sexes were willing to answer psychosocial questions. Sexual activity and relationships of many adult BE patients seems to be impaired. Not surprisingly, sexual activity and awareness were different in males and females even in a multi-organ anomaly. DISCUSSION To date, one of the main goals of the medical treatment of BEEC/BE patients is to enable normal sexual life and fertility. However, only a few outcome studies have focused on these issues with contradicting results, most of them not using standardized outcome measures. In accordance with other studies, our female BE patients have dyspareunia and most of our male BE patients were able to ejaculate. But the question of normal force of ejaculation, ejaculated volume, or semen analysis remains unanswered. Despite partial confirmation of previous findings, there is inconsistency referring to the outcome measured by the available studies. This might in part be explained by the fact that, other than this study, most previous studies are the result of single-institution experience. Thus, selection bias in the patient sampling due to different a clinical collective in different hospitals may be the consequence. Furthermore, patients' honesty and self-reflection in answering difficult questions regarding their sexual and cosmetic impairments is questionable. In addition, studies include a wide range of age groups and are connected with this life period. Fears and condition-specific anxieties might change over time. Hence, the strengths of this study are the nationwide and treating physician-independent data acquisition as well as the large sample size of adult patients with a very rare congenital malformation. Unfortunately, more detailed analyses on sexual function and current psychosocial situation, for example correlation of data with clinical symptoms such as continence status, was not possible as data were mainly not answered by patients. CONCLUSION To improve the quality of life of patients with BEEC/BE, treatment and follow-up should emphasize physical but also psychological care in these patients. Physicians should further re-evaluate their preconceptions and should take care of the patients throughout their lives.
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Affiliation(s)
- Weon Park
- Helios Center for Pediatric Surgery, Berlin, Germany
| | - Nadine Zwink
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Germany
| | - Wolfgang H Rösch
- Department of Pediatric Urology, University Medical Center Regensburg, Germany
| | - Eberhard Schmiedeke
- Department of Pediatric Surgery and Urology, Centre for Child and Youth Health, Klinikum Bremen-Mitte, Germany
| | - Raimund Stein
- Division of Pediatric Urology, Department of Urology, University of Mainz, Medical School, Germany
| | - Dominik Schmidt
- Department of Pediatric Surgery, Charité Universitätsmedizin Berlin, Germany
| | - Meinolf Noeker
- Department of Pediatrics, Pediatric Psychology, University of Bonn, Germany
| | - Ekkehart Jenetzky
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Germany; Department for Child and Adolescent Psychiatry, Johannes Gutenberg-University, Germany
| | - Heiko Reutter
- Institute of Human Genetics, University of Bonn, Germany; Department of Neonatology, Childrens' Hospital, University of Bonn, Germany
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Walder R, Mouriquand P, Ruffion A, Rudigoz RC. [Ileocystoplasty, pregnancy and delivery]. ACTA ACUST UNITED AC 2015; 45:380-7. [PMID: 25980901 DOI: 10.1016/j.jgyn.2015.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 02/06/2015] [Accepted: 04/15/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Bladder augmentation is commonly used in neurological and other congenital anomalies of the lower urinary tract. In pregnant women, this reconstructive surgery may affect pregnancy and delivery. The obstetrical consequences of these urological procedures are scarcely reported in literature. MATERIAL AND METHOD Eight pregnancies in 6 pregnant women with ileocystoplasty were followed in our institution between 1998 and 2014. RESULTS Urinary tract infections were the most frequent undesirable record event (5 patients, 7 pregnancies). Obstetrical complications were not more frequent compared to common pregnancies. Delivery was programmed at 37WA. Cesarean section was favoured in this group although natural delivery is possible. CONCLUSION Urological complications were the major problem in this series. The type of delivery depends on the past surgical history and the obstetrical prognosis.
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Affiliation(s)
- R Walder
- Pôle de gynécologie-obstétrique, hôpital de la Croix-Rousse, 103, boulevard de la Croix-Rousse, 69004 Lyon, France.
| | - P Mouriquand
- Service de chirurgie urologique pédiatrique, hôpital Femme-Mère-Enfant, 59, boulevard Pinel, 69500 Bron, France.
| | - A Ruffion
- Service d'urologie, hôpital Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite, France.
| | - R-C Rudigoz
- Pôle de gynécologie-obstétrique, hôpital de la Croix-Rousse, 103, boulevard de la Croix-Rousse, 69004 Lyon, France.
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Singh N, Kriplani A, Mahey R, Kachhawa G. Management of narrow introitus with Fenton's operation followed by successful pregnancy in a woman with repaired bladder exstrophy. J OBSTET GYNAECOL 2014; 35:426. [PMID: 25188695 DOI: 10.3109/01443615.2014.954531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- N Singh
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences , New Delhi , India
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Deans R, Liao LM, Wood D, Woodhouse C, Creighton SM. Sexual function and health-related quality of life in women with classic bladder exstrophy. BJU Int 2014; 115:633-8. [DOI: 10.1111/bju.12811] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Rebecca Deans
- University of New South Wales and Royal Hospital for Women; Sydney Australia
| | - Lih-Mei Liao
- Department of Women's Health; University College London Hospitals; London UK
| | - Dan Wood
- Department of Urology; University College London Hospitals; London UK
| | | | - Sarah M. Creighton
- Department of Women's Health; University College London Hospitals; London UK
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Considering the Psychosocial Aspects of Sexual Health for People with Exstrophy–Epispadias Complex: A Critical Narrative Review. SEXUALITY AND DISABILITY 2014. [DOI: 10.1007/s11195-014-9346-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Naiditch JA, Radhakrishnan J, Chin AC, Cheng E, Yerkes E, Reynolds M. Fate of the uterus in 46XX cloacal exstrophy patients. J Pediatr Surg 2013; 48:2043-6. [PMID: 24094955 DOI: 10.1016/j.jpedsurg.2013.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 02/02/2013] [Accepted: 02/05/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Genetically female cloacal exstrophy (46XX CE) patients develop complications later in life due to their abnormal uterine anatomy, resulting in various invasive gynecologic procedures. Furthermore, they have difficulty becoming pregnant, and if they do conceive, they are unlikely to carry the pregnancy to term. We performed this review to determine the rate of gynecological complications, the fate of the uterus, and the rate of pregnancy in 46XX cloacal exstrophy patients. METHODS All charts for 46XX CE patients treated by us were reviewed following IRB approval. Patient age at last follow-up, surgical management of the uterus, uterine complications, and pregnancies were recorded. RESULTS The charts of all 16 of our 46XX CE patients who survived past the neonatal period were reviewed. Two patients underwent hemi-hysterectomy (HH): 1 for an atretic hemi-uterus at birth, another for abnormal uterine insertion at 3 years. A third patient initially had HH for hydrometrocolpos leading to ureteral and colonic obstruction at 14 years but she required a completion hysterectomy a year later. Four patients underwent total hysterectomy (TH) at the outset: 2 neonates for a diminutive uterus with extreme disparity in the halves, another for uterine prolapse at 1 month of age, and a fourth for hematometrocolpos at 16 years of age. Six patients reached adulthood without requiring gynecologic intervention; one of these six is now being managed at another institution. Two patients are prepubertal and one was lost to follow-up. The only patient in the series who became pregnant miscarried at 11 weeks gestation. CONCLUSION Out of 13 post-pubertal patients 6 have retained the entire uterus and another 2 had a hemi-hysterectomy. One patient who became pregnant miscarried at 11 weeks gestation. We believe it is appropriate to avoid ablative genital surgery as far as possible and for these patients to become pregnant after detailed discussion with physicians experienced in the care of 46XX CE patients.
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Affiliation(s)
- Jessica A Naiditch
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Abstract
Despite advances in the management of exstrophy epispadias complex (EEC), the quality of life of these patients is far from good. The post-operative period is complicated by numerous and variable events - infection, dehiscence, upper tract dilatation with deterioration, fistulas, stone formation and incontinence to name a few of the major complications. Redo surgery for bladder closure, bladder neck reconstruction, epispadias repair and closure of fistulas are frequently required. The current focus is on limiting the frequency and morbidity of the reconstructive procedures. A successful initial closure and early satisfactory cosmetic and functional results are gratifying for the family and the health care team, but this is only the beginning of the lifelong care necessary for bladder exstrophy (BE) patients. In this article, the long-term outcome of various treatment options and the continent procedures in BE has been reviewed, tracing the journey of these patients into adolescence and adulthood.
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Affiliation(s)
- Jai K Mahajan
- Department of Paediatric Surgery, Institute- Advanced Paediatric centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Anusionwu I, Tekes A, Stec AA, Gearhart JP, Wright EJ. Comparison of musculoskeletal anatomic relationships, determined by magnetic resonance imaging, in postpubertal female patients with and without classic bladder exstrophy. BJU Int 2013; 112:E195-200. [PMID: 23360094 DOI: 10.1111/j.1464-410x.2012.11753.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Several studies in the paediatric literature have characterized the pelvic musculoskeletal anatomy of infants and children with bladder exstrophy using MRI and three-dimensional CT. The pelvic floor anatomy of female patients with bladder exstrophy who have undergone somatic growth and puberty is less well described. This study uses MRI to characterize comprehensively the pelvic anatomy of postpubertal females with classic bladder exstrophy by measuring 15 pelvic floor variables previously described in younger children with bladder exstrophy. OBJECTIVE To characterize pelvic musculoskeletal anatomy in postpubertal females with classic bladder exstrophy, and to compare this with females without bladder exstrophy. PATIENTS AND METHODS The authors reviewed the medical records of all females in our institutional review board-approved bladder exstrophy database of 1078 patients and identified those with classic bladder exstrophy who underwent pelvic magnetic resonance imaging (MRI) after the age of 12 years. Indications for MRI included haematuria, adnexal lesion, perineal fistula, non-pelvic cancer staging, abdominal wall hernia and vaginal stenosis. Age- and race-matched female patients without exstrophy who underwent MRI evaluation for similar indications were included for comparison. The MRI protocol included axial, sagittal and coronal T1- and/or T2-weighted imaging. RESULTS The study included 30 patients with a median (range) age of 22.5 (12-55) years at time of MRI. Ten patients had bladder exstrophy while 20 control patients did not. A smaller percentage of levator ani was located in the anterior compartment of the pelvis in patients with bladder exstrophy compared with controls. The iliac wing angle, puborectalis angle, ileococcygeous angle, levator ani width, symphyseal diastasis, erectile body diastasis, posterior bladder neck distance and posterior anal distance was greater in patients with bladder exstrophy than in those without. The ischial angle and obturator internus angle were narrower in patients with bladder exstrophy than in those without, and there was no significant difference between levator ani surface area, sacral anal angle, sacral bladder neck angle and bladder neck erectile body distance between the two patient groups. CONCLUSIONS In postpubertal females with bladder exstrophy, significant deviations from normal pelvimetry exist, including posterior location of the majority of the levator ani muscle, a wider ileococcygeous angle and a wider symphyseal diastasis. These differences are similar to those described in previous comparisons of younger children with bladder exstrophy and control children.
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Affiliation(s)
- Ifeanyi Anusionwu
- James Buchanan Brady Urological Institute, Johns Hopkins Medical Institution, Baltimore, MD 21224, USA.
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Mandal A, Chaudhuri S, Manna SS, Jana SK, Biswas T, Das S. Successful pregnancy outcome in a woman with untreated ectopia vesicae: a case report and review of literature. J Obstet Gynaecol Res 2012; 39:868-71. [PMID: 23279661 DOI: 10.1111/j.1447-0756.2012.02053.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 08/16/2012] [Indexed: 11/30/2022]
Abstract
We report the case of a pregnancy in a 25-year-old woman who was born with ectopia vesicae and split pelvis, but had not undergone any reconstructive or diversion surgery in childhood. Her antenatal period was uneventful and the infant was delivered by cesarean section at term due to breech presentation. The baby had no congenital anomalies. The postoperative period was uneventful and they were discharged from the hospital in a good general condition.
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Affiliation(s)
- Apurba Mandal
- Department of Obstetrics and Gynecology, Nilratan Sircar Medical College, Kolkata, India
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Anusionwu I, Baradaran N, Trock BJ, Stec AA, Gearhart JP, Wright EJ. Is Pelvic Osteotomy Associated with Lower Risk of Pelvic Organ Prolapse in Postpubertal Females with Classic Bladder Exstrophy? J Urol 2012; 188:2343-6. [DOI: 10.1016/j.juro.2012.08.034] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Indexed: 11/24/2022]
Affiliation(s)
- Ifeanyi Anusionwu
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Nima Baradaran
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Bruce J. Trock
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - Andrew A. Stec
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - John P. Gearhart
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
| | - E. James Wright
- James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland, and Department of Urology, Medical University of South Carolina, Charleston, South Carolina (AAS)
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Stec AA, Tekes A, Ertan G, Phillips TM, Novak TE, Solaiyappan M, Huisman TA, Sponseller PD, Gearhart JP. Evaluation of Pelvic Floor Muscular Redistribution After Primary Closure of Classic Bladder Exstrophy by 3-Dimensional Magnetic Resonance Imaging. J Urol 2012; 188:1535-42. [DOI: 10.1016/j.juro.2012.02.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Indexed: 10/28/2022]
Affiliation(s)
- Andrew A. Stec
- Department of Urology, Medical University of South Carolina, Charleston, South Carolina
| | - Aylin Tekes
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Gulhan Ertan
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Timothy M. Phillips
- Department of Urology, San Antonio Military Medical Center, San Antonio, Texas
| | - Tom E. Novak
- Department of Urology, San Antonio Military Medical Center, San Antonio, Texas
| | - Meiyappan Solaiyappan
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Thierry A.G.M. Huisman
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Paul D. Sponseller
- Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - John P. Gearhart
- Division of Pediatric Urology, Department of Urology, The Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Giron AM, Passerotti CC, Nguyen H, Cruz JASD, Srougi M. Bladder exstrophy: reconstructed female patients achieving normal pregnancy and delivering normal babies. Int Braz J Urol 2012; 37:605-10. [PMID: 22099272 DOI: 10.1590/s1677-55382011000500006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2011] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Bladder exstrophy (BE) is an anterior midline defect that causes a series of genitourinary and muscular malformations, which demands surgical intervention for correction. Women with BE are fertile and able to have children without this disease. The purpose of this study is to assess the sexual function and quality of life of women treated for BE. MATERIALS AND METHODS All patients in our institution treated for BE from 1987 to 2007 were recruited to answer a questionnaire about their quality of life and pregnancies. RESULTS Fourteen women were submitted to surgical treatment for BE and had 22 pregnancies during the studied period. From those, 17 pregnancies (77.2%) resulted in healthy babies, while four patients (18.1%) had a spontaneous abortion due to genital prolapse, and there was one case (4.7%) of death due to a pneumopathy one week after delivery. There was also one case (5.8%) of premature birth without greater repercussions. During pregnancy, three patients (21.4%) had urinary tract infections and one patient (7.14%) presented urinary retention. After delivery, three patients (21.4%) presented temporary urinary incontinence; one patient (7.14%) had a vesicocutaneous fistula and seven patients (50%) had genital prolapsed. All patients confirmed to have achieved urinary continence, a regular sexual life and normal pregnancies. All patients got married and pregnant older than the general population. CONCLUSIONS BE is a severe condition that demands medical and family assistance. Nevertheless, it is possible for the bearers of this condition to have a satisfactory and productive lifestyle.
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Affiliation(s)
- Amilcar Martins Giron
- Urology Department, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Deans R, Banks F, Liao LM, Wood D, Woodhouse C, Creighton SM. Reproductive outcomes in women with classic bladder exstrophy: an observational cross-sectional study. Am J Obstet Gynecol 2012; 206:496.e1-6. [PMID: 22537419 DOI: 10.1016/j.ajog.2012.03.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/05/2012] [Accepted: 03/21/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We sought to examine the reproductive outcomes of 52 women with classical bladder exstrophy. STUDY DESIGN This was an observational study with cross-sectional and retrospective arms. RESULTS The average age of the sample was 33 years (range, 17-63). Of those who had tried, 19/38 (66%) had conceived. A total of 57 pregnancies (3 sets of twins) were reported for the 19 patients and resulted in 34/57 live births (56%), 21/57 miscarriages (35%), 1/57 (2%) termination, and 4/57 (7%) stillbirths or neonatal deaths. Four deliveries resulted in major complications including 1 transection of the ureter (4%), 1 fistula formation (4%), and 2 postpartum hemorrhages (8%). There were 2 admissions to intensive care, one for urinary sepsis and another for massive obstetric hemorrhage. CONCLUSION Fertility is impaired in women with bladder exstrophy. Pregnancy is high risk both for the mother and baby. Delivery should be at a tertiary referral obstetric unit with urology cover. In the majority of cases planned cesarean section is the most appropriate mode of delivery.
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Bildircin FD, Ayyildiz HS, Tosun M, Malatyalioglu E, Ariturk E, Sakinci M. Successful pregnancy and delivery in a patient with bladder exstrophy. J Pediatr Adolesc Gynecol 2012; 25:e69-71. [PMID: 22578486 DOI: 10.1016/j.jpag.2012.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 12/27/2011] [Accepted: 02/01/2012] [Indexed: 11/15/2022]
Abstract
Bladder exstrophy (BE) is a rare congenital anomaly. Owing to the advanced reconstructive surgical techniques and effective antibiotics, the incidence of urinary and systemic complications in patients with BE has decreased and the life expectancy has increased. However, this brings along social, sexual, and psychological problems; particularly, successful pregnancy and delivery is extremely rare in females with BE. We present a pregnancy of an 18-year-old female with BE, who has been followed at our university hospital since birth.
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Affiliation(s)
- Fatma Devran Bildircin
- Department of Gynecology and Obstetrics, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
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Nakhal RS, Deans R, Creighton SM, Wood D, Woodhouse CRJ. Genital prolapse in adult women with classical bladder exstrophy. Int Urogynecol J 2012; 23:1201-5. [DOI: 10.1007/s00192-012-1717-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 02/09/2012] [Indexed: 10/28/2022]
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Stec AA, Baradaran N, Gearhart JP. Congenital renal anomalies in patients with classic bladder exstrophy. Urology 2011; 79:207-9. [PMID: 22055685 DOI: 10.1016/j.urology.2011.09.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 09/08/2011] [Accepted: 09/16/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To determine the proportion and type of renal anomalies that occur in children born with classic bladder exstrophy. MATERIAL AND METHODS All patients in a database of 1044 patients with the bladder exstrophy-epispadias-cloacal exstrophy complex were reviewed. Those with classic bladder exstrophy had their complete medical records reviewed and children with radiographic evidence of congenital renal anomalies were identified and characterized. RESULTS A total of 674 patients were identified with classic bladder exstrophy, of whom 462 had renal ultrasounds at the authors' institution. In this population, 13/462 (2.8%) had concomitant renal anomalies. The most common malformation was a duplicated collecting system in 6 patients. Hypoplastic or absent kidneys were present in 3 patients, pelvic kidney in 2, ureteropelvic junction obstruction in 1, and multicystic dysplastic kidney in 1 patient. CONCLUSION Isolated renal anomalies occur at a rate of 2.8% in children born with classic bladder exstrophy. Although uncommon in this rare birth defect, anatomic understanding of the entire genitourinary system is critical for operative planning and long-term follow-up of patients with bladder exstrophy.
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Affiliation(s)
- Andrew A Stec
- Department of Urology, Medical University of South Carolina, Charleston, SC 29425, USA.
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Colorectal anomalies in patients with classic bladder exstrophy. J Pediatr Surg 2011; 46:1790-3. [PMID: 21929991 DOI: 10.1016/j.jpedsurg.2011.03.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 03/15/2011] [Accepted: 03/16/2011] [Indexed: 11/23/2022]
Abstract
AIM This study aims to determine the proportion and type of colorectal anomalies that occur in children born with classic bladder exstrophy (CBE). METHODS All patients in a database of 1044 patients with the bladder exstrophy-epispadias-cloacal exstrophy complex were reviewed. Those with CBE had their complete medical records reviewed. Children noted to have gastrointestinal malformations were identified, and all aspects of their history were extracted. RESULTS A total of 676 patients were identified with CBE, of whom 12 patients were identified who had a concomitant colorectal anomaly. In this population, the proportion of colorectal anomalies is 1.8%. The most common gastrointestinal anomaly was imperforate anus in 8 patients. Two patients had severe rectal stenosis requiring serial dilations, and 2 patients were born with congenital rectal prolapse. CONCLUSIONS Excluding all variants and cloacal patients with exstrophy, isolated colorectal anomalies occur at a rate of 1.8% in children born with CBE, a 72-fold increase compared with the general population. Although uncommon in this rare birth defect, the morbidity is significant and warrants prompt evaluation and treatment of both the genitourinary and colorectal anomalies.
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Ansari MS, Cervellione RM, Gearhart JP. Sexual function and fertility issues in cases of exstrophy epispadias complex. Indian J Urol 2011; 26:595-7. [PMID: 21369401 PMCID: PMC3034077 DOI: 10.4103/0970-1591.74477] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
In patients with EEC, the issues such as sexuality, sexual function and fertility gain more importance once theses patients advance from puberty to adulthood. The aim of this review is to critically examine the available evidence on these issues. A systemic literature search was performed in Medline over the last 25 years using the key words: Exstrophy, sexual function and pregnancy. Search results were limited to studies of patients with exstrophy published in English literature. A total of 1500 publications were found and subsequently screened by title and when appropriate by abstracts. Of these, 40 publications pertinent to the subject were included for the analysis. The publications were supplemented by an additional 15 publications obtained from their bibliographies. The studies were rated according to the guidelines published by the US department of health and human services. Heterosexuality is usually expressed in both the sexes and most of them have adequate sexual function. Urinary diversion in some series seems to result in better ejaculatory hence fertility outcome in male patients. Recent series have shown equally good results with primary reconstruction. Most of the female patients have normal fertility while male patients have significantly low fertility. Most of the male and female patients with EEC have adequate sexual function. Most of the female patients have normal fertility while most of the male patients have significantly low fertility.
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Affiliation(s)
- M S Ansari
- Department of Urology, Division of Pediatric Urology, The James Buschanan Brady Urological Institute, The John Hopkins Hospital, Baltimore, MD, 21287 USA
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Ebert AK, Falkert A, Hofstädter A, Reutter H, Rösch WH. Pregnancy management in women within the bladder–exstrophy–epispadias complex (BEEC) after continent urinary diversion. Arch Gynecol Obstet 2011; 284:1043-6. [DOI: 10.1007/s00404-011-1945-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Accepted: 06/03/2011] [Indexed: 12/01/2022]
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Abstract
Cloacal exstrophy, one of the most severe congenital anomalies compatible with life, occurs in up to 1 in 200,000 lives births. The condition affects nearly every major organ system with severe neurologic, skeletal, gastrointestinal, and genitourinary ramifications. With increased understanding of the anatomy and embryology combined with refinements in prenatal diagnosis and postnatal care, there is now near-universal survival of patients with cloacal exstrophy. Functional and cosmetic outcomes have improved with modifications in surgical technique. However, debate continues regarding the issue of gender identity, and long-term data are still accruing with respect to the best strategy for management. Despite the extensive malformations noted, many patients have gone on to live fruitful lives.
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Affiliation(s)
- Timothy M Phillips
- Department of Urology, Pediatric Urology, Wilford Hall Medical Center, Lackland AFB, TX 78236, USA.
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Abstract
The bladder exstrophy-epispadias-cloacal exstrophy complex is a spectrum of genitourinary malformations requiring multiple major reconstructive operations on each affected child. The need for surgical correction in this condition often continues through adolescence and into adulthood. Experience in caring for individuals with exstrophy-epispadias has taught us a great deal about the long-term functional, psychological, and social outcomes involved. Children undergoing repeated hospital admissions and extensive multiple operations have the potential for long-term adjustment problems with incontinence, ambulatory difficulties, psychological disturbance, sexual dysfunction, and issues surrounding self-esteem and social integration. By examining relevant published works from the world literature over the last 20 years, in this article we address with each of these areas and offers some insight into the ongoing issues.
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Affiliation(s)
- Andrew D Baird
- Department of Pediatric Surgery/Urology, Alder Hey Children's Hospital, NHS Foundation Trust, Liverpool, United Kingdom.
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Bartelink LR, Feitz WF, Kluivers KB, Withagen MIJ, Vierhout ME. Surgical treatment of uterine prolapse in women with bladder exstrophy: report of two cases with modified Prolift procedure. Int Urogynecol J 2011; 22:889-91. [PMID: 21360218 PMCID: PMC3112350 DOI: 10.1007/s00192-011-1368-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 01/22/2011] [Indexed: 11/01/2022]
Abstract
The incidence of pelvic organ prolapse is 18% in women with bladder exstrophy. A vaginal technique to correct the prolapse may be preferable in these women with multiple abdominal operations in their histories. We have performed a modified Prolift procedure for the repair of severe uterine prolapse in two young women. A review of the literature is presented.
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Affiliation(s)
- Lidewij R Bartelink
- 791 Department of Obstetrics and Gynaecology, UMC St Radboud Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Ansari MS, Gearhart JP, Cervellione RM, Sponseller PD. The application of pelvic osteotomy in adult female patients with exstrophy: applications and outcomes. BJU Int 2011; 108:908-12. [PMID: 21314813 DOI: 10.1111/j.1464-410x.2010.10018.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE • To apply the technique of pelvic osteotomy to a select group of adult female patients with exstrophy, in view of the low complication rate and acceptable success rate of the technique. PATIENTS AND METHODS • We applied this technique as an adjunct to uterovaginal suspension and abdominal wall repair after our prior success in treating patients with extreme pelvic diastasis. • Bilateral innominate (transverse) and vertical iliac osteotomies were done from an anterior approach and an external fixator was placed. The fixator and pelvic bones were gradually cranked together over a period of 2-3 weeks until the diastasis was less than 4 cm. • Then sacrocolpopexy was performed with revision of the abdominal wall and revision genitoplasty along with the placement of an intrasymphyseal titanium plate. RESULTS • Six patients presented with uterine/vaginal prolapse and concerns about the appearance of their abdominal wall and genitalia. Three patients had undergone uterine suspension before and one patient had had five prior attempts at suspension, which failed. The mean (range) age was 22.3 (18-26) years. • All the patients underwent staged reduction of pubic diastasis and sacrocolpopexy along with revision of the abdominal wall and in four cases revision genitoplasty was also performed. The mean (range) diastasis was 12.8 (8-18) cm and 2.8 (3-4) cm before and after staged reduction respectively. • Complications included transient femoral nerve palsy (two) and foot drop secondary to sciatic nerve stretch (one), which resolved with time. The symphyseal plate needed to be removed in three patients: secondary to persistent pain at the site (one), persistent discharge from the lower abdominal wound (one) and erosion into the anterior wall of the vagina (one). • At a mean (range) follow-up of 60.7 (2-137) months the cosmetic and functional outcome of the abdominal wall reconstruction and genitoplasty was good with all the patients being satisfied. Five patients are currently sexually active and none has had a recurrence of their prolapse. None has become pregnant yet. CONCLUSIONS • Although the morbidity of this procedure in the adult is not insignificant, it is a valuable adjunct to pelvic floor reconstruction in young women of childbearing age even in those who have had prior suspension procedures. • In addition, it allows the movement of lateral previously unoperated skin into the midline, allowing scar and skin replacement with healthier more vascularized tissue.
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Affiliation(s)
- Mohd S Ansari
- Sanjay Gandhi Postgraduate Institute of Medical Sciences - Urology and Renal Transplantation, Lucknow, India.
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Castagnetti M, Berrettini A, Zhapa E, Rigamonti W, Zattoni F. Issues with the external and internal genitalia in postpubertal females born with classic bladder exstrophy: a surgical series. J Pediatr Adolesc Gynecol 2011; 24:48-52. [PMID: 20869278 DOI: 10.1016/j.jpag.2010.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 05/31/2010] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To report our experience with surgical management of gynecological issues in postpubertal female patients born with classic bladder exstrophy (BE). DESIGN Retrospective review of clinical charts. SETTING Tertiary pediatric urology unit. PARTICIPANTS 16 postpubertal female BE patients. INTERVENTIONS Cosmetic surgery to the external genitalia, widening of vaginal introitus, and treatment of pelvic organ prolapse. MAIN OUTCOME MEASURES patient satisfaction and additional gynecological problems during follow-up. RESULTS Eight cases (14-43 years old) underwent cosmetic procedures. All resulted in improved cosmesis, but one case complained of reduced erogenous sensitivity after clitoridoplasty. Five cases (17-20 years old) underwent widening of the vaginal introitus. The modification was as short as possible to avoid any foreshortening of the dorsal vaginal wall. Three cases 33-45 years old presented with pelvic organ prolapse. All were sexually active. One had already given birth. All the three had previously been submitted elsewhere to a posterior vaginal cutback and one to hysterectomy. Two are still awaiting further treatment due to recurrent prolapse. CONCLUSION Female BE patients can seek advice to improve the appearance of the external genitalia at any ages. Clitoridoplasty should be considered carefully, because it may harm erogenous sensitivity. Problems with the vaginal introitus typically present at around 20 years of age, probably when BE patients become sexually active. Opening too widely the introitus can cause a foreshortening of the posterior vaginal wall, predisposing to pelvic organ prolapse. Treatment of pelvic organ prolapse is difficult.
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Affiliation(s)
- Marco Castagnetti
- Section of Paediatric Urology, Department of Oncological and Surgical Sciences, University Hospital of Padova, Padua, Italy.
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