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Harris TGW, Khandge P, Wu WJ, Leto Barone AA, Manyevitch R, Sholklapper T, Bivalacqua TJ, Burnett AL, Redett RJ, Gearhart JP. Sexual health outcomes after penile reconstruction in the exstrophy-epispadias complex. J Pediatr Urol 2022; 18:747-755. [PMID: 35277349 DOI: 10.1016/j.jpurol.2022.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/01/2022] [Accepted: 02/15/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The penis in exstrophy-epispadias complex (EEC) males is diminutive and patients are often dissatisfied with appearance and length. Due to an increased risk of psychosexual dysfunction, patients desire penile reconstruction. Surgical options include penile lengthening with a full thickness skin graft (SG) or tissue expansion (TE) used for cutaneous coverage or neophalloplasty using a radial forearm free flap or pedicled antero-lateral thigh flap. OBJECTIVE The aim of this study was to assess sexual health outcomes before and after SG or TE assisted lengthening and neophalloplasty. STUDY DESIGN Patients aged 18 years or older, who underwent penile reconstruction were identified using an institutionally approved database of EEC patients. Patient perception of penile appearance, sexual function, their frequency of sexual intercourse and overall satisfaction with reconstruction were assessed using a survey consisting of validated and non-validated questions. RESULTS Eighty-three patients underwent penile reconstruction, 57 met the inclusion criteria and 28 responded to the survey (49.1%). Fourteen were reconstructed using a SG, 6 with TE and 8 underwent neophalloplasty. Median time from reconstruction to survey completion was 4.4 years (range 1.2-13.2) Four patients had a diagnosis of epispadias, 1 cloacal exstrophy, 23 classic bladder exstrophy (CBE). Before reconstruction patients were dissatisfied with their penile appearance with a median penile perception score of 4.5 compared to 7.5 after surgery (p = 0.0034, Fig. 1). Twenty-three patients were dissatisfied with penile length, with 18 reporting an improvement following reconstruction (p = 0.0002). There was no correlation in time after reconstruction with PPS or satisfaction with penile length (p = 0.86 and p = 0.55, respectively). Overall, the median Sexual Health Inventory for Men (SHIM) score was 19, with no difference between the surgical groups (p = 0.33). Nine patients engaged in sexual intercourse before reconstruction which increased to 17 afterwards. CONCLUSION All three surgical methods improved patient perception of penile appearance and length. Patients who previously never engaged in intercourse were able to and those who had were doing so more frequently, of which a greater proportion were in a relationship. The results are encouraging though must be interpreted with caution due to the small number of responders and possible risk of bias. These findings provide vital information for future patients and routine psychological assessment will help manage patient expectations to improve satisfaction.
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Affiliation(s)
- Thomas G W Harris
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Preeya Khandge
- Jeffs Division of Pediatric Urology, Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wayland J Wu
- Jeffs Division of Pediatric Urology, Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angelo A Leto Barone
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Roni Manyevitch
- Jeffs Division of Pediatric Urology, Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tamir Sholklapper
- Jeffs Division of Pediatric Urology, Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Trinity J Bivalacqua
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Redett
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Gearhart
- Jeffs Division of Pediatric Urology, Brady Urological Institute, Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Harris KT, Villela NA, Alam R, Wu WJ, Artigas P, DiCarlo HN, Gearhart JP. The exstrophy experience: A national survey assessing urinary continence, bladder management, and oncologic outcomes in adults. J Pediatr Urol 2022:S1477-5131(22)00525-3. [PMID: 36456414 DOI: 10.1016/j.jpurol.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND OBJECTIVE The bladder exstrophy-epispadias complex (BEEC) is a rare spectrum of congenital genitourinary malformations with an incidence of 1:10,000 to 1:50,000. Advances in reconstructive surgical techniques have improved clinical outcomes, but there is a paucity in data about disease sequela in adulthood. This is the largest survey to date in the United States exploring the urinary continence, bladder management, and oncologic outcomes in adults with BEEC. METHODS Respondents were over the age of 18 with a diagnosis of bladder exstrophy, cloacal exstrophy, or epispadias. They were treated at the authors' institution, included in the Association for the Bladder Exstrophy Community (A-BE-C) mailing list, and/or engaged in A-BE-C social media. A survey was created using uniquely designed questions and questionnaires. Survey responses between May 2020 and July 2020 were processed using Research Electronic Data Capture (REDCap). Quantitative and qualitative statistics were used to analyze the data with significance at p < 0.05. RESULTS A total of 165 patients completed the survey. The median age was 31.5 years (IQR 25.9-45.9). Many patients considered themselves continent of urine, with a median satisfaction score of 74 (IQR 50-97) on a scale from 0 (consider themselves to be completely incontinent) to 100 (consider themselves to be completely continent). There was less leakage among those with a continent urinary diversion compared to those who void or catheterize per urethra (p = 0.003). Patients with intestinal-urinary tract reconstruction, such as augmentation cystoplasty or neobladder creation, were more likely to perform bladder irrigations (p = 0.03). Patients with continent channels were more likely to report UTI than all other forms of bladder management (89.0% vs. 66.2%, p = 0.003). Three (1.9%) patients were diagnosed with bladder cancer. A small portion of patients (27.2%) were given bladder cancer surveillance recommendations by a physician. DISCUSSION Most patients achieved a satisfactory level of urinary continence, with the highest continence rates in those with a continent urinary diversion. Those with intestinal-urinary tract reconstruction were more likely to perform bladder irrigations, perhaps to avoid complications from intestinal mucous production. The rates of self-reported UTI and were higher in patients with continent channels, but recurrent UTIs were not affected by the type of genitourinary reconstruction. Bladder cancer exists in this population, highlighting the need for long-term follow-up. CONCLUSION Most BEEC patients achieve a satisfactory level of urinary continence, with the best outcomes in those with a continent urinary diversion. This population requires long-term follow-up with a transitional urologist to ensure adequate oncologic care.
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Canalichio KL, Ahn J, Hwang C, Amies AM, Merguerian P, Shnorhavorian M. Long-term urological and gynecological outcomes following complete primary repair in females with bladder exstrophy. J Pediatr Urol 2021; 17:608.e1-608.e8. [PMID: 34391690 DOI: 10.1016/j.jpurol.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 06/30/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Long-term continence outcomes in patients undergoing complete primary repair of exstrophy (CPRE) have shown that a subset of patients do not achieve continence until after puberty. We aim to update the continence outcomes as well as describe gynecological outcomes for females having undergone CPRE. MATERIALS AND METHODS This was a retrospective review between 1989 and 2019 at a single institution. Inclusion criteria were females with classic bladder exstrophy who underwent CPRE. Exclusion criteria were variant diagnoses and age <4 years. Continence was defined as dry for ≥3 h (volitional voiding or clean intermittent catheterization (CIC)). Partial continence was defined as minor stress incontinence or enuresis. Vaginal stenosis was evaluated in post-pubertal patients. RESULTS Eighteen patients met inclusion criteria. Median age at last follow-up was 15.9 years (IQR 13.1, 18.4). All patients underwent primary closure <30 days of life (n = 18). Subsequent procedures included bladder augmentation (n = 4), continent catheterizable channel (n = 7), bladder neck injections (n = 12) and bladder neck reconstruction (n = 12). Continence and partial continence were achieved in 6/18 (33.3%) and 9/18 (50.0%), respectively, with mean 3.2 ± 2.5 continence procedures at 9.6 years (IQR 7.3, 15.2). Volitional voiding was seen in 11/18 (61.1%) and 7/18 (38.9%) performed CIC, with no significant difference in continence. Mean bladder capacity was 199 ml ± 96 versus 90 ml ± 29 in the volitional voiding versus CIC group (P = 0.0047). Eleven women with median age of 18.0 years (IQR 15.2, 21.4) had recorded menarche: 6/11 (54.5%) patients reported painful/irregular menses, controlled with hormonal therapy. Six of 11 (54.5%) women had vaginal stenosis managed with vaginal dilation (n = 2) or vaginoplasty (n = 4). Three (27.3%) reported tampon use and penetrative intercourse. CONCLUSION Overall, the majority of women who have undergone CPRE achieved complete or partial continence, though most required additional procedures and time to attain it. Additionally, volitional voiding was achievable. Bladder capacity was significantly lower in patients dependent on CIC. Most required medical or surgical interventions for gynecologic concerns post menarche. This study underscores the unique needs of girls and young women with bladder exstrophy and further supports the importance of close long-term urologic and gynecologic management throughout development.
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Affiliation(s)
- Katie L Canalichio
- University of Louisville, 501 East Broadway Suite 270, Louisville, KY, 40202, USA; Norton Healthcare, 4123 Dutchmans Lane Suite 102, Louisville, KY, 40207, USA.
| | - Jennifer Ahn
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Catalina Hwang
- University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Anne-Marie Amies
- University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Paul Merguerian
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Margarett Shnorhavorian
- Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA; University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
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Ben Ahmed Y, Boulma R, Landolsi M, Boukesra T, Boussetta R, Hamza M, Chibani I, Guitouni A, Charieg A, Nouira F, Jlidi S. Quality of life of children operated for bladder exstrophy. Prog Urol 2021; 32:146-154. [PMID: 34244063 DOI: 10.1016/j.purol.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 05/13/2021] [Accepted: 05/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Bladder exstrophy is a rare malformation with functional and psychological issues affecting children's quality of life. This study aims to evaluate the urinary continence and the quality of life of patients operated for bladder exstrophy in our institution. METHODS This is a retrospective study including fifteen patients operated for bladder exstrophy between 1995 and 2015. All patients underwent a physical examination and an interview with a psychiatrist. Urinary continence was evaluated by dryness periods. Quality of life was evaluated by the QoL SF-36 scale. RESULTS All patients underwent primary early bladder closure. Posterior osteotomy was performed initially in 6 cases, and during the redo surgery in 7 cases. Leakage was recorded in 4 cases, fistula in 9 patients. Twelve patients had one or more redo surgery. Final bladder closure success rate was of 80%. Additional continence surgical procedures were performed by a Young Dees technique in 8 cases and with bladder enlargement associated with Mitrofanoff continent derivation in 5 cases. Only two patients over fifteen did not use diapers. All the items of QoL score according SF-36 were under the normal value (75%) except physical functioning and physical limitation. These scores go worst with age. Scores were better for continent boys in both physical and psychological items, but the difference was not significant However, significant difference was observed between boys having less than 3 surgeries and those having more than three procedures. Psychological and social scores were better for girls than for boys and differences were significant. CONCLUSIONS The risk of urinary incontinence is high in children managed for bladder exstrophy. Boys are more affected than girls with subsequent psychological and social repercussions. In our study, quality of life depends more on number of surgery than continence results. Psychological problems should be screened early for accurate treatment. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Y Ben Ahmed
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - R Boulma
- Urology unit surgery department FSI Hospital Tunis, Tunisia.
| | - M Landolsi
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - T Boukesra
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - R Boussetta
- Paediatric orthopedy department Children Hospital Bachir Hamza, Tunis, Tunisia
| | - M Hamza
- Pedo-psychiatric department, Marsa Hospital, Tunisia
| | - I Chibani
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - A Guitouni
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - A Charieg
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - F Nouira
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
| | - S Jlidi
- Paediatric surgery department, Children Hospital Bachir Hamza, Tunis, Tunisia
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Canalichio KL, Ahn J, Artigas P, Amies Oelschlager AE, Rowe C, Merguerian P, Shnorhavorian M. Patient-reported outcomes in adult females with bladder exstrophy: A study of long-term sexual, reproductive and urinary outcomes using social media. J Pediatr Urol 2020; 16:567.e1-7. [PMID: 32698983 DOI: 10.1016/j.jpurol.2020.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Limited data exist on patient-reported outcomes in adults with bladder exstrophy (BE). We partnered with the Association for the Bladder Exstrophy Community (A-BE-C) using social media to survey adult females with BE. The aim of the study was to assess long-term patient-reported sexual, reproductive and continence outcomes. MATERIALS AND METHODS Between December 3, 2018 and January 18, 2019, A-BE-C promoted an anonymous survey of adult females with BE on social media. The survey included the Female Sexual Function Index (FSFI) and International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) in addition to questions on demographics, reproductive and gynecological outcomes. RESULTS A total of 130 women with a median age of 30 years (IQR 26, 41) completed the survey. The majority of women were born in the United States (N = 86, 66.2%). Women reported a median of 10 (IQR 5, 17) surgeries performed for their condition. The mean ICIQ-SF score was 6.2 ± 6.2 (moderate). Only 19.2% (N = 25) reported volitionally voiding and the majority reported intermittent catheterization through a catheterizeable channel or the urethra (Summary Table). The mean FSFI score was (20.1 ± 9.0), indicating risk for sexual dysfunction (FSFI < 26.55). Of the respondents, 28.5% (N = 37) were treated for uterine prolapse, 56.9% (N = 74) required surgery in order to use tampons or have penetrative intercourse, and over half (55.4%) reported some degree of dissatisfaction with the appearance of their external genitalia. Forty-seven women (36.2%) reported pregnancies, and of these 32 (68.1%) reported complications with pregnancy. Outcomes of 100 pregnancies included miscarriage/abortion (41.0%), preterm vaginal (3.0%), preterm cesarean section (19.0%), term vaginal (2.0%), and term cesarean section (35.0%). Seven (15.2%) women identified having children with a medical diagnosis, none of which included BE. Infertility was reported in 17.3% (22/127) women. Women identified sexual function, fertility, and body image as areas that need future research. CONCLUSION This is the largest study of patient-reported outcomes in females with BE achieved through partnership with an advocacy group and social media. We found that continence and sexual function were both impaired in adult women with BE. Respondents reported poor obstetric and gynecological outcomes including infertility, uterine prolapse, vaginal stenosis, and need for multiple surgeries. BE surgeons, through multi-institutional collaboration, should continue to reassess surgical techniques at initial repair to better address these functional issues. These results should be a part of counseling parents of newborns with BE.
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Abstract
PURPOSE Transition in urology is defined by the process that allows an adolescent or a young adult with a congenital or acquired urogenital anomaly to assume increasing responsibility for their own health care and to become the primary decision maker in their care. METHODS A review of the literature regarding transitional care for lifelong urologic congenital anomalies was performed with the aim of reporting expert opinion when data are non-existent. This review focuses on special considerations for adolescents and young adults with spina bifida, bladder exstrophy, anorectal malformations and differences of sexual development. RESULTS Urologic goals during the transition from childhood to adulthood continue to include attention to the preservation of renal function and optimization of lower urinary tract function. Additional concerns include care to decrease long-term surgical complications (especially after augmentation cystoplasty), to monitor for malignancy, to prepare for sex activity and fertility, and to help the adult patient in decision making. Transition aims to maximize quality of life and independence by ensuring uninterrupted appropriate care through a multidisciplinary approach which varies by geographical location and healthcare setting. Barriers include patient and family factors as well as provider and system related factors. A dedicated team is an important element of successful transition.
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Truong H, Salib A, Rowe CK. The Use of Social Media in Pediatric Urology-Forging New Paths or Crossing Boundaries? Curr Urol Rep 2019; 20:72. [PMID: 31620926 DOI: 10.1007/s11934-019-0928-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW There has been a remarkable change in how people connect, access, and share professional and medical information over social media. This perspective article describes opportunities, potential pitfalls, and guidelines for social media use by pediatric urology providers. RECENT FINDINGS Pediatric urologists have effectively used social media to connect and share expertise, augment scientific conference participation, promote themselves and their research, disseminate guidelines and best practices, participate in virtual journal clubs, and engage with patients and their families. Information shared over social media is not protected by copyright law, not confidential, not regulated, permanent, and subjected to public domain and scrutiny. Despite these potential pitfalls, social media is a useful tool if best practices are observed and online communication adheres to professional guidelines and organizational policy. Social media use in healthcare is here to stay and pediatric urologists have online visibility whether or not they choose to actively participate. Despite new legal, ethical, and professional considerations that social media introduces, a well-executed social media presence provides pediatric urologists a wealth of new opportunities for networking, research, and disseminating high-quality medical information online.
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Affiliation(s)
- Hong Truong
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1025 Walnut St, Suite 1112, Philadelphia, PA, 19107, USA. .,Division of Pediatric Urology, Connecticut Children's Medical Center, Hartford, CT, USA.
| | - Andrew Salib
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1025 Walnut St, Suite 1112, Philadelphia, PA, 19107, USA.,Division of Pediatric Urology, Connecticut Children's Medical Center, Hartford, CT, USA
| | - Courtney K Rowe
- Department of Urology, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, 1025 Walnut St, Suite 1112, Philadelphia, PA, 19107, USA.,Division of Pediatric Urology, Connecticut Children's Medical Center, Hartford, CT, USA
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Szymanski K. Letter to the editor regarding: Rowe et al. Using social media for patient-reported outcomes: a study of genital appearance and sexual function in adult bladder exstrophy patients. J Pediatr Urol 2018; 14:483-484. [PMID: 30309791 DOI: 10.1016/j.jpurol.2018.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Affiliation(s)
- K Szymanski
- Riley Hospital for Children, Division of Pediatric Urology, Indiana University School of Medicine, 705 Riley Hospital Dr., Suite 4230, USA.
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