Scottish Firefighters Occupational Cancer and Disease Mortality Rates: 2000-2020

BACKGROUND

Increased mortality from cancers and other diseases has been reported in USA, Canadian, and Nordic firefighters. However, UK firefighters are understudied.

AIMS

To determine whether UK firefighters suffer increased mortality from cancers and other diseases when compared with the general population.

METHODS

Mortality from cancer and other diseases in Scottish male firefighters between 2000 and 2020 was compared with the general Scottish male population and expressed as standardized mortality ratios (SMRs) (with 95% confidence intervals, CI).

RESULTS

Significant overall excess cancer mortality was found for Scottish firefighters compared with the general population (SMR 1.61, CI 1.42-1.81). Scottish firefighters were nearly three times more likely to die of malignant neoplasms (unspecified sites) (SMR 2.71, CI 1.71-4.00). Excess cancer mortality was also found for several site-specific cancers, including prostate (SMR 3.80, CI 2.56-5.29), myeloid leukaemia (SMR 3.17, CI 1.44-5.58), oesophagus (SMR 2.42, CI 1.69-3.29) and urinary system (kidney and bladder) (SMR 1.94, CI 1.16-2.91). Mortality from neoplasms of unknown behaviour was over six times greater in Scottish firefighters (SMR 6.37, CI 2.29-12.49). Additionally, significantly higher mortality was found for: acute ischaemic heart diseases (SMR 5.27, CI 1.90-10.33), stroke (SMR 2.69, CI 1.46-4.28), interstitial pulmonary diseases (SMR 3.04, CI 1.45-5.22), renal failure (SMR 3.28, CI 1.18-6.44) and musculoskeletal system diseases (SMR 5.64, CI 1.06-13.83).

CONCLUSIONS

UK firefighters suffer significant excess mortality from cancer and other diseases when compared with the general population. Preventative health monitoring and presumptive legislation are urgently required to protect UK firefighters' health.

Culture and awareness of occupational health risks amongst UK firefighters

Firefighters are exposed to toxic chemicals not only from the fire incidents they attend, but also from their contaminated station and/or personal protective equipment (PPE). Little is currently known about firefighters' awareness, attitudes, and behaviours towards contaminants which was assessed in the UK firefighter contamination survey. Results revealed that lack of training on fire effluents and their health outcomes are strongly associated with increased fire smoke/contaminant exposure. Notably, untrained firefighters were at least twice as likely to: never clean personal protective equipment (PPE) (Crude Odds Ratio, OR 2.0, 1.5-2.7), infrequently send their PPE for professional cleaning (OR 2.0, 1.6-2.4), remain in the workwear (t-shirt etc.) worn while attending a fire incident (OR up to 3.6, 2.3-5.6), and indicate that cleaning at fire stations is not taken seriously (OR 2.4, 2.2-2.6). Firefighters personally viewing contamination as a "badge of honour" (BoH) were at least twice as likely to: remain in contaminated PPE after fire incidents (OR 2.3, 1.4-3.9), eat with sooty hands (OR 2.2, 1.9-2.5), notice soot in the nose/throat (OR 3.7, 2.7-5.2), and smell fire smoke on the body for more than a day after incidents (OR 2.0, 1.6-2.4). They were also more likely to indicate that cleaning at fire stations is not taken seriously (OR 2.5, 2.2-2.9) and that fire stations smell of smoke always/most of the time (OR 2.3, 2.0-2.6). Strong links were also found between belief in the BoH and never cleaning PPE (OR 1.9, 1.4-2.7), and eating while wearing contaminated PPE (OR 1.8, 1.5-2.2).

Contamination of UK firefighters personal protective equipment and workplaces

Firefighters' personal protective equipment (PPE) is a potential source of chronic exposure to toxic contaminants commonly released from fires. These contaminants have also been found in fire stations. However, little research characterises the routes via which fire contaminants travel back to fire stations. The UK Firefighter Contamination Survey provides information on firefighters' PPE provision, decontamination, and storage practices. All serving UK firefighters were eligible to take part in the survey, which comprised 64 questions. A total of 10,649 responses were included for analysis, accounting for roughly 24% of the UK's firefighting workforce. Results revealed that most firefighters (84%) de-robe contaminated PPE/workwear after re-entering the appliance cab. There was a significant decreasing tendency to send PPE for cleaning after every incident with increasing seniority of role, length of service, and fire attendance frequency. Around one third of firefighters cleaned PPE after every incident. A number of issues were linked to external professional cleaning services, e.g. shrinkage, fit, turn-around time, and stock of reserve/pooled PPE. PPE storage was found to be a potential source of cross contamination, with almost half of firefighters (45%) indicating clean and dirty PPE is not stored separately. More than half of firefighters (57%) stored fire gloves (an item sent for professional decontamination by only 19% of firefighters, and never cleaned by 20%) within other items of PPE such as helmets, boots and tunic/trouser pockets. The survey's results can be used to target gaps in decontamination measures within UK Fire and Rescue Services.

Cancer incidence amongst UK firefighters

Firefighters suffer an increased risk of cancer from exposures to chemicals released from fires. Our earlier research has found that fire toxicants not only remain on firefighters' PPE, but are also tracked back to fire stations. The UK Firefighter Contamination Survey assesses firefighters' risk of developing cancer due to occupational exposure to fire toxins. Over 4% of surveyed firefighters were found to have a cancer diagnosis, with the age-specific cancer rate up to 323% higher (35-39 year olds) than that of the general population. Firefighters who had served ≥ 15 years were 1.7 times more likely to develop cancer than those who had served less time. Firefighters were at least twice as likely to be diagnosed with cancer if they noticed soot in their nose/throat (odds ratio (OR) = 2.0, 1.1-3.5), or remained in their PPE for more than four hours after attending a fire incident (OR = 2.3, 1.1-5.2). Also associated with an increased likelihood of cancer was: eating while wearing PPE (OR = 1.8, 1.2-2.7); failing to store clean/dirty PPE separately (OR = 1.3, 1.0-1.7); working in a station that smells of fire (OR = 1.3, 1.0-1.8) or not having designated (separated) clean and dirty areas (OR = 1.4, 1.1-1.7); using an on-site washing machine to launder fire hoods (OR = 1.3, 1.0-1.7); feeling that cleaning is not taken seriously at work (OR = 1.5, 1.2-2.0).

Burning behaviour of rainscreen façades

Four reduced-height (5 m) BS 8414-1 façade flammability tests were conducted, three having mineral-filled aluminium composite material (ACM-A2) with polyisocyanurate (PIR) and phenolic (PF) foam and stone wool (SW) insulation, the fourth having polyethylene-filled ACM (ACM-PE) with PIR insulation. Each façade was constructed from a commercial façade engineer's design, and built by practising façade installers. The ACM-PE/PIR façade burnt so ferociously it was extinguished after 13.5 min, for safety. The three ACM-A2 cladding panels lost their structural integrity, and melted away from the test wall, whereupon around 40% of both the combustible PIR and PF insulation burnt and contributed to the fire spread. This demonstrates why all façade products must be non-combustible, not just the outer panels. For the three ACM-A2 tests, while the temperature in front of the cavity was independent of the insulation, the temperatures within it varied greatly, depending on the insulation. The system using PF/A2 allowed fire to break through to the cavity first, as seen by a sharp increase in temperature after 17 min. For PIR/A2, the temperature increased sharply at 22 minutes, as the panel started to fall away from the wall. For SW/A2, no rapid temperature rise was observed.

Smoke toxicity of rainscreen façades

The toxic smoke production of four rainscreen façade systems were compared during large-scale fire performance testing on a reduced height BS 8414 test wall. Systems comprising 'non-combustible' aluminium composite material (ACM) with polyisocyanurate (PIR), phenolic foam (PF) and stone wool (SW) insulation, and polyethylene-filled ACM with PIR insulation were tested. Smoke toxicity was measured by sampling gases at two points - the exhaust duct of the main test room and an additional 'kitchen vent', which connects the rainscreen cavity to an occupied area. Although the toxicity of the smoke was similar for the three insulation products with non-combustible ACM, the toxicity of the smoke flowing from the burning cavity through the kitchen vent was greater by factors of 40 and 17 for PIR and PF insulation respectively, when compared to SW. Occupants sheltering in a room connected to the vent are predicted to collapse, and then inhale a lethal concentration of asphyxiant gases. This is the first report quantifying fire conditions within the cavity and assessing smoke toxicity within a rainscreen façade cavity.

Stability of Isocyanates Sampled in Fire Smokes

Inhalation of airborne isocyanates is associated with acute asthma attacks and inflammation in the respiratory tract as well as cancer. These highly reactive compounds are used as monomers in various applications such as foams for insulation materials and upholstery furniture and are therefore commonly found in fire smoke from insulation materials, such as rigid polyisocyanurate (PIR) foams. Consequently, there is an increasing concern regarding the potential adverse health effects they may cause during this type of exposure.The aim of this study was to investigate the stability of generated isocyanates from aerobic pyrolysis of PIR after sampling in the derivatization solution as well as after sample preparation to establish the optimal storage conditions and rate of degradation. Both airborne and particle-bound isocyanates were collected, using dibutylamine as derivatization agent in a midget impinger and impregnated filter after the impinger. The rapid degradation of the generated isocyanates after sampling emphasizes the need for a prompt sample preparation and analysis, in particular for the collected mono-isocyanates, as the concentration decreased by 50% within 4-8 h.

Environmental contamination following the Grenfell Tower fire

The Grenfell Tower fire in central London, started within a flat, engulfed the whole 24 storey building in flames, killed 72 people and spread toxic effluent via the plume and particulate deposits. Soil samples from 6 locations up to 1,2 km from the Tower, together with semi-burnt fire debris and char samples, were collected 1 and 6 months after the fire. Additionally, dust samples and condensates were collected from a flat 160 m away from the Tower after 17 months. Samples were analysed for common potentially toxic components of fire effluents and synthetic vitreous fibres. Samples collected within 140 m of the Tower showed, amongst other toxicants, polychlorinated dibenzo-p-dioxin concentrations 60 times greater than UK urban reference soil levels; benzene levels were 40 times greater; levels of 6 key polycyclic aromatic hydrocarbons (PAHs) were approximately 160 times greater. PAHs levels are approximately 20 times greater than those reported from nearby Hyde Park before the fire. To explain the presence of these pyrogenic contaminants char and partially burnt debris were also collected and analysed. Benzene, PAHs, isocyanates and phosphorus flame retardants were found. Hydrogen cyanide and synthetic vitreous fibres were present in both soil and debris. Particulate and pyrogenic contamination in the immediate vicinity is clearly evident, and may have leached out of fire debris, char and dust. Further analysis of the area around the Tower is necessary to understand potential health risks.

Robot-assisted laparoscopic midureteral stricture repair and percutaneous stent placement in an infant

Mid-ureteral strictures in infants are a rare cause of hydronephrosis. In this surgical technique video we demonstrate a repair of a mid-ureteral stricture using a robot- assisted laparoscopic approach to mobilize and excise the stricture using the assistance of a hitch stitch as well as placement of a percutaneous stent. This technique was easily performed and successful for this patient.

Fire behaviour of modern façade materials - Understanding the Grenfell Tower fire

The 2017 Grenfell Tower fire spread rapidly around the combustible façade system on the outside of the building, killing 72 people. We used a range of micro- and bench-scale methods to understand the fire behaviour of different types of façade product, including those used on the Tower, in order to explain the speed, ferocity and lethality of the fire. Compared to the least flammable panels, polyethylene-aluminium composites showed 55x greater peak heat release rates (pHRR) and 70x greater total heat release (THR), while widely-used high-pressure laminate panels showed 25x greater pHRR and 115x greater THR. Compared to the least combustible insulation products, polyisocyanurate foam showed 16x greater pHRR and 35x greater THR, while phenolic foam showed 9x greater pHRR and 48x greater THR. A few burning drips of polyethylene from the panelling are enough to ignite the foam insulation, providing a novel explanation for rapid flame-spread within the facade. Smoke from polyisocyanurates was 15x, and phenolics 5x more toxic than from mineral wool insulation. 1 kg of burning polyisocyanurate insulation is sufficient to fill a 50m³ room with an incapacitating and ultimately lethal effluent. Simple, additive models are proposed, which provide the same rank order as BS8414 large-scale regulatory tests.

Flame retardants in UK furniture increase smoke toxicity more than they reduce fire growth rate

This paper uses fire statistics to show the importance of fire toxicity on fire deaths and injuries, and the importance of upholstered furniture and bedding on fatalities from unwanted fires. The aim was to compare the fire hazards (fire growth and smoke toxicity) using different upholstery materials. Four compositions of sofa-bed were compared: three meeting UK Furniture Flammability Regulations (FFR), and one using materials without flame retardants intended for the mainland European market. Two of the UK sofa-beds relied on chemical flame retardants to meet the FFR, the third used natural materials and a technical weave in order to pass the test. Each composition was tested in the bench-scale cone calorimeter (ISO 5660) and burnt as a whole sofa-bed in a sofa configuration in a 3.4 × 2.25 × 2.4 m³ test room. All of the sofas were ignited with a No. 7 wood crib; the temperatures and yields of toxic products are reported. The sofa-beds containing flame retardants burnt somewhat more slowly than the non-flame retarded EU sofa-bed, but in doing so produced significantly greater quantities of the main fire toxicants, carbon monoxide and hydrogen cyanide. Assessment of the effluents' potential to incapacitate and kill is provided showing the two UK flame retardant sofa-beds to be the most dangerous, followed by the sofa-bed made with European materials. The UK sofa-bed made only from natural materials (Cottonsafe^®) burnt very slowly and produced very low concentrations of toxic gases. Including fire toxicity in the FFR would reduce the chemical flame retardants and improve fire safety.

Analysis of fire deaths in Poland and influence of smoke toxicity

Dwelling fires have changed over the years because building contents and the materials used in then have changed. They all contribute to an ever-growing diversity of chemical species found in fires, many of them highly toxic. These arise largely from the changing nature of materials in interior finishes and furniture, with an increasing content of synthetic materials containing higher levels of nitrogen, halogen and phosphorus additives. While there is still a belief that carbon monoxide is the major lethal toxic agent in fires, the hydrogen cyanide and acid gases released from these additives are now well-recognised as major contributory causes of incapacitation, morbidity and mortality in domestic fires. Data for the total number of 263 fire death cases in the Mazowieckie region (mainly Warsaw area) of Poland between 2003-2011 for dwellings fires were obtained from pathologists, forensic toxicologists, fire fighters and analysed. Factors contributing to the death such as the findings of the full post mortem examination (age, sex, health status, burns), the toxicological analysis (carbon monoxide, alcohol etc.), and a thorough investigation of the scene (fire conditions, fuel, etc.) were taken into account and are summarised.

Release of volatile and semi-volatile toxicants during house fires

Qualitative results are presented from analysis of volatile and semi-volatile organic compounds (VOCs/SVOCs) obtained through sampling of gaseous effluent and condensed particulates during a series of experimental house fires conducted in a real house. Particular emphasis is given to the 16 polycyclic aromatic hydrocarbons (PAHs) listed by the Environmental Protection Agency due to their potentially carcinogenic effects. The initial fuel packages were either cooking oil or a single sofa; these were burned both alone, and in furnished surroundings. Experiments were performed at different ventilation conditions. Qualitative Gas Chromatography-Mass Spectrometry (GC-MS) analysis found VOC/SVOC releases in the developing stages of the fires, and benzo(a)pyrene - the most carcinogenic PAH - was found in at least one sampling interval in the majority of fires. A number of phosphorus fire retardants were detected, in both the gaseous effluent and particulates, from fires where the initial fuel source was a sofa. Their release during the fire is significant as they pose toxicological concerns separate from those presented by the PAHs.

A review of exposure and toxicological aspects of carbon nanotubes, and as additives to fire retardants in polymers

Carbon nanotubes (CNTs) have attracted considerable interest due to their unique physical, chemical, optical and electrical properties opening avenues for a large number of industrial applications. They have shown potential as fire retardant additives in polymers, reducing heat release rate and increasing time to ignition in a number of polymers. Relevant work on the types, properties and applications has been reviewed particularly considering their application in fire situations. There are concerns over the health risks associated with CNTs and many papers have likened CNTs to the health problems associated with asbestos. There are contradictions relating to the toxicity of CNTs with some papers reporting that they are toxic while others state the opposite. Directly comparing various studies is difficult because CNTs come in many combinations of size, type, purity levels and source. CNTs can potentially be released from polymers during the combustion process where human exposure may occur. While this review has shed some light regarding issues relating to toxicity under different fire scenarios much more thorough work is needed to investigate toxicity of CNTs and their evolution from CNT-polymer nanocomposites in order to reach firm conclusions.

Self-assembly fabrication of hollow mesoporous silica@Co-Al layered double hydroxide@graphene and application in toxic effluents elimination

Here, we propose a self-assembly process to prepare hierarchical HM-SiO2@Co-Al LDH@graphene, with the purpose of combining their outstanding performance. Hollow mesoporous silica was first synthesized as the core, using a novel sonochemical method, followed by a controlled shell coating process and chemical reduction. As a result of the electrostatic potential difference among HM-SiO2, Co-Al LDH, and graphene oxide, the HM-SiO2 spheres were coated by Co-Al LDH and graphene. Subsequently, the HM-SiO2@Co-Al LDH@graphene spheres were introduced into an epoxy resin (EP) matrix for investigation of their toxic effluents capture and elimination effectiveness during combustion. The amount of toxic CO and volatile organic compounds from the epoxy resin decomposition significantly suppressed after incorporating the HM-SiO2@Co-Al LDH@graphene hybrids, implying a reduced toxicity.

Synthesis of mesoporous silica@Co-Al layered double hydroxide spheres: layer-by-layer method and their effects on the flame retardancy of epoxy resins

Hierarchical mesoporous silica@Co-Al layered double hydroxide (m-SiO2@Co-Al LDH) spheres were prepared through a layer-by-layer assembly process, in order to integrate their excellent physical and chemical functionalities. TEM results depicted that, due to the electrostatic potential difference between m-SiO2 and Co-Al LDH, the synthetic m-SiO2@Co-Al LDH hybrids exhibited that m-SiO2 spheres were packaged by the Co-Al LDH nanosheets. Subsequently, the m-SiO2@Co-Al LDH spheres were incorporated into epoxy resin (EP) to prepare specimens for investigation of their flame-retardant performance. Cone results indicated that m-SiO2@Co-Al LDH incorporated obviously improved fire retardant of EP. A plausible mechanism of fire retardant was hypothesized based on the analyses of thermal conductivity, char residues, and pyrolysis fragments. Labyrinth effect of m-SiO2 and formation of graphitized carbon char catalyzed by Co-Al LDH play pivotal roles in the flame retardance enhancement.

Analysis of toxic effluents released from PVC carpet under different fire conditions

A large number of investigations have been reported on minimising the PAH and PCDD/F yields during controlled combustion, such as incineration. This study is an attempt to quantify acute and chronic toxicants including PAH and PCDD/F in conditions relating to unwanted fires. This paper investigates distribution patterns of fire effluents between gas and aerosol phase, and the different particle size-ranges produced under different fire conditions. PVC carpet was selected as the fuel as a precursor for both PAH and PCDD/F. In order to generate fire effluents under controlled fire conditions, the steady-state tube furnace, was chosen as the physical fire model. Fire scenarios included oxidative pyrolysis, well-ventilated and under-ventilated fires. Fire effluent measurements included: carbon monoxide, carbon dioxide, hydrogen chloride, polycyclic aromatic hydrocarbons, chlorinated dibenzo-dioxins and furans and soot. The distribution patterns between gas and particle phase, and the size-ranges of the particles produced in these fires together with their chemical composition is also reported. Significant quantities of respirable submicron particles were detected, together with a range of PAHs. Lower levels of halogenated dioxins were detected in the fire residue compared with those found in other studies. Nevertheless, the findings do have implications for the health and safety of fire and rescue personnel, fire investigators, and other individuals exposed to the residue from unwanted fires.

Fire retardant effects of polymer nanocomposites

Among the many and varied applications of nanotechnology, the dispersion of nanoscopic fillers to form polymer nanocomposites with improved fire behaviour illustrates the potential and diversity of nanoscience. Different polymers decompose in different ways and fire retardants act to inhibit the decomposition or flaming combustion processes. Polymer nanocomposites form barriers between the fuel and air, reducing the rate of burning, but beyond that there is little consistency in their effects. It is shown that the decomposition products of polypropylene are changed by the presence of nanoclay, although there is only a small influence on the mass loss rate. The rheological properties of molten polymer nanocomposites are radically different from those of virgin polymers, and these will profoundly affect the heat transfer through the material, resulting in a shorter time to ignition and lower peak in the heat release rate, typical of polymer nanocomposites. The dispersion of nanofillers within polymers is generally measured in the cold polymer, but since this does not reflect the condition at the time of ignition, it is proposed that temperature ramped rheological measurements are more appropriate indicators of dispersion. The influence of polymer nanocomposite formation on the yields of toxic products from fire is studied using the ISO 19700 steady state tube furnace, and it is found that under early stages of burning more carbon monoxide and organoirritants are formed, but under the more toxic under-ventilated conditions, less toxic products are formed.

Double In Situ Approach for the Preparation of Polymer Nanocomposite with Multi-functionality

A novel one-step synthetic route, the double in situ approach, is used to produce both TiO(2) nanoparticles and polymer (PET), and simultaneously forming a nanocomposite with multi-functionality. The method uses the release of water during esterification to hydrolyze titanium (IV) butoxide (Ti(OBu)(4)) forming nano-TiO(2) in the polymerization vessel. This new approach is of general significance in the preparation of polymer nanocomposites, and will lead to a new route in the synthesis of multi-functional polymer nanocomposites.

Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights

OBJECTIVES

To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships.

METHODS

Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls.

RESULTS

The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls).

CONCLUSIONS

These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights

PURPOSE

We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery.

MATERIALS AND METHODS

3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls.

RESULTS

The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls.

CONCLUSIONS

This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.