BERKELEY, CA (UroToday.com) - This large series of major bladder exstrophy reconstructions represents the pinnacle of reconstructive challenges for the pediatric or adult reconstructive urologist. Many patients in this group had undergone multiple exstrophy closures with resultant small capacity, thickened, poor quality bladders, and a child still left incontinent. Others had undergone prior bladder neck reconstructions with continued leakage of urine, hydronephrosis, etc. Thus, one cannot stress enough the need for appropriate preoperative workup to develop a solid plan for reconstruction while trying to limit intraoperative and postoperative complications. After prior failed bladder neck reconstruction, BNR + augmentation, or BNR+ augmentation+ a continent stoma, reconstructive procedures must be tailored for each individual case in order to decrease the risk associated with reoperating after the failed aforementioned procedures.
In order to decrease complications of further bladder neck surgery, we often transect the bladder neck to lessen the risk of further leakage from below with excellent results using double-layer closure, AlloDerm®, Evicel®, and omentum, if available, to lessen the risk of a recurrent leak. While some argue the urethral/bladder neck should be left open as a "pop-off" valve in this group of patients, the great doyen of exstrophy surgery, Bob Jeffs, said that this always ended up being a "leak-off" valve instead requiring further surgery to make the child reliably dry. Thus, to lower the complications and increase dryness, bladder neck transection is often required as a salvage procedure to increase the attainment of continence in these multiply operated patients.
In our practice, a minimum bladder capacity of 50 cc’s is required to have a bladder template large enough for augmentation. One reason we have begun to transect the bladder neck more is to allow the capacity taken up by a BNR to be used to make the template larger for a more straightforward augmentation. The choice of bowel segment used for augmentation usually depends on the surgeons 's experience and judgment. However, in our experience, the proximity of the redundant sigmoid colon makes augmentation easy without a great deal of abdominal dissection, thus lowering the risks of adhesions and bowel obstruction. We also favor colon because of the utility of using the anterior taenia for reimplantation of the appendix or tapered ileal segment.
Ureteral reimplantation into the bladder template must be carefully considered, as some of these small leathery bladders are hostile to the dissection of a long submucosal tunnel. While our preference is using the bladder template, again reimplantation into a supple, never-operated taenia offers ease of performance and security to the reconstructive surgeon and less incidence of ureteral obstruction in our hands. While techniques have improved, these procedures can pose significant challenges to the reconstructive surgeon in planning, performance, and follow up. Nonetheless, with experience, care, and careful follow up, complications can be limited and more manageable in this special group of patients.
John P. Gearhart, MD, FAAP, FACS, FRCS(Hon)(Ed) as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Robert D. Jeffs Professor of Pediatric Urology
Charlotte Bloomberg Children's Center
The Brady Urological Institute
The Johns Hopkins School of Medicine
The Johns Hopkins Hospital