Presentation Authors: Mahir Maruf*, Jason Michaud, Matthew Kasprenski, Mohammad Zaman, Karl Benz, John Jayman, Marlo Eldridge, Heather Di Carlo, John Gearhart, Baltimore, MD
Introduction: The modern reconstruction of classic bladder exstrophy (CBE) permits now a focus on functional outcomes, such as urinary continence. But reports of continence outcomes have been limited to small series of homogeneous patients. Herein, the authors present surgical approaches to urinary incontinence and long-term continence outcomes after successful bladder repairs in a large heterogeneous group of CBE patients.
Methods: A prospectively maintained institutional database of 1336 exstrophy-epispadias complex patients was reviewed for CBE patients who have undergone both a successful bladder closure from 1975 to 2017 and a subsequent procedure to establish urinary continence.
Results: A total of 433 patients were found to have successful bladder closure and procedure for urinary incontinence. The primary closures were performed at a median of 2 days (range 0 days - 7.9 years), of which 309 (71%) were successful. The remaining 124 patients required more than one closure. In total, 240 patients (61%) underwent pelvic osteotomy during their primary or repeat closure. A bladder neck reconstruction (BNR) was the most common initial technique, used in 317 patients (73%) at a median age of 5.1 years (range 1-17). However, 77 of these patients (24%) underwent other surgical techniques, and 31 (10%) underwent repeat BNR. Thus, at last follow-up, 192 (44.3%) and 46 (10.6%) patients maintained a BNR with and without augmentation, respectively. A total of 173 (40%) maintained a continent urinary diversion (CUD) after a bladder neck transection (BNT). And the remaining 22 (5%) employed other urinary diversions. The median follow-up time from last continence procedure was 5.5 years (range 1.3-33). A total of 350 patients had their continence assessed, of which 269 (77%, CI [72-81]) were identified as continent. In the 167 evaluated BNR patients, 102 were continent (61%, CI [53-68]). In the 133 patients evaluated after BNT and CUD, 127 were continent (96%, CI [90-98]). When adjusting for sex, primary closure outcome, and osteotomy, and multivariable logistic regression revealed that only older age over at evaluation was significant for predicting continence in BNR patients (OR 1.3, CI [1.2-1.4]; p < 0.007).
Conclusions: In the era of modern reconstruction of CBE, a majority of patients will be continent of urine following a successful bladder closure but multiple continence procedures may be required. In select patients, BNR may be used for urinary continence. However if BNR fails or the patients are not candidates for BNR, most will be continent by CUD after BNT.