DETERMINATES OF CONTINENCE AFTER BLADDER NECK RECONSTRUCTION IN THE BLADDER EXSTROPHY POPULATION

Background: Continence in the bladder exstrophy population requires the coordinated and staged surgical management involving the successful closure of the exstrophy bladder, early epispadias repair, and bladder neck reconstruction (BNR) after an appropriate bladder capacity. In some select cases, initial bladder closure and epispadias may be closed concomitantly. To further delineate factors that may predict eventual continence after bladder neck plasty, we have retrospectively reviewed our patient records. Methods: The records of 88 patients who underwent total bladder exstrophy reconstruction at our institution between 1975 and 1997 were reviewed. 57 patients with BNR were available for analysis after excluding 23 patients awaiting BNR, 3 patients who achieved continence without BNR, 4 patients with recent BNR, but less than one year follow-up, and 1 patients lost to follow-up. Their medical records were reviewed and data analyzed. Results: The median and mean age for primary closure were 10 days and five months, respectively. The average age of BNR was 4.4 years with a mean capacity of 88 cc. Of these 57 patients, 42 (74%) are continent and voiding urethrally without need for augmentation or CIC. 9 (16%) patients have social continence, dry for more than three hours during the day, 2 patients required diversion for continence after failed BNR. 3 patients are wet. Analysis of bladder capacity measurements prior to BNR revealed patients with bladder capacity greater than 75 cc at the time of BNR or with an average increase in capacity of more than 21 cc/year resulted in better outcome. Whereas 2 patients were wet and 2 required urinary diversion in the group with the smaller bladder capacity and poor bladder growth, only one patient was completely wet in the optimal group. No correlation between age of BNR and continence was found. Conclusion: Determinates of continence in the bladder exstrophy population are multifactorial. In our experience 74% are all completely dry, day and night, and 89% can obtain "social continence," being dry for at least 3 hours. However, with careful evaluation of bladder capacity and bladder growth, urinary continence may be improved in this population with better patient selection.
David Y. Chan, MD, Robert D. Jeffs, MD, FAAP, and John P. Gearhart, MD, FAAP. James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD. (Presented by Dr. [...]