Urethral obstruction after primary exstrophy closure: What is the fate of the genitourinary tract?

Purpose: We assessed the impact of posterior urethral obstruction after pri mary bladder exstrophy closure. Materials and Methods: A review of the records of patients with classic bla dder exstrophy at our institution identified 29 boys and 12 girls with a me an age of 11.75 years who had had posterior urethral outlet obstruction aft er closure was done in the neonatal period. Results: Of these 41 patients 75% underwent closure elsewhere. At closure o steotomies were done in 13 patients and 23 were younger than 72 hours. Para exstrophy skin flaps were used at primary closure in 27 cases (66%). Obstru ction presented as recurrent urinary tract infection, upper tract deteriora tion with or without renal failure, bladder stones, difficult catheterizati on, urethral stitch erosion, a full bladder on ultrasound, a prolonged dry interval, urinary retention, inability to catheterize, bladder rupture, rec tal prolapse and epididymitis or prostatitis. Usually the initial obstructi ve episode developed within 60 days of closure and it was recurrent. Therap y included suprapubic catheter placement, vesicostomy, ureterostomy, nephro stomy and multiple urethral manipulations, such as dilation with or without steroid injection, internal urethrotomy, urethral stitch removal, clean in termittent catheterization or open urethroplasty. All 6 patients who underw ent long-term diversion via vesicostomy, ureterostomy or a conduit for grea ter than 6 months required permanent bowel segments for reconstruction, whi le in 5 of the 6 who underwent short-term diversion via nephrostomy or supr apubic tube placement for less than 6 months reconstruction was bowel-free. Of the 36 children in whom functional reconstruction was performed 9 are u ndergoing staged reconstruction, reconstruction failed in 14, 4 are sociall y dry and 9 are continent. Conclusions: Posterior urethral obstruction after exstrophy closure markedl y decreases the success of staged bladder reconstruction, presents a signif icant risk to the upper urinary tract and should be detected early.