Periurethral muscle complex reassembly for exstrophy-epispadias repair

Purpose: Continence is a difficult goal in exstrophy-epispadias complex rep air. It is presumed that all anatomical components involved in the exstroph y-epispadias abnormality are present but laterally and anteriorly displaced . The penile disassembly technique for epispadias restores the normal anato mical relationship of the male genital components. Its extension to complet e primary bladder exstrophy closure enables deeper positioning of the bladd er neck within the pelvic diaphragm. We identified the perineal striated mu scular complex and present its appropriate periurethral reassembly as a mai n step in exstrophy-epispadias complex repair. Materials and Methods: Bladder exstrophy and epispadias repairs were perfor med in 10 male and 3 female consecutive patients with the exstrophy-epispad ias complex, including 1-stage reconstruction in 2 male newborns and 2 fema les with exstrophy, and as further surgery in a female with cloacal exstrop hy and previous failed 1-stage repair, 4 males with incontinent epispadias (secondary repair in 1) and 4 males with epispadias in whom exstrophy closu re had been previously done. In the males after bladder plate closure and c orporeal body splitting a sagittal incision was made in the intersymphyseal tissue and extended posteriorly to the perineal body midline. The bipolar electrical stimulator was used to identify pelvic muscle components in the sagittal plane and reapproximate them along the tubularized posterior ureth ra to form the periurethral muscle complex. In the 3 females the urethral p late and vagina were similarly mobilized posterior through the sagittal inc ision of the perineal body. No patient underwent bladder neck plasty. Results: At 9 months to 4 years of followup cosmesis was good in 12 patient s, while 1 required secondary glanular urethroplasty. There was mild pyelec tasis in 3 cases but no severe hydronephrosis and no renal function deterio ration. Pyelonephritis developed in 6 patients (46%). Cystography at 1 year showed that bladder capacity was 35 to 80 and 65 to 120 cc in exstrophy an d epispadias cases, respectively. There was cyclic voiding with 30 to 90-mi nute dry intervals in 7 patients (54%), of whom 5 had exstrophy and 2 had e pispadias. Daytime voiding control. with a 2 to 3-hour voiding interval was achieved in 1 female with exstrophy and 2 patients with epispadias (23%). Incontinence was present in 2 patients with previous exstrophy closure and 1 with cloacal exstrophy (23%). Conclusions: Early restoration of a physiological vesicourethral balance of coordinated activity is feasible for the progressive achievement of contin ence in patients with the exstrophy-epispadias complex. Sagittal splitting of the perineal tissue with identification of the muscle components as well as midline reassembly of the periurethral striated muscular complex helps to reconfigure the pelvic anatomy in a more normal fashion and allows bette r restoration of coordinated vesicourethral activity.