A population based analysis of continence outcomes and bladder exstrophy

Purpose: Whereas the literature on bladder exstrophy is replete with outcom es of specific continence surgical procedures in highly select patients, th ere are no data on the outcomes related to continence for a complete exstro phy population, which is more comprehensive with respect to a variety of su rgical procedures performed to achieve continence. To provide urologists an d patients with an overview of potential continence outcomes devoid of any selection bias, we report on a comprehensive exstrophy population, focusing on the various procedures required for urinary continence. Materials and Methods: We reviewed the charts of all patients with bladder and cloacal exstrophy who underwent a staged repair to achieve urinary cont inence at a single institution between 1988 and 1998. Urinary continence wa s then correlated to the types of surgical procedures, and subgroup analysi s for predictors of urinary continence was performed. The type of bladder n eck reconstruction allowed subgrouping cases into group 1-bladder neck reco nstruction only, group 2-bladder neck reconstruction with augmentation and/ or appendicovesicostomy and group 3-bladder neck closure. Results: Of the 43 patients identified 26 were male, 4 had cloacal exstroph y and 3 had complex exstrophy variants with ectopic hindgut and spina bifid a. Groups 1 to 3 comprised 9, 15 and 19 patients with urinary continence ra tes of 56%, 67% and 100%, respectively. The age at which patients became co ntinent was delayed in groups 2 and 3 (8.2 and 8.7 years, respectively) com pared to group 1 (4.8). Of all the potential varients measured gender was t he strongest predictor of continence with 94% of females versus 69% of male s achieving it. Of the males those with (57%) compared to those without (83 %) a history of bladder neck stenosis or paraexstrophy flaps had worse cont inence. Repeat bladder neck reconstruction was only successful in 23% of pa tients. Conclusions: All patients can be rendered continent but many may achieve th is successful outcome by other procedures following initial bladder neck re construction. When managing failed bladder neck reconstruction, the type of surgical repair chosen may need to address the need for enhanced bladder s torage and the issue of potential bladder augmentation. The advances made i n the treatment of the epispadiac urethra may now facilitate clean intermit tent catheterization. Earlier recognition of the need for adjunctive storag e procedures in addition to bladder neck reconstruction may facilitate the timing of providing enhanced continence, independence and self-esteem, and do so with fewer operative procedures. We speculate that the current comple te urethral and bladder repair in newborns will add further to the storage functions of the native bladder tissues and improve the potential of achiev ing more effective bladder outlet control.