COMPARISON OF PREOPERATIVE INNERVATION PATTERN AND POSTRECONSTRUCTIVEURODYNAMICS IN THE EXSTROPHY-EPISPADIAS COMPLEX

A primary neurogenic component is often being postulated to be respons ible for unfavourable postoperative results of bladder growth and cont inence in the exstrophy-epispadias complex. On the other hand, we have seen favourable clinical situations and urodynamic follow-up after pr imary reconstruction employing the 'Erlangen technique' without eviden ce of primary dysinnervation. Since there are only few data available on this issue, we decided to apply immunocytochemistry and histochemis try for neuronal markers as a further step to elucidate this problem. Transmural biopsies were obtained during reconstructive surgery from t he bladder dome and trigone of 22 children between September 1994 and June 1995. Indirect immunocytochemistry for vasoactive intestinal poly peptide (VIP), neuropeptide Y (NPY), substance P (SP) calcitonin gene- related product (CGRP) and protein gene product (PGP) 9.5, a universal marker for neuronal tissue and histochemistry for nicotinamide adenin e dinucleotide phosphate diaphorase (NADPHd), was performed on 14-mu m cryostat sections. During the same period of time, control biopsies f rom 6 healthy bladders of an age-compatible group were subjected to th e same examination. In addition, 19 patients were examined urodynamica lly after reconstruction in order to compare postoperative bladder fun ction with the preexisting innervation pattern. No evidence of dysinne rvation was found either morphologically or urodynamically in cases of isolated epispadias and classical exstrophy. Cases of exstrophies aft er failed reconstruction had muscular innervation deficiencies but inc reased sub- and intraepithelial innervation. This group, according to morphological changes, also demonstrated bladder wall instability, dec reased bladder compliance and absent detrusor contractions during mict urition. All cloacal exstrophies had an extremely uneven innervation p attern with noticeable calibre differences of nerve fibres and bundles with simultaneously increased innervation density. Functionally these bladders were marked by small capacity and decreased compliance and a bsent detrusor function. All exstrophies in conjunction with an anal a tresia or with a caudal regression syndrome (so-called 'transition for ms') had a nearly universal pathological innervation pattern, compatib le with cloacal exstrophies and had equally unfavourable functional fi ndings. Cloacal exstrophies and 'transition forms' seemed to have prim arily a completely different pattern of innervation when compared to n ormal bladders. Prognosis of bladder function in these children remain s unclear.