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Surgical Complications of Major Genitourinary Reconstruction in the Exstrophy-Epispadias-Cloacal Exstrophy Complex
Dylan Stewart, MD, Brian Inouye, MD, Bhavik B. Shah, MD, Eric Z. Massanyi, MD, Heather N. DiCarlo, MD, Nima Baradaran, MD, John P. Gearhart, MD.
Johns Hopkins University, Baltimore, FL, USA.

BACKGROUND: The performance of augmentation cystoplasty (AC) and creation of a continent urinary reservoir are well accepted treatment options for patients with bladder exstrophy. However, these surgical procedures can be arduous, especially in subjects with multiple failed exstrophy closures. The authors examine their experience with the surgical complications associated with various techniques used to perform AC and continent urinary diversion (CUD) in this select population.
METHODS: The authors performed an institutional review board-approved retrospective review of 1188 cases of the exstrophyepispadias-cloacal exstrophy complex and identified 124 patients who underwent CUD with or without simultaneous AC. Surgical indications, operative technique, length of hospital stay, age, pre-operative bladder capacities, and prior genitourinary surgeries were reviewed. Special attention was given to post-operative surgical complications, which included formation of bladder stones, pyelonephritis, stomal stenosis, bladder fistulas, small bowel obstructions, post-operative ileus, bladder perforations, wound dehiscences, stoma prolapses, pelvic abscesses, worsening renal function, bladder wall polyps, stomal ischemia, hematuria-dysuria syndrome, and pelvic floor hernias. Statistical significance between operative techniques and each complication was calculated using Fishers Exact Tests.
RESULTS: Among the patients reviewed, 124 underwent CUD (77 male, 47 female) of which 4 had complete female epispadias, 11 had complete male epispadias, 96 had classic bladder exstrophy, and 13 had cloacal exstrophy or a cloacal variant. Median (range) follow up time after initial diversion was 5 years (6 months- 20 years). Appendiceal (79%) and tapered ileal segments (14%) were the primary bowel segments used to create continent catheterizable channels. 35% of the patients who underwent CUD had at least 1 failed bladder closure. The most common complications that required stomal revisions were stomal stenosis (13%), stomal leak (5%), and stomal prolapse (4%). 110 (89%) patients underwent AC. The most common techniques for AC were sigmoid cystoplasty (44%) and ileocystoplasty (42%). The most common complications associated with AC were bladder stone formation (28%), bladder fistula formation (7%) and small bowel obstruction (SBO) (5%). 83% of patients with SBO required surgical correction. No differences in complication rates were found between patients who underwent appendicovesicostomy vs. continent ileovesicostomy or sigmoid cystoplasty vs. ileocystoplasty. There was a significant difference in abscess formation in neobladder patients compared to partial augmentation patients (P = .0172). No complications were noted in the two patients who underwent AC using native ureters.
CONCLUSIONS: To our knowledge, this is the largest study to look at CUD in the exstrophy population. Either appendix or ileum, when performing CUD, and ileum or colon, when performing AC, may be used with equally low complication outcomes. The use of native genitourinary tissue will reduce or eliminate the likelihood of complications. Ultimately, a multi-disciplinary approach involving pediatric surgeons, pediatric urologists, and other surgical consultants is essential in ensuring satisfactory results.


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