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The Inadequate Bladder Template: Its Effect on Outcomes in Classic Bladder Exstrophy
John Jayman, BA, Mahir Maruf, MD, Heather DiCarlo, MD, Karl Benz, BA, Matthew Kasprenski, MD, John Gearhart, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.

BACKGROUND: In newborn classic bladder exstrophy (CBE) patients with a template inadequate for closure, a delayed primary closure (DPC) is conducted to permit growth of the bladder template. This study reports the surgical and long-term urinary continence outcomes in patients with a poor bladder template undergoing DPC and compares them to patients who underwent DPC for reasons unrelated to bladder quality.METHODS: An institutionally approved, prospectively maintained database of 1329 exstrophy-epispadias complex patients was reviewed for CBE patients who underwent DPC at the authors’ institution. A bladder template was considered inadequate for neonatal closure if found to be inelastic, <3cm in diameter, and/or covered in hamartomatous polyps. Linear regression was used to assess longitudinal bladder growth between groups. A cumulative incidence curve was constructed to assess the time to continence. RESULTS: In total, 63 patients (53 male, 10 female) undergoing DPC were identified. Of these, 36 had poor bladder templates (Group 1). The remaining 27 patients (Group 2) had adequate templates and their bladder closure was delayed for reasons unrelated to bladder quality. At the time of DPC, those in Group 1 were relatively older compared to those in Group 2 (median of 229 vs 128 days, p=0.094). All 36 Group 1 patients and 26 (96%) Group 2 patients underwent pelvic osteotomy during DPC (p=0.429) and all had a successful primary closure. There was little difference in longitudinal bladder capacities between Group 1 and Group 2 (p=0.518). There was minimal difference in the median number of continence procedures between groups, both having 1 [IQR 1-1] continence procedure (p=0.880). Eight patients in Group 1, and 3 patients in Group 2 underwent a bladder neck transection with urinary diversion. Of the 13 and 16 patients who have undergone a continence procedure in Group 1 and 2, respectively, 11 (84.6%) and 13 (81.3%) are continent of urine. The age of first continence procedure was different between Groups 1 and 2 at 8.0 years [5.8-9.9] and 4.8 [3.5-6.0], respectively p=0.009. The majority of patients in Group 1 established continence at a relatively later age compared to those in Group 2, at 11.4 (8.0-14.8) years and 7.9 (2.6-13.2) years of age respectively p=0.087.
CONCLUSIONS: DPC of the exstrophic bladder has high rates of success when pelvic osteotomy is utilized as an adjunct. Patients with a DPC for reasons of an inadequate bladder have comparable rates of bladder growth when compared to DPC of an adequate bladder. The inadequate bladder affects the type of continence procedure, with the majority of patients requiring a continent urinary diversion. Patients with an inadequate bladder have a later age of first continence procedure and a relatively later age of continence, because of an inherently smaller bladder at birth. The inadequate bladder patients require longer periods of surveillance to access bladder growth and capacity in preparation of a continence procedure. Furthermore, as the majority of inadequate bladder patients require a catheterizable channel for continence, the age of continence is likely influenced by patients preparation as they transition from volitional voiding to catheterization.

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