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REAL TIME INTRAOPERATIVE ASSESSMENT OF PENILE BLOOD FLOW DURING BLADDER EXSTROPHY REPAIR: A SIMPLE TECHNIQUE TO PREVENT CATASTROPHIC PENILE INJURY
Martin Kaefer, MD1, Kahlil Saad, MD1, Patricio Gorgollo, MD2, Benjamin Whittam, MD1, Richard Rink, MD1, Molly Fuchs, MD3, Diana Bowen, MD4, and Rama Jayanthi for the Pediatric Urology Midwest Alliance (PUMA), MD3.
1Indiana University, Indianapolis, IN, USA, 2Mayo Clinic, Rochester, MN, USA, 3Ohio State University, Columbus, OH, USA, 4Northwestern University, Chicago, IL, USA.

Background
The successful repair of Bladder Exstrophy remains one of the biggest challenges in Pediatric Urology. The primary focus has long been on the achievement of urinary continence. Historically there has been less focus on early penile outcomes. Recent reports of penile injury following initial repair have led us to seek methods for assessing intraoperative penile blood flow. To this end we have incorporated penile perfusion testing using intraoperative laser angiography in to our operative approach. We hypothesize that assessment of penile perfusion at various points in the procedure is a feasible technique that may assist in decision making during the repair of this complex condition.
Methods
Consecutive patients presenting with the bladder exstrophy were evaluated at four stages of their operation (i.e. following induction of anesthesia, after bladder mobilization, following internal rotation of the pubis and at the end of the procedure) by infusing indocyanine green (IG) at a dose of 1 mg per 10 kg body weight. IG is an inexpensive fluorescent agent that provides real time measurement of tissue perfusion with the ability to redose every 15 minutes. Measurements were taken at 80 seconds post infusion and the medial thigh served as the reference control. In that IG values are not yet a validated predictor for penile viability, the decision to proceed with penile reconstruction was made based on the operating surgeon's clinical assessment. Postoperative penile viability was evaluated by visual inspection and palpation three months following the procedure.
Results
Three consecutive patients were included in this pilot study. Perfusion was easy to measure and posed no significant technical difficulties. Penile perfusion changed little between the initial measurement and completion of bladder dissection, ranging from 179 -324 % (mean 235%) of control. Following internal rotation of the hips with apposition of the symphysis pubis the values decreased to 48%-122% (mean 73%) of control. In two patients a decision was made to proceed with complete repair while in the third the penis appeared clinically compromised and a decision was made to proceed with a staged approach. After the procedure the two complete primary repair patients had 44% and 50% relative perfusion, whereas the staged patient had a relative value of 160%. In all three cases the penis was symmetric and healthy at three months of follow up.
Conclusions
This pilot study demonstrates that the measurement of penile perfusion utilizing intraoperative laser angiography is easy to employ and should be considered a reasonable adjunct to tissue assessment and operative decision making in this complex condition. Marked reduction in penile blood flow may occur without any outward clinical signs. Penile perfusion seems to be reduced by apposition of the symphysis pubis and, in the immediate postoperative period, there may be further reduction in penile blood flow with CPRE as opposed to a staged repair.

CaseProcedureBeginning valueAfter bladder dissectionAfter internal rotation of hipsAt conclusion of case
1CPRE22820412250
2Staged30732450160
3CPRE2031794844

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