Bladder Neck Reconstruction in Bladder Exstrophy: Comparison of Young-Dees-Leadbetter and Modified BNR
Ted Lee, MD, MSc, Briony Varda, MD, Alyssia Venna, BA, Jonathan T. Xu, MD, Richard S. Lee, MD, Joseph Borer, MD.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Bladder neck reconstruction (BNR) aims to alleviate persistent incontinence after initial bladder exstrophy (BE) closure. The goal is to create a balance between bladder outlet resistance and volitional voiding. We previously utilized a Young Dees Leadbetter (YDL) technique, which includes a muscle wrap of the bladder neck. In 2014, we employed a new modified BNR (mBNR) technique, which is limited to a full thickness anterior detrusor closure. The objective of this study was to compare outcomes of two different BNR techniques: YDL versus mBNR. We hypothesized that those undergoing YDL technique have better continence outcomes but greater morbidity associated with high post void residuals, including bladder stone formation and reliance on self catheterization.
Methods: We identified BE patients undergoing BNR from 2002 to 2021. Continence outcomes included obstruction (not voiding spontaneously), controlled voiding (no pad), intermittent leakage (pad usage with dry periods), and continuous incontinence (no dry periods). We excluded those undergoing concomitant augmentation cystoplasty, cloacal exstrophy or epispadias diagnosis, and history of spinal cord abnormalities.
Results: 22 BNRs were performed: 10 YDL and 12 mBNR. The cohorts did not differ in age at BNR (4.5 vs 10years, p=0.33), preoperative percentage of expected bladder capacity (54 vs 49%, p=0.58), or pubic diastasis (5.4 vs 4.0cm, p=0.10). 40% of YDL group and none of mBNR group underwent concomitant catheterizable channel (p=0.03). The intraoperative bladder neck width following tapering was significantly narrower in the YDL group (14.4 vs. 20.0mm, p<0.0001). The mean follow-up was longer in YDL group (11.6 vs 2.3years, p < 0.0001). Post void residual was significantly higher in YDL group (83.3 vs 18.8mL, p=0.01). Continence outcomes are outlined in table. Notably, 50% of YDL group did not void spontaneously postoperatively while all patients who underwent mBNR were voiding spontaneously. Three patients undergoing YDL required additional surgeries for de novo bladder stones while none of mBNR patients formed bladder stones requiring surgical removal.
Conclusions: The mBNR technique is associated with higher rates of spontaneous voiding compared to the YDL technique. Although this may result in improved continence in the YDL technique, it comes at the cost of increased reliance on clean intermittent catheterization and higher rate of bladder stone formation.
| YDL (n=10) | mBNR (n=12) | |
| Obstructed (not spontaneously voiding) | 5 (50%) | 0 (0%) |
| Controlled voiding (no pads) | 4 (40%) | 3 (30%) |
| Intermittent leakage (pad usage with dry periods) | 1 (10%) | 8 (67%) |
| Complete incontinence (no dry periods) | 0 (0%) | 1 (8%) |
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