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Attainment of volitional voiding - 15 years of the Kelly operation
Peter M. Cuckow, FRCS, Neil Featherstone, FRCS, Karen Ryan, RSCN, Divyesh Y. Desai, FRCS.
Great Ormond Street Hospital, London, United Kingdom.

BACKGROUND: Continent reconstruction of bladder exstrophy aims either to achieve controlled obstruction or a physiologically functioning bladder outlet, in one or several stages, with or without osteotomies. Continence follows the development of bladder capacity. We present the results of our approach: an early primary bladder closure without osteotomies, followed by radical soft tissue (Kelly) reconstruction in the second year of life.
METHODS: Since 1999, consecutive patients with classic bladder exstrophy have entered our surgical protocol. From the start, our unselected patients have been regularly assessed by our nurse specialists by non-invasive urodynamics and ultrasound. After Kelly operation, emerging continence has been categorised using a family friendly adaptation of ICCS definitions, shown in the table:
Continence LevelClinical Correlation
IRetaining urine with a ‘dry interval’; some control but still needing to wear protection
IISufficient dry intervals by day; in underwear and not needing protection; wet at night
IIIDry both by day and by night; no protection or accidents; like a “normal” child

RESULTS: Of 101 patients (70M, 31F); 93 have been followed for more than a year post Kelly, 53 > 5 years, 22 > 10 years. Kelly operations were all performed by the same surgeon. In some patients bladder closure and epispadias repairs were done before referral.
Male Results1 year3 years5 years10 years

Female Results1 year3 years5 years10 years

Secondary Cases (M+F)1 year3 years5 years10 years

CONCLUSIONS: The Kelly operation has been successful in achieving continence, which evolves as the child grows and bladder capacity increases: At 10 years, 81% of males are dry by day, 44% by day and night and 13% have been augmented, whilst in females 67% are dry by day, 33% also at night and 33% have been augmented. Secondary cases followed to 5 years show 78% daytime continence, 33% also at night and 22% have been augmented. Videourodynamics has demonstrated good detrusor function during volitional voiding.

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