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Ureteral Reimplantation before Bladder Neck Reconstruction in Exstrophy Patients: Is There a Need?
Ali Tourchi, MD, Brian M. Inouye, MD, Heather N. Di Carlo, MD, Ezekiel Young, MD, Angela Gupta, MD, Mahmood Abdelwahab, MD, John Gearhart, MD.
Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Vesicoureteral reflux (VUR) following primary closure of bladder exstrophy can usually be managed conservatively until ureteral reimplantation (UR) at the time of bladder neck reconstruction (BNR). However, VUR in these patients is occasionally associated with febrile urinary tract infection (UTI) and worsening renal function necessitating UR prior to BNR. This study evaluates a single referral center’s experience with VUR and its role in management before BNR in exstrophy patients after modern staged repair of exstrophy (MSRE).
Methods: A total of 199 patients who underwent MSRE were identified from an institutional review board approved database. Patient demographics, closure history, post primary closure (PPC) VUR, history of febrile UTI, cystography outcomes, renal function, history of UR prior to BNR, and UR outcomes were recorded. Univariate and multivariate analyses were performed to determine factors predicting high grade VUR, and need for pre-BNR reimplantation.
Results: Following primary closure, VUR was observed in 150 (75.4%) patients of whom 31(15.58%) had high grade VUR. Closure without osteotomy and post-closure outlet obstruction were independently associated with PPC high grade VUR (p<0.05)(table). 22 (11.06%) patients required pre-BNR UR. Female gender and those with high grade VUR were more likely to need UR prior to BNR (p<0.05). Early UR did not affect the continence rate in these patients. (table)
Conclusions: VUR following exstrophy closure can generally be managed with conservative treatment. However, about 11% of patients undergoing MSRE will require UR before BNR. Closure without osteotomy and patients that develop outlet obstruction following closure are at increased risk for developing high grade VUR.

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