Background
Bladder exstrophy-epispadias complex (BEEC) is a rare, but serious congenital malformation. After achieving urinary continence and upper tract preservation, genital reconstruction is performed for function and cosmesis. We evaluated our institutional experience with vaginoplasty, including technical considerations and postoperative outcomes.
Methods
An IRB-approved database was used to conduct an institutional retrospective review of BEEC patients undergoing vaginoplasty from 2000-2023. Patients with XY karyotype, primary vaginoplasty during BEEC closure or at another institution, or no follow-up visits with a urologist at least six months post-vaginoplasty were excluded. Data on age, reconstruction method, and suture type was collected. Postoperative complications were analyzed with the primary surgical outcome of vaginal stenosis requiring re-operation (VS) and secondary surgical outcomes including urinary tract infection (UTI), surgical site infection (SSI), dehiscence, rectal injury, fistula, and symptomatic pelvic organ prolapse (POP) within 30 days, 90 days, and six months of vaginoplasty.
Results
A total of 240 female BEEC patients were identified with 54 (22.5%) undergoing vaginoplasty. Mean age at vaginoplasty was 14.6 +/- 7 years old. The majority of cases were perineal flap vaginoplasty (87%). Nylon suture was most commonly used (42.6%), with PDS used in 24.1% of cases. Median follow-up time was 55 months. Postoperative complication rates were VS 14.8%, SSI 5.6%, and UTI 3.7%, dehiscence 3.7%, 0% rectal injuries, 0% fistula, and 9.2% symptomatic POP (Table 1). The overall complication rate was 18.5%. We found no significant association between reconstruction method and VS (p=0.1). Among VS events, PDS was used in 62.5% of cases (p=0.015). On univariable analysis, PDS use was significantly associated with VS (OR 7.92, 95% CI [1.56-40.1], p=0.012). This finding remained significant when adjusting for reconstruction method on multivariable analysis (OR 10.0, 95% CI [1.79-56.1], p=0.009) (Table 2).
Conclusions
This is the largest retrospective study of BEEC patients undergoing vaginoplasty reported in the literature to the best of our knowledge. We observed that while the overall incidence of postoperative complications is low, VS is most common. Symptomatic POP was the second most common postoperative complication, but of these patients, the majority were managed conservatively. Use of PDS during vaginoplasty was significantly associated with VS, suggesting that other suture types may be more advantageous for successful surgical outcomes.
