BackgroundComplete Primary Repair of Bladder Exstrophy (CPRE) includes closure of the bladder defect and concomitant epispadias repair. Urinary continence is a long-term indicator of surgical success and is associated with improved quality of life. We hypothesized that urinary continence is predicated on increase in bladder capacity and maturation of the pelvic floor, and that continence outcomes improve with longer follow-up.
MethodsWe utilized a prospectively maintained database of all children undergoing a CPRE for classic bladder exstrophy (CBE) with osteotomies between 2009 and 2022. Inclusion criteria was primary and redo surgical procedures that presented to our institution; those with epispadias, lack of follow-up or having undergone bladder augment/bladder neck closure were excluded. Abstracted data focused on age at CPRE, bladder capacity on VCUG and patient/family reported continence interval. A bladder capacity (BC) of 100 ml and dry interval (DI) when voiding per urethra without CIC of at least 90 minutes were considered positive indicators of continence. The 90 minutes interval was chosen based on caregiver satisfaction interviews. Fixed-effects regression models were applied to assess the impact of post-op years on bladder capacity and dry interval, with predicted values plotted to visualize the trends of these parameters over time.
ResultsStudy cohort comprised 120 children, 88 boys and 32 girls with CBE undergoing CPRE at a median 1.8 years age, of which 30 were redo CPRE for a failed repair. 45 (37.50%) achieved a BC of at least 100ml and 26 (21.6%) report a dry interval of at least 90 minute without CIC, voiding per urethra, at a median follow-up of 72 and 48 months respectively after initial surgery. Of the 18 patients who reached our target cutoffs, 5 underwent a secondary Bladder Neck Repair. Analysis showed significant positive association between post-op years and increasing bladder capacity (β=13.52, p<0.001)—i.e. the bladder capacity increased 13.5 ml/year. Each year of postoperative follow-up was associated with an increase in dry interval of 7.7 min. (Figure 1). In 14 children with a minimum of 9 years of follow-up, targeted BC was achieved in 8 (57%), and 7 (50%) achieved a dry interval of at least 90 minutes.
ConclusionsThis study highlights substantial obstacles in achieving urinary continence in the near and intermediate term in a cohort, though inclusion of redo procedures could impact overall continence outcomes. The positive correlation between increasing time from closure and bladder capacity/continence may support an approach of expectant management prior to considering irreversible continence procedures.
Fixed Effects Regression Results
| Model | Variable | Coefficient | Std. Err. | t | P>|t| | [95% Conf. Interval] |
| Bladder Capacity | postop year | 13.52273 | 2.610209 | 5.18 | 0.00 | 8.123098 - 18.92236 |
| Dry Interval | postop year | 7.65625 | 2.745941 | 2.79 | 0.015 | 1.724006 - 13.58849 |
