Vesicocutaneous stulae are technically considered failures, as the management would necessarily imply a redo surgery [23].

Outlet obstruction has also been observed in CPRE and Kelly’s repair, in form of complete obliteration of the urethra. It is unclear whether this is due to technical problems during extensive mobilisation causing ischaemia to the urethra [2].

The initial management of a failed repair is conservative with debriding the devital­ised tissue, removal of foreign bodies and treating wound infection with culture­appropriate antibiotics. There should be no attempts at immediate repeat closure. A minimum interval of 4–6months is considered optimal before attempting any surgi­cal procedure [3, 11]. This allows time for the wound to mature and the inamma­tion to subside.

Before planning any surgical procedure for failure, a complete evaluation is man­datory. This should include examination under anaesthesia, pelvic x-rays, ultra­sound and renal scans. Cystograms and cystoscopy are indicated in cases of prolapse, vesicocutaneous stula or bladder outlet obstruction, while CT scans or MRI is recommended when previous osteotomies have been done.

Although a failed repair decreases the chances of a compliant, good capacity and continent bladder, all failed primary repairs should be given a chance for redo repair, if the bladder plate is healthy and genital reconstruction is possible.

Redo Exstrophy repair may be undertaken as a single-stage CPRE or as MSRE.The basic tenets of a redo repair include: (1) radical dissection of the blad­der and posterior urethra, (2) deep placement of the bladder, bladder neck and ure­thra as one unit in the pelvis, (3) osteotomy with external xators or traction to secure post-operative immobilisation, (4) adequate post-operative sedation, pain relief and control any distracting forces and (5) pre-operative intramuscular testos­terone, which by increasing phallic length and girth may reduce likelihood of inad­vertent injury [26].

Rather, the superior dissection at the dome of the bladder is performed, separat­ing the peritoneum and supercial adhesions from the dome. In redo cases, some­times it is impossible to avoid entering the peritoneum. If this occurs, the peritoneotomy may even facilitate lateral dissection when the planes are especially obliterated from previous surgery.

Once this lateral dissection is completed in an antegrade direction up to the lat­eral intersymphyseal bands, we proceed to the penile skin dissection. Regardless of whether a previous epispadias repair has been done, the penile skin is degloved, the neurovascular bundles are identied all the way to their course underneath the bone at the corporal insertion into the pubic bone. Often this dissection is particularly difcult as the brosis from the previous surgery can cause the bundles to be dis­placed from their original position. Once the bundles are safeguarded, the deep intersymphyseal bands are accurately identied and divided under vision (Fig.17.5). The radical division of all the bands in this area between the bladder neck, urethra and the pubis helps to completely free the bladder plate, which can then be easily lifted up or pushed into the pelvis without any restriction. It would be worth bearing in mind that enthusiastic medial dissection at this point could compromise the width of the bladder neck.

midshaft and moving proximally and distally. The broses from the previous sur­gery make this dissection tedious. The proximal prostatic and bladder neck dissec­tion is tricky, where the urethra may get thin or narrow. Similarly, the distal dissection from the glans may be troublesome. The tip of the urethral plate is kept connected to the glans. Sometimes, however, the proximal radical mobilisation may shorten the urethra, or the distal plate may not be supple enough, or may have been damaged in the previous surgery. In such cases, it is more advisable to give a hypospadiac meatus, as described by Mitchell and Bagli’s modication with a complete disas­sembly [22]. The pre-operative use of testosterone has been advocated as a means to enhance the growth of the urethral plate, increase its pliability and vascularity and minimise the incidence of hypospadias, especially in redo cases and older children [26, 34]. The authors have also been able to obtain an orthotopic meatus in most cases with the use of pre-operative testosterone enanthate intramuscular injections (2mg/kg at 5weeks and 3weeks before surgery) combined with topical application of testosterone cream.

The bladder closure is started after bringing out and securing the ureteric cathe­ters, suprapubic tube and a per-urethral stent. The closure is done in single or double layer with 3-0 PDS, with simple or mattress sutures, as per the quality of the bladder and surgeon’s preference. The urethroplasty is done preferably with interrupted sutures, leaving the glansplasty for after pubic bone approximation.

As discussed earlier, osteotomy is imperative for a successful redo closure. An adequate osteotomy will allow the surgeon to place the bladder and posterior ure­thra in the pelvis while the hip bones are internally rotated to bring the pubes in close approximation to bridge the intersymphyseal gap. Depending on the severity of the diastasis, expertise of the orthopaedic surgeon and whether a previous oste­otomy has been done, the osteotomy best suited for the patient can be performed. Sometimes a combination of transverse innominate and vertical iliac osteotomy may be necessary, if the diastasis cannot be overcome by a single osteotomy. The authors have found the modied Salter’s osteotomy to be adequate in most cases. Usually, a single strong 1-0 PDS suture securely knotted on the outside is sufcient to keep the approximation in place. Sometimes an additional suture may be neces­sary. Such a snug approximation can sometimes cause vascular compression and create a penile compartment syndrome. Active bleeding from the glans and any glans congestion should be checked for before being satised with the symphyseal