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21 Surgical Options forRefractory Urinary Incontinence inClassic Bladder Exstrophy
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357
Urinary Reconstruction for Bladder Exstrophy in the Developing World: Special Consideration and Technique
SudiptaSen, PavaiArunachalam, andRaviKishoreBarla
Abbreviations
BA Bladder augmentation
BNC Bladder neck closure
CIC Clean intermittent catheterization
RAM Rectus Abdominis Muscle ap
YDL Young-Dees-Leadbetter bladder neck plasty
Introduction
22
This article is based on our experience in managing exstrophy over 40years in two
large tertiary care hospitals in India. We do not intend to sum up the published literature on the subject with its wide variation in the methods of management and the
results obtained thereby. Results obtained with regard to continent voluntary voiding are stressed in the majority of published literature, including textbook chapters.
However, the management of “failed exstrophy” is not given sufcient importance
even though these comprise a large proportion of children plagued by dehisced
repairs, uncertain continence, urinary infection, upper tract deterioration, calculi,
S. Sen (*)
Department of Pediatric Surgery, PSG IMS&R, Coimbatore, Tamil Nadu, India
Department of Pediatric Surgery, CMC Hospital, Vellore, Tamil Nadu, India
P. Arunachalam
Department of Pediatric Surgery, PSG IMS&R, Coimbatore, Tamil Nadu, India
R. K. Barla
Department of Pediatric Surgery, CMC Hospital, Vellore, Tamil Nadu, India
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
A. R. Shukla, R. S. Joshi (eds.), Bladder Exstrophy and Epispadias,
https://doi.org/10.1007/978-3-031-91238-2_22
359
360
Fig. 22.1 Management protocol for exstrophy
S. Sen et al.
and male sexual inadequacy. Added to this are the nancial and psychological burdens of repeated surgery with less-than-optimal results. These issues have forced us
to shift the goalpost from “continence and voluntary voiding” to “dryness on clean
intermittent catheterization (CIC) with protected upper tracts” as the essential and
more realistic goal in exstrophy management. The patients who presented with
exstrophy (not including the patients referred after failed surgery) were mangaed in
two stages by us. In infancy, exstrophy epispadias repair was completed and around
ve years of age, they undergo bladder augmention, bladder neck plasty, ureteric
reimplant and appendicular Mitrofanoff for intermittent catheterization. We have
developed modications to the standard techniques of the above repairs, which will
be described herein (Fig.22.1).
Operative Technique
Bladder Turn-In andEpispadias Repair withRectus Abdominis
Muscle Flap (RAM) Cover [1]
An incision is made around the bladder plate and then vertically extended cephalad
in the midline until the proposed site of the neo umbilicus. Subcutaneous aps are
reected bilaterally. On the left side, the subcutaneous dissection is continued until
the lateral margin of the left rectus sheath is seen. Any associated inguinal hernia is
now corrected. The left anterior rectus sheath is vertically opened in the paramedian
position along the medial border of the left rectus muscle. The rectus muscle is then
separated off the anterior and posterior rectus sheaths, taking care at the brous
intersections to avoid damage to the anterior rectus sheath. The rectus muscle at the
22 Urinary Reconstruction for Bladder Exstrophy in the Developing World: Special…
361
upper end of the incision is divided. The lower half of the left rectus muscle is mobilized by serially dividing the neurovascular supply entering its lateral aspect. The
inferior epigastric vessels are carefully preserved. This results in a ap of the lower
rectus abdominis retaining its attachment to the pubic bone and being supplied by
the inferior epigastric vessels. This muscle ap is turned across the interpubic defect
to cover the repaired bladder.
The retropubic space is now developed bilaterally, and the bladder plate is isolated by dividing its lateral attachments to the pubic bone (inter-symphysial band).
In the male, the lowermost attachments to the pubis are left undivided until the
epispadias are dissected and corporal neurovascular bundles are visualized. The
dome of the bladder is now mobilized by dividing the urachus and the umbilical
arteries and separating the peritoneum until the ureteral entry into the back of the
bladder is visualized.
Dissection for epispadias correction begins at the penile ventrum. Keeping the
neurovascular bundles in view, the bladder and urethral plate are completely separated as a single unit from the corporal bodies and the lower pubic attachments,
while keeping the glans attachment intact (Cantwell–Ransley technique) [2].
Bladder closure is now done, leaving ureteric and suprapubic catheters, which are
brought out through the bladder dome. The urethra is constructed over an 8 Fr feeding tube. Glansplasty is done. Intercorporeal sutures are placed medial to the neurovascular bundle, in the zone from which the urethral plate had been dissected, thus
approximating the corporal bodies dorsal to the reconstructed urethra.
The rectus abdominis muscle (RAM) ap is turned medially over the repaired
bladder to bridge the gap between the pubic bones. The cut edge of the rectus ap is
sutured to the right pubic bone and right rectus sheath, thus providing anterior support to the repaired bladder. These sutures (2–0 polyglactin) should be of the horizontal mattress type and should incorporate the nearest brous intersection of the
RAM ap to prevent it from cutting through the muscle of the RAM ap. In addition, the lower margin of the muscle ap is utilized to provide a cover to the penopubic angle by a triangular stitch incorporating the two corporal bodies and the
lower edge of the muscle ap (Fig.22.2).
The opened left rectus sheath is now repaired. At the upper edge of the transposed muscle, both rectus sheaths are anchored to the RAM ap to get a secure
abdominal closure. The catheters exiting the bladder dome are brought out through
the body of the transposed RAM ap, traverse a subcutaneous course, and exit at the
proposed neo-umbilical site. Midline skin closure is made possible because of the
mobilized skin aps. The penile skin closure is performed by a modied Pippi Salle
method utilizing an island ap from the ventral penile skin [3].
Catheters are left in double diapers. A child is not immobilized and fed after
6hours if concomitant augmentation is not done. The urethral catheter is removed
after a week.
Ureteric and suprapubic catheters are kept for a period of 3weeks.
This method of doing away with pubic bone approximation (with or without
osteotomy) and bridging the musculo-fascio-skeletal defect in the anterior
abdominal wall with the mobilized RAM has given us very satisfactory results.
362
ab
cd
S. Sen et al.
Fig. 22.2 Schematic diagram (a–d) illustrating repair of exstrophy using RAM ap cover to
bridge the inter-pubic gap. The lower half of the left RAM is dissected from within the rectus
sheath, dividing the muscle in the mid-abdomen, dividing its lateral neurovascular supply, but
retaining its attachment to the pubic bone and supply from the left inferior epigastric vessels. The
bladder and urethra are closed as a single unit, and the RAM ap is turned inferior medially to
bridge the interpubic gap in front of the repaired bladder. A triangular suture at the lower edge of
the RAM ap closes the peno-pubic gap
The operation is simple, with minimal blood loss, free of tension, and does not
require any internal or external xation. We have found it very suitable for a
developing country for primary and redo repairs, with concomitant epispadias
repair. Bladder augmentation can also be done concomitantly in older children
[1] (Fig.22.3).
22 Urinary Reconstruction for Bladder Exstrophy in the Developing World: Special…
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ab
de
c
f
Fig. 22.3 Preoperative (a), operative (b–e), and follow-up pictures (f) of a case of dehisced
exstrophy repaired using the RAM ap technique, showing polypoid bladder plate (a) lower left
rectus abdominis isolated from within the rectus sheath, retaining its pubic attachment and the left
inferior epigastric vessels (b). The bladder and urethral plate were dissected off their lateral attachments and repaired as a single unit (c). The RAM ap is used to bridge the inter-pubic gap, triangular suture buttressing the peno-pubic angle (d). Abdominal musculofascial closure completed (e)
The Final Reconstruction
The bladder plate in exstrophy, especially after previous failed surgery, is often
small and, as such, results in a small-volume bladder. After bladder neck surgery,
this small-volume bladder can result in high bladder pressures. This, in addition to
the VUR (in exstrophy, VUR is universal), causes renal scarring, HUN, and ultimate
renal damage. In addition, dryness is also not achieved. The usual solution to all the
above is bladder augmentation. There are, however, several other issues during
bladder augmentation for exstrophy. They are as follows:
1. Bladder neck repair is essential to provide dryness. This is usually done as a long
YDL plasty. In failed cases with stiff bladder plates, bladder neck closure may
be required.