Update and mid-term follow up of classic bladder exstrophy managed by the Toronto approach (Modified staged repair): Continence status, sexual function and upper tract functional outcomes.

INTRODUCTION: The modified staged repair, or Toronto approach to reconstruct classic bladder exstrophy, involves bladder neck (BN) tailoring and bilateral ureteral reimplantation during primary closure, and later epispadias repair using external corpora rotation and a rotational penile skin flap. It aims to incorporate the advantages of complete primary repair while minimizing risks of upper tract deterioration and penile ischemia and improve cosmetic appearance of the genitalia. We present long-term outcomes for our initial patient series.

METHODS: All patients with initial operation between 2000 and 2014 were reviewed. Data on demographics, continence, erectile and ejaculatory function, cosmetic appearance of the genitalia, and upper tract status were collected.

RESULTS: Twelve male and four female patients were identified, with median follow-up of 12.7 (IQR 10.9-15.4) and 12.5 years (IQR 10.6-15.6), respectively. Full continence (voiding with no leaks, dry periods ≥3 h) was achieved in two of 12 males and two of four females. Five of 12 males and all four females had dry periods longer than 1 h. Nine of 12 males and all females attained volitional voiding. Three of 12 males and one of four females underwent additional continence procedures. None have undergone augmentation cystoplasty or bladder neck closure. Of seven males with preliminary sexual function data, all experienced erections, straight in five, with recurrent dorsal curvature and ventral curvature in one patient each. Four of seven ejaculate and none have attempted penetrative intercourse. All seven males reported satisfactory cosmetic appearance despite a subjectively shorter penis. Although transitory dilations of the ureters were seen immediately post op, none had scarring, hydronephrosis, or febrile urinary tract infections at latest follow-up. One patient had an eGFR on the upper range of CKD 2, while the rest of the cohort had eGFR ≥ 90 mL/min/1.73m2. Mean bladder capacity on ultrasound was 145 mL for males and 97 mL for females.

CONCLUSION: The present data suggests that the modified staged repair of exstrophy (Toronto approach) is associated with acceptable continence outcomes while minimizing escalation to augmentation cystoplasty and bladder neck closure. Most patients void volitionally and stay dry for 1-3 h, but few are fully continent or able to remain dry for 3 h or more. No patients in the cohort had CKD3 or worse, and none had hydronephrosis or history of febrile urinary tract infections. Most males experience ejaculation and straight erections. There was no glanular or corporal tissue loss.