Functional reconstruction of exstrophied bladder. Timing and technique. Follow-up of 39 cases.

Thirty-nine cases of functional reconstruction of exstrophied bladder are reviewed. There were 20 females and 19 males. In a first group of 31 staging was planned and carried out in 26 while 3 are awaiting a second stage. In a second group of 8 a single operation was performed. Out of the 31 early cases there were 2 deaths and 10 failures, 16 show good or very good functional result. All 16 show moderate renal scarring from reflux pyelonephritis which occurred between I and II stage. Single operation consisted of innominate osteotomy, bladder and bladder neck and urethral reconstruction and anti-reflux procedure (osteotomy was omitted in a 3 days old baby). Three, operated upon when aged 8 mths., 1 year and 4 years, were breakdowns of previous closure. They are incontinent and will need further surgery at the bladder outlet. Four are dry in the morning and suffer from occasional stress incontinence and enuresis. One, now aged 4 years, still wears pads. These last 5 are awaiting final assessment of and eventually further surgery to improve continence. In all 8 cases pyelo-calyceal cavities are normal except for a moderate right dilatation in one because of kinking of the reimplanted ureter. Delay in bladder closure (mean age 5 mths.) and severe changes to the bladder wall and possibly staging seems to be responsible for most of the failures and for renal damage occurring, after closure, in bladders showing moderate compliance. Single operation allows full protection of upper tract and kidney and should be preferred in patients aged over 2 months. Better functional results may be obtained if operation is performed soon after birth.