Modified bladder neck reconstruction in patients with incontinence after staged exstrophy/epispadias closures

Reconstruction of the urethra without adequate circumferential muscular support is a significant problem in bladder neck surgery for urinary incontinence. Fascial, muscular and artificial slings have been used for support of the bladder neck after reconstruction. We used a demucosalized detrusor muscle pedicle to wrap around the bladder neck base along with other continence techniques in children who experienced incontinence after staged closure of exstrophy and epispadias. We describe our experience using the pedicle wraparound along with the Mitchell modification of Young-Dees-Leadbetter bladder neck reconstruction.

We reviewed our continence rates using a detrusor wraparound in 8 eligible patients with failed staged exstrophy-epispadias repair. We defined incontinence as any degree of leakage through the bladder neck day or night.

Of the 8 patients studied 2 were female and 6 were male. Mean patient age at surgery was 7.6 years (range 4 to 11). Mean followup was 3.2 years (range 0.5 to 5). All patients with staged exstrophy-epispadias repair failure are currently continent. Five patients underwent simultaneous bladder augmentation. All but 2 patients catheterize via a Mitrofanoff channel. Three patients void volitionally and 5 use clean intermittent catheterization per Mitrofanoff. Two patients required dextranomer/hyaluronic acid injections at the bladder neck postoperatively to achieve complete dryness.

The detrusor bladder neck wraparound, while successful, may require concomitant surgery, including augmentation, clean intermittent catheterization and endoscopic injection therapy, to achieve continence following failure of staged exstrophy-epispadias repair. The detrusor bladder neck wrap appears to be a safe and effective adjunctive procedure in this patient population. We believe it has an important role in the achievement of urinary dryness.