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Inguinal pathology and its association with classical bladder exstrophy
D A Husmann1, G A McLorie, B M Churchill
1Hospital for Sick Children, Toronto, Ontario.
Insights
Children with bladder exstrophy have a high risk of developing inguinal hernias, especially boys undergoing staged reconstruction. Early detection and repair of patent processus vaginalis are crucial to prevent incarcerated hernias.
Area of Science:
- Pediatric Surgery
- Urology
- Congenital Anomalies
Background:
- Classical bladder exstrophy is a complex congenital anomaly.
- Inguinal hernias are a known complication, but incidence and timing require further elucidation.
Purpose of the Study:
- To determine the incidence and timing of inguinal hernia development in patients with classical bladder exstrophy.
- To identify risk factors for inguinal hernia formation.
- To evaluate the efficacy of current management strategies.
Main Methods:
- Retrospective review of 134 classical bladder exstrophy cases.
- Analysis of follow-up data for inguinal hernia development and repair.
- Comparison of hernia incidence between staged reconstruction and primary cystectomy/diversion.
Main Results:
- 56% of boys and 15% of girls developed inguinal hernias over 10 years.
- 46% of hernias were diagnosed within the first year post-initial procedure.
- Boys undergoing staged reconstruction had a significantly higher risk of hernias (P < .001).
- Over 50% of hernias diagnosed in the first year were incarcerated.
Conclusions:
- Bladder exstrophy patients, particularly boys with staged reconstruction, face a high risk of inguinal hernias.
- Inadequate inguinal canal obliquity and increased intra-abdominal pressure contribute to herniation.
- Proactive inguinal examination and repair of patent processus vaginalis during initial closure are recommended to reduce morbidity.
Abstract:
One hundred thirty-four cases of classical bladder exstrophy, managed at our institution, were reviewed. Fifty-six percent of the boys and 15% of the girls developed inguinal hernias over an average follow-up time-span of 10 years. Thirty-one percent of the patients with hernias underwent repair at the time of initial bladder closure. Forty-six percent of the patients who developed a hernia were diagnosed during the first year following their initial procedure. More than 50% of the individuals in the latter category presented with an incarcerated hernia, and required emergent management. Boys managed by staged reconstruction had a statistically significant risk of developing an inguinal hernia (P less than .001) compared with boys undergoing primary cystectomy and diversion. We believe the increased incidence of herniation with this congenital anomaly is secondary to a lack of obliquity of the inguinal canal, due to pubic diastasis along with an increased elevation of intraabdominal pressure following initial closure of the abdominal wall and bladder plate. To decrease the attendant morbidity of incarcerated hernias in this population, we stress the need for careful physical examination of the inguinal region and spermatic cord prior to surgery, along with repair of the patent processus vaginalis at the time of initial repair.