Comparison of preoperative innervation pattern and postreconstructive urodynamics in the exstrophy-epispadias complex

A primary neurogenic component is often being postulated to be responsible for unfavourable postoperative results of bladder growth and continence in the exstrophy-epispadias complex. On the other hand, we have seen favourable clinical situations and urodynamic follow-up after primary reconstruction employing the 'Erlangen technique' without evidence of primary dysinnervation. Since there are only few data available on this issue, we decided to apply immunocytochemistry and histochemistry for neuronal markers as a further step to elucidate this problem. Transmural biopsies were obtained during reconstructive surgery from the bladder dome and trigone of 22 children between September 1994 and June 1995. Indirect immunocytochemistry for vasoactive intestinal polypeptide (VIP), neuropeptide Y (NPY), substance P (SP) calcitonin gene-related product (CGRP) and protein gene product (PGP) 9.5, a universal marker for neuronal tissue and histochemistry for nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd), was performed on 14-micron cryostat sections. During the same period of time, control biopsies from 6 healthy bladders of an age-compatible group were subjected to the same examination. In addition, 19 patients were examined urodynamically after reconstruction in order to compare postoperative bladder function with the preexisting innervation pattern. No evidence of dysinnervation was found either morphologically or urodynamically in cases of isolated epispadias and classical exstrophy. Cases of exstrophies after failed reconstruction had muscular innervation deficiencies but increased sub and intraepithelial innervation. This group, according to morphological changes, also demonstrated bladder wall instability, decreased bladder compliance and absent detrusor contractions during micturition. All cloacal exstrophies had an extremely uneven innervation pattern with noticeable calibre differences of nerve fibres and bundles with simultaneously increased innervation density. Functionally these bladders were marked by small capacity and decreased compliance and absent detrusor function. All exstrophies in conjunction with an anal atresia or with a caudal regression syndrome (so-called 'transition forms') had a nearly universal pathological innervation pattern, compatible with cloacal exstrophies and had equally unfavourable functional findings. Cloacal exstrophies and 'transition forms' seemed to have primarily a completely different pattern of innervation when compared to normal bladders. Prognosis of bladder function in these children remains unclear.