Reconstructive urology

Stenzl, Arnulf

doi:10.1590/S1677-55382004000500021

UROLOGICAL SURVEY

Reconstructive urology

Complete primary repair of bladder exstrophy: initial experience with 33 cases

Hammouda HM, Kotb H

Urology (Pediatric Urology Division) Department, Assiut University, Assiut, Egypt

J Urol. 2004; 172(4 Pt 1): 1441-4; discussion 1444

PURPOSE: We evaluated our initial experience with complete primary repair of bladder exstrophy in 33 children.

MATERIALS AND METHODS: Between 1998 and 2001, 33 children with classic bladder exstrophy were treated with 1-stage primary repair for the first time in all except 4, who had undergone previous failed initial bladder closure. Our series included 26 boys and 7 girls with a mean age of 2 months (range 3 weeks to 14 months). The bladder was closed in continuity with the urethra and complete penile disassibly was used for epispadias repair. Anterior transverse innominate osteotomy was performed in all cases. Combined general and caudal anaesthesia were applied in all cases with an indwelling epidural caudal catheter in 7.

RESULTS: Median followup was 42 months (range 24 to 62). Enterocystoplasty was needed in 3 cases during primary repair of a small bladder plate. Wound dehiscence was not recorded. Bladder neck fistula was reported in 2 children, while urethral fistula was recorded in 1 boy. Abdominal ultrasound detected no hydronephrosis in all except 3 patients. Voiding cystourethrogram showed vesicoureteral reflux in 6 patients. No loss of renal function or febrile urinary tract infection was recorded. A dry interval of 3 hours or greater was reported in 24 children (72.7%), while 9 who were incontinent of urine after failed toilet training needed other procedures to achieve continence.

CONCLUSION: Complete primary repair with penile disassibly provides a good approach to achieve this purpose without the need for bladder neck reconstruction in some cases. Selection of the proper surgical technique together with adjunctive procedures such as osteotomy and a pain-free early postoperative period can maximize the chance of successful exstrophy repair.

Editorial Comment

Reconstruction of the bladder, bladder neck and urethra in bladder exstrophy patients is still a major challenge for a reconstructive urologist. The series presented here with 33 children out of whom 29 underwent a 1-stage primary repair for the first time is probably the largest series to date. All operations were done in boys and girls less than 14 months old. Preoperative assessment was simple with an intravenous pyelography or abdominal ultrasound. All surgical interventions were done by the same pediatric urologist in all cases. Apart from a well documented surgical technique, meticulous surgical handling was probably the most important factor for having better results than in many other series. There was a 76% continence rate in all children at a toilet trained age. Only three patients - those that underwent enterocystoplasty - were only continent on clean intermittent catheterization.

It is riarkable that incision of the muscular bladder wall is a possible way to increase bladder capacity in those children where the bladder tiplate is too small. It is here that tissue engineering at some time may become useful when earlier (maybe in utero) biopsy harvests may be expanded in the laboratory to be used to increase the detrusor. The bulging or expanding mucosa usually is not the probli especially not in very young children.

Dr. Arnulf Stenzl

Professor and Chairman of Urology

Eberhard-Karls-University Tuebingen

Tuebingen, Germany

Lymphadenectomy with cystectomy: is it necessary and what is its extent?

Ghoneim MA, Abol-Enein H

Urology & Nephrology Center, Gomhouria Street, Mansoura, Dakahlia 35516, Egypt

Eur Urol. 2004; 46: 457-461

No Abstract Available

Editorial Comment

Several decades ago, well known urologic surgeons in the field made it clear that lymphadenectomy is an important part of anterior exenteration. It was, however, thought to be useful only for staging. More recent reports, however, both from the USA and Europe have shown that patients with minimal involvient of lymph nodes and curable primary transitional cell cancer of the bladder may survive even without further adjuvant treatment. This means that nodal disease defined as N-1 in the TNM systi can be cured surgically, at least in some cases. In one larger report the authors even found the T-stage to be more important and the actual prognostic factor for survival regardless whether patients were staged as N-0 or N-1 [1]. This prompted some authors to propose an extension of pelvic lymphadenectomy cranially to the common iliac and the para-aortic region.

The para-aortic and especially the common iliac region were the main trunk of the sympathetic fibers supplying the hypogastric plexus could be found. The division of these fibers may lead to functional problis in the rinant urethra in patients undergoing an orthotopic neobladder after cystectomy [2]. The present paper by two well-known experienced surgeons is a well worked-up series of 200 patients undergoing radical cystectomy and extended lymphadenectomy. Only two surgeons performed all cystectomies, thereby reducing the possibility of an operator dependent variation. The nodes from each anatomic region were sent on a separate tiplate for pathologic evaluation. It was dionstrated that none of the patients with minimal lymph node disease-and those were the ones that had a chance of cure-had nodal involvient outside the pelvic region. They did find extrapelvic nodal disease, but in all cases these pN2 patients. Most of us agree with the authors’ conclusion that these are not the patients which can be cured surgically.

For reconstructive purposes it is important that we can limit our lymphadenctomy in certain patients to a level where we do not have to dissect the sympathetic autonomic nerve supply to the hypogastric plexus and pelvic floor. Thereby functional results of an orthotopic neobladder and vagina can be improved without compromising oncological results.

REFERENCES

1. Vieweg J, Gschwend JE, Herr HW, Fair WR: The impact of primary stage on survival in patients with lymph node positive bladder cancer. J Urol. 1999; 161: 72-6.

2. Stenzl A, Colleselli K, Bartsch G: Update of urethra-sparing approaches in cystectomy in women. World J Urol. 1997; 15: 134-8.