A Comprehensive Review of the Complete Primary Repair Technique for Bladder-Exstrophy-Epispadias Reconstruction: First Surgical Attempt Should Be the Best One
Urology Journal,
Vol. 22 No. 01 (2025),
12 January 2025
,
Page 1-13
https://doi.org/10.22037/uj.v21i.8396
Abstract
Purpose: To evaluate the effectiveness of the Complete Primary Repair of Exstrophy (CPRE) technique for bladder exstrophy-epispadias complex (BEEC) reconstruction and its comparison with the Modern Staged Repair of Exstrophy (MSRE) technique.
Materials and Methods: A comprehensive literature review of CPRE and MSRE was conducted, focusing on factors such as continence rates, postoperative outcomes, and complications. Various studies on pelvic biometry, surgical approaches, and long-term evaluations of renal function and continence were analyzed.
Results: CPRE demonstrates promising outcomes, particularly in resource-limited settings, by reducing the number of surgeries and associated risks compared to MSRE. Success rates for continence post-CPRE were higher when performed correctly in the first attempt, with fewer complications such as vesicoureteral reflux and hydronephrosis. Pelvic biometry assessments, including bladder neck placement and levator ani angle, were significant predictors of successful continence outcomes.
Conclusion: CPRE offers a viable alternative to MSRE, particularly in low-resource environments, with favorable continence and renal outcomes. Proper surgical execution in the first attempt is critical for long-term success, emphasizing the importance of surgeon expertise and postoperative care. Further long-term studies are necessary to solidify CPRE's role as the primary surgical approach for BEEC.
- Bladder Exstrophy
- Epispadias
- Reconstructive Surgical Procedures
- Continence
- Postoperative Complications
How to Cite
References
Gearhart JP, Mathews R. Exstrophy-epispadias complex. Campbell-Walsh Urology. 2007;9:3547-3550.
Bujons A, Lopategui DM, Rodríguez N, Centeno C, Caffaratti J, Villavicencio H. Quality of life in female patients with bladder exstrophy-epispadias complex: long-term follow-up. J Pediatr Urol. 2016;12:210-e1.
Halachmi S, Farhat W, Konen O, et al. Pelvic floor magnetic resonance imaging after neonatal single stage reconstruction in male patients with classic bladder exstrophy. J Urol. 2003;170:1505-1509.
Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, Gearhart JP. Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights. J Urol. 2001;166:1444-1449.
Fuchs J, Glüer S, Mildenberger H. One-stage reconstruction of bladder exstrophy. European journal of pediatric surgery. 1996;6:212-215.
Khemchandani SI. The long-term outcomes after staged repair of exstrophy-epispadias complex. J Indian Assoc Pediatr Surg. 2016;21:158-163.
Ebert A, Scheuering S, Schott G, Roesch WH. Psychosocial and psychosexual development in childhood and adolescence within the exstrophy-epispadias complex. J Urol. 2005;174:1094-1098.
Lowentritt BH, Van Zijl PS, Frimberger D, Baird A, Lakshmanan Y, Gearhart JP. Variants of the exstrophy complex: a single institution experience. J Urol. 2005;173:1732-1737.
Cervellione RM, Mantovani A, Gearhart J, et al. Prospective study on the incidence of bladder/cloacal exstrophy and epispadias in Europe. J Pediatr Urol. 2015;11:337-e1.
Zaman MH, Young EE, Maruf M, et al. Practice patterns in classic bladder exstrophy: A global perspective. J Pediatr Urol. 2020;16:425-432.
Morrill CC, Haffar A, Harris TGW, Crigger C, Gearhart JP. Current management of classic bladder exstrophy in the modern era. African Journal of Urology. 2023;29:27.
Ebert AK, Falkert A, Germer U, Rösch WH. Biometry of the pubovisceral muscle and levator hiatus assessed by three‐dimensional ultrasound in females with bladder exstrophy–epispadias complex after functional reconstruction. Ultrasound in Obstetrics and Gynecology. 2009;34:98-103.
Ait-Ameur A, Wakim A, Dubousset J, Kalifa G, Adamsbaum C. The AP diameter of the pelvis: a new criterion for continence in the exstrophy complex? Pediatr Radiol. 2001;31:640-645.
Purves JT, Gearhart JP. The bladder exstrophy-epispadias-cloacal exstrophy complex. In: Pediatric Urology: Expert Consult. Elsevier; 2009:386-415.
Woodhouse CRJ, Hinsch R. The anatomy and reconstruction of the adult female genitalia in classical exstrophy. Br J Urol. 1997;79:618-622.
Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, Gearhart JP. Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights. J Urol. 2001;166:1444-1449.
Stec AA, Pannu HK, Tadros YE, et al. Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights. Urology. 2001;58:1030-1035.
Jeffs RD. Functional closure of bladder exstrophy. Birth Defects Orig Artic Ser. 1977;13:171-173.
Grady RW, Mitchell ME. Newborn exstrophy closure and epispadias repair. World J Urol. 1998;16:200-204.
Lattimer JK, Dean AL, Dougherty LJ, Ju D, Ryder C, Uson A. Functional closure of the bladder in children with exstrophy: a report of twenty-eight cases. J Urol. 1960;83:647-655.
Grady RW, Mitchell ME. Complete primary repair of exstrophy. J Urol. 1999;162:1415-1420.
Grady RW, Mitchell ME. Complete primary repair of exstrophy: surgical technique. Urologic Clinics of North America. 2000;27:569-578.
Inouye BM, Purves JT, Routh JC, et al. How to close classic bladder exstrophy: are subspecialty training and technique important? J Pediatr Urol. 2018;14:426-e1.
Ebert AK, Schott G, Bals-Pratsch M, Seifert B, Rösch WH. Long-term follow-up of male patients after reconstruction of the bladder–exstrophy–epispadias complex: Psychosocial status, continence, renal and genital function. J Pediatr Urol. 2010;6:6-10.
Kasprenski M, Benz K, Maruf M, Jayman J, Di Carlo H, Gearhart J. Modern management of the failed bladder exstrophy closure: a 50-yr experience. Eur Urol Focus. 2020;6:383-389.
SURER I, BAKER LA, JEFFS RD, GEARHART JP. Combined bladder neck reconstruction and epispadias repair for exstrophy-epispadias complex. J Urol. 2001;165:2425-2427.
Gearhart JP, Mathews R. Penile reconstruction combined with bladder closure in the management of classic bladder exstrophy: illustration of technique. Urology. 2000;55:764-770.
Gearhart JP, Baird A, Nelson CP. Results of bladder neck reconstruction after newborn complete primary repair of exstrophy. J Urol. 2007;178:1619-1622.
Kanabolo D, Cain M, Brown M, et al. Long term renal outcome and risk of elevated blood pressure in children undergoing complete primary repair of bladder exstrophy (CPRE). J Pediatr Urol. 2023;19:370-e1.
Kajbafzadeh AM, Sabetkish S, Sabetkish N. Ureteric-urethral engraftment as a new surgical technique for management of incontinence in bladder exstrophy complex: A retrospective cohort. International Journal of Surgery. 2017;46:158-163.
Alsowayan O, Capolicchio JP, Jednak R, El-Sherbiny M. Long-term functional outcomes after bladder exstrophy repair: A single, low-volume centre experience. Canadian Urological Association Journal. 2016;10:E94.
Giron AM, Mello MF, Carvalho PA, Moscardi PRM, Lopes RI, Srougi M. One-staged reconstruction of bladder exstrophy in male patients: long-term follow-up outcomes. International braz j urol. 2017;43:155-162.
Peppas DS, Tchetgen MB, Lee BR, Jeffs RD, Gearhart JP. A quantitative histological analysis of the bladder in classical bladder exstrophy in various stages of reconstruction utilizing color morphometry. The Exstrophy—Epispadias Complex: Research Concepts and Clinical Applications. Published online 1999:41-47.
Novak TE, Costello JP, Orosco R, Sponseller PD, Mack E, Gearhart JP. Failed exstrophy closure: management and outcome. J Pediatr Urol. 2010;6:381-384.
Husmann DA, McLorie GA, Churchill BM. Closure of the exstrophic bladder: an evaluation of the factors leading to its success and its importance on urinary continence. J Urol. 1989;142:522-524.
Ellison JS, Ahn J, Shnorhavorian M, Grady R, Merguerian PA. Long-term fate of the upper tracts following complete primary repair of bladder exstrophy. J Pediatr Urol. 2017;13:394-e1.
Ebert AK, Zwink N, Reutter HM, et al. Treatment strategies and outcome of the exstrophy–epispadias complex in germany: data from the german CURE-Net. Front Pediatr. 2020;8:174.
Hammouda HM, Kotb H. Complete primary repair of bladder exstrophy: initial experience with 33 cases. J Urol. 2004;172:1441-1444.
Sabetkish S, Sabetkish N, Eftekharzadeh S, Kajbafzadeh AM. Single-staged male bladder exstrophy–epispadias complex reconstruction with pubic bone adaptation without osteotomy: 15-year single-center experience. Int Urol Nephrol. 2021;53:191-198.
Joshi RS, Eftekharzadeh S, Shukla AR, et al. Kidney function outcomes in patients after complete primary repair of bladder exstrophy and penopubic epispadias: Results from the international bladder exstrophy consortium. J Pediatr Urol. 2023;19:34-e1.
Handa N, Bowen DK, Guo J, Chu DI, Kielb SJ. Long-term kidney outcomes in exstrophy-epispadias complex: how patients present as adults. Urology. 2021;154:333-337.
Haffar A, Hirsch AM, Crigger CB, et al. Multi-staged vs single-staged pelvic osteotomy in the modern treatment of cloacal exstrophy: bridging the gap. J Pediatr Surg. 2023;58:2308-2312.
Ebert AK, Schott G, Bals-Pratsch M, Seifert B, Rösch WH. Long-term follow-up of male patients after reconstruction of the bladder–exstrophy–epispadias complex: Psychosocial status, continence, renal and genital function. J Pediatr Urol. 2010;6:6-10.
Borer JG, Gargollo PC, Kinnamon DD, et al. Bladder growth and development after complete primary repair of bladder exstrophy in the newborn with comparison to staged approach. J Urol. 2005;174:1553-1558.
Borer JG, Gargollo PC, Hendren WH, et al. Early outcome following complete primary repair of bladder exstrophy in the newborn. J Urol. 2005;174:1674-1679.
Chua ME, Ming JM, Fernandez N, et al. Modified staged repair of bladder exstrophy: a strategy to prevent penile ischemia while maintaining advantage of the complete primary repair of bladder exstrophy. J Pediatr Urol. 2019;15:63-e1.
Caione P, Zavaglia D, Capozza N. Pelvic floor reconstruction in female exstrophic complex patients: different results from males? Eur Urol. 2007;52:1777-1783.
Ebert AK, Bals-Pratsch M, Seifert B, Reutter H, Rösch WH. Genital and reproductive function in males after functional reconstruction of the exstrophy-epispadias complex—long-term results. Urology. 2008;72:566-569.
Inouye BM, Massanyi EZ, Di Carlo H, Shah BB, Gearhart JP. Modern management of bladder exstrophy repair. Curr Urol Rep. 2013;14:359-365.
Bueno-Jiménez A, Serradilla J, Nava B, et al. Preliminary results of complete delayed primary bladder exstrophy reconstruction in male patients. Cir Pediatr. 2020;33:75-78.
Hammouda HM, Shahat AA, Oyoun NA, Safwat AS, Elderwy AA, Elgammal MA. Long term evaluation of continence after complete primary bladder exstrophy repair. J Pediatr Urol. 2023;19:696-e1.
Baradaran N, Cervellione RM, Stec AA, Gearhart JP. Delayed primary repair of bladder exstrophy: ultimate effect on growth. J Urol. 2012;188:2336-2342.
Cervellione RM, Fishwick J, Khan T. Routine delayed bladder exstrophy closure. In: 3rd International Bladder Exstrophy Symposium, Baltimore, Maryland. ; 2009.
Cervellione RM, Husmann DA, Bivalacqua TJ, Sponseller PD, Gearhart JP. Penile ischemic injury in the exstrophy/epispadias spectrum: new insights and possible mechanisms. J Pediatr Urol. 2010;6:450-456.
Dickson AP. The management of bladder exstrophy: the Manchester experience. J Pediatr Surg. 2014;49:244-250.
Shultz WG. Plastic repair of exstrophy of bladder combined with bilateral osteotomy of ilia. J Urol. 1958;79:453-458.
Wild AT, Sponseller PD, Stec AA, Gearhart JP. The role of osteotomy in surgical repair of bladder exstrophy. In: Seminars in Pediatric Surgery. Vol 20. Elsevier; 2011:71-78.
Kajbafzadeh AM, Talab SS, Elmi A, Rad MV, Mazaheri T, Tanhaeivash R. Use of biodegradable plates and screws for approximation of symphysis pubis in bladder exstrophy: applications and outcomes. Urology. 2011;77:1248-1253.
Halachmi S, Farhat W, Konen O, et al. Pelvic floor magnetic resonance imaging after neonatal single stage reconstruction in male patients with classic bladder exstrophy. J Urol. 2003;170:1505-1509.
Suson KD, Sponseller PD, Gearhart JP. Bony abnormalities in classic bladder exstrophy: the urologist’s perspective. J Pediatr Urol. 2013;9:112-122.
Shah BB, Di Carlo H, Goldstein SD, et al. Initial bladder closure of the cloacal exstrophy complex: outcome related risk factors and keys to success. J Pediatr Surg. 2014;49:1036-1040.
Haney NM, Crigger CB, Sholklapper T, et al. Pelvic osteotomy in cloacal exstrophy: A changing perspective. J Pediatr Surg. 2023;58:478-483.
Shnorhavorian M, Song K, Zamilpa I, Wiater B, Mitchell MM, Grady RW. Spica casting compared to Bryant’s traction after complete primary repair of exstrophy: safe and effective in a longitudinal cohort study. J Urol. 2010;184:669-674.
Sirisreetreerux P, Lue KM, Ingviya T, et al. Failed primary bladder exstrophy closure with osteotomy: multivariable analysis of a 25-year experience. J Urol. 2017;197:1138-1143.
Meldrum KK, Baird AD, Gearhart JP. Pelvic and extremity immobilization after bladder exstrophy closure: complications and impact on success. Urology. 2003;62:1109-1113.
Jani MM, Sponseller PD, Gearhart JP, Barrance PJ, Genda E, Chao EYS. The hip in adults with classic bladder exstrophy: a biomechanical analysis. Journal of Pediatric Orthopaedics. 2000;20:296-301.
Mathews R, Gearhart JP, Bhatnagar R, Sponseller P. Staged pelvic closure of extreme pubic diastasis in the exstrophy-epispadias complex. J Urol. 2006;176:2196-2198.
Inouye BM, Lue K, Abdelwahab M, et al. Newborn exstrophy closure without osteotomy: is there a role? J Pediatr Urol. 2016;12:51-e1.
Silver RI, Sponseller PD, Gearhart JP. Staged closure of the pelvis in cloacal exstrophy: first description of a new approach. J Urol. 1999;161:263-266.
CAPOLICCHIO G, MCLORIE GA, FARHAT W, MERGUERIAN PA, BÄGLI DJ, KHOURY AE. A population based analysis of continence outcomes and bladder exstrophy. J Urol. 2001;165:2418-2421.
Lloyd JC, Spano SM, Ross SS, Wiener JS, Routh JC. How dry is dry? A review of definitions of continence in the contemporary exstrophy/epispadias literature. J Urol. 2012;188:1900-1904.
Shnorhavorian M, Grady RW, Andersen A, Joyner BD, Mitchell ME. Long-term followup of complete primary repair of exstrophy: the Seattle experience. J Urol. 2008;180:1615-1620.
Kajbafzadeh AM, Sabetkish S, Sabetkish N, Eftekharzadeh S, Daryabari SS. Insights and outcomes of single-staged repair of female bladder exstrophy–epispadias complex without osteotomy: 15 Years experience of a single institution. J Pediatr Urol. 2022;18:355-361.
Woodhouse CRJ, North AC, Gearhart JP. Standing the test of time: long-term outcome of reconstruction of the exstrophy bladder. World J Urol. 2006;24:244-249.
Sabetkish S, Kajbafzadeh AM. Bladder Herniation as an Auto-Augmentation Technique in Bladder Exstrophy: Initial Experience in Patients with Small Bladder Plate. Urology. 2020;139:151-155.
Yonez MK, Atalan G, Karayigit MO, Alpman U. Use of fascia lata autograft for repair of urinary bladder defect in rabbits. Acta Veterinaria Brno. 2019;88:57-63.
Husmann DA, Gearhart JP. Loss of the penile glans and/or corpora following primary repair of bladder exstrophy using the complete penile disassembly technique. J Urol. 2004;172:1696-1701.
Braga LHP, Lorenzo AJ, Jrearz R, Bagli DJ, Salle JLP. Bilateral ureteral reimplantation at primary bladder exstrophy closure. J Urol. 2010;183:2337-2341.
Kufner M, Gearhart JP, Mathews R. Impact of epispadias repair on bladder growth in boys with classic bladder exstrophy. J Pediatr Urol. 2010;6:578-581.
Kouame BD, Kouame GSY, Sounkere M, et al. Aesthetic, urological, orthopaedic and functional outcomes in complex bladder exstrophy-epispadias’s management. African Journal of Paediatric Surgery. 2015;12:56-60.
Surer I, Baker LA, Jeffs RD, Gearhart JP. The modified Cantwell-Ransley repair for exstrophy and epispadias: 10-year experience. J Urol. 2000;164:1040-1043.
Mathews R, Hubbard JS, Gearhart JP. Ureteral reimplantation before bladder neck plasty in the reconstruction of bladder exstrophy: indications and outcomes. Urology. 2003;61:820-824.
Salle JLP. Commentary to “Penile ischemic injury in the exstrophy/epispadias spectrum: New insights and possible mechanisms.” J Pediatr Urol. 2010;6:457-458.
Hernandez DJ, Purves T, Gearhart JP. Complications of surgical reconstruction of the exstrophy–epispadias complex. J Pediatr Urol. 2008;4:460-466.
Kanabolo D, Cain M, Brown M, et al. Long term renal outcome and risk of elevated blood pressure in children undergoing complete primary repair of bladder exstrophy (CPRE). J Pediatr Urol. 2023;19:370-e1.
Giron AM, Mello MF, Berjeaut RH, et al. Single-stage abdominoplasty using groin flaps without Osteotomies: management of exstrophy-epispadias complex. Urology. 2018;120:266.
Arab HO, Helmy TE, Abdelhalim A, Soltan M, Dawaba ME, Hafez AT. Complete primary repair of bladder exstrophy: critical analysis of the long-term outcome. Urology. 2018;117:131-136.
Kureel SN, Gupta A, Kumar S, Singh V, Dalela D. A novel midline scroto-perineal approach facilitating innervation preserving sphincteroplasty and radical corporal detachment for reconstruction of exstrophy-epispadias. Urology. 2011;78:668-674.
Youssif M, Badawy H, Saad A, Hanno A, Mokhless I. Single-stage repair of bladder exstrophy in older children and children with failed previous repair. J Pediatr Urol. 2007;3:391-394.
Bharati K, Ashish J, Kumar T, Paras K. Anatomical repair of exstrophy bladder. Pediatr Surg Int. 2004;20:455-459.
Riccabona M, Lusuardi L, Beckers G, Koen M. Blasenekstrophie-Epispadiekomplex: Management und präliminare Ergebnisse. Aktuelle Urol. 2003;34:402-406.
Montagnani CA. Functional reconstruction of exstrophied bladder. Timing and technique. Follow-up of 39 cases. Zeitschrift für Kinderchirurgie. 1988;43:322-330.
Sack BS, Kryger J V, Mitchell ME, Durkee CT, Lyon R, Groth TW. Clinical pathway for early discharge after complete primary repair of exstrophy and epispadias by using a spica cast. J Pediatr Urol. 2015;11:212-e1.
- Abstract Viewed: 770 times
- 8396/pdf Downloaded: 446 times