Despite more than a century of study, the problem of surgical correction of bladder exstrophy remains highly relevant. Bladder exstrophy is a complex congenital anomaly occurring in approximately 1 in 15,000–40,000 newborns. The optimal timing of surgical correction and the most effective surgical techniques remain subjects of ongoing discussion. This is largely due to the high rate of unsatisfactory functional outcomes, particularly regarding urinary continence, as well as severe complications involving the urinary system, including infections caused by the mixing of urine and feces. The large number of proposed surgical techniques indicates that a universally satisfactory method for correcting this defect has not yet been established 1–3. Currently, two principal approaches to the surgical correction of bladder exstrophy are recognized: reconstruction of the bladder using local tissues and the creation of an artificial bladder. Reconstruction using local tissues is considered the most physiological approach and represents a promising direction for further research. However, successful implementation of this technique requires an adequately sized bladder plate. Surgical correction is recommended within the first 72 hours of life and should include restoration of the pubic symphysis and formation of the internal urethral sphincter. These procedures are lengthy and therefore require careful consideration of anesthetic risks 4. The second surgical strategy involves the creation of an artificial bladder using intestinal segments. A significant limitation of these procedures is the increased risk of urinary tract infection, which may lead to secondary renal damage and chronic renal failure 1–4. According to most treatment approaches, regardless of bladder plate size, correction should initially involve reconstruction using local tissues during the first week of life. Some authors recommend simultaneous correction of epispadias during bladder reconstruction. If microcystis persists after neonatal surgery and urinary incontinence remains unresolved, secondary reconstructive surgery for bladder creation may be required. Between 2000 and 2016, 49 children with bladder exstrophy were treated at our clinic. Ten neonates aged 2–12 days underwent bladder reconstruction using local tissues. Postoperative complications occurred in five patients. In two cases, wound dehiscence occurred together with disruption of the sutured bladder plate. In one of these cases, symphyseal reconstruction had not been performed, while the second patient underwent surgery on the 10th day of life in the presence of inflammatory changes of the bladder mucosa caused by fungal infection. In one child at the age of six months, agitation resulted in evagination of the bladder through a 0.3 cm defect in the anterior abdominal wall, accompanied by strangulation of the protruding bladder segment, which necessitated emergency removal of the native bladder. In two children, the reconstructed bladder demonstrated poor functional capacity, with persistent urinary incontinence and recurrent exacerbations of chronic urinary tract infections. These patients continue to undergo follow-up and rehabilitation therapy while further treatment strategies are being considered. In the remaining patients, the surgical outcomes were considered satisfactory. Surgical creation of an artificial bladder was performed in 15 children aged 2–8 years, with simultaneous formation of the urethra. Five children underwent surgery after the age of 10 years, including three who had previously undergone unsuccessful reconstruction using local tissues. In 14 patients aged 8 months to 1 year, an artificial bladder was created using a surgical technique developed at our clinic, with satisfactory results. Three children who had previously undergone surgery using an earlier technique developed at the clinic 5 required reconstruction of the neourethra using an improved method due to retraction of the inter-reservoir septum. Two children previously operated on at other institutions using the A.V. Melnikov technique 1 presented with urinary incontinence, fecal stone formation, and severe urinary tract infections. Both required repeat reconstructive surgery using the technique developed at our clinic. Reconstruction was performed at ages 12 and 14 years, respectively. We developed a surgical method for the treatment of bladder exstrophy (Patent No. 30906, March 11, 2008) 6. The procedure is performed as follows. A lower midline laparotomy is performed, followed by isolation of the bladder plate and transection of the urachus. The sigmoid colon is mobilized with sufficient length to allow placement in the perineal region. The rectum is transected at the junction with the sigmoid colon, and the proximal end is sutured. The ureters are implanted into the isolated segment of sigmoid colon, which is positioned laterally. A reservoir is then created from the sigmoid colon and closed with a double-layer suture. The newly formed reservoir is positioned and fixed at the level of the anterior peritoneal fold. Demucosation of the rectum is performed distally along nearly the entire semicircumference, leaving a narrow strip of mucosa no more than 1 cm wide at the 5–6 o'clock position. The separated mucosa is excised from the perineal side. The sigmoid reservoir is brought down intrarectally and secured with cutaneous-mucosal sutures around the anal circumference and the newly formed urethra. From the abdominal cavity, the edges of the incised muscular layer of the rectum are sutured to the transposed intestine, and the pelvic floor is peritonized. During the procedure, the newly formed reservoir is irrigated with a 1–2% povidone-iodine solution. As a result, the neo-formed urethra and the transposed intestinal reservoir are positioned within the rectal sphincter complex, providing urinary continence while preventing the mixing of urine and feces. Surgical outcomes were evaluated one year after the procedure. Long-term follow-up was available for 12 children over a period of seven years. Outcome assessment included patient complaints and standard clinical criteria: urinary and fecal continence, absence of urine–feces mixing, condition of the upper urinary tract assessed by ultrasound and excretory urography, and laboratory results of blood and urine tests. In recent years, endoscopic evaluation of the newly formed bladder reservoir has also been performed. Among the examined patients, outcomes were considered good in eight cases and satisfactory in four cases. Conclusions Reconstruction of bladder exstrophy using local tissues represents the most physiological surgical approach. Surgical creation of an artificial bladder belongs to the category of reconstructive plastic procedures. Among the currently proposed techniques, the method developed at our clinic has demonstrated the most favorable outcomes.
Danshyn et al. (Fri,) studied this question.