0022-5347/91/1452-0350$03.00/0 Vol. 145, 350-352, February 1991 Printed in U. S.A.
THE JOURNAL OF UROLOGY Copyright © 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
DETERMINANTS OF SUCCESS P. A. MERGUERIAN, G. A. McLORIE, N. D. McMULLIN, A. E. KHOURY, D. A. HUSMANN B. M. CHURCHILL
AND
From the Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT
We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61 % were continent based on a significantly higher urethral continence length (25.8 ± 6.4 mm., mean plus or minus standard error) and a higher urethral closing pressure (69.4 ± 5.8 em. water) compared to the incontinent male population (11.4 ± 3.1 mm. and 43.4 ± 4.6 em. water). No significant difference was noted in the bladder capacity of these 2 groups. Of the female population 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 ± 4.4 mm.) and a higher urethral closing pressure (62.7 ± 10.2 em. water) compared to the incontinent female subjects (8.4 ± 2.5 mm. and 32.7 ± 6.9 em. water). Moreover, those who were continent had a significantly higher bladder capacity (201.2 ± 39.5 m!.) compared to those who were incontinent (84.3 ± 23.6 mI.). These findings support a multifactorial mechanism in achieving continence but they suggest that of all the factors urethral length may be the most important. KEY WORDS:
bladder exstrophy, urinary incontinence
The fundamental objectives of surgical reconstruction for bladder exstrophy are closure of the abdominal wall defect, achievement of urinary continence and preservation of renal function. 1 Success in the creation of adequate urinary storage and emptying is of primary importance to the over-all result. The accepted form of treating bladder exstrophy today is the staged approach as advocated by Jeffs. 2 Shortly after birth the bladder and abdominal wall are closed primarily with or without osteotomy. At about age 3 years and if the bladder capacity is greater than 60 mI., the urethral continent mechanism is reconstructed as a second stage. In the male patient the epispadias is repaired as a third procedure. Also, if the bladder capacity is less than 60 mi. the epispadias is repaired first to provide slightly more resistance to bladder emptying and, thus, increase the bladder capacity. The most successful procedure to date for reconstructing the urethral control mechanism is the Young-Dees-Leadbetter procedure. 3- 5 In patients with small bladders, late closure and multiple closures adequate bladder capacity may not develop after stage 1 reconstruction to allow one to proceed and reconstruct the urethral control mechanism. These patients will require bladder augmentation to provide adequate urinary storage. 6 In an effort to define further the characteristics associated with the achievement of continence, we have compared the urodynamic findings in our exstrophy patients after completion of reconstruction. MATERIALS AND METHODS
Between 1957 and 1987, 136 cases of bladder exstrophy were treated at our institution. Since the early 1970s these patients have undergone planned staged reconstruction. A total of 37 patients who had completed staged reconstruction and who were evaluated urodynamically after reconstruction were available for analysis. Cystometry was performed using carbon dioxide as a filling medium at an intermediate flow rate of 100 mi. per minute as previously described7 ,8 and a constant 'flow cystometrogram. Urethral pressure profiles were measured with a triple lumen 7F urethral catheter with a pull rate of 5 cm. per minute. The parameters studied were b ladder capacity, urethral closing presAccepted for publication August 17, 1990.
sure and urethral continence length. Bladder capacity was defined as the volume of fluid infused into the bladder until leakage of urine through the urethra occurred. In patients with no urethral control mechanism bladder capacity was defined as the volume of fluid needed to reach a bladder pressure of 40 cm. water when the bladder neck was occluded. All patient records were reviewed to determine current continent status. Continence was defined as being completely dry for a minimum of 3 hours without the need for mechanical or pharmacological aids. Patients who had bladder augmentation were excluded as were patients on clean intermittent catheterization. The patients were divided into 4 groups: continent boys, continent girls, incontinent boys and incontinent girls. The relationship of bladder capacity, urethral continence length and urethral closing pressure to continence status was examined and represented graphically in each group. The results obtained were subjected to statistical analysis using the unpaired Student t test. RESULTS
A total of 19 girls and 18 boys who had undergone complete urodynamic evaluation after staged reconstruction were available for analysis. Of the male population 11 (61 %) were continent. When compared to the incontinent male population they had a statistically significant longer urethral continence length (25.8 ± 6.4 versus 11.4 ± 3.1 mm., p
THE JOURNAL OF UROLOGY Copyright © 1991 by AMERICAN UROLOGICAL ASSOCIATION, INC.
DETERMINANTS OF SUCCESS P. A. MERGUERIAN, G. A. McLORIE, N. D. McMULLIN, A. E. KHOURY, D. A. HUSMANN B. M. CHURCHILL
AND
From the Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT
We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61 % were continent based on a significantly higher urethral continence length (25.8 ± 6.4 mm., mean plus or minus standard error) and a higher urethral closing pressure (69.4 ± 5.8 em. water) compared to the incontinent male population (11.4 ± 3.1 mm. and 43.4 ± 4.6 em. water). No significant difference was noted in the bladder capacity of these 2 groups. Of the female population 57.9% were continent. They also demonstrated a higher urethral continence length (21.1 ± 4.4 mm.) and a higher urethral closing pressure (62.7 ± 10.2 em. water) compared to the incontinent female subjects (8.4 ± 2.5 mm. and 32.7 ± 6.9 em. water). Moreover, those who were continent had a significantly higher bladder capacity (201.2 ± 39.5 m!.) compared to those who were incontinent (84.3 ± 23.6 mI.). These findings support a multifactorial mechanism in achieving continence but they suggest that of all the factors urethral length may be the most important. KEY WORDS:
bladder exstrophy, urinary incontinence
The fundamental objectives of surgical reconstruction for bladder exstrophy are closure of the abdominal wall defect, achievement of urinary continence and preservation of renal function. 1 Success in the creation of adequate urinary storage and emptying is of primary importance to the over-all result. The accepted form of treating bladder exstrophy today is the staged approach as advocated by Jeffs. 2 Shortly after birth the bladder and abdominal wall are closed primarily with or without osteotomy. At about age 3 years and if the bladder capacity is greater than 60 mI., the urethral continent mechanism is reconstructed as a second stage. In the male patient the epispadias is repaired as a third procedure. Also, if the bladder capacity is less than 60 mi. the epispadias is repaired first to provide slightly more resistance to bladder emptying and, thus, increase the bladder capacity. The most successful procedure to date for reconstructing the urethral control mechanism is the Young-Dees-Leadbetter procedure. 3- 5 In patients with small bladders, late closure and multiple closures adequate bladder capacity may not develop after stage 1 reconstruction to allow one to proceed and reconstruct the urethral control mechanism. These patients will require bladder augmentation to provide adequate urinary storage. 6 In an effort to define further the characteristics associated with the achievement of continence, we have compared the urodynamic findings in our exstrophy patients after completion of reconstruction. MATERIALS AND METHODS
Between 1957 and 1987, 136 cases of bladder exstrophy were treated at our institution. Since the early 1970s these patients have undergone planned staged reconstruction. A total of 37 patients who had completed staged reconstruction and who were evaluated urodynamically after reconstruction were available for analysis. Cystometry was performed using carbon dioxide as a filling medium at an intermediate flow rate of 100 mi. per minute as previously described7 ,8 and a constant 'flow cystometrogram. Urethral pressure profiles were measured with a triple lumen 7F urethral catheter with a pull rate of 5 cm. per minute. The parameters studied were b ladder capacity, urethral closing presAccepted for publication August 17, 1990.
sure and urethral continence length. Bladder capacity was defined as the volume of fluid infused into the bladder until leakage of urine through the urethra occurred. In patients with no urethral control mechanism bladder capacity was defined as the volume of fluid needed to reach a bladder pressure of 40 cm. water when the bladder neck was occluded. All patient records were reviewed to determine current continent status. Continence was defined as being completely dry for a minimum of 3 hours without the need for mechanical or pharmacological aids. Patients who had bladder augmentation were excluded as were patients on clean intermittent catheterization. The patients were divided into 4 groups: continent boys, continent girls, incontinent boys and incontinent girls. The relationship of bladder capacity, urethral continence length and urethral closing pressure to continence status was examined and represented graphically in each group. The results obtained were subjected to statistical analysis using the unpaired Student t test. RESULTS
A total of 19 girls and 18 boys who had undergone complete urodynamic evaluation after staged reconstruction were available for analysis. Of the male population 11 (61 %) were continent. When compared to the incontinent male population they had a statistically significant longer urethral continence length (25.8 ± 6.4 versus 11.4 ± 3.1 mm., p
