Early and late complications of bladder exstrophy surgery at Al- Ribat University Paediaric Surgery Center

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1 Early and late complications of bladder exstrophy surgery at Al- Ribat University Paediaric Surgery Center Islam M Mukhtar, MD, MRCSEd *, Omer Alamin, FRCSI, Altahir Bagadi, MD **, Tarig Hassan Haj Ali, MD ** National Hospital of Life, Jizan, Saudi Arabia *, Al-Ribat University Hospital ** ال م ضاع فاث ال م ب كرة وال م تأخرة من عم ل يت جراح يت ف ي ال م ثان ت إك شاف د.اعال ظطف خزبس, غزشف ا ؾ ١ بح ا ؽ عبصا - ا ىخ ا ؼشث ١ خ ا غؼ د ٠ خ ث فغ ١ س. ػ ش اال ١ ؾ ذ خ ١ ش, غزشف ا شثبؽ ا غب ؼ ا غ دا د. ا طب ش ثمبد, غزشف ا شثبؽ ا غب ؼ ا غ دا د. ؽبسق ؽغ ؽبط ػ, غزشف ا شثبؽ ا غب ؼ ا غ دا يقذيح ا ضب خ ا زجزح ػ ١ ت خ م غ ١ ش لبر خ ؽ ي ػالع ب ظ ذ فزشح رئسق ا شػ األؽجبء ؼب. بن ا ؼذ ٠ ذ ا زم ١ بد ا غشاؽ ١ خ ا ز ٠ غش رطج ١ م ب ؼالع ب. ع ذ ف اػبدح رظ ١ ؼ ا ضب خ رؾ ٠ ا ج ي ا ذائ ا ا غزم ١. غ ر ه ظ ا غئاي ا ؾبئش ؽ ي افؼ خ ١ بس ض ١ ش غذي ف ع ١ غ أ ؾبء ا ؼب أوضش ر ه ثب غجخ شػ ا غ دا ١١. Abstract Background Exstrophy of the bladder is a very serious nonlethal anomaly. Many surgical techniques have been applied to manage exstrophy. The objective of this study was to identify early and late complications of bladder exstrophy surgery in Sudan. Methods This is a descriptive, retrospective and prospective small-scale hospital-based study conducted at Al-Ribat University Hospital for 6 years from January 2006 to June The study included 37 patients with urinary bladder exstrophy. The data were collected using a predesigned data sheet and analysed using the software SPSS version 18. Thirty-seven patients were studied, with a male to female ratio of 3:2. Eighteen patients were studied retrospectively, and Results the remaining 19 patients were followed prospectively. Sixty-five percent of the Corresponding author Islam Mustafa Mukhtar jagrio.jawri7@gmail.com their life. Wound infection was an early complication in 17% of patients who underwent primary reconstruction, followed by wound dehiscence in 13% of patients. Only 9% of patients who underwent urinary diversion developed wound dehiscence. Late complications were urinary tract infections (UTIs), which were observed in 60.7% of patients who underwent primary reconstruction, followed by urinary tract stones in 13% of patients. Hydronephrosis was reported in 4.3% of patients and vesicoureteric reflux in 4.3% of patients. The stone impacted in the external opening of 4.3% of patients with primary reconstruction. Urinary tract stones developed in 14.7% of patients who underwent urinary diversion, and UTIs developed in 7.1% of patients. Fifty-two percent of patients with primary reconstruction developed total urinary incontinence, and 48% of patients were partially continent. No urinary incontinence was observed in the patients who underwent urinary diversion. Other rare complications included bowel adhesion, pyelonephrosis, perinephric abscess and vesical fistula. 136

2 Conclusion Diversion is a suitable option for treating bladder exstrophy in those who live far away from surgical services. To ensure acceptable outcomes, patients should be followed up to check for hyperchloremia and malignancy. Keywords: Bladder exstrophy, primary reconstruction, diversion Introduction The success of bladder exstrophy closure depends on many factors, including tensionfree closure, free outlet of urine, secure placement of suprapubic tubes and stents, wound care and avoiding infection, minimising movement and preventing raised intra-abdominal pressure (1,2,3). The size of the urinary bladder and its functional capacity are important factors in determining the final outcome of the surgical intervention. Successful closure of a good sized bladder template is the single most important predictor of eventual voided continence. Wound dehiscence, bladder prolapse and urethral outlet obstruction are the most common complications following primary repair of urinary bladder exstrophy (4). The most recent study in Sudan of urinary bladder exstrophy surgery was a retrospective study at Soba University Hospital which focused on late complications of bladder exstrophy surgery (5). The aim of this study was to identify early and late complications of bladder exstrophy surgery in the Paediatric Surgery Centre at Al-Ribat University Hospital to determine the most suitable procedure for these patients. Patients and Methods This was a descriptive, retrospective and prospective hospital based-study conducted in Al-Ribat University Hospital from January 2006 to June The study population was composed of 37 patients who underwent urinary bladder exstrophy surgery during the defined period of the study. Informed consent was obtained from the patients before performing the surgery. Data were collected using a predesigned questionnaire that covered the following parameters: age, socioeconomic status, family history, presentations and type of surgery. Information was also obtained on early complications, such as wound infection and dehiscence, and late complications, such as stones, reflux, renal failure and hyperchloremia in urinary diversion group. Primary reconstruction was done in stages and started by simple closure of bladder and the abdominal wall, followed by epispadias repair after six months and later bladder neck reconstruction (BNR). Diversion involved uretero-rectal end to side anastomosis with anti-reflux tunnelling and nippling of the ureter, followed by cystectomy after six months. Diversion was performed in patients with failed primary reconstruction. Results Thirty-seven patients participated in this study. Eighteen of these were followed retrospectively, and 19 were followed prospectively. In those followed retrospectively, 12 underwent primary reconstruction, 4 underwent diversion, and 2 underwent both procedures. In those followed prospectively, 11 underwent primary reconstruction, 4 underwent diversion, and 4 underwent both procedures. Two-thirds of the patients presented in the neonatal period, and two-thirds (32.5%) were presented in the first year of life. More than 17% of the patients were presented at age less than 5 years. Over 17% of the patients were presented at age more than 5 years (17.5%) (mean /- STD deviation ). More than half of the patients (60%) came from central areas of Sudan. Two-thirds (72.5%) resided in central Sudan, and 10%, 7.5%, 5% and 5% resided in the north, west, east and south, respectively. Two-thirds (67.5%) of the patients in the study had low socioeconomic status. In the initial assessment, all the patients presented with continual wetting (Table 1). Early complications, including wound 137

3 dehiscence and infection, were found in 27.3% and 18.2% of patients, respectively, who underwent primary reconstruction and were followed retrospectively. In contrast, 37.5% of patients in the diversion group who were followed prospectively developed early complications (Tables 2 and 3). Table 1: Initial assessment of patients who underwent bladder exstrophy surgery in Al-Ribat University Hospital Paediatric Centre (n=37). Continual wetting since birth % Positive family history 1 2.5% Normal rectal control % Pain in one or both loins 1 2.5% Episode of febrile illness % Febrile 4 10% Waddling gait 26 65% Bladder only exposed % Bladder mucosa show polyps % Groin hernia 8 20% Testis descended to scrotum 24 (n=26) 92% Anterior displaced anus % Rectal prolapsed present 2 5% Competent rectal sphincter 3 95% Palpable Rt or Lt kidney 0 0% Table 2: Early and late postoperative complications in the primary reconstruction group prospectively followed after bladder exstrophy surgery in Al- Ribat University Hospital Paediatric Centre (n=11). Wound dehiscence % Wound infection % Totally incontinent % Vesico-ureteric reflux % Rt or Lt hydronephrosis 0 0% Urinary stone % Recurrent urinary tract infection(uti) % Normal renal function % Urethral stenosis 0 0% Slip of ureteric stent 0 0% Vesical fistula 0 0% Table 3: Early and late postoperative complications in the diversion group prospectively followedafter bladder exstrophy surgery in Al-Ribat University Hospital Paediatric Centre (n=8). Wound infection % Total continence 8 100% Unable to void and defecate separately 8 100% Clinical evidence of UTI 2 25% Dilated both ureteric in intravenous urography 0 (n=2) 0% (IVU) Dilated calyceal system (IVU) 0 (n=2) 0% Stone (IVU) 0 (n=2) 0% Hyperchloremia 0 (n=2) 0% Slip of ureteric stent 2 25% Discussion Wound infection was the most common early complication following primary reconstruction for urinary bladder exstrophy, occurring in 18.2% of the patients followed retrospectively and in 18.2% of those followed prospectively. In those who underwent urinary diversion and were followed prospectively, wound infection occurred in 37.5% of the patients. None of the patients who underwent primary reconstruction and diversion developed wound infection. The second most common complication was wound dehiscence, which was observed in 13% of the patients retrospectively and in 27.3% of the patients prospectively. It occurred in 33% of the patients who underwent both procedures. The study by Suliman did not focus on early complications. They identified late complications following primary reconstruction for urinary bladder exstrophy in two patients: an adhesive small bowel obstruction and a perinephric abscess. In the patients who underwent primary reconstruction 45.5% were continent after the procedure. In those followed prospectively, urinary continence was achieved in 9.1% of the patients. Similar results were achieved by 138

4 Kramer who reported good urinary continence in 17% of patients (total number of patients 103) (6). Adalen et al found good urinary continence in 45% of patients in their study (7), and Suliman observed good urinary continence in 75% of patients. All the patients who underwent urinary diversion in study group were continent compared to Suliman s study which were 91% of the patients were continent, and 83% of the patients were continent in Kramer s study (6). In our study recurrent urinary tract infections (UTIs) were observed in 63.3% of the patients who underwent primary reconstruction and in 81.8% of the patients who were followed prospectively. In the diversion group, UTIs were reported in 14.3% of the patients in the retrospective group and in 25% of the patients who were followed prospectively. Spence reported UTIs in 54% of patients (total number of patients 26) in their study (8). In the Suliman s study, 45% of the patients who underwent diversion suffered from recurrent UTIs. Adalen et al reported chronic UTIs and a dilated upper urinary tract in 30% of patients (7). UTIs were observed only in 16.7% of patients who underwent primary reconstruction and urinary diversion. Kamal reported urinary bladder stones in 47% of patients in their study (total number of patients 12) (9). They observed hydronephrosis in only one patient who underwent diversion compared with 38% of the patients in Suliman s study. In a study conducted in 1966, Spence found that 50% of patients (total number of patients 26) had varying degrees of collecting system deterioration.(7) Only one patient had urethral stenosis, one patient had vesical fistula, and one patient had pyelonephritis in our study compared to Kamal study who found that four patients had vesical fistulae, and three patients had urethral stricture (total number of patients 12). No clinical or biochemical evidence of hyperchloremia in our study of people, this may be explained by low implantation of the ureter in the rectum decreasing the reabsorption of chloride because of the small space of the rectum compared to the sigmoid. The hot climate where the study was conducted also likely played a major role in this finding through the excretion of chloride due to excessive sweating. Gearhart and Jeffs stated that clean intermittent catheterization, combined with bladder augmentation and continent stoma creation, represents a feasible salvage procedure for carefully selected exstrophy patients with persistent upper urinary tract changes, small bladder capacity and urinary incontinence (10). This procedure is difficult to apply in our population because of the cost effectiveness of the catheter. In addition, in the present study, 67.5% of the patients were of low socioeconomic status. It is difficult to educate mothers with low economic status about clean catheterisation. Therefore, we performed diversion rather than primary reconstruction for those who presented late in life. This approach works well at our hospital because it ensures patients satisfaction, enabling them to void and defecate separately (85.7%) and to achieve complete dryness postoperatively (100%). Natural sphincters can be used that differentiate between air, fluid and hard stool. Long-term follow-up is necessary to check for clinical or biochemical evidence of hyperchloremia, as well as potential malignancy (colorectal). Modern staged reconstruction of bladder exstrophy described by Mitchell consists of primary bladder closure in infancy, epispadias repair between 6 and 12 months of age and bladder neck reconstruction around age of 5 years when the child exhibits a desire to be dry and bladder capacity is greater than 80 ml (11). We considered performing this staged reconstruction in our study population because most (65%) patients were presented before they are one year old. It can also avoid complications of one-stage reconstruction. 139

5 In conclusion, wound infection was the most common early complication, followed by wound dehiscence, adhesive small bowel obstruction and perinephric abscess. Late complications were recurrent UTIs, urinary stones, urethral stricture, vesical fistula and pyelonephritis. Diversion is considered to be a References 1. Gearhart JP, Ben-Chaim J, Sciortino C, Sponseller PD, Jeffs RD. The multiple reoperative bladder exstrophy closure: what affects the potential of the bladder? Urology 1996;47:240e3. 2. 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;142:522e4. 3. Gearhart JP, Jeffs RD. Management of the failed exstrophy closure. J Urol 1991;146:610e2. 4. David JH, Todd P, John PG. Complications of surgical reconstruction of the exstrophy epispadias complex. J Pediatric Urol 2008;4: Sulieman H, original thesis of bladder exstrophy surgery, not publish, Kramar SA. Overview: exstrophy and epispadias. In: current operative urology. better of the postoperative dryness following the procedure. It also eliminates any potential of a bad odour. Long-term follow up is mandatory for those who undergo diversion because of the potential risk of developing vesico-ureteric reflux, hyperchloraemia and malignancy. Philadelphia: JB Lippincott Co.; 1992.p Adalen RJ, O`phelan EH, Chisholm TC, McParland FA, Sweeter TH. Exstrophy of the bladder: long term result of bilateral iliac osteotomy and two stage anatomic repair. Clin Orthop J 1980;151: Spence HM. Ureterosigmoidostomy for bladder; result in personal series of cases. Br J Urolo 1966;38(1): Kamal JS. Staged management of bladder exstrophy. JKAU Med Sci 2009;16(1): Gearhart JP, Jeffs RD. Augmentation cystoplasty in the failed exstrophy reconstruction. J Urol 1988;139(4): Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: a contemporary series. J Pediatric Urol 2007;3(4):311e5. 140