Evaluation of the bony pelvis in classic bladder exstrophy by using 3D-CT: further insights.

OBJECTIVES: To provide a complete look at the bony pelvis in children with classic bladder exstrophy: dimensions, orientation, and relationships. METHODS: Three-dimensional computed tomography was used in 6 boys and 1 girl, 5 of whom underwent primary closure and 2 who underwent reclosure at 4 and 8 months. These exstrophy pelves (intrapelvic angles and osseous dimensions) were compared with 26 age and sex-matched controls. RESULTS: The iliac wing angle was 11.4 degrees larger in the classic bladder exstrophy cases. The sacroiliac joint angle was 9.9 degrees more externally rotated in the exstrophy cases. The pelvis was rotated 14.7 degrees in the superoinferior plane in the exstrophy cases. The mean pubic diastasis was 4.2 cm (0.6 cm in controls). The inter-triradiate distance in the patients with classic bladder exstrophy averaged 6.0 cm (4.2 cm in controls). CONCLUSIONS: These new findings provide a better understanding of the bony pelvis, especially its posterior portion, in patients with classic bladder exstrophy. The results of this study revealed the orientation of the sacroiliac joints to be more externally oriented than previously thought and the pelvis to be rotated inferiorly, a previously unknown observation. Both of these factors will be important in the planning of newer osteotomies and pelvic reconstruction.

Modified Young-Dees-Leadbetter bladder neck reconstruction: new concepts about old ideas.

INTRODUCTION: The modern Young-Dees-Leadbetter bladder neck reconstruction is a procedure that has evolved during the past 82 years. During this time, the modifications and contributions of several urologic surgeons have improved the procedure and ultimate patient outcomes. We review the evolution and describe in detail our version of the Young-Dees-Leadbetter bladder neck reconstruction procedure. TECHNICAL CONSIDERATIONS: Optimally, patients should have a minimal bladder capacity of 85 mL and be mature enough to participate in a postoperative voiding program. Adequate radical exposure of the lateral aspects of the bladder and bladder neck are important. Cephalotrigonal or cross-trigonal ureteral reimplantation is typically performed to mobilize the ureters in relation to the proposed bladder neck and correct reflux. A mucosal template 15 mm wide by 30 mm long is created that will serve as the reconstituted posterior urethra and bladder neck. Triangular lateral bladder mucosal wedges are marked and demucosalized. The neourethra is closed over an 8F Firlit tube. The demucosalized flaps are brought over the urethra sequentially in a "vest-over-pants" fashion with the final layer consisting of suspension sutures. Finally, ureteral stents and a suprapubic tube are used, but no urethral catheter is left in place. CONCLUSIONS: The modern Young-Dees-Leadbetter bladder neck reconstruction is the result of the contributions of various urologic surgeons during 82 years. When patients are appropriately selected, it is an effective method of lower urinary tract reconstruction in cases of congenital urinary incontinence.

Pelvic floor anatomy in classic bladder exstrophy using 3-dimensional computerized tomography: initial insights.

PURPOSE: We present the pelvic floor anatomy of the major pelvic floor musculature in classic bladder exstrophy, including the levator ani, obturator internus and obturator externus. By improving our knowledge of pelvic floor anatomy we hope to understand better the relationship of the pelvic floor to the bony anatomy as well as the role of osteotomy in changing pelvic floor anatomy to enhance urinary control after surgery. MATERIALS AND METHODS: 3-Dimensional computerized tomography was done in 6 boys and 1 girl, including 5 patients 2 days to 5 months old (mean age 7 months) undergoing primary closure and 2 who were 4 and 8 years old undergoing repeat closure. The pelvic floor musculature, including the levator ani, obturator internus and obturator externus, in these cases was compared to that in 26 age and sex matched controls. RESULTS: The levator ani musculature encompasses a significantly wider area of 9.5 cm.2 in patients with classic bladder exstrophy than in controls. The anterior segment of the levator ani was shorter (1.2 cm.) and the posterior segment of the levator ani was longer (2.5 cm.) than in controls. The degree of divergence of the levator ani in classic exstrophy was significantly more outwardly rotated (38.8 degrees) than controls. In addition, the transverse diameter of the levator hiatus was 2-fold that in our control group and in that of published controls, while the length of the hiatus was 1.3-fold that in normal controls. There was also significant flattening, involving a 31.7 degree decrease in steepness between the right and left halves of the levator ani, of the puborectal sling in classic bladder exstrophy versus controls. Because of these findings, there is more anterior superior rotation in the pelvic floor in exstrophy cases. The obturator internus was more outwardly rotated (15.1 degrees) in exstrophy and the obturator externus also showed more outward rotation (16.9 degrees) than in controls. CONCLUSIONS: This study provides better understanding of the pelvic floor anatomy in classic bladder exstrophy. Significant differences have been documented in the pelvic floor in classic bladder exstrophy cases and controls. Hopefully these differences may have a pivotal role in providing new insight into long-term issues, such as urinary and fecal incontinence, and pelvic organ prolapse, in classic bladder exstrophy.