CompletePrimaryRepairofExstrophy:Pitfallsand
PracticalitiesDouglasA.Canning,MDJosephG.Borer,MDDanaA.Weiss,MD
TheHendren Project,February28,2018
SessionStructure
• Topic1Discussion:• GoalsofCompletePrimaryRepairofExstrophy• PitfallsofCPRE
• Casediscussion:• Case1:nearmiss– glansischemia• Case2:Protocolchangetoaddressthenearmiss
• Topic2Discussion:• Utility/Futilityofureteralreimplant duringCPRE
• CaseDiscussion:• Case1:Cephalo-trigonalreimplants attimeofsurgery• Case2:Delayedcephalo-trigonalreimplants
Hendren ProjectWebinarGoals
• Audienceparticipation!• Makessessionmoredynamic,interesting,andvaluable• ParticipateintheQuestion polls--allanswersareanonymous!
• PleaseusetheCOMMENTS&QUESTIONSbox(locatedontherightsideofthescreen)toaskasmanyquestionsandtoofferasmanyopinionsaspossible!
Background:TheDelayedCompleteRepair
• CPREdescribedin1998byMitchell• Closureofbladder• Reconstructionofbladderneck• Urethroplasty• Epispadiasrepair
• Goal:• Createappropriatebladderoutletresistance• Allowfornormalbladdercyclingfromearlyage• Allowforoptimalbladdergrowthanddevelopment
Background– ConcernswithCPRE
• Immediateconcerns:• Dehiscence• PenileIschemiaà Glans/CorporalInjury• Balancebetweentootightandtooloose(bladderneck)
• Laterconcerns:• Highvolumereflux• Persistentincontinence
Question1:
• Howdoyoucloseaprimarybladderexstrophy?A. CPREB. ModernstagedrepairC. KellyprocedureD. Primarydiversion(MainzII)
Question2:
• WhatisyourbiggestconcernduringaCPRE?A. BladderdehiscenceB. GlansischemiaC. UrethralfistulaD. Penopubic fistulaE. Lackofbladdergrowthovertimeduetopooroutlet
resistance
Topic1:Penileischemia
EarlyExperiences:BigConcerns• Twodehiscences• bothinboyswithoutosteotomy
• Twoglans/corporalinjuries• onefollowingseparation• onein6montholdwithepispadiaswhohadthesymphasis splitaspartoftherepairwithoutosteotomy
• Takeaways:• CPREcanbereallydangerous• Osteotomyiscriticaltosafeclosure
Glans/corporalinjury
Husman,Gearhart:J.Urol.172(4Pt2):1696-700;discussion1700-1,2004Oct.
Newbornwithepispadias:• Primaryclosurewithepispadiasrepair• Noosteotomy• Bladderneckreconstruction• Completedissassembly withanatomicalclosure
• Whatdoyoudotopreventglansandcorporalischemia?A. Don’tclosepubicsymphysisB. PosteriorosteotomyC. AnteriorosteotomyD. LeaveagapinpubisifthereissignofischemiaE. Sprinklepapaverine onpenisduringclosure
Question3:
“BeNo”Event
• Howtoavoidthe”BeNo”Event• KeepGlansintact• Temperedclosureofpubis• Inciseglanstowatchforbleeding• BEAWAREofthepotential,andopenthepubisiftheglansappearsdusky
ACautionaryTale
Topic2:CPREwithBilateralUreteral
Reimplant
Theconcurrentre-implantation
• Cephalotrigonal technique• DescribedbyCanningandJeffs in1993
• DoneattimeofCPRE• DescribedbyBragaandPippi Sallein2010
ConcurrentCPRE-BURoutcomes
• Doyoudoaureteralreimplantation atthetimeofCPRE?A. YesB. NoC. DependsonbladdersizeD. Dependsonbladderpolyps
Question4:
There-implantquestion
PRO• Allowsbladdertocycleefficiently• Avoidsprogressiveureteraldilationduringcycling• MaypreventUTI’s
Con• Smallbladderplatemaynotallowforlongtunnel• Persistentrefluxmayoccur• Addstimetoalreadylongprocedure
BURatCPRE– caseforandagainstinBoyandGirl
Thankyouforyourparticipation!