Anterior perineal reconstruction in exstrophy-epispadias complex.

OBJECTIVES: To assess the role of correct anatomical reconfiguration of the anterior perineal musculature in exstrophy-epispadias (E-E) patients. To stress the use of a bipolar stimulator to detect the perineal muscular complex intraoperatively, and to increase the functional results of reconstruction in E-E patients.

METHODS: A total of 22 patients with E-E complex were treated in a 7-year period: 17 patients presenting classic bladder extrophy (aged 3 days to 6 years) and 5 incontinent male epispadias (aged 9 months to 16 years). An electric bipolar stimulator was used to identify and reapproximate at the midline the muscular fibers that constitute the periurethral muscular complex, as a part of the anterior perineal membrane. Outcome was evaluated at 24 months from surgery, considering bladder capacity, dry intervals, urinary infections (UTI's), upper tract deterioration and surgical complications (fistula, obstruction, dehiscence). Results were compared with a matched group of 19 E-E patients treated in the previous 5-year period, without the presented technique (control group). Student T-test was used for statistical analysis, considering p<or=0.05 as significant.

RESULTS: No bladder neck or urethral dehiscence was observed. Mean bladder capacity at 2-year follow-up was 80 cc in the exstrophic patients and 120 cc in the male epispadias. Mean dry interval increased to 75 minutes in the exstrophy patients and to 130 minutes in the male epispadias. Full daytime continence was achieved in 3 exstrophic and in all the epispadic patients. The difference with the control group of patients was significant (p<0.05).

CONCLUSIONS: Proper identification of the anterior perineal muscular complex, using a bipolar stimulator, and its reapproximation at the posterior urethra on the midline was demonstrated to be effective in increasing bladder cycling and in developing adequate bladder volume, anticipating coordinated micturition.