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We report a case of secondary urinary reconstruction of previously separated conjoined twins with exstrophic bladder and urinary incontinence. Patients were male and aged 13-year-old. Twin one had a history of failed enterocystoplasty that extruded and was visible like an exstrophic neobladder. He underwent a procedure to close bladder neck and reconfigure abdominal wall. After the procedure the patient developed a fistula that was treated, but it persisted and, for this reason, a catheterizable pouch was constructed and native bladder was discarded. Twin two required the immediately construction of catheterizable pouch using the Macedo's technique. Currently, both patients are continent at 4 hour intervals. The mean follow-up was 8 months. Modern continent urinary diversion techniques offer new perspectives and hope for such complex population.

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ABSTRACT Objective To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstro- phy cases, and to compare the results with the application of low-barrier wrap. Materials and Methods Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps. Results The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC. Conclusion Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more "exstrophy-friendly".

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This video provides a case report of a 3 year old girl with epispadia and the highlights of the surgery. A cystoscopic guided bladder neck plication was performed to achieve continence. Key points include: (1) Skin incision planning; (2) Cutaneous flap liberation to create a new urethra; (3) Complete bladder neck release to allow a controlled plication; (4) Use of cystoscopy to achieve the ideal bladder neck closure; (5) Bladder neck manipulation to achieve continence.

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OBJECTIVE: To assess the role of high-barrier plastic wrap in reducing the number and size of polyps, as well as decreasing the inflammation and allergic reactions in exstrophy cases, and to compare the results with the application of low-barrier wrap. MATERIALS AND METHODS: Eight patients with bladder exstrophy-epispadias complex (BEEC) that had used a low density polyethylene (LDPE) wrap for coverage of the exposed polypoid bladder in preoperative care management were referred. The main complaint of their parents was increase in size and number of polyps. After a period of 2 months using the same wrap and observing the increasing pattern in size of polyps, these patients were recommended to use a high-barrier wrap which is made of polyvinylidene chloride (PVdC), until closure. Patients were monitored for the number and size of polyps before and after the change of barriers. The incidence of para-exstrophy skin infection/inflammation and skin allergy were assessed. Biopsies were taken from the polyps to identify histopathological characteristics of the exposed polyps. RESULTS: The high barrier wrap was applied for a mean ± SD duration of 12±2.1 months. Polyps' size and number decreased after 12 months. No allergic reaction was detected in patients after the usage of PVdC; three patients suffered from low-grade skin allergy when LDPE was applied. Also, pre-malignant changes were observed in none of the patients in histopathological examination after the application of PVdC. CONCLUSION: Polyps' size and number and skin allergy may significantly decrease with the use of a high-barrier wrap. Certain PVdC wraps with more integrity and less evaporative permeability may be more "exstrophy-friendly".

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ABSTRACT We report a case of secondary urinary reconstruction of previously separated conjoined twins with exstrophic bladder and urinary incontinence. Patients were male and aged 13-year-old. Twin one had a history of failed enterocystoplasty that extruded and was visible like an exstrophic neobladder. He underwent a procedure to close bladder neck and reconfigure abdominal wall. After the procedure the patient developed a fistula that was treated, but it persisted and, for this reason, a catheterizable pouch was constructed and native bladder was discarded. Twin two required the immediately construction of catheterizable pouch using the Macedo's technique. Currently, both patients are continent at 4 hour intervals. The mean follow-up was 8 months. Modern continent urinary diversion techniques offer new perspectives and hope for such complex population.

RESUMO Relata-se caso de reconstrução urinária em gêmeos siameses previamente separados com apresentação clínica de bexiga extrófica e incontinência urinária. Os dois pacientes eram do sexo masculino com idade de 13 anos. O primeiro gêmeo apresentava falha da enterocistoplastia com extrusão e visualização da neobexiga extrófica, tendo sido submetido ao fechamento do colo vesical e à reconfiguração da parede abdominal. Após o procedimento, o paciente desenvolveu fístula, que foi tratada, mas persistiu. Posteriormente, optamos por bolsa cateterizável, descartando a bexiga nativa. O segundo gêmeo foi submetido à construção imediata de bolsa cateterizável, por meio da técnica de Macedo. Atualmente, ambos os pacientes estão continentes em intervalos de 4 horas. O seguimento médio foi de 8 meses. As atuais técnicas de derivação urinária oferecem novas perspectivas e esperança para esta população complexa.

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ABSTRACT Purpose: This study was to confirm the safety and efficacy of BC dressing when used in surgical male wound healing at the urogenital area. Methods: Open, non-controlled clinical study of phase II. A total of 141 patients, among those children, adolescents and adults with hypospadias (112), epispadias (04), phymosis (13) and Peyronie's disease (12) that had a BC dressing applied over the operated area after surgery. A written informed consent was obtained from all participants. Study exclusion criteria were patients with other alternative treatment indications due to the severity, extent of the injury or the underlying disease. The outcomes evaluated were efficacy, safe and complete healing. The costs were discussed. Results: In 68% patients, the BC dressing fell off spontaneously. The BC was removed without complications in 13% of patients at the outpatient clinic during the follow-up visit and 17% not reported the time of removal. In 3% of the cases, the dressing fell off early. Complete healing was observed between 8th and 10th days after surgery. The BC dressings have shown a good tolerance by all the patients and there were no reports of serious adverse events. Conclusion: The bacterial cellulose dressings have shown efficacy, safety and that can be considered as a satisfactory alternative for postoperative wound healing in urogenital area and with low cost.

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PURPOSE: This study was to confirm the safety and efficacy of BC dressing when used in surgical male wound healing at the urogenital area. METHODS: Open, non-controlled clinical study of phase II. A total of 141 patients, among those children, adolescents and adults with hypospadias (112), epispadias (04), phymosis (13) and Peyronie's disease (12) that had a BC dressing applied over the operated area after surgery. A written informed consent was obtained from all participants. Study exclusion criteria were patients with other alternative treatment indications due to the severity, extent of the injury or the underlying disease. The outcomes evaluated were efficacy, safe and complete healing. The costs were discussed. RESULTS: In 68% patients, the BC dressing fell off spontaneously. The BC was removed without complications in 13% of patients at the outpatient clinic during the follow-up visit and 17% not reported the time of removal. In 3% of the cases, the dressing fell off early. Complete healing was observed between 8th and 10th days after surgery. The BC dressings have shown a good tolerance by all the patients and there were no reports of serious adverse events. CONCLUSION: The bacterial cellulose dressings have shown efficacy, safety and that can be considered as a satisfactory alternative for postoperative wound healing in urogenital area and with low cost.

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INTRODUCTION: Complete female epispadia (CFE) is a rare congenital anomaly occurring in 1 of 500,000 live births. The goals of CFE management include achieving continence, while protecting the kidneys, and creating functional, cosmetic external genitalia. PATIENT AND METHODS: We demonstrate in this video the steps of the surgery and present midterm follow-up of a 6-year-old child with CFE. RESULTS AND DISCUSSION: The patient had an excellent cosmetic result, and reported continence of 3 h period with mild leakage. The perineal infrapubic approach offers the possibility of restoring cosmesis and providing resistance in one surgery precluding the need for abdominal bladder neck surgery.

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Salvage surgical procedures after failed reconstruction for an extrophy-epispadias complex are extremely challenging. The goals are to restore continence and improve aesthetic appearance in order to provide quality of life and an improved body image to the patient. We describe the surgical steps in an adult patient who presented anal urinary incontinence and a poor body image due to the absence of an umbilicus and the presence of hypertrophic scars. He underwent a modified Mainz II reconstruction of the lower urinary tract at childhood for an extrophy-epispadias complex. Restoration of continence was achieved by the construction of a modified Mainz I pouch with a continent stoma in a neo-umbilicus. Body image improved dramatically by the construction of a neo-umbilicus, a surgical revision of the hypertrophic abdominal scars and an abdominoplasty. It is mandatory that such demanding surgery should only be attempted as a combined multidisciplinary effort with urologists and plastic/reconstructive surgeons.

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Salvage surgical procedures after failed reconstruction for an extrophy-epispadias complex are extremely challenging. The goals are to restore continence and improve aesthetic appearance in order to provide quality of life and an improved body image to the patient. We describe the surgical steps in an adult patient who presented anal urinary incontinence and a poor body image due to the absence of an umbilicus and the presence of hypertrophic scars. He underwent a modified Mainz II reconstruction of the lower urinary tract at childhood for an extrophy-epispadias complex. Restoration of continence was achieved by the construction of a modified Mainz I pouch with a continent stoma in a neo-umbilicus. Body image improved dramatically by the construction of a neo-umbilicus, a surgical revision of the hypertrophic abdominal scars and an abdominoplasty. It is mandatory that such demanding surgery should only be attempted as a combined multidisciplinary effort with urologists and plastic/reconstructive surgeons.

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OBJECTIVE: To show the relevance of cosmetic appearance in the adequate treatment of patients with exstrophy-epispadias complex (EEC), and to indicate that surgery by experienced teams can improve the long-term treatment forecast and the patient's body image. PATIENTS AND METHODS: From 1978 to 2002, 71 patients diagnosed with EEC were treated in the authors' institution; 24 (aged 2-23 years) were selected to undergo different surgical procedures. The criterion for surgery considered interviews conducted by the psychology team with the parents and children. The plastic surgery and paediatric urology teams carried out the procedures jointly; the follow-up was 0.33-7 years. RESULTS: Five female patients and six male had abdominoplasty to treat multiple scars; eight had intermittent catheterization conduits repositioned from the right iliac fossa to the umbilicus. Six female patients had plastic surgery of the external genitalia and three had a broad mobilization of the urogenital sinus. Thirteen male patients had a small penis and had the corpora cavernosa fully mobilized and the penis reconstructed. Five female patients and one male had anterior osteotomy. One patient with no left testis had it replaced and one patient with uterine prolapse had the uterus fixed to the posterior abdominal wall. Six patients had a second procedure, in two because the outcome of the initial operation was poor and in the others to complement the initial treatment. In all but one patient there was an improvement in the objective criteria, e.g. school absences, difficulty in establishing long-lasting social relationships and refusal to participate in sports activities. However, none of the patients would attempt sexual intercourse. CONCLUSIONS: Body image, self-esteem, sexuality, sexual function and fertility are deemed crucial by adolescents; in patients with EEC customised surgical procedures can give a satisfactory aesthetic outcome, and be a further reason for adequately following occasional urinary complications and renal function, to avoid loss to follow-up.

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Antecedentes: El apéndice cecal se ha utilizado con éxito en el niño para reemplazar el uréter, la uretra, para vesicostomías continentes en ciertas patologías vesicales (técnica de Mitrofanoff). Objetivo: Mostrar los resultados obtenidos con esta técnica y además abogar por la conservación del apéndice cecal. Material y métodos: Entre febrero de 1991 a octubre de 1997 se efectuaron 46 vesicostomías continentes. Se empleó la operación de Mitrofanoff utilizando el apéndice cecal en 39 casos. En los restantes, por ausencia de apéndice, se usó como tubo el uréter, íleon o colon modelados. La edad de los pacientes osciló entre los 1 y 24 años, con una media de 9 años. Se operaron 32 varones y 14 mujeres. La indicación de la vesicostomía continente fue: a) en enfermos con pobre vaciamiento vesical en cateterismo intermitente limpio, con dificultad para realizarlo por alteraciones anatómicas cérvico/uretrales (estenosis, divertículos, malformaciones, anfractuosidades) o sensibilidad uretral aumentada; b) pacientes con oclusión uretral definitiva o temporaria; c) reservorios vesicales para continencia y vaciamiento del mismo. En 41 casos la vesicostomía se asoció a otros procedimientos simultáneos (cierre del cuello vesical, ampliación vesical, tratamiento de reflujo y onfaloplastia). El tiempo de seguimiento osciló entre 6 a 82 meses con una media de 46 meses. En el período de seguimiento, 32 pacientes no presentaron complicaciones. Resultados: En 7 niños se presentó estenosis del ostoma con dificultad para el cateterismo, 5 se dilataron y 2 se corrigieron quirúrgicamente. En 5 casos (no ubicados en la cicatriz umbilical) se produjo un ectropión mucoso, que si bien no dificultó el cateterismo, por razones estéticas se resecó. Sólo un paciente con tubo realizado con un segmento ileal persiste levemen incontinente. En 2 pacientes hubo inconvenientes en el pasaje de la sonda que requirió la colocación de vesicostomía percutánea transitoria. Ningún niño mostró deterioro de su función renal atribuible al procedimiento. El vaciamiento periódico y completo redujo francamente el número de infecciones urinarias. Conclusiones: La vesicostomía continente con apéndice cecal (Técnica de Mitrofanoff) es un excelente método y de escasa morbilidad. Bien indicado facilita el vaciamiento vesical periódico y permite al niño mantenerse seco y libre de infección, mejorando su calidad de vida... (AU)

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Antecedentes: El apéndice cecal se ha utilizado con éxito en el niño para reemplazar el uréter, la uretra, para vesicostomías continentes en ciertas patologías vesicales (técnica de Mitrofanoff). Objetivo: Mostrar los resultados obtenidos con esta técnica y además abogar por la conservación del apéndice cecal. Material y métodos: Entre febrero de 1991 a octubre de 1997 se efectuaron 46 vesicostomías continentes. Se empleó la operación de Mitrofanoff utilizando el apéndice cecal en 39 casos. En los restantes, por ausencia de apéndice, se usó como tubo el uréter, íleon o colon modelados. La edad de los pacientes osciló entre los 1 y 24 años, con una media de 9 años. Se operaron 32 varones y 14 mujeres. La indicación de la vesicostomía continente fue: a) en enfermos con pobre vaciamiento vesical en cateterismo intermitente limpio, con dificultad para realizarlo por alteraciones anatómicas cérvico/uretrales (estenosis, divertículos, malformaciones, anfractuosidades) o sensibilidad uretral aumentada; b) pacientes con oclusión uretral definitiva o temporaria; c) reservorios vesicales para continencia y vaciamiento del mismo. En 41 casos la vesicostomía se asoció a otros procedimientos simultáneos (cierre del cuello vesical, ampliación vesical, tratamiento de reflujo y onfaloplastia). El tiempo de seguimiento osciló entre 6 a 82 meses con una media de 46 meses. En el período de seguimiento, 32 pacientes no presentaron complicaciones. Resultados: En 7 niños se presentó estenosis del ostoma con dificultad para el cateterismo, 5 se dilataron y 2 se corrigieron quirúrgicamente. En 5 casos (no ubicados en la cicatriz umbilical) se produjo un ectropión mucoso, que si bien no dificultó el cateterismo, por razones estéticas se resecó. Sólo un paciente con tubo realizado con un segmento ileal persiste levemen incontinente. En 2 pacientes hubo inconvenientes en el pasaje de la sonda que requirió la colocación de vesicostomía percutánea transitoria. Ningún niño mostró deterioro de su función renal atribuible al procedimiento. El vaciamiento periódico y completo redujo francamente el número de infecciones urinarias. Conclusiones: La vesicostomía continente con apéndice cecal (Técnica de Mitrofanoff) es un excelente método y de escasa morbilidad. Bien indicado facilita el vaciamiento vesical periódico y permite al niño mantenerse seco y libre de infección, mejorando su calidad de vida...

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A better anatomical and embryological knowledge has allowed a significant advance in the management of male epispadias. Surgery has the following goals: 1. reconstruction of the urethra to enable urine voiding, either spontaneously or by intermittent catheterization through a neomeatus placed at the distal portion of the glans; 2. attainment of urinary continence preserving the upper urinary tract; 3. reconstruction of the penis so that its morphological characteristics be adequate to enable sexual relations; 4. achievement of a favorable esthetical appearance. Modern techniques provide good results with a low rate of complications. At present, the best technique for male epispadias repair is the modification introduced by ransley in the technique originally described by Cantwell. Although Mitchell's technique is promising more experience is to be gained through a close follow-up of patients

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Paciente com epispádia incontinente, 19 anos, submetida a enterocistoplastia e correçao uretral, que engravidou. Durante a gestaçao, apresentou várias infecçoes urinárias, sem comprometimento da bolsa ileal, da funçao renal ou do feto. Foi submetida a cesariana eletiva, a termo, sem intercorrências tanto para o feto quanto para a mae. As dificuldades no manuseio destas pacientes pelo obstetra sao discutidas.

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Se comentan los detalles técnicos y la evolución de 15 pacientes tratados en un período de 13 años. Entre los 14 varones, en 5 casos el epispadias fue total, en 3 peneano medio y en 6 limitado al glande. En una niña correspondió a la forma subsinfisiaria. Todos los pacientes se estudiaron previamente a la intervención con urografía intravenosa(U.I.V.) y cistografía. La continencia se valoró pre y posteriormente. La reparación del pene se realizó mediante una uretroplastía tipo Cantwell más o menos extensa y con modificaciones, excepto en un caso en el que se usó un colgajo prepucial intercalado. La reconstrucción del cuello vesical se efectuó según la técnica de Young-Dees modificada por Mollard en 4 pacientes con la forma total. Dos pacientes presentaron complicaciones. En la actualidad todos tienen resultados estéticos satisfactorios y los cuatros casos en que se practicó la plastía de cuello, la continencia es completaexcepto en uno que tiene pequeños escapes

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Se comentan los detalles técnicos y la evolución de 15 pacientes tratados en un período de 13 años. Entre los 14 varones, en 5 casos el epispadias fue total, en 3 peneano medio y en 6 limitado al glande. En una niña correspondió a la forma subsinfisiaria. Todos los pacientes se estudiaron previamente a la intervención con urografía intravenosa(U.I.V.) y cistografía. La continencia se valoró pre y posteriormente. La reparación del pene se realizó mediante una uretroplastía tipo Cantwell más o menos extensa y con modificaciones, excepto en un caso en el que se usó un colgajo prepucial intercalado. La reconstrucción del cuello vesical se efectuó según la técnica de Young-Dees modificada por Mollard en 4 pacientes con la forma total. Dos pacientes presentaron complicaciones. En la actualidad todos tienen resultados estéticos satisfactorios y los cuatros casos en que se practicó la plastía de cuello, la continencia es completaexcepto en uno que tiene pequeños escapes

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Use of the ventral preputial island flap technique for repair of epispadias has yielded satisfying functional and cosmetic results. We report a modification of this technique in a patient with proximal penile epispadias without exstrophy. We used the Duckett modification of the onlay island flap using ventral preputial skin and coupled it with a proximal flip-flap of perimeatal skin without division of the urethral plate. This achieved an excellent result.

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We review 38 cases of surgically corrected incontinent epispadias with a followup of 5 months to 18 years. In 20 cases the Leadbetter, in 8 the Tanagho and in 8 the Young-Dees techniques of bladder neck reconstruction were used. Of 3 patients with minimal (15 to 25 ml.) bladder capacity the Arap procedure was performed in 1, while small constriction of the bladder neck to improve the bladder capacity and compliance was done in 2. In 1 of the latter patients a 60 ml. capacity was achieved and a secondary Leadbetter operation provided an excellent result. Continence was attained after the initial operation in 18 patients, followup is too short to determine the result in 3 and 15 did not acquire urinary control. Revision of the bladder neck plasty was performed in 11 patients, which resulted in continence in 4 and partial continence in 2. Among 34 patients with an adequate followup 22 (73.3 per cent) are continent and 8 (26.4 per cent) are incontinent. The results were similar with the 3 techniques.

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