Annals of African Medicine

COMMENTARY
Year
: 2014  |  Volume : 13  |  Issue : 4  |  Page : 232--233

The Perils of bladder exstrophy repairs in Africa


Lukman Olajide Abdur-Rahman 
 Lecturer and Consultant Paediatric Surgeon, Department of Surgery, Division of Pediatric Surgery, University of Ilorin and University of Ilorin Teaching Hospital, Ilorin, Nigeria

Correspondence Address:
Lukman Olajide Abdur-Rahman
Department of Surgery, Division of Pediatric Surgery, University of Ilorin and University of Ilorin Teaching Hospital, Ilorin
Nigeria




How to cite this article:
Abdur-Rahman LO. The Perils of bladder exstrophy repairs in Africa.Ann Afr Med 2014;13:232-233


How to cite this URL:
Abdur-Rahman LO. The Perils of bladder exstrophy repairs in Africa. Ann Afr Med [serial online] 2014 [cited 2020 Apr 4 ];13:232-233
Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/232/142301


Full Text

Bladder exstrophy is a variant of the exstrophy spectrum which presents a great management challenge because of the complexity of the pathologic anatomy. The difficulty in determining the prevalence and incidence of these congenital anomalies in Africa is a result of unsatisfactory surgical interventions which discouraged publications and high rate of infanticide and homicide committed by caregivers (parents and relations) out of stigmatization and frustration. Care providers (surgeons and allied health workers) are challenged by the fact that there are lack of prenatal diagnosis and poor post natal management.

The condition though not life threatening defies several techniques of management which are often modified according to extent of the abnormality, surgeon's experience, availability of hospital staff, skills and facilities, and possibilities for follow-up. The management goes beyond the repairs alone because their social, reproductive and sexual lives also need to be catered for. Inability to achieve this holistic and comprehensive care has led to catastrophic outcomes. [1]

Generally a primary bladder closure and staged correction of urinary continence and repair of epispadias is accepted, problems encountered have brought about acceptable modifications such as the use of mesh repair for abdominal wall closure to avoid tension; urinary diversion as alternative to primary bladder closure as been suggested because ensuring properly secured ureteric catheters for up to 3 weeks or beyond to keep the bladder closure dry and prevent dehiscence has been a great challenge. [2],[3] The goals of early osteotomy (anterior or posterior) in securing approximation of the symphysis to prevent uterine prolapse and secure a good overall functional outcome have been debated because despite this, the symphysis often reopen. [4],[5] Rectus fascial flaps have been used in its place to provide adequate lower abdominal fascial support emphasizing the need to avoid forceful pelvic closure. [2],[6],[7],[8] The decision on which patient should undergo bladder neck repair is elucidated in a study by Baird and colleagues [9] who confirmed that bladder volume greater than 85 mls were likely to achieve urinary continence. Several inventions and modifications of traction and splints for support of the pelvis after primary closure of the bladder have been utilized but the need for splints and tractions have recently been downplayed because of accompanying pressure ulcers, inconvenience for maternal care and risk of respiratory and otitis media in the patients. [10]

Continence management after achieving bladder closure is another challenge which may warrant 'selective' reconstruction designed for voiding and/or intermittent urethral catheterization. In our setting where many patients are presented late or after previous failed reconstruction, the bladder plate are inadequate and poorly compliant and may need augmentation or complete urinary diversion using several options. [8],[11],[12] In these cases there is also the need to manage the upper tract which may also be compromised.

The management of exstrophy complex is challenging and demands that the care provider is conversant with the pathologies and the technical options in making the patients achieve optimal outcome. [5] The patients would require a prolong follow up into adult life and should be provided necessary support as warranted.

References

1Sanni RB, Denoulet D, Coulibaly B, Nandiolo R, Vodi L, Mobiot ML. The treatment of bladder exstrophy at the University Hospital Center in Treichville (Abidjan). Ann Urol (Paris) 1997;31:371-4.
2Hosseini SM, Sabet B, Zarenezhad M. Abdominal wall closure in bladder exstrophy complex repair by rectus flap. Ann Afr Med 2011;10:243-5.
3Ebert AK, Reutter H, Ludwig M, Rösch WH. The Exstrophy-epispadias complex. Orphanet J Rare Dis 2009;4:23.
4Stec AA, Pannu HK, Tadros YE, Sponseller PD, Fishman EK, Gearhart JP. Pelvic floor anatomy in classical bladder exstrophy by using 3dimensional computerized tomography: Initial insights. J Urol 2001;166:1444-9.
5Sponseller PD, Bisson LJ, Gearhart JP, Jeffs RD, Magid D, Fishman E. The anatomy of the pelvis in the exstrophy complex. J Bone Joint Surg 1995;77:177-89.
6Horton CE, Sadove RC, Jordan GH, Sagher U. Use of the rectus abdominis muscle and fascia flap in reconstruction of epispadias/exstrophy. Clin Plast Surg1988;15:393-7.
7Mansour AM, Sarhan OM, Helmy TE, Awad B, Dawaba MS, Ghali AM. Management of bladder exstrophy epispadias complex in adults: Is abdominal closure possible without osteotomy? World J Urol 2010;28:199-204.
8Celayir S, Kiliç N, Eliçevik M, Büyükünal C. Rectus abdominis muscle flap (RAMF) technique for the management of bladder exstrophies: Late clinical outcome and urodynamic findings. Br J Urol 1997;79:276-8.
9Baird AD, Nelson CP, Gearhart JP. Modern staged repair of bladder exstrophy: A contemporary series. J Pediatr Urol 2007;3:311-5.
10Castagnetti M, Berrettini A, Beniamin F, Rigamonti W. Thoraco-pelvic orthosis: A portable and removable bassinet for secure patient immobilization after primary bladder exstrophy closure. Pediatr Surg Int 2010;26:1229-32.
11Mteta KA, Mbwambo JS, Eshleman JL, Aboud MM, Oyieko W. Urinary diversion in children with mainly exstrophy and epispadias: Alternative to primary bladder closure. Central Afr J Surg 2000;46:318-20.
12Hollowell JG, Ransley PG. Surgical Management of Incontinence in Bladder Exstrophy. Br J Urol 1991;68:543-8.