Ureteral reimplantation before bladder neck plasty in the reconstruction of bladder exstrophy: indications and outcomes.

Objectives: After initial closure, all exstrophy patients have vesicoureteral reflux. This reflux is usually managed with antimicrobial prophylaxis, surveillance, and ureteral reimplantation concurrent with bladder neck plasty. Patients with recurrent urinary tract infections or worsening hydronephrosis may require earlier correction of reflux. This subset of patients was reviewed to determine the ability to correct reflux adequately, the difficulty with subsequent bladder neck plasty, and the long-term continence results.

Methods: We reviewed an exstrophy database of more than 700 patients and identified 19 who underwent ureteral reimplantation independent of bladder neck plasty. All had undergone bladder closure in infancy. Eleven had since undergone modified Young-Dees-Leadbetter bladder neck plasty. Five patients were awaiting bladder neck reconstruction, 2 girls were continent without bladder neck plasty, and one had undergone augmentation.

Results: Indications for early ureteral reimplant were recurrent febrile infections despite adequate prophylaxis (n = 15) or worsening hydronephrosis on follow-up (n = 4). In the 11 patients who had undergone subsequent bladder neck repair, prior reimplantation did not increase the operative difficulty or complications. The continence results among these 11 were comparable with those in patients without prior reimplantation. In 1 patient, reflux recurred and was corrected at the time of bladder neck plasty. None had further urinary tract infections, and hydronephrosis improved in three and stabilized in one.

Conclusions: In patients who present with recurrent infections or worsening hydronephrosis after initial exstrophy closure, early reimplantation can be undertaken. If performed with later bladder neck plasty in mind, the surgical treatment of incontinence is not compromised and recurrent infections and upper tract changes will be abated.