Introduction: Following successful closure of patients with classic bladder exstrophy (CBE), the next major milestone is the establishment of urinary continence. However, prior to determining the appropriate continence surgery, it is imperative to reach an adequate bladder capacity of 100 cc minimum in order to make the decision between bladder neck reconstruction (BNR) and continent stoma with or without augmentation cystoplasty (AC). The authors sought to examine the timing of when patients achieve this threshold bladder capacity to be eligible for BNR.
Methods: An institutional database of 1388 exstrophy patients was retrospectively reviewed for CBE patients after successful primary bladder closure. Bladder capacities was measured via gravity cystography. The cohort was stratified by location, neonatal (=28 days) or delayed closure period and osteotomy status. The bladder capacities were categorized to either reaching goal or not and a cumulative event analysis was performed. The event being reaching 100cc capacity or greater and time being the number of years between bladder closure and attainment of goal capacity.
Results: Two hundred fifty-three patients met inclusion criteria from 1982 to 2019. The majority were of male gender (72.9%), had their closure performed at the authors’ institution (52.5%), within the neonatal period (80.7%), and without an osteotomy (51.7%). 64.9% of patients reached goal bladder capacity. There were no significant differences in those who did or did not achieve goal except for clinical follow up. The cumulative event analysis demonstrated that a median time of 5.73 years (95% CI 5.2 – 6.20) corresponded with a 50% event probability of reaching goal capacity. Cox-proportional hazards showed location of closure was significant associated with hazards of reaching goal bladder capacity (HR = 0.58, CI 0.40 – 0.85, p = 0.005). Based on this model, the median time to event would be 5.20 years (95% CI 4.76 – 5.80) for cases done at the authors’ hospital and 6.26 years for those performed at an outside (95% CI 5.77 – 7.24).
Conclusions: These findings help counsel families appropriately on the odds of attaining goal capacity at various ages. For those who do not reach 100cc by 5 years of age, it helps further characterize the odds of requiring bladder augmentation and the best timing for reconstructive surgery in order to safely gain urinary continence. Families may also be assured that most patients would have the breadth of options when it comes to continence surgery as more than half of patients reached the bladder capacity threshold.
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