Gracilis muscle sling for select incontinent "bladder exstrophy cripples".
OBJECTIVE
Functional reconstruction of children born with bladder exstrophy results in a successful outcome in the majority. However, failed bladder neck repair, especially after multiple surgical attempts, compromises the quality of the tissues and, thus, limits surgical options. In these cases conventional sphincteroplasty and other continence procedures, such as rectus sheath sling or artificial urinary sphincters, are ill-advised due to ischemia and fibrosis of the bladder neck.


METHODS
We transferred the gracilis muscle as a vascularized pedicle flap around the bladder neck in 5 children born with bladder exstrophy, of whom 3 were "exstrophy cripples" with multiple previous failed attempts at reconstruction, and 2 were older with failed prior attempts at bladder closure. In the latter 2 cases a 1-stage repair was performed, which included bladder augmentation, ureteroneocystotomy, epispadias repair and bladder neck wrap with gracilis muscle. The other 3 children underwent gracilis muscle wrap of the compromised bladder neck.


RESULTS
All 5 children were dry between clean intermittent catheterization 2 to 13 years postoperatively. Complications included urinary tract infection in all 5 cases, stomal stenosis in 2, small bowel obstruction in 1 and bladder stones in 2. However, no complication was related to the gracilis muscle transfer.


CONCLUSIONS
Vascularized gracilis muscle flap can be used to wrap around the compromised bladder neck of incontinent patients born with bladder exstrophy. The muscle appears to provide a leak proof, cough competent sling that increases bladder outlet resistance and, thus, provides dry intervals between catheterization. The long-term results of up to 13 years have been satisfactory.
Gershbaum
M D
MD
Department of Urology, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, New York, USA.
Stock
J A
JA
Hanna
M K
MK
D001746:Bladder Exstrophy / Q000150:complications / Q000601:surgery*; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D019651:Plastic Surgery Procedures; D013524:Surgical Flaps; D014547:Urinary Diversion / Q000379:methods*; D014549:Urinary Incontinence / Q000209:etiology / Q000601:surgery*