title: The failed complete repair of bladder exstrophy: insights and outcomes.
abstract: OBJECTIVE
  We describe the complications of complete repair and their management.
  
  
  METHODS
  A total of 19 patients were referred after failed complete repair. Total dehiscence occurred in 6 males, major bladder prolapse in 3, minor prolapse in 3, pubic separation in 1, impassable stricture in 1, and total hemiglans and corporal loss in 2. Overall, partial glans loss was seen in 7 patients, urethral loss in 5 and penile skin loss in 3. One female had complete dehiscence and 1 had major prolapse, both losing the urethrovaginal septum. One female had an impassable stricture.
  
  
  RESULTS
  Six males with dehiscence underwent re-closure with osteotomy. Urethral replacement was performed with full thickness skin graft (FTSG) in 3 and with buccal mucosa in 3. Five patients underwent a modified Cantwell-Ransley (C-R) epispadias repair after placement of skin expanders, and 1 awaits repair. The 3 patients with major prolapse underwent re-closure with osteotomy. A urethral buccal graft was used in 1 patient, FTSG was used in 2 at a later operation and all 3 underwent C-R epispadias repair. Of the 3 patients with minor prolapse 2 underwent re-closure with osteotomy using urethral buccal graft or FTSG followed later with a C-R repair. The final patient with minor prolapse underwent re-closure with osteotomy and C-R repair after testosterone stimulation. One patient with pubic separation and urethral and skin loss underwent re-closure with osteotomy, C-R repair after skin expanders and later bladder neck repair. In 1 case a ureteral graft replaced a posterior urethral stricture. Of the 2 patients with hemiglans and corporal loss 1 underwent penile torsion repair and later hypospadias repair, while the other is being observed. Two females underwent re-closure with osteotomy and urethral replacement with tubularized bladder. The case of stricture was managed endoscopically.
  
  
  CONCLUSIONS
  Complications of complete repair are similar to those of other repairs but more serious if soft tissue loss occurs. Because of these increased risks, this procedure and its formidable complications are best managed by experienced exstrophy surgeons.
authors.affiliation: Division of Pediatric Urology, Department of Urology, The James Buchanan Brady Urological Institute, The Johns Hopkins Hospital and Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Baird
mesh_terms: D001746:Bladder Exstrophy / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation; D017211:Treatment Failure; D013520:Urologic Surgical Procedures / Q000379:methods*