title: Vesical preservation in patients with late bladder exstrophy referral: histological insights into functional outcome.
abstract: OBJECTIVE
  We evaluated bladder growth after combined bladder and epispadias repair in children 5 years or older, and correlated the histological findings with final surgical outcomes.
  
  
  METHODS
  We prospectively evaluated 8 late bladder exstrophy referrals from a series of 26 patients treated during a 5-year period. Evaluated outcome measures were bladder capacity (expressed as percentage of expected bladder capacity for age), upper tracts status, continence and histological findings (collagen-to-smooth muscle ratio and type III-to-total collagen ratio). Data were analyzed using nonparametric Spearman rank correlation coefficient and Mann-Whitney U test.
  
  
  RESULTS
  Mean age at combined bladder and epispadias repair was 8.9 years. Volitional voiding with a mean ± SD bladder capacity of 90 ± 7.48 ml was achieved in all patients except 1 with a suprapubic fistula. However, mean ± SD bladder capacity was 33.1% ± 7.47% of expected bladder capacity, and was inversely proportional to age at surgery. Mean ± SD compliance and pressure specific bladder volume less than 20 cm H2O were 13.86 ± 4.97 ml/cm H2O and 69.29 ± 18.07 ml, respectively. Two patients had nonobstructive hydroureteronephrosis with bilateral polar scarring. Mean ± SD collagen-to-smooth muscle and type III-to-total collagen ratios were 2.96 ± 1.062 and 0.4 ± 0.106, respectively. The latter showed a significant negative correlation to bladder compliance (p = 0.025).
  
  
  CONCLUSIONS
  Successful anatomical closure stimulates bladder growth, even in cases of late referral. However, due to histological alterations, these bladders are poorly distensible and noncompliant. Thus, to have an acceptable functional outcome with preserved upper tracts, augmentation cystoplasty is needed in cases of late referral.
authors.affiliation: Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India. Electronic address: puriarchana@hotmail.com.
authors.forename: Archana
authors.initials: A
authors.lastname: Puri
authors.affiliation: Department of Pathology, University College of Medical Sciences, Delhi, India.
authors.forename: Kiran
authors.initials: K
authors.lastname: Mishra
authors.affiliation: Department of Pediatric Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: Satyajit
authors.initials: S
authors.lastname: Sikdar
authors.affiliation: Department of Psychiatry, Lady Hardinge Medical College, New Delhi, India.
authors.forename: K E S
authors.initials: KE
authors.lastname: Unni
authors.affiliation: Department of Surgery, Lady Hardinge Medical College, New Delhi, India.
authors.forename: A K
authors.initials: AK
authors.lastname: Jain
mesh_terms: D000293:Adolescent; D001746:Bladder Exstrophy / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003558:Cystoscopy; D057210:Delayed Diagnosis; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D011446:Prospective Studies; D019651:Plastic Surgery Procedures / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D014563:Urodynamics / Q000502:physiology*; D013520:Urologic Surgical Procedures / Q000379:methods*
keywords: bladder exstrophy; delayed diagnosis; histology; patient outcome assessment; urodynamics