title: Ureteral reimplantation before bladder neck reconstruction in modern staged repair of exstrophy patients: indications and outcomes.
abstract: OBJECTIVE
  To evaluate a single referral center's experience with vesicoureteral reflux (VUR) and its role in management before bladder neck reconstruction (BNR) in exstrophy patients after modern staged repair of exstrophy (MSRE). VUR after primary closure of bladder exstrophy can usually be managed conservatively until ureteral reimplantation (UR) at the time of BNR. However, VUR in these patients is occasionally associated with febrile urinary tract infection and worsening renal function necessitating UR before BNR.
  
  
  METHODS
  A total of 199 patients who underwent MSRE were identified from an institutional review board-approved database. Patient demographics, closure history, postprimary closure VUR, history of urinary tract infection, cystography outcomes, renal function, history of UR before BNR, and UR outcomes were recorded. Univariate and multivariate analyses were performed to determine factors predicting high-grade VUR and the need for pre-BNR UR.
  
  
  RESULTS
  After primary closure, VUR was observed in 150 patients (75.4%) of whom 31 (15.58%) had high-grade VUR. Closure without osteotomy and postclosure outlet obstruction were independently associated with postprimary closure high-grade VUR (P <.05). Twenty-two patients (11.06%) required pre-BNR UR. Female gender and those with high-grade VUR were more likely to require UR before BNR (P <.05). Early UR did not affect the continence rate.
  
  
  CONCLUSIONS
  VUR after exstrophy closure can generally be managed with conservative treatment and periodic monitoring of the upper urinary tracts. About 11% of patients undergoing MSRE will require UR before BNR. Closure without osteotomy and patients who develop outlet obstruction after closure are at increased risk for developing high-grade VUR.
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Ali
authors.initials: A
authors.lastname: Tourchi
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Heather N
authors.initials: HN
authors.lastname: Di Carlo
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Brian M
authors.initials: BM
authors.lastname: Inouye
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Ezekiel
authors.initials: E
authors.lastname: Young
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Angela
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Mahmood
authors.initials: M
authors.lastname: Abdelwahab
authors.affiliation: Robert D Jeffs Division of Pediatric Urology, James Buchanan Brady Urological Institute, the Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: jgearha2@jhmi.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gearhart
mesh_terms: D001746:Bladder Exstrophy / Q000150:complications* / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004842:Epispadias / Q000150:complications* / Q000601:surgery*; D005260:Female; D006801:Humans; D006869:Hydronephrosis / Q000209:etiology; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010027:Osteotomy; D011704:Pyelonephritis / Q000209:etiology; D012092:Replantation; D018570:Risk Assessment; D012737:Sex Factors; D013997:Time Factors; D014513:Ureter / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*; D001748:Urinary Bladder Neck Obstruction / Q000150:complications; D014552:Urinary Tract Infections / Q000209:etiology; D014718:Vesico-Ureteral Reflux / Q000209:etiology* / Q000601:surgery