Complex sequential treatment of penile malformation in boys with epispadias and bladder exstrophy

Introduction. Main symptoms of epispadias are characterized by partial or complete splitting of the urethra. The penis is shortened due to the separation of symphysis pubis and has dorsal deformation because of tunica albuginea hypoplasia on its dorsal side. The glans penis is flattened and the foreskin covers only its ventral side. Boys with subtotal and total epispadias have partial or complete urinary incontinence. Materials and methods. 110 patients, who underwent surgery for epispadias and bladder exstrophy (aged 5 days to 18 years), were retrospectively analyzed from 2000 to 2014. Among the patients, 51 of them were suffering from epispadias (27 boys had subtotal and 24 - total epispadias). Bladder exstrophy was found in 57 patients and cloacal exstrophy - in 2 boys. All patients were divided into three groups. The first group comprised 10 patients who received surgery by the method proposed by Duplay. The second group included 18 children who received Cantwell urethral reconstructive surgery with the mobilization of cavernous bodies and shift of the newly-formed urethra under the cavernous bodies. The procedure was combined with the surgery for osteosynthesis of pubis symphysis disruption and urinary bladder neck reconstruction. The third group comprised 82 boys who received a package of measures to magnify the length of cavernous bodies of the penis. In first stage, primary correction of urinary bladder deficiency was performed (in case of bladder exstrophy combined with the mobilization of periosteal corpus cavernosum cruris). During the second stage, urethral formation was being conducted combined with cavernous bodies dilatation according to the modified Cantwell protocol. In this case, the following procedures were performed: complete removal of the urethral plate up to the end of the glans penis; mobilization of the cavernous bodies coupled with their complete separation from cicatricial scarring and elongation of the dorsal part of the cavernous bodies (by performing pultiple incisions in the tunica albuginea, which is referred as grafting); urethroplastics. The third stage included plastic surgery of the cervix vesicae in order to create a mechanism for urine retention in boys who suffer from urinary incontinence. Results. Distinct results were traced in patients aged from 5 months to 14 years. Among the complications, we observed urethral fistula, urethral stricture, residual deformations of the cavernous bodies and the urethral diverticuli, which was found in one child. Complications were observed in 60% of the patients in the first group and in 38.9% - in the second. The third group, in which complex step-by-step approach was applied, demonstrated complications only in 19.5% of cases. Conclusions. The proposed package of measures aimed at treating epispadias allows to achieve suitable cosmetic and functional results, lower the frequency of complications from 60% to 19.51% and magnify the length of the penis from 50% to 85% (compared to normal values).