Vesical exstrophy: repair using radical mobilisation of soft tissues

By more radical mobilisation of both internal and external sphincter muscles of the bladder and urethra than has hitherto been undertaken, physiological continence of urine has been achieved in patients with vesicourethral exstrophy. The purpose of this paper is to describe the surgical technique used in the type regarded as the classic anomaly, though the principles apply to all variants in males and females. The key features are relevant to the second stage of a three-stage procedure. The periosteum on the inner sides of the ischium and pubis with the attachments of the involuntary and voluntary sphincter muscles and the pudendal vessels and nerves is mobilised on both sides so that these outstretched muscles can be converted into a wrap around the newly constructed “membranous” urethra without the need for iliac or pubic osteostomy. This new “membranous” urethra is made from the urethral plate, which is uplifted from its bed on the dorsum of the penis, rotated posteriorly between the crura, hinged proximally at the level of the verumontanum, tubularised, and relocated posteriorly within the grasp of the external sphincter complex. This necessitates the construction of an interim penoscrotal urethrostomy prior to penile urethroplasty. The physiological continence rating achieved so far in 19 patients is 73%. The identification and localisation of a latent but effective external sphincter muscle complex situated deep in the pelvis and totally separated from the dorsal penile plate in the male and from the urethrovaginal outlet in the female formed the basis and rationale of this new radical soft-tissue mobilisation technique.