Abstract：
The bladder exstrophy-epispadias complex includes some of the most challenging conditions treated by pediatric urologists. They are associated with the need for multiple intricate reconstructive procedures, aimed at restoring the anatomy and function of the bladder, urethra and external genitalia. These patients often endure multiple redo reconstructive procedures to improve urinary function, sexual function and cosmesis throughout the first two decades of life. In this article, we present the 30-year experience of a single surgeon performing redo surgery for males born with epispadias and bladder exstrophy. Through detailed documentation of 6 clinical cases, we highlight technical aspects that may contribute to a successful surgical reconstruction in these patients. The article is focused specifically on patients undergoing redo epispadias repair with or without concomitant continence procedures. We make the case for complete penile disassembly with external rotation of the corpora to correct recurrent dorsal curvature; this approach also allows the surgeon to have access to the proximal urethra and bladder neck after opening the intersymphiseal scar/band. This is useful when additional procedures on the bladder, such as bladder neck tailoring, are necessary. We also highlight the importance of avoiding reverse Byars\' flaps when performing skin closure, due to the resulting midline scar. Besides being associated with a poor cosmetic outcome, it can also contribute to recurrent dorsal curvature. The authors advocate for rotational skin flaps to cover the penile shaft. Correction of dorsal curvature and improved cosmesis obtained with complete penile disassembly sometimes comes at the expense of the urethra being left as a hypospadias (figure). This will require further surgeries (usually a 2-stage buccal mucosa graft), much like the treatment of proximal hypospadias. Redo epispadias surgery in males remains a challenge. The systematic approach offered by the case scenarios may help guide surgeons dealing with this difficult condition. Patient with complications after repair of classic bladder exstrophy. A) Stone retrieved from posterior urethra after complete penile disassembly. B) After opening the inter-symphiseal scar, the bladder has been opened and the bladder neck tailored. C) Complete penile disassembly has been completed with corporal bodies and urethra individualized. D,E,F) Final appearance of the repair; abdominal wall was closed with anterior rectus sheath flaps, penile skin was closed with rotational flaps and urethra ended up as a hypospadias.
摘要：
膀胱外翻-外翻综合征包括儿科泌尿科医师治疗的一些最具挑战性的疾病。它们与需要多个复杂的重建程序有关，旨在恢复膀胱的解剖结构和功能，尿道和外生殖器。这些患者经常忍受多次重做重建手术以改善泌尿功能，在生命的头二十年里，性功能和美容。在这篇文章中,我们介绍了30年的经验，一个单一的外科医生进行重做手术的男性出生与膀胱外翻。通过对6例临床病例的详细记录，我们强调了可能有助于这些患者成功手术重建的技术方面.本文专门针对接受或不伴有节制手术的重做尿道下裂修复的患者。我们为通过体部的外部旋转来完全拆卸阴茎以纠正复发性背侧弯曲提供了理由；这种方法还可以使外科医生在打开结间疤痕/带后进入近端尿道和膀胱颈。当膀胱上的额外程序时，这是有用的，比如膀胱颈剪裁，是必要的。我们还强调了在进行皮肤闭合时避免反向Byars\'皮瓣的重要性，由于产生的中线疤痕。除了与不良的美容结果有关，它也可以有助于复发性背弯曲。作者主张旋转皮瓣覆盖阴茎轴。通过完全拆卸阴茎而获得的背部弯曲的矫正和改善的美容效果有时是以尿道下裂留下尿道为代价的（图）。这将需要进一步的手术（通常是2阶段颊粘膜移植），就像治疗近端尿道下裂一样.在男性中进行重做上腹部手术仍然是一个挑战。病例场景提供的系统方法可能有助于指导外科医生处理这种困难的情况。经典膀胱外翻修复术后并发症的患者。A）完成阴茎拆卸后，从尿道后部取出石头。B)打开后，膀胱已被打开，膀胱颈部已定制。C）完整的阴茎拆卸已经完成，身体和尿道个性化。D,E,F）修复的最终外观；腹壁用前直肌鞘瓣闭合，阴茎皮肤用旋转皮瓣闭合，尿道最终成为尿道下裂。
