FUNCTIONAL
CLOSURE
OF
BLADDER
EXSTROPHY
A
Review
of
Fifty
Cases
Stanley J. Landau, M.D., and John K. Lattimer, M.D.
Squier Urological Clinic, Presbyterian and Babies HospitaLs, Columbia-Presbyterian Medical Center,
New York City, New York
(Submitted for publication July 24, 1962; accepted September 21.)
This work was supported in part through the generosity of Governor and Mrs. Charles Edison.
ADDRESS: (S.J.L.) The Presbyterian Hospital, Columbia-Presbyterian Medical Center, 622 West 168th Street, New York 32, New York.
433
I
N 1955, a program of functional closurefor bladder exstrophy was initiated on
the Pediatric Urological Service of Babies
Hospital in New York. The experience with
functional closure on this Service has now
grown to more than 50 cases, and the length
of follow-up has exceeded 3 years in enough
cases to warrant an interim evaluation of
the operative procedure and results. This
review is part of a continuing study of
func-tional closure of the exstrophied bladder.
Earlier results have been reported
previ-2 Close follow-up has been
main-tamed on these patients in an effort to
answer many questions. For example, is
functional closure of tile exstrophied
blad-der compatible with preservation of normal
renal function and architecture? Is the
achievement of urinary continence possible
with this operation? Can a satisfactory
cos-metic result be expected? The information
collected in the quest of the answers to
these questions forms the basis for this
re-port.
MATERIALS AND METHODS
Fifty patients with exstrophy of the
blad-der treated by functional closure were
stud-ied (see Appendix). Thirty-four were males,
and 16 were females. All of the cases, with
one exception, were patients with complete
bladder exstrophy.3 The one patient with
incomplete exstrophy presented with
epi-spadias and exstrophy of the lower portion
of the bladder. Forty-two patients were
“virgin” cases operated upon by various
resident and attending urologists of the
Staff. Eight patients were operated upon
elsewhere and have been subsequently
fol-lowed and/or operated upon further at our
clinic, or were referred to us for a second
attempt at closure. It is our practice to
readmit these patients at periodic intervals
for complete re-evaluation of their urinary
tracts. The length of follow-up in these 50
cases is listed in Table I. The longest
fol-low-up was 6 years.
Age at Closure
In the past, the tendency was to defer
functional closure until the child had
at-tamed the age of one year. It was felt that
the child could then better withstand the
operation, and that the bladder and penis
would be larger, thereby facilitating the
procedure. More recently, the operations
have been performed on children between
the ages of 3 and 6 months. The children
have all tolerated the procedure well. There
has been no mortality, and in no instance
was it impossible to close and re-implant
the bladder even though some were so
tiny as to cause concern. Table II illustrates
the ages at which the operation was
car-ned out. The only adult patient on whom
the procedure was performed was a
21-year-old female.
Technique
The technique has been reported
else-wh245 except that one major
modifi-cation has been added: all patients are now
prepared for functional closure by
under-going bilateral iliac asteotomies 7 to 10 days
prior to closure. At the time this procedure
is performed by the orthopedic department,
TABLE I
LENGTH OF FoLi.ow-uP
TABLE II
AGE AT FUNCTIONAL CLOSIRE OF BLADDER ExSTIIOPHY
0-3mo 2
3-6mo 7
6-12 mo 17
1-2yr 15
2-4yr 5
4-6yr S
6-12 yr I
>l2yr I
:&
. #{149},i.. . - .
SI.j:’i
,
434.
Time Patients
(no.)
0-6mo 12
6-l2mo 9
1-2yr 4
2-3yr 5
>3yr 20
Total 50
the child is placed in a body cast which
tends to bend the sides of the pelvis
to-gether. Two or three days following the
osteotomies, the cast is wedged further,
bringing the tissues together. A large
“win-dow” (Fig. 1) is cut in the cast prior to the
bladder surgery through which the
urologi-Patients
Age
(no.)
Total 50
cal procedure is carried out. There has been
no lack of operating space as a result of
the cast, which is removed 6 to 8 weeks after
its application. The purpose of the iliac
TABLE IV
ABNORMAL PREOPERATIVE UROGRAPHIC CHANGES IN
17 PATIENTS WITH EXSTROPHY OF THE BLADDER
ARTICLES
osteotomies is not primarily orthopedic.
In-deed, follow-up in our series has demon
strated no apparent impairment or
deform-ity of ambulation if osteotomy was not
performed. The children have been able to
participate in any athletic endeavor of their
choosing without difficulty, including ice
skating and skiing. Iliac osteotomy has,
however, made the closure of the
abdomi-nal wail easier, markedly reduced the
oper-ating time and significantly reduced the
incidence of wound breakdown. Bladder
closure and epispadias repair has been
per-formed in one stage in all but one of the
forty two “virgin” cases. The single case in
which a two stage procedure was done was
an early case in which the staging was
de-cided upon before surgery.
PREOPERATIVE FINDINGS
A significant number of patients had
as-sociated congenital anomalies, both urinary
and extraurinary. Except in the cases of
imperforate anus and pyloric stenosis,
which required immediate surgery, these
associated anomalies in no way interferred
with the functional closure. Inguinal
her-nias, which were the most common
associ-ated anomaly, were repaired at a later date
after the exstrophy repair (Table III).
Preoperative excretory urograms were
available in 45 cases. Twenty-eight were
read as normal, while the remainder
showed some degree of hydroureter and/or
TABLE III
ASSOCIATED CONGENITAL ANOMALIES IN 50 CHILDREN WITH EX.STROPHY OF THE URINARY BLADDER
Inguinal hernia 17
Prolapse of rectum 7
Double kidney (unilateral) 4
Anal stenosis 4
Undescended testicle 4
Congenital absence of a kidney
Osseous malformation of the spine 2
Absent vagina 1
Pyloric stenosis I
Imperforate anus 1
Total 43
Pathology Slight Moderate Severe
Hydronephrosis 8 5 1
Hydroureter 9 5 1
Urethral tortuosity 3 1 1
hydronephrosis, as indicated in Table IV.
The changes were most often unilateral.
Three patients demonstrated unilateral
de-creased renal function by intravenous
py-elogram, though all patients had normal
serum nonprotein nitrogen values
preopera-tively.
In the 37 cases in which the bladder size
was recorded preoperatively, 15 were noted
to be 4 cm or less in diameter. Eighteen of
34 bladders (53%) could be manually
in-verted into the abdomen preoperatively
when the child was not crying or straining.
Of 36 cases in which the observation was
recorded, the exposed bladder was
coy-ered with a thickened pad of urothelium
in 23 patients (64%). The hypertrophied
uro-thelium frequently required trimming at the
time of surgery before the bladder could be
closed.
Prolapsed ureters were not an uncommon
preoperative finding. This was recorded in
16 cases preoperatively. No attempt was
made at correction of the ureteral prolapse
at the time of the functional closure. In our
experience, amputation of the prolapsed
ureter invited stricture formation, while
meatotomy served only to accentuate the
vesicoureteral reflux which was usually
present postoperatively.
Biopsies of the bladder epithelium were
taken in 32 cases at the time of surgery.
The changes of chronic cystitis were seen
in all the specimens. In addition to this
ex-pected change, squamous metaplasia was
not an uncommon finding, with glandular
metaplasia and intestinal mucosa less fre..
quently seen (Table V).
While it will be important to note in
the
TABLE V
BLADDER Bios IN CHILDREN WITH EXSTROPHY
OF THE BLADDER
29 14 15 Reflux (86%) Unilateral Bilateral 26* 7 19
* #{216}fSOcases tested.
Pathology Report Cases(no)
.
Chronic cystitis
Squamous metaplasia
Glandular metaplasia
Intestinal mucosa
No biopsy taken
32 18 4 2
18
carcinoma of the bladder will be any higher
in this group as compared with the general
population, to date there has been no
evi-dence of malignant change in either the
preoperative or postoperative biopsies.
POSTOPERATIVE FINDINGS
Complications
The most frequent postoperative
compli-cation, occurring in 58% of cases, was fistula
formation requiring surgical closure. The
sites of the fistulae were almost equally
di-vided between the urethral and suprapubic
areas. Stricture, pyelonephritis, and stone
formation did occur but with considerably
less frequency (Table VI). Single or rare
attacks of clinical pyelonephritis were
diag-nosed in only 14% of cases and were often
related to stricture of the urethra. This is
a surprisingly low incidence when one
con-siders that positive urine cultures were
noted in 36 of 38 patients tested at their
last follow-up visit.
Vesicoureteral reflux was tested for in 30
patients, with use of the standard Columbia
cystogram method,6 and was present in 86%
of these cases. The reflux was bilateral in 19
cases and unilateral in 7 cases. In most of
the cases where urinary continence has not
yet been achieved, reflux has not been a
problem insofar as upper tract destruction
is concerned. As urinary continence
im-proved and bladder neck resistence
in-creased, progressive hydroureteronephrosis
secondary to reflux necessitated anti-refiux
operations in four patients.
Postoperative partial abdominal wound
breakdown occurred in 10 cases (20%). Eight
of these were early cases, in which tile
pa-tient did not have the benefit of an iliac
osteotomy preoperatively. This
complica-tion has become rare since the
incorpora-tion of tile osteotomies into the operative
program.
The number and variation of operative
procedures and treatments that have been
employed to correct tile above listed
com-plications are noted in Table VII. As was
anticipated, closure of pinhole vesical and
urethrocutaneous fistulae were the most
fre-quent operative procedures. Periodic
tire-theral calibration and dilation to correct or
prevent strictures along tile urethra and at
the bladder neck were done almost
rou-tinely at the time of follow-up cystoscopy.
Two of the eight epispadias repairs were
the second part of an elective two-stage
procedure. The remaining six were to
cor-rect major breakdown of the epispadias
re-pair performed at the time of the initial
surgery.
TABLE VI
POSTOPERATIVE COMPLICATIONS IN 50 C1III.DuEN
UNDERGOING FUNCTIONAL CLOSURE OF AN
EXSTROPHIED BLADDER Fistula (58%) Suprapubic Urethral Cases Complication (no.)
Stricture (20%) 10
Urethra and bladder neck 6
Urethral meatus 6
Uretero-vesical junction 4
Partial abdominal wound breakdown (20%) 10
Pyelonephritis (14%) 7
Stone formation (12%) 6
Kidney 1
Urethra 2
30
:
200.
0
10
0
Normal Abnormal No
. FollowJJp
POST-OP PYELOGRANS
PRE -OP
PY ELOGRAM
GROUP 8
20
‘:U
IIi_
Abnormal Normal Worse Improved No
Follow-Up
PYELOGRAM OP PYELOGRAMS
ARTICLES
PYELOGRAPHIC CHANGES
The preoperative intravenous pyelograms
were divided into two groups. Group A (28
Patielits) consisted of those patients with
normal preoperative pyelograms. Group B
(17 patients) were those patients with some degree of hydroureter of hydronephrosis
preoperatively. The postoperatively
pyelo-graphic changes are recorded in Figure 2.
Seventeen patients in Group A continued
to have normal upper urinary tracts, while
nine now demonstrate some degree of
up-per tract dilatation. Of the 17 patients in
Group B with abnormal preoperative
pyelo-grams, 8 have normal upper tracks now, 4
are improved, while 5 have shown some
pro-gression of their preoperative dilatation.
Bladder Size and Capacity
The preoperative bladder size has been
correlated with bladder capacity following
surgery. In tile 37 patients in whom the
bladder size was recorded before surgery,
22 were measured to be 4 cm or more in
diameter, while the remaining 15 were
smaller. Preoperative and postoperative
bladder capacities have been measured in
27 patients. Sixteen of these patients had a
bladder measurement of 4 cm or more
pre-operatively, and all but 4 of the 16 had a
TABLE VII
SURGICAL PROCEDURES SECONDARY TO FUNCTIONAL
CLosuuF oi TILE EXSTROPHIED BLADDER (50 CASES)
Procedure Cases
(no.)
Closure of fistula 17
Urethroplasty 6
Secondary epispadias repair 8
Urethral ineatotomy 5
Anti-reflux operation 7
Ureteral reimplantation I
Cystolithotomy 3
Y-V-plasty of bladder neck S
Nephrostomy 2
Ureteral meatotomy 2
TUR of bladder neck 2
Total 56
ffO1/P A
El
Normal
Fic. 2. Pyelographic changes in patients after
func-tional closure of the exstrophied bladder.
normal bladder capacity at follow-up. In
the group of 11 patients whose bladder
measured less than 4 cm before surgery, 6
had a normal capacity postoperatively
(Figure 3).
It should be noted that most of the
chil-dren in this latter group are our more
re-cent cases and had their operative
pro-cedures at 3 to 6 months of age, when the
bladder would be expected to be small. The
period of follow-up has not been long
enough in these cases to evaluate whether
or not the bladders will increase in
capac-ity. It would seem, on the basis of earlier
cases, that the bladder capacity does
in-crease with time, growth of the patient, and
increasing continence. In 31 patients tested
for residual urine, significant residuals were
present in only five cases. Cystometrics and
thermal sensation were tested in five
pa-tients; fairly normal results were found in
each patient.
ILIAC OSTEOTOMIES
Iliac osteotomies were performed before
pa-ACCEPTABLE BLADDER CAPACITY
96/.
0L
NO AFTER
OSTEOTOMY OSTEOTOMY
0/
Io00
50
I-0
4CM ormore
Less than 4cm
FIG. 3. Bladder capacity in 27 patients after
func-tional closure of the exstrophied bladder.
tients, iliac osteotomy was performed after
bladder closure to assist in closing fistuli,
and in 23 it was not performed at all.
Com-parison of the x-rays taken before and after
iliac osteotomy reveals no measurable
per-manent narrowing of the gap in the
sym-physis following surgery in 10 cases, and
some degree of narrowing in 8 cases. In the
remaining six cases, the films taken through
the casts were technically too unsatisfactory
to allow accurate measurements.
While the degree of reapproximation of
the pubic bones at the symphysis has been
slight, the closer reapproximation of the
abdominal wall tissues after iliac osteotomy
is very real. There is no question that the
performance of ileostomy prior to
func-tional closure has greatly facilitated the
ab-dominal closure. The need for flaps of
rec-tus muscle or sheath to close the defect in
the abdominal musculature as well as the
need for skin grafts, rotation of skin flaps,
or Z-plasty of the skin has virtually been
eliminated. Of the 23 patients who did not
have the benefit of iliac osteotomy prior to
their functional closure, 21 (91%) required
either flaps of rectus muscle or sheath and!
or skin grafts or flaps to close the
abdomi-nal wall defect. Of the 24 patients who did
have osteotomy prior to functional closure,
only 7 (30%) required a graft or flap (Fig.
4). Four of these seven patients were early
cases in our series.
The incidence of postoperative
abdomi-nal wound breakdown has also been
signifi-cantly reduced as a result of the
osteot-omies. Of the 10 cases of wound
break-down occurring in this series of 50 patients,
8 occurred in patients without osteotomies
as compared with only 2 in patients with
osteotomies (Fig. 5).
The cosmetic result has also been
im-proved since the osteotomies have been
done. Prior to their introduction, the
ab-dominal scars were frequently somewhat
unsightly due to the necessity for skin
grafts or flaps. Now the child is usually
left with a single midline suprapubic scar.
Tile only complication we have experienced
with the procedure is that occasionally
res-piratory embarrassment has occurred due
to abdominal distention within the cast.
This has been easily overcome by bivalving
and taping the cast to accommodate the
dis-tention.
Urinary Continence
We have arbitrarily chosen 3 years of age
as the age at which urinary continence
#{149}1
. I00
50
Fic. 4. Percentages of patients requiring plastic
closure of the abdominal wall with and without
0/ ‘0
I00
50
0 H
PARTIALLY
CONTI NENT INCONTINENT
0
8
(I)
I-.
z
Ui
5
0
w
z :#{149}:#{149}::#{149}::#{149}:#{149}::#{149}:#{149}:#{149}:#{149}:#{149}:
0
NO WITH
OSTEOTOMY OSTEOTOMY
FIG. 5. Abdominal wound breakdown with and
without iliac osteotomy.
could and should be forthcoming. Our
cri-tenon of continence has been (1) the ability
to appreciate the need to void, (2) the ability
to defer the act of voiding until an
ap-propriate place can be reached, and (3) the
ability to initiate voiding voluntarily.
All 30 patients below 3 years are
incon-tinent by the above criteria. None are
nor-mal, although seven of the group are
begin-ning to show some degree of continence.
They are able to remain dry for long
pen-ods of time and are able to void with a
forceful stream. Of the 20 patients who are
3 years or older, 6 are partially continent
and 14 are incontinent by the above
cii-teria. Ten of these 14 children are able to
void with a forceful stream. An additional
female patient operated upon recently
re-ports complete continence (Fig. 6).
COMMENT
As our experience with tile procedure has
increased over tile past 6 years, several of
our early questions and fears have been
answered to our satisfaction; some still
re-main unsolved. An important consideration
in aiiy new operative technique is its
re-producibility by surgeons other than the
ABDOMINAL WOUND BREAKDOWN
WITH 6 WITHOUT ILIAC OSTEOTOMY
Over 3yrs of ge
20
PatientsFIG. 6. Urinary continence in patients after func-tional closure of the exstrophied bladder.
innovators. Functional closure of the
ex-strophied bladder has been modified and
perfected to a point where it is part of the
surgical armentariuni of tile attending and
senior resident staff of our clinic. There has
been no mortality to date. Recently the
operation ilas been performed at an earlier
age (3 to 6 months), and no untoward
tech-nical or clinical difficulties as a result have
been noted. Since the children are now
be-ing operated upon at an earlier age, the
bladder diameter preoperatively has
fre-quently been 3 cm or less. In spite of this,
it has always been possible to close and
re-implant the bladder. The bladder has, in
the majority of cases, attained an
accept-able bladder capacity. The operating time
has been diminished. Tile need for flaps
of rectus sheath or muscle as well as skin
grafts and flaps has almost been eliminated.
The incidence of wound separation and
breakdown has been reduced, and the
cos-metic results have been very acceptable to
the parents. These improvements have been
largely the result of the incorporation of
pro-440
gram. While the results of this procedure
have been equivocal in so far as
diminish-ing the degree of separation of the
sym-physis, there has been a very definite
re-ap-proximation of the tissues of the abdominal
wall, affording a much easier and less
complicated closure.
Postoperative pyelograms have remained
normal or improved from the preoperative
picture in 65% of cases, with only minor
de-grees of hydroureter or hydronephrosis
ap-pearing in 20% of cases. Preoperative upper
tract dilatation was worse postoperatively
in only 11% of cases.
Vesicoureteral reflux seems to be inherent
in the ureterovesical junction of exstrophied
bladders and was present in 86% of the
cases tested. Reflux, with its potential for
upper tract dilatation and destruction,
in-creases as bladder neck resistance and
con-tinence improve. Severe reflux and upper
tract dilatation has necessitated seven
anti-reflux procedures in four patients. They
have been either of the
Leadbetter-Poli-tano7 or Bischoff8 technique and, in our
hands, have not been uniformly successful
in correcting the reflux. We are presently
engaged in evaluating new antireflux
pro-cedures, which we are hopeful will
im-prove on the limitations of the present
pro-cedures.
The most disquieting feature of our
fol-low-up has been the small percentage of
patients who have achieved complete
con-tinence. While there are encouraging
num-bers of children who are able to void with
a strong stream and are dry for periods of
time, these patients as yet remain partially
incontinent and as yet cannot control their
stream and time of voiding. While we are
hopeful that with further growth and
train-ing, the number who achieve complete
con-tinence will increase, we are alert to the
possible necessity of an operative procedure
on the urethra and bladder neck that will
improve the degree of continence in these
children.
The most appealing feature of functional
closure of bladder exstrophy has always
been that it offered the possibility of
re-storing a major congenital malformation to
as normal a state as was possible. While
cystectomy and some form of urinary
diver-sion (which is still the preferred treatment
in many areas) might have been simpler,
the long-term complications of urinary
di-version, their psychological implications,
and the wish to avoid, if possible, the
con-demnation of a child to a permanent
ex-ternal appliance made the functional
do-sure desirable. We have further felt that
functional closure was not irrevocable and
a urinary diversion could always be
re-sorted to if the functional closure was not
satisfactory.
ADDENDUM
Since this article was written, 10 additional
pa-tients have been operated upon, bringing the total
number of functional closure cases to 60.
REFERENCES
1. Lattimer, J. K., et al.: Reconstruction of urinary
bladder in children with exstrophy. J. Urol., 77:424, 1957.
2. Lattimer, J. K., et al.: Functional closure of the
bladder in children with exstrophy. J. Urol.,
83:647, 1960.
3. Uson, A. C., Lattimer, J. K., and Melicow,
M. M. : Types of exstrophy of urinary bladder
and concomitant malformations : a report based on 82 cases. PEDIATRICS, 23:927, 1959.
4. Young, H. H. : The first case in which a normal
bladder and urinary control have been
ob-tamed by plastic operation: exstrophy of the
bladder. Surg. Gynec. Obst., 74:729 1942
5. Sweetser, T. H., et al.: Exstrophy of the blad-der: its treatment by plastic surgery. J. Urol.,
75:448, 1952.
6. Dean, A., Jr., Lattimer, H. K., and McCoy, C.:
The standard Columbia University cystogram.
J. Urol., 78:662, 1957.
7. Politano, V. A. and Leadbetter, W. F. : An oper-alive technique for the correction of vesico-ureteral refiux. J. Urol., 79:932, 1958.
8. Bischoff, P. : Operative treatment of megalo-ureter. J. Urol., 85:268, 1961.
9. Landau, S. J.: Ureteroneocvstostomv : a review of 72 cases with a comparison of two
tech-niques. J. Urol., 87:343, 1962.
Acknowledgment
The author wishes to express his appreciation to Drs. George \V. Fish, Ralph J. Veenema,
Stan-ley B. Braham, and Archie L. Dean, Jr., for
Continued on next page Appendix
-Patient Sex
-Iear of
Closure
Age at Closure
(yr)
Come nts
1. (ILC.) M 1954 Operated upon elsewhere; P0StOP IVP worse; diminished bladder
262I24 capacity; incontinent
2. (ME.) F 1954 Primary closure elsewhere; wire approximating pul)is eroded
#1278896 through urethra with secondary urethral stones; wire removed
here; postop IVP normal; incontinent
3. (kB.) M 1954 Primary closure eLsewhere; cystolithotomy for stones here; severe #1184811 refiux required antirefiux operation; postop IVP worse;
incon-tinent
4_ (MM.) iI 1955 1)eveloped bladder stones; required cystolithotomy and Y-V-#232470 plasty of bladder neck; postop IVP normal; incontinent l)ut voids
with a stream
5. (R.F.) 1I 1955 Urethral stricture requiring meatotomy; postop IVP normal;
hi-#1228298 lateral refiux; incontinent but voids with a stream
6. (l)B.) ii: 1955 I Primary closure elsewhere; secondary epispadias repair here;
#1347166 postop IVP normal; incontinent
7. (MJ%I.) F 1955 i1r Partial breakdown of abdominal wound; postop IVP improved;
#1218969 incontinent
8. (5K.) M 1955 1 Primary closure elsewhere resulted in bladder slough; colocysto-#1362456 plasty here; postop IVP worse; incontinent
9. (L.S.) F 1956 3 Primary closure elsewhere; no ganglion cells on ureteral biopsy;
#300018 spinal bifida; postop IVP worse; incontinent
10. (A.P.) M 1956 4 Closure successful on third attempt; postop IVP normal;
incon-f293852 tinent
11. (J.S.) M 1956 44 Uncomplicated postop course; postop IVP normal; now almost
#1274204 completely continent
12. (A.V.) iI 1956 Uncomplicated postop course; postop IVP normal; refiux;
pa-#1414716 tially continent
13. (E.P.) M 1956 24 Incomplete exstrophy; postop urethral stricture required,
urethro-152838 plasty; postop IVP normal; incontinent
14. (P.R.) F 1956 Uncomplicated postop course; postop IVP normal; bilateral refiux; #271519 incontinent but voids with a stream
15. (R.M.) rsi: 1956 i Primary closure elsewhere; secondary epispadias repair here; postop
#1356670 IVP normal; reflux; partially continent
16. (J.C.) F 1957 1 Nephrolithotomy; urethral stricture; bilateral antireflux
opera-#182223 tions and Y-V-plasty of bladder neck; postop IVP worse; partially
Continued on next page
Appendix (Continued)
Patient Sex
Year
of
Closure
Age
at
Closure (yr)
COflhlflSflt*
17. (C.P.) F 1957 Left double kidney; uncomplicated postop course; postop IVP
nor-#1S2992 mal; incontinent
18. (R.H.) isi: 1957 Postop skin slough; postop IVP normal; small bladder;
incon-#1331812 tinent
19. (D.C.) M 1957 1 Uncomplicated postop course; postop IVP normal; reflux;
incon-#1380343 tinent but voids with good stream
20. (J.A.) 1I 1958 1 Wires approximating pubis eroded into urethra requiring their re-#1384507 moval and urethroplasty; postop IVP improved; incontinent
21. (G.McK.) M 1958 f Wires approximating pubis eroded into urethra requiring their re-#1344083 moval and urethroplasty; postop IVP worse; incontinent
22. (N.L.) 11 1958 Wires approximating pubis eroded into urethra requiring their
re-#1365578 moval, ureterolithotomy and ureteroplasty; postop IVP worse;
refiux; incontinent
23. (K.P.) M 1958 Urethral stone; postop IVP normal; refiux; incontinent but voids
#1350624 with a stream
24. (A.B.) M 1958 Cystolithotomy; postop IVP worse; partially continent #1378248
25. (MM.) F 1958 24 Urethral stricture; dilated bladder; bilateral anti-reflux operation;
#1388528 postop IVP worse; partially continent
26. (MB.) M 1958 Dermal graft for facial defect; unsuccessful partial abdominal
#1359694 wound breakdown; diminished bladder capacity; postop IVP
worse; refiux; incontinent
27. (K.K.) M 1958 14 Uncomplicated postop course; postop IVP normal; reflux;
incon-#305089 tinent
28. (S.W.) M 1958 I Uncomplicated postop course; postop IVP normal; reflux;
incon-#1375104 tinent
29. (J.L.) M 1959 5 Suprapubic uistula closed surgically; postop 1VP normal;
incon-#1417423 tinent
30. (R.D.) M 19.59 I Required urethroplasty for urethral fistula; postop IVP normal;
#1448625 no reflux; partially continent
31. (M.Mc.) M 1959 6 Rectal prolapse; U.V.J. stricture requiring ureteral re-implantation;
#1393420 postop IVP worse; incontinent
32. (M.V.) 1I 1959 24 Urethroplasty for urethral fistula; postop IVP normal;
incon-#1424427 tinent but voids with a stream
33. (D.S.) M 1959 (?) Breakdown of epispadias repair required secondary procedure;
Appendix (Continued)
Patient Sex
Year
of Closure
Age
at
Closure (1ff)
Commenia
34. (M.Mc.) F 1959 1 Uncomplicated postop course; postop IVP normal; reflux;
incon-#1437089 tinent
35. (S.C.) F 1960 Uncomplicated postop IVP improved; incontinent
#1490355
36. (L.S.) M 1960 1 Urethral stricture; bilateral antirefiux operations; postop IVP
#1483679 worse; incontinent
37. (J.Y.) F 1960 Vesicoeutaneous fistula closed surgically; postop IVP normal;
in-#1461397 continent
38. (D.W.) M 1960 Uncomplicated postop course; postop IVP improved from preop;
#1497519 incontinent
39. (SR.) F 1960 Suprapubic fistula not yet closed; postop IVP normal; incontinent
#1490369
40. (P.Q.) M 1960 Bladder reimplanted, epispadias repair planned as a secondary
#1467826 procedure; postop IVP normal
41. (S.V.) F 1960 34 First closure failed elsewhere; second attempt here followed by #1472523 abdominal wound breakdown; severe upper tract dilatation and
nonfunction of left kidney
42. (RB.) 1L 1960 1 Uncomplicated postop course; postop IVP normal; incontinent
#1468805
43. (R.M.) F 1961 21 Vesicocutaneous fistula closed surgically; preop upper tract
dilata-#1508590 tion unchanged postop; incontinent
44. (T.K.) F 1960 3 Uncomplicated postop course; postop IVP worse; reflux;
corn-#1480658 pletely continent
45. (J.M.) M 1961 Breakdown of epispadias repair; urethroplasty planned; poetop
#1518869 IVI’ normal; incontinent
46. (D.T.) F 1961 Uncomplicated postop course; postop IVP normal; incontinent
#1531013
47. (D.G.) M 1961 4 Required tracheostomy postop for laryngoepasmn; incontinent
#1527809
48. (J.B.) M 1961 Uncomplicated postop course; postop IVP normal; incontinent
#1527788
49. (ST.) M 1961 1 Uncomplicated poetop course; preop upper tract dilatation
un-#1487801 changed postop; incontinent
50. (S.Mc.) F 1961 Uncomplicated postop course; postop IYP normal; reflux
