#OXFORDClinicalCase: Classic bladder exstrophy and complete
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A 10-year-old male presented with bladder exstrophy, having not undergone any surgical intervention prior. Physical examination revealed classic bladder exstrophy and multiple large polyps on the mucosal surface. Complete rectal prolapse due to a significant widening of the pubic symphysis and the levator ani complex were also divergent, leading to weakness in the pelvic floor as well as fecal incontinence. The decision was to perform complete bladder closure with augmentation and preservation of the bladder template for reimplanting the ureters and using the dilated sigmoid for augmentation.

As a first step of reconstructing this complicated anomaly, bilateral anterior oblique iliac osteotomies via separate incisions were performed. An incision was made around the periphery of the exstrophic bladder plate, and a plane of dissection was established between the rectus fascia and bladder. Dissection was continued toward the pubis, and the incision was then extended distally to the verumontanum on both sides of the prostatic urethra, leaving a wide strip of bladder neck and urethral plate. Reimplanting the ureters on the bladder template was done using modified Lich–Gregoir reimplantation. The next step was the augmentation of the bladder using the dilated sigmoid. After isolating a segment of sigmoid about 10 cm, opened the segment along its anti-mesenteric border and then sutured it to the opened bladder template.

A cystostomy tube was performed depending on Monti’s procedure by using a part of the augmented bladder. 16 Fr catheter was used, and the stoma was made at the level of the new umbilicus. End-to-end anastomosis was performed on the divided sigmoid, and the rectum was ligated to the sacrum with 2 Prolene sutures. Ureteral catheters were removed 14 days after surgery. At 3-month follow-up, upper urinary tract imaging studies and urine tests were normal, and the patient did not suffer from any anorectal problems. The patient is prepared for bladder neck reconstruction and epispadias repair. As soon as bladder neck reconstruction is performed, the child will be ready for continence training.