Successful bladder closure is essential for recovery of urinary function in patients. The modern staged repair of exstrophy (MSRE) and the complete primary repair ofexstrophy (CPER) are two widely used surgical methods. Other approaches include the Mainz Ⅱ Repair, the radical softtissue mobilization, the Erlangen Approach and the Warsaw Approach. As a serious deformity, CBE not only affects physical function in adulthood, but also leads to psychological, social and professional disabilities in patients. Berrettini et al systematically evaluated sexual function and psychosexual correlates in patients with the exstrophy-epispadias complex, Finding that repairing abdominal wall defects can improve patients' libido and contribute to the improvement of patients' quality of life. Brian et al. described 116 patients with bladder exstrophy in detail. The satisfaction rate of abdominal wall shape was 96% during postoperative follow-up. It was also concluded that repairing abdominal wall defect was the most important part to improve patient satisfaction.
In the 12 adult patients in this study, not only surgical repair was complicated and difficult, but abdominal wall incision healing was influenced by numerous factors. 1.Valgus bladder mucosa due to significant local scar tissue, direct reduction and suture after the incision tension is large. 2.Minor postoperative activity can significantly increase abdominal pressure and further increase incision tension. 3. Some cases may develop bladder cancer and therefore require extended resection. 4. Bowel substitution, abdominostomy, and reconstruction of the urinary tract are complex and invasive procedures. 5. Full-thickness abdominal wall defects requiring restoration of structure and tension as far as possible.Therefore, only the application of well-vascularized myofascial flap and deep fasciocutaneous flap for the repair of abdominal wall defects can better repair abdominal wall defects with bladder eversion, Ensuring sufficient tension in the reconstructed abdominal wall and reducing the occurrence of complications such as postoperative abdominal incisional hernia.In addition, multi-layer repair and reconstruction of the abdominal wall, vulva, in order to achieve stronger abdominal wall defects, better abdominal wall and vulva shape requirements.
The strengths of the surgical approach in this study are the following. 1.The surgical design(multi-layer reconstruction of the shallow flap pedicled by the deep abdominal fascia and the deep joint aponeurosis flap composed by anterior sheath of rectus abdominis - aponeurosis of external oblique.) basically meets the requirements of anatomical reduction, while there is no fatal damage to the original abdominal wall, and it is not easy to cause the occurrence of abdominal incisional hernia after donor site and recipient site surgery. 2.The surgical design uses abdominal tissue as far as possible to repair abdominal wall defects, with relatively small destruction and relatively reduced difficulty in operation, which can shorten the repair time of abdominal wall defects, reduce intraoperative bleeding, shorten the operation time compared with perforator flaps, free flaps. At the same time, it costs less than artificial meshes, and reduces the economic burden of patients and their families. 3.Even if surgery fails, there is an opportunity to repair using other methods such as the anterolateral thigh muscle, tensor fascia lata, vulvofemoral flap, and artificial mesh. 4. Multiple groups of deep fasciocutaneous flaps had reliable blood supply, which met the requirements of multi-level repair of abdominal wall, and the shape of abdominal wall was good after operation. 5.Multiple groups of flaps are conducive to vulvecoplasty, postoperative female shape is full, the recovery effect is better, men can also reconstruct the shape of the lower abdomen, not easy to produce high leakage of urine serious complications. However, there is also some limition in this surgical protocol. Patients with bladder exstrophy in childhood can achieve the repair and reconstruction of abdominal wall defects by pulling the pubic symphysis, but adults with increasing age, due to long-term chronic inflammatory stimulation, the probability of local malignant transformation increases, the extent of resection increases, and the repair is more difficult and complex.