Vaginoplasty in female bladder exstrophy-epispadias complex: Analysis of operative technique, outcomes, and complications.

Abstract

Introduction and objective: Bladder exstrophy-epispadias complex (BEEC) is a rare, but serious congenital malformation. After achieving urinary continence and upper tract preservation, genital reconstruction is performed for function and cosmesis. We evaluated our institutional experience with vaginoplasty, including technical considerations and post-operative outcomes.

Patients and methods: An IRB-approved database was used to conduct an institutional retrospective review of BEEC patients undergoing vaginoplasty from 2000 to 2024. Patients with XY karyotype, primary vaginoplasty during BEEC closure or at another institution, or no urologic follow-up visits at least six months post-vaginoplasty were excluded. Data on age, reconstructive method, and suture type was collected. Post-operative complications were analyzed with the primary surgical outcome of vaginal stenosis requiring re-operation (VS) and secondary surgical outcomes including urinary tract infection (UTI), surgical site infection (SSI), dehiscence, rectal injury, fistula, and symptomatic pelvic organ prolapse (POP) after vaginoplasty.

Results: A total of 240 female BEEC patients were identified with 54 (22.5 %) undergoing vaginoplasty. Median age at vaginoplasty was 15.6 years old. The majority of cases were perineal flap vaginoplasty (88.9 %). Nylon suture was most commonly used (46.3 %), with Vicryl and PDS used in 31.5 % and 22.2 % of cases, respectively. Median follow-up time was 55.2 months. Post-operative complication rates were VS 14.8 %, UTI 3.7 %, SSI 7.4 %, dehiscence 3.7 %, rectal injuries 0 %, fistula 0 %, and symptomatic POP 12.9 % (Table 1). The perioperative complication rate per-patient from post-operative day 1-90 was 20.4 % and the overall lifetime complication rate per-patient was 33.3 %. We found no significant association between reconstructive method and VS (p = 0.2). Among VS events, PDS was used in 50 % of cases (p = 0.041). On univariable analysis, PDS use was significantly associated with VS (OR 4.75, 95 % CI [1.02-23.1], p = 0.042). This finding remained significant when adjusting for reconstructive method on multivariable analysis (OR 5.83, 95 % CI [1.06-32.3], p = 0.043) (Table 2).

Conclusions: As children with BEEC mature into adulthood, optimizing surgical outcomes for genital reconstruction is critical. In this large retrospective cohort of BEEC patients undergoing vaginoplasty, we observed that VS was the most common post-operative complication. Symptomatic POP was the second most common post-operative complication, but of these patients, the majority were managed conservatively. Use of PDS during vaginoplasty was significantly associated with VS, suggesting that other suture types may be more advantageous for successful surgical outcomes, but further investigation into the clinical significance of this finding is warranted.