Epispadias and incontinence: the challenge of the small bladder.

The 12-year experience at our hospital with epispadias and incontinence is reviewed and attention is focused on the approach to patients with a small bladder capacity. Of 29 children 20 had incontinence associated with the epispadias (13 boys and 7 girls). A total of 15 patients underwent definitive management of the incontinence with a Young-Dees bladder neck reconstruction with or without ureteral reimplantation and they are evaluable. Nine patients (6 boys and 3 girls) had a bladder capacity that was believed to be inadequate for satisfactory bladder neck reconstruction (less than 60 ml.). To date, 7 of these children have undergone staged reconstruction with urethroplasty for epispadias as the initial operation. Bladder capacity increased 95 ml. on the average (range 60 to 140 ml.) after the urethroplasty. No child had hydronephrosis before or after bladder neck reconstruction. Review of the results of bladder neck reconstruction in all patients with a mean followup of 2.9 years (range 7 months to 13 years) demonstrates an 87 per cent satisfactory continence rate (9 of 9 boys and 4 of 6 girls). In the patients who underwent staged reconstruction the results were similar, with a 100 per cent continence rate in evaluable patients (5 of 5 boys and 2 of 2 girls). In conclusion, urethroplasty before bladder neck reconstruction in the epispadiac child with a small bladder allows an increase in capacity, thus, obviating for the most part the need for procedures such as bladder augmentation in the majority of these patients.