Single‐stage subsymphyseal cystoscopic‐guided bladder neck plication and urethrogenitoplasty in female epispadias: presentation of long‐term follow‐up
Authors: Kajbafzadeh Abdol‐Mohammad , Talab Saman S. , Elmi Azadeh , Tourchi Ali 
Published: January 2011

Study Type – Therapy (case series)Level of Evidence 4What’s known on the subject? and What does the study add?Although female epispadias are considered as a rare congenital anomaly the urologist should keep the diagnosis in the back of their mind when examining a child with abnormal external genitalia or unexplained urinary incontinence in order to reach early diagnosis and subsequent prevention of bladder maldevelopment.The main goal in the management of female epispadias is satisfactory continence status with the ability of volitional micturition, together with reconstruction of cosmetically acceptable and functional external genitalia.A limitation to the previously described continence surgery in these patients is the lack of a practical intraoperative method for evaluation of the proper degree of ultimate bladder outlet resistance.For the first time, we introduced the single‐stage subsymphyseal urethrogenitoplasty along with cystoscopic‐guided bladder neck pliation technique as a real‐time intraoperative method for objective evaluation of the bladder outlet resistance, in order to improve continence outcomes and provide a safe pressure within the upper urinary tract. Considering the promising outcomes of the present method in female epispadias, it seems reasonable to defer more invasive currently used approaches and classic continence surgeries, until the outcome from this procedure is evaluated.OBJECTIVE• To investigate the feasibility of an endoscopic technique as a guide to evaluate bladder outlet resistance during bladder neck plication (BNP) for treatment of female epispadias.PATIENTS AND METHODS• The postoperative outcomes with long‐term follow‐up of 10 girls with epispadias were reviewed (four had a previous history of bulking agent injection into the BN).• After taking a skin flap from the area between the crura of the bifid clitoris, subsymphyseal dissection was continued to the BN.• Under cystoscopic guidance, BNP was performed using absorbable sutures (two cases) or non‐absorbable sutures (eight) aiming to attain a smooth closure of the BN during gradual withdrawal of the cystoscope.• Finally, urethrogenitoplasty was accomplished by urethral reconstruction with tubularization of the inter‐clitorial flap followed by monsplasty and approximation of the two hemi‐clitorises.RESULTS• The mean (range) follow‐up was 9.1 (5–15) years.• After primary surgery seven of the 10 girls were continent and all could void normally.• Of the three failed cases (including two that underwent BNP using absorbable suture), two became dry after injection of bulking agent into the BN and the remaining girl underwent BN reconstruction; she was socially continent at the final follow‐up.• Ultimately, all 10 girls were socially continent, including six who were completely dry.• Urodynamic studies showed an increase in mean bladder capacity (P < 0.001) and a significant time‐dependent improvement of the leak‐point pressure and maximum urinary flow rate.CONCLUSIONS• The present series suggests that single‐stage subsymphyseal urethrogenitoplasty together with cystoscopic‐guided BNP for management of female epispadias is reliable and effective with definite advantages.• The high success rate and safety of the procedure are important factors for the introduction of this method as a valid option for treatment of this rare congenital anomaly.