exstrophy-epispadias complex: analysis of 34 patients. Br J Urol, 82: 865, 1998 7. Grady, R. W. and Mitchell, M. E.: Complete primary repair of exstrophy. J Urol, 162: 1415, 1999 8. Baka-Jakubiak, M.: Combined bladder neck, urethral and penile reconstruction in boys with the exstrophy-epispadias complex. BJU Int, 86: 513, 2000 9. Leadbetter, G. W., Jr.: Surgical correction of total urinary incontinence. J Urol, 91: 261, 1964 10. Jones, J. A., Mitchell, M. E. and Rink, R. C.: Improved results using a modification of the Young-Dees-Leadbetter bladder neck repair. Br J Urol, 71: 555, 1993 11. Kajbafzadeh, A. M., Duffy, P. G. and Ransley, P. G.: The evolu- tion of penile reconstruction in epispadias repair: a report of 180 cases. J Urol, 154: 858, 1995 12. Mitchell, M. and Ba ¨ gli, D.: Complete penile disassembly for epispadias repair: the Mitchell technique. J Urol, 155: 300, 1996 13. Capolicchio, G., McLorie, G. A., Farhat, W., Merguerain, P. A., Ba ¨ gli, D. J. and Khoury, A. E.: A population based analysis of continence outcomes and bladder exstrophy. J Urol, 165: 2418, 2001 14. Ngan, J. H. and Mitchell, M. E.: Exstrophic anomalies: recent advances and long-term outlook. Indian J Pediatr, 64: 327, 1997 15. Hollowell, J. G. and Ransley, P. G.: Surgical management of incontinence in bladder exstrophy. Br J Urol, 68: 543, 1991 16. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: Modified Young-Dees-Leadbetter bladder neck reconstruction in patients with successful primary bladder closure elsewhere: a single institution experience. J Urol, 165: 2438, 2001 17. Reiner, W. G.: Psychosocial concerns in bladder and cloacal exstrophy patients. Dial Pediatr Urol, 22: 8, 1999 18. McMahon, D. R., Cain, M. P., Husmann, D. A. and Kramer, S. A.: Vesical neck reconstruction in patients with the exstrophy- epispadias complex. J Urol, 155: 1411, 1996 19. Hollowell, J. G., Hill, P. D., Duffy, P. G. and Ransley, P. G.: Bladder function and dysfunction in exstrophy and epispadias. Lancet, 338: 926, 1991 EDITORIAL COMMENT The authors report a long and rather large experience with a difficult problem. Using a strict definition of urinary continence, their results with classic staged repair for bladder exstrophy are relatively poor compared to what they might expect with virtually any other reconstructive procedure. Their results are also not unique as is well referenced in the article. Such reports make me concerned about the physiology of the repair and not the surgeons involved. The Young-Dees-Leadbetter technique robs from what may be an already abnormal bladder to construct a bladder neck and urethra. It is difficult to consistently achieve a balanced outlet with that repair, one that provides resis- tance for storage as well as relaxation for voiding. The fact that the authors could never achieve continence for their patients with a reoperative Young-Dees-Leadbetter repair alone adds to my concern. It suggests to me that there is a basic problem with the total repair and not a minor issue that could be made better by relatively simple revision. It remains to be seen how much that complete primary repair of bladder exstrophy, which potentially may result in a better bladder and better prospects for continence, will impact results such as these. If those patients still ultimately require some manner of a similar bladder neck repair, I suspect that some will continue to have similar problems with continence and emptying. We must continue to work to understand the exstrophy anomaly, in regard to what the patient starts with and what we achieve surgically. Clearly, we all wish to achieve better results for patients with exstrophy on a consistent basis. Mark C. Adams Department of Pediatric Urology Vanderbilt Children’s Hospital Nashville, Tennessee CONTINENCE AND CLASSIC BLADDER EXSTROPHY 1453

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exstrophy-epispadias complex: analysis of 34 patients. Br JUrol, 82: 865, 1998

7. Grady, R. W. and Mitchell, M. E.: Complete primary repair ofexstrophy. J Urol, 162: 1415, 1999

8. Baka-Jakubiak, M.: Combined bladder neck, urethral and penilereconstruction in boys with the exstrophy-epispadias complex.BJU Int, 86: 513, 2000

9. Leadbetter, G. W., Jr.: Surgical correction of total urinary incon-tinence. J Urol, 91: 261, 1964

10. Jones, J. A., Mitchell, M. E. and Rink, R. C.: Improved resultsusing a modification of the Young-Dees-Leadbetter bladderneck repair. Br J Urol, 71: 555, 1993

11. Kajbafzadeh, A. M., Duffy, P. G. and Ransley, P. G.: The evolu-tion of penile reconstruction in epispadias repair: a report of180 cases. J Urol, 154: 858, 1995

12. Mitchell, M. and Bagli, D.: Complete penile disassembly forepispadias repair: the Mitchell technique. J Urol, 155: 300,1996

13. Capolicchio, G., McLorie, G. A., Farhat, W., Merguerain, P. A.,Bagli, D. J. and Khoury, A. E.: A population based analysis ofcontinence outcomes and bladder exstrophy. J Urol, 165: 2418,2001

14. Ngan, J. H. and Mitchell, M. E.: Exstrophic anomalies: recentadvances and long-term outlook. Indian J Pediatr, 64: 327,1997

15. Hollowell, J. G. and Ransley, P. G.: Surgical management ofincontinence in bladder exstrophy. Br J Urol, 68: 543, 1991

16. Surer, I., Baker, L. A., Jeffs, R. D. and Gearhart, J. P.: ModifiedYoung-Dees-Leadbetter bladder neck reconstruction in pa-tients with successful primary bladder closure elsewhere: asingle institution experience. J Urol, 165: 2438, 2001

17. Reiner, W. G.: Psychosocial concerns in bladder and cloacalexstrophy patients. Dial Pediatr Urol, 22: 8, 1999

18. McMahon, D. R., Cain, M. P., Husmann, D. A. and Kramer, S. A.:Vesical neck reconstruction in patients with the exstrophy-epispadias complex. J Urol, 155: 1411, 1996

19. Hollowell, J. G., Hill, P. D., Duffy, P. G. and Ransley, P. G.:Bladder function and dysfunction in exstrophy and epispadias.Lancet, 338: 926, 1991

EDITORIAL COMMENT

The authors report a long and rather large experience with adifficult problem. Using a strict definition of urinary continence,their results with classic staged repair for bladder exstrophy arerelatively poor compared to what they might expect with virtuallyany other reconstructive procedure. Their results are also not uniqueas is well referenced in the article.

Such reports make me concerned about the physiology of therepair and not the surgeons involved. The Young-Dees-Leadbettertechnique robs from what may be an already abnormal bladder toconstruct a bladder neck and urethra. It is difficult to consistentlyachieve a balanced outlet with that repair, one that provides resis-tance for storage as well as relaxation for voiding. The fact that theauthors could never achieve continence for their patients with areoperative Young-Dees-Leadbetter repair alone adds to my concern.It suggests to me that there is a basic problem with the total repairand not a minor issue that could be made better by relatively simplerevision. It remains to be seen how much that complete primaryrepair of bladder exstrophy, which potentially may result in a betterbladder and better prospects for continence, will impact results suchas these. If those patients still ultimately require some manner of asimilar bladder neck repair, I suspect that some will continue to havesimilar problems with continence and emptying. We must continueto work to understand the exstrophy anomaly, in regard to what thepatient starts with and what we achieve surgically. Clearly, we allwish to achieve better results for patients with exstrophy on aconsistent basis.

Mark C. AdamsDepartment of Pediatric UrologyVanderbilt Children’s HospitalNashville, Tennessee

CONTINENCE AND CLASSIC BLADDER EXSTROPHY 1453

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