Tubularized Trapezoid Flap Neoumbilicoplasty-Simple Technique for Umbilical Reconstruction in Bladder Exstrophy

Abstract

Umbilical preservation or reconstruction of a neoumbilicus has now become a part of exstrophy repair. We describe an easy method of umbilicoplasty concurrent with the initial bladder closure or at subsequent stages and present our experience with this technique in 36 patients during the past 5 years.
Umbilical reconstruction using this technique was done in 36 patients (23 boys and 13 girls), with mean age of 1.5 years (range 2 days to 16 years). A superiorly based trapezoid skin flap was raised at the beginning of the procedure, with its base along a line joining the highest points on the iliac crests and leaving the umbilical remnant at the apex of the flap. At the end of the repair, the flap was vertically oriented and tubularized around the suprapubic and ureteral catheters. After removal of the catheters, the tubularized flap was allowed to follow the natural course of healing.
With a mean follow-up of 3 years (range 3 months to 5 years), all but 2 patients have developed a satisfactory dimpled umbilical scar. The sequence of events in the formation of an umbilical scar simulated that of the umbilical remnant in a newborn (ie, a cord to a proboscoid to a dimpled navel with a hidden central stalk). Even in the patients who developed wound infection, a cosmetic umbilicus was formed.
The technique is easy to perform, free of complications, and gives reproducible cosmetic results comparable to various other methods described in published reports.

Full text

Pediatric Urology
Tubularized Trapezoid Flap
Neoumbilicoplasty—Simple Technique for
Umbilical Reconstruction in Bladder Exstrophy
Shiv Narain Kureel, Kumar Abdul Rashid, and Jiledar Rawat
OBJECTIVES Umbilical preservation or reconstruction of a neoumbilicus has now become a part of exstrophy
repair. We describe an easy method of umbilicoplasty concurrent with the initial bladder closure
or at subsequent stages and present our experience with this technique in 36 patients during the
past 5 years.
METHODS Umbilical reconstruction using this technique was done in 36 patients (23 boys and 13 girls),
with mean age of 1.5 years (range 2 days to 16 years). A superiorly based trapezoid skin flap was
raised at the beginning of the procedure, with its base along a line joining the highest points on
the iliac crests and leaving the umbilical remnant at the apex of the flap. At the end of the repair,
the flap was vertically oriented and tubularized around the suprapubic and ureteral catheters.
After removal of the catheters, the tubularized flap was allowed to follow the natural course of
healing.
RESULTS With a mean follow-up of 3 years (range 3 months to 5 years), all but 2 patients have developed
a satisfactory dimpled umbilical scar. The sequence of events in the formation of an umbilical
scar simulated that of the umbilical remnant in a newborn (ie, a cord to a proboscoid to a
dimpled navel with a hidden central stalk). Even in the patients who developed wound infection,
a cosmetic umbilicus was formed.
CONCLUSIONS The technique is easy to perform, free of complications, and gives reproducible cosmetic
results comparable to various other methods described in published reports. UROLOGY 73:
70 –73, 2009. © 2009 Elsevier Inc.
The umbilicus forms an important surface ana-
tomic landmark on the anterior abdominal wall
and is the only esthetic scar on the body surface.
In patients in whom the umbilicus is absent, deformed,
malpositioned, or removed because of a surgical proce-
dure, umbilical reconstruction can be desirable, because
its absence or deformity evokes a poor self-image.
1-5
In
the case of bladder exstrophy, the umbilicus is usually a
rudimentary hyperpigmented crescentic scar capping the
globe of the exstrophic bladder. The umbilicus is usually
removed at the initial bladder exstrophy closure, al-
though umbilical translocation has been reported by
some investigators that resulted in its malpositioning.
1,3,4
Whenever sacrificed, a cosmetic umbilicus must be re-
constructed.
1-8
We describe a simple technique of
neoumbilicoplasty by tubularization of a trapezoid skin
flap, wherein the tube is used as an outlet for the drainage
catheters. After removal of the catheters, the skin tube is
allowed to follow its natural course of healing and be-
comes a cosmetic, rounded, dimpled umbilicus. We
present our experience with this technique and its results
in 36 patients during past 5 years. The advantages of the
technique compared with other techniques are discussed.
MATERIAL AND METHODS
Our database for the study comprised 36 patients (23 boys and
13 girls) with bladder exstrophy in whom a neoumbilicus was
reconstructed using this technique from 2002 to 2007. All other
patients with exstrophy– epispadias complex in whom umbilical
reconstruction was not done or some other method was used
were excluded. In 27 patients (16 boys and 11 girls), the
umbilicus was reconstructed at the initial bladder closure, and
in 9 patients (7 boys and 2 girls), the procedure was done at a
subsequent procedure, such as epispadias repair, bladder neck
reconstruction, augmentation cystoplasty, or an antireflux pro-
cedure. The youngest patient was a 48-hour-old male neonate
and the oldest was a 16-year-old boy with a failed exstrophy
who underwent a redo single-stage repair. The mean age at
surgery was 1.5 years, with infants forming the largest age group
(43%).
We placed the neoumbilicus at the center of a line joining
the highest points on the iliac crests, which was marked by a
thread between the 2 points. In the case of primary bladder
From the Department of Pediatric Surgery, CSM Medical University (formerly King
George Medical University), Lucknow, India
Reprint requests: Shiv Narain Kureel, M.B.B.S., M.S., Mch.(Paed. Surg.), De-
partment of Pediatric Surgery, CSM Medical University, Lucknow, India 226003.
E-mail: paeduro@gmail.com
Submitted: March 13, 2008, accepted (with revisions): May 15, 2008
70 © 2009 Elsevier Inc. 0090-4295/09/$34.00
All Rights Reserved doi:10.1016/j.urology.2008.05.030

closure, a trapezoid flap with a base to apex ratio of 2:1 was
marked at the top of the exstrophied bladder by a tangential
line at the junction of the umbilical remnant and the bladder
joined by 2 upward oblique lines (Fig. 1A). If bladder closure had
already been performed, a similar flap was marked at the highest
point of the vertical midline incision, such that its base coin-
cided with the line joining the highest points on the iliac crests
(Fig. 1B).The width of the base of the flap was determined by
horizontally pinching the anterior abdominal wall skin between
the thumb and the index finger (Fig. 1C). This gave an approx-
imate estimate of the skin defect that could be closed without
tension. The flap was raised before the circumvesical incision
was extended such that the crescentic umbilical remnant lay at
the apex of the flap (Fig. 1D). A vertical incision was made in
the linea alba to enter the extraperitoneal space. This provided
a healthy area to start with and made the dissection into the
extraperitoneal perivesical plane easier (Fig. 1E). At the ab-
dominal wound closure, the flap was vertically oriented and
tubularized around the suprapubic and ureteral catheters, using
a heavy suture (2-0 polyglactin) at the base of the flap, which
forms the point of greatest tension (Fig. 1F-H).
At present, we prefer to tubularize the flap only around the
suprapubic catheter and to take the 2 ureteral catheters out
through 2 small punctures just above the flap.
RESULTS
After removal of the drainage catheters, postoperatively
after 2-3 weeks, the tubularized flap was observed and
allowed to follow the course of healing similar to that of
the postnatal umbilical remnant. It becomes a proboscoid
umbilicus in the next 2-3 months (Fig. 2A,B) and a
normally placed, dimpled umbilicus within 5-6 months
(Fig. 2C,D). The results of all 36 patients were available,
with a mean follow-up of 3 years (range 3 months to 5
years). It resulted in an umbilical scar in all but 2 patients
to the satisfaction of the parents and the surgeon. In
these 2 patients, a heavy suture material had not been
used for approximation of the flap base and resulted in
dehiscence of the tubularized flap and an unsatisfactory
umbilical scar. Understanding the gravity of the anomaly,
the parents were always more satisfied than the surgeon.
Even in those patients who developed superficial wound
infection and/or vesicocutaneous fistulas, the tubularized
flap healed with an umbilical scar of satisfactory cosmetic
appearance (Fig. 2B).
COMMENT
Although the primary goals of exstrophy reconstruction
are continence with normal upper urinary tracts and
functional external genitalia with a pleasing cosmetic
appearance, the continued successful treatment of this
challenging anomaly has allowed surgeons to improve the
cosmetic appearance of the abdomen.
1,2
Classic textbook
descriptions of bladder exstrophy reconstruction recom-
mend excision of a triangular skin patch above the blad-
der that includes the umbilical remnant.
7,9
Whenever
excised, a cosmetic umbilicus must be reconstructed.
1-10
We have preserved this skin patch to allow it to be
included in the trapezoid flap for neoumbilical recon-
struction. Although opinions regarding the shape differ, a
neoumbilicus should have a natural morphology, a suffi-
Figure 1. Steps of technique for neoumbilicoplasty. (A) Trap-
ezoid skin flap is mapped. (B) Mapping of flap in patient who
had already undergone initial bladder closure without umbili-
coplasty. (C) Width of base estimated by horizontal pinch.
(D) Flap raised. (E) Linea alba incised vertically and dissec-
tion continued into extraperitoneal plane. (F-H) At end of
procedure, flap tubularized around drainage catheters.
UROLOGY 73 (1), 2009 71

cient and prominent depression, and must be created
without causing too many additional scars.
2,8,10
In most
of the techniques of umbilicoplasty described in pub-
lished reports, a dimpled look to the neoumbilicus right
from its reconstruction seemed to be the main con-
cern.
1-8,10
We have aimed our technique at an umbilicus
of adequate size, depth, and orientation so as to have a
near-normal appearance. In contrast to all other tech-
niques of umbilicoplasty, we do not use any sutures to
anchor the neoumbilicus to the fascia to dimple it at the
first instance. It attained its final shape without any
additional surgical maneuvering, simulating the normal
healing course of the umbilical vestige of an infant.
The technique per se had no complications. The com-
plications such as wound infection, wound dehiscence,
and urinary fistulas are frequently associated with the
exstrophy repair but were never found to affect the cos-
metic results of the neoumbilicus using our technique.
This is because the base of the tubularized flap was always
in healthy area. An important added advantage of the
technique is that raising the flap at the beginning of the
procedure exposes the linea alba in a virgin scar-free area
of the lower anterior abdominal wall. A vertical incision
in the linea alba made entry into the extraperitoneal
perivesical plane much easier. A neoumbilicus has also
been used simultaneously for the concealment of a Mitro-
fanoff catheterizable urinary stoma.
1,2,5
We have yet not
used the neoumbilicus for the concealment of a Mitro-
fanoff stoma. However, we believe that it can be done
simultaneously by exteriorizing the stoma just superior to
the base of the tubularized flap that is expected to fall
within the depth of the umbilicus in the future. In the
case of staged exstrophy repairs, the catheterizable uri-
nary stoma can be cosmetically concealed within the
dimpled mature scar of the neoumbilicus that was recon-
structed at the initial bladder closure.
Figure 2. (A) Protuberant umbilicus at 3 months after single-stage bladder exstrophy repair with umbilicoplasty in female
infant. (B) Umbilicus at 2 months after staged exstrophy repair in male patient who developed wound infection and urinary
fistula. (C) Cosmetic dimpled neoumbilicus after 1 year in same patient as Fig. 2A. (D) Umbilicus 1 year after single-stage
redo repair in 16-year-old boy with failed exstrophy repair.
72 UROLOGY 73 (1), 2009

CONCLUSIONS
We believe that umbilicoplasty makes the reconstruction
of bladder exstrophy more cosmetic and adds satisfaction
to the patient, as well as the surgeon. The described
technique, in contrast to other reported techniques, is
extremely simple, with no technical sophistication. The
results are consistently reproducible without any proce-
dure-related complications. The only small disadvantage,
we believe, is the relatively longer time it takes to be-
come a dimpled umbilicus.
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