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Epispadias: A Plan of Treatment
Vol. 107, Printed
THE JouRNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
EPISPADIAS: A PLAN O_F TREATMENT HOWARD B. MAYS From the Department of Urology, University of Maryland School of Medicine, Baltimore, Maryland
The selection of a plan of treatment for the occasionally encountered patient with epispadias requires careful consideration of the basic problems involved and a well-planned program if the eventual result is to be the most normal possible individual. The many abnormal circumstances found in association with epispadias of varying degrees indicate the necessity for various methods of treatment. Epispadias is never present as a normal embryological development and, unlike hypospadias, the most frequently encountered varieties of epispadias present the most significant associated anatomic and functional problems. Since primary attention must be directed to the related factors, their correction will significantly influence the planning of epispadias correction. Therefore, correction by stages is recommended and the plastic surgical correction of the penile deformity should be delayed. The preputial flap procedure is presented with modifications and variations. The simple spadic penis is the rarest form of epispadias encountered, followed by the balanic and simple penile deformities. The next most frequently encountered form is penopubic epispadias which may occur with or without incontinence. An important characteristic of this group is the possible existence of borderline or transitional continence which may not be readily apparent. Epispadias with associated vesical exstrophy is the most commonly encountered variety. Because of the relative rarity of the least distorting forms of epispadias requiring comparatively simple corrective measures, attention is directed to the more significant and challenging problems of complete epispadias. PROGRAM FOR CORRECTION OF COMPLETE EPISP ADIAS
The problem of epispadias without exstrophy requires critical attention to the possible existence of a functioning sphincter or the conceivable existence of transitional or borderline continence. A decision may require prolonged observation; premature corrective efforts may prejudice a good final result. Any degree of exstrophy requires evaluation of the status and size of the bladder and estimation of the amount and effect of eventration accompanying the more significant deformities. The status of the upper urinary tract requires early attention although the ureters and kidneys are usually quite satisfactory. Although some form of Accepted for publication January 22, 1971. Read at annnal meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 28-31, 1970.
urinary diversion may subsequently be necessary, even the presence of a small bladder does not necessarily indicate the need for early diversion. The existence of incontinence is not significant since an infant will be incontinent during the months. Generally, the uretcrovesical junctions no immediate attention. A definitive penile plastic operation at age is contraindicated in any degree of since premature operative procedures may well preclude the best possible functional and cosmetic result. The apron of preputial tissue, characteristic of epispadias, is left untouched pending the eventual use of this tissue as a valuable aid to reconstruction. Inguinal hernia occurs frequently with and may be sufficiently severe to require probably separate surgical correction. Concurrent rearrangement of the existing abdominal wall components with approximation of separated but otherwise relatively normal rectus muscle and fascia may be accomplished effectively in some instances. However, experience has shown that large hernias may require early separate correction. Subsequently, the skin and fascia overlying ously existing hernias may be used to The best abdominal wall revision tained by a separate surgical endeavor. and closure of the abdominal defect to the level of the inter-symphyseal deficiency, closing the bladder whether large or small, provide a measure of protection for the bladder epithelium and Fascia! flaps derived from the rectus sheath and external oblique aponeurosis aided relaxing incisions in fascia and skin form an effective abdominal wall. The closure of a large bladder prepare for eventual development of vesical function. Although closure includes the vesical neck, a decision to attempt bladder correction should be postponed. The continuation of incontinence at this stage is not a problem. the small bladder ultimately will be sacrificed m part, its temporary retention will provide a tective conduit and will provide tissue for the quent development of a prostatic fossa. Occasionally, although seldom, a carefully selected case may be considered for retention of the bladder and for attempted repair of the anteriorly separated teric structures. This instance is admittedly an idea] goal not often attained but the possibility is not. prejudiced by this plan of staged treatment. Osteotomy has not been considered Satisfactory abdominal wall reconstruction accomplished without necessity of this and osteotomy has not been considered 251
252
MAYS
the correction of the frequently described gait abnormality. Experience and observation have repeatedly demonstrated that locomotion disability associated with exstrophy is insignificant and not disabling, and it is questionable whether appreciable improvement or change is accomplished by osteottomy. Osteotomy has not been considered necessary for plastic penile reconstruction or for the occasional case of vesical neck reconstruction. Urinary diversion may be required in most instances of epispadias with exstrophy. Ureterosigmoidal diversion has been used effectively as a temporary or permanent form of diversion and may be performed concurrently with abdominal wall rearrangement. The ileal conduit provides an effective means of urinary diversion; however, previous rearrangement of the abdominal wall is a distinct aid to the subsequent positioning and functioning of the ileostomy. Generally, abdominal wall closure if accompanied by temporary or permanent ureterosigmoidal diversion should be postponed for a year or longer. The decision to use ileal diversion should be deferred still longer. Adequate plastic correction of epispadias with chordee improvement and urethral formation is time-consuming and should require separate consideration if a satisfactory functional and cosmetic result is to be attained. Postponement of this phase of correction to an elected time provides the distinct advantage of an increased size of the penis and a more cooperative patient. Delay of operation until the child is 3 to 5 years old or even later is recommended. Good results have been obtained with 2 corrective plastic reconstructions done when the patients were 16 and 22 years old. The operative procedure for the correction of epispadias most frequently described was presented
by Cantwell in 1895. Numerous modifications have been presented but basically the procedure involves the formation of a dorsally derived tubular flap. The problems of insufficient tube length, inelasticity and restricted erections have been recognized. The rare forms of balanic and simple penile deformities have relatively little or no chordee and may be readily corrected. More frequently encountered is the short dorsal surface of the complete epispadias associated with an acute upward chordee with a short penis and close approximation to the abdominal wall. Chordee correction requires lengthening of this surface. An indication of the inadequacy of this tissue for the formation of the urethra becomes evident when the penis is extended by traction during chordee correction. Tissue of greater length and pliability is required and is readily attainable by converting the apron of prepuce to a single-layered flap. The method of treatment of epispadias using the preputial tissue presented in 1948 has been modified and often used effectively. The adequacy of this tissue is demonstrated when the organ is extended. Characteristically, the lumen increases proportionate to body growth. PROCEDURE
Two silk sutures are placed through the glans for traction, thus emphasizing the restricting effects of ventral chordee. A circumferential incision is made about the vesical neck or the residual of bladder planned for formation of a prostatic fossa. Parallel incisions are made on the dorsum of the penis from the circumscribed orifice or prostatic fossa to the glans. These incisions are carried about the glans, allowing a cuff of several millimeters width attached to the glans (fig. 1, A). The preputial apron, which is characteristic of all cases of epispadias,
i
'
Fm. 1. A, circumferential incision about vesical neck or prostatic fossa, parallel ventral incisions and paraglanular incision. Preputial apron is demonstrated. B, excision of dorsal and intercavernosal restricting tissue. Essential feature is complete denudation which assists chordee correction and elongation of penis.
EPISPADIAS
is preserved and left attached to the ventral integument. The penis is completely denuded, preserving all possible blood supply. The broad band of fibrous tissue between the corpora cavcrnosa is resectccl, including; the wedge of fibrous intcrcavcrnosal tissue down to the ventral fascia. The excision must be carefully performed, eliminating all possible areas of constriction from the level of the corona to the infundibulum (fig. 1, B). Thereafter,
the penis becomes notably more pliable and the length is appreciably increased. Chordee correction may be aided further by dissection about the base of the penis and partial incision of the ,,._,,,,,cu,,,,,, fascia. The dorsal vessels are usually and must be preserved and the attachment of the corpora to the separated pubes must be left undisturbed. The epithelial layers of the preputial apron should
FIG. 2. A, development of prepntial apron into single layered epithelial flap. Ventral fascia! incision to intercavernosal sulcus. B, maximum chordee correction and elong,,tion. Development of subglanular tmrnel and relationship to prepntial flap. C, development of urethra from preputial flap. Flap is trimmed to appropri ate size. Urethra is drawn between corpora.
FrG. 3. A, anastomosis of urethral tube to prostatic fossa or vesical neck. Diagonal course of urethra from hypospadic position to vesical neck or prostatic fossa is illustrated. Approximation of corpora cavernosa. Spadic glans deformity is corrected. B, epithelial reinvestment of penis. Glans sutures attached by elastic to one thigh assist chordee correction.
254
MAYS
be carefully separated by sharp and blunt dissection, preserving all possible blood supply. This maneuver creates a single layer of epithelium appreciably more extensible than would appear apparent. The epithelial pouch thus produced is developed into a single flap by lateral incisions opening the pouch to produce the greatest possible length (fig. 2, A). A short transverse incision is made through the ventral fascia into the intercavernosal sulcus immediately proximal to the corona. The fascia! opening is enlarged to allow the subsequent unrestricted passage of the urethral tube to be developed (fig. 2, A and B). The preputial flap is formed into a tube, turning the epithelial surface inward and approximating the edges beginning first at the end of the flap using interrupted sutures of 3 or 4-zero atraumatic catgut. As the urethral tube is developed it is drawn through the ventral incision beneath the glans and diagonally upward between the corpora (fig. 2, C). The urethral tube thus created from the preputial flap is usually of sufficient length to extend from a hypospadic position to the anteriorly located vesical neck or the preserved prostatic fossa. This tube may be developed about a section of rubber tubing of adequate length and diameter. Occasionally, if the vesical neck is intact, a catheter of adequate size may be used for drainage and this is particularly applicable to older patients. When bladder diversion is indicated it must of necessity be the suprapubic route. A nephrostomy tube such as the Cummings type serving the combined purpose of suprapubic drainage and as a mold for urethral development has been used effectively. A variation of the procedure using a portion of the dorsally derived epithelium formed into a proximal tube combined with the preputial flap urethra as described may be considered. While this procedure provides additional urethral length the requirement of mid-penile anastomosis and the rather deficient blood supply of the dorsally derived epithelium should be considered. Generally, the use of the preputial flap has been found sufficient. The newly formed urethra is approximated to the infundibulum with interrupted sutures reinforced by a second suture layer. The widely separated corpora cavernosa are drawn together over the diagonally placed urethra with interrupted sutures. This procedure reconstitutes the fascial plane and encloses the newly-formed urethra in its entirety from the hypospadic position of the orifice to the anteriorly located vesical neck or prostatic fossa (fig. 3, A). A triangle of epithelium is excised from the broad
anterior surface of the glans. The penis is reinvested with interrupted sutures about the coronal cuff and in the midline anteriorly from the dorsal surface of the glans to the base of the penis. Short relaxing incisions may be required for adequate reinvestment without tension. The penis is extended by attaching the glans traction sutures to either thigh using an elastic band and adhesive (fig. 3, B). The hypospadiac position of the newly created urethral orifice is a distinct advantage. The voiding position is quite satisfactory and there is a lessened tendency to restriction and curvature when erect. The subsequent transfer of the meatus to the tip of the glans is feasible but requires additional operative procedure of dubious value. SUMMARY The selection of a plan of treatment for epispadias requires consideration of the basic problems and potential for correction or improvement of each case encountered. Because primary attention must be directed to the related circumstances, staging is recommended with postponement of the plastic penile correction until the optimum functional status has been determined. The preputial flap procedure is adaptable to any program of treatment. REFERENCES BoIFFIN, A.: Epispadias complete Penopubien; reconstruction du col de la vessie apres symphysiotomie. A Franc. de Chir. Proc. verb. Par., 9: 576, 1895.
CANTW~JLL, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann. Surg., 22: 689, 1895.
DUPLAY, S.: Sur le traitement chirurgical de l'hypospadias et de l'epispadias. Bull. et mem. Soc. de Chir. de Par., 6: 169, 1880. GRoss, R. E. and CRESSON, S. L.: Treatment of epispadias: a report of 18 cases. J. Urol., 68: 477, 1952.
HINMAN, F., Ju.: A method of lengthening and repairing the penis in exstrophy of the bladder. J. Urol., 79: 237, 1958. LATTIMER, J. K. and SMITH, M. J. V.: Exstrophy closure: a followup on 70 cases. J. Urol., 95: 356, 1966.
MARSHALL, V. F. and MUECKE, E. C.: Variations in exstrophy of the bladder. J. Urol., 88: 766, 1962. MARSHALL, V. F. and MUECKE, E. C.: Functional closure of typical exstrophy of the bladder. J. Urol., 104: 205, 1970. MAYS, H.B.: Epispadias with incontinence: a method of treatment. J. Urol., 60: 749, 1948. MUECKE, E. C.: The role of the cloaca! membrane in exstrophy: the first successful experimental study. J. Urol., 92: 659, 1964. YOUNG, H. H.: A new operation for epispadias. J. Urol., 2: 237, 1918.
THE JouRNAL OF UROLOGY
Copyright © 1972 by The Williams & Wilkins Co.
EPISPADIAS: A PLAN O_F TREATMENT HOWARD B. MAYS From the Department of Urology, University of Maryland School of Medicine, Baltimore, Maryland
The selection of a plan of treatment for the occasionally encountered patient with epispadias requires careful consideration of the basic problems involved and a well-planned program if the eventual result is to be the most normal possible individual. The many abnormal circumstances found in association with epispadias of varying degrees indicate the necessity for various methods of treatment. Epispadias is never present as a normal embryological development and, unlike hypospadias, the most frequently encountered varieties of epispadias present the most significant associated anatomic and functional problems. Since primary attention must be directed to the related factors, their correction will significantly influence the planning of epispadias correction. Therefore, correction by stages is recommended and the plastic surgical correction of the penile deformity should be delayed. The preputial flap procedure is presented with modifications and variations. The simple spadic penis is the rarest form of epispadias encountered, followed by the balanic and simple penile deformities. The next most frequently encountered form is penopubic epispadias which may occur with or without incontinence. An important characteristic of this group is the possible existence of borderline or transitional continence which may not be readily apparent. Epispadias with associated vesical exstrophy is the most commonly encountered variety. Because of the relative rarity of the least distorting forms of epispadias requiring comparatively simple corrective measures, attention is directed to the more significant and challenging problems of complete epispadias. PROGRAM FOR CORRECTION OF COMPLETE EPISP ADIAS
The problem of epispadias without exstrophy requires critical attention to the possible existence of a functioning sphincter or the conceivable existence of transitional or borderline continence. A decision may require prolonged observation; premature corrective efforts may prejudice a good final result. Any degree of exstrophy requires evaluation of the status and size of the bladder and estimation of the amount and effect of eventration accompanying the more significant deformities. The status of the upper urinary tract requires early attention although the ureters and kidneys are usually quite satisfactory. Although some form of Accepted for publication January 22, 1971. Read at annnal meeting of Mid-Atlantic Section, American Urological Association, Hot Springs, Virginia, October 28-31, 1970.
urinary diversion may subsequently be necessary, even the presence of a small bladder does not necessarily indicate the need for early diversion. The existence of incontinence is not significant since an infant will be incontinent during the months. Generally, the uretcrovesical junctions no immediate attention. A definitive penile plastic operation at age is contraindicated in any degree of since premature operative procedures may well preclude the best possible functional and cosmetic result. The apron of preputial tissue, characteristic of epispadias, is left untouched pending the eventual use of this tissue as a valuable aid to reconstruction. Inguinal hernia occurs frequently with and may be sufficiently severe to require probably separate surgical correction. Concurrent rearrangement of the existing abdominal wall components with approximation of separated but otherwise relatively normal rectus muscle and fascia may be accomplished effectively in some instances. However, experience has shown that large hernias may require early separate correction. Subsequently, the skin and fascia overlying ously existing hernias may be used to The best abdominal wall revision tained by a separate surgical endeavor. and closure of the abdominal defect to the level of the inter-symphyseal deficiency, closing the bladder whether large or small, provide a measure of protection for the bladder epithelium and Fascia! flaps derived from the rectus sheath and external oblique aponeurosis aided relaxing incisions in fascia and skin form an effective abdominal wall. The closure of a large bladder prepare for eventual development of vesical function. Although closure includes the vesical neck, a decision to attempt bladder correction should be postponed. The continuation of incontinence at this stage is not a problem. the small bladder ultimately will be sacrificed m part, its temporary retention will provide a tective conduit and will provide tissue for the quent development of a prostatic fossa. Occasionally, although seldom, a carefully selected case may be considered for retention of the bladder and for attempted repair of the anteriorly separated teric structures. This instance is admittedly an idea] goal not often attained but the possibility is not. prejudiced by this plan of staged treatment. Osteotomy has not been considered Satisfactory abdominal wall reconstruction accomplished without necessity of this and osteotomy has not been considered 251
252
MAYS
the correction of the frequently described gait abnormality. Experience and observation have repeatedly demonstrated that locomotion disability associated with exstrophy is insignificant and not disabling, and it is questionable whether appreciable improvement or change is accomplished by osteottomy. Osteotomy has not been considered necessary for plastic penile reconstruction or for the occasional case of vesical neck reconstruction. Urinary diversion may be required in most instances of epispadias with exstrophy. Ureterosigmoidal diversion has been used effectively as a temporary or permanent form of diversion and may be performed concurrently with abdominal wall rearrangement. The ileal conduit provides an effective means of urinary diversion; however, previous rearrangement of the abdominal wall is a distinct aid to the subsequent positioning and functioning of the ileostomy. Generally, abdominal wall closure if accompanied by temporary or permanent ureterosigmoidal diversion should be postponed for a year or longer. The decision to use ileal diversion should be deferred still longer. Adequate plastic correction of epispadias with chordee improvement and urethral formation is time-consuming and should require separate consideration if a satisfactory functional and cosmetic result is to be attained. Postponement of this phase of correction to an elected time provides the distinct advantage of an increased size of the penis and a more cooperative patient. Delay of operation until the child is 3 to 5 years old or even later is recommended. Good results have been obtained with 2 corrective plastic reconstructions done when the patients were 16 and 22 years old. The operative procedure for the correction of epispadias most frequently described was presented
by Cantwell in 1895. Numerous modifications have been presented but basically the procedure involves the formation of a dorsally derived tubular flap. The problems of insufficient tube length, inelasticity and restricted erections have been recognized. The rare forms of balanic and simple penile deformities have relatively little or no chordee and may be readily corrected. More frequently encountered is the short dorsal surface of the complete epispadias associated with an acute upward chordee with a short penis and close approximation to the abdominal wall. Chordee correction requires lengthening of this surface. An indication of the inadequacy of this tissue for the formation of the urethra becomes evident when the penis is extended by traction during chordee correction. Tissue of greater length and pliability is required and is readily attainable by converting the apron of prepuce to a single-layered flap. The method of treatment of epispadias using the preputial tissue presented in 1948 has been modified and often used effectively. The adequacy of this tissue is demonstrated when the organ is extended. Characteristically, the lumen increases proportionate to body growth. PROCEDURE
Two silk sutures are placed through the glans for traction, thus emphasizing the restricting effects of ventral chordee. A circumferential incision is made about the vesical neck or the residual of bladder planned for formation of a prostatic fossa. Parallel incisions are made on the dorsum of the penis from the circumscribed orifice or prostatic fossa to the glans. These incisions are carried about the glans, allowing a cuff of several millimeters width attached to the glans (fig. 1, A). The preputial apron, which is characteristic of all cases of epispadias,
i
'
Fm. 1. A, circumferential incision about vesical neck or prostatic fossa, parallel ventral incisions and paraglanular incision. Preputial apron is demonstrated. B, excision of dorsal and intercavernosal restricting tissue. Essential feature is complete denudation which assists chordee correction and elongation of penis.
EPISPADIAS
is preserved and left attached to the ventral integument. The penis is completely denuded, preserving all possible blood supply. The broad band of fibrous tissue between the corpora cavcrnosa is resectccl, including; the wedge of fibrous intcrcavcrnosal tissue down to the ventral fascia. The excision must be carefully performed, eliminating all possible areas of constriction from the level of the corona to the infundibulum (fig. 1, B). Thereafter,
the penis becomes notably more pliable and the length is appreciably increased. Chordee correction may be aided further by dissection about the base of the penis and partial incision of the ,,._,,,,,cu,,,,,, fascia. The dorsal vessels are usually and must be preserved and the attachment of the corpora to the separated pubes must be left undisturbed. The epithelial layers of the preputial apron should
FIG. 2. A, development of prepntial apron into single layered epithelial flap. Ventral fascia! incision to intercavernosal sulcus. B, maximum chordee correction and elong,,tion. Development of subglanular tmrnel and relationship to prepntial flap. C, development of urethra from preputial flap. Flap is trimmed to appropri ate size. Urethra is drawn between corpora.
FrG. 3. A, anastomosis of urethral tube to prostatic fossa or vesical neck. Diagonal course of urethra from hypospadic position to vesical neck or prostatic fossa is illustrated. Approximation of corpora cavernosa. Spadic glans deformity is corrected. B, epithelial reinvestment of penis. Glans sutures attached by elastic to one thigh assist chordee correction.
254
MAYS
be carefully separated by sharp and blunt dissection, preserving all possible blood supply. This maneuver creates a single layer of epithelium appreciably more extensible than would appear apparent. The epithelial pouch thus produced is developed into a single flap by lateral incisions opening the pouch to produce the greatest possible length (fig. 2, A). A short transverse incision is made through the ventral fascia into the intercavernosal sulcus immediately proximal to the corona. The fascia! opening is enlarged to allow the subsequent unrestricted passage of the urethral tube to be developed (fig. 2, A and B). The preputial flap is formed into a tube, turning the epithelial surface inward and approximating the edges beginning first at the end of the flap using interrupted sutures of 3 or 4-zero atraumatic catgut. As the urethral tube is developed it is drawn through the ventral incision beneath the glans and diagonally upward between the corpora (fig. 2, C). The urethral tube thus created from the preputial flap is usually of sufficient length to extend from a hypospadic position to the anteriorly located vesical neck or the preserved prostatic fossa. This tube may be developed about a section of rubber tubing of adequate length and diameter. Occasionally, if the vesical neck is intact, a catheter of adequate size may be used for drainage and this is particularly applicable to older patients. When bladder diversion is indicated it must of necessity be the suprapubic route. A nephrostomy tube such as the Cummings type serving the combined purpose of suprapubic drainage and as a mold for urethral development has been used effectively. A variation of the procedure using a portion of the dorsally derived epithelium formed into a proximal tube combined with the preputial flap urethra as described may be considered. While this procedure provides additional urethral length the requirement of mid-penile anastomosis and the rather deficient blood supply of the dorsally derived epithelium should be considered. Generally, the use of the preputial flap has been found sufficient. The newly formed urethra is approximated to the infundibulum with interrupted sutures reinforced by a second suture layer. The widely separated corpora cavernosa are drawn together over the diagonally placed urethra with interrupted sutures. This procedure reconstitutes the fascial plane and encloses the newly-formed urethra in its entirety from the hypospadic position of the orifice to the anteriorly located vesical neck or prostatic fossa (fig. 3, A). A triangle of epithelium is excised from the broad
anterior surface of the glans. The penis is reinvested with interrupted sutures about the coronal cuff and in the midline anteriorly from the dorsal surface of the glans to the base of the penis. Short relaxing incisions may be required for adequate reinvestment without tension. The penis is extended by attaching the glans traction sutures to either thigh using an elastic band and adhesive (fig. 3, B). The hypospadiac position of the newly created urethral orifice is a distinct advantage. The voiding position is quite satisfactory and there is a lessened tendency to restriction and curvature when erect. The subsequent transfer of the meatus to the tip of the glans is feasible but requires additional operative procedure of dubious value. SUMMARY The selection of a plan of treatment for epispadias requires consideration of the basic problems and potential for correction or improvement of each case encountered. Because primary attention must be directed to the related circumstances, staging is recommended with postponement of the plastic penile correction until the optimum functional status has been determined. The preputial flap procedure is adaptable to any program of treatment. REFERENCES BoIFFIN, A.: Epispadias complete Penopubien; reconstruction du col de la vessie apres symphysiotomie. A Franc. de Chir. Proc. verb. Par., 9: 576, 1895.
CANTW~JLL, F. V.: Operative treatment of epispadias by transplantation of the urethra. Ann. Surg., 22: 689, 1895.
DUPLAY, S.: Sur le traitement chirurgical de l'hypospadias et de l'epispadias. Bull. et mem. Soc. de Chir. de Par., 6: 169, 1880. GRoss, R. E. and CRESSON, S. L.: Treatment of epispadias: a report of 18 cases. J. Urol., 68: 477, 1952.
HINMAN, F., Ju.: A method of lengthening and repairing the penis in exstrophy of the bladder. J. Urol., 79: 237, 1958. LATTIMER, J. K. and SMITH, M. J. V.: Exstrophy closure: a followup on 70 cases. J. Urol., 95: 356, 1966.
MARSHALL, V. F. and MUECKE, E. C.: Variations in exstrophy of the bladder. J. Urol., 88: 766, 1962. MARSHALL, V. F. and MUECKE, E. C.: Functional closure of typical exstrophy of the bladder. J. Urol., 104: 205, 1970. MAYS, H.B.: Epispadias with incontinence: a method of treatment. J. Urol., 60: 749, 1948. MUECKE, E. C.: The role of the cloaca! membrane in exstrophy: the first successful experimental study. J. Urol., 92: 659, 1964. YOUNG, H. H.: A new operation for epispadias. J. Urol., 2: 237, 1918.