Aesthetic aspects of reconstructive clitoroplasty in females with bladder exstrophy - Epispadias complex

Background: Genital anomalies in females born with classic bladder exstrophy-epispadias complex (EEC) include a bifid clitoris and anterior displacement of vagina. The aesthetic aspects of the genitals acquire greater significance with age and may affect self-esteem. We review our experience with clitoral reconstruction in an EEC population with an emphasis on aesthetic outcomes. Methods: The study group had 26 female patients; three patients with isolated epispadias and 23 with bladder exstrophy. The patients were separated into four separate groups based on reconstructive technique. Group 1 (n = 3) had tubularisation of skin between clitoral bodies for urethral reconstruction; group 2 (n = 12) underwent staged exstrophy reconstruction; group 3 (n = 8) had initial surgery elsewhere and were referred for secondary reconstructive surgery with clitoroplasty accompanied by puboplasty to reconstruct the fourchette; and group 4 (n = 3) had total urogenital sinus mobilisation. The aesthetic outcome was assessed subjectively by the surgeon, parent and age-appropriate patient during follow-up. Results: A total of 33 clitoroplasties were performed. Primary clitoroplasty was performed in 18 patients, while a secondary clitoroplasty was done in 15. The follow-up ranged from 3 months to 31 years. Three patients had partial clitoral atrophy and in one patient the gap between clitoral bodies was widely separated and incapable of being joined. Twenty-three of the26 patients (88%) had a satisfactory or excellent aesthetic outcome following clitoroplasty. Conclusions: Excellent aesthetic outcomes can be achieved by clitoroplasty in EEC patients by using a variety of surgical techniques. We recommend a 'second look' reassessment near puberty to identify poor cosmesis and offer secondary clitoroplasty to improve aesthetic outcome.