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Abbreviations and Acronyms BE bladder exstrophy REFERENCES 1. Hanna MK: Reconstruction of umbilicus during functional clo- sure of bladder exstrophy. Urology 1986; 340: 27. 2. Feyaerts A, Mure PY, Jules JA, Morel-Journel N and Mouriquand P: Umbilical reconstruction in patients with exstrophy: the kangaroo pouch technique. J Urol 2001; 2026: 165. 3. Sumfest JM and Mitchell ME: Reconstruction of the umbilicus in exstrophy. J Urol 1994; 453: 151. 4. Barroso U, Jednak R, Barthold JS and Gonzalez R: A technique for constructing an umbilicus and a concealed catheterizable stoma. BJU Int 2001; 117: 87. 5. Hanna MK and Ansong K: Reconstruction of umbilicus in blad- der exstrophy. Urology 1984; 324: 24. 6. Pinto PA, Stock JA and Hanna MK: Results of umbilicoplasty for bladder exstrophy. J Urol 2000; 2055: 164. EDITORIAL COMMENT The umbilicus is a functionless depressed scar but, nonethe- less, it is an important aesthetic landmark since it defines the waistline. The authors describe a modification of a method reported in 1984 for umbilicoplasty in patients born with BE, in which the skin is turned upward instead of downward and sutured to the linea alba (reference 5 in article). In the current series the authors raise 2 additional skin flaps, which are then rotated medial and sutured to the linea alba. Mean followup is 6 months with a satisfactory outcome in all patients. I take issue with the statement of the authors that most attempts to create an umbilicus leave a flat scar. The V or U-shaped skin flap that we reported in 1984 is sutured distal to the rectus sheath (reference 5 in article). In time the buried skin flap forms a tube (the Denis Browne principle). The flap serves to house or form the back wall for the cystotomy tube, which is left in situ for several weeks fol- lowing bladder closure. The flap can be incorporated in con- tinent diversion since the flap can be sutured to the spatu- lated appendix in cases in which a stoma and bladder augmentation are deemed appropriate. The flap can also be tubularized and sutured to the linea alba in primary or secondary umbilical construction. This versatile flap has stood the test of time and followup in 69 patients for 1 to 19 years has been reported (reference 6 in article). The other surgical method transfers the mature umbilicus from an ectopic to a more normal location (reference 1 in article). The practice in those days was to delay bladder closure for sev- eral months. This technique has now been abandoned since we now advocate early reconstruction. In my experience the loss of depth of the neo-umbilicus occurs many years postoperatively, mainly due to weight gain. Followup in the reported series is only 6 months and, therefore, the claim of superiority of the reported technique is unsubstantiated since it has not yet survived the test of time. It is interesting to note the progress that we have made in BE treatment. It has always been my contention as well as that of my older patients that aesthetics are as important as function. This study represents a clear sign that we have come a long way and I applaud the authors for pursuing the road to perfection for reconstructive surgery. Moneer K. Hanna Department of Urology New York Hospital-Cornell Medical Center New York, New York REPLY BY AUTHORS We agree that long term followup is necessary to validate the new approach we have described. However, since this article was written the followup of this series is now 18 months, and the umbilical reconstructions remain stable and cosmetically extremely satisfactory. CONSTRUCTION OF NATURAL LOOKING UMBILICUS FOR BLADDER EXSTROPHY 1872

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Abbreviations and Acronyms

BE � bladder exstrophy

REFERENCES

1. Hanna MK: Reconstruction of umbilicus during functional clo-sure of bladder exstrophy. Urology 1986; 340: 27.

2. Feyaerts A, Mure PY, Jules JA, Morel-Journel N and MouriquandP: Umbilical reconstruction in patients with exstrophy: thekangaroo pouch technique. J Urol 2001; 2026: 165.

3. Sumfest JM and Mitchell ME: Reconstruction of the umbilicusin exstrophy. J Urol 1994; 453: 151.

4. Barroso U, Jednak R, Barthold JS and Gonzalez R: A techniquefor constructing an umbilicus and a concealed catheterizablestoma. BJU Int 2001; 117: 87.

5. Hanna MK and Ansong K: Reconstruction of umbilicus in blad-der exstrophy. Urology 1984; 324: 24.

6. Pinto PA, Stock JA and Hanna MK: Results of umbilicoplastyfor bladder exstrophy. J Urol 2000; 2055: 164.

EDITORIAL COMMENT

The umbilicus is a functionless depressed scar but, nonethe-less, it is an important aesthetic landmark since it definesthe waistline. The authors describe a modification of amethod reported in 1984 for umbilicoplasty in patients bornwith BE, in which the skin is turned upward instead ofdownward and sutured to the linea alba (reference 5 inarticle). In the current series the authors raise 2 additionalskin flaps, which are then rotated medial and sutured to thelinea alba. Mean followup is 6 months with a satisfactoryoutcome in all patients.

I take issue with the statement of the authors that mostattempts to create an umbilicus leave a flat scar. The V orU-shaped skin flap that we reported in 1984 is sutured distalto the rectus sheath (reference 5 in article). In time theburied skin flap forms a tube (the Denis Browne principle).The flap serves to house or form the back wall for thecystotomy tube, which is left in situ for several weeks fol-

lowing bladder closure. The flap can be incorporated in con-tinent diversion since the flap can be sutured to the spatu-lated appendix in cases in which a stoma and bladderaugmentation are deemed appropriate. The flap can also betubularized and sutured to the linea alba in primary orsecondary umbilical construction. This versatile flap hasstood the test of time and followup in 69 patients for 1 to 19years has been reported (reference 6 in article). The othersurgical method transfers the mature umbilicus from anectopic to a more normal location (reference 1 in article). Thepractice in those days was to delay bladder closure for sev-eral months. This technique has now been abandoned sincewe now advocate early reconstruction.

In my experience the loss of depth of the neo-umbilicusoccurs many years postoperatively, mainly due to weightgain. Followup in the reported series is only 6 months and,therefore, the claim of superiority of the reported techniqueis unsubstantiated since it has not yet survived the test oftime.

It is interesting to note the progress that we have made inBE treatment. It has always been my contention as well asthat of my older patients that aesthetics are as important asfunction. This study represents a clear sign that we havecome a long way and I applaud the authors for pursuing theroad to perfection for reconstructive surgery.

Moneer K. HannaDepartment of Urology

New York Hospital-Cornell Medical CenterNew York, New York

REPLY BY AUTHORS

We agree that long term followup is necessary to validatethe new approach we have described. However, since thisarticle was written the followup of this series is now 18months, and the umbilical reconstructions remain stableand cosmetically extremely satisfactory.

CONSTRUCTION OF NATURAL LOOKING UMBILICUS FOR BLADDER EXSTROPHY1872