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Page 10 of 12 Bizic et al. Plast Aesthet Res 2022;9:14 https://dx.doi.org/10.20517/2347-9264.2021.102

concerns regarding the esthetic appearance of their penis, 20 had normal erections, 6 reported recurrent
[13]
[21]
curvature, and 9 reported retrograde ejaculation . Kibar et al. also reported concerns related to
continence after penopubic epispadias or exstrophy-epispadias complex repair in the long run. They found
the rate of continence ranging 22%-65%, as reported by other institutions. The authors also concluded that
complete urinary continence can be obtained in 70%-90% of patients after bladder neck reconstruction.

The mean follow-up in our study was 88 months, and overall satisfaction in terms of cosmesis and function
was achieved in 78.8% of our patients. Complications occurred in 23 out of 33 patients in our sample, with
the majority of complications occurring in Group A. The most common complication was skin dehiscence,
which was seen in eight patients from both groups. Urethral fistula occurred in 22.2% of patients in Group
A and in 20% in Group B, which is in accordance with literature data [13,20,26] . Recurrence of penile curvature
is relatively common even up to 60%, and in our series recurrent penile curvature occurred in 12.1% and
required surgical repair in 50% . Severe complications, such as glans or corporal ischemia and partial or
[26]
[21]
complete loss, were not seen in our sample, while the literature reports an incidence of 5%-12% .
Regarding the scoring on the IIEF questionnaire, the 11 patients who were old enough to fill in the
questionnaire scored 25 or greater out of 30 regarding the quality of erection, sexual desire, and intercourse,
which is in accordance with other studies . Ejaculation problems are still present in the majority of
[26]
patients with epispadias, exstrophy-epispadias, and severe hypospadias according to the literature data and
range up to 53% . However, certain studies report very high percentage of normal ejaculation with 93% of
[26]
patients, while this was present in 81.8% of our patients [26,27] .

In conclusion, penile epispadias, either isolated or associated with bladder exstrophy, represent one of the
most difficult congenital genital anomalies requiring multistaged treatment, sometimes with questionable
success. Surgery at an early age and anatomical restoration of penile entities provides acceptable outcomes
in terms of esthetics and functionality. On the other hand, redo epispadias repair after failed surgery in
childhood is still a demanding procedure and should be performed only in highly specialized centers. Lack
of vascularized and hairless tissue for urethral reconstruction, crippled penis, residual curvature, and
hypotrophic corpora cavernosa are additionally challenging for the reconstructive urologist. The radical
surgical approach is often needed to achieve functionality and esthetics.

Long-term follow-up of patients with epispadias is necessary to observe the postoperative complications in
time and to treat them adequately. Follow-up of sexually mature and active patients treated for epispadias is
needed for better understanding of sexual functioning of this group of individuals.

DECLARATIONS
Acknowledgments
This Manuscript is supported by Ministry of Science and Technological Development of Serbia No 175048.

Authors’ contributions
Made substantial contribution to conception and design of the study: Bizic MR, Djordjevic ML
Performed data analysis and interpretation: Stojanovic B, Joksic I
Performed data acquisition and provided technical support: Stojanovic B, Bencic M, Joksic I
Performed supervision and had responsibility for the organization and course of the project and the
manuscript preparation: Bizic MR, Djordjevic ML
Performed writing of the manuscript: Bizic MR, Stojanovic B, Bencic M
Performed critical review of the manuscript: Djordjevic ML