Outcome of Sling Cystourethropexy in the Pediatric Population: A Critical Review

What makes the bladder neck sling procedure a success in a selected population of children and adolescents? A STROBE-compliant investigation

INTRODUCTION

Achievement of continence in children suffering from neurogenic bladder dysfunction or severe urogenital malformation is of fundamental importance to the wellbeing of affected children and their families. A valid approach to treating incontinence with hypoactive sphincter is the placement of a bladder neck sling thus increasing outlet resistance of the bladder.

OBJECTIVES

In this retrospective study in children and adolescents, we aimed to assess the outcome of bladder neck sling procedures conducted at our institution. In addition, we aimed to identify predictors of the successful correction of incontinence.

PATIENTS AND METHODS

We treated 36 patients (25 girls, 11 boys, aged 5.0-19.7 years). In total, 32 (88.9%) patients suffered from neurogenic incontinence. Overall, 16 patients had previously received unsuccessful injection of bulking agent into the bladder neck. For the bladder neck sling, we used a fascial strip of rectus abdominis muscle (n = 29), detrusor muscle (n = 6), or combined fascial and detrusor strip (n = 1). In 8 (22.2%) patients, the surgical procedure involved wrapping the strip around the bladder neck, while in 6 (16.7%) patients, the bladder neck was suspended with the sling. In 22 (61.1%) patients, the two techniques were combined. Overall, 22 (61.1%) and 9 (25.0%) patients additionally underwent enterocystoplasty or detrusorotomy, respectively. We assessed urinary continence of our patients after 3-6 months (first evaluation) and ≥12 months (final evaluation). We classified the state of continence as 'dry' (dry for >3 h between catheterizations and dry at night), 'significantly improved' (minimal incontinence, no more than one protective pad per day, interval of at least 3 h between catheterizations, dry at night, and no demand for additional treatment), or 'wet'. Bladder neck sling treatment was considered successful if the patient was rated as 'dry' or 'significantly improved'.

RESULTS

At the first evaluation, the bladder neck sling procedure proved successful in 19 (52.8%) patients. Enterocystoplasty significantly increased the success rate compared to detrusorotomy or no bladder augmentation (68.1% vs. 28.6%; p = 0.04). The remaining 17 patients who were still classified as wet after bladder neck sling placement subsequently underwent one or more additional interventions, i.e. implant injection (n = 11), bladder augmentation (n = 10), and/or sling replacement (n = 5). At the final evaluation after a median follow-up of 64.5 months (range, 12-181 months), continence without sling replacement was achieved in 29 (80.6%) of the 36 patients.

CONCLUSION

In our study population, bladder neck sling placement achieved good results in the treatment of severe organic urinary incontinence with hypoactive sphincter. To optimize treatment outcome, bladder neck sling placement should be combined with enterocystoplasty.

Lifelong Congenital Urology: The Challenges for Patients and Surgeons

CONTEXT

Patients born with complex congenital genitourinary anomalies (including bladder exstrophy, cloacal exstrophy, epispadias, neurogenic bladder, hypospadias and posterior urethral valves) often require major reconstructive surgery in childhood. These conditions, their treatment and sequelae require lifelong follow-up. This has created the need for adult urologists to provide care as these patients grow into adults.

OBJECTIVE

To evaluate current strategies for transition and provide a current position statement with examples of the challenges faced by patients and their health care teams as a result of these conditions and their treatment.

EVIDENCE ACQUISITION

Each of the authors was asked to provide a 500-word synthesis, based on current literature; to highlight the challenges faced in an area of their expertise.

EVIDENCE SYNTHESIS

The authors assembled in March 2018 to form a consensus based on the data gathered. The aforementioned sections were reviewed and following the consensus discussion the paper was formulated and reviewed.

CONCLUSIONS

Lifelong care of congenital problems is challenging and essential for many but not all. Expertise is needed to provide the best care for patients and make the best use of resources. Specialist centres appear to be the most effective and safe model. In the long term it would be ideal to establish an evidence base focused on the common long-term problems with these conditions to ensure excellent care with appropriate expertise.

PATIENT SUMMARY

Patients born with complex congenital anomalies of the genitourinary system require specialist care in childhood. Many will need lifelong care to manage their condition and the treatment of it. There is growing interest in this area of medicine and this consensus statement addresses the need for lifelong care in this group. The aim is to ensure that all patients that need care at any age are able to find what they need.

Clinical indications for augmentation in children with neurogenic urinary incontinence following bladder outlet procedures: Results of a 14-year observational study

PURPOSE

We report continence, upper tract changes, and augmentation indications and rates in consecutive patients undergoing bladder outlet surgery without augmentation for neurogenic urinary incontinence.

METHODS

From 2000 to 2007, 37 patients underwent bladder neck sling (BNS), and from 2007 to 2013, 45 patients had Leadbetter/Mitchell bladder neck revision plus sling (LMS), all without augmentation. Mitrofanoff channels were created in all cases. Twenty children with persistent outlet insufficiency underwent bladder neck closure (BNC). All patients had pre- and postoperative urodynamic testing (UD).

RESULTS

Mean follow-up was 60 months after BNS, 38 months after LMS, and 29 months after BNC. Continence (dry, no pads) was achieved significantly more often with LMS versus BNS (66% vs. 37%). There were no significant differences between these patients in preoperative UD % capacity, end filling pressure (EFP), or compliance. Those that became dry had a greater % capacity on postoperative UD, but postoperative EFP was similar between dry and wet LMS and BNS patients. BNC resulted in dryness in 65% of patients, with most incontinence occurring from the Mitrofanoff stoma associated with filling pressures > 40 cm. A total of 10 (12%) children had augmentation, seven after BNC. Clinical indications were end filling pressures > 40 cm plus hydronephrosis ≥ grade 3, and/or persistent incontinence. Need for augmentation was not predicted by preoperative urodynamic parameters. Postoperative UD in those who were augmented showed significantly less % capacity and compliance, and significantly greater EFP, than those not augmented.

CONCLUSIONS

Dryness was achieved in only 33% of BNS versus 66% of LMS and BNC patients. Twelve percent of consecutive children undergoing bladder outlet surgery for neurogenic incontinence developed clinical parameters leading to augmentation. These occurred most often after BNC.

Perioperative and Short-Term Outcomes of Robotic vs Open Bladder Neck Procedures for Neurogenic Incontinence

PURPOSE

Complex urological reconstruction may be facilitated by the improved magnification and dexterity provided by a robotic approach. Minimally invasive surgery also has the potential advantages of decreased length of stay and improved convalescence. We reviewed perioperative and short-term outcomes between robot-assisted and open bladder neck sling/repair with catheterizable channel in patients with neurogenic bladder.

MATERIALS AND METHODS

We performed an institutional review board approved retrospective chart review of all patients who underwent open or robotic bladder neck reconstruction without augmentation cystoplasty for refractory urinary incontinence between 2010 and 2014. Age at surgery, operative time, length of stay, complications within 30 days of surgery and future continence procedures (injection of bladder neck/catheterizable channel, additional bladder neck surgery, botulinum toxin A injection) were compared between the groups.

RESULTS

A total of 45 patients underwent bladder neck reconstruction (open in 26, robotic in 19) with a mean follow up of 2.8 years. There was no difference in preoperative urodynamics, age at surgery or length of stay (median 4 days in each group, p >0.9). Operative time was significantly longer in the robotic group (8.2 vs 4.5 hours, p <0.001). Three patients (16%) undergoing robotic and 3 (12%) undergoing open surgery had a complication within 30 days (p >0.9). Of patients undergoing open repair 14 (56%) underwent 23 subsequent surgeries for incontinence. By comparison, 8 patients undergoing robotic repair (42%) underwent 12 additional procedures (p = 0.5).

CONCLUSIONS

Although a robotic approach may take longer to perform, it does not result in increased complications or length of stay, or worsened continence outcomes.

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

OBJECTIVE

We report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence.

MATERIALS AND METHODS

Consecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually.

RESULTS

There were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet).

CONCLUSIONS

Upper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.

Urologic care of the neurogenic bladder in children

Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.

Preperitoneoscopic approach for bladder neck sling suspension in a boy: preliminary experience

OBJECTIVES

This report is aimed at describing our preliminary experience with the preperitoneoscopic approach to the bladder neck for rectus fascial sling suspension in neurogenic bladder.

MATERIALS AND METHODS

A 13-year-old boy with spina bifida was admitted to our institution to treat bladder incontinence. A bladder neck suspension and bladder augmentation was planned. The preperitoneal space was progressively gained by blunt dissection under direct vision (laparoscopy with a single left subcostal trocar), and a total of three preperitoneal ports were inserted. Dissection of the bladder proved to be relatively easy, and the retropubic space as well as the deep pelvis were safely exposed. Owing to the excellent endoscopic visualization, the bladder was dissected downward from the rectum. Once complete mobilization of the bladder neck was achieved, an umbilical tape was passed around the proximal urethra to create an adequate passage for the fascial sling.

RESULTS

The preperitoneoscopic procedure lasted 2 hours. No complications occurred. A good daytime dry period was achieved at the 4-month follow-up.

DISCUSSION

Direct visualization of the bladder neck and minimal dissection to the deep pelvis are the key points of this approach. Provided certain technical details are considered, the minimally invasive preperitoneal access is a valuable alternative to the open approach for the rectus fascial sling procedure, particularly when dealing with male patients. Technical advances will, presumably, lead to a complete minimally invasive treatment of urinary incontinence in male patients with spina bifida.

[Vesicosphincteric and sexual disorders associated with spina bifida and myelomeningocele]

Neurogenic bladder secondary to spina bifida can have a very variable clinical presentation, but all forms share a common feature: a high risk of deterioration of the patient's quality of life and their life expectancy due to damage to the upper urinary tract. In this article, the authors present the epidemiological characteristics of this disease, its main clinical and urodynamic signs and discuss the prognosis of the disease, with particular emphasis on the value of close surveillance of these high-risk patients.

Mini-invasive collagen sling in the treatment of urinary incontinence due to sphincteric incompetence

OBJECTIVE

To assess the technical feasibility of mini-invasive sling procedure and present preliminary results in the treatment of urinary incontinence due to sphincteric insufficiency.

MATERIALS AND METHODS

Thirteen patients (6 males, 7 females, 8 with myelomeningocele, 1 with tethered spinal cord, 3 with bladder exstrophy, 1 with epispadias) underwent sling procedure with porcine dermis acellular collagen matrix (Pelvilace, Bard medical, UK). The median age was 15.5 (range 8.9-27.5) years. A suprapubic catheter was inserted for the measurement of leak point pressure during the operation. In females vaginal and in males perineal incision was used for sling insertion. The sling was introduced under cystoscopic control. The sling was not fixed with sutures. The outcomes were reviewed at 1, 6 and 12 month after the operation.

RESULTS

The median leak point pressure increased from 21.5 (range 5-25) cm H2O to 85 (range 70-100) cm H2O. At 1 month 8 and at 6 months 3 out of 13 patients were dry. At 12 months, none out of 11 patients was completely dry. However, at 12 months some improvement in incontinence was detected in 9 out of 11 patients. Two patients had primary failures. One patient got sling erosion to urethra after a tightening attempt. In one patient detrusor overactivity increased after the sling procedure.

CONCLUSIONS

Pelvilace sling is safe and easy to introduce in both males and females if pelvic floor anatomy is normal. Although immediate results were promising in neuropathic incontinence, the results seem to deteriorate to unacceptable low level already during the first year. In exstrophy patients the results are generally poor.

Bladder Neck Sling and Appendicovesicostomy Without Augmentation for Neurogenic Incontinence in Children

PURPOSE

Most children undergoing bladder neck sling for neurogenic urinary incontinence also have undergone bladder augmentation. However, complications from enterocystoplasty and uncertainty regarding its indication during bladder outlet enhancement led us to perform slings without augmentation. Herein we report outcomes in consecutive patients.

MATERIALS AND METHODS

A total of 30 patients with neurogenic bladder underwent tight 360-degree fascial sling wrap around the bladder neck and appendicovesicostomy without augmentation. Indications included detrusor leak point pressure less than 50 cm water and stress urinary incontinence. Urodynamics were obtained in all patients preoperatively, in 26 at a mean of 6 months postoperatively and in 16 at a mean of 24 months postoperatively.

RESULTS

Satisfactory continence defined as 2 or fewer damp pads daily was achieved in 83% of patients with followup of 6 to 60 months (mean 22). Symptomatic hyperreflexia and/or loss of compliance developed in 8 patients postoperatively, which responded to anticholinergics in 7. The remaining patient underwent enterocystoplasty 18 months later, for an augmentation rate of 3%. No patient had hydronephrosis or reflux.

CONCLUSIONS

Evaluated parameters, including bladder capacity and compliance determined during preoperative urodynamics, did not predict the need for augmentation. Satisfactory continence can be achieved for neurogenic bladder by sling without enterocystoplasty.

BLADDER NECK SLING FOR TREATMENT OF NEUROGENIC INCONTINENCE IN CHILDREN WITH AUGMENTATION CYSTOPLASTY: LONG-TERM FOLLOWUP

PURPOSE

We retrospectively reviewed the outcome and long-term followup (mean 4.16 years) of bladder neck slings for the treatment of neurogenic urinary incontinence in 58 patients (15 males) who also underwent bladder augmentation.

MATERIALS AND METHODS

A total of 58 patients with neurogenic bladder (43 females and 15 males, median age 11.4 years) underwent a rectus fascial sling procedure as part of the reconstructive efforts for continence between July 1991 and July 2003. Criteria for enhancement of bladder outlet resistance included a detrusor leak point pressure of less than 45 cm H2O, an open bladder neck during bladder filling at low detrusor pressures and clinical evidence of stress incontinence.

RESULTS

Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). A total of 51 patients (88%) obtained good continence results. Five females and 2 males remained incontinent following the sling procedure. Four females underwent a secondary open bladder neck procedure at a mean of 18 months after the initial procedure (artificial urinary sphincter in 2, bladder neck closure in 2). Two male patients (5 and 17 years old) had daily underwear staining or dampness with exercise or transfer.

CONCLUSIONS

We consider bladder neck slings the procedure of choice for the enhancement of bladder outlet resistance in the majority of patients with neurogenic bladder who need augmentation cystoplasty and whom we do not expect will be capable of voiding spontaneously. In males and females satisfactory long-term continence can be expected with the use of the rectus fascial sling.

Bladder Neck Cinch for Pediatric Neurogenic Outlet Deficiency

PURPOSE

The fascial bladder neck sling achieves continence in 50% to 90% of children with neurogenic outlet deficiency. Most slings apply only partial pressure around the bladder neck. We evaluated the effectiveness of a rectus fascia bladder neck cinch which applies circumferential pressure around the bladder neck and elevation as a means of increasing outlet resistance.

MATERIALS AND METHODS

Fifteen children with spina bifida underwent a fascial bladder neck cinch procedure at the time of augmentation cystoplasty. A 1 to 1.5 cm width of variable length rectus fascia was harvested and a vertical slit was made in 1 end. The fascia was "cinched" tightly around the bladder neck and secured to the symphysis or rectus fascia.

RESULTS

The 14 girls and 1 boy ranged in age range from 4 to 17 years. All children had neurogenic intrinsic sphincter deficiency and a poorly compliant and/or small capacity bladder. Followup ranged from 10 to 36 months (followup in 12 greater than 1 year). Postoperatively, all children perform clean intermittent catheterization. At the last followup 8 girls and the boy (60%) were dry (no leak and no pads at 4 hours from the last catheterization and dry throughout the night).

CONCLUSIONS

Rectus fascia used as a bladder neck cinch is effective but no better than other bladder neck slings for decreasing urinary incontinence. The bladder neck cinch appears to be an acceptable addition to the technique of fascial slings. However, we have subsequently changed our technique because these results did not meet our expectations.

Outcome of continence procedures in the pediatric patient: a single institutional experience

PURPOSE

Achieving continence remains a major goal in the treatment of children with neurogenic and/or anatomical voiding dysfunction. We reviewed our experience with continence procedures in pediatric lower urinary tract reconstruction.

MATERIALS AND METHODS

We reviewed the records of all pediatric patients who underwent continence procedures at our institution since July 1993. We reviewed the diagnosis, type of primary reconstructive procedure, concomitant procedure(s) and initial success rate. In cases of primary failure we noted the type of secondary continence procedure performed and the ultimate success rate. Success was defined as dry intervals of at least 4 hours when the patient was compliant with a catheterization or voiding regimen.

RESULTS

Primary continence procedures were performed in 43 cases and secondary procedures were performed in 6 for a total of 49 continence procedures. The diagnoses included myelomeningocele in 22 patients, exstrophy in 12, epispadias in 3, bilateral single system ureteral ectopia in 3 and spinal cord injury in 3. A total of 32 primary procedures were performed concomitantly with or were preceded by bladder augmentation with creation of a catheterizable stoma. The remaining 11 patients underwent a continence procedure only. The diagnosis in these 11 patients was exstrophy in 5, epispadias in 3, with spinal cord injury in 2 and myelomingocele in 1. Mean followup was 35 months (range 1 to 95). Initial continence procedures included Young-Dees-Leadbetter bladder neck repair in 14 cases, of which 11 (79%) were initially successful, a urethral sling in 9 with 7 initial successes (78%), bladder neck division and closure in 7 with all successful (100%), collagen in 5 with 1 success (20%), other urethral lengthening procedure (eg Pippi Salle or Kropp) in 4 with 3 successes, (75%), combined urethral sling and Young-Dees-Leadbetter in 2 with 1 success (50%), and an artificial sphincter and fascial wrap in 1 each, which were successful. Of the 6 secondary procedures performed for primary failure collagen was injected in 4 and the bladder neck was divided and closed in 2. All were successful.

CONCLUSIONS

Various lower urinary tract procedures can be performed to achieve successful continence in the pediatric population. At our institution all procedures had a reasonable success rate except primary collagen injection. Collagen injection and bladder neck division/closure proved to be reliable secondary procedures in cases of primary failure.

The rectus myofascial wrap in the management of urethral sphincter incompetence

OBJECTIVE

To review our experience with a modified rectus/pyramidalis myofascial sling, described more than a century ago for treating refractory urinary incontinence in children with neurogenic sphincteric incompetence.

PATIENTS AND METHODS

Thirty-seven patients (23 females and 14 males, aged 8-21 years) presented with urinary incontinence which failed to respond to medical treatment. In 36 patients the cause of the incontinence was a neurogenic bladder; one patient had sustained a traumatic injury to the bladder neck and urethra. Patient selection was based on videocysto-urethrographic detection of an incompetent bladder neck, and a low maximum closure pressure during urethral pressure profilometry. The bladder was augmented in 33 of the 37 patients.

RESULTS

Of the 37 patients, 34 (92%) are dry between catheterizations; the follow-up was 0.5-10 years. Two of the male patients continued to have persistent incontinence requiring bladder neck closure and creation of a continent stoma. One of the female patients developed stress incontinence after 4 years of being dry, with a rectus sling.

CONCLUSION

The rectus myofascial sling provides long-term satisfactory dry intervals between catheterizations in patients with neurogenic sphincteric incompetence. The cinch-wrap modification appears to enhance the occlusive effect of the sling, particularly in males.

Management of intrinsic sphincter deficiency in adolescent females with normal bladder emptying function

PURPOSE

Intrinsic sphincter deficiency is rare in adolescent females with normal bladder emptying function. Information regarding the long-term outcome of therapy in this group of patients is sparse. We report our long-term experience with 3 adolescent females with intrinsic sphincter deficiency and normal bladder function who were treated with an artificial urinary sphincter. We critically reviewed the literature regarding experience with anti-incontinence surgery in adolescent females, not only regarding the outcome of the surgical technique, but also issues not usually considered in older adults, including the impact of physical development and future childbearing.

MATERIALS AND METHODS

The charts of 3 adolescent females with intrinsic sphincter deficiency were reviewed. In addition, relevant peer reviewed articles were selected by a MEDLINE search. The results of the artificial urinary sphincter, pubovaginal sling and periurethral injection of bulking agents were reviewed. Long-term efficacy, the complication rate, impact of pregnancy and physical development were assessed.

RESULTS

The 3 patients had an excellent long-term outcome with the artificial urinary sphincter, including 1 with 2 pregnancies that ended in a normal vaginal delivery. The literature showed that a good long-term outcome was consistently achieved with the artificial urinary sphincter. An equally good outcome was achieved with the pubovaginal sling but long-term data are lacking. While periurethral injection of a bulking agent provides good initial results, they do not appear to be durable. In addition, the artificial urinary sphincter does not appear to impact pregnancy or physical development negatively.

CONCLUSION

Data support the artificial urinary sphincter and pubovaginal sling as effective therapies in adolescent females with intrinsic sphincter deficiency. However, long-term data on the pubovaginal sling are not available. When considering the impact on future childbearing and physical development, the artificial urinary sphincter is a favorable option.

Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders

PURPOSE

Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder.

MATERIALS AND METHODS

From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases.

RESULTS

With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%.

CONCLUSIONS

Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.

Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders

PURPOSE

Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder.

MATERIALS AND METHODS

From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases.

RESULTS

With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%.

CONCLUSIONS

Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.

The Pippi Salle urethral lengthening procedure; experience and outcome from three United Kingdom centres

OBJECTIVE

To assess the outcome of the Pippi Salle (Kropp onlay) urethral lengthening procedure in the treatment of neuropathic urinary incontinence.

PATIENTS AND METHODS

Twenty-eight patients (12 males and 16 females, mean age at surgery 12.6 years, range 7-32) were identified who underwent the procedure between 1993 and 1997 in the United Kingdom. Outcomes were assessed by a review of the case notes.

RESULTS

Of the 28 patients, 18 (64%) were rendered continent by day, and 17 (61%) by day and night. Twelve of the 16 females were completely dry, and a further girl was dry by day, giving overall daytime continence in 13 patients; five males were rendered continent (P=0.03, chi-square test). Four patients required revision surgery; in five patients (two females and three males) the method was abandoned and they underwent an alternative procedure, and a further four are being reassessed.

CONCLUSION

The Pippi Salle procedure should be considered as a first-line treatment option for neuropathic incontinence in females. Its place in the management of incontinent males is less convincing.

Urinary continence and erectile function after bladder neck sling suspension in male patients with spinal dysraphism

OBJECTIVE

To assess the outcome of using sling suspensions combined with clean intermittent catheterization (CIC) in patients with spina bifida, of whom a third are incontinent through pelvic floor paralysis.

PATIENTS AND METHODS

Between March 1992 and April 1997, 14 male patients (mean age at surgery 11.7 years, range 6.5-15.2) with spina bifida and neurogenic sphincter incontinence underwent a puboprostatic sling suspension as a primary treatment. The procedure, via an abdominoperineal approach, consists of suspending the bladder neck by placing a simple U-shaped rectus abdominus fascial sling. The perineal approach is used to develop the plane between the rectum and Denonvillier's fascia, and to prepare the passage of the sling alongside the prostate. Apart from the sling procedure, eight of the 14 patients underwent autoaugmentation of the bladder and two underwent ileocystoplasty during the same operation. All patients used CIC daily. Erectile function was assessed by reports from the patients and their parents, and continence by report and urodynamic studies.

RESULTS

Of the 14 patients, 13 achieved urinary continence with no additional procedures; one required a subsequent submucosal injection at the suspension site with silicone particles in povidone (Macroplastique(R)) to become continent. Two patients reported slight leakage at night. Before surgery, all but one patient reported having spontaneous or mechanically manipulated erections; none had erections on psychological stimulation. After surgery, erectile function was preserved in 13 of the 14 patients; in one there were problems establishing the right dissection plane between the rectum and prostate, but spontaneous erections returned a year after surgery.

CONCLUSION

In males, the abdominoperineal puboprostatic sling suspension using rectus abdominis fascia appears to be a successful treatment for sphincter incontinence in patients with spina bifida, and safely maintains erectile function.

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Pubovaginal sling cystourethropexy has rapidly become one of the primary surgical treatment options for women with urinary incontinence. The procedure has evolved over time with regard to clinical indications, patient selection criteria and surgical techniques. This article reviews the historical development of pubovaginal sling cystourethropexy, including recent technical advances. The selection of graft materials is considered and the utility of fascia lata emphasized. Clinical results and potential complications of the procedure are also reviewed.