Bladder Wall Pedicle Wraparound Sling for Neurogenic Urinary Incontinence in Children

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.

Detrusor wraparound for bladder neck reconstruction in cohort of children with bladder exstrophy

OBJECTIVE

To evaluate the outcome of the detrusor wraparound bladder neck technique of bladder neck reconstruction in 28 children with bladder exstrophy.

METHODS

The records of all patients with bladder exstrophy who underwent detrusor wraparound bladder neck were reviewed. A total of 28 consecutive patients were identified and included 21 boys and 7 girls, with a mean age at surgery of 8.3 years. All patients had undergone previous exstrophy closure (17 staged and 11 complete). Of the 28 patients, 8 (29%) had undergone previous endoscopic injection of a bulking agent at the bladder neck. At surgery, 13 patients (46%) required concomitant ileocystoplasty and a continent outlet. Continence was defined as complete dryness with no urine leakage either through the urethra or the continent outlet.

RESULTS

The mean follow-up duration was 31 months (range 13-48). All augmented patients were continent using clean intermittent catheterization through the outlet. Complete dryness was achieved in 20 (71%) of 28 patients. However, the continence rate was only 47% in the nonaugmented group compared with 100% in the augmented group. Six of the incontinent children underwent bladder neck injection using a bulking agent but dryness was achieved in only 1 (17%).

CONCLUSION

The detrusor wraparound bladder neck technique is a viable option for bladder neck reconstruction for incontinent children after exstrophy closure. However, bladder augmentation and continent outlet construction are the pillars of optimal success. Injection of bulking agent at the bladder neck for failure has had poor success.

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.

Pediatric Urinary Incontinence: Evaluation of Bladder Wall Wraparound Sling Procedure

PURPOSE

In 1996 a surgical procedure for sphincter deficiency was reported in patients with neurogenic urinary incontinence. To our knowledge we report the first series that assesses this procedure since it was initially described.

MATERIALS AND METHODS

Seven female and 7 male patients with spinal dysraphism and neurogenic intrinsic sphincter deficiency underwent surgery between 1997 and 2005. All patients had an associated poorly compliant or small capacity bladder. Patient age ranged from 8 to 22 years (mean 14) and all patients presented with persistent urinary incontinence despite intermittent catheterization and pharmacotherapy. Evaluation was based on clinical examination, as well as preoperative and postoperative urodynamic assessments. The surgical procedure involved wrapping a pedicle strip of anterior bladder wall around the bladder neck and fixing it on the pubic symphysis. Bladder augmentation cystoplasty was also routinely performed during the same procedure.

RESULTS

Of 14 patients 13 were completely dry and 1 had stress incontinence. Followup was 2 to 8 years (mean 5). Postoperative urodynamic evaluation showed a maximum urethral pressure increase of 40%. We also observed an increase in bladder capacity of 105% and improved bladder compliance (7 ml/cm H(2)O preoperatively vs 35 ml/cm H(2)O postoperatively).

CONCLUSIONS

The bladder wall wraparound sling procedure provides excellent results for continence in association with bladder augmentation.

Miniature Intravesical Urethral Lengthening Procedure for Treatment of Pediatric Neurogenic Urinary Incontinence

PURPOSE

Resistance to flow in a fluid conduit is proportional to tube length divided by the radius to the fourth power (Poiseuille's law). We report the results of a miniature intravesical urethral lengthening procedure where outlet resistance is increased by minimizing the diameter of the intravesical urethral tube.

MATERIALS AND METHODS

Nine pediatric patients with preoperative intractable incontinence underwent the miniature intravesical urethral lengthening procedure along with continent catheterizable stoma (9 patients) and bladder augmentation (8). The intravesical portion of the urethral lengthening was 3 cm (traditionally 6 cm), and the urethra was tubularized around an 8Fr feeding tube (traditionally a 16Fr catheter). After the tubularized caudal portion was tunneled under the trigone the cephalad part of the urethra was placed as an onlay to the posterior bladder wall without ureteral reimplantation.

RESULTS

At a mean followup of 31 months (range 10 to 47) 8 patients reported dry intervals of 3 hours or more, with minor leak per urethra only if they were overdue on the catheterization schedule. Mean postoperative abdominal leak point pressure was 71 cm H(2)O (range 28 to 116). Upper tracts were well preserved in all patients. One patient required bladder neck closure for intractable incontinence.

CONCLUSIONS

The miniature intravesical urethral lengthening procedure requires minimal bladder tissue and is easy to perform. It appears to be an effective alternative in bladder neck reconstructive techniques, avoiding the need for ureteral reimplantation due to its small size, while functioning as a pop-off valve when the bladder is overly full. This procedure should be avoided in patients who lack a trigonal bar.

Modified Bladder Neck Reconstruction in Patients With Incontinence After Staged Exstrophy/Epispadias Closures

PURPOSE

Reconstruction of the urethra without adequate circumferential muscular support is a significant problem in bladder neck surgery for urinary incontinence. Fascial, muscular and artificial slings have been used for support of the bladder neck after reconstruction. We used a demucosalized detrusor muscle pedicle to wrap around the bladder neck base along with other continence techniques in children who experienced incontinence after staged closure of exstrophy and epispadias. We describe our experience using the pedicle wraparound along with the Mitchell modification of Young-Dees-Leadbetter bladder neck reconstruction.

MATERIALS AND METHODS

We reviewed our continence rates using a detrusor wraparound in 8 eligible patients with failed staged exstrophy-epispadias repair. We defined incontinence as any degree of leakage through the bladder neck day or night.

RESULTS

Of the 8 patients studied 2 were female and 6 were male. Mean patient age at surgery was 7.6 years (range 4 to 11). Mean followup was 3.2 years (range 0.5 to 5). All patients with staged exstrophy-epispadias repair failure are currently continent. Five patients underwent simultaneous bladder augmentation. All but 2 patients catheterize via a Mitrofanoff channel. Three patients void volitionally and 5 use clean intermittent catheterization per Mitrofanoff. Two patients required dextranomer/hyaluronic acid injections at the bladder neck postoperatively to achieve complete dryness.

CONCLUSIONS

The detrusor bladder neck wraparound, while successful, may require concomitant surgery, including augmentation, clean intermittent catheterization and endoscopic injection therapy, to achieve continence following failure of staged exstrophy-epispadias repair. The detrusor bladder neck wrap appears to be a safe and effective adjunctive procedure in this patient population. We believe it has an important role in the achievement of urinary dryness.

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.

THE MITROFANOFF PROCEDURE: 20 YEARS LATER

PURPOSE

We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup.

MATERIALS AND METHODS

Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux.

RESULTS

One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion.

CONCLUSIONS

The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.

The Mitrofanoff procedure: 20 years later

PURPOSE

We review our initial cases of continent cystostomy to assess long-term functional results and complications after a minimum of 15 years of followup.

MATERIALS AND METHODS

Between 1976 and 1984, 23 continent cystostomies were performed on 15 boys and 8 girls with neuropathic bladders. Mean patient age at surgery was 8 years and 4 months (range 3 to 16) and mean followup was 20 years (range 15 to 23). The neurological lesions were due to 21 myelomeningocele (2 associated with an imperforated anus in 21 cases), spinal neuroblastoma in 1 and complex genitourinary malformation associated with an imperforated anus in 1. Closure of the bladder neck was performed in 21 cases (16 during the same procedure, 5 secondarily) and 2 did not undergo this procedure. The appendix was used as the catheterizable conduit in 20 cases, 1 ureter in 2 and a bladder tube in 1. Bladder augmentation was performed during the same procedure in 2 cases and at a later stage in 8. Five patients presented with unilateral or bilateral secondary vesicoureteral reflux.

RESULTS

One death occurred after conversion to cutaneous diversion due to a postoperative infection leading to a ventriculoperitoneal valve infection. The remaining 22 patients were followed every 6 to 12 months. No metabolic disorder, secondary malignancy or spontaneous bladder perforation was noted. Bilateral upper tract deterioration was found in 10 cases leading to secondary bladder augmentation by enterocystoplasty in 6 and creation of noncontinent diversion in 4. Leakage occurred after bladder neck closure in 5 patients. Bladder stones were found in 5 patients (2 had prior bladder augmentation). Complications related to the conduit included stomal stenosis or persistent leakage in 11 cases, which required surgical revision and/or repeated dilations and 1 noncontinent diversion after revision failure. Five patients presented with intestinal occlusion due to volvulus in 3 and adhesion in 2. We noted that after 10 years of followup complications were rare and concerned mostly the catheterizable conduit. Therefore, 16 patients had a good and stable result while 6 have noncontinent diversion.

CONCLUSIONS

The rate of complications has a tendency to decrease with time. The results obtained in this series may appear less satisfactory than those of more recent series, which may be due to the fact that these oldest continent cystostomies correspond to acquisition of experience of this novel approach, and to a period when the concept of low pressure reservoir was not yet established and bladder augmentations were not routinely performed. Since 1984 no continent cystostomy performed at our institution was converted into a noncontinent diversion. This series with long followup demonstrates that continent cystostomy is a procedure with lasting efficiency.

Bladder neck reconstruction in children

Bladder neck reconstruction in children is a challenging undertaking. Goals must be established for each patient, either continence or dryness. Knowledge of the various types of bladder neck reconstructive procedures and what they are designed to do is important when considering bladder neck reconstruction. A detailed description of urethral lengthening, reimplantation, and other bladder neck reconstructive procedures is presented.

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.

Myofascial wrap to treat intractable urinary incontinence in children

OBJECTIVES

The management of intractable urinary incontinence in the patient with cloacal or bladder exstrophy/epispadias, failed bladder neck plasty, or failed augmentation cystoplasty remains a surgical challenge. The myofascial wrap, a modification of the rectus fascial wrap, was developed to treat intractable urinary incontinence due to sphincteric incompetence in these problematic cases. A full-thickness, vascularized pedicle of anterior rectus sheath, rectus abdominis muscle, and posterior rector sheath is incorporated into a bladder neck wrap to provide support, mucosal coaptation, and active muscular tone.

METHODS

Eight patients (5 females and 3 males) with total urinary incontinence due to sphincteric incompetence underwent the myofascial wrap. Urinary tract pathology included cloacal exstrophy (2), female epispadias (2), classic bladder exstrophy (1), male epispadias (1), myelomeningocele (1), and a pelvic tumor (1). The procedure is performed by harvesting a full-thickness strip of pedicled rectus muscle along with the anterior and posterior fascial sheaths. The strip is passed underneath and then over the bladder neck in a near 360 degrees wrap. The free end of the wrap is anchored into the pubic bone in an ipsilateral subperiosteal pouch.

RESULTS

Six of the 8 patients are completely continent, and 2 patients void spontaneously without the need for catheterization.

CONCLUSIONS

The myofascial wrap provides support, mucosal coaptation, and muscular tone to an incompetent sphincter and bladder neck. Favorable results in a very difficult population of pediatric patients warrant its continued use.

A simplified Kropp procedure for incontinence

PURPOSE

A simplified Kropp bladder neck reconstruction was done to achieve urinary continence.

MATERIALS AND METHODS

A total of 23 patients with an incompetent bladder neck underwent the procedure, including 22 with a neurogenic bladder secondary to myelodysplasia and 1 with bladder exstrophy. The bladder neck operation was incorporated into comprehensive lower tract reconstruction that included simultaneous augmentation cystoplasty in 20 patients, ureteroneocystostomy in 6 and appendicovesicostomy in 6.

RESULTS

Of the 23 patients 21 (91%) are continent. Complications included difficult catheterization in boys and new onset vesicoureteral reflux.

CONCLUSIONS

This operation is easily performed and effective for achieving continence.

Outcome of sling cystourethropexy in the pediatric population: a critical review

PURPOSE

We performed a critical retrospective analysis of the records of all consecutive children who underwent sling cystourethropexy at our institutions. We particularly assessed the incidence and outcome in children who underwent enterocystoplasty in addition to a sling procedure.

MATERIALS AND METHODS

Between May 1992 and August 1994, 24 girls and 15 boys 4 to 17 years old (mean age 9) consecutively underwent 1 of 4 techniques of sling cystourethropexy for stress urinary incontinence using rectus fascia via an abdominal approach. Diagnoses included spinal dysraphism in 34 patients, spinal trauma in 2, cecoureterocele in 1, epispadias in 1 and classic bladder exstrophy in 1. All children underwent preoperative video urodynamics. In 4 patients only a sling procedure was performed (group 1), while in 9 others a sling procedure was performed after enterocystoplasty (group 2). In 26 patients a sling procedure and concomitant enterocystoplasty were performed (group 3).

RESULTS

Patients who underwent concomitant enterocystoplasty had more hyperactive preoperative urodynamics than those who did not. Postoperative continence was subcategorized in terms of patient age, sex, diagnosis (neurogenic versus nonneurogenic), preoperative video-urodynamics, surgeon technique, group (that is with or without cystoplasty) and type of enterocystoplasty (that is stomach versus ileum). Of these factors only concomitant enterocystoplasty was predictive of postoperative dry continence (73% of group 3, 33% of group 2 and 25% of group 1). In most patients who were not dry postoperative video urodynamics suggested suboptimal outlet resistance overcome by a hyperactive detrusor. No patient had postoperative upper tract deterioration.

CONCLUSIONS

These results suggest that concomitant enterocystoplasty should be critically considered for pediatric patients undergoing sling cystourethropexy.