The artificial sphincter AS800 in congenital urinary incontinence

Outcomes of robot-assisted urinary sphincter implantation for male neurogenic urinary incontinence

OBJECTIVES

To report the functional outcomes of robot-assisted laparoscopic artificial urinary sphincter implantation (R-AUS) in men with neurogenic stress urinary incontinence (SUI).

PATIENTS AND METHODS

A monocentric retrospective study included all consecutive adult male neuro-urological patients who underwent R-AUS for SUI between January 2011 and August 2018. The AUS was implanted via a transperitoneal robot-assisted laparoscopic approach. Intraoperative and early postoperative complications were reported (Clavien-Dindo classification). Continence was defined as no pad usage. Revision and explantation rates were also evaluated.

RESULTS

Overall, 19 men with a median (interquartile range [IQR]) age of 45 (37-54) years were included. No conversion to laparotomy was needed. Three minor (Clavien-Dindo Grade I-II) early postoperative complications occurring in three (15.8%) patients were reported. The median (IQR) follow-up was 58 (36-70) months. At the end of the follow-up, the continence rate was 89.5%. The AUS revision and explantation rates were 5.3% and 0%, respectively.

CONCLUSION

A R-AUS is a safe and efficient procedure for AUS implantation in adult male neuro-urological patients, referring to the challenging open technique.

Puboprostatic sling repair for treatment of urethral incompetence in adult neurogenic incontinence

PURPOSE

An incompetent urethral sphincter can be a significant factor contributing to urinary incontinence in patients with neurogenic bladders. We review our experience with 12 men who underwent a puboprostatic sling.

MATERIALS AND METHODS

The study included 12 men (mean age 37.1 years) with neurogenic bladder due to spinal cord injury in 9 and spina bifida in 3. All patients were diagnosed with urethral incompetence based on fluorourodynamic evaluation. Medical therapy failed in all 12 patients and all complained of urine leakage with activity. All patients underwent placement of an autologous fascial sling distal to the prostatic urethra via an abdominal approach. Ten patients also underwent simultaneous bladder augmentation to correct high intravesical pressures.

RESULTS

Followup ranged from 1 to 39 months (average 14.25). All patients manage the bladder with intermittent catheterization. Of the patients 8 are completely dry between catheterizations and 2 had significant improvement with only minimal leakage (1 pad per day), with an overall success rate of 83%. One patient improved initially but subsequently underwent placement of an artificial urinary sphincter for residual stress incontinence. In 1 patient several external sphincterotomies failed despite adequate sling placement. There were no complications related to the placement of the sling and all patients are able to perform intermittent catheterization without difficulty.

CONCLUSIONS

In select male patients the puboprostatic sling can be an effective and safe method to treat urethral incompetence secondary to neurogenic voiding dysfunction.

Gracilis muscle neosphincter for treating urinary incontinence

The purpose of this study was to test the anatomical and functional feasibility of using a gracilis muscle free flap to create a urinary sphincter. Anatomical studies were performed in 12 human cadavers and short-term (n = 7) and long-term (n = 8) functional studies were performed in dogs. In the short-term functional studies, the left gracilis muscle was transferred into the pelvis and wrapped around the urethra and the right gracilis muscle was wrapped around a stent. A cuff electrode was placed on the muscle's nerve pedicle and used to stimulate the neosphincter while peak pressure, fatigue rate, and perfusion measurements were performed. In the long-term functional studies, intramuscular electrodes were inserted into the neosphincter to stimulate the flap. The flaps were wrapped around the urethra and dogs were followed for 16 weeks, during which time urodynamic measurements were performed. Our anatomical studies demonstrated that the gracilis muscle free flap could be transferred into the pelvis to create a urinary neosphincter. Our short-term functional study demonstrated that gracilis muscle free-flap function and perfusion were not compromised by transfer. In our long-term functional study, all neosphincters provided bladder outlet resistance pressures consistent with continence. Our anatomical, short-term, and long-term functional studies indicate that a gracilis muscle free-flap neosphincter is an effective procedure for treating urinary incontinence.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

Vaginal stenosis and hydrometrocolpos: late complication of inadvertent perivaginal placement of an artificial urinary sphincter in prepubertal girls(1)

Urinary incontinence in pediatric and adolescent patients has been successfully managed with the artificial urinary sphincter for several decades. Placement of the sphincter can be difficult in the preadolescent girl due to poorly developed vaginal tissue that can result in difficulty establishing the surgical plane between the bladder and vagina. We report 2 patients in whom the sphincter was placed around the urethra and vagina, a complication that has been reported in only 1 patient previously. All 3 patients presented with hematometrocolpos and bloody vaginal discharge. All were successfully managed with replacement of the sphincter cuff around the urethra and delayed vaginoplasty.

The outcome of artificial urinary sphincter placement after a mean 15-year follow-up in a paediatric population

OBJECTIVE

To evaluate the long-term outcome in children who had an artificial urinary sphincter (AUS) placed, after a minimum of 10 years of follow-up.

PATIENTS AND METHODS

The medical records of patients who had an AUS placed at the Children's Hospital of Michigan were reviewed and a telephone questionnaire was then completed by all patients with an AUS currently in place.

RESULTS

Forty-seven children initially had an AUS placed between October 1978 and August 1986; medical records and follow-up were available for 32. After a mean follow-up of 15.4 years, 13 patients had had the AUS removed and 19 currently have an intact AUS. Erosion or infection was responsible for all AUS removals. Possible risk factors for AUS removal were prior AUS erosion, prior bladder neck surgery and a balloon pressure of >70 cmH2O. Eighteen of 19 patients with an intact AUS are dry and seven void volitionally. Revision was the most common reason for additional surgery, but the revision rate has decreased with the most current AS-800 model, to 0.03 revisions per patient-year. Of the 13 patients with an AS-800 model placed after 1987, nine have not required revision. Upper tract changes were mild and uncommon.

CONCLUSION

The AUS is a durable and effective surgical option in the management of neurogenic urinary incontinence, and is the only reliable technique that can preserve volitional voiding. With technical improvements to the AUS and a longer follow-up, the revision rate has decreased. Causes of AUS removal may be preventable with improvements in surgical technique and patient selection. AUS placement should be considered as a first choice for the surgical management of neurogenic sphincteric incompetence.

The development and evolution of artificial urethral sphincters

This history and evolution of mechanical devices designed to achieve urinary continence are reviewed. The following devices were studies: Foley clamp, Kaufman prosthesis, Giori, Summers and Rosen sphincters, Gruneberger and Cleveland Clinic magnetic designs, Craggs sphincter and the AMS family of sphincters (AMS 721, AMS 761, AMS 742 (A, B, C), AMS 792, AMS 800). The design of active hydraulic devices is discussed in more detail. This review analyses the problems relating to the application of pressure and the presence of foreign material around the urethra. 'Volume set' devices are universally unsuccessful and detrimental for urethral integrity as opposed to 'pressure set' hydraulic sphincters (e.g. AMS 800). The implications for the design of artificial implants are discussed.

Upsizing of the artificial urinary sphincter cuff to facilitate spontaneous voiding

OBJECTIVES

Following placement of an artificial urinary sphincter (AUS) in the male child, functional and mechanical alterations can ensue, resulting in an inability to void spontaneously. One possible mechanical etiology in the patient entering puberty is prostatic growth within the fixed mechanical confines of the AUS cuff, resulting in progressive bladder outlet obstruction. Unrecognized infravesical obstruction can, in turn, lead to upper urinary tract deterioration, sepsis, or renal failure. We evaluated the effect of somatic growth and maturation of the male urethra on voiding dynamics in boys with an AUS to specifically determine whether revision of the sphincter cuff (ie, upsizing) is beneficial in restoring the ability to void spontaneously.

METHODS

A retrospective review of 124 children with an AUS was performed. Eleven boys were identified whose bladder neck cuffs were later upsized in an attempt to improve bladder emptying. All boys were prepubertal at the time of original cuff placement. The average interval between the initial operation and cuff upsizing was 5 years.

RESULTS

Following original sphincter placement, 8 patients emptied to completion spontaneously and 3 patients emptied by intermittent catheterization. All eight of the spontaneous voiders experienced progressive difficulty emptying after they entered puberty and ultimately had to rely on clean intermittent catheterization to empty completely. Follow-up subsequent to cuff exchange averaged more than 5 years (range 1 to 10 years). Despite an average increase of 10 mm in cuff size, all patients continued to depend on intermittent catheterization to empty completely.

CONCLUSIONS

Upsizing the bladder cuff in the maturing male who experiences difficulty with bladder emptying does not restore the ability to void spontaneously.

Urethral needle suspension for male urinary incontinence

A rectus fascia sling was used to suspend the bulbous urethra in 12 males with total sphincteric incontinence. Incontinence was related to prostatectomy in 3 patients, to spinal trauma in 3, and to myelodysplasia in 6 patients. In 3 patients augmentation ileocystoplasty was added to the procedure because of reduced bladder capacity and compliance. Needle suspension of the sling simplified the procedure and obviated difficult retroprostatic dissection. After an average of 13 months 10 out of 11 patients were totally dry, 2 of these are voiding spontaneously with little residual while the rest are on intermittent catheterization. One patient is still wet because of severe postoperative detrusor instability. Urethral erosion occurred in one patient in whom the sling was removed. No upper tract deterioration was found until the last follow-up. In conclusion, a rectus fascia sling is a readily available alternative to the artificial urinary sphincter with comparable success and less reoperation rates. Needle suspension of the sling simplified its application in male patients.

Female bladder exstrophy

Bladder exstrophy is one of the most challenging congenital urinary tract abnormalities. Apart from the open bladder the patient also has various other abnormalities, including urogenital, musculoskeletal and anorectal defects. The size of the exstrophic bladder varies from patient to patient. In the female the clitoris to bifid and the vagina is anteriorly placed. In this paper various aspects of female bladder exstrophy are reviewed in detail, including incidence, etiology, anatomy and clinical features, together with early, medium-term and long-term surgical management. The aim is to achieve a functional bladder closure, although some patients are better off with a urinary diversion. Considering the complexity of the urogenital problems and the surgical management thereof, all patients require lifelong follow-up.

Long-term results of the artificial urinary sphincter in male patients with neurogenic bladder

The records of patients who received an artificial urinary sphincter at the University of Minnesota were reviewed. A total of 19 patients fulfilled the following criteria: male gender, neurogenic sphincteric incompetence, no previous surgery on the bladder neck, myelodysplasia and more than 5 years of followup. Mean age at the time of implantation was 8 years, mean age at the last followup was 16.5 years and mean followup was 8 years. At the last followup 16 patients (84.2%) were continent and 3 were expected to regain continence after revision or bladder augmentation. At the last followup 78.9% of the patients were on anticholinergic medications and 73.8% voided by clean intermittent catheterization. A fourth of the patients voided spontaneously. The annual revision rate was 0.2 revisions per patient. Seven patients (36.8%) have undergone or will require bladder augmentation. Upper tract dilatation developed in 2 patients and the function of 1 of 38 renal units at risk was lost. We conclude that the artificial urinary sphincter is an excellent modality for the initial surgical treatment of neurogenic sphincteric incompetence in male patients. Careful patient selection and lifelong surveillance are essential to success and safety.

Fascial sling for the management of urinary incontinence due to sphincter incompetence

The surgical management of urinary incontinence due to sphincter incompetence is still a challenging issue for urologists to date. We reviewed our experience with the fascial sling performed in 10 male and 3 female patients 3 to 72 years old (median age 13 years) with sphincter incompetence, including 11 with a neurogenic bladder (8 with myelodysplasia, 2 after pelvic operation and 1 after spinal cord injury), 1 after transurethral resection of the prostate and 1 after surgical injury to the bladder neck. Patient selection for a sling procedure was based on cystography (an open bladder neck) and urodynamic findings (underactive external urethral sphincter on electromyography and low maximum urethral closure pressure). A free graft of fascia was harvested from the rectus fascia in 8 patients and from the fascia lata in 5, and the fascial sling was placed around the bladder neck in 11 and the bulbous urethra in 2. Augmentation cystoplasty was performed concomitantly in 9 patients with poor bladder compliance (8 ileocystoplasty and 1 gastrocystoplasty). Postoperative followup ranged from 4 to 63 months (mean 36). Nine patients became continent and 3 improved significantly but remain damp. Of these 12 patients 10 with a neurogenic bladder were placed on intermittent catheterization, while the 2 without a neurogenic bladder are able to void normally. The remaining patient with surgical failure due to inadvertent wound infection received an indwelling urethral catheter. In all but this patient preoperative and postoperative maximum urethral closure pressures were 34.3 +/- 5.7 and 37.2 +/- 3.8 cm. water, respectively, without a significant increase. However, postoperative simultaneous measurements of intravesical and intraurethral pressure demonstrated a dramatic increase in intraurethral pressure during coughing or straining because of the action of the sling. Postoperative upper urinary tract deterioration has not been documented to date. Although various surgical options have been available, the fascial sling seems to be promising in the management of refractory urinary incontinence due to sphincter incompetence.

Urethral lengthening with anterior bladder wall flap for urinary incontinence: a new approach

Urethral irregularity (impeding catheterization) and failure to achieve continence are common complications in surgery for urinary incontinence. We describe a surgical technique using an anterior bladder wall flap that is sutured to the posterior wall in an onlay fashion creating a flap valve mechanism. Experimental work in dogs demonstrated a significant increase in the leak point pressure in the surgical group when compared to controls (p = 0.019). Voiding cystourethrography and bladder inspection demonstrated an anterior flap valve with no fistula formation in all animals. Histological examination showed a viable anterior bladder wall flap in all cases. This technique was then applied to 6 patients with neurogenic bladder and low urethral resistance that failed to resolve with medical treatment. Urinary continence was achieved in 4 patients. In 1 patient a vesicourethral fistula developed 3 months postoperatively, since the mother failed to catheterize for 12 hours. This technique is a useful alternative in the treatment of urinary incontinence.

The flip-flap technique to lengthen the urethra (Salle procedure) for treatment of neurogenic urinary incontinence

We report the clinical results of a urethral lengthening procedure for neurogenic urinary incontinence. The urethra is lengthened by using a full thickness anterior bladder wall flap that is based at the urethra. This flap is approximated to a longitudinal strip of the trigonal mucosa and musculature. This neourethra is covered by urothelium creating a tunneled urethra, which creates a compressible flap valve mechanism that occludes with bladder filling. The ureters are reimplanted superior to the repair. Technical feasibility was first documented in the dog. Four myelomeningocele children with low urethral resistance and urinary incontinence refractory to medical management have undergone this procedure since July 1992. The 3 patients who have been followed for longer than 1 year are described. Two patients require concomitant bladder augmentation. Comparison of preoperative and postoperative urodynamics revealed increased urethral resistance. All 3 patients are clinically improved and dry on intermittent catheterization during the day. The patient without bladder augmentation has occasional nocturnal wetting. Since the posterior urethra and bladder wall remain intact without suture lines there have been no problems with catheterization. The upper tracts remain normal. We believe that this procedure is a helpful addition to the care of children with neuropathic incontinence. The technical aspects and results of this procedure are discussed in detail.

The use of the AMS800 artificial urinary sphincter in combination with the gastric tube for continence in the canine model

An experimental canine model was designed to examine the potential use of the artificial urinary sphincter around a gastric tube. The artificial urinary sphincter was placed around a tubularized gastric flap as part of a continent gastric reservoir in 4 dogs and in 2 additional dogs the gastric tube was anastomosed to the native bladder. Two dogs underwent placement of the artificial urinary sphincter around the gastric tube 4 weeks postoperatively and the remainder had the sphincter placed simultaneously with creation of the gastric tube. All dogs with the gastric reservoir underwent urodynamics before and after activation of the sphincter. Only 61 to 70 cm. water pressure balloons were used. All dogs were continent postoperatively on clean intermittent catheterization every 8 hours. There were no erosions or problems with catheterization. Urodynamics confirmed a complaint system and an average increase of capacity of 410% after artificial urinary sphincter activation (4 dogs). There was no leakage at capacity. Histology of the artificial urinary sphincter and neighboring (control) regions, and of the reservoir at 1 (2 dogs), 3 (3 dogs) and 6 months (1 dog) was obtained. Microscopic examination of the cuff site showed mild serosal hyperplasia and fibrosis, a well preserved muscularis and mild to moderate focal mucosal atrophy. These changes were slightly more evident at 6 months. Mucosal folds were well preserved with normal submucosa and lamina propria. In the control region histology was well preserved and similar to native stomach. We conclude that the artificial urinary sphincter around a gastric tube can provide urinary continence. The minimal changes in histology under the cuff are encouraging and support the potential for use of the gastric tube with the artificial urinary sphincter, although longer term effects are unknown.

Lower urinary tract reconstruction using stomach and the artificial sphincter

We implanted the artificial urinary sphincter at gastrocystoplasty in 13 male and 5 female patients. The diagnoses were classical bladder exstrophy (8 patients), myelodysplasia (8), cloacal exstrophy (1) and bilateral ectopic ureters (1). Mean patient age was 14.3 years (range 7 to 32.5). Six patients (5 with bladder exstrophy and 1 with clocal exstrophy) had failed bladder neck continence procedures, 3 myelodysplastic patients had failed artificial urinary sphincter placement, and 1 exstrophy patient had failed a Young-Dees bladder neck repair and artificial urinary sphincter placement. The sphincter cuff was placed around the reconstructed bladder neck in these patients, while in the remainder the artificial urinary sphincter was placed around the intact bladder neck. Mean followup was 20.3 months (range 1 to 5). Of the patients 16 (88%) are continent day and night, while 2 are wet. A total of 11 patients (61%) use Valsalva's maneuver alone for voiding and the remainder use Valsalva's maneuver and/or clean intermittent catheterization for bladder evacuation. Complications related to the artificial urinary sphincter were recurrent pump erosion requiring conversion to a Mitrofanoff continent stoma in 1 patient, and mechanical dysfunction requiring pump cuff and reservoir replacement in 3. There were no complications due to infection. Our report demonstrates that the combination of augmentation gastrocystoplasty and an artificial urinary sphincter leads to urinary continence and can allow for spontaneous urination. The rate of infectious complications is not increased when the 2 procedures are combined simultaneously.

Influence of preoperative bladder capacity and compliance on the outcome of artificial sphincter implantation in patients with neurogenic sphincter incompetence

We performed a retrospective study of 23 patients with neurogenic sphincteric incompetence who had undergone implantation of an artificial urinary sphincter to determine if bladder capacity and compliance as determined by cystometrography could predict the need for enterocystoplasty. Study criteria were neurogenic sphincteric incompetence, no previous operations on the lower urinary tract, and performance of preoperative and postoperative cystometrography. Patients were 5 to 17 years old at implantation. Incontinence was caused by myelomeningocele (18 patients), sacral agenesis (3) and spinal cord tumor (2). The 8 patients for whom preoperative cystometric bladder capacity was greater than 60% of the expected capacity for age have been followed for a mean of 60 months. All 8 patients are continent and none required enterocystoplasty. Preoperative bladder compliance exceeded 2 ml./cm. water in all patients (group 1). Of the 15 patients for whom preoperative cystometric bladder capacity was less than 60% of the expected value (group 2, small bladders) 8 followed an average of 72 months had a compliance greater than 2 ml./cm. water and have done well without bladder augmentation. In contrast, 7 patients in this group (46%) required enterocystoplasty: 6 for persistent or recurrent incontinence and 1 for upper tract changes. The average interval between artificial sphincter placement and enterocystoplasty was 14 months. Patients with a small bladder that required augmentation had a preoperative bladder compliance of less than 2 ml./cm. water. We conclude that small bladder capacity, as determined by cystometrography in patients with neurogenic sphincteric incompetence but a bladder compliance of less than 2 ml./cm. water predicts the future need for bladder augmentation. In all other patients, with good medical treatment and followup, the possible adverse effects of a small capacity bladder can be prevented or corrected. With this strategy we have been able to avoid enterocystoplasty with its attending potential complications in 70% of our patients with neurogenic incontinence and favorable urodynamics regardless of preoperative cystometric bladder capacity.

Neuropathic urinary incontinence in pediatric patients: management with artificial sphincter

From June 1982 to November 1990, 37 patients, aged 13 to 19 years (35 males and 2 females), were treated in our division for neuropathic urinary incontinence with an artificial sphincter. All patients were treated before sphincter implantation with drugs, transurethral sphincterotomy in boys, and bladder flap urethroplasty was carried out in females during the surgical procedure. The cuff was placed at the bladder neck in 33 cases, and in 4 cases at the urethral bulb. The sphincter was activated about 3 weeks after implantation and after 2 months in two patients with associated bladder augmentation. Operative and perioperative complications occurred in four cases during the initial phase of our experience. Later we had to perform 19 revisions on 14 patients due to mechanical and surgical failure (reoperation rate, 0.38). Thirty-three patients are presently dry (90% of successes). Postoperatively, normal upper urinary tract conditions were found in all patients except two.

Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence

Intractable incontinence in selected male patients with a neurogenic bladder has been treated by increasing bladder compliance with augmentation cystoplasty and increasing urethral resistance with the artificial urinary sphincter. However, there are a number of complications associated with the use of an artificial urinary sphincter. As an alternative, we performed bladder neck tapering and bladder neck slings in 13 men with a neurogenic bladder and an incompetent urethra (10 with spina bifida and 3 with spinal cord injury) undergoing bladder augmentation. Mean patient age was 27 years (range 17 to 40 years) and mean followup was 34.3 months (range 5.5 to 49 months). Postoperatively, there was a 113% increase in mean bladder capacity (from 260 to 550 cc) and a 62% decrease in mean bladder pressure at capacity (from 53 to 20 cm. water). The earliest 2 patients with a Marlex sling suffered erosions that were treated with transurethral excision. As a result, the 11 subsequent patients had a rectus fascial sling. Nine patients (69.2%) are completely dry on self-catheterization, 2 (15.4%) required collagen injections for improved continence and 2 failures (15.4%) required additional procedures. The complications in these patients are comparable to, if not better than, the use of an artificial urinary sphincter. We conclude that a fascial sling with bladder neck tapering is an excellent alternative to the artificial urinary sphincter in the treatment of male neurogenic bladder with an incompetent urethra.

Surgical management of incontinence in bladder exstrophy

Between 1978 and 1990, 86 patients with previously closed classical bladder exstrophy and 10 patients seeking undiversion have presented for continence management and have undergone selective reconstruction designed for voiding and/or intermittent urethral catheterisation. The reconstruction in these 96 patients has been reviewed. Eight of the 10 patients undergoing undiversion achieved a satisfactory state of continence but 4 required Mitrofanoff procedures to enable catheterisation. Of the other 86 patients, 2 reached a satisfactory state of continence without further surgery; 79 underwent bladder neck surgery for continence either without augmentation (n = 32) or with augmentation (n = 47). Twenty of the 32 patients who were treated by bladder neck reconstruction alone were later found to require augmentation. Five patients had very early augmentation either to facilitate neonatal closure or on account of severe upper tract dilatation. Of these, 1 became continent without further surgery and 4 demonstrated the need for bladder neck reconstruction. Thus 12 children achieved successful continence (n = 6) or are evolving satisfactorily with potential success (n = 6) as a result of bladder neck reconstruction. Of the 71 patients requiring bladder neck reconstruction and augmentation, 68 have completed their surgery. The current status of these patients is: satisfactory in 57 (80%) (42 void/urethral clean intermittent catheterisation (CIC), 7 waiting to learn CIC, 5 Mitrofanoff, 3 artificial urinary sphincter (AUS]. Of the remaining 11 patients (20%), 8 are unsatisfactory to varying degrees and the status of the other 3 is unknown.

Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia

The surgical management of sphincteric incompetence in patients with myelodysplasia is a formidable problem. In 10 female patients and 4 male patients with myelodysplasia a free graft of rectus fascia was used to suspend the urethra, termed the periurethral and puboprostatic sling procedures, respectively. All but 1 patient also underwent augmentation cystoplasty, usually with sigmoid colon. Patient age ranged from 7 to 25 years (mean 12.6 years) and followup ranged from 2 to 27 months (mean 12 months). Of the patients 12 are completely dry on clean intermittent catheterization, 1 has undergone 2 subsequent urethral suspension procedures but remains incontinent and 1 experiences nocturnal enuresis but is dry during the day. The periurethral sling appears to be as effective as the artificial urinary sphincter, the Young-Dees-Leadbetter bladder neck reconstruction and the Kropp procedure in the management of sphincteric incompetence in female patients. In male patients experience with the puboprostatic sling is limited but thus far it is encouraging.

Success of the artificial urinary sphincter after failed surgery for incontinence

We implanted the artificial urinary sphincter in 15 incontinent patients for whom multiple urethral and bladder neck operations, including sphincter placement, had been unsuccessful. The 5 male and 10 female patients ranged from 3 to 26 years old (mean age 11 years). The etiology of incontinence was neurogenic bladder in 10 patients, epispadias in 2, exstrophy in 1, ectopic ureters in 1 and traumatic urethral disruption in 1. Of the 15 patients 13 required augmentation enterocystoplasty and clean intermittent catheterization. The initial anti-incontinence procedures were Young-Dees-Leadbetter bladder neck reconstruction in 10 patients, artificial urinary sphincter placement in 4 and bladder neck suspension in 1. Causes of failure of the primary treatment were erosion (artificial urinary sphincter), and incontinence and/or difficult catheterization (Young-Dees-Leadbetter). Followup from the last salvage operation averaged 21 months (range 6 to 37 months). A total of 58 operations was performed. Among the 4 patients in whom the artificial urinary sphincter eroded the bladder neck repeated attempts to place the cuff at the same site were unsuccessful and erosion occurred in all 4 within 1 year. Sphincter placement was more successful among the 11 patients who initially underwent Young-Dees-Leadbetter bladder neck reconstruction or bladder neck suspension; acceptable continence was attained in 8 patients (73%). We conclude that placement of the sphincter cuff around a previously eroded bladder neck probably will result in erosion. Sphincter implantation should be attempted in patients in whom bladder neck reconstruction has failed. Persistence in the treatment of these patients is essential because multiple operations often are necessary to achieve continence.

Compatibility of enterocystoplasty and the artificial urinary sphincter

Placement of the artificial urinary sphincter during augmentation enterocystoplasty may lead to infection, erosion and eventual removal of the device. To assess compatibility of artificial urinary sphincter implantation and enterocystoplasty we reviewed the records of 30 patients who had undergone enterocystoplasty and artificial urinary sphincter placement simultaneously (11), enterocystoplasty before artificial urinary sphincter placement (12) and artificial urinary sphincter placement before enterocystoplasty (7). The 19 male and 11 female patients were between 4 and 42 years old (median age 13.5 years). Followup in 28 patients ranged from 6 months to 8 years (average 17 months). Incontinence resulted from myelodysplasia in 16 patients, sacral agenesis in 3, spinal cord injury in 6, posterior urethral valves in 1, bilateral ectopic ureters in 1 and epispadias-exstrophy in 3. Erosion occurred in 2 patients (7 per cent): 1 female patient who underwent simultaneous sphincter implantation and enterocystoplasty and who had undergone previously many bladder neck reconstructive procedures, including polytetrafluoroethylene (Teflon) injection, and 1 female patient in whom the augmented bladder was entered at artificial urinary sphincter implantation. Mechanical failure occurred 4 times in 3 patients and the artificial urinary sphincter was improperly placed in 1. Over-all continence rate was 87 per cent (26 of 30 patients). Simultaneous placement of the artificial urinary sphincter and enterocystoplasty did not seem to affect the outcome of sphincter implantation if good bowel preparation, intravenous antibiotics and sterility of urine were accomplished preoperatively. Entering the augmented bladder during sphincter implantation may predispose to infection and erosion.