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BLADDER NECK SLING FOR TREATMENT OF NEUROGENIC INCONTINENCE IN CHILDREN WITH AUGMENTATION CYSTOPLASTY: LONG-TERM FOLLOWUP
0022-5347/05/1736-2128/0 THE JOURNAL OF UROLOGY® Copyright © 2005 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 173, 2128 –2131, June 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000157688.41223.d2
BLADDER NECK SLING FOR TREATMENT OF NEUROGENIC INCONTINENCE IN CHILDREN WITH AUGMENTATION CYSTOPLASTY: LONG-TERM FOLLOWUP M. CASTELLAN, R. GOSALBEZ, A. LABBIE, E. IBRAHIM
AND
M. DISANDRO
From the Division of Pediatric Urology, Miami Children’s Hospital and Jackson Memorial Hospital, and Department of Urology, University of Miami, Miami, Florida
ABSTRACT
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. KEY WORDS: urinary incontinence; bladder, neurogenic; pediatrics
Patients with neurogenic incontinence frequently exhibit a mixed pattern of incontinence due to the combination of functional and structural anomalies of the bladder (small capacity, low compliance and hyperreflexia), and bladder neck and external sphincter abnormalities (low detrusor leak point pressure and low stress leak point pressure).1, 2 Conservative treatment of neurogenic urinary incontinence using clean intermittent catheterization (CIC) in conjunction with pharmacological therapy, notably anticholinergic medication/␣-adrenergic agents, may produce continence in a variable number of patients. In others reconstructive surgery of the bladder and/or bladder neck is necessary to achieve urinary continence. Surgical treatment options to increase bladder outlet resistance in patients with neurogenic bladder include artificial urinary sphincter (AUS), bladder neck reconstruction, injection of bulking agents around the bladder neck and fascial sling procedures.3 The fascial sling technique for managing neurogenic urinary incontinence was initially reported in 1982 by Woodside and Borden.4 Although frequently used, published operative series of obstructive bladder neck sling in neurogenic cases include small numbers or lack long-term followup.3 We retrospectively reviewed the outcome of bladder neck slings in 58 patients (15 males) with neurogenic urinary incontinence who also underwent augmentation cystoplasty with a mean followup of 4.16 years. MATERIALS AND METHODS
A total of 147 patients with neurogenic bladder (86 females and 61 males) underwent bladder augmentation between Submitted for publication September 30, 2004.
July 1991 and July 2003. Of these patients 63 also underwent a rectus fascial bladder neck sling procedure as part of the reconstructive efforts for continence. Among this group we evaluated 58 patients (43 females and 15 males) ranging in age from 4 to 40 years (median 11.4 years) who underwent both procedures and had a followup of longer than 1 year. The underlying cause of incontinence was spina bifida in 52 patients, spinal cord injury in 5 and Conradi syndrome/vertebral anomalies in 1. The 15 males were 4 to 17 years old (median age 10 years), of whom 6 were postpubertal. Preoperative evaluation included renal and bladder ultrasound, and an isotopic renogram or excretory urogram for evaluation of upper urinary tract function. All patients underwent videourodynamics preoperatively while on maximal drug therapy. Urodynamic measurements included detrusor leak point pressure, stress leak point pressure, bladder capacity and detrusor compliance. Preoperative urodynamic studies showed markedly decreased bladder capacity that was less than 60% of expected capacity for age, with low compliance in all patients. Only those cases that failed conservative management with pharmacological agents and CIC were considered for reconstructive surgery. 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 pressure and clinical evidence of stress incontinence. A fascial sling procedure was performed in those patients with neurogenic incontinence, whom we did not expect would be capable of voiding spontaneously. Bladder augmentation was performed previously or simultaneously in all 58 patients
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BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY
using ileum (32), sigmoid (16), stomach (8) and ureter (2). A urinary continent stoma with appendix or transverse tubularized intestinal segments was created in 49 patients (84%). Operative exposure was obtained through a suprapubic approach in all cases. The technique for bladder neck slings has been described previously.5 Briefly, the procedure begins with dissection of the bladder neck through an anterior or posterior approach. Since August 1999 bladder neck dissection has been done through a posterior approach as described by Lottmann et al.6 We then harvest a 10 to 12 cm long and 1.5 cm wide segment of rectal fascia. This fascial segment is left attached at the base where the incision is wider. The free end of the fascial flap is then passed around the bladder neck, and then the fascia is secured with 2 horizontal mattress sutures of 2-zero nylon on the ipsilateral side to the posterior surface of the pubic symphysis. Next, we apply traction to the free fascial end and we suture this end to the posterior wall of the periosteum in a manner similar to that used on the contralateral side. We emphasize that the goal of the fascial bladder neck sling in this group of patients is not only bladder neck suspension, but also obstructive coaptation, which increases passive and stress leak point pressures. Associated procedures are detailed in the table. RESULTS
Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). Postoperatively, all patients performed CIC through a continent stoma (49) or per urethra (9). We define a good postoperative result as the achievement of complete passive urinary continence for periods of 4 to 6 hours during the day and 6 to 8 hours at night, as well as the absence of stress urinary incontinence. According to these criteria, 51 patients (88%) obtained good results. During followup there has been no evidence of upper urinary tract deterioration on serial renal ultrasound, normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Postoperative videourodynamic studies were available in 28 of these patients (55%). Following a bladder neck sling procedure the passive leak point pressure increased from 0 to 20 cm H2O (mean 9 cm H2O). In 21 of these 28 patients the sling was effective in creating a coaptation of the bladder neck during the filling phase, which at the same time is displaced superiorly and anteriorly in an intra-abdominal position, thus, simultaneously correcting the problems of passive and stress incontinence. Five females and two males remained incontinent after the sling procedure. Preoperative videourodynamic studies demonstrated markedly decreased bladder capacity that was less than 60% of expected capacity for age, with low compliance. Preoperatively, detrusor leak point pressures were less that 30 cm H2O in 2 of these patients, 30 to 40 cm H2O in 1 and 40 to 45 cm H2O in 1. These patients underwent bladder augmentation with sigmoid (3), ileum (1) and stomach (1). In all 5 female patients postoperative urodynamic studies revealed that bladder augmentation was successful in in-
Associated procedures No. Pts Bladder augmentation (58 pts): Ileum Sigmoid Stomach Ureter Mitrofanoff procedure (49 pts): Appendix Yang-Monti ileum Yang-Monti sigmoid Gastric tube Meckel diverticulum
32 16 8 2 24 15 8 1 1
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creasing bladder capacity to a volume appropriate for age and improving detrusor compliance. However, a low detrusor leak point pressure suggested that failures were all secondary to an unsuccessful bladder neck sling. Two of these female patients underwent collagen injection at the bladder neck. In 1 patient symptoms initially improved but on longterm followup she remained incontinent between catheterizations. In the other patient the procedure was unsuccessful from the beginning. In this patient an artificial urinary sphincter was placed at 1 year following the sling procedure. Another procedure was done at the bladder neck in 3 female patients (artificial urinary sphincter in 1, closure of bladder neck in 2) at a mean of 18 months following the initial sling procedure. Two male patients, 5 and 17 years old, had daily underwear staining or dampness with exercise or transfers from wheelchair. Videourodynamics showed postoperative detrusor leak point pressures of 35 and 40 cm H2O, respectively, stress incontinence with Valsalva maneuver and an open bladder neck. These patients perform CIC every 3 to 4 hours and are still receiving anticholinergic medication, and neither has undergone a secondary procedure yet. Two female patients who catheterized per a Mitrofanoff channel had development of occlusion of the bladder neck on long-term followup. We hypothesized that trauma to the bladder neck during dissection was likely responsible for the eventual occlusion. In both patients dissection of the bladder neck was done through an anterior approach. Two patients (1 male and 1 female) had development of wound dehiscence that required subsequent re-closure. In addition, a 27-year-old female had a perforation of the augmented bladder on 2 occasions at 3 and 4 years after cystoplasty. Compliance with intermittent catheterization has been an issue with this patient. One female died of unrelated problems several years later.
DISCUSSION
In children with neurogenic urinary incontinence secondary to low bladder outlet resistance surgical treatment remains challenging. The majority of patients will require surgical manipulation of the bladder neck to achieve socially acceptable urinary continence, and many of these patients also have detrusor abnormalities requiring bladder augmentation.7, 8 The rectus fascial sling is one of the many techniques frequently used for treating incontinence in children secondary to neurogenic sphincter incontinence. Although frequently used, reports of long-term followup are sparse.3, 9, 10 In the majority of the published series followup has been short and the continence rate has ranged from 40% to 100%.3, 4, 8 –10 This retrospective review was undertaken to determine the long-term success of bladder neck slings and to determine whether delayed complications occur. It is believed that the mechanism by which continence is achieved using a sling includes increased passive and dynamic urethral and bladder neck resistance. By compressing and fixing the bladder neck in a retropubic position we increase the fixed outlet resistance and prevent urethral hypermobility.5, 8 We emphasize that the goal of the sling in this group of patients is not only bladder neck suspension, but also obstructive coaptation, allowing the patient to empty by CIC, either through the urethra or through a continent stoma. Clean intermittent catheterization per urethra is not compromised by the sling. While the angle between the urethra and the bladder neck changes, the urethra itself remains straight with no angulations. In some girls the anterior vaginal wall may also retract upward, drawing the urethral meatus into the vaginal introitus, making visualization somewhat harder. However, difficulty with catheteriza-
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BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY
tion is uncommon, as most of these patients identify the urethral meatus by palpation and not direct visualization. The more common alternatives to bladder neck slings include artificial urinary sphincters and injection of bulking agents to enhance bladder neck resistance. The latter procedure has limited success in the short term that further decreases as time progresses, requiring multiple injections. Artificial urinary sphincters are extremely effective in increasing bladder outlet resistance and will allow spontaneous voiding in selected patients. However, there is a wellknown and documented increased risk of erosion and malfunction as time progresses, leading to higher revision and removal rates.3 In addition, several studies have demonstrated that simultaneous enterocystoplasty and artificial urinary sphincter placement may increase infectious complication rates, ranging in some reports from 20% to 50%.11–13 The artificial urinary sphincter offers advantages over sling procedures in those patients who may be capable of spontaneous voiding. Following a bladder neck sling procedure the passive detrusor leak point pressure has a modest increase.14 Maintaining a safe detrusor leak point pressure is extremely important and has been found to have significant implications in the upper tracts.2 This feature is one of the main advantages of the bladder neck sling over other bladder outlet procedures, such as the artificial urinary sphincter, which may impose substantially higher fixed bladder outlet resistance, and, therefore, place the upper tracts at a higher risk of deterioration if bladder compliance worsens or the patient fails to perform clean intermittent catheterization properly. In our series 15 patients were males (9 prepubertal and 6 postpubertal). Initially, it was thought that the sling procedure was best suited for girls but more recent studies have also revealed good results in boys.15, 16 Two males patients (1 prepubertal and 1 postpubertal) remain incontinent following sling placement. Although a small series, our experience with males has been favorable, with an 87% continence rate. Despite applying significant tension to the sling, the incidence of complication has been relatively low in the literature.3, 16, 17 Anecdotal reports include erosion of the bladder neck, difficult catheterization, ureteral and rectal perforation, and wound infection.3 Two obese patients in this series had fascial wound dehiscence requiring surgical correction. Obese patients in general are more prone to this complication, as the fascia is more attenuated and closure may be more difficult. We must emphasize that due to the fascial harvesting, rectus fascia closure in patients with neurogenic bladder requires special attention and care. In our series 4 female patients with persistent incontinence underwent subsequent open procedures of the bladder neck. Interestingly, at reoperation the previous sling was identified in 3 of 4 patients, and the dissection between the fascia and bladder neck was straightforward, with a clearly identified plane of dissection. Two patients followed 36 and 40 months after secondary AUS placement remain completely continent, with the sphincter functioning correctly and no erosion. This is a small group of patients to draw any significant conclusions but we believe that if the bladder neck is not injured at the time of the initial sling, a secondary AUS should not carry any increased risk of complications. A potential criticism of this study is that considering our high continence success rate, we may be including in our series patients who could have become continent with augmentation cystoplasty alone. We do not dispute this possibility. Our selection criteria leave a small margin of error for patients to remain incontinent postoperatively but we believe that this approach is justified, considering the historical rates of incontinence following augmentation cystoplasty alone.18 Ideally, when treating urinary incontinence surgically one should attempt to achieve continence with a single procedure. Furthermore, secondary bladder outlet proce-
dures following augmentation cystoplasty pose a significant surgical challenge. By establishing strict selection criteria we strive to achieve high continence rates in patients with abnormal bladder outlet resistance and urethral hypermobility. We believe that the bladder neck sling is an attractive alternative for managing incontinence in neurogenic cases with bladder neck and sphincter anomalies. A satisfactory continence rate was achieved and remained durable with time. In those patients who cannot empty spontaneously the bladder neck sling offers significant advantages over other techniques due to its simplicity, low cost, low incidence of complications and high rate of success. 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 use of the rectus fascial sling. REFERENCES
1. Wan, J., McGuire, E. J., Bloom, D. A. and Ritchey, M. L.: Stress leak point pressure: a diagnostic tool for incontinent children. J Urol, 150: 700, 1993 2. McGuire, E. J., Cespedes, R. D. and O’Connell, H. E : Leak-point pressures. Urol Clin North Am, 23: 253, 1996 3. Kryger, J. V., Gonza´lez, R. and Berthold, J. S.: Review Article: Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol, 163: 256, 2000 4. Woodside, J. R. and Borden, T. A.: Pubovaginal sling procedure for the management of urinary incontinence in a myelodysplastic girl. J Urol, 127: 744, 1982 5. Gosalbez, R. and Castellan, M.: Defining the role of the bladderneck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence. World J Urol, 16: 285, 1998 6. Lottmann, H., Traxer, O., Aigrain, Y. and Melin, Y.: La voie d’abord retro-vesicale pour l’implantation du sphincter artificial AMS 800 chez l’enfant et l’adolescent: technique et resultants chez huit patients. Ann Urol, 33: 357, 1999 7. Bauer, S. B., Peters, C. A., Colodny, A. H., Mandell, J. and Retik, A. B.: The use of rectus fascia to manage urinary incontinence. J Urol, 142: 516, 1989 8. Decter, R. M.: Use of the fascial sling for neurogenic incontinence: lessons learned. J Urol, 150: 683, 1993 9. Elder, J. S.: Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia. J Urol, 144: 434, 1990 10. Austin, P. F., Westney, O. L., Leng, W. W., McGuire, E. J. and Ritchey, M. L.: Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders. J Urol, 165: 2369, 2001 11. Strawbridge, L. R., Kramer, S. A., Castillo, O. A. and Barrett, D. M.: Augmentation cystoplasty and the artificial genitourinary sphincter. J Urol, 142: 297, 1989 12. Light, J. K., Lapin, S. and Vohra, S.: Combined use of bowel and the artificial sphincter in reconstruction of the lower urinary tract: infectious complications. J Urol, 153: 331, 1995 13. Theodorou, Ch., Plastiras, D., Moutzouris, G., Floratos, D., Mertziotis, N. and Miliaras, J.: Combined reconstructive and prosthesis surgery in complicated lower urinary tract dysfunction. J Urol, 157: 472, 1997 14. Gormley, E. A., Bloom, D. A., McGuire, E. J. and Ritchey, M. L.: Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol, 152: 822, 1994 15. Nguyen, H. T., Bauer, S. B., Diamond, D. A. and Retik, A. B.: Rectus fascial sling for the treatment of neurogenic sphincteric incontinence in boys: is it safe and effective? J Urol, 166: 658, 2001 16. Herschhorn, S. and Radomski, S. B.: Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence. J Urol, 147: 1073, 1992 17. Perez, L. M., Smith, E. A., Broecker, B. H., Massad, C. A.,
BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY Parrott, T. S. and Woodard, J. R.: Outcome of sling cystourethropexy in the pediatric population: a critical review. J Urol, 156: 642, 1996 18. Herschorn, S. and Hewitt, R. J.: Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder. Urology, 52: 672, 1998 EDITORIAL COMMENT This article is an important contribution to the surgical treatment of incontinence in the patient with neurogenic bladder. It represents the largest series managed by bladder neck sling in combination with bladder augmentation. The authors demonstrate the potential to achieve high continence rates in a complex patient population. Prior studies have had rather widely variable results. The authors describe and apply the appropriate criteria to select patients. It certainly would not be appropriate to apply bladder neck surgery to all patients undergoing augmentation, since there can be significant additional risks. These authors seem to select for those patients who would not benefit from augmentation alone. It is possible that some patients might have done well with augmentation alone but as the authors state, the high success rate in this select group with 1 operation makes this an attractive approach. However, it is not clear that the bladder neck sling alone achieves continence in patients who could otherwise avoid bladder augmentation. There is not an article that convincingly shows high conti-
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nence of slings alone in neurogenic bladder cases that are not augmented. If slings are so successful in enhancing outlet resistance, why is this so? Why does it only work well with concomitant augmentation? We must continue to uphold strict criteria for the application of bladder augmentation. John V. Kryger Department of Pediatric Urology University of Wisconsin Children’s Hospital Madison, Wisconsin REPLY BY AUTHORS There are no large series addressing the use of slings alone in the treatment of patients with neurogenic bladder with urinary incontinence. Therefore, the assertion that slings only work well with bladder augmentation may be erroneous. There are multiple surgical techniques to enhance bladder outlet resistance each with its own advantages and disadvantages. The bladder neck sling as discussed in our article is an obstructive procedure leading to the need for CIC and, therefore, it is ideal to combine with bladder augmentation. Our preference is to treat patients with low outlet resistance of neurogenic origin but adequate bladder capacity and compliance with an artificial urinary sphincter, which allows them the possibility to void spontaneously postoperatively. Bladder neck slings increase bladder outlet resistance only marginally (up to 20 cm H2O, fix the bladder neck to prevent stress incontinence and have a safer profile than AUS.
Vol. 173, 2128 –2131, June 2005 Printed in U.S.A.
DOI: 10.1097/01.ju.0000157688.41223.d2
BLADDER NECK SLING FOR TREATMENT OF NEUROGENIC INCONTINENCE IN CHILDREN WITH AUGMENTATION CYSTOPLASTY: LONG-TERM FOLLOWUP M. CASTELLAN, R. GOSALBEZ, A. LABBIE, E. IBRAHIM
AND
M. DISANDRO
From the Division of Pediatric Urology, Miami Children’s Hospital and Jackson Memorial Hospital, and Department of Urology, University of Miami, Miami, Florida
ABSTRACT
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. KEY WORDS: urinary incontinence; bladder, neurogenic; pediatrics
Patients with neurogenic incontinence frequently exhibit a mixed pattern of incontinence due to the combination of functional and structural anomalies of the bladder (small capacity, low compliance and hyperreflexia), and bladder neck and external sphincter abnormalities (low detrusor leak point pressure and low stress leak point pressure).1, 2 Conservative treatment of neurogenic urinary incontinence using clean intermittent catheterization (CIC) in conjunction with pharmacological therapy, notably anticholinergic medication/␣-adrenergic agents, may produce continence in a variable number of patients. In others reconstructive surgery of the bladder and/or bladder neck is necessary to achieve urinary continence. Surgical treatment options to increase bladder outlet resistance in patients with neurogenic bladder include artificial urinary sphincter (AUS), bladder neck reconstruction, injection of bulking agents around the bladder neck and fascial sling procedures.3 The fascial sling technique for managing neurogenic urinary incontinence was initially reported in 1982 by Woodside and Borden.4 Although frequently used, published operative series of obstructive bladder neck sling in neurogenic cases include small numbers or lack long-term followup.3 We retrospectively reviewed the outcome of bladder neck slings in 58 patients (15 males) with neurogenic urinary incontinence who also underwent augmentation cystoplasty with a mean followup of 4.16 years. MATERIALS AND METHODS
A total of 147 patients with neurogenic bladder (86 females and 61 males) underwent bladder augmentation between Submitted for publication September 30, 2004.
July 1991 and July 2003. Of these patients 63 also underwent a rectus fascial bladder neck sling procedure as part of the reconstructive efforts for continence. Among this group we evaluated 58 patients (43 females and 15 males) ranging in age from 4 to 40 years (median 11.4 years) who underwent both procedures and had a followup of longer than 1 year. The underlying cause of incontinence was spina bifida in 52 patients, spinal cord injury in 5 and Conradi syndrome/vertebral anomalies in 1. The 15 males were 4 to 17 years old (median age 10 years), of whom 6 were postpubertal. Preoperative evaluation included renal and bladder ultrasound, and an isotopic renogram or excretory urogram for evaluation of upper urinary tract function. All patients underwent videourodynamics preoperatively while on maximal drug therapy. Urodynamic measurements included detrusor leak point pressure, stress leak point pressure, bladder capacity and detrusor compliance. Preoperative urodynamic studies showed markedly decreased bladder capacity that was less than 60% of expected capacity for age, with low compliance in all patients. Only those cases that failed conservative management with pharmacological agents and CIC were considered for reconstructive surgery. 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 pressure and clinical evidence of stress incontinence. A fascial sling procedure was performed in those patients with neurogenic incontinence, whom we did not expect would be capable of voiding spontaneously. Bladder augmentation was performed previously or simultaneously in all 58 patients
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BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY
using ileum (32), sigmoid (16), stomach (8) and ureter (2). A urinary continent stoma with appendix or transverse tubularized intestinal segments was created in 49 patients (84%). Operative exposure was obtained through a suprapubic approach in all cases. The technique for bladder neck slings has been described previously.5 Briefly, the procedure begins with dissection of the bladder neck through an anterior or posterior approach. Since August 1999 bladder neck dissection has been done through a posterior approach as described by Lottmann et al.6 We then harvest a 10 to 12 cm long and 1.5 cm wide segment of rectal fascia. This fascial segment is left attached at the base where the incision is wider. The free end of the fascial flap is then passed around the bladder neck, and then the fascia is secured with 2 horizontal mattress sutures of 2-zero nylon on the ipsilateral side to the posterior surface of the pubic symphysis. Next, we apply traction to the free fascial end and we suture this end to the posterior wall of the periosteum in a manner similar to that used on the contralateral side. We emphasize that the goal of the fascial bladder neck sling in this group of patients is not only bladder neck suspension, but also obstructive coaptation, which increases passive and stress leak point pressures. Associated procedures are detailed in the table. RESULTS
Followup ranged from 1 year to 10 years, 3 months (mean 4.16 years). Postoperatively, all patients performed CIC through a continent stoma (49) or per urethra (9). We define a good postoperative result as the achievement of complete passive urinary continence for periods of 4 to 6 hours during the day and 6 to 8 hours at night, as well as the absence of stress urinary incontinence. According to these criteria, 51 patients (88%) obtained good results. During followup there has been no evidence of upper urinary tract deterioration on serial renal ultrasound, normal upper tracts remained normal and there was either improvement or stabilization of hydronephrosis. Postoperative videourodynamic studies were available in 28 of these patients (55%). Following a bladder neck sling procedure the passive leak point pressure increased from 0 to 20 cm H2O (mean 9 cm H2O). In 21 of these 28 patients the sling was effective in creating a coaptation of the bladder neck during the filling phase, which at the same time is displaced superiorly and anteriorly in an intra-abdominal position, thus, simultaneously correcting the problems of passive and stress incontinence. Five females and two males remained incontinent after the sling procedure. Preoperative videourodynamic studies demonstrated markedly decreased bladder capacity that was less than 60% of expected capacity for age, with low compliance. Preoperatively, detrusor leak point pressures were less that 30 cm H2O in 2 of these patients, 30 to 40 cm H2O in 1 and 40 to 45 cm H2O in 1. These patients underwent bladder augmentation with sigmoid (3), ileum (1) and stomach (1). In all 5 female patients postoperative urodynamic studies revealed that bladder augmentation was successful in in-
Associated procedures No. Pts Bladder augmentation (58 pts): Ileum Sigmoid Stomach Ureter Mitrofanoff procedure (49 pts): Appendix Yang-Monti ileum Yang-Monti sigmoid Gastric tube Meckel diverticulum
32 16 8 2 24 15 8 1 1
2129
creasing bladder capacity to a volume appropriate for age and improving detrusor compliance. However, a low detrusor leak point pressure suggested that failures were all secondary to an unsuccessful bladder neck sling. Two of these female patients underwent collagen injection at the bladder neck. In 1 patient symptoms initially improved but on longterm followup she remained incontinent between catheterizations. In the other patient the procedure was unsuccessful from the beginning. In this patient an artificial urinary sphincter was placed at 1 year following the sling procedure. Another procedure was done at the bladder neck in 3 female patients (artificial urinary sphincter in 1, closure of bladder neck in 2) at a mean of 18 months following the initial sling procedure. Two male patients, 5 and 17 years old, had daily underwear staining or dampness with exercise or transfers from wheelchair. Videourodynamics showed postoperative detrusor leak point pressures of 35 and 40 cm H2O, respectively, stress incontinence with Valsalva maneuver and an open bladder neck. These patients perform CIC every 3 to 4 hours and are still receiving anticholinergic medication, and neither has undergone a secondary procedure yet. Two female patients who catheterized per a Mitrofanoff channel had development of occlusion of the bladder neck on long-term followup. We hypothesized that trauma to the bladder neck during dissection was likely responsible for the eventual occlusion. In both patients dissection of the bladder neck was done through an anterior approach. Two patients (1 male and 1 female) had development of wound dehiscence that required subsequent re-closure. In addition, a 27-year-old female had a perforation of the augmented bladder on 2 occasions at 3 and 4 years after cystoplasty. Compliance with intermittent catheterization has been an issue with this patient. One female died of unrelated problems several years later.
DISCUSSION
In children with neurogenic urinary incontinence secondary to low bladder outlet resistance surgical treatment remains challenging. The majority of patients will require surgical manipulation of the bladder neck to achieve socially acceptable urinary continence, and many of these patients also have detrusor abnormalities requiring bladder augmentation.7, 8 The rectus fascial sling is one of the many techniques frequently used for treating incontinence in children secondary to neurogenic sphincter incontinence. Although frequently used, reports of long-term followup are sparse.3, 9, 10 In the majority of the published series followup has been short and the continence rate has ranged from 40% to 100%.3, 4, 8 –10 This retrospective review was undertaken to determine the long-term success of bladder neck slings and to determine whether delayed complications occur. It is believed that the mechanism by which continence is achieved using a sling includes increased passive and dynamic urethral and bladder neck resistance. By compressing and fixing the bladder neck in a retropubic position we increase the fixed outlet resistance and prevent urethral hypermobility.5, 8 We emphasize that the goal of the sling in this group of patients is not only bladder neck suspension, but also obstructive coaptation, allowing the patient to empty by CIC, either through the urethra or through a continent stoma. Clean intermittent catheterization per urethra is not compromised by the sling. While the angle between the urethra and the bladder neck changes, the urethra itself remains straight with no angulations. In some girls the anterior vaginal wall may also retract upward, drawing the urethral meatus into the vaginal introitus, making visualization somewhat harder. However, difficulty with catheteriza-
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BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY
tion is uncommon, as most of these patients identify the urethral meatus by palpation and not direct visualization. The more common alternatives to bladder neck slings include artificial urinary sphincters and injection of bulking agents to enhance bladder neck resistance. The latter procedure has limited success in the short term that further decreases as time progresses, requiring multiple injections. Artificial urinary sphincters are extremely effective in increasing bladder outlet resistance and will allow spontaneous voiding in selected patients. However, there is a wellknown and documented increased risk of erosion and malfunction as time progresses, leading to higher revision and removal rates.3 In addition, several studies have demonstrated that simultaneous enterocystoplasty and artificial urinary sphincter placement may increase infectious complication rates, ranging in some reports from 20% to 50%.11–13 The artificial urinary sphincter offers advantages over sling procedures in those patients who may be capable of spontaneous voiding. Following a bladder neck sling procedure the passive detrusor leak point pressure has a modest increase.14 Maintaining a safe detrusor leak point pressure is extremely important and has been found to have significant implications in the upper tracts.2 This feature is one of the main advantages of the bladder neck sling over other bladder outlet procedures, such as the artificial urinary sphincter, which may impose substantially higher fixed bladder outlet resistance, and, therefore, place the upper tracts at a higher risk of deterioration if bladder compliance worsens or the patient fails to perform clean intermittent catheterization properly. In our series 15 patients were males (9 prepubertal and 6 postpubertal). Initially, it was thought that the sling procedure was best suited for girls but more recent studies have also revealed good results in boys.15, 16 Two males patients (1 prepubertal and 1 postpubertal) remain incontinent following sling placement. Although a small series, our experience with males has been favorable, with an 87% continence rate. Despite applying significant tension to the sling, the incidence of complication has been relatively low in the literature.3, 16, 17 Anecdotal reports include erosion of the bladder neck, difficult catheterization, ureteral and rectal perforation, and wound infection.3 Two obese patients in this series had fascial wound dehiscence requiring surgical correction. Obese patients in general are more prone to this complication, as the fascia is more attenuated and closure may be more difficult. We must emphasize that due to the fascial harvesting, rectus fascia closure in patients with neurogenic bladder requires special attention and care. In our series 4 female patients with persistent incontinence underwent subsequent open procedures of the bladder neck. Interestingly, at reoperation the previous sling was identified in 3 of 4 patients, and the dissection between the fascia and bladder neck was straightforward, with a clearly identified plane of dissection. Two patients followed 36 and 40 months after secondary AUS placement remain completely continent, with the sphincter functioning correctly and no erosion. This is a small group of patients to draw any significant conclusions but we believe that if the bladder neck is not injured at the time of the initial sling, a secondary AUS should not carry any increased risk of complications. A potential criticism of this study is that considering our high continence success rate, we may be including in our series patients who could have become continent with augmentation cystoplasty alone. We do not dispute this possibility. Our selection criteria leave a small margin of error for patients to remain incontinent postoperatively but we believe that this approach is justified, considering the historical rates of incontinence following augmentation cystoplasty alone.18 Ideally, when treating urinary incontinence surgically one should attempt to achieve continence with a single procedure. Furthermore, secondary bladder outlet proce-
dures following augmentation cystoplasty pose a significant surgical challenge. By establishing strict selection criteria we strive to achieve high continence rates in patients with abnormal bladder outlet resistance and urethral hypermobility. We believe that the bladder neck sling is an attractive alternative for managing incontinence in neurogenic cases with bladder neck and sphincter anomalies. A satisfactory continence rate was achieved and remained durable with time. In those patients who cannot empty spontaneously the bladder neck sling offers significant advantages over other techniques due to its simplicity, low cost, low incidence of complications and high rate of success. 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 use of the rectus fascial sling. REFERENCES
1. Wan, J., McGuire, E. J., Bloom, D. A. and Ritchey, M. L.: Stress leak point pressure: a diagnostic tool for incontinent children. J Urol, 150: 700, 1993 2. McGuire, E. J., Cespedes, R. D. and O’Connell, H. E : Leak-point pressures. Urol Clin North Am, 23: 253, 1996 3. Kryger, J. V., Gonza´lez, R. and Berthold, J. S.: Review Article: Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol, 163: 256, 2000 4. Woodside, J. R. and Borden, T. A.: Pubovaginal sling procedure for the management of urinary incontinence in a myelodysplastic girl. J Urol, 127: 744, 1982 5. Gosalbez, R. and Castellan, M.: Defining the role of the bladderneck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence. World J Urol, 16: 285, 1998 6. Lottmann, H., Traxer, O., Aigrain, Y. and Melin, Y.: La voie d’abord retro-vesicale pour l’implantation du sphincter artificial AMS 800 chez l’enfant et l’adolescent: technique et resultants chez huit patients. Ann Urol, 33: 357, 1999 7. Bauer, S. B., Peters, C. A., Colodny, A. H., Mandell, J. and Retik, A. B.: The use of rectus fascia to manage urinary incontinence. J Urol, 142: 516, 1989 8. Decter, R. M.: Use of the fascial sling for neurogenic incontinence: lessons learned. J Urol, 150: 683, 1993 9. Elder, J. S.: Periurethral and puboprostatic sling repair for incontinence in patients with myelodysplasia. J Urol, 144: 434, 1990 10. Austin, P. F., Westney, O. L., Leng, W. W., McGuire, E. J. and Ritchey, M. L.: Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders. J Urol, 165: 2369, 2001 11. Strawbridge, L. R., Kramer, S. A., Castillo, O. A. and Barrett, D. M.: Augmentation cystoplasty and the artificial genitourinary sphincter. J Urol, 142: 297, 1989 12. Light, J. K., Lapin, S. and Vohra, S.: Combined use of bowel and the artificial sphincter in reconstruction of the lower urinary tract: infectious complications. J Urol, 153: 331, 1995 13. Theodorou, Ch., Plastiras, D., Moutzouris, G., Floratos, D., Mertziotis, N. and Miliaras, J.: Combined reconstructive and prosthesis surgery in complicated lower urinary tract dysfunction. J Urol, 157: 472, 1997 14. Gormley, E. A., Bloom, D. A., McGuire, E. J. and Ritchey, M. L.: Pubovaginal slings for the management of urinary incontinence in female adolescents. J Urol, 152: 822, 1994 15. Nguyen, H. T., Bauer, S. B., Diamond, D. A. and Retik, A. B.: Rectus fascial sling for the treatment of neurogenic sphincteric incontinence in boys: is it safe and effective? J Urol, 166: 658, 2001 16. Herschhorn, S. and Radomski, S. B.: Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence. J Urol, 147: 1073, 1992 17. Perez, L. M., Smith, E. A., Broecker, B. H., Massad, C. A.,
BLADDER NECK SLING FOR NEUROGENIC INCONTINENCE AUGMENTATION CYSTOPLASTY Parrott, T. S. and Woodard, J. R.: Outcome of sling cystourethropexy in the pediatric population: a critical review. J Urol, 156: 642, 1996 18. Herschorn, S. and Hewitt, R. J.: Patient perspective of long-term outcome of augmentation cystoplasty for neurogenic bladder. Urology, 52: 672, 1998 EDITORIAL COMMENT This article is an important contribution to the surgical treatment of incontinence in the patient with neurogenic bladder. It represents the largest series managed by bladder neck sling in combination with bladder augmentation. The authors demonstrate the potential to achieve high continence rates in a complex patient population. Prior studies have had rather widely variable results. The authors describe and apply the appropriate criteria to select patients. It certainly would not be appropriate to apply bladder neck surgery to all patients undergoing augmentation, since there can be significant additional risks. These authors seem to select for those patients who would not benefit from augmentation alone. It is possible that some patients might have done well with augmentation alone but as the authors state, the high success rate in this select group with 1 operation makes this an attractive approach. However, it is not clear that the bladder neck sling alone achieves continence in patients who could otherwise avoid bladder augmentation. There is not an article that convincingly shows high conti-
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nence of slings alone in neurogenic bladder cases that are not augmented. If slings are so successful in enhancing outlet resistance, why is this so? Why does it only work well with concomitant augmentation? We must continue to uphold strict criteria for the application of bladder augmentation. John V. Kryger Department of Pediatric Urology University of Wisconsin Children’s Hospital Madison, Wisconsin REPLY BY AUTHORS There are no large series addressing the use of slings alone in the treatment of patients with neurogenic bladder with urinary incontinence. Therefore, the assertion that slings only work well with bladder augmentation may be erroneous. There are multiple surgical techniques to enhance bladder outlet resistance each with its own advantages and disadvantages. The bladder neck sling as discussed in our article is an obstructive procedure leading to the need for CIC and, therefore, it is ideal to combine with bladder augmentation. Our preference is to treat patients with low outlet resistance of neurogenic origin but adequate bladder capacity and compliance with an artificial urinary sphincter, which allows them the possibility to void spontaneously postoperatively. Bladder neck slings increase bladder outlet resistance only marginally (up to 20 cm H2O, fix the bladder neck to prevent stress incontinence and have a safer profile than AUS.