- Email: [email protected]
Neuropathic urinary incontinence in pediatric patients: Management with artificial sphincter
Neuropathic Urinary Incontinence in Pediatric Patients: Management With Artificial Sphincter ByG. Belloli, P. Campobasso, Vicenza, l 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. Copyright o 1992 by W.B. Saunders Company INDEX WORDS: sphincter.
Urinary incontinence,
neuropathic,
artificial
0
VER THE LAST several years there has been growing experience with the use of artificial sphincters in the treatment of neurologic urinary incontinence.1-5 In this paper we report our experience in the management of neurophatic urinary incontinence with an artificial sphincter. MATERIALS
AND METHODS
The indications for implantation of an artificial urinary sphincter in the neuropathic bladder have been summarized in Table 1. It is obvious that one should look for every possible way of obtaining an appreciable “continence” with nonoperative methods, such as scheduled voiding or intermittent vesical catheterization usually associated with pharmacologic treatment, and the patients should be able to manage the prosthesis as well. In our experience the “ideal” neuropathic bladder suitable for implantation must be areflexic, with a normal or only slightly reduced compliance. and with a cystometric capacity greater than 200 to 2.50mL (Fig 1). It is also important that bladder emptying be relatively easy and without residual.h-“’ Of the 216 patients older than the age of 10, out of a total of 451 neuropathic bladders, we only found ideal urodynamic conditions in about 15% of the cases. However, a detrusor hyperreflexia or a reduced vesical capacity and/or compliance can be ameliorated with appropriate pharmacological treatment (Fig 2). From June 1982 to November 1990,37 patients, aged between 13 and 19 years, were treated with implantation of an artificial urinary sphincter in our department. Thirty-five were male and two female. In 33 cases myelomeningocele was the cause, and in the other three a partial sacral agenesis; the neuropathic bladder of the remaining case was the consequence of pelvic surgery (Table 2). Preoperative treatment involved pharmacological treatment with oxybutynin chloride at the indicated doses and continued even after the operation, transurethral sphincterotomy. possibly at JournalofPediatric
Surgery, Vol27, No 11 (November), 1992: pp 1461-1464
and A. Mercurella
Italy
hours 2 and 10 in all males, bladder flap urethroplasty in one girl and antibiotic prophylaxis 1 day before surgery (Table 3). In the first 2 cases we applied model AS 792 (AMS, Minnetonka, MN); both these sphincters were substituted with the last model (AS 800). In the other cases model AS 800 was used, with all improvements introduced over the past years. The cuff was placed at the bladder neck in 33 cases and in 4 cases, with a previous operation on the neck, at the urethral bulb (Table 4). Obviously in these last cases, the lower pressure balloon was chosen (Table 4). Usually the sphincter was activated about 3 weeks after implantation. RESULTS
In Table 5 all the complications, operative, perioperative, and late, are summarized; the last ones are of a mechanical and surgical nature. All of the operative complications occurred during the initial phase in our experience. We operated 19 times for late complications on 14 patients to make a total of 56 surgical procedures in 37 patients (Table 6), with a reoperation rate of 0.38 (14137). Thirty-three patients, presently, are “dry” during the day (90% of successes) and empty their bladders by abdominal straining periodically every 21/2 to 3 hours; 22 patients (59%) are dry also during the night (Table 6). Radiologic and urodynamic follow-up were done periodically after a minimum of 1 year or more in 34 patients. In all but two (Table 7) we found a normal upper urinary tract and no important postoperative changes in the urodynamic controls (Figs 3,4, and 5). In two patients an upper urinary tract dilatation and renal function deterioration developed. One patient was a preoperative urodynamically borderline case, with reduced vesicle capacity and compliance, and refused bladder augmentation. The other developed an urethral stricture, unrecognized because he didn’t present himself for follow-up for 3 years. DISCUSSION
In our experience about 54% of the patients with neuropathic bladder older than 12 to 13 years are dry
From the Department of Pediatric Surgery and Regional Center for Spina Bifida, Regional Hospital, Vicenza. Italy. Date accepted: June 18. 1991. Address reprint requests to G. Belloli. MD, Department of Pediattic Surgery, Regional Hospital. 36100 Vicenza, Italy. Copyright o 1992 by W B. Saunders Company 0022-34681921271 I-0022$03.00l0 1461
BELLOLI, CAMPOBASSO,
1462
Table 2. Details of Patients
Table 1. Indications for Artificial Sphincter Implantation l
35 males
Impossibility of controlling incontinence by other conservative 37 patients
methods l
l
[
2 females
Patients with nearly complete somatic development (> 11 to 12
Age: from 13 to 19 yr
years old)
Myelodysplasia: 33 cases
Patients with a valid IQ, psychologically motivated, not psycho-
Partial sacral agenesis: 3 cases
logically weak
After pelvic surgery: 1 case
l
Good physical condition for use of the prostesis
l
Absence of urological complications, or only complications of
l
“Acceptable” MCC and bladder compliance, absence of detru-
modest entity, easily controlled or treated sor hyperreflexia or easy pharmacological control 0 Nonobstructed bladder voiding without residual urine or with minimal residual
AND MERCURELLA
Table 3. Preoperative Treatment Oxybutynin chloride (“Ditropan”): 35 cases (0.3 to 0.5 mg/kg/d: maximum, 20 mg/d) External transurethral sphincterotomy: 35 cases (males) (6 to 8 wk prior to implantation) Bladderflap urethroplasty: 1 case (female) Antibiotic prophylaxis (parenteral and local) (1 day prior to surgery)
Table 4. Characteristics of the Sphincter AS 792: 2 Cases (both substituted with model AS 800) AS 800: 35 cases Balloon’s pressure 21 cases: 61-70 cm HZ0 12 cases: 71-80 cm H,O 4 cases: 51-60 cm H,O Fig 1. “ideal” urodynamics for artificial urinary sphincter of a patient with neuropathic urinary incontinence. Arrows show urine loss. Patient is in supine position. Bladder filling rate was 10 mL/ min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
Site of the cuff Bladder neck: 33 cases Bulbous urethra: 4 cases Primary deactivation in all the cases Activation after about 3 weeks; after 2 months in 2 patients with associated bladder augmentation
Table 5. Complications Operative and perioperative Lesion of the bladder neck (1) Lesion of anterior wall of the rectum (1) Scrotal hematoma (2) Late Blocked control-assemblies (AS 792) (2) Blocked control-pumps (AS 800) (7) Kinked tubes (4) Lesion of the cuffs (2) Malposition of the balloons (2) Upward displacement of the control-pump (1) Infection (1)
Table 6. Results “Dry” during the day (they
33/37 (go%)*
empty the bladder every 2.5 to 3 h) Failure
4 (2 UUT dilatation, 1 suppressiont, 1 lost at followup)
No. of surgical procedures Fig 2. Urodynamic record (A) before and (B) after treatment with oxybutynin chloride in a candidate for implantation of artificial urinary sphincter. Arrows show urine loss. Patient is in supine position. Bladder filling rate was 10 mL/min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
56
(19 reoperations: 14 patients) NOTE. Follow-up from 1 yr to 8.5 yr (mean, 4.5 yr).
l59% of the patients are “dry” also during the night. tPatient with associated bladder augmentation.
NEUROPATHIC URINARY INCONTINENCE
Table 7. Long-Term Results UUT: Renal function
32 normal 2 dilatation 32 normal 2 deteriorated
Postoperative urodynamic study No important modifications in 32 UPP (at the site of the cuff): 45 to 50 cm H20
during the day with conservative management involving intermittent vesical catheterization or scheduled voiding usually associated with pharmacological treatment9 In our opinion and experience at least another 25% to 30% of patients can become dry with surgical treatment. This includes implantation of an artificial urinary sphincter with or without bladder augmentation1-12and procedures on the bladder neck,i”J4 sling procedures,i5J6 use of Mitrofanoffs principle; these last procedures associated or not with bladder augmentation and with necessity of intermittent catheterization.2,1’ Our experience with artificial sphincters in
Fig 4. (A) Urodynamics of a patient before implantation of an artificial urinary sphincter. Arrows shown urine loss. (B) Urodynamics of the same patient 6 years after implantation. Small arrows show opening of urinary sphincter and urinary flow before Valsalva’s maneuver. Patient is in the supine position, Bladder filling rate was 10 mL/min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
the treatment of pediatric neuropathic bladder is rather limited and our follow-up is not too long; however, it has been long enough to provide reliable results. These results lead us believe that use of an
Fig 3. IVP of a patient 4 years after implantation urinary sphincter.
of an artificial
Fig 5. Urethral pressure profile of a patient with closed artificial urinary sphincter. The site of cuff was at the bladder neck; the balloons’ pressure was 61 to 70 cm H20.
1464
BELLOLI, CAMPOBASSO,
artificial urinary sphincter in the surgical treatment of neurogenic urinary incontinence is, without a doubt, an effective method.2,3,11 In our opinion accurate screening of cases and a precise surgical procedure are the best ways to obtain a high success rate. Use of enterocystoplasty can broaden the indications for implant of the prosthesis, even if it is predictable that the success rate in these cases will not be so high. It is obvious that the presence of an artificial prosthesis will always be a great question mark in the evaluation of long-term results because it can obviously develop mechanical complications at any moment. Recently Barrett and Parulkar reported that the mean number of secondary procedures in their series was 0.56 at 3 years.” Similarly, the
AND MERCURELLA
reoperation rate was 0.35 in the experience of Gonzales et a1,180.55 in 11 pubertal boys controlled for prostatic development and sexual function by Jumper et al,lg and 0.56 in 39 children operated on by Grein and Schreiter.20 Most of these revisions were a result of mechanical failure. For this reason, even if a well-functioning artificial sphincter drammatically changes the behaviour of these adolescents and permits a normal social life, we believe that the hydraulic system of the latest and improved model should be further perfected. At the same time we believe that the adolescents with an artificial sphincter must be monitored carefully and indefinitively with at least an annual assessment of the upper tract and a periodic semiannual urodynamic evaluation.
REFERENCES 1. Belloli G, Campobasso P: Trattamento dell’incontinenza urinaria con sfintere artificiale nelle vesciche neuropatiche. Presented at the meeting “Urodynamics 84,” Milan, Italy, October 1984 2. Hanna MK: Artificial urinary sphincter for incontinent children. Urology 18:370-373, 1981 3. Mitchell ME, Rink RC: Experience with the artificial urinary sphincter in children and young adults. J Pediatr Surg 18:700-705, 1983 4. Mollard P. Meunier P, Berard C, et al: Treatment de I’incontinence urinaire d’origine neurologique chez I’enfant et l’adolescent. J Urol (Paris) 90:227-236, 1984 5. Scott FB, Bradley WE, Timm GW: Treatment of urinary incontinence by implantable prostetic sphincter. Urology 1:252259.1973 6. Belloli G, Salano F, Campobasso P: Treatment of urinary incontinence with artificial urinary sphincter in pediatric neuropathic bladder. Presented at the meeting of the International Congress of BAPS. Wien, Austria, July 1985 7. Belloli G: II trattamento dell’incontinenza urinaria nella vescica neuropatica con sfintere urinario artificiale. Presented at the first National Congress of the Italian Society for Pediatric Urology, Vicenza, Italy, April 1985 8. Belloli G, Bedogni L, Musi 1: L’incontinenza urinaria nella vescica neuropatica del bambino: Trattamento con applicazione di sfintere urinario artificiale. Med Surg Pediatr 7:685-690, 1985 9. Belloli G: Fisiopatologia dell’incontinenza urinaria di natura neuropatica e trattamento, in Belloli G (ed): Sequele e Problematiche de1 Bambino e dell’Adolescente con Spina Bifida. Vicenza, Italy, CEDIV. 1990, pp 125-147 10. Furlow WL, Barret DM: Management of complicated sphinc-
ter incontinence: artificial urinary sphincter, in Barret DM, Wein AJ (eds): Controversies in Nemo-Urology. New York, NY, Churchill Livingstone, 1984, p 407 11. Scott BF, Fisham JJ, Shabsig R: The impact of the artificial urinary sphincter in the neurogenic bladder on the upper urinary tract. J Urol 136:636-642,1986 12. Furlow WL: The artificial genitourinary sphincter. Proceedings of VIII International Congress of Nephrology. Montreal, Canada, 1978, p 409 13. Rink RC, Mitchell ME: Bladder neck/urethral reconstruction in neuropathic bladder. Dial Pediatr Urol 10:5, 1987 14. Kropp KA, Angwafo FF: Urethral lengthening and reimplantation for neurogenic incontinence in children. J Urol 135:533-536, 1986 15. McGuire FJ, Lytton B: Pubovaginalis sling procedure for the management of stress urinary incontinence. J Urol119:82-84,1978 16. Bauer SB, Peters CA, Colodny AH, et al: The use of rectus fascia to manage urinary incontinence. J Urol 142:516-519, 1989 17. Barrett DM, Parulkar BG: The artificial sphincter (AS 800). Experience in children and young adults. Urol Clin North Am 16:119-132, 1989 18. Gonzales R, Koleilat N, Austin C, et al: The artificial sphincter AS 800 in congenital urinary incontinence. J Urol 142:512-515, 1989 19. Jumper BM, McLorie GA, Churchill BM, et al: Effects of the artificial urinary sphincter on prostatic development and sexual function in pubertal boys with meningomyelocele. J Urol 144:438442,199O 20. Grein U, Schreiter F: Le sphincter artificial chez I’enfant. J Urol (Paris) 96:93-96,199O
Urinary incontinence,
neuropathic,
artificial
0
VER THE LAST several years there has been growing experience with the use of artificial sphincters in the treatment of neurologic urinary incontinence.1-5 In this paper we report our experience in the management of neurophatic urinary incontinence with an artificial sphincter. MATERIALS
AND METHODS
The indications for implantation of an artificial urinary sphincter in the neuropathic bladder have been summarized in Table 1. It is obvious that one should look for every possible way of obtaining an appreciable “continence” with nonoperative methods, such as scheduled voiding or intermittent vesical catheterization usually associated with pharmacologic treatment, and the patients should be able to manage the prosthesis as well. In our experience the “ideal” neuropathic bladder suitable for implantation must be areflexic, with a normal or only slightly reduced compliance. and with a cystometric capacity greater than 200 to 2.50mL (Fig 1). It is also important that bladder emptying be relatively easy and without residual.h-“’ Of the 216 patients older than the age of 10, out of a total of 451 neuropathic bladders, we only found ideal urodynamic conditions in about 15% of the cases. However, a detrusor hyperreflexia or a reduced vesical capacity and/or compliance can be ameliorated with appropriate pharmacological treatment (Fig 2). From June 1982 to November 1990,37 patients, aged between 13 and 19 years, were treated with implantation of an artificial urinary sphincter in our department. Thirty-five were male and two female. In 33 cases myelomeningocele was the cause, and in the other three a partial sacral agenesis; the neuropathic bladder of the remaining case was the consequence of pelvic surgery (Table 2). Preoperative treatment involved pharmacological treatment with oxybutynin chloride at the indicated doses and continued even after the operation, transurethral sphincterotomy. possibly at JournalofPediatric
Surgery, Vol27, No 11 (November), 1992: pp 1461-1464
and A. Mercurella
Italy
hours 2 and 10 in all males, bladder flap urethroplasty in one girl and antibiotic prophylaxis 1 day before surgery (Table 3). In the first 2 cases we applied model AS 792 (AMS, Minnetonka, MN); both these sphincters were substituted with the last model (AS 800). In the other cases model AS 800 was used, with all improvements introduced over the past years. The cuff was placed at the bladder neck in 33 cases and in 4 cases, with a previous operation on the neck, at the urethral bulb (Table 4). Obviously in these last cases, the lower pressure balloon was chosen (Table 4). Usually the sphincter was activated about 3 weeks after implantation. RESULTS
In Table 5 all the complications, operative, perioperative, and late, are summarized; the last ones are of a mechanical and surgical nature. All of the operative complications occurred during the initial phase in our experience. We operated 19 times for late complications on 14 patients to make a total of 56 surgical procedures in 37 patients (Table 6), with a reoperation rate of 0.38 (14137). Thirty-three patients, presently, are “dry” during the day (90% of successes) and empty their bladders by abdominal straining periodically every 21/2 to 3 hours; 22 patients (59%) are dry also during the night (Table 6). Radiologic and urodynamic follow-up were done periodically after a minimum of 1 year or more in 34 patients. In all but two (Table 7) we found a normal upper urinary tract and no important postoperative changes in the urodynamic controls (Figs 3,4, and 5). In two patients an upper urinary tract dilatation and renal function deterioration developed. One patient was a preoperative urodynamically borderline case, with reduced vesicle capacity and compliance, and refused bladder augmentation. The other developed an urethral stricture, unrecognized because he didn’t present himself for follow-up for 3 years. DISCUSSION
In our experience about 54% of the patients with neuropathic bladder older than 12 to 13 years are dry
From the Department of Pediatric Surgery and Regional Center for Spina Bifida, Regional Hospital, Vicenza. Italy. Date accepted: June 18. 1991. Address reprint requests to G. Belloli. MD, Department of Pediattic Surgery, Regional Hospital. 36100 Vicenza, Italy. Copyright o 1992 by W B. Saunders Company 0022-34681921271 I-0022$03.00l0 1461
BELLOLI, CAMPOBASSO,
1462
Table 2. Details of Patients
Table 1. Indications for Artificial Sphincter Implantation l
35 males
Impossibility of controlling incontinence by other conservative 37 patients
methods l
l
[
2 females
Patients with nearly complete somatic development (> 11 to 12
Age: from 13 to 19 yr
years old)
Myelodysplasia: 33 cases
Patients with a valid IQ, psychologically motivated, not psycho-
Partial sacral agenesis: 3 cases
logically weak
After pelvic surgery: 1 case
l
Good physical condition for use of the prostesis
l
Absence of urological complications, or only complications of
l
“Acceptable” MCC and bladder compliance, absence of detru-
modest entity, easily controlled or treated sor hyperreflexia or easy pharmacological control 0 Nonobstructed bladder voiding without residual urine or with minimal residual
AND MERCURELLA
Table 3. Preoperative Treatment Oxybutynin chloride (“Ditropan”): 35 cases (0.3 to 0.5 mg/kg/d: maximum, 20 mg/d) External transurethral sphincterotomy: 35 cases (males) (6 to 8 wk prior to implantation) Bladderflap urethroplasty: 1 case (female) Antibiotic prophylaxis (parenteral and local) (1 day prior to surgery)
Table 4. Characteristics of the Sphincter AS 792: 2 Cases (both substituted with model AS 800) AS 800: 35 cases Balloon’s pressure 21 cases: 61-70 cm HZ0 12 cases: 71-80 cm H,O 4 cases: 51-60 cm H,O Fig 1. “ideal” urodynamics for artificial urinary sphincter of a patient with neuropathic urinary incontinence. Arrows show urine loss. Patient is in supine position. Bladder filling rate was 10 mL/ min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
Site of the cuff Bladder neck: 33 cases Bulbous urethra: 4 cases Primary deactivation in all the cases Activation after about 3 weeks; after 2 months in 2 patients with associated bladder augmentation
Table 5. Complications Operative and perioperative Lesion of the bladder neck (1) Lesion of anterior wall of the rectum (1) Scrotal hematoma (2) Late Blocked control-assemblies (AS 792) (2) Blocked control-pumps (AS 800) (7) Kinked tubes (4) Lesion of the cuffs (2) Malposition of the balloons (2) Upward displacement of the control-pump (1) Infection (1)
Table 6. Results “Dry” during the day (they
33/37 (go%)*
empty the bladder every 2.5 to 3 h) Failure
4 (2 UUT dilatation, 1 suppressiont, 1 lost at followup)
No. of surgical procedures Fig 2. Urodynamic record (A) before and (B) after treatment with oxybutynin chloride in a candidate for implantation of artificial urinary sphincter. Arrows show urine loss. Patient is in supine position. Bladder filling rate was 10 mL/min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
56
(19 reoperations: 14 patients) NOTE. Follow-up from 1 yr to 8.5 yr (mean, 4.5 yr).
l59% of the patients are “dry” also during the night. tPatient with associated bladder augmentation.
NEUROPATHIC URINARY INCONTINENCE
Table 7. Long-Term Results UUT: Renal function
32 normal 2 dilatation 32 normal 2 deteriorated
Postoperative urodynamic study No important modifications in 32 UPP (at the site of the cuff): 45 to 50 cm H20
during the day with conservative management involving intermittent vesical catheterization or scheduled voiding usually associated with pharmacological treatment9 In our opinion and experience at least another 25% to 30% of patients can become dry with surgical treatment. This includes implantation of an artificial urinary sphincter with or without bladder augmentation1-12and procedures on the bladder neck,i”J4 sling procedures,i5J6 use of Mitrofanoffs principle; these last procedures associated or not with bladder augmentation and with necessity of intermittent catheterization.2,1’ Our experience with artificial sphincters in
Fig 4. (A) Urodynamics of a patient before implantation of an artificial urinary sphincter. Arrows shown urine loss. (B) Urodynamics of the same patient 6 years after implantation. Small arrows show opening of urinary sphincter and urinary flow before Valsalva’s maneuver. Patient is in the supine position, Bladder filling rate was 10 mL/min. EMG, sphincteric electromyography (mean value); PV, bladder pressure; PA, rectal pressure; F, urinary flow; RV, postvoiding residual.
the treatment of pediatric neuropathic bladder is rather limited and our follow-up is not too long; however, it has been long enough to provide reliable results. These results lead us believe that use of an
Fig 3. IVP of a patient 4 years after implantation urinary sphincter.
of an artificial
Fig 5. Urethral pressure profile of a patient with closed artificial urinary sphincter. The site of cuff was at the bladder neck; the balloons’ pressure was 61 to 70 cm H20.
1464
BELLOLI, CAMPOBASSO,
artificial urinary sphincter in the surgical treatment of neurogenic urinary incontinence is, without a doubt, an effective method.2,3,11 In our opinion accurate screening of cases and a precise surgical procedure are the best ways to obtain a high success rate. Use of enterocystoplasty can broaden the indications for implant of the prosthesis, even if it is predictable that the success rate in these cases will not be so high. It is obvious that the presence of an artificial prosthesis will always be a great question mark in the evaluation of long-term results because it can obviously develop mechanical complications at any moment. Recently Barrett and Parulkar reported that the mean number of secondary procedures in their series was 0.56 at 3 years.” Similarly, the
AND MERCURELLA
reoperation rate was 0.35 in the experience of Gonzales et a1,180.55 in 11 pubertal boys controlled for prostatic development and sexual function by Jumper et al,lg and 0.56 in 39 children operated on by Grein and Schreiter.20 Most of these revisions were a result of mechanical failure. For this reason, even if a well-functioning artificial sphincter drammatically changes the behaviour of these adolescents and permits a normal social life, we believe that the hydraulic system of the latest and improved model should be further perfected. At the same time we believe that the adolescents with an artificial sphincter must be monitored carefully and indefinitively with at least an annual assessment of the upper tract and a periodic semiannual urodynamic evaluation.
REFERENCES 1. Belloli G, Campobasso P: Trattamento dell’incontinenza urinaria con sfintere artificiale nelle vesciche neuropatiche. Presented at the meeting “Urodynamics 84,” Milan, Italy, October 1984 2. Hanna MK: Artificial urinary sphincter for incontinent children. Urology 18:370-373, 1981 3. Mitchell ME, Rink RC: Experience with the artificial urinary sphincter in children and young adults. J Pediatr Surg 18:700-705, 1983 4. Mollard P. Meunier P, Berard C, et al: Treatment de I’incontinence urinaire d’origine neurologique chez I’enfant et l’adolescent. J Urol (Paris) 90:227-236, 1984 5. Scott FB, Bradley WE, Timm GW: Treatment of urinary incontinence by implantable prostetic sphincter. Urology 1:252259.1973 6. Belloli G, Salano F, Campobasso P: Treatment of urinary incontinence with artificial urinary sphincter in pediatric neuropathic bladder. Presented at the meeting of the International Congress of BAPS. Wien, Austria, July 1985 7. Belloli G: II trattamento dell’incontinenza urinaria nella vescica neuropatica con sfintere urinario artificiale. Presented at the first National Congress of the Italian Society for Pediatric Urology, Vicenza, Italy, April 1985 8. Belloli G, Bedogni L, Musi 1: L’incontinenza urinaria nella vescica neuropatica del bambino: Trattamento con applicazione di sfintere urinario artificiale. Med Surg Pediatr 7:685-690, 1985 9. Belloli G: Fisiopatologia dell’incontinenza urinaria di natura neuropatica e trattamento, in Belloli G (ed): Sequele e Problematiche de1 Bambino e dell’Adolescente con Spina Bifida. Vicenza, Italy, CEDIV. 1990, pp 125-147 10. Furlow WL, Barret DM: Management of complicated sphinc-
ter incontinence: artificial urinary sphincter, in Barret DM, Wein AJ (eds): Controversies in Nemo-Urology. New York, NY, Churchill Livingstone, 1984, p 407 11. Scott BF, Fisham JJ, Shabsig R: The impact of the artificial urinary sphincter in the neurogenic bladder on the upper urinary tract. J Urol 136:636-642,1986 12. Furlow WL: The artificial genitourinary sphincter. Proceedings of VIII International Congress of Nephrology. Montreal, Canada, 1978, p 409 13. Rink RC, Mitchell ME: Bladder neck/urethral reconstruction in neuropathic bladder. Dial Pediatr Urol 10:5, 1987 14. Kropp KA, Angwafo FF: Urethral lengthening and reimplantation for neurogenic incontinence in children. J Urol 135:533-536, 1986 15. McGuire FJ, Lytton B: Pubovaginalis sling procedure for the management of stress urinary incontinence. J Urol119:82-84,1978 16. Bauer SB, Peters CA, Colodny AH, et al: The use of rectus fascia to manage urinary incontinence. J Urol 142:516-519, 1989 17. Barrett DM, Parulkar BG: The artificial sphincter (AS 800). Experience in children and young adults. Urol Clin North Am 16:119-132, 1989 18. Gonzales R, Koleilat N, Austin C, et al: The artificial sphincter AS 800 in congenital urinary incontinence. J Urol 142:512-515, 1989 19. Jumper BM, McLorie GA, Churchill BM, et al: Effects of the artificial urinary sphincter on prostatic development and sexual function in pubertal boys with meningomyelocele. J Urol 144:438442,199O 20. Grein U, Schreiter F: Le sphincter artificial chez I’enfant. J Urol (Paris) 96:93-96,199O