Long-term Follow-up of Bladder Outlet Procedures in Children with Neurogenic Urinary Incontinence - Beyond the Abstract

Achieving continence in children with urinary incontinence is a challenge, especially in incontinence secondary to neurogenic sphincteric deficiency. When non-surgical therapy, such as anticholinergic medication and intermittent catheterization fails a surgical therapy could be considered. Surgical options to increase the bladder outlet resistance are: bladder neck sling, bladder neck reconstruction, artificial urinary sphincter and injection of bulking agents.  In the past twenty-five years, our institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstruction. This study evaluates the long-term outcome of bladder outlet procedures in children with neurogenic urinary incontinence.

A bladder neck reconstruction increases bladder outlet resistance by lengthening and narrowing the urethra with tubularization of the trigone. The bladder neck sling procedure was based on coaptation, elevation, and narrowing of the urethra by a suspension of the bladder neck by placing an autologous rectus fascial strip around the bladder neck and fixing the ends to the pubic symphysis. The choice of a bladder outlet procedure with or without concomitant surgery such as bladder augmentation and continent catheterizable urinary channel is influenced by the patient's needs, gender, and bladder function and the surgeon's preference. A bladder outlet procedure was combined with bladder augmentation if a low compliant bladder and/or a small capacity insufficiently responsive to anticholinergics was seen.
In this study, 60 children with mainly myelomeningocele as etiology of neurogenic urinary incontinence, underwent a bladder outlet procedure. Dry rate within one year was 38.3%. After a median follow-up of 10.4 years, continence rate was modest to good (77%, without urinary leakage for a minimum of 4 hours), although re-intervention was required in 42% to achieve this result.

In view of the young patient population, awareness of the outcome on the long term is important, but scientific reports are sparse. In the discussion, a summary of the literature is given. Those long-term results are valuable for patient counseling and to create awareness in patients and parents about what to expect. Future studies should add validated patient-reported outcome measurements to evaluate the effect on symptoms and quality of life.

Written by: Toscane C. Noordhoff,1 Joop van den Hoek,1 Marit J. Yska,1 Katja P. Wolffenbuttel,1 Bertil F.M. Blok,1 and Jeroen R. Scheepe1

1. Department of Urology and Pediatric Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands

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