EDITORIAL COMMENT
1
tion is performed the pedicle for the bowel segment used in augmentation may also be placed between the bladder neck and urethral stump to separate them. 5 We concur that these technical considerations are needed to minimize the chance of a urethral fistula. However, fistula still occurred in our patients who underwent the modified bladder neck closure (the numbers were too small to determine statistical signifi- cance in outcome between the 2 techniques). We believe that despite optimal surgical techniques, fistula can develop when the patient is not compliant with a postoperative catheter- ization schedule. Furthermore, bladder outlet closure inevitably alters blad- der dynamics and can contribute to development of urinary incontinence postoperatively. Decreased bladder capacity re- quiring augmentation developed in 3 of our 4 patients with incontinence via the abdominal stoma. Thus, all of our pa- tients who underwent bladder neck closure also underwent augmentation. Increased bladder capacity from augmenta- tion allows storage of urine at low pressure and prevents the development of hydronephrosis in patients who have under- gone bladder neck closure. Finally, we observed that compliance with intermittent catheterization postoperatively is crucial to the success of bladder neck closure. Our patients with a fistula postopera- tively were older and performed their own catheterization rather than being dependent on their parents. While evi- dence of urethral fistula developed soon after surgery in some patients, others had a significant period of dryness before incontinence occurred. Failure to empty the bladder regu- larly may have promoted the development of fistula. The effects of compliance with catheterization can be observed in those patients with leakage via the abdominal stoma after being completely dry for more than 1 year. In these patients no change in bladder dynamics could be detected but leakage could be demonstrated if bladder volume exceeded 650 cc. Many of these patients, who were older and performed their own catheterization, admitted to not catheterizing for more than 8 hours. While bladder neck closure is an effective procedure for patients with severe urinary incontinence, it is not without associated complications. Stomal stenosis is a significant problem, occurring in approximately 30% of our patients. Since there is no other access into the bladder, this compli- cation is potentially dangerous leading to bladder perfora- tion. Patients who undergo bladder neck closure should be educated about this problem to prevent acute presentation of inability to catheterize. Interestingly, in some of our patients the continent conduit can act as a “pop-off” valve. However, the conduit should not be depended upon to relieve pressure of the bladder when it is over distended. Bladder stone for- mation is another potential complication of bladder neck closure. This problem is related in part to inefficient elimi- nation of mucous formation via the continent conduit, 3 and compliance with frequent emptying and irrigation of the bladder. CONCLUSIONS Bladder neck closure is an effective method of achieving continence, especially in those children who have previously undergone multiple failed bladder outlet surgeries. However, its success depends on technical considerations, recognition of changes in bladder dynamics and patient compliance with regular intermittent catheterization. Compliance issues should be suspected in patients with late onset of urinary incontinence following bladder neck closure. The procedure is safe as long as patients and their families are aware of its potential complications, including stomal stenosis and blad- der stones. REFERENCES 1. Kryger, J. V., Gonza ´lez, R. and Barthold, J. S.: Surgical man- agement of urinary incontinence in children with neurogenic sphincteric incompetence. J Urol, 163: 256, 2000 2. Reid, R., Schneider, K. and Fruchtman, B.: Closure of the blad- der neck in patients undergoing continent vesicostomy for urinary incontinence. J Urol, 120: 40, 1978 3. Khoury, A. E., Agarwal, S. K., Ba ¨gli, D., Merguerian, P. and McLorie, G. A.: Concomitant modified bladder neck closure and Mitrofanoff urinary diversion. J Urol, 162: 1746, 1999 4. Macedo, A., Jr. and Srougi, M.: A continent catheterizable ileum- based reservoir. BJU Int, 85: 160, 2000 5. Ullrich, N. F. E. and Wessells, H.: A technique of bladder neck closure combining prostatectomy and intestinal interposition for unsalvageable urethral disease. J Urol, 167: 634, 2002 6. Borzi, P. A., Bruce, J. and Gough, D. C.: Continent cutaneous diversions in children: experience with the Mitrofanoff proce- dure. Br J Urol, 70: 669, 1992 7. Woodhouse, C. R. and Gordon, E. M.: The Mitrofanoff principle for urethral failure. Br J Urol, 73: 55, 1994 8. Jayanthi, V. R., Churchill, B. M., McLorie, G. A. and Khoury, A. E.: Concomitant bladder neck closure and Mitrofanoff di- version for the management of intractable urinary inconti- nence. J Urol, 154: 886, 1995 9. Hensle, T. W., Kirsch, A. J., Kennedy, W. A., II and Reiley, E. A.: Bladder neck closure in association with continent urinary diversion. J Urol, 154: 883, 1995 10. Hoebeke, P., De Kuyper, P., Goeminne, H., Van Laecke, E. and Everaert, K.: Bladder neck closure for treating pediatric in- continence. Eur Urol, 38: 453, 2000 EDITORIAL COMMENT It is generally believed that bladder neck closure is the final surgery to achieve dryness. The authors report on 20 children with severe urinary incontinence despite multiple bladder outlet proce- dures. This series shows that in the short term only 40% of patients were dry, and morbidity was 60%. Although following additional surgery 85% of patients achieved dryness with longer followup only 40% were completely dry and 47% had leakage through the abdom- inal stoma with loss of the “pop-off” urethral outlet. Other complica- tions were stomal stenosis (30%) and stone formation (40%). The authors are to be congratulated on this sobering report, which confirms the notion that bladder neck closure is not necessarily the final surgery to achieve dryness. There is significant morbidity, and this study supports my personal bias in avoiding this approach except in desperate situations. The relatively high incidence of stone formation (40%) in this series suggests a high rate of noncompliant patients, that is failure to empty and irrigate the urinary reservoir adequately. This series demonstrates that patient compliance is crucial in maintaining continence and preventing fistula formation. Perhaps we need a compliance test before we embark on major reconstructive surgery that requires clean intermittent catheteriza- tion. Moneer K. Hanna 800 River Rd. 2B Cove Lane North North Bergen, New Jersey BLADDER NECK CLOSURE FOR SEVERE URINARY INCONTINENCE 1116
Transcript of EDITORIAL COMMENT
tion is performed the pedicle for the bowel segment used inaugmentation may also be placed between the bladder neckand urethral stump to separate them.5 We concur that thesetechnical considerations are needed to minimize the chanceof a urethral fistula. However, fistula still occurred in ourpatients who underwent the modified bladder neck closure(the numbers were too small to determine statistical signifi-cance in outcome between the 2 techniques). We believe thatdespite optimal surgical techniques, fistula can develop whenthe patient is not compliant with a postoperative catheter-ization schedule.
Furthermore, bladder outlet closure inevitably alters blad-der dynamics and can contribute to development of urinaryincontinence postoperatively. Decreased bladder capacity re-quiring augmentation developed in 3 of our 4 patients withincontinence via the abdominal stoma. Thus, all of our pa-tients who underwent bladder neck closure also underwentaugmentation. Increased bladder capacity from augmenta-tion allows storage of urine at low pressure and prevents thedevelopment of hydronephrosis in patients who have under-gone bladder neck closure.
Finally, we observed that compliance with intermittentcatheterization postoperatively is crucial to the success ofbladder neck closure. Our patients with a fistula postopera-tively were older and performed their own catheterizationrather than being dependent on their parents. While evi-dence of urethral fistula developed soon after surgery in somepatients, others had a significant period of dryness beforeincontinence occurred. Failure to empty the bladder regu-larly may have promoted the development of fistula. Theeffects of compliance with catheterization can be observed inthose patients with leakage via the abdominal stoma afterbeing completely dry for more than 1 year. In these patientsno change in bladder dynamics could be detected but leakagecould be demonstrated if bladder volume exceeded 650 cc.Many of these patients, who were older and performed theirown catheterization, admitted to not catheterizing for morethan 8 hours.
While bladder neck closure is an effective procedure forpatients with severe urinary incontinence, it is not withoutassociated complications. Stomal stenosis is a significantproblem, occurring in approximately 30% of our patients.Since there is no other access into the bladder, this compli-cation is potentially dangerous leading to bladder perfora-tion. Patients who undergo bladder neck closure should beeducated about this problem to prevent acute presentation ofinability to catheterize. Interestingly, in some of our patientsthe continent conduit can act as a “pop-off” valve. However,the conduit should not be depended upon to relieve pressureof the bladder when it is over distended. Bladder stone for-mation is another potential complication of bladder neckclosure. This problem is related in part to inefficient elimi-nation of mucous formation via the continent conduit,3 andcompliance with frequent emptying and irrigation of thebladder.
CONCLUSIONS
Bladder neck closure is an effective method of achievingcontinence, especially in those children who have previouslyundergone multiple failed bladder outlet surgeries. However,its success depends on technical considerations, recognition
of changes in bladder dynamics and patient compliance withregular intermittent catheterization. Compliance issuesshould be suspected in patients with late onset of urinaryincontinence following bladder neck closure. The procedure issafe as long as patients and their families are aware of itspotential complications, including stomal stenosis and blad-der stones.
REFERENCES
1. Kryger, J. V., Gonzalez, R. and Barthold, J. S.: Surgical man-agement of urinary incontinence in children with neurogenicsphincteric incompetence. J Urol, 163: 256, 2000
2. Reid, R., Schneider, K. and Fruchtman, B.: Closure of the blad-der neck in patients undergoing continent vesicostomy forurinary incontinence. J Urol, 120: 40, 1978
3. Khoury, A. E., Agarwal, S. K., Bagli, D., Merguerian, P. andMcLorie, G. A.: Concomitant modified bladder neck closureand Mitrofanoff urinary diversion. J Urol, 162: 1746, 1999
4. Macedo, A., Jr. and Srougi, M.: A continent catheterizable ileum-based reservoir. BJU Int, 85: 160, 2000
5. Ullrich, N. F. E. and Wessells, H.: A technique of bladder neckclosure combining prostatectomy and intestinal interpositionfor unsalvageable urethral disease. J Urol, 167: 634, 2002
6. Borzi, P. A., Bruce, J. and Gough, D. C.: Continent cutaneousdiversions in children: experience with the Mitrofanoff proce-dure. Br J Urol, 70: 669, 1992
7. Woodhouse, C. R. and Gordon, E. M.: The Mitrofanoff principlefor urethral failure. Br J Urol, 73: 55, 1994
8. Jayanthi, V. R., Churchill, B. M., McLorie, G. A. and Khoury,A. E.: Concomitant bladder neck closure and Mitrofanoff di-version for the management of intractable urinary inconti-nence. J Urol, 154: 886, 1995
9. Hensle, T. W., Kirsch, A. J., Kennedy, W. A., II and Reiley, E. A.:Bladder neck closure in association with continent urinarydiversion. J Urol, 154: 883, 1995
10. Hoebeke, P., De Kuyper, P., Goeminne, H., Van Laecke, E. andEveraert, K.: Bladder neck closure for treating pediatric in-continence. Eur Urol, 38: 453, 2000
EDITORIAL COMMENT
It is generally believed that bladder neck closure is the finalsurgery to achieve dryness. The authors report on 20 children withsevere urinary incontinence despite multiple bladder outlet proce-dures. This series shows that in the short term only 40% of patientswere dry, and morbidity was 60%. Although following additionalsurgery 85% of patients achieved dryness with longer followup only40% were completely dry and 47% had leakage through the abdom-inal stoma with loss of the “pop-off” urethral outlet. Other complica-tions were stomal stenosis (30%) and stone formation (40%).
The authors are to be congratulated on this sobering report, whichconfirms the notion that bladder neck closure is not necessarily thefinal surgery to achieve dryness. There is significant morbidity, andthis study supports my personal bias in avoiding this approachexcept in desperate situations. The relatively high incidence of stoneformation (40%) in this series suggests a high rate of noncompliantpatients, that is failure to empty and irrigate the urinary reservoiradequately. This series demonstrates that patient compliance iscrucial in maintaining continence and preventing fistula formation.Perhaps we need a compliance test before we embark on majorreconstructive surgery that requires clean intermittent catheteriza-tion.
Moneer K. Hanna800 River Rd.2B Cove Lane NorthNorth Bergen, New Jersey
BLADDER NECK CLOSURE FOR SEVERE URINARY INCONTINENCE1116
