Surgical Management of Neurogenic Sphincter Incompetence in Children

Abstract

We report on the results of a literature review regarding the indications and results of operations to increase bladder outlet resistance to achieve dryness in children with neurogenic sphincter incompetence (NSBD). The relative advantages and disadvantages of injection of bulking agents, periurethral slings, bladder neck reconfiguration, artificial sphincters, and bladder neck closure based on a literature review and our combined clinical experience are discussed. Based on this review and our experience, we propose that periurethral injection of bulking agents is not justified as a primary treatment. Likewise, operations that reconfigure the bladder neck are not very useful since most patients also require bladder augmentation and an abdominal catheterizable channel. Bladder neck slings with autologous tissues are effective, mostly in females bur in the majority of patients a bladder augmentation is necessary. There is a role also for implantation of artificial urinary sphincters but when done as an isolated procedure, close monitoring to detect possible detrusor changes is needed. Bladder neck closure is an effective measure when other methods have failed.

Keywords: artificial sphincters; bladder neck closure; bladder neck reconstruction; children; injection of bulking agents; neurogenic bladder; urethral slings; urinary incontience.

Figure 1

Schematic grouping of causes of neurogenic incontinence based on urodynamic findings [adapted from González and Guzmán (2)]. (A) Detrusor and sphincter mechanisms hypoactive. (B) Detrussor hyperactive or hypocompliant, sphincter hypoactive. (C) Detrusor hypoactive, sphincter hyperactive. (D) Detrusor and sphincter hyperactive (dyssynergic). Reproduced with permission from Dr. Quek.