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Review
.2016 Feb;5(1):145-57.
doi: 10.3978/j.issn.2223-4683.2015.12.11.

Management options for sphincteric deficiency in adults with neurogenic bladder

Affiliations
Review

Management options for sphincteric deficiency in adults with neurogenic bladder

Jeremy B Myers et al. Transl Androl Urol.2016 Feb.

Abstract

Neurogenic bladder is a very broad disease definition that encompasses varied disease and injury states affecting the bladder. The majority of patients with neurogenic bladder dysfunction do not have concomitant intrinsic sphincteric deficiency (ISD), but when this occurs the challenges of management of urinary incontinence from neurogenic bladder are compounded. There are no guidelines for surgical correction of ISD in adults and most of the literature on treatment of the problem comes from treatment of children with congenital diseases, such as myelomeningocele. Our goal, in this review, is to present some of the common surgical options for ISD [including artificial urinary sphincters, bladder slings, bladder neck reconstruction (BNR) and urethral bulking agents] and the evidence underlying these treatments in adults with neurogenic bladder.

Keywords: Adult; deficiency; intrinsic; neurogenic bladder; sphincter; surgery.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
A case of a 19-year-old male with myelomenigocele, illustrating ambiguity about the need for bladder neck reconstruction. (A) An open bladder neck with incompetent internal sphincter pre-operatively; (B) a post-operative computed tomographic cystogram showing the appearance of the Young-Dees bladder neck reconstruction, which appears to be a fixed small caliber fistula; (C) pooling of contrast in the prostatic fossa between the bladder neck repair and the dyssynergic external sphincter.
Figure 2
Figure 2
The use of modified AUS connected to a tissue expander with the goal of using the least amount of fixed resistance necessary to prevent incontinence. (A) A tissue expander being prepared to be connected to an AUS reservoir and cuff; (B) the complete “Y” connection between the tissue expander (under the skin of the abdominal wall) and the reservoir and cuff of the AUS. AUS, artificial urinary sphincter.
Figure 3
Figure 3
Placement of a modified Virtue sling (Coloplast, Minnesota, USA). (A) Exposure of the bulbospongiosus muscle overlying the urethra; (B) placement of the transobturator arms from in to out; (C) removal of the suprapubic arms to prevent obstruction of passage of a rigid cystoscope into the bladder; (D) preparing for tensioning the sling; (E) tight coaptation of the sling within the urethra.
Figure 4
Figure 4
Young–Dees–Leadbetter repair—involves lengthening the urethra, often some narrowing up to or including the trigone, with excision of bladder mucosa and wrapping of the repair with detrusor muscle leaflets.
Figure 5
Figure 5
Kropp bladder neck reconstruction—a lengthened urethra is constructed of an anterior plate of the bladder and the urethra is transected from the bladder neck. The elongated urethra is then tunneled underneath the posterior bladder mucosa creating a flap valve.
Figure 6
Figure 6
Pippi Salle bladder neck repair—a lengthened urethra is constructed of a composite of a posterior and anterior strip of bladder. The mucosa of the lateral edges of the posterior strip of bladder is freed and brought over the neo-urethra creating a mucosal tunnel and a flap valve.
See this image and copyright information in PMC

References

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    1. Khoury AE, Dave S, Peralta-Del Valle MH, et al. Severe bladder trabeculation obviates the need for bladder outlet procedures during augmentation cystoplasty in incontinent patients with neurogenic bladder. BJU Int 2008;101:223-6. - PubMed
    1. Medel R, Ruarte AC, Herrera M, et al. Urinary continence outcome after augmentation ileocystoplasty as a single surgical procedure in patients with myelodysplasia. J Urol 2002;168:1849-52. - PubMed
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