Urinary tract deterioration associated with the artificial urinary sphincter

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

Clinical indications for augmentation in children with neurogenic urinary incontinence following bladder outlet procedures: Results of a 14-year observational study

PURPOSE

We report continence, upper tract changes, and augmentation indications and rates in consecutive patients undergoing bladder outlet surgery without augmentation for neurogenic urinary incontinence.

METHODS

From 2000 to 2007, 37 patients underwent bladder neck sling (BNS), and from 2007 to 2013, 45 patients had Leadbetter/Mitchell bladder neck revision plus sling (LMS), all without augmentation. Mitrofanoff channels were created in all cases. Twenty children with persistent outlet insufficiency underwent bladder neck closure (BNC). All patients had pre- and postoperative urodynamic testing (UD).

RESULTS

Mean follow-up was 60 months after BNS, 38 months after LMS, and 29 months after BNC. Continence (dry, no pads) was achieved significantly more often with LMS versus BNS (66% vs. 37%). There were no significant differences between these patients in preoperative UD % capacity, end filling pressure (EFP), or compliance. Those that became dry had a greater % capacity on postoperative UD, but postoperative EFP was similar between dry and wet LMS and BNS patients. BNC resulted in dryness in 65% of patients, with most incontinence occurring from the Mitrofanoff stoma associated with filling pressures > 40 cm. A total of 10 (12%) children had augmentation, seven after BNC. Clinical indications were end filling pressures > 40 cm plus hydronephrosis ≥ grade 3, and/or persistent incontinence. Need for augmentation was not predicted by preoperative urodynamic parameters. Postoperative UD in those who were augmented showed significantly less % capacity and compliance, and significantly greater EFP, than those not augmented.

CONCLUSIONS

Dryness was achieved in only 33% of BNS versus 66% of LMS and BNC patients. Twelve percent of consecutive children undergoing bladder outlet surgery for neurogenic incontinence developed clinical parameters leading to augmentation. These occurred most often after BNC.

New hydronephrosis and/or vesicoureteral reflux after bladder outlet surgery without augmentation in 75 children with neurogenic bladder

OBJECTIVE

We report new upper tract changes in children after bladder neck (BN) surgery without augmentation for neurogenic incontinence.

MATERIALS AND METHODS

Consecutive children with neurogenic sphincteric incompetency had BN surgery without augmentation. Postoperative renal sonography and fluoroscopic urodynamics were done at 6 months, 12 months, and then annually.

RESULTS

There were 75 patients with mean follow-up of 48 months. Of these, 17 (23%) developed new hydronephrosis (HN) or vesicoureteral reflux (VUR). All HN resolved with medical management, as did 25% of VUR cases. Persistent VUR was treated by dextranomer/hyaluronic acid injection, or re-implantation in two patients undergoing re-operative BN surgery. There was no association between these upper tract changes and end filling pressures (<40 cm vs. >40 cm) or continence status (dry vs. wet).

CONCLUSIONS

Upper tract changes developed in 25% of patients with neurogenic bladders after BN surgery without augmentation during a follow-up of 48 months. All new HN and most new VUR resolved with medical management or minimally invasive intervention. No patient developed upper tract changes requiring augmentation.

Total continence reconstruction using the artificial urinary sphincter and the Malone antegrade continence enema

PURPOSE

Surgical management of children with myelomeningocele addresses 2 aspects of the disease, neurogenic bladder and neurogenic bowel. Results of total continence reconstruction using an artificial urinary sphincter and Malone antegrade continence enema are presented.

MATERIALS AND METHODS

We performed a retrospective chart review of patients who underwent simultaneous artificial urinary sphincter placement and a Malone antegrade continence enema procedure. From 1997 to 2007 a total of 21 patients with myelomeningocele underwent total continence reconstruction using the artificial urinary sphincter. Mean patient age was 10.4 years (range 6 to 22) and mean followup was 4.7 years (range 0.66 to 11.7). Artificial urinary sphincter cuff was placed around the bladder neck. A Malone antegrade continence enema was performed using appendix in 19 patients and cecal based flaps in 2. Two patients underwent concomitant augmentation cystoplasty. Six patients had concomitant Mitrofanoff vesicostomy using split appendix in 4 and Monti tube in 2.

RESULTS

Immediate postoperative complications were observed in 5 patients, including prolonged ileus (2), urinary tract infection (2) and superficial wound dehiscence (1). Seventeen patients (81%) achieved complete urinary continence and 5 were voiding with sphincter cycling. Improvement in urinary continence with dry intervals greater than 3 hours was reported in 2 patients. There were 19 patients (90%) who reported fecal continence, with 2 reporting soiling 1 to 2 times a week. Malone antegrade continence enema stoma stenosis occurred in 3 patients and 2 required revisions. Sixteen patients (76%) achieved complete continence of stool and urine. During followup 2 artificial urinary sphincters were explanted and 8 patients (38%) underwent bladder augmentation.

CONCLUSIONS

Urinary and fecal continence in patients with myelomeningocele is achievable with a single total continence reconstruction procedure using the artificial urinary sphincter and the Malone antegrade continence enema with durable results.

Urologic care of the neurogenic bladder in children

Initial care of newborns with spina bifida centers on preventing bladder and upper tract damage from detrusor leak point pressure of greater than 40 cm H(2)O. The authors recommend using urodynamic-based management to select patients with elevated pressures for anticholinergic therapy and intermittent catheterization (CIC), using diapers and observation with biannual renal sonography for the remainder. At the age of toilet training, children who have urodynamic evidence of uninhibited contractions or rising pressure during filling are started on anticholinergics and CIC, or have their dosage increased until pressures less than 40 cm H(2)O and areflexia are achieved. Sphincter incompetency is diagnosed in incontinent children with pressures less than 40 cm H(2)O and areflexia or stress incontinence. Augmentation is indicated in patients with hydronephrosis or reflux and end-filling pressures or DLPP less than 40 cm H(2)O despite medical management to the point of patient tolerance. A minority of patients, not yet well-defined, will also need augmentation after bladder outlet surgery for similar postoperative indications.

Nocturnal bladder emptying for reversing urinary tract deterioration due to neurogenic bladder

Although daytime clean intermittent catheterization with urotropic medications is often sufficient therapy to relieve urinary retention and elevated intravesical pressures, neglecting the bladder affected by neuropathy or other significant pathologies during sleeping hours can lead to overdistension of the bladder and its deleterious consequences. The effect of this seemingly inconsequential clean intermittent catheterization interlude for some patients on an ideal daytime-only management protocol can lead to a syndrome of nighttime overdistension of the bladder, which can result in recurrent urinary tract infections, worsened incontinence, decreased bladder compliance and capacity, and progressive hydroureteronephrosis and renal insufficiency. Fortunately, nocturnal bladder emptying has emerged as a specific antidote for the syndrome of nighttime overdistension of the bladder, and because nocturnal bladder emptying can reverse or prevent bladder and upper tract deterioration, it is suggested that conventional therapies performed only during the daytime may have been inadequate for certain subgroups of patients who require a new therapeutic paradigm for their optimal management.

Bladder Neck Sling and Appendicovesicostomy Without Augmentation for Neurogenic Incontinence in Children

PURPOSE

Most children undergoing bladder neck sling for neurogenic urinary incontinence also have undergone bladder augmentation. However, complications from enterocystoplasty and uncertainty regarding its indication during bladder outlet enhancement led us to perform slings without augmentation. Herein we report outcomes in consecutive patients.

MATERIALS AND METHODS

A total of 30 patients with neurogenic bladder underwent tight 360-degree fascial sling wrap around the bladder neck and appendicovesicostomy without augmentation. Indications included detrusor leak point pressure less than 50 cm water and stress urinary incontinence. Urodynamics were obtained in all patients preoperatively, in 26 at a mean of 6 months postoperatively and in 16 at a mean of 24 months postoperatively.

RESULTS

Satisfactory continence defined as 2 or fewer damp pads daily was achieved in 83% of patients with followup of 6 to 60 months (mean 22). Symptomatic hyperreflexia and/or loss of compliance developed in 8 patients postoperatively, which responded to anticholinergics in 7. The remaining patient underwent enterocystoplasty 18 months later, for an augmentation rate of 3%. No patient had hydronephrosis or reflux.

CONCLUSIONS

Evaluated parameters, including bladder capacity and compliance determined during preoperative urodynamics, did not predict the need for augmentation. Satisfactory continence can be achieved for neurogenic bladder by sling without enterocystoplasty.

Endourethral injection of bulking agents for urinary incontinence in children

OBJECTIVE

To assess the early and late outcome of endourethral injection with bulking agents in children with urinary incontinence (a neuropathic bladder or exstrophy-epispadias complex), by reviewing our experience over a 5-year period.

PATIENTS AND METHODS

The records of 15 children (10 boys) were reviewed retrospectively; 10 had spina bifida and a neurogenic bladder, four had a neurogenic bladder from other causes and one had epispadias. All children had a stable low-pressure detrusor and a compliant bladder with sphincteric weakness on preoperative urodynamic testing. Four children had undergone previous enterocystoplasty with a Mitrofanoff stoma, with concomitant urethral lengthening in two and a Goretex trade mark bladder neck sling in two. Three children voided spontaneously while 12 depended on intermittent catheterization. The agent was injected under general anaesthesia in all patients but one, with an endourethral submucosal injection of the bulking agent into four or more points at the junction of the bladder neck and proximal urethra, aiming to obtain visual occlusion of the urethra. The median (range) number of injections was 2 (1-3); five children had one injection, seven had two and three had three. There were no procedure-related complications and most were day-case procedures. Initially PTFE paste was used as the bulking agent, being replaced by bovine collagen or polydimethylsiloxane in the latter half of the series.

RESULTS

At a median (range) follow-up of 28 (11-65) months three children were completely dry after a single injection; there was no change in four and a short-term improvement (median 25 months, range 4 days to 37 months) in eight. After this period all children deteriorated to their original incontinence grade; hence the overall cure rate was three of 15.

CONCLUSION

This experience with a long-term follow-up differs from previously reported high success rates for the endourethral injection of bulking agents for urinary incontinence in children. Despite a short-term benefit, in the long-term this technique was unreliable and often ineffective. Patients and their carers should be given a realistic and guarded prognosis.

Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders

PURPOSE

Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder.

MATERIALS AND METHODS

From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases.

RESULTS

With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%.

CONCLUSIONS

Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.

Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders

PURPOSE

Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak point pressure. In contrast, fascial slings are designed to achieve continence by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic bladder.

MATERIALS AND METHODS

From October 1994 until February 1999, 10 females and 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age was 14 years (range 8 to 18) and all were incontinent despite aggressive medical management. Urodynamic evaluation was performed preoperatively and postoperatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance was only compared in the 12 nonaugmented cases.

RESULTS

With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in mean stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance was unchanged in the nonaugmented group (22.00 versus 26.78 ml/cm. H2O). Four patients (22.22%) remained wet after surgery, of whom 2 were successfully treated with a repeat sling procedure and 1 with collagen injection for an overall continence rate of 94.44%.

CONCLUSIONS

Fascial slings can be effectively used in pediatric patients for neuropathic incontinence. Furthermore, stress urinary incontinence is corrected by increasing the Valsalva or stress leak point pressure with preservation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.

The contemporary role of the artificial urinary sphincter

The artificial urinary sphincter has been in use for more than 25 years as a treatment for urinary incontinence due to intrinsic sphincter deficiency. Recent clinical studies have increased our knowledge concerning its use in children and in adult patient populations. Particularly, more long-term data and data on the combination of the artificial urinary sphincter with reconstructive techniques that utilize the bowel have become available. Some interesting new ideas regarding changes in the design of the artificial urinary sphincter have been advanced.

Normal urodynamics in patients with bladder exstrophy: are they achievable?

PURPOSE

Urodynamic study was performed in patients with exstrophy to determine the effect of bladder neck reconstruction and the ability to achieve normal urodynamics following surgery.

MATERIALS AND METHODS

A total of 30 exstrophy cases at different stages of reconstruction were retrospectively reviewed in terms of bladder capacity, compliance, stability and presence of detrusor contractions following urodynamic study.

RESULTS

Bladder capacity increased from a third predicted volume for age to half after reconstruction. Approximately 80% of patients had compliant and stable bladders before bladder neck reconstruction. Following bladder neck reconstruction approximately half of the patients maintained normal compliance with a smaller number maintaining normal stability. A quarter of patients maintained normal filling dynamics following bladder neck reconstruction, and 19% maintained normal filling and voiding dynamics after reconstruction.

CONCLUSIONS

The majority of closed exstrophy bladders have normal filling dynamics before bladder neck reconstruction. Compliance and stability are impaired following bladder neck reconstruction. Approximately 25% of patients with exstrophy may maintain normal detrusor function following reconstruction. However, less invasive alternatives to the Young-Dees-Leadbetter bladder neck reconstruction should be sought.

The outcome of artificial urinary sphincter placement after a mean 15-year follow-up in a paediatric population

OBJECTIVE

To evaluate the long-term outcome in children who had an artificial urinary sphincter (AUS) placed, after a minimum of 10 years of follow-up.

PATIENTS AND METHODS

The medical records of patients who had an AUS placed at the Children's Hospital of Michigan were reviewed and a telephone questionnaire was then completed by all patients with an AUS currently in place.

RESULTS

Forty-seven children initially had an AUS placed between October 1978 and August 1986; medical records and follow-up were available for 32. After a mean follow-up of 15.4 years, 13 patients had had the AUS removed and 19 currently have an intact AUS. Erosion or infection was responsible for all AUS removals. Possible risk factors for AUS removal were prior AUS erosion, prior bladder neck surgery and a balloon pressure of >70 cmH2O. Eighteen of 19 patients with an intact AUS are dry and seven void volitionally. Revision was the most common reason for additional surgery, but the revision rate has decreased with the most current AS-800 model, to 0.03 revisions per patient-year. Of the 13 patients with an AS-800 model placed after 1987, nine have not required revision. Upper tract changes were mild and uncommon.

CONCLUSION

The AUS is a durable and effective surgical option in the management of neurogenic urinary incontinence, and is the only reliable technique that can preserve volitional voiding. With technical improvements to the AUS and a longer follow-up, the revision rate has decreased. Causes of AUS removal may be preventable with improvements in surgical technique and patient selection. AUS placement should be considered as a first choice for the surgical management of neurogenic sphincteric incompetence.

Upsizing of the artificial urinary sphincter cuff to facilitate spontaneous voiding

OBJECTIVES

Following placement of an artificial urinary sphincter (AUS) in the male child, functional and mechanical alterations can ensue, resulting in an inability to void spontaneously. One possible mechanical etiology in the patient entering puberty is prostatic growth within the fixed mechanical confines of the AUS cuff, resulting in progressive bladder outlet obstruction. Unrecognized infravesical obstruction can, in turn, lead to upper urinary tract deterioration, sepsis, or renal failure. We evaluated the effect of somatic growth and maturation of the male urethra on voiding dynamics in boys with an AUS to specifically determine whether revision of the sphincter cuff (ie, upsizing) is beneficial in restoring the ability to void spontaneously.

METHODS

A retrospective review of 124 children with an AUS was performed. Eleven boys were identified whose bladder neck cuffs were later upsized in an attempt to improve bladder emptying. All boys were prepubertal at the time of original cuff placement. The average interval between the initial operation and cuff upsizing was 5 years.

RESULTS

Following original sphincter placement, 8 patients emptied to completion spontaneously and 3 patients emptied by intermittent catheterization. All eight of the spontaneous voiders experienced progressive difficulty emptying after they entered puberty and ultimately had to rely on clean intermittent catheterization to empty completely. Follow-up subsequent to cuff exchange averaged more than 5 years (range 1 to 10 years). Despite an average increase of 10 mm in cuff size, all patients continued to depend on intermittent catheterization to empty completely.

CONCLUSIONS

Upsizing the bladder cuff in the maturing male who experiences difficulty with bladder emptying does not restore the ability to void spontaneously.

Outcome of sling cystourethropexy in the pediatric population: a critical review

PURPOSE

We performed a critical retrospective analysis of the records of all consecutive children who underwent sling cystourethropexy at our institutions. We particularly assessed the incidence and outcome in children who underwent enterocystoplasty in addition to a sling procedure.

MATERIALS AND METHODS

Between May 1992 and August 1994, 24 girls and 15 boys 4 to 17 years old (mean age 9) consecutively underwent 1 of 4 techniques of sling cystourethropexy for stress urinary incontinence using rectus fascia via an abdominal approach. Diagnoses included spinal dysraphism in 34 patients, spinal trauma in 2, cecoureterocele in 1, epispadias in 1 and classic bladder exstrophy in 1. All children underwent preoperative video urodynamics. In 4 patients only a sling procedure was performed (group 1), while in 9 others a sling procedure was performed after enterocystoplasty (group 2). In 26 patients a sling procedure and concomitant enterocystoplasty were performed (group 3).

RESULTS

Patients who underwent concomitant enterocystoplasty had more hyperactive preoperative urodynamics than those who did not. Postoperative continence was subcategorized in terms of patient age, sex, diagnosis (neurogenic versus nonneurogenic), preoperative video-urodynamics, surgeon technique, group (that is with or without cystoplasty) and type of enterocystoplasty (that is stomach versus ileum). Of these factors only concomitant enterocystoplasty was predictive of postoperative dry continence (73% of group 3, 33% of group 2 and 25% of group 1). In most patients who were not dry postoperative video urodynamics suggested suboptimal outlet resistance overcome by a hyperactive detrusor. No patient had postoperative upper tract deterioration.

CONCLUSIONS

These results suggest that concomitant enterocystoplasty should be critically considered for pediatric patients undergoing sling cystourethropexy.

Ten-year experience with the artificial urinary sphincter in children

PURPOSE

To assess the efficacy of the artificial urinary sphincter survival and continence were first evaluated 5 years ago. We now evaluated the effects of the artificial urinary sphincter more than a decade after implantation.

MATERIALS AND METHODS

Before 1985 an artificial urinary sphincter was implanted in 22 male and 14 female consecutive patients 4 to 30 years old (median age 12). In addition, between 1985 and 1990, 18 other children underwent artificial urinary sphincter implantation. Results of both series were compared.

RESULTS

Of the 25 sphincters in the original series that were functioning after 5 years 1 was removed and 2 patients were lost to followup, resulting in 22 functioning implants (61% of the patients). Mean survival time of the prostheses was 12.1 years and average followup for functioning sphincters was 13.7 years. There was no statistically significant difference in artificial urinary sphincter survival between the original group at 5 years and the second group treated after 1985. Of the patients in both groups with sphincters in place 32 of 39 (82%) were dry. Augmentation cystoplasty was performed in 9 of 18 patients (50%) in the second series (5 preoperatively and 4 postoperatively) compared to 10 of 36 (28%) in the original series at 5 years (3 preoperatively and 7 postoperatively). Renal failure developed in 6 patients from both series.

CONCLUSIONS

The artificial urinary sphincter is a durable long-term solution for children with intractable incontinence. Long-term surveillance of the urinary tract is mandatory because of the potential for renal failure in patients who have bladder hypertonicity after placement of the device.

Post-prostatectomy incontinence: urodynamic findings and treatment outcomes

PURPOSE

We examined urodynamic findings and treatment outcomes in a large population of men with post-prostatectomy incontinence.

MATERIALS AND METHODS

A total of 215 men was referred for evaluation and treatment of significant post-prostatectomy incontinence. Urodynamic evaluation consisted of provocation multichannel medium fill cystometry with vigorous attempts to demonstrate incontinence. Treatment was directed by the results of the urodynamic study. A pad scoring system was used to gauge the severity of incontinence before and after treatment.

RESULTS

Based on the results of urodynamic studies 40% of the men had genuine stress incontinence alone and approximately 60% had a major component of bladder dysfunction contributing to incontinence. Treatment results of 135 men demonstrated a significant decrease in pad score (p<0.001) for those treated with anticholinergics, those undergoing artificial sphincter insertion and those treated pharmacologically before sphincter placement.

CONCLUSIONS

In our large series most men with prostatectomy incontinence did not have genuine stress incontinence alone. Thus, urodynamic studies are critical, not only to define cause of incontinence but to direct effective therapy.

Pubovaginal slings for the management of urinary incontinence in female adolescents

A pubovaginal sling is an effective treatment for type III incontinence secondary to poor proximal urethral sphincter function. We used a pubovaginal sling to treat incontinence in 15 female adolescents. The etiology of incontinence was spinal dysraphism in 10 patients and prior trauma in 3. Simultaneous bladder augmentation was performed in the remaining 2 patients for poor bladder compliance. Three patients required additional procedures including repeat slings in 2 and repeat augmentation in 1. Of 13 patients followed for more than 6 months 11 remain dry, 1 leaks small amounts and wears 1 pad per day, and 1 did not achieve acceptable continence and was subsequently managed with bladder augmentation and a Mitrofanoff procedure. The upper urinary tracts have remained normal in all 13 patients. The pubovaginal sling has proved to be safe and successful in these children. The overall continence rate of 92% compares favorably to other available modalities.

Experience with AS 800 artificial sphincter in pediatric and young adult patients

Congenital or acquired sphincteric urinary incontinence in children and young adults is a severe social and physical burden. As a therapeutic option, we implanted 61 AS 800 artificial sphincters in 59 patients (46 males and 13 females). The mean age of the patients was 17.5 years (range, 6 to 34 years), and mean follow-up was forty-three months (range, 5 to 84 months). In addition to artificial sphincter implantation, intestinal cystoplasty was required in 22 patients to obviate problems of increased detrusor contractility or decreased detrusor compliance, or both. Continence was good in 47 patients (80%) and fair in 8 (14%). Four patients (7%) were awaiting sphincter modification or cystoplasty, or both. Careful and prolonged follow-up is mandatory in all patients managed in this fashion to preclude the deleterious effects of subtle changes in detrusor or ureteral function on the integrity of the upper urinary tracts.

Continence in the myelodysplastic patient following enterocystoplasty

To evaluate the ability of augmentation cystoplasty alone to provide a low pressure bladder and an adequate degree of continence in the myelodysplastic patient, the clinical records and urodynamic data of the last 18 consecutive such patients undergoing augmentation cytoplasty at our institution were reviewed. Two patients underwent colocystoplasty and 16 underwent ileocystoplasty. No patient underwent any procedure on the bladder neck or urethra. The 2 colocystoplasty patients exhibited episodic dampness attributed to contractions of the augmentation but all of the ileocystoplasty patients were dry during the day except 1 who had a urethral resistance of only 19 to 22 cm. water. On the basis of this review, ileocystoplasty alone appears to be sufficient for satisfactory continence in patients with a neurogenic bladder undergoing vesical augmentation if bladder outlet resistance exceeds 25 to 30 cm. water.

Successful outcome of artificial urinary sphincters in men with post-prostatectomy urinary incontinence despite adverse implantation features

A total of 75 men with post-prostatectomy urinary incontinence underwent artificial urinary sphincter implantation with a mean followup of 3.7 years. Average patient age at implantation was 67 years, with 30 men being 70 years old or older. In only 15 men (20%) was there no adverse implantation feature, while the remainder had adverse features, such as detrusor hyperactivity (44), bladder neck or urethral stricture disease (27), previous radiation therapy (11) and metastatic prostate cancer (11). Although men with ideal implantation characteristics, men with normal detrusors and men who underwent prostatectomy for benign disease had slightly better outcome in terms of urinary continence, in general each group of men with and without adverse features had satisfactory urinary continence. Other than men with a benign prostate, who fared better, each group of men with and without adverse features had equal need for device revisions. In conclusion, men with post-prostatectomy urinary incontinence should not be excluded from consideration for artificial urinary sphincter implantation based on the failure to meet ideal implantation criteria provided such adverse features are recognized and appropriately addressed.

The long-term results of artificial sphincters in children

To determine the long-term efficacy of the artificial urinary sphincter, 36 consecutive children in whom a prosthesis was implanted between August 1978 and July 1985 were followed for a minimum of 5 years and re-evaluated within the last 3 months. Of the 36 sphincters 27 (75%) are currently in place; 2 of these 27 sphincters are dysfunctional due to fluid leakage. Of the 25 functioning sphincters 14 have required no further prosthetic operation, 10 needed 1 revision and 1 patient had 5 revisions. Fluid leakage, occurring in 12 patients, was the most common complication requiring reoperation. Twenty patients are completely continent (11 of whom without any medication) and 5 are occasionally damp. The over-all success rate at 2 and 5 years was 84 and 62%, respectively. The mean survival time of the prosthesis was 7.2 years and the mean standard interval was greater than 10.5 years. Patients with higher balloon pressures (81 to 100 cm. water) had more complications, and a decreased rate of success than those with lower pressure balloons (51 to 80 cm. water, p = 0.02). There was no difference in success rates between boys and girls (p = 0.98), although girls who had a prior bladder neck operation tended to have a higher rate of cuff erosion. Sphincters placed after 1980 (model AS800) had a lower reoperation rate than those placed earlier. In selected instances, the artificial urinary sphincter appears to be a viable long-term alternative for management of children with intractable incontinence who have either failed or are unsuitable for other methods of treatment.

Urodynamic evaluation of the continence mechanism following urethral lengthening--reimplantation and enterocystoplasty

In an attempt to create continence in myelomeningocele children we performed urethral lengthening/submucosal reimplantation, a form of bladder neck reconstruction, to create a valve allowing catheterizable access to the bladder. We present the urodynamic findings of 23 patients 4 to 89 months (mean 43.1 months) after bladder neck reconstruction and enterocytoplasty to determine the continence mechanism of this 1-way valve and characteristics of the augmented bladder. Standard cystometrograms with simultaneous pressure recording of the submucosal portion of the neourethra were undertaken with a 10F, triple lumen, urethral pressure profile catheter. Baseline pressures in the submucosal neourethra were higher than in the bladder (mean 25.3 versus 13.4 cm, water, p less than 0.001). Submucosal tunnel and bladder pressures paralleled throughout filling, with mean tunnel pressures remaining greater at the time of first (53.6 versus 45.5 cm. water, p less than 0.01) and peak (62.9 versus 55.8 cm. water, p greater than 0.05) cystoplasty contractions. Bladders augmented with detubularized ileum had fewer significant contractions (greater than 40 cm. water) than other types of cystoplasties (36% versus 92%) and over-all they had first and peak contractions at greater volumes and lesser magnitude. We conclude that continence following urethral lengthening/reimplantation results from an anatomical arrangement allowing transmission of dynamic bladder pressure changes to the submucosal neourethra and that urethral pressure exceeds bladder pressure throughout filling. Additionally, our data suggest that detubularized ileum provides a large capacity, low pressure reservoir suitable for augmentation.

The surgical management of urinary incontinence in myelodysplastic children

Over a 4-year period, 69 patients with intractable urinary incontinence secondary to myelodysplasia have undergone surgical therapy to try to achieve continence. Preoperative evaluation used uroradiological and urodynamic studies, including measurement of leak point pressure and leak point volume. Twenty-one patients had a procedure to increase outlet resistance, 30 patients had bladder augmentation, and 18 patients had both procedures performed. Fifty-seven of the 69 patients have achieved total continence for a success rate of 83%.

The perineal artificial sphincter for acquired incontinence--a cut and dried solution?

Sixteen males with stress incontinence due to sphincter damage were investigated with videourodynamic studies after implantation of a perineal artificial urinary sphincter. Twelve patients were rendered dry; 4 remained incontinent, all of whom were shown by cystometry to have incontinence from detrusor instability. Of these, 2 also had stress incontinence proven by videourography. Detrusor instability was present in 9 patients before implantation; the instability worsened considerably in 2 patients and new instability was shown in another 2 patients. The limitations of the artificial urinary sphincter and the implications of detrusor instability in patients with an artificial sphincter are discussed. The artificial urinary sphincter is an extremely successful device for the treatment of acquired stress incontinence.

Urethral dilation improves bladder compliance in children with myelomeningocele and high leak point pressures

Among 350 children with myelomeningocele 18 with elevated leak point pressures were managed by urethral dilation and followed for 1 to 5 years. Longitudinal measurements of bladder compliances revealed durable improvement in the pressure-volume relationships after dilation. These data suggest that noncompliant bladders are acquired because of high outlet resistance, and early intervention may improve long-term bladder storage characteristics.

Management of urinary incontinence by bladder tube urethral lengthening and submucosal reimplantation

We reviewed the first 25 urethral lengthening and reimplantation procedures done at our institution in 24 patients. All patients had failed to achieve dryness on medical or surgical therapy for total urinary incontinence. A total of 32 patients had neurogenic incontinence. The patients were followed for 1.5 to 7 years. Late complications included catheterization difficulties, vesicoureteral reflux, febrile urinary tract infection, calculi and peritonitis. Reoperations were required in 19 patients primarily because of our initial failure to recognize the necessity of providing a low pressure, high capacity reservoir. The reoperation rate on the continence mechanism was low. Of 24 patients 20 are continent and require no pads or diapers.

Upper urinary tract deterioration after implantation of artificial urinary sphincter

The preoperative urodynamic evaluations of twenty patients with myelomeningocele who had had artificial sphincter implantation because of urinary incontinence were reviewed. Four patients developed hydronephrosis and severe impairment of renal function between two and six years after implantation of the artificial sphincter. The condition was partly reversible after removal of the artificial sphincter. The urodynamic evaluation prior to implantation revealed in the four mentioned patients compared to the 16 patients with normal upper urinary tract, a tendency to lower bladder compliance, lower bladder capacity and more severe detrusor hyperreflexia, but it was not possible to make a clear discrimination between the two groups. Attention is drawn to this unfortunate combination of effects after artificial sphincter implantation. Periodic control of the upper urinary tract by urography is recommended.