Management of Sphincter Insufficiency in Patients with Neurogenic Bladder and Bladder Augmentation - Beyond the Abstract
Perhaps the most straightforward issue to address is a poorly functioning bladder, which can be treated with oral medication, botulinum toxin injections, or bladder augmentations for the most resistant cases. The aim of our study was to explore the need and effectiveness of bladder neck procedures (BNPs) in patients with neurogenic bladder who had undergone bladder augmentation. We evaluated all pediatric patients with neurogenic bladder in our hospital who had undergone enterocystoplasty to determine the frequency, type, and efficiency of treatments for sphincter insufficiency.
All patients underwent urodynamic investigations before any BNP to ensure that the bladder volume was age-appropriate and had a low maximal detrusor pressure. We also made certain that patients were adhering to the recommended frequency of the CIC program. The bladder neck injection (BNI) was usually the first treatment option due to its minimally invasive nature and its suitability for younger children. If BNI was ineffective or unsuitable because of a compromised bladder neck, our second option was the fascial sling procedure. We aimed to avoid bladder neck closure whenever possible.
The median age at bladder augmentation was 11.9 years (IQR 8.5-14.8) and at the last control 21.8 years (IQR 18.9-31.1). Out of 87 patients, 37 (43%) underwent bladder neck procedures due to incontinence. Full continence was achieved in 36% of the 28 patients who underwent one or multiple BNIs and in 64% of the 14 patients who had a sling operation, with outcomes consistent across sexes. All five females who underwent bladder neck closure became continent. At the end of the follow-up, 74% of patients were fully continent, 22% had occasional incontinence episodes, and 5% still experienced daily incontinence necessitating pads.
The study indicates that treating sphincter insufficiency in patients with a neurogenic bladder remains challenging despite the availability of numerous treatment options. The sling operation is more effective than BNI, but it's unsuitable for very young patients. Additionally, the role of minimally invasive sling techniques remains uncertain for this group, and none of our patients underwent this approach. In this study, we were not able to measure leakage volumes properly, but especially in many patients with infrequent incontinence, it was mostly minor leaks or droplets. Rare incontinence episodes were often also associated with bladder overfilling. Accordingly, patient cooperation in treatment is crucial to achieve continence.
Written by: Niklas Pakkasjärvi & Taskinen Seppo, Pediatric Urology, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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