Laparoscopic bladder neck reconstruction

Abstract

Urinary incontinence due to bladder neck incompetence is a common condition presented to paediatric urologists. The most frequent situation is incontinence in children suffering from spina bifida and neuropathic bladder-sphincteric dysfunction. Urinary incontinence in these patients poses not only a medical but also a significant psychological and social problem. The associated low self-esteem, stigmatisation by the society and adverse influence in school performance all render it a serious health issue with multiple negative effects on a childs development. The medical obligation to treat this condition with an aim for protection of the upper urinary tract and achieving a socially acceptable degree of continence can never be denied. However, successful management remains a technical challenge to the paediatric urologists. The introduction of the concepts of continent diversion and clean intermittent catheterisation, in combination with augmentation cystoplasty for bladders with poor compliance and reduced capacity, and bladder neck surgery for bladders with outlet incompetence, has allowed many of these children to become dry. Although different surgical options exists in current literature for bladder neck reconstruction, a consensus has yet to be achieved. With advances in laparoscopic surgery, the introduction of a laparoscopic extravesical approach using a bladder neck sling provides a further option with the added advantages of a clear and magnified view of the pelvic cavity. It also allows for other advanced laparoscopic bladder surgery such as laparoscopic bladder augmentation and laparoscopic-assisted Mitrofanoff appendicovesicostomy to be performed as a single-stage operation. It is not uncommon that preoperative urodynamic studies sometimes may not be able to tell whether concurrent bladder neck reconstruction is necessary to achieve continence particularly in those poorly compliant bladders. Therefore some patients may have undergone bladder augmentation and subsequently require a second surgical procedure for bladder neck reconstruction to enhance dryness. This would mean inevitable exploration of areas with dense adhesions and may even carry the risk of injuring the vascular pedicle of the augmented bladder. With the development of a pneumovesical approach to intravesical surgery it is now also possible to perform bladder neck reconstruction without opening up the bladder. © Springer-Verlag Berlin Heidelberg 2008.