Abstract General Information

Title

CONTINENCE SURGERY FOR THE MANAGEMENT OF URINARY INCONTINENCE DUE TO NEUROGENIC BLADDER: AN EXPERIENCE OF 73 CASES AND THEIR FOLLOW UP.

Introduction and objective

Neurogenic bladder sphincter dysfunction presents a management challenge for pediatric surgeons. The primary treatment goals are preserving renal function, preventing urinary tract infections, achieving adequate social continence and effective bladder emptying. Conservative management approaches, including clean intermittent catheterization and pharmacotherapy, are initially employed. However, urinary incontinence remains a challenge in a significant number of cases. Bladder augmentation with/without Bladder Neck tightening are often required for achieving sufficient social continence. Other adjunctive procedures such as creation of a continent catherisable conduit and stoma and ureteric reimplantation are also performed as part of the Continence surgery.
Our Centre has been doing these operations for more than 20 years. In this paper we will present our experience in 73 such cases and their follow up of 3 years and beyond. We will highlight the technical lessons learnt.

Method

This study presents a retrospective analysis of 73 NGB patients who underwent surgery for their Urinary Incontinence and who had a minimum follow up of 3 years. A strict pre and postoperative protocol was followed, including pre-operative assessment and workup, intra-operative manoeuvres, and post-operative management. Patients and parents received comprehensive counselling and participated in peer support groups. Investigations, such as micturating cystourethrogram, cystometry, and renal scans, were conducted to evaluate patient progress.

Results

In a retrospective analysis of 73 patients, 68 had MMC & 5 had sacral agenesis. Of the 68 MMC patients, 59 had lumbosacral involvement, 5 had sacral involvement, and 4 had thoracolumbar involvement.
Pre-operative Bladder capacities ranged from 5 ml to 600 ml with a mean of 174.96 ml and Post-operative bladder capacities ranged from 170ml to 850 ml with a mean of 357.9ml
The Preop mean Leak Point Pressure (LPP) was 30.25 cm of water, with 16 patients having an LPP greater than 40 cm, 14 patients with an LPP less than 15 cm, and 51 patients with an LPP between 15 and 40 cm.
Bladder augmentation was performed in all patients, with colocystoplasty in 70, ileocystoplasty in 3.
Bladder neck tightening was performed in 63 cases where 58 patients underwent Anterior Rectus Fascia Sling and 5 patients underwent Ventrisuspension
Intermediate to long-term complications occurred in 16 patients, including recurrent UTI in 9, vesical calculi in 3, stenosis of the mitrofanoff in 1, reflux in 1, and stoma revision in 1.
Post-augmentation, the mean dry interval increased from 79.57 to 208.12 minutes.
The surgical technical modifications and improvements that were thought to be of significance were a meticulous sealing of leaks, Patch augment instead of a Cap configuration and a 360o Sling wrap, These will be discussed in the presentation.

Conclusion

Bladder augmentation with/without Bladder neck tightening and cutaneous catheterizable conduits provides an effective treatment option for neurogenic bladder sphincter dysfunction. This study highlights the importance of a comprehensive approach, strict protocol adherence, and proper patient education to optimize outcomes and minimize complications. The paper will also discuss technical issues for improving results of the surgery.