BLADDER NECK CLOSURE IN ASSOCIATION WITH CONTINENT URINARY-DIVERSION

Bladder neck closure is not a standard part of continent urinary diver sion. When bladder augmentation and continent urinary diversion are do ne simultaneously, it is frequently convenient and advantageous to lea ve the native bladder neck intact as long as there is a reasonable deg ree of intrinsic continence. Even in patients with marginal control th e effect of lowering intravesical pressure and increasing intravesical volume will, often produce acceptable continence. At times, particula rly in patients who have undergone multiple surgical procedures involv ing the bladder neck, there is poor intrinsic resistance. To provide a cceptable continence in these cases bladder neck closure is a necessar y part of continent diversion. Between 1990 and 1993 we treated 6 male and 7 female patients, most of whom underwent simultaneous bladder au gmentation and continent urinary diversion, and they had poor intrinsi c outlet resistance. Patient age ranged from 8 to 22 years. Underlying diagnoses included thoracic myelomeningocele in 5 patients, bladder e xstrophy in 5, bladder leiomyosarcoma in 1 and extensive pelvic trauma in 1 as well as 1 previously separated conjoined twin. Three patients had artificial urinary sphincter failure and 3 had failure of urethra l sling procedures. A clean intermittent catheterization program had f ailed in 12 patients and all 13 had diurnal incontinence. Bladder neck and urethral resistance was evaluated using voiding cystourethrograph y and urodynamics to measure leak point pressure and bladder capacity. Reliable bladder neck closure is historically difficult to achieve an d is best done at the time of diversion. We have had initial success i n 12 of our 13 cases and subsequently in all 13 using a technique of b ladder neck division, 2-layer closure and omental interposition betwee n the bladder neck closure and urethra.