PLACEMENT OF A BLADDER NECK PURSE-STRING CUFF FOR THE MANAGEMENT OF INCONTINENCE IN CHILDREN WITH MYELODYSPLASIA

Objectives. Numerous surgical procedures have been developed in an att empt to increase bladder compliance and/or outlet resistance for the t reatment of intractable incontinence in children with neurogenic lower urinary tract dysfunction. We report our experience with the developm ent of a biocompatable purse-string cuff to increase outlet resistance by providing circumferential compression at the bladder neck. Methods . A total of 12 children (6 boys, 6 girls) with myelodysplasia and per sistent incontinence despite clean intermittent catheterization (CIC) and pharmacotherapy underwent urodynamic testing and cystoscopy that r evealed neurogenic bladders with concomitant intrinsic sphincter defic iency. Through an anterior approach, the bladder neck was mobilized an d wrapped with 5-mm polytetrafluoroethylene tubing. Five-millimeter wo ven polyester tape was then placed circumferentially within the polyte trafluoroethylene tubing lumen, purse-stringed under tension with a si licone tubing shed to appose the mucosa of the bladder neck, and secur ed under such tension with a surgical clip. Ten of the 12 patients und erwent concomitant augmentation cystoplasty. Results. Nine of 12 child ren (age range at time of operation 2.5 to 16 years) are continent on CIC in follow-up ranging from 6 months to 12 years. Four cuffs had to be surgically removed postoperatively. Two were removed secondary to i nadvertent transvaginal placement. Two other cuffs were removed for in fection. One child with persistent postoperative incontinence had the cuff retightened through a minor surgical procedure and has remained d ry. Annual renal ultrasound examinations reveal stabilization of upper urinary tracts throughout the follow-up period in all but 1 patient. Postoperative urodynamic studies reveal increased bladder capacity, de creased intravesical pressures, and increased leak point pressures. Co nclusions. The purse-string bladder neck cuff in combination with augm entation cystoplasty, when warranted, provides excellent, durable cont inence rates in children with myelodysplasia and neurogenic bladders. Attributes of the cuff are its relative low cost, ease of construction , unchanged angle of the bladder neck making catheterization easy, and potential adjustability in patients with persistent incontinence. (C) 1998, Elsevier Science Inc. All rights reserved.