Posterior approach to the bladder neck for implantation of the artificial urinary sphincter.

Blind dissection of the bladder neck during implantation of an artificial u rinary sphincter (AMS 800) may lead to injury of either the bladder, genita l tract or even the rectum. Significant bleeding may occur. A posterior app roach to the bladder neck allowing visual control of the anatomical structu res is described. From November 1995 to February 1998, 8 adolescents (12-19 years old) underwent AMS 800 artificial urinary sphincter implantation for the treatment of severe incontinence associated with neurogen bladder; one patient had had a previous augmentation. Three had a simultaneous ileocyst oplasty and another patient had a simultaneous bilateral extravesical urete ric reimplant. The procedure consisted of separation of the bladder from th e peritoneum, allowing the development of a dissection plane between the re ctum and genital tracts posteriorly and the ureters and bladder neck anteri orly; the dissection is extended to the base of the prostate. The endopelvi c fascia is then incised laterally and on both sides the neurovascular bund les are perforated under visual control and the cuff is positioned safely a round the bladder neck, above the prostate and in front of the genital trac t. The bladder was opened only in the case of associated ileocystoplasty, t hus avoiding prolonged bladder drainage. The mean operating time was 2.5 ho urs and the blood loss never exceeded 300 cc. This route was nor found to b e convenient in the case of the patient with a previous augmentation; 7 sph incters function normally with a follow-up of 18 to 44 months; one was neve r activated and the patient is dry under CIC. This route for exposure of th e bladder neck allows visual control of the anatomical structures, accurate positioning of the cuff, avoids bladder opening and reduces bleeding. It c an be used for other procedures such as bladder neck suspension or Mulleria n cavity removal.