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.