Advantages of rectus fascial slings for urinary incontinence in children with neuropathic bladders

Purpose: Many surgical procedures to improve outlet resistance in children with neuropathic bladders are obstructive and increase the detrusor leak po int pressure. In contrast, fascial slings are designed to achieve continenc e by increasing the Valsalva or stress leak point pressure without altering the detrusor leak point pressure. We evaluate the effectiveness of fascial slings in achieving continence in pediatric patients with neuropathic blad der. Materials and Methods: From October 1994 until February 1999, 10 females an d 8 males with neuropathic bladder secondary to myelodysplasia or traumatic spinal cord injury underwent fascial sling procedures. Mean patient age wa s 14 years (range 8 to 18) and all were incontinent despite aggressive medi cal management. Urodynamic evaluation was performed preoperatively and post operatively. Specific urodynamic measurements included detrusor leak point pressure, stress leak point pressure and detrusor compliance. Compliance wa s only compared in the 12 nonaugmented cases. Results: With a mean followup of 21.2 months (range 6 to 57), preoperative and postoperative urodynamics revealed little change in mean detrusor leak point pressure (23.2 versus 23.22 cm. H2O) but a substantial increase in me an stress leak point pressure (41.6 versus 64.5 cm. H2O). Mean compliance w as unchanged in the nonaugmented group (22.00 versus 26.78 ml./cm. H2O). Fo ur patients (22.22%) remained wet after surgery, of whom 2 were successfull y treated with a repeat sling procedure and 1 with collagen injection for a n overall continence rate of 94.44%. Conclusions: Fascial slings can be effectively used in pediatric patients f or neuropathic incontinence. Furthermore, stress urinary incontinence is co rrected by increasing the Valsalva or stress leak point pressure with prese rvation of the detrusor leak point pressure. Preservation of detrusor leak point pressure is particularly advantageous because other forms of bladder outlet procedures achieve continence at the expense of increasing detrusor pressures, thus placing the upper tracts at risk for damage.