What makes the bladder neck sling procedure a success in a selected population of children and adolescents? A STROBE-compliant investigation

Abstract

-Achieving urinary continence while not placing the upper tract and renal function in jeopardy remains an important goal in the management of children with neurogenic bladder. In the select group of patients with outlet dysfunction, this usually entails a bladder outlet procedure which can be combined with an enterocystoplasty or not. The authors in this manuscript try to evaluate possible factors affecting the success of the bladder neck sling (BNS) procedure for patients with outlet dysfunction. They did a very good job in defining continence which can often be a problem with this type of manuscript. They also provide pre and post-procedure urodynamics as well as their criteria for proceeding with sling alone versus adding bladder augmentation or detrusorotomy. The number of patients and length of follow-up are also strengths of the paper. Yet, it is important to realize this is a very selective group of patients of whom most already failed bladder neck bulking agent with anticholinergic therapy and clean intermittent catheterization. Additionally, based on pre-operative UDS parameters, these patients had marginal bladder compliance and a median percentage of expected bladder capacity of only 57%. When added together, these factors would suggest that this patient population would not be considered from the start to be a good candidate for an outlet procedure alone. In contrast, the subjects of a study by Snodgrass et al. looking similarly at BNS alone had a median percentage of bladder capacity of 74% and 73% of them had bladder pressure below 25 cm H2O [1]. While this seems like a much better patient group in which to avoid augmentation, ultimately like the authors mentioned, a portion of this group did require augmentation but not all of them [2]. Thus, the conclusion that augmentation should be considered for all patients undergoing sling or any other outlet procedure to achieve the best outcomes needs to be interpreted with caution. As we continue to debate for the optimal way to safely achieve continence in these patients, the data presented here certainly can help aid in the decision as to when augmentation needs to be offered at the time of the outlet procedure.-Additionally, it may not be correct to assume that just because the patient's incontinence seems improved and they do not want another procedure equals true satisfaction. We must ensure that patients also agree to a definition of success that includes being improved but not completely dry through currently available standardized quality of life questionnaires (QOL). This may have been beyond the scope of this manuscript and is certainly a flaw of many manuscripts before it as the definition of continence is characterized by the surgeon and not the patients. Yet, as shown by Szymanski et al. any degree of urinary incontinence in patients with neurogenic bladder older than 10 years of age is associated with lower QOL scores [3]. I am certain that most surgeons reading our journal would not be satisfied being a bit wet and would prefer being completely dry.