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

Abstract

Achievement of continence in children suffering from neurogenic bladder dysfunction or severe urogenital malformation is of fundamental importance to the wellbeing of affected children and their families. A valid approach to treating incontinence with hypoactive sphincter is the placement of a bladder neck sling thus increasing outlet resistance of the bladder. In this retrospective study in children and adolescents, we aimed to assess the outcome of bladder neck sling procedures conducted at our institution. In addition, we aimed to identify predictors of the successful correction of incontinence. We treated 36 patients (25 girls, 11 boys, aged 5.0-19.7 years). In total, 32 (88.9%) patients suffered from neurogenic incontinence. Overall, 16 patients had previously received unsuccessful injection of bulking agent into the bladder neck. For the bladder neck sling, we used a fascial strip of rectus abdominis muscle (n=29), detrusor muscle (n=6), or combined fascial and detrusor strip (n=1). In 8 (22.2%) patients, the surgical procedure involved wrapping the strip around the bladder neck, while in 6 (16.7%) patients, the bladder neck was suspended with the sling. In 22 (61.1%) patients, the two techniques were combined. Overall, 22 (61.1%) and 9 (25.0%) patients additionally underwent enterocystoplasty or detrusorotomy, respectively. We assessed urinary continence of our patients after 3-6 months (first evaluation) and ≥12 months (final evaluation). We classified the state of continence as 'dry' (dry for >3h between catheterizations and dry at night), 'significantly improved' (minimal incontinence, no more than one protective pad per day, interval of at least 3h between catheterizations, dry at night, and no demand for additional treatment), or 'wet'. Bladder neck sling treatment was considered successful if the patient was rated as 'dry' or 'significantly improved'. At the first evaluation, the bladder neck sling procedure proved successful in 19 (52.8%) patients. Enterocystoplasty significantly increased the success rate compared to detrusorotomy or no bladder augmentation (68.1% vs. 28.6%; p=0.04). The remaining 17 patients who were still classified as wet after bladder neck sling placement subsequently underwent one or more additional interventions, i.e. implant injection (n=11), bladder augmentation (n=10), and/or sling replacement (n=5). At the final evaluation after a median follow-up of 64.5 months (range, 12-181 months), continence without sling replacement was achieved in 29 (80.6%) of the 36 patients. In our study population, bladder neck sling placement achieved good results in the treatment of severe organic urinary incontinence with hypoactive sphincter. To optimize treatment outcome, bladder neck sling placement should be combined with enterocystoplasty.