Lower Urinary Tract Denervation, Decentralization, and Neuromodulation

Altering the innervation of the urinary tract is the focus of several strategies for the management of storage failure and is the central mechanism for procedures that vary from sacral rhizotomy to intravesical botulinum toxin. In addition, interventions may involve different levels of the nervous system, such as the spinal cord, nerve roots, or peripheral nerves. Of note, noncentral denervation proximal to the postganglionic neuron is properly termed “decentralization” and because the bladder is innervated by a short-neuron system, almost all denervation procedures outside the central nervous system that we will describe are properly referred to as decentralization. In general, more central procedures would appear more suitable for patients with spinal cord injury (SCI) or neurogenic detrusor overactivity, and although central denervation is theoretically very effective, it may also have a potentially wider range of unintended consequences. Peripheral decentralization is more selective for the bladder and more suitable for idiopathic detrusor overactivity, as other structures innervated by the sacral nerves remain neurologically intact (Madersbacher, 2000). There would seem to be only a small role for most of the procedures discussed in this section, because conservative measures are often sufficient in significantly improving or alleviating storage symptoms in most patients. Although favorable results have been reported with denervation techniques, some of these procedures have been accompanied by significant adverse outcomes that have limited their usefulness. One significant problem with central denervation and decentralization is that neuroplasticity often results in a variable restoration of neurologic function, with an even less desirable result than was present originally in many cases (Madersbacher, 2000). This section will focus on surgical techniques of bladder denervation, both central and peripheral. Sacral neuromodulation is covered in Chapter 70.

Central (Subarachnoid) Block

These procedures, comprise chemical rhizolysis, sacral rhizotomy, and conusectomy, selective anterior sacral rhizotomy, and dorsal rhizotomy are seldom used today and are discussed fully on the Expert Consult website.

Sacral Neuromodulation

Sacral neuromodulation is currently the most commonly used surgical procedure to treat patients with refractory urgency-frequency or urgency incontinence. For more information on the indications, procedural aspects, treatment results, and complications of sacral neuromodulation, see Chapter 70.

Peripheral, Perivesical, and Intravesical Bladder Denervation

Transvaginal Denervation

A number of procedures fall into the category of attempts to achieve a peripheral denervation. The exact nature of these denervations is unclear and may involve interruption of sensory, motor, or both types of innervation. As evident from neuroanatomic considerations, at best, such attempts achieve primarily neurologic decentralization and, at most, partial peripheral denervation. Although many authors report relatively high success rates for these procedures, it is unclear why they are not used more frequently. Because they are primarily used for detrusor overactivity, it is likely that many clinicians use nonsurgical methods first and are often successful in managing detrusor overactivity with fewer side effects. Also, because these procedures are uncommonly performed, many clinicians are unfamiliar with how to perform the procedure, and the success rate is likely much lower than when performed by clinicians who commonly perform these procedures. Lastly, many clinicians have begun to use neuromodulation or botulinum toxin injections to treat refractory overactive bladder, leaving the role of transvaginal denervation in question.

Regarding the literature on transvaginal denervation, in many articles, there is little description of what “success” actually means. In addition, there are few studies with long-term follow-up, and “postoperative assessment” often means a few months of follow-up. A comprehensive summary of the surgical treatment of detrusor overactivity by peripheral denervation was reported by Mundy in 1985; however, many reports have been published since that time.

Transvaginal partial denervation of the bladder was originally described by Ingelman-Sunberg in 1959. The original procedure, which was an extensive denervation, was used mostly for the treatment of refractory urge-urinary incontinence, and in the originator’s hands, success rates of up to 80% were achieved. Mundy (1985) reported that other investigators found success in 50% to 65% of cases, and Torrens (1985) noted that “the technique has not found favor with other workers.”

More recently, Cespedes and associates (1996) described McGuire’s modification (limited lateral vaginal dissections) of the Ingelman-Sundberg procedure in 25 women with urinary urgency incontinence and detrusor overactivity who had failed behavioral and medical therapy (Fig. 75–1). Transvaginal local anesthesia was used as a test to determine which patients would benefit from the procedure, with significant improvement of urgency symptoms considered a positive test. Twenty-five patients were found to have a positive test; the number of patients unsuccessfully tested was not reported. Sixteen (64%) of these patients were cured of urgency incontinence at a mean follow-up of 14.8 months. Of the 16 patients cured, 9 patients required one medication, and 2 required two medications. Madersbacher (2000) comments that a follow-up period of 15 months is too short to determine long-term effects.

Figure 75–1 Terminal pelvic nerve branches enter the bladder near the trigone. A, To assess preoperatively in clinic whether the patient would benefit from the procedure, local anesthetic (0.25% bupivacaine) is injected subtrigonally to block the nerves which would be denervated by the operative procedure. B, Normal saline is injected submucosally to facilitate dissection of the vaginal mucosa off the bladder. C, Position of the trigone outlined by a catheter balloon inflated to 30 mL. D, Inverted-”U” vaginal incision is made. E, Dissection of the vaginal mucosa and deeper tissues off the underlying bladder. F, Completed dissection.

Long-term follow-up was reported by Westney and associates (2002), who retrospectively reviewed 28 patients with refractory urgency incontinence, having undergone the modified procedure with a mean follow-up of 44.1 months. Of these, 68% were cured (54%) or improved (14%). Based on these results and the prior series, the authors concluded that the modified Ingelman-Sundberg procedure is an efficacious, minimally invasive option for this difficult-to-treat patient population.

Acupuncture

The use of acupuncture as a therapeutic treatment modality is described in Chinese medical texts as early as 300 BC. Acupuncture is a form of somatic sensory stimulation using a variety of procedures that involve stimulation of specific anatomical locations by insertion of thin, solid, metallic needles into the skin. In the classic forms of acupuncture, needles are stimulated manually to achieve the desired effects. In more modern forms of acupuncture, heat or electrical stimulation may be provided by the addition of an energy source or be performed needleless, as in laser acupuncture. Indeed, McGuire and coworkers’ (1983) developed transcutaneous posterior tibial nerve stimulation for bladder inhibition that was based on the acupuncture points. The use of acupuncture has been described for a number of urologic symptoms, including urinary urgency, frequency, incontinence, nonobstructive urinary retention, enuresis, and neurogenic detrusor overactivity. Acupuncture is generally a well-tolerated procedure, and although side effects are generally uncommon and minimal in nature, treatment may occasionally result in localized pain, hematoma, infection, and even organ puncture. Several treatment sessions are usually required.

There has been much interest in determining the mechanism by which acupuncture exerts its beneficial effects. According to traditional Chinese medicine, concepts such as the meridian system, circulation of Qi, and other related theories remain difficult to define and characterize. Sato (1997) has shown somatovisceral reflexes evoked from somatic afferent stimulation may induce either excitatory or inhibitory changes in bladder function and sphincter activity. Bergström and associates (2000) hypothesized any one or a combination of (1) endorphinergic effects at the sacral spinal cord level or above, (2) inhibitory somatovisceral reflexes, and (3) increase in peripheral circulation as possible mechanisms of action. The true nature of how acupuncture exerts its beneficial effects remains incompletely understood.

Bergström and associates (2000) reported on the results of classic acupuncture performed twice weekly in a group of 15 elderly women with urgency or mixed incontinence. In this open, uncontrolled study, subjective assessments of improvement and objective measurements in the form of grams of leakage over 48 hours were encouraging, not only at the end of the study but also after 1 and 3 months. More recently, Emmons and Otto (2005) compared acupuncture versus placebo acupuncture in the treatment of women with overactive bladder and urinary urgency incontinence. The number of incontinent episodes decreased by 59% in the treatment group compared with 40% in the placebo group. The treatment group had a significant improvement in bladder capacity, urgency, frequency, and quality-of-life scores compared with the placebo group.

Many studies have been performed to determine the efficacy of acupuncture; however, the level of evidence continues to be limited secondary to difficulties in performing adequate placebo controlled, double-blind studies. In addition, acupuncture requires extensive training, is performed by few clinicians, and few teachers exist. Overall, the importance of acupuncture may not just be in learning or performing the procedure; it may be more important to learn the mechanisms by which it achieves these results, in order to develop easier and less invasive methods of achieving the same (or better) clinical results.

Bladder Distention Therapy

Initially described by Helmstein in 1972 for the treatment of patients with bladder carcinoma, this treatment modality has undergone several modifications. Bladder overdistention, most familiar for its use in the treatment of interstitial cystitis (see Chapter 12), has also been used for other diverse indications, including nocturnal enuresis, irritative symptoms following radiation or BCG, and for patients with overactive bladder.

No standard technique has been clearly defined for this procedure and, as such, several variations exist. Bladder distention may be performed under regional or general anesthesia. The bladder is then distended by either a balloon catheter or more commonly by saline infused cystoscopically or through a urethral catheter. The ideal pressure and duration needed to distend the bladder has not been well defined. Dunn and colleagues (1974) described prolonged bladder distention of several hours at a pressure equal to the patients’ systolic blood pressure. At this pressure, therapeutic benefit is thought to derive from ischemic changes induced in submucosal afferent nerve endings and stretch receptors (Dunn et al, 1977). In a primarily interstitial cystitis population, Hanno and Wein (1991) described distending the bladder to 80 cm H₂O for several minutes with good results. Bladder rupture, historically as high as 5% to 10%, is the most significant complication after bladder distention therapy. Other possible complications include hematuria, back pain, and urinary retention.

Ramsden and colleagues (1976) reported good to excellent results in the treatment of patients with detrusor overactivity, while most others have reported inferior results with this treatment modality. In this same patient population, Jorgensen and coworkers (1985) reported a success rate of only 1 in 15 (6%) patients. In a retrospective review by Taub and Stein (1994), 8 of 22 (36%) of patients with frequency and urgency of various etiologies had subjective improvement, while no patient with detrusor overactivity improved. They also demonstrated that short duration distention therapy (15 to 30 minutes) was as efficacious as prolonged therapy (6 hours). Lloyd and colleagues (1992) reported that only 6 of 29 women with severe irritative symptoms, including 6 patients with interstitial cystitis and none with neurogenic detrusor overactivity, had a good response to treatment. In a study of 26 women with frequency and urgency, Liapis and associates (2001) found a statistically significant increase in bladder capacity after treatment; however, only 4 (15%) had any improvement in symptoms beyond 9 months. Although largely regarded as an ineffective procedure in patients with storage failure secondary to neurogenic detrusor overactivity, bladder overdistention may provide substantial, but usually temporary, improvement to some patients with non-neurogenic storage symptoms who have failed medical therapy.

Nonsurgical Compressive and Occlusive Devices

Urethral compression devices have been used to successfully control urinary incontinence in males for over 250 years, with little change in their construction during this time. Indeed, the Heister penile clamp was described in Institutiones Chirurgicale, a surgical textbook published in 1750. This device closely resembles the Cunningham clamp, a device commonly used today (Madjar et al, 2001). These devices are primarily used to treat patients with pure sphincteric incontinence, most commonly postprostatectomy incontinence (PPI), because normal bladder capacity and storage pressures are a relative requirement. Continence is achieved by mechanically compressing the urethra between two foam pads. The device is adjusted by slowly increasing the level of compression until continence is attained, because this allows the lowest pressure to be applied, keeping obstruction of blood flow to a minimum. Regardless, these devices should be unclamped regularly at 3- to 4-hour intervals, because prolonged or excessive compression can cause pressure-related injury to the penis. Additionally, these devices should not be worn during an erection or while sleeping. Pressure-related injuries may also be more prevalent in patients with impaired sensation or cognition; therefore penile clamp usage in this population should be considered a relative contraindication. Several other compression devices are available and are similar in both design and function to the Cunningham clamp. Moore and colleagues (2004) reported efficacy, comfort, and patient satisfaction with three penile compression devices: the Cunningham clamp, the C3, and the U-Tex. The study population included 12 men with postprostatectomy incontinence requiring continuous pad protection. Over 4 consecutive days, patients were randomly assigned to use either one of the three devices, or pads alone as a control group. Each group wore the device or pads continuously for 4 hours (maximum time recommended for continuous usage), and pad weights were obtained before and after the study period to quantify leakage. Additionally, patients were asked to complete a questionnaire at the conclusion of the study. Urine leakage was significantly reduced by all three devices evaluated; however, the Cunningham clamp was the most efficient of the three devices tested, reducing urine leakage by nearly 85%. The Cunningham clamp was also noted to reduce cavernosal blood flow significantly more than the other devices. Overall, patients rated the Cunningham clamp the most acceptable and preferable of the devices evaluated.

Although these devices manage sphincteric incontinence relatively well, they are rarely used today because they are inconvenient, and many minimally invasive options for male sphincteric incontinence now exist. These devices remain useful for patients who cannot undergo surgical therapy due to medical conditions, and for patients who have severe leakage during the early postprostatectomy period, while surgical treatment is contraindicated.

The renewed interest in conservative management of female sphincteric incontinence, and lower urinary tract symptoms associated with pelvic organ prolapse, has prompted the development and investigation of several nonsurgical devices. Unfortunately, due to the location and anatomy of the female urethra, no compressive or occluding device has been introduced that successfully treats sphincteric incontinence without causing significant side effects or patient discomfort. In addition, reliable external urinary collection devices do not exist for females, making the Foley catheter the most common method of treatment for intractable sphincteric incontinence. Therefore the role of these devices in the algorithm of conservative management of female sphincteric incontinence remains unclear. A more thorough description of these devices, along with the indications and efficacy, are discussed in Chapter 69.

Pelvic organ prolapse may be associated with sphincteric incontinence, overactive bladder symptoms, and/or urinary retention due to anatomic urethral obstruction. Vaginal support devices that support the anterior vaginal wall, thereby supporting the bladder neck and proximal urethra, should theoretically improve both stress incontinence due to urethral hypermobility and allow normal voiding by reducing urethral obstruction. Some devices may even improve stress incontinence due to intrinsic sphincter deficiency, if the urethra is sufficiently compressed. Intravaginal devices, such as tampons, contraceptive diaphragms, pessaries, and pessary-like devices specifically designed for bladder neck support have all been used with variable results. The issues that exist with these devices include the need for intermittent removal and cleaning, problems with device placement, and dislodgement due to the variable anatomy of the vagina, and patient discomfort.

Female urethral occlusive devices may be external or internal, depending on whether the device occludes the urethra or bladder neck from the outside or must be inserted into the urethra. Examples of these devices include urethral meatal occlusive devices and urethral inserts. These devices are most useful in patients with mild to moderate sphincteric incontinence without significant detrusor overactivity or decreased compliance. The characteristics of an ideal occlusive or supportive device include (1) efficacy, (2) comfort, (3) ease of application/insertion/removal, (4) no interference with voiding, (5) lack of tissue damage, (6) no increase of infection risk, (7) no compromise of subsequent therapy, (8) cosmetic acceptance, and (9) no interference with sexual activity. Unfortunately, no occlusive or supportive device currently fulfills all these requirements.

Sphincteric Injection Therapy

Injection therapy is commonly employed as a minimally invasive treatment option for male and female stress incontinence. Although it is theoretically a temporary treatment, typically lasting only 6 to 12 months, the ease of reinjection in a clinical setting renders it a potentially permanent solution in selected patients. Injectables treat stress incontinence by increasing the abdominal leak point pressure by several mechanisms, including increased mucosal sealing pressure and improvement in the mucosal seal mechanism (Appell, 2002). Females most likely to benefit from this procedure have intrinsic sphincter deficiency (ISD), a normally contractile bladder, and a well-supported urethra. This constellation of requirements is most commonly fulfilled by elderly females; however, several authors have demonstrated improvement in younger patients with stress urinary incontinence (SUI) due primarily to urethral hypermobility (Appell, 2009). The rarity of injectable use in this population really reflects the efficacy and widespread use of the newer minimally invasive slings, compared with the relative ineffectiveness of injectables.

The lack of standardization in defining success, largely attributable to the nonpermanent nature of this treatment, makes it difficult to accurately assess the true cure and improved rates after treatment. Nevertheless, the most extensively studied injectable, glutaraldehyde cross-linked (GAX) collagen, has consistently resulted in improvement and/or cure in 60% to 80% of selected female patients. Most patients will require two injections to achieve dryness and will require reinjection every 6 to 12 months to maintain continence. The injections can be performed indefinitely without any apparent side effects. If the patient fails injection therapy, it does not hinder other surgical procedures.

In males, postprostatectomy incontinence can also be managed with injection therapy. The best results are obtained with patients with mild incontinence (one to three pads per day), while patients who have undergone radiation, bladder neck incision, or cryotherapy have less favorable responses (Cespedes, 2000). Most patients require four to five injections, with reinjections every 6 to 12 months to maintain dryness (Cespedes, 2000). Westney and colleagues (2005) reported their results of collagen injection in 322 men with ISD after therapy for prostate carcinoma or benign prostatic hyperplasia. The authors reported that after a mean of 4.37 injections, and irrespective of therapy, overall improvement was approximately 50% with a mean duration of 6 months.

The ideal bulking agent should be durable, biocompatible, should not migrate, or cause significant inflammatory reaction at the injection site. Unfortunately, no current injectable has all of these qualities. In the future, advances in the field of tissue engineering, including autologous chondrocytes and cultured myoblasts, may offer new and exciting options in the treatment of stress urinary incontinence using injectables. For a more thorough discussion of the history, indications, techniques, and results of bulking procedures, including a review of the injectable agents currently available, refer to Chapter 77.

Vesicourethral Suspension and Prolapse Repair (Female)

Vesicourethral suspension procedures, such as the Burch and MMK (Marshall-Marchetti-Krantz) procedures, have been successfully used for many years to treat stress incontinence secondary to urethral hypermobility, most commonly defined as stress incontinence occurring with an abdominal leak point pressure (ALPP) greater than 100 cm H₂O. More recently, with the increasing popularity of the minimally invasive mesh slings, their use has diminished substantially, and they are rarely used unless a simultaneous abdominal procedure, such as a hysterectomy or abdominal sacral colpopexy, is planned. In addition, the Burch colposuspension was recently shown to be inferior to the autologous pubovaginal sling in a randomized, controlled study (Albo et al, 2007). Although vaginal prolapse does not, per se, cause urinary continence, a deficiency of vaginal support is shared by both conditions. Therefore, urinary incontinence secondary to hypermobility would imply that vaginal prolapse, especially the anterior wall, likely coexists and should be repaired at the same time. Severe vaginal wall prolapse has also been associated with occult urinary incontinence, defined as stress incontinence that only occurs with reduction of the prolapse. Patients with severe vaginal prolapse, with or without complaints of incontinence, should be carefully assessed preoperatively by reduction of the prolapse during the stress incontinence evaluation (see Fig. 75–2). This condition and additional descriptions of these procedures are further discussed in Chapters 71 and 72.

Pubovaginal Slings and Tension-Free Tape Procedures

Autologous fascia pubovaginal slings, popularized by McGuire in the 1980s, were originally used for female patients with poor sphincteric function. Historically, female patients with stress incontinence have been divided into groups based on etiologies of either urethral hypermobility or intrinsic sphincter deficiency (ISD). It has become clearer over time that almost all patients leak due to a combination of hypermobility and intrinsic sphincter deficiency, with each component of incontinence on a continuum. Using this logic, a sling would be the ideal treatment because it successfully corrects both urethral hypermobility and ISD. More recently, pubovaginal slings have been supplanted by a wide variety of minimally invasive tension-free mesh sling procedures. These procedures, although less invasive, have never shown success rates superior to the 90% cure rate of the original pubovaginal slings, which are still considered by most to be the gold standard therapy. Autologous or cadaveric fascial slings are still commonly used in situations where the sling must be pulled more tightly, as with the obstructing slings sometimes used in patients with neurogenic incontinence. Theoretically, mesh slings are “tension- free” slings and therefore would be much more likely to erode into the urethra if pulled tightly. In cases where mesh is preferred, a “spiral” or “circumferential” sling, which wraps completely around the urethra, can be used; however, this requires a urethrolysis to gain access to the retropubic space and passage of the needles from the abdomen to the opposite side of the vagina to gain circumferential compression. This procedure and many others are more fully described in Chapter 73.

Artificial Urinary Sphincter and Male Perineal Sling

The introduction by Scott and coworkers (1974) of the artificial urinary sphincter (AUS) signified a major advancement in the treatment of sphincter-related incontinence. The AUS has been successfully used in the management of stress incontinence of various etiologies and can be implanted in adults and children of both sexes. Postprostatectomy incontinence remains the most common indication for AUS insertion, with female patients accounting for only 1% of the patients in whom the devices are implanted yearly, typically for neurogenic disease (Lee et al, 2009). Although the AUS is commonly used in patients with neurogenic incontinence, it is important to remember that because of the ability of the AUS to greatly increase outlet resistance, social continence may be gained at the expense of renal deterioration in patients with poor detrusor compliance. In general, storage pressures and bladder capacities should be normalized prior to placement of an AUS.

For treatment of PPI, the AUS has been quite successful and remains the gold standard therapy. Nevertheless, revisions may be necessary due to atrophy, infections, erosions, or mechanical problems. In addition, some patients are reluctant to have the AUS placed for a variety of reasons, including the desire to “void normally” without having to manipulate a device. More recently, the male sling has had a resurgence of popularity in the search for a minimally invasive, efficacious, “natural voiding” alternative to treat PPI. The male sling is a passively obstructive device that appears to function by increasing the urethral closure pressure and functional sphincteric length, thereby augmenting existing sphincteric function. This may be why it does not work as well in patients with severe sphincteric incontinence. Male slings are easily placed using a perineal approach and can be fixated using either bone anchors (into the inferior pubic ramus) or a transobturator approach. Although slings are more commonly used in patients with mild to moderate PPI, and the AUS with more severe PPI, high rates of continence and patient satisfaction have been reported using both the male sling and AUS in properly selected patients (Rajpurkar et al, 2005; Gallagher et al, 2007). A more thorough and in-depth discussion of the male sling and artificial urinary sphincter are covered in Chapter 79.

Closure of the Bladder Outlet

Complete closure of the bladder neck is rarely necessary, because a compressive bladder neck sling is more easily performed, is less morbid, and allows transurethral access if necessary. The main indication for bladder outlet closure is urethral destruction secondary to prolonged catheter drainage in neurogenic bladder patients. The clinical course is typically a progressive worsening of leakage around the catheter, requiring progressively larger-bore catheters and larger volumes of fluid in the balloon, ultimately resulting in a dilated, nonfunctional urethra and bladder neck. It is thought that a long-term Foley catheter and balloon can cause pressure necrosis and bladder neck erosion, especially in the setting of recurrent bladder spasms. In these patients, an obstructing sling or AUS is rarely feasible. For patients with some residual normal urethra, Chancellor and colleagues (1994a) reported on the use of a combined “tight” autologous pubovaginal sling and lower urinary tract reconstruction in 14 female patients with urethras destroyed by long-term Foley use. At 24 months, they reported excellent results with minimal incontinence or other complications. They concluded that at least 1 cm of normal urethra was required for proper functioning of the sling. For patients without residual normal urethra, management options include transvaginal, transabdominal, or combined closure of the bladder neck with simultaneous continent or incontinent urinary diversion, incontinent ileovesicostomy, or suprapubic catheter placement.

Feneley (1963) reported on 24 female patients with neurologic disease who underwent transvaginal bladder neck closure and suprapubic tube placement. Overall results were good; however, a vesicovaginal fistula developed in 4 patients, resulting in persistent incontinence. Zimmern and associates (1985) reported on 6 female patients using a transvaginal closure. At 21 months of follow-up, all patients were cured with no fistulas or incontinence reported. Levy and colleagues (1994) reported a 40% success rate using a transvaginal bladder neck closure. They subsequently modified the approach, using a combined transvaginal-transabdominal approach, and reported a 100% success rate at a mean 16-month follow-up for the subsequent 10 patients. Shpall and Ginsberg (2004) reported on 39 patients who underwent a combined transabdominal bladder neck closure and various continent and incontinent diversions. At a mean of 37 months, 6 patients (15%) developed fistulas; however, 4 patients were successfully repaired, for an overall 95% cure rate. Most recently, O’Connor and colleagues (2005) reported on 35 patients with a mean 79-month follow-up who underwent a transabdominal bladder neck closure for refractory incontinence. They were initially successful in 28 (83%) patients with an overall 94% cure rate after one revision.

As illustrated in this historical perspective, the risk of complications, specifically a vesicovaginal fistula, is relatively common and can be difficult to repair. It is important to remember that a bladder neck closure is much more difficult than a simple closure of the bladder wall. The bladder neck is usually hyperactive in patients with neurologic disease, and every voiding reflex includes active opening and closing of the bladder neck, which forcibly attempts to destroy the bladder neck closure. To reduce this risk, postoperative suppression of the voiding reflex using prolonged continuous catheter drainage (3 weeks) and liberal use of anticholinergics is imperative. In addition, to reduce the risk of fistula, the repair must be watertight from the beginning, and this requires a precise mucosal closure using a running suture and multiple additional layers of muscle to reinforce the strength of the repair (see Fig. 75–3). Lastly, a drain should be used to minimize fistula formation should suture line leakage occur. When performed correctly, a bladder neck closure with simultaneous lower urinary tract reconstruction remains an excellent treatment option in those patients with a destroyed bladder neck or urethra.

Bladder Outlet Reconstruction

Sphincteric incontinence with a fixed, nonvolitional, open bladder outlet may be congenital or acquired. In most cases, the sphincteric musculature is insufficient and denervated and therefore does not provide sufficient closure pressure to prevent incontinence. Techniques have been developed that concentrate on increasing urethral resistance by either tightening or lengthening the urethral segment, such as the Kropp and Pippi-Salle procedures (see Chapter 129) or by constructing a mechanism more similar to the native sphincter. In 1919, Hugh Hampton Young first described a technique to reconstruct the bladder outlet to improve sphincteric continence. Originally, the procedure included resecting a portion of bladder neck and reconstructing the bladder outlet with constricting sutures to effectively narrow its caliber. This technique was further modified by Dees (1949) and Leadbetter (1964). In theory, circularly arranged muscle fibers located in close proximity to the bladder neck are used to re-create a functional, tubularized neourethra that replicates the outlet resistance of a normal sphincteric outlet, but with variable volitional control. The Leadbetter modification involves proximal reimplantation of the ureters to allow more extensive tubularization of the trigone and, theoretically, improved outlet resistance. The construction of this neourethra may be formed from tissue of the anterior bladder neck as described by Tanagho (1981), or from the posterior surface of the bladder wall and trigone, according to any of the variations of the Young-Dees-Leadbetter technique. Leadbetter (1985) reported long-term success rates of 60% to 70% in 34 patients; however, the exact definition of success in this paper is unclear. Clinically, these procedures are most useful for patients with a good-capacity, acontractile bladder and who are mentally and physically able to perform CIC on a regular basis. In addition, care should be taken in the setting of poor bladder compliance or significant detrusor overactivity, because these patients commonly need bladder augmentation. For further discussion regarding the original technique described by Young, and its several variations, refer to Chapters 124 and 129.

Myoplasty for Functional Sphincter Reconstruction

The Holy Grail for sphincteric incontinence may well be the replacement of the dysfunctional sphincter with a new, functional native replacement. The first attempt at this type of sphincteric replacement was a skeletal muscle transposition reported by Deming (1926). He used unstimulated gracilis muscle wrapped around the urethra, which reportedly did improve sphincteric continence; however, the unstimulated skeletal muscle required the patient to voluntarily contract (adduct) the leg for prolonged periods to provide outlet resistance. Additional problems with the use of unstimulated graciloplasty include (1) poor sustainability of the contraction due to the fast twitch, non–fatigue-resistant fibers of the gracilis, (2) high passive resistance resulting in urethral obstruction, (3) postsurgical changes resulting in the loss of resting tension and reduced contractility, (4) the potential for fibrosis due to segmental vascularization (Stenzl, 1998). The next improvement in functional sphincteric replacement was the development of external stimulation of the gracilis using implanted electrodes (Janknegt et al, 1995). They developed an electrical stimulation program that was able to transform fatigable type 2 skeletal muscle fibers to the slow type I fibers that were able to sustain a long-lasting contraction. This early report described three patients who achieved “good results” and one patient who became dry at night. Two years later, Chancellor and colleagues (1997) reported their series using a gracilis urethral wrap in five men with neurogenic bladder dysfunction and severe sphincteric stress incontinence. The procedure was considered successful in four patients; however, three required CIC, and two of these patients had persistent stress incontinence.

The shortcomings of using the gracilis was noted by Stenzl (1998), who commented that the electrically stimulated gracilis muscle was an improvement over the unstimulated muscle; however, the bulky musculature and propensity for stricture formation caused an inherent passive obstruction. This shortcoming was scientifically overcome by Palacio and coworkers (1998) in an animal model using a free but innervated flap of well-vascularized proximal gracilis muscle in female dogs. The smaller size of the graft allowed it to be more easily transposed around the urethra while stimulation of the sphincter was carried out using the graft’s own motor innervation. Unfortunately, this apparently successful animal model has never been reported in a human clinical study.

The most recent twist in an attempt to improve the function of a neurologically damaged sphincter includes injecting allogenic muscle–derived progenitor cells (MDPC) directly into the sphincter (Cannon et al, 2003). The authors used a rat model in which the urethra was mechanically denervated and subsequently injected with MDPCs, which dramatically improved the fast-twitch muscle contraction amplitude from 8.8% to 87% (compared with normal amplitude). Although promising, this innovative and minimally invasive option for sphincteric incontinence has not yet been proven in follow-up human clinical studies.

Augmentation Cystoplasty

Bladder augmentation offers the best chance to construct a “normal” urinary system and, as such, should be considered before attempting urinary diversion. The ability to void without self- catheterization is not guaranteed, especially in men; therefore, this procedure should only be considered for patients who have the ability and motivation to perform CIC, because bladder rupture can be a life-threatening complication. CIC performed by a caretaker is rarely adequate and makes the patient dependent on a caretaker. If the urethra is not a reliable conduit—due to urethral stricture, or access to the native urethra is limited by spasticity, obesity, or contracture—a continent abdominal stoma or alternate procedure should be considered.

Originally, augmentation cystoplasty was used for the treatment of bladder fibrosis secondary to tuberculous cystitis (Smith et al, 1977

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