In adults, fascial slings may be performed transvaginally, and a small patch of fascia is secured with suspension sutures. In pediatric patients with congenital anomalies, fascial slings have in general been placed from above, often at the time of bladder augmentation. Before placement, the pelvic floor is cleared of overlying fatty tissue and a 2-cm incision made through the endopelvic fascia on either side of the bladder neck and proximal urethra (Fig. 96.1A). This area may be identified by palpation of a transurethral catheter and balloon seated at the bladder neck. Using blunt dissection, a plane is developed between the bladder neck and vagina in girls or rectum in boys (Fig. 96.1B). This plane may at times be more easily developed from the cul-de-sac by dissecting behind the bladder and ureters from above. With a difficult dissection, it may be useful to open the bladder, in particular if bladder augmentation is planned.

Once the proper plane is developed and the appropriate length of graft determined, a rectus abdominis fascial strip 1 cm in width and appropriate in length is harvested. The fascia may be taken in either a vertical or horizontal fashion depending on the initial incision. Fascia from other sites has been utilized but requires a second incision. Autologous cadaveric tissue or biodegradable scaffolds may also be used.

All of the grafts are in general brought through the rectus muscle and anterior rectus fascia on either side and approximated to the anterior rectus fascia using permanent sutures (Fig. 96.1C). If long enough, the two limbs of the sling may also be approximated to each other superficial to the fascia.

In patients with stress incontinence, the sling is placed tightly enough to maintain the proximal urethra and bladder neck in the appropriate anatomic position. Too snug of placement in such a setting may impede spontaneous voiding. When used for patients with neurogenic dysfunction who will not rely on spontaneous voiding, the sling may be pulled up more tightly to improve compression of the bladder neck and proximal urethra. If intermittent catheterization postoperatively will be performed through the native urethra, intraoperative catheterization should be repeated frequently to make sure the fascial sling is not placed so tight as to impede catheterization.

A commonly employed modification of the traditional suspensory sling, used by many reconstructive surgeons, is the wrap-around sling. In this modification, the sling material (fascial or other) is wrapped around the bladder neck completely prior to securing the free ends in the manner of a suspensory sling. The theoretic advantage of this approach is greater coaptation of the bladder neck tissue than with a traditional sling while preserving the ability to perform intermittent catheterization per urethra (8).

The Young-Dees-Leadbetter bladder neck repair is typically performed in the setting of exstrophy-epispadias complex in the modern staged repair of exstrophy and after epispadias repair. Ideally, it is performed when a patient’s bladder capacity under anesthesia by gravity cystography is at least 85 mL and when the patient can participate in a strict postoperative voiding program (9). After bladder exstrophy closure, the procedure is typically performed through a lower midline incision. For patients with epispadias who do not require augmentation, the reconstruction may be done through a Pfannenstiel incision.

The anterior bladder is opened. This incision is carried as far distally into the proximal urethra as possible. Splitting of the intersymphyseal band with subsequent closure may allow closure and tapering of the proximal urethra. Virtually all exstrophy patients require antireflux surgery, and typically, the ureteral hiatus is initially quite low in the bladder. The ureters are mobilized and reimplanted into the bladder 3 to 4 cm more cephalad in location. Typically, the ureters are reimplanted with a cross-trigonal technique, although the tunnels may even be angled upward in a cephalad direction from the new hiatus. A 12- to 15-mm wide strip of mucosa is preserved in the posterior midline of the urethra and bladder trigone for reconstruction of the neourethra. Parallel incisions through mucosa are made on either side of this strip and the triangles of trigone mucosa on either side excised (Fig. 96.2A). Submucosal infiltration of dilute epinephrine in those two areas may aid in excision and decrease bleeding. The midline strip of mucosa and subsequent neourethra are typically made 4 to 6 cm long depending on how much proximal urethra is exposed and reconstructed. The midline strip is tubularized over an 8 Fr catheter using absorbable sutures to approximate the edges. This tubularization may be done with interrupted or running absorbable sutures but should be tension-free (Fig. 96.2B). Small purchases of the adjacent superficial muscle
of the trigone may be included with the mucosa for strength. The closure is easier to begin distally and finished cephalad. The lateral flaps of trigone muscle are then wrapped over the neourethra in an overlapping fashion. To do so without tension, the muscle must be incised transversely at the cephalad margin of the mucosal excision. One flap of muscle is wrapped over the neourethra and approximated to the underside of the other muscle flap using interrupted, absorbable mattress sutures. The second flap of muscle is then wrapped over the first and approximated to the outside of the muscle, again with absorbable sutures (Fig. 96.2C). A soft urethral catheter is left in place during healing but should be secured so as to avoid tension on the neourethra. Ureteral stents or catheters are often left in place because of potential edema. The bladder is closed in two layers.