Surgery for 

Bladder Neck/Urethra
48
David Manuel Castro-Diaz and Barbara Padilla-Fernandez

48.1 S
 urgery to Decrease Outflow sures are avoided. Sometimes, a degree of continence can be
Resistance maintained, though this depends on preservation of bladder
neck function and, in men, the degree of prostatic
48.1.1 Sphincterotomy resistance.
Though it can diminish urologic complications of DESD,
Surgical sphincterotomy aims to decrease outlet resistance in sphincterotomy is not without risk. Pre-surgical counseling
order to protect the upper urinary tracts, reduce risk of uri- should include discussion of possible hemorrhage, erectile
nary tract infection, and diminish rates of autonomic dysre- dysfunction, retrograde ejaculation, urethral stricture, and
flexia in the face of neurogenic DESD [1]. Indications fistula formation. Practical problems include chronic incon-
include worsening hydronephrosis, vesicoureteral reflux, tinence, which can lead to unpleasant odors, soiled garments
autonomic dysreflexia and recurrent UTIs believed to be due and, more concerning, skin breakdown and the development
to poor bladder emptying. This procedure is performed of ulcers. In Pan’s series of 116 sphincterotomies, no patient
transurethrally with the goal of dividing, either completely required transfusion. Other authors have noted a rate of clini-
or partially, the fibers of the external urethral sphincter [2]. It cally significant bleeding of about 10%, but also state that
has been described using either electrocautery [3] or laser transfusion is rare [2, 7]. When Yalla et  al. compared men
energy [4] for division. Typically, the incision is extended at undergoing sphincterotomy at the 12 o’clock position vs. the
the 12 o’clock position from the mid-prostatic urethra to the 3 and 9 o’clock positions, he found a 9% transfusion rate in
bulbomembranous junction. The depth can be difficult to the 3/9 group and gave no transfusions in the 12 o’clock
gauge, but early pioneers of the procedure report it should be group [8]. Contemporary reports on erectile dysfunction
carried down until the plane of the periurethral venous rates vary from 3 to 7% after sphincterotomy [2, 9] with rates
sinuses is seen [5]. It has been recommended for patients of urethral stricture between 3 and 13% [10].
with concomitant bladder neck dysfunction that an addi- Moreover, sphincterotomy should not be considered a
tional 6 o’clock incision of the bladder neck be made, as with permanent solution for DESD and these patients do require
traditional transurethral incision of the prostate [6]. A large-­ ongoing monitoring for recurrent infections, upper tract
caliber three-way catheter is then inserted to allow for uri- deterioration, and recurrence of DESD. Pan et al. described a
nary drainage and continuous bladder irrigation if needed. series of 84 primary sphincterotomy patients from their cen-
These are typically removed in 24–48  h post operatively. ter, treated from 2001 to 2009 [11]. Of these, at mean follow
There have been no randomized trials comparing laser up of 6.4 years, failure of initial sphincterotomy—classified
sphincterotomy to the electrocautery approach, but propo- as patients who experienced urosepsis, persistent or recur-
nents of the laser approach believe that it conveys a lower rent DESD, upper tract dilation, or worsening renal func-
risk of bleeding. tion—occurred in 68% of patients. Mean time to failure after
With the hypertonic sphincter disabled, the detrusor leak the primary procedure was 36 months. The success rate of
point pressure decreases, and dangerously high storage pres- secondary sphincterotomy in these patients was 43%, with
improvements in storage and emptying parameters being
D. M. Castro-Diaz (*) preserved on average for 80 months. Lockhart reported fail-
Department of Urology, University Hospital of the Canary Islands, ures in 25% of his 60 all-male sphincterotomy series, defined
Tenerife, Spain
as persistent symptomatic UTIs or high residual urine vol-
B. Padilla-Fernandez umes greater than 100  mL, and found that the majority of
University of La Laguna, Tenerife, Spain

© Springer Nature B.V. 2019 383

L. Liao, H. Madersbacher (eds.), Neurourology, https://doi.org/10.1007/978-94-017-7509-0_48
384
failures were in patients with poorly contractile bladders,
such that the bladder was not able to empty even in the face
of reduced outlet pressure [12]. In his series, Lockhart reports
50% success in men with detrusor areflexia, but 84% success
in men with detrusor hyperreflexia.
48.1.2 Bladder Neck Incision
Some urologists combine external sphincterotomy with
some degree of bladder neck incision in their attempt to sur-
gically correct DESD. Bladder neck incisions are classically
performed with two incisions at extending from just distal to
the ureteral orifices, though the bladder neck fibers, and into
the prostatic urethra. Studying the specific contributions of
bladder neck incision toward maintaining upper tract health
and avoiding urinary tract infections in patients with neuro-
genic bladders is difficult, as few authors describe the extent
to which their external sphincterotomy incises the bladder
neck and/or whether they combine a formal, separate bladder
neck incision with that procedure. To date, there are no pub-
lished series in which bladder neck incision is the only ther-
apy used for treatment of DESD.
In their series of adult patients followed at a spinal cord
injury rehabilitation center, Vainrib and colleagues identified
97 patients who underwent “bladder neck incision and exter-
nal sphincterotomy” (BNI/ES) [13]. Of these, 47% required
at least one revision BNI/ES. Common indications for revi-
sion included autonomic dysreflexia, elevated detrusor pres-
sures, recurrent UTIs, elevated PVRs, hydronephrosis, and
new-onset renal insufficiency. In their series, the decision to
undertake ES alone vs. BNI alone vs. a combined procedure
was based on urodynamic and radiographic findings that
indicated the site of lower urinary tract obstruction. However,
they note that early in their series, all patients underwent
combined BNI/ES, as that was the initial standard of care in
their practice. Patient data were reviewed in aggregate, with-
out differentiation between those who underwent BNI and
those who did not, nor those with obstruction primarily at the
bladder neck vs. primarily at the external sphincter. Of note,
success rates (53% at 106 months) and durability of improve-
ment (105–148  months) were similar to other studies in
which BNI was not a standard accompaniment to ES.
The most common complication was bleeding, though no
patients required blood transfusion. Additional complica-
tions unique to BNI include bladder neck contracture, though
Vainrib reports that none of the 46 patients requiring revision
in his study had a bladder neck contracture or urethral stric-
ture. Additionally, the desire to target BNI to bladder neck
obstruction may encourage the use of more frequent videou-
rodynamics, which may add expense to the care of the patient
cohort and may not correlate with substantial improvements
in outcomes.
D. M. Castro-Diaz and B. Padilla-Fernandez
48.1.3 Stents
External urethral stents are an attractive alternative for those
who cannot perform CIC and wish to avoid the perceived
risks of sphincterotomy. They have been demonstrated to
decrease voiding pressures and residual urine volumes [14].
In addition, they are potentially reversible, as the stent can be
removed, and do not carry the risk of erectile dysfunction
seen with more invasive procedures. Both temporary (remov-
able) and permanent stents exist [15].
The most commonly used stent is the UroLume perma-
nent stent (American Medical Systems, Minnetonka, MN), a
tubular woven mesh stainless steel alloy. The radial mesh
exerts a strong, continuous, outward force against the ure-
thral lumen to maintain patency up to 42  Fr. This implant
was first designed for the treatment of BPH, but has been
investigated in the neurogenic bladder population as well.
Indeed, a 20-year series was published by the Spinal Cord
Injuries Centre of the UK’s Royal National Orthopedic
Hospital, where the UroLume stent was first used for DESD
patients [16]. Their series included 12 patients with suprasa-
cral SCI who underwent UroLume stent placement from
1988 to 1990, ranging in age from 26 to 65 years. Of these
patients, six have functional stents and preserved renal func-
tion at 19–21  years post-operatively. Of the remaining six
patients, two had early encrustation requiring stent removal,
one died of infection at 7 years post-insertion with a func-
tional stent, and two were lost to follow up at 1–3 years with
functional UroLume stents in situ. The final patient devel-
oped bladder cancer and required cystectomy and urinary
diversion 14 years after stent insertion.
However, of the six patients with UroLume stents in
place, further procedures have been required. Five required
bladder neck incisions for development of VUR (4), UTI (4),
hydronephrosis (1), and bladder stones (1). The authors
believe that the bladder neck dyssnergia was likely present
prior to stenting, but disguised by the DESD and only
revealed once this aberrant voiding pattern was resolved with
stent placement. Their patient with bladder stones also
required cystolitholapaxy. The mean time to these complica-
tions was nine years. Two of the patients with VUR required
sub-ureteric bulking agent injection for resolution of
VUR.  The authors do report that erectile function was not
altered by stent placement for any of these men and that they
were easily able to perform cystoscopy when indicated while
the stent was indwelling. The group at the Spinal Cord
Injuries Centre reports a substantial decrease in maximum
detrusor pressure from 94 cm/H2O (range 76–112) preopera-
tively to 67 cm/H2O (range 36–88, p < 0.01) after 20 years.
While intended for permanent use, successful removal of
the UroLume stent has been reported [17]. The stent can be
removed by grasping a wire at least 2 mm from the edge and
gently pulling to collapse the stent mechanically, which
48  Surgery for Bladder Neck/Urethra
elongates and narrows the stent, allowing for removal.
Alternatively, the tines can be dissembled in situ and
removed piecemeal. If there is substantial epithelialization,
preliminary disruption of this tissue with either elecrocau-
tery resection or laser ablation may be required. In their
series, the North American Study Group reported a 13%
stent removal rate, mostly for stent migration. Of these
patients, 90% went on to undergo successful placement of a
subsequent stent.
Permanent stents may cause problems if epithelialization
is poor or if a hyperplastic response leads to urethral occlu-
sion. Concern for these risks has prompted interest in tempo-
rary urethral stent placement as an attractive alternative.
Game et  al. describe their experience with temporary ure-
thral stenting in their 2008 series [18]. From 1994 until 2003,
they treated 147 men with mean age of 41 years with tempo-
rary urethral stents placement for neurogenic DESD.  All
patients were either unable or unwilling to perform CIC and
were interested in an alternate form of bladder management.
They placed the stents endoscopically: 121 with lidocaine
jelly in awake patients, 9 with neuroleptanalgesia, and 17
under general anesthesia. Patients were monitored 1 and
3  months post operatively, and then every three months
thereafter. They had four cases of hypertensive crisis due to
autonomic dysreflexia and one case of urethral bleeding.
Early postoperative complications were seen in 21%: UTI
with symptoms in 10%, urinary retention in 5% (requiring
suprapubic tube placement in five patients), and gross hema-
turia in 3%. One patient had a stroke related to hypertensive
crisis and ultimately expired; another suffered bradycardia
and resuscitated cardiac arrest. Later complications included
symptomatic UTI in 8% and difficulties using condom cath-
eters in 7%. Stent migration was reported in 29% of patients.
Mean PVRs were > 200 mL lower in the postoperative set-
ting (mean 298  mL preoperatively vs. 81  mL post opera-
tively, p < 0.01). Upper tract dilation rates were lower in the
postoperative period as well (three patients vs. 12 patients,
p = 0.03). The majority of stented patients leaked urine into
a condom catheter (70%) as their preferred method of blad-
der management.
Ultimately, the mean duration of temporary stenting was
10  ±  16  months. Upon stent removal, encrustation was
observed in 3% and granulation tissue in 10%. All stents
were easily removed per the authors’ report. In their series of
147 patients, a permanent urethral sphincter stent was placed
in 63% of patients after removal of the temporary stents. The
authors describe temporary stenting as useful bridge therapy
to allow time for upper motor function to improve after an
acute injury and/or to test the therapeutic intervention of ure-
thral stenting prior to placing a permanent stent. At this time,
the Memotherm (Angiomed, Karlsruhe, Germany) and
Diabolo (Coloplast, Humlebaek, Denmark) stents remain
commercially available.
385
Stents are not without complications, including encrusta-
tion, migration, erosion, recurrent UTIs, overgrowth of gran-
ulation tissue and possible obstruction. Chancellor et  al.
reported stent migration rates of 30% and urethral erosion
rates of about 2% at 5 years after insertion [14]. Moreover,
removal of urethral stents can be challenging. Some authors
also raise the theoretical possibility of autonomic dysreflexia
due to stretch of the urethral wall; however, this complica-
tion appears to be rarely borne out in practice. Ultimately, as
with all neurogenic bladder patients, those with urethral
stents will require attentive follow up to assess urodynamic
parameters, upper tract health, and stone risk, and infectious
complications.
48.2 Surgery to Restore Continence
48.2.1 Urethral Slings: Men and Women
48.2.1.1 Pubovaginal Slings
Pubovaginal slings have long been the treatment of choice
for both adults and children with neurogenic SUI since they
can achieve urethral compression and also give support [19].
Continence rates are high (85–90%), and it is an established
procedure in women with the ability to self-catheterise
because a high tension is given to the sling [20–23]. It was
initially described in 1907 using autologous gracilis or
pyramidalis muscle [24], but it was reintroduced with modi-
fications in 1978 by McGuire and Lytton [25].
Several materials have been used for the pubovaginal
slings [26]:
• Autologous graft materials: the tissue is harvested from
the same patient’s body, which offers maximum bio-­
compatibility and excellent incorporation into the host tis-
sue with minimal inflammatory reaction [27, 28]. The
most commonly used sling material is the anterior part of
the rectus muscle fascia [29, 30], but other techniques
have been described as the fascia lata sling obtained from
the lateral tight [31, 32] and the vaginal wall harvesting
the midline vaginal mucosa and the underlying periure-
thral support structures to create a sling initially described
by Raz [33] and modified afterwards by several groups
[34, 35].
• Allograft materials: the tissue is obtained from human
cadaveric donors and needs lyophilization (freeze-drying)
and sterilization by gamma radiation in order to decrease
the risk of transmission of infectious agents to the recipi-
ent [32]. Slings usually belong to fascia lata and rectus
muscle fascia.
• Xenograft materials: the tissue is transferred from one
species to another. The diisocyanate processing method is
used to suppress the immune response and decrease the
386
risk of infection. Common xenografts for pubovaginal
slings are bovine pericardium, porcine bowel, and porcine
dermis [36, 37].
• Synthetic prosthetic materials: loosely woven polypropyl-
ene mesh is the most commonly used material because it
allows for the best ingrowth of the host tissue and macro-
phage transition [28, 38, 39]. However, erosion/exposure
and infections are more often reported with these materi-
als [40].
The outcomes after fascia lata allograft slings are con-
troversial [41, 42] and some authors have reported the
allograft-­associated transmission of s human immunodefi-
ciency virus in one in eight million cases and prion infec-
tions [43, 44], and autograft rectus muscle fascia is more
commonly used [45, 46]. Comparing to synthetic or
allograft slings, a longer operating time due to graft har-
vesting and repositioning of the patient is needed, and asso-
ciated morbidities of the harvesting site such as bleeding
and infection may appear [47].
For the harvesting of the rectus fascial graft in women, a
Pfannenstiel incision 2 cm above the pubic symphysis is per-
formed with the dissection carried down to the rectus fascia.
A 2 × 10–12 cm rectus fascia graft is marked out and the edges
of the graft are dissected and freed from the underlying rec-
tus muscle. Running sutures of polypropylene are stitched
onto each end of the graft with the sutures left long. After
placement of a urethral catheter and hydrodiseccion of the
vaginal mucosa, the bladder neck is identified by palpation
of the catheter balloon. A vertical incision is made from 2 cm
below the meatus to the level of the bladder neck. Then, lat-
eral vaginal flaps using a combination of sharp and blunt dis-
section are created, which are lifted up with Allis clamps and
the ischiopubic ramus is palpated. A window is created in the
ipsilateral endopelvic fascia using Metzenbaum scissors
pointing upward, toward the ipsilateral shoulder, and open-
ing the space between the endopelvic fascia and ischiopubic
rami that has previously been hydrodissected. The ends of
the graft sutures are tied to the blunt ends of the trocars and
brought out through the vaginal incisions. By careful guid-
ance behind the pubis, the trocars are brought out through the
abdominal incisions. A cystoscopy with a 70-degree should
be performed to check for any urethra or bladder injury
before pulling out the trocars completely. The two free ends
of the sutures are then pulled up while keeping an artery for-
ceps or scissors in place between the fascia and periurethral
tissue. The suture ends are tied together above the rectus fas-
cia with a finger placed underneath the knot to avoid exces-
sive tension [47].
Although it is more common to identify neurogenic SUI
in women, puboprostatic fascial slings have also been suc-
cessfully used in men [19, 20, 48–50]. An abdominal
approach is commonly used (especially if the procedure is
D. M. Castro-Diaz and B. Padilla-Fernandez
going to be performed during an augmentation cysto-
plasty) beginning with a midline incision extending from
the symphysis up to the umbilicus and opening the space
of Retzius. The endopelvic fascia is then identified and
incised to obtain the plane between the urethra and rectum,
and a right angle clamp is passed under the urethra avoid-
ing injury to the rectum. A free graft of rectus fascia mea-
suring approximately 10  ×  1.5  cm is obtained from the
edge of the incision and it is then passed around the urethra
just distal to the prostate. The ends are secured to (ipsi- or
contralateral) Cooper’s ligament using 1-0 polypropylene
[20].
48.2.1.2 Midsuburethral Synthetic Slings
Midsuburethral synthetic slings are the choice of election in
female non-neurogenic SUI, but they have been introduced
later in neurogenic patients [51]. They have gained popular-
ity because surgeons avoid operative morbidity and compli-
cations of harvest site pain and infection of the autologous
fascia slings. Early and late continence rates in this subgroup
of patients is comparable to the general population, although
the need of catheterisation is higher conditioned by patient’s
neurogenic disorder [52, 53]. De novo overactive bladder
can also appear that can be managed with antimuscarinics
and botulinum toxin injections [52, 54].
Some authors have reported their experience with poly-
propylene male urethral slings with good continence results
but with persistent need of intermittent catheterization and
also reporting infections and technical problems in the initial
cases [55, 56]. Avoiding an abdominal incision and perform-
ing the surgery with a perineal approach may allow to
undergo an outpatient procedure. New-onset catheterisation
rates are lower than with puboprostatic fascial slings and
infections or other complications may be minimised in spe-
cialised centres [55, 57, 58].
Polypropylene mini-slings have been also used in both
men and women with neurogenic SUI and with previous
need of intermittent catheterization with good continence
rates [59], but there is still limited data on long-term conti-
nence rates.
48.2.2 Artificial Urinary Sphincter: Men
and Women
Artificial urinary sphincter (AUS) has been frequently placed
in children with myelomeningocele. It consists of three com-
ponents: a pressure-regulating balloon, an inflatable cuff,
and a control pump. The advantage of AUS placement in this
population is that patients may be able to void spontaneously
and avoid intermittent catheterization [60, 61]. On the other
hand, up to 34% of children without augmentation cysto-
plasty prior to AUS placement may require augmentation
48  Surgery for Bladder Neck/Urethra
due to deterioration of bladder dynamics after AUS place-
ment [60, 61].
A systematic review by Farag et al. analysing the success
rate of the surgical treatment of neurogenic SUI and the
individual effectiveness of each surgical modality (AUS,
slings and bulking agents) included 30 studies involving 849
patients (525 males and 324 females) with a median age
21 years old (range 3–80). The AUS studies reported a lon-
ger mean follow-up, highly significant success rates com-
pared to urethral bulking but no statistical differences
compared to suburethral slings, and higher reoperation rates
[62].
The complication rates and reoperation rates are higher
than in non-neurogenic patient groups (up to 60%), so it is
advisable that patients are conscientiously informed about
the success rates as well as the complications that might
occur after the procedure [62–64]. Reinterventions are com-
monly due to infection, urethral atrophy or erosion, and
mechanical failure [65, 66].
Some authors prefer to implant the AUS at the bladder
neck rather than bulbar urethra because those AUS are
larger and urologists would have a lesser chance of damag-
ing the device with a large-bore rigid cystoscope if needed.
Similarly, it is less probable to damage the device for
patients on intermittent catheterization regimes (with
direct trauma on the urethra) and those wheelchair-bound
(who can develop perineal pressure sores close to the bul-
bar urethra) [61]. No statistically significant difference has
been found when comparing this position to the common
bulbar urethral devices in terms of success, failure or reop-
eration rates, but the complication rates were lower [62].
In France, an expert consensus has been reached on the use
of bladder neck implantation in male neurogenic SUI
patients [67].
Laparoscopic placement of AUS in the bladder neck/peri-
prostatic in patients with neurogenic SUI has been described,
and even the robot-assisted transperitoneal procedure in six
men with neurogenic SUI secondary to spinal cord injury
with no revision or complication reported after a median
follow-up of 13 months (range 6–21) [68].
Another modified technique has been described, replac-
ing the intrascrotal pump with a port that was used 6 weeks
after surgery for inflating the implant with the exact amount
of fluid needed to achieve continence during a video-­
urodynamic control. This port can be also accessed later to
adjust the filling if urinary leakage reappears and it can be
even used if leakage of the implant is suspected by injecting
contrast media into the system [69]. The majority of patients
with neurogenic bladder dysfunction secondary to spinal
cord lesion need intermittent catheterization, and they some-
times lack the dexterity and mobility to handle the pump, so
this method could be a good alternative in this subgroup of
patients.
387
48.2.3 Urethral Bulking Agents
Patients with spinal cord lesions below the level of the sacral
micturition center commonly experience sphincteric incom-
petence which leads to stress urinary incontinence (SUI)
[62]. In these patients, mild stress urinary incontinence can
sometimes be treated with procedures to increase the bladder
outlet resistance. One such procedure is endoscopic place-
ment of urethral bulking agents [70]. This treatment is mini-
mally invasive and can usually be performed in the office
[71]. Agents include bovine cross-linked collagen and dex-
tranomer hyaluronic acid.
Collagen injections for intrinsic sphincter deficiency in
neurogenic bladder patients were first described in the late
1980s by Shortliffe et al., who treated 17 adults and achieved
53% improvement or cure of SUI [71]. A 1995 study by JK
Bennett and colleagues described their experience with 12
neurogenic bladder patients [72]. Their group reported
injecting the crosslinked collagen under the urethral mucosa
so as to increase the coaptation of the urethral walls, enhanc-
ing the competence of the patient’s sphincter and inhibiting
SUI.  In their series, 64% were substantially improved or
cured with regard to their SUI.  The mean pretreatment
Valsalva leak point pressure was 60 cm H2O, which improved
to 117  cm H2O in post-operative patients. None of the
patients experienced significant complications during the
24  month follow up period and all were able to continue
CIC. These studies and others like them [73, 74], support the
use of collagen as an alternative or adjunct to pharmacother-
apy, surgical reconstruction, or implantation of a prosthesis
in the management of SUI in the neurogenic bladder patient.
Lightner et al. included spinal cord injured women with
sphincteric deficiency in their trial of cystoscopic injection
of dextranomer hyaluronic acid, and found this product to be
“neither safe nor efficacious,” with a high rate of pseudoab-
scess (11%) and de novo urge incontinence (46%), as well as
poor patient-reported efficacy (only 33% with durable
improvement in voiding symptoms). The group recommends
against the use of dextranomer hyaluronic acid for periure-
thral injections [70].
In their meta-analysis, Farag and colleauges reported
27% success with bulking agents at a median of 30 months
follow up [62]. The six studies that used bulking agents
included 126 patients (65% male), with collagen used in
74% and polydimethysiloxane in 22% [62]. The median
reported complication rate was 4% with a 12% reoperation
rate. One third of patients received three or more injections
of bulking agent prior to study completion. Success rates
were greater in patients whose neurogenic SUI was treated
with a urethral sling or artificial urinary sphincter, rather than
a bulking agent, however both had higher rates of complica-
tions, and the AUS group had a median 51% reoperation rate.
The authors conclude that the AUS is the gold standard for
388
neurogenic SUI, with a urethral sling being a reasonable
second-line option.
48.2.4 Bladder Neck and Urethral
Reconstruction
The bladder neck is a critically important structure in pre-
venting loss of the urine from the bladder. During bladder
filling, the bladder neck must remain closed. It should be
also stress competent. These sphincteric properties must
become quiet during voiding, reverse their roles, and form a
compliant tube through which urine can pass [75]. Regardless
of the primary cause, urine leakage in the absence of a detru-
sor contraction is the definition of an incompetent urinary
sphincter mechanism [76].
Urinary incontinence as a result of bladder neck incompe-
tence is a serious medical, social, and psychologic problem
for children, parents, and caregivers. Causes of bladder neck
incompetence in children include neurogenic bladder
(myelodysplasia, sacral agenesis, or other congenital or
acquired spinal cord injuries), the exstrophy-epispadias com-
plex [77], cloacal malformations, bilateral or single ureteral
ectopia, and trauma [75]. Seventy percent of children with
myelodysplasia have an incompetent bladder neck [78].
When urinary incontinence persists after correct anticholin-
ergic treatment and clean intermittent catheterization, blad-
der neck reconstruction is recommended. It is also
recommended in adult patients with urinary incontinence
with a congenitally incompetent bladder neck [79], an
extremely common and lifelong issue affecting up to 71% of
patients who present to transitional clinics [80].
Common findings leading to bladder neck reconstruction
are open bladder neck on cystography during low pressure
urine storage and abdominal leak point pressure less than
40 cm H2O based on urodynamic study besides a poor com-
pliance [81].
As suggested by Kropp, bladder neck reconstruction
should be performed for achieving continence in patients
with normal bladder innervation, normal detrusor muscle
function, a prior history of normal voiding, and correctable
bladder neck anatomy. On the contrary, bladder neck recon-
struction should be performed for dryness when patients
have faulty innervation, an abnormal or non-functioning
detrusor muscle, numerous prior failed bladder neck recon-
structive procedures for continence, and the prior initiation
of an intermittent catheterization program [75].
An ideal BOP for neurogenic bladder patients should
achieve the following [82]:
• socially acceptable dryness, which is commonly accepted
as a minimum of 3–4  h dry-interval with intermittent
catheterizations;
D. M. Castro-Diaz and B. Padilla-Fernandez
• not to compromise bladder volume, bladder function or
upper urinary tract;
• allow easy catheterization and a pop-off mechanism at
high pressures;
• long-term reliability,
• easy performance with a short learning curve.
Various techniques have been described: Young-Dees-­
Leadbetter (YDL) [83–85], the Kropp repair [86], the Pippi-­
Salle [87], and the modified Leadbetter/Mitchell (LM) repair
[88]. Studies reviewing these bladder neck reconstruction
techniques report reasonable continence rates ranging from
50 to 85%. Other authors have reported case series with dif-
ferent techniques, for example bladder neck reconstruction
by lengthening, narrowing and tightening the bladder neck
with a combined tubularized posterior urethroplasty and cir-
cumferential fascial wrap [89]. Robot-assisted bladder neck
reconstruction has been described [90, 91].
In 1986, Kropp et al. [86] reported their experience with
the creation of a bladder tube allowing a catheter to be passed
into the bladder but avoiding urine leakage. For this purpose,
a rectangular bladder pedicle flap is outlined on the anterior
bladder wall and based upon the bladder neck. Afterwards,
the bladder is completely separated from the bladder neck
and a tube is created rolling the flap over a Foley catheter.
This tube is then attached to the bladder creating a broad
submucosal tunnel between the ureteral orifices, and the
bladder is closed down to and around the bladder neck. They
also described the development of the tubularized bladder
flap from the posterior bladder wall. Several modifications to
simplify Kropp procedure have been described, for example
incomplete detachment of the bladder neck [92], placement
of the detrusor tube in a shallow [93], excision the muscular
layers of the tube down to the mucosa [94].
Later, Pippi Salle et  al. [87] developed another surgical
technique using an anterior bladder wall flap which was
sutured to the posterior wall in an onlay fashion creating a
flap valve mechanism. One of the main differences with the
previous repair is that two parallel incisions were made in the
posterior trigonal mucosa to expose the muscle, and both
ureters were reimplanted using a crosstrigonal method. They
have also described their own modification of the technique
in order to avoid formation of urethrovesical fistula and/or
partial necrosis of the intravesical neourethra like creating a
widened base to the urethral flap, a lateralized flap in those
patients with previous bladder surgery and discontinuation
of routine ureteroneocystostomy [95].
Specifically in incontinent children after staged exstro-
phy/epispadias reconstruction, a detrusor wraparound was
first described as the Heiss loop by Gil-Vernet in 1953 and
Woodbourne in 1968, and then popularized as the anterior
detrusor loop by Mollard in 1980 [96, 97]. Kurzrock et al.
also described a similar technique in a patient population
48  Surgery for Bladder Neck/Urethra
with neurogenic incontinence in 1996 [98]. These reports
preceded the development of the Mitchell modification of
Young-Dees-Leadbetter bladder neck reconstruction, also
known as Leadbetter/Mitchell repair [98]. The main steps in
this technique are the transverse opening of the bladder neck
followed by the performance of parallel incisions lateral to
the trigone almost reaching the ureteral orifice and leaving a
posterior strip of trigone. The anterior bladder wall is
retracted cranially and the urethra is then tubularized with
the completion of the bladder closure. The newly tubularized
neourethra is then coapted and supported by an autologous
strip of demucosalized detrusor flap that is wrapped once cir-
cumferentially around the bladder neck.
Bladder neck reconstruction may be complemented with
augmentation cystoplasty if the patients have a poor bladder
compliance even after anticholinergic treatment [99], end
filling pressures >40 cm H2O (or >80 cm H2O) and/or hydro-
nephrosis grade 3–4 [100]. Both procedures may be done in
the same surgery or cystoplasty may be indicated and per-
formed afterwards in order to avoid mucous interfering with
catheter drainage, bladder stones, metabolic acidosis, vita-
min B12 deficiency, and risk of death from bladder rupture
with sepsis and shunt contamination and/or future malignan-
cies [101]. Some authors also describe bladder neck recon-
struction after augmentation cystoplasty with/without a
catheterizable channel [102]. It is also possible to combine
bladder neck reconstruction with a sling procedure. A study
by Snodgrass and Barber reported that patients undergoing
LM procedure plus fascial sling were significantly less likely
to require pads postoperatively than those with a sling alone
[103]. In high-volume centres, combination of different sur-
gical techniques as primary continence procedures is feasi-
ble and achieve reasonable success rates [104].
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