OBJECTIVE: This study describes the management of urinary incontinence (UI) in eight girls with congenital pouch colon (CPC) associated with anorectal malformation (ARM).
METHODS: From 2013 to 2015, six girls with CPC and UI underwent bladder neck reconstruction (BNR). Four girls had complete UI (CUI) and two girls partial UI (PUI). From 2019 to 2023, four girls, including two with failed BNR, underwent bladder neck closure (BNC) and augmentation cystoplasty (AC) with a continent stoma. Subtypes of CPC were Complete CPC (n = 7) and Incomplete CPC (n = 1). All girls had a double vagina; short, wide urethra; and reduced bladder capacity with an open, incompetent bladder neck (BNI). During BNR, a neourethra was constructed from a 1.5-2 cm-wide and 1.5-3-cm-long trigonal strip. During BNC, AC was performed using a 20 cm ileal segment (n = 3) and by a colonic pouch segment, preserved during earlier colorraphy (n = 1). Continent stoma included a Monti\'s channel (n = 3) and appendicovesicostomy (n = 1).
RESULTS: BNR produced moderate improvement of UI (n = 2), while UI was still very severe (n = 4). During BNC, intraoperative complications included iatrogenic vaginal tears (n = 4). Early complications included partial dehiscence of the ileocystoplasty (n = 1), partial adhesive small bowel obstruction (n = 1), and difficulty in stomal catheterization with prolonged drainage from the pelvic drain (n = 1). Late complications included unilateral grade II vesicoureteric reflux (n = 2) and vesicovaginal fistula (VVF) (n = 2) needing trans-vaginal closure in one girl. Urinary stones (n = 2) with stomal leakage of urine in one girl needed open cystolithotomy twice (n = 1), and endoscopic lithotripsy (n = 1). At follow-up, all patients have high overall satisfaction with the procedure and their continence status.
CONCLUSIONS: BNC with AC and a catheterizable stoma satisfactorily achieves continence in girls with CPC and UI, vastly improving quality of life. If lower urinary tract (LUT) anatomy is favorable, BNR with/without AC can be the initial surgical procedure. BNC should be the primary procedure in girls with unfavorable LUT anatomy and for failed BNR.
METHODS: IV.

BACKGROUND: Epispadias, which occurs on the more mild end of the Bladder Exstrophy Epispadias Complex (BEEC) spectrum, presents still with a wide range of severity in boys, from mild glanular epispadias to penopubic epispadias with severe urethral and bladder neck defects. Surgical management ranges from isolated epispadias repair to epispadias repair with bladder neck reconstruction (BNR) with or without pelvic osteotomies.
OBJECTIVE: We aimed to evaluate outcomes in epispadias treated at three institutions prior to formation of a formal collaboration. In addition, we sought to delineate outcomes based on anatomic severity at time of diagnosis, and initial procedure performed in cases of penopubic epispadias.
METHODS: IRB approved databases were retrospectively queried at three institutions for patients who underwent repair of epispadias between 1/1993 and 1/2013. Degree of epispadias, age and technique at initial repair, and self-reported continence status at last follow-up were recorded. Continence was categorized as: wet, intermediate (dry 2-3 h), or dry, while also distinguishing those who void and those who require clean intermittent catheterization (CIC). Those not seen since 1/1/2015, younger than 10 years at last follow up, or in whom continence data were not recorded were excluded.
RESULTS: A total of 48 boys were identified; 36 met inclusion criteria. The epispadias cohort consisted of 8 glanular epispadias (GE) (22%); 8 penile epispadias (PE) (22%), and 20 penopubic epispadias (PPE) (56%) with a median follow-up of 11.3 years (3.2-26.2 years). Overall, 33 of 36 (92%) boys void per urethra. Within the group that voids, 19/33 (58%) are completely dry, while 6/33 (18%) are wet. Among patients who underwent initial epispadias repair without concurrent or subsequent bladder neck reconstruction, continence rates were: GE 63% (5/8); PE 75% (6/8); PPE 71% (5/7). Among the 9 boys with PPE who underwent initial epispadias repair with concurrent BNR, 22% (2/9) were dry with no further surgeries. Overall, 8/20 (40%) of boys with PPE void with complete dryness.
CONCLUSIONS: This multi-center retrospective review of continence in epispadias demonstrates that even some boys with glanular and penile epispadias can have challenges with continence, and boys with penopubic epispadias may remain wet despite careful preoperative assessment of bladder neck functionality and concurrent BNR.
CONCLUSIONS: Continence outcomes in boys with all degrees of epispadias can be variable. Even boys with more distal defects may have significant bladder neck deficiency. And those with the most severe form of epispadias may require bladder neck reconstruction to achieve continence.

BACKGROUND: This study aims at investigating the continence outcome in primary epispadias patients treated at a tertiary center. The authors hypothesized that additional continence procedures following primary epispadias repair is not routinely needed.
METHODS: Patients treated for primary epispadias at the authors\' institution between 2007 and 2019 and toilet trained, were identified from a prospective maintained database. Males underwent chordee correction, urethroplasty and glanuloplasty. Females underwent genitoplasty with reduction urethroplasty. If continence was not achieved by 4-5 years of age, pelvic floor muscle (PFM) biofeedback therapy was performed. Other continent procedures were discussed with family/patient if still incontinent.
METHODS: urinary continence.
RESULTS: PFM biofeedback therapy, continence surgery, hydronephrosis. Type of epispadias, age at repair and follow-up presented as median was also reported.
RESULTS: Thirty-three patients (29 males) were included. Twelve had penopubic epispadias, 13 glanular/penile, 4 duplicated urethra, 4 females. Median age at repair: 2 years (IQR 1-3), at follow-up: 8 years (IQR 6-10). Daytime continence: 100 % in penile/glanular; 33 % in penopubic and 75 % in duplicated urethra. Nighttime continence: respectively 92 %, 50 % and 100 %. 24 % of males were intermittently incontinent. All patients except one voided urethrally. One patient underwent bladder neck closure, ileocystoplasty and Mitrofanoff. One girl achieved daytime continence, 2 were intermittently incontinent, one continuously incontinent. All were enuretic. 38 % of boys and 100 % of girls had biofeedback therapy. None had hydronephrosis/renal impairment.
CONCLUSIONS: Most children with primary epispadias can achieve social urinary continence spontaneously or with the support of PFM biofeedback therapy. Other continence procedures should be reserved for patients who do not attain satisfactory continence.
METHODS: Treatment study - level IV.

Following successful closure of patients with classic bladder exstrophy (CBE), the next major milestone is the establishment of urinary continence. Prior to determining the most appropriate continence surgery, it is imperative to reach an adequate bladder capacity minimum of 100 cc in order to make the decision between bladder neck reconstruction (BNR) or continent stoma, with or without augmentation cystoplasty (AC).
To examine the timing of when patients achieve threshold bladder capacity for BNR eligibility. We hypothesize most patients will achieve an adequate bladder capacity (100 cc) by 7 years old when continence surgeries will begin to be considered.
An institutional database of 1388 exstrophy patients was retrospectively reviewed for CBE patients after successful primary bladder closure. Bladder capacities were measured via gravity cystography and data presented as descriptive statistics. The cohort was stratified by location, neonatal (≤28 days) or delayed closure period and osteotomy status. The bladder capacities were categorized to either reaching goal or not and a cumulative event analysis was performed. The event being reaching 100 cc capacity or greater and time being the number of years between bladder closure and attainment of goal capacity.
253 patients met inclusion criteria between 1982 and 2019. The majority were of male gender (72.9%), had their closure performed at the authors\' institution (52.5%), within the neonatal period (80.7%), and without an osteotomy (51.7%). 64.9% of patients reached goal bladder capacity. There were no significant differences in those who did or did not achieve goal except for clinical follow up. Cumulative event analysis demonstrated a median time of 5.73 years (95% CI 5.2-6.20) corresponded with a 50% event probability of reaching goal capacity. Cox-proportional hazards showed location of closure was significantly associated with hazards of reaching goal bladder capacity (HR = 0.58, CI 0.40-0.85, p = 0.005). Based on this model, the median time to event would be 5.20 years (95% CI 4.76-5.80) for cases done at the authors\' hospital and 6.26 years for those performed at an outside hospital (95% CI 5.77-7.24).
These findings help surgeons counsel families appropriately on the odds of attaining goal capacity at various ages. For those who do not reach 100 cc by five years of age, it helps further characterize the odds of requiring a continent stoma with bladder augmentation and the best timing for reconstructive surgery in order to safely gain urinary continence. Families may also be assured that most patients would have the breadth of surgical options when it comes to continence as more than half of patients reached the bladder capacity threshold.

UNASSIGNED: Patients with neurogenic urinary incontinence due to an incompetent outlet may be offered bladder neck reconstruction, but the quest for the perfect surgical-outlet procedure continues. Our aim was to characterize continence and complications after modified Mitchell urethral lengthening/bladder neck reconstruction (MMBNR) with sling and to introduce a modification of exposure that facilitates subsequent steps of MMBNR.
UNASSIGNED: A single-institution, retrospective cohort study of patients who underwent primary MMBNR between May 2011 and July 2019 was performed. Data on demographics, urodynamic testing, operative details, unanticipated events, continence, bladder changes, and additional procedures were collected. A 2013 modification that permits identification of the incompetent bladder neck prior to urethral unroofing was applied to the last 17 patients. The trigone and bladder neck are exposed via an oblique low anterolateral incision on the bladder. Ureteral reimplantation is not routinely performed. Focal incision of the endopelvic fascia after posterior plate creation limits breadth of blunt dissection for sling placement. Descriptive statistics were utilized.
UNASSIGNED: A total of 25 patients (13 females) had MMBNR with sling at a median age of 10 years [interquartile range (IQR) 8-11]. Bladder augmentation was performed concurrently in 14/25 (56%) patients. At a median of 5.0 (IQR 3.9-7.5) years follow-up after MMBNR, 9/11 (82%) without bladder augmentation and 13/14 (93%) with bladder augmentation had no leakage per urethra during the day without further continence procedures. Of the three patients with persistent incontinence, two achieved continence with bladder wall Botox injection (overall continence 24/25, 96%). New and recurrent vesicoureteral reflux was noted in five patients and one patient, respectively. Two patients required subsequent bladder augmentation for pressures and one other will likely require it. None have required bladder neck closure or revision.
UNASSIGNED: MMBNR with sling provides promising continence per urethra in neurogenic bladder with low need for secondary continence procedures. Ongoing modifications may achieve elusive total continence.

Bladder neck contracture after prostate surgery is a rare but feared complication. The treatment of choice is endoscopic incision or resection of fibrotic tissue. In case of ineffective transurethral correction, bladder neck reconstruction has to be done. In this report, we present a complicated case treated with combined transurethral and laparoscopic bladder neck reconstruction with buccal mucosal graft inlay. Using retrograde endoscopy fibrotic tissue in the bladder neck was resected to achieve a smooth and wide prostate cavity. After that the laparoscopy performed. The retropubic space is created and prostatic urethra opened via longitudinal prostatic-vesical incision. Buccal mucosal graft was fixed in place. Bladder and prostatic urethra were closed with resorbable suture. Two weeks after surgery the urethral catheter was removed and adequate voiding reestablished. After eleven months patient had no urination complaints and any sings of recurrence. Thus, the combined surgical approach for bladder neck reconstruction using buccal mucosa inlay may be a durable option for treatment of recalcitrant bladder neck contracture.

BACKGROUND: Girls\' pelvic fracture bladder neck avulsion and urethral rupture is rare however it causes great morbidity. The management is complex and not standard yet. We report our experience and a technique of bladder neck reconstruction with anterior bladder wall flap.
METHODS: We retrospectively analysed data of 5 girls with pelvic fracture bladder neck avulsion and urethral rupture admitted to our institution from July 2017 to October 2019. They all came to our institution with a suprapubic tube. Patients\' trauma was all initially treated at other hospitals, 4 had suprapubic cystotomy and 1 had urethral realignment. One girl also had three other urethroplasties at other hospitals. We took pubectomy, posterior ureth roplasty and bladder neck reconstruction with anterior bladder wall flap in these 5 girls. Post-operative assessments included voiding cystourethrography, uroflowmetry and urethroscopy after urethral catheter removal. Verbal consent to participate was obtained from the parent or legal guardian of the children.
RESULTS: Operation time ranged from 120 to 180 min. Follow-up time is 12 to 27 months. Uroflowmetry showed that maximum urine flow rate improved significantly. Cystourethrography indicated good continuity of the urethra. Two girls had urinary incontinence postoperatively but were continent 3 months later. One patient developed vesical-abdominal fistula and got repaired by surgery 6 months later. She was continent ever since. Other complications were not observed during the follow-up period.
CONCLUSIONS: Our method of bladder neck reconstruction using bladder flap as a patch is feasible and provides good continence, especially for those with serious bladder neck avulsion and urethral rupture caused by extensive trauma and those who had posttraumatic urethral distraction needed second repair.

BACKGROUND: Many surgical procedures have been developed to improve continence in myelomeningocele patients. Our modification of the Mitchell bladder neck reconstruction involves removal of a diamond-shaped wedge of the anterior bladder neck, tubularization of the bladder neck and urethra to increase outlet resistance, and addition of a bladder neck autologous fascial sling.
OBJECTIVE: We aimed to evaluate rates of continence and re-operation in children with myelomeningocele undergoing this Modified Mitchell bladder neck reconstruction.
METHODS: We retrospectively identified children with myelomeningocele having undergone bladder neck reconstruction at our tertiary care referral center from 2012 to 2016.
RESULTS: We identified twelve patients with myelomeningocele undergoing this modified bladder neck reconstruction with sling, four female and eight male, median age at the time of surgery was 7 years old. After initial bladder neck reconstruction with sling only 33% were dry. All patients with bothersome leakage after reconstruction underwent bladder neck bulking. Two patients of twelve (17%) ultimately underwent bladder neck closure and achieved dryness. 58% of patients ultimately achieved continence (Summary Figure).
CONCLUSIONS: Our modification of the bladder neck reconstruction with autologous fascial sling showed midterm rates of incontinence near 60%, with initial post-operative continence at 33%. Our patients, however, required higher rates of reoperation (43%) than previous results would suggest (27%). The first line of re-treatment was bladder neck bulking, but this showed low success. While this procedure is minimally invasive and safe, reasonable expectations of efficacy should be established with families when offering this option. Two patients (17%) required bladder neck closure to achieve dryness. While bladder neck closure is often considered a procedure of last resort, both of these patients were immediately dry. Perhaps bladder neck closure should be considered earlier in our algorithm of surgical continence.
CONCLUSIONS: Our rates of continence with the Modified Mitchell bladder neck reconstruction with a fascial sling were similar to prior bladder neck reconstructions. We did find higher rates of reoperation, and further modifications are warranted to continue to improve continence after surgical procedures in the myelomeningocele population. Select cases may warrant early consideration of bladder neck closure.

Objective: To evaluate the feasibility of three bladder neck reconstruction (BNR) techniques in laparoscopic radical prostatectomy (laparoscopic RP) and their effects on urinary continence. Methods: We retrospectively analyzed 121 patients with organ-confined prostate cancer, who underwent laparoscopic RP in our center from March to December 2018. Three BNR techniques-zero o\'clock reconstruction (ZOR), six o\'clock reconstruction (SOR), and three/nine o\'clock reconstruction (T/NOR)-applied in patients with large bladder opening after prostate resection are described comprehensively. Demographic and perioperative data were collected and analyzed using Pearson\'s chi-square and one-way analysis of variance test. Multivariate analysis was performed to explore predictors that affected continence recovery in 24 hours, 1 month, 3 months, and 6 months after catheter removal. Results: Laparoscopic RP was performed in all patients, wherein 37, 35, 34, and 15 patients underwent bladder neck preservation, ZOR, SOR, and T/NOR techniques, respectively. There were more high-risk patients and larger mean prostate volume in groups with BNR techniques. Perioperatively, patients with reconstruction techniques had longer operation and anastomosis time, more estimated blood loss, and more positive margin status. Nevertheless, there was no significant difference among four groups regarding continence recovery in 24 hours, 1 month, 3 months, and 6 months after catheter removal. On multivariable analysis, positive apical margin and long anastomosis time were independent adverse predictors of continence recovery in 24 hours. Large prostate volume and positive apical margin were adverse factors of continence recovery at 1, 3, and 6 months. Conclusion: Three different kinds of BNR techniques were safe and feasible in laparoscopic RP and had no different impact on continence recovery. Positive apical margin, large prostate volume, and long anastomosis time were independent adverse predictors of continence.

Treatment in children and adolescents with a neurogenic bladder is primarily conservative with the goal of preserving the upper urinary tract combined with a good reservoir function of the bladder. However, sometimes-even in childhood-conservative management does not prevent the development of a low-compliant bladder or overactive detrusor.
After a systematic literature review covering the period 2000-2017, the ESPU/EUAU guideline for neurogenic bladder underwent an update.
In these patients, surgical interventions such as botulinum toxin A injections into the detrusor muscle, bladder augmentation, and even urinary diversion may become necessary to preserve the function of the upper (and lower) urinary tracts. The creation of a continent catheterizable channel should be offered to patients with difficulties performing transurethral clean intermittent catheterization. However, a revision rate of up to 50% needs to be considered. With increasing age continence of urine and stool becomes progressively more important. In patients with persistent weak bladder outlets, complete continence can be achieved only by surgical interventions creating a higher resistance/obstruction at the level of the bladder outlet with a success rate of up to 80%. In some patients, bladder neck closure and the creation of a continent catheterizable stoma is an option.
In all these patients close follow-up is mandatory to detect surgical complications and metabolic consequences early.