Surgical treatment of urinary incontinence.

Urinary incontinence of the severity encountered in spina bifida and bladder exstrophy can deal a shattering blow to the fragile self esteem of children and young people. Patients stigmatised by incontinence in childhood are often underachievers at school and denied employment opportunities as young adults. Treatment is aimed at creating the degree of continence required to enable them to fulfil an active, independent role in most aspects of normal adult life. The single most influential contribution to the management of neuropathic bladder has been intermittent clean catheterisation, a concept introduced and popularised by Lapides et al in the 1970s. In conjunction with pharmacological manipulation, notably anticholinergic treatment with oxybutinin, intermittent clean catheterisation will produce continence in approximately 50% of patients. Where the bladder is small, poorly compliant, or hyperreflexic, or in the presence of significant weakness of the striated sphincter, surgical reconstruction represents the only realistic route to total continence. It should be noted, however, that in most instances intermittent catheterisation will still be required to empty the reconstructed bladder. Within the overall framework of treatment the goal of restoring continence must take second place to the overriding priority of safeguarding renal function. Previously chronic renal failure was the single most common cause of late mortality in adolescents and young adults with spina bifida. Before the advent of bladder reconstruction, protection of upper tract function could often only be achieved at the price of continence— for example, bladder outflow obstruction resulting from detrusor-sphincter dyssynergia was generally treated surgically by ablating the bladder neck and striated sphincter complex, which invariably resulted in incontinence. Utilising newer forms of surgical reconstruction, the preservation of renal function and the restoration of continence become mutually compatible goals. Augmenting a small, poorly compliant neuropathic bladder with intestine will enhance continence by increasing the storage capacity, while at the same time protecting renal function by improving compliance and reducing pressure within the bladder and the upper urinary tract. Viewed simplistically, two essential functions are required of the bladder: (a) to store adequate volumes of urine at safe, physiological pressures; and (b) to empty to completion under voluntary control. When the bladder is surgically reconstructed, the first requirement—that is, storage—is generally met by incorporating segments of intestine into the bladder (augmentation or substitution), coupled, where necessary, with some technique designed to enhance sphincteric resistance. The second requirement—that is, voluntary emptying—is generally accomplished by intermittent clean catheterisation.