Bladder neck closure in association with continent urinary diversion.

Bladder neck closure is not a standard part of continent urinary diversion. When bladder augmentation and continent urinary diversion are done simultaneously, it is frequently convenient and advantageous to leave the native bladder neck intact as long as there is a reasonable degree of intrinsic continence. Even in patients with marginal control the effect of lowering intravesical pressure and increasing intravesical volume will often produce acceptable continence. At times, particularly in patients who have undergone multiple surgical procedures involving the bladder neck, there is poor intrinsic resistance. To provide acceptable continence in these cases bladder neck closure is a necessary part of continent diversion. Between 1990 and 1993 we treated 6 male and 7 female patients, most of whom underwent simultaneous bladder augmentation and continent urinary diversion, and they had poor intrinsic outlet resistance. Patient age ranged from 8 to 22 years. Underlying diagnoses included thoracic myelomeningocele in 5 patients, bladder exstrophy in 5, bladder leiomyosarcoma in 1 and extensive pelvic trauma in 1 as well as 1 previously separated conjoined twin. Three patients had artificial urinary sphincter failure and 3 had failure of urethral sling procedures. A clean intermittent catheterization program had failed in 12 patients and all 13 had diurnal incontinence. Bladder neck and urethral resistance was evaluated using voiding cystourethrography and urodynamics to measure leak point pressure and bladder capacity. Reliable bladder neck closure is historically difficult to achieve and is best done at the time of diversion. We have had initial success in 12 of our 13 cases and subsequently in all 13 using a technique of bladder neck division, 2-layer closure and omental interposition between the bladder neck closure and urethra.