Rafael Gosalbez á Miguel Castellan De®ning the role of the bladder-neck sling in the surgical treatment of urinary incontinence in children with neurogenic incontinence AbstractPatient selection for the creation of a fascial sling procedure to increase outlet resistance has been somewhat controversial. We review our experience with the fascial sling technique and report our patient selec- tion process. Since 1991, 30 patients, including 6 males and 24 females aged 4±20 years (mean 10 years), un- derwent a rectus fascial sling procedure as part of their reconstructiveorts for continence. The underlying cause of incontinence was neurogenic in 28 patients. All maleswere prepubertal. Videourodynamics were per- formed in allpatients preoperatively. Criteria for en- hancementof bladder-outletresistanceincludeda detrusor leak-point pressure (LPPd) of <50 cmH 2 O; a stress leak-point pressure (LPPs) of <100 cmH 2 O; an open bladder neck, irrespective of LPP; and clinical ev- idence ofstress incontinence, irrespective of videouro- dynamic parameters. Technical aspects of the procedure are discussed. Augmentation cystoplasty was performed in 29 patients with poor bladder compliance. In 18 pa- tients a catheterizable stoma was also created. The pe- riod of follow-up currently ranges from 2 to 70 (mean 37) months. In all, 28 patients (93%) became continent and 2 female patients remain incontinent with a low LPP. All patients are on clean intermittent catheteriza- tion (CIC); 12 patients(40%) are catheterizing per urethra withoutdiculty. All prepubertal malesare completely dry. The fascialsling repair has many ad- vantages over other methods for increasing outlet re- sistance, including simplicity of technique, eectiveness, minimal likelihood of erosion, and low cost. Pediatric urologists routinely face the challenge of as- sessing and treating urinary incontinence. A large per- centage ofchildren with incontinence are aected by neurologicde®citsderived from spinal malforma- tions that result in detrusor muscle, bladder-neck, and externalsphincter dysfunction. In certain cases, phar- macologicmanipulationwith anticholinergics/alpha- adrenergics and intermittent catheterization succeed in helping the patient achieve social urinary continence. In others,reconstructive surgery over the bladder and/or bladder neck is necessary for the achievement of conti- nence. In our experience, patients with neurogenic uri- nary incontinence frequently (>60%) exhibita mixed pattern of incontinence, that is, passive incontinence and stress incontinence, which is due to the combination of functionaland structuralanomaliesof the detrusor muscle(small capacity,low compliance,and hype- rre¯exia) and bladder-neckand externalsphincter anomalies (low detrusor leak-point pressure and stress leak-pointpressure). In such cases, fashioning of a bladder-neck sling in combination with augmentation cystoplasty provides the best means of achieving total urinary continence. Multiple other techniques to in- crease bladder resistance have been described over the years,and a detailed description of these is beyond the scope of this article. We believe, however, that in those patientswith neurogenicincontinencewho cannot empty spontaneously the bladder-neck sling oers sig- ni®cant advantages over other techniques (see Table 1) due to its simplicity, low cost,ease ofcatheterization postoperatively, low incidenceof complications, and high index of success. The following is a review of our experience with bladder-neck slings in 30 consecutive patients and a description of the technical aspects that may contribute to a good long-term result. World J Urol (1998) 16: 285±291 Ó Springer-Verlag 1998 R. Gosalbez (&) Division of Pediatric Urology, Jackson Memorial Hospital, University of Miami School of Medicine, Miami, Florida, USA M. Castellan Department of Urology, Miami Children Hospital, University of Miami School of Medicine, Miami, Florida, USA