Incontinence Following Bladder Neck Reconstruction—Is There a Role for Endoscopic Management? David M. Kitchens, Eugene Minevich,* William R. DeFoor, Pramod P. Reddy, Jeffrey Wacksman, Martin A. Koyle† and Curtis A. Sheldon From the Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, and Children’s Hospital, University of Colorado School of Medicine, Denver, Colorado (MAK) Purpose: Little has been reported concerning the efficacy of endoscopic injection of dextranomer/hyaluronic acid for the treatment of residual incontinence following bladder neck reconstruction. We present the experience of 2 institutions using endoscopic submucosal injection of dextranomer/hyaluronic acid to correct incontinence in patients who had previously undergone bladder neck reconstruction with or without concomitant enterocystoplasty. Materials and Methods: A retrospective chart review was performed with patient demographics, indications for treatment and outcomes recorded. All patients had adequate bladder capacity and compliance on maximized medical therapy before injection. Continence was defined as at least a 3-hour daytime dry interval, while improvement was defined as an increase in the daytime dry interval to at least 2 hours. Results: A total of 14 patients (10 females and 4 males) underwent 21 injections. At a median followup of 17 months 10 patients had successful results (6 continent, 4 improved). Conclusions: Endoscopic injection of dextranomer/hyaluronic acid to correct incontinence following bladder neck recon- struction appears safe and can increase the daytime dry interval in more than 70% of carefully selected patients. Continued followup is necessary to evaluate the long-term effectiveness of this treatment. Key Words: urinary incontinence, dextranomer, urologic surgical procedures, bladder B ladder neck reconstruction is a well accepted option to treat urinary incontinence in children secondary to poor outlet resistance, especially in the exstrophy/ epispadias and MM populations. Continence rates of 40% to 100% are achievable, depending on the diagnosis, definition of continence, duration of followup and surgical approach. 1–3 Inability to achieve a balance between bladder outlet resis- tance, patency for spontaneous voiding and a “pop off” mech- anism can lead to persistent incontinence following BNR. There are few studies available regarding the efficacy and safety of endoscopic injection of D/HA copolymer for treat- ment of incontinence following BNR. 4,5 We present the ex- perience of 2 institutions using endoscopic injection of D/HA to correct persistent incontinence following BNR with or without previous enterocystoplasty. MATERIALS AND METHODS A retrospective cohort study from 2 pediatric institutions was performed of patients with persistent urinary inconti- nence following BNR who underwent endoscopic injection of D/HA between 2003 and 2006. Patient demographics, indi- cations for treatment and outcomes were extracted from the medical records. All patients being considered for injection were incontinent while on maximized medical therapy, con- sisting of intermittent catheterization every 3 to 4 hours while taking the maximum tolerable dose of an oral anticho- linergic. Patients completed a voiding diary in the week before the preoperative outpatient clinic visit to assess du- ration of daytime dry intervals before injection. Assessment of functional capacity and compliance with filling cys- tometrogram was also performed before injection. Patients were excluded from the study if they were not on maximized medical therapy or they were deemed not to have adequate functional capacity during urodynamic evaluation. Bladder neck injection was performed as outpatient sur- gery. Injection was carried out either in a retrograde fashion via the native urethra, or in an antegrade approach via Mitrofanoff neourethra or suprapubic bladder access. Injec- tion was first attempted in a retrograde fashion. If this approach was not possible due to poor visualization of the bladder neck or it was believed that inadequate coaptation of the bladder neck was taking place, then antegrade injection was attempted. Endoscopy through the native urethra was performed with either a 9.5Fr or 10Fr panendoscope, depending on surgeon preference. Endoscopy was performed through the Mitrofanoff neourethra with a panendoscope that was at least 1Fr smaller than the calibrated catheterizable tract. Endoscopy via percutaneous access was performed with a 9.5Fr panendoscope. In 1 patient in whom the bladder neck was visualized via the Mitrofanoff the injection needle could Submitted for publication June 23, 2006. Presented at annual meeting of American Urological Association, Atlanta, Georgia, May 20 –25, 2006. * Correspondence and requests for reprints: Division of Pediatric Urology, Cincinnati Children’s Hospital Medical Center, 3333 Bur- net Ave., MLC 5037, Cincinnati, Ohio 45229-3039 (telephone: 513- 636-7143; FAX: 513-636-6753; email: eugene.minevich@cchmc.org). † Financial interest and/or other relationship with Q-Med. 0022-5347/07/1771-0302/0 Vol. 177, 302-306, January 2007 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2006.09.012 302