Bladder Neck Bulking with Antegrade and Retrograde Endoscopic Dextranomer/Hyaluronic Acid Copolymer

Bryan T Kansas, Sameer N Chawla, Gregory E Dean, Michael G Packer, Mark R Zaontz, Andrew J. Kirsh*, Hal C. Scherz*
Temple U Hospital, Philadelphia, PA

Introduction:Endoscopic bladder neck bulking techniques offer potential for a minimally invasive treatment for medically refractory urinary incontinence. We review our experience using an antegrade and retrograde approach in placing dextranomer/hyaluronic acid copolymer into the bladder neck.
Methods:28 children have been treated since April of 2003. Those treated include 19 patients with spina bifida, 2 with cord tethering, 5 with epispadias/exstrophy, and 2 with stress urinary incontinence. Urodynamics confirmed both low leak point pressures (LPP) and adequate bladder capacity. Patients were treated with either a retrograde, antegrade, or a combination approach. In the antegrade approach, pre and post treatment LPPs were recorded and a supra-pubic tube (SPT) was left in place.
Results:Mean follow-up was 13 months (6-20 months). Patients averaged 1.6 injections (range 1-3). 8 patients were treated using the retrograde approach while the remaining 20 were treated either in an antegrade or mixed approach. Mean injected volume was 4.5 ml (range 3-6 ml). 75% (21/28) of patients are socially continent. 10% (3/28) had failure of bladder neck coaptation whereas the remaining 15% (4/28) experienced a rapid fall-off in efficacy. In successful antegrade patients, intra-operative LPPs rose from <30 cm H20 to >60 cm.
Conclusions:Our experience demonstrates that this is a viable therapeutic minimally invasive option for children with urinary incontinence. Some patients have experienced prolonged success, re-treatment can be beneficial. The antegrade approach offers several advantages including intraoperative LPPs, improved visualization, and placement of a SPT to limit post-procedural remodeling by avoiding catheterization of the bladder neck.

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