EDITORIAL COMMENT

The authors should be commended for their efforts to avoidbladder augmentation with its inherent complications inthese patients with refractory urinary incontinence. Byavoiding bladder augmentation in all patients but 1 theauthors provide a unique opportunity to analyze what occursin neurogenic bladders when outlet resistance is increased.The data presented are interesting but we have an alterna-tive view on how to interpret the results and draw conclu-sions, perhaps due to a different definition of favorable out-come. The authors consider it a successful result whenpatients accomplish dryness or mild dampness (1 to 2 padsdaily) between catheterizations. In our opinion a mildly in-continent or “less wet” case still remains as an unfavorableoutcome. Perhaps our definition is too strict. However, webelieve that successful treatment should result in a conti-nent patient or a dry period of at least 3 to 4 hours betweencatheterizations.

I believe the authors accept minor leaking episodes andactually consider them potentially advantageous when theystate that the bladder may not decompensate because slingsmay not compress the outlet as efficiently as the artificialurinary sphincter. A success rate of 83% is reported but if wecompute only patients dry between catheterizations, theoverall success rate decreases to 56%. In addition, it isimportant to keep in mind that bladders may decompensatewith time, and the followup in this series is relatively short(mean 22 months, with 10 patients followed for 12 months orless). It is also noteworthy that 8 of 26 patients (31%) neededto be started on oral or intravesical instillation of anticho-linergics 6 months postoperatively, implying early bladderdeterioration. In addition, 14 of 26 patients (54%) had wors-ening of capacity and compliance at initial followup. Fur-thermore, loss of compliance with time was also seen in 10 ofthe 16 patients (63%) who underwent late urodynamic eval-uation. Therefore, although many patients do well initiallyafter sling alone, close monitoring is essential since somemay ultimately decompensate, requiring augmentation.

The authors state that patient gender, age and ambula-tory status did not predict surgical outcome. Females had asuccessful outcome, and all failures occurred in males, con-firming previous reports in the literature. Although no sta-tistical significance between males and females wasreached, this result was likely due to the small number ofsubjects.

In summary, the authors describe a unique and interest-ing experience regarding urodynamic responses after in-creasing outlet resistance alone in patients with neurogenicincontinence. Although this approach is clinically appealing,I would caution the reader about possible long-term bladderdeterioration. Therefore, this group of patients should becarefully monitored, keeping in mind that augmentationmay be needed in the future. In addition, I believe it isimportant to be aware that increasing bladder outlet resis-tance with slings alone may be associated with mild damp-ening in approximately half of the cases. I congratulate theauthors on their efforts to simplify the treatment of patientswith neurogenic incontinence.

J. L. Pippi SalleDivision of Urology

Hospital for Sick ChildrenUniversity of Toronto

Toronto, Ontario, Canada

REPLY BY AUTHORS

By definition increased outlet resistance with sling de-creases calculated compliance (cc/cm H2O) unless bladdercapacity increases. Of the 16 patients with increased DLPPon initial postoperative urodynamics 12 had decreased vol-umes and, therefore, decreased compliance. If this repre-sents bladder decompensation then it occurred without de-velopment of trabeculation, reflux or hydronephrosis.Compliance decreased in only 5 of our patients, was stable in2 and increased in 9. Rather than raise concern for ultimatedecompensation, these observations could suggest thatmany bladders improve with time after initial response tooutlet enhancement, as previously noted by Churchill et al(reference 14 in article). We emphasize that neither capacityby age based formula nor compliance in cc/cm H2O predictedsuccess or the need for enterocystoplasty. We agree thatfuture outcomes for these patients are unclear, but so arefuture outcomes in children undergoing augmentation.

In reported series more children treated with slings haveundergone augmentation than those treated with AUS, al-though slings compress the outlet less. Definitions of successfor surgical procedures to achieve continence elude stan-dardization, but our results are comparable to those of otherslings with enterocystoplasty series. These observations fur-ther question the need for routine augmentation in childrentreated with slings for neurogenic incontinence.

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