Surgery to improve bladder outlet function

Introduction The bladder outlet in patients with neurogenic voiding dysfunction is subject to two main abnormalities: outlet underactivity, leading to urine leakage with increased intra-abdominal pressure; and nonrelaxing urethral sphincter obstruction, resulting in reduced urine flow at the time of bladder emptying.1 This chapter is therefore divided into two sections: surgical treatment of the underactive or incompetent bladder outlet and surgical treatment of the nonrelaxing or hyperactive bladder outlet (detrusor-sphincter dyssynergia or DSD). Procedures currently used to alleviate sphincteric deficiency in the neurogenic bladder population are injection of urethral bulking agents, slings, artificial urethral sphincters, bladder neck reconstruction procedures, and bladder neck closure. The surgical options currently available for the treatment of intractable DSD are sphincterotomy, insertion of a temporary or permanent urethral stent, balloon dilatation of the external sphincter, botulinum A toxin injection into the external sphincter, and use of a chronic indwelling catheter. The choice of surgical treatment depends on a number of factors, the most important of which are sex of the patient, the patient's comorbidities and functional status, the severity of urine leakage, whether or not the patient has had previous anti-incontinence procedures, patient and caregiver preferences, and, last but not least, the experience and expertise of the surgeon.