[Posterior approach to the bladder for implantation of the 800 AMS artificial sphincter in children and adolescents: techniques and results in eight patients].

Blind dissection of the bladder neck during implantation of an artificial urinary sphincter (AMS 800) may lead to injury of either the bladder, genital tract or even the rectum. Significant bleeding may occur. A posterior approach to the bladder neck allowing visual control of the anatomical structures is described. From November 1995 to February 1998, 8 adolescents (12-19 years old) underwent AMS 800 artificial urinary sphincter implantation for the treatment of severe incontinence associated with neurogen bladder; one patient had had a previous augmentation. Three had a simultaneous ileocystoplasty and another patient had a simultaneous bilateral extravesical ureteric reimplant. The procedure consisted of separation of the bladder from the peritoneum, allowing the development of a dissection plane between the rectum and genital tracts posteriorly and the ureters and bladder neck anteriorly; the dissection is extended to the base of the prostate. The endopelvic fascia is then incised laterally and on both sides the neurovascular bundles are perforated under visual control and the cuff is positioned safely around the bladder neck, above the prostate and in front of the genital tract. The bladder was opened only in the case of associated ileocystoplasty, thus avoiding prolonged bladder drainage. The mean operating time was 2.5 hours and the blood loss never exceeded 300 cc. This route was not found to be convenient in the case of the patient with a previous augmentation; 7 sphincters function normally with a follow-up of 18 to 44 months; one was never activated and the patient is dry under CIC. This route for exposure of the bladder neck allows visual control of the anatomical structures, accurate positioning of the cuff, avoids bladder opening and reduces bleeding. It can be used for other procedures such as bladder neck suspension or Müllerian cavity removal.