Surgical management of the neuropathic bladder

In a simplified view, the "normal" bladder, through a multifaceted neuromuscular event, allows the basic functions of urinary storage and emptying. More specifically, the urinary bladder accommodates increasing urinary volume with little to no increase in vesicular pressure while maintaining continence. The normal act of emptying integrates the relaxation of the urinary sphincters (external and internal) with the subsequent bladder contraction to void to completion when full. There are a multitude of conditions, both congenital and acquired, that can affect the bladder's ability to perform these functions in a smooth and coordinated fashion. The most common causes of pediatric bladder dysfunction necessitating surgical intervention are those associated with spina bifida/myelodysplasia, posterior urethral valves, and bladder exstrophy. Over the last 2 decades, the evolution of complex reconstruction for lower urinary tract dysfunction has resulted in an improved quality of life for children afflicted with upper urinary tract changes or incontinence despite maximum utilization of nonoperative therapies. Because each patient represents a unique therapeutic entity, an individualized approach to each child is recommended.