Treatment of refractory urinary incontinence in female patients with a neurogenic bladder or lower urinary tract malformation can be challenging. In this population, reconstructive procedures like augmentation cystoplasty and continent cutaneous diversion are often needed in order to achieve a higher capacity bladder with better compliance while assuring optimal voiding. In patients who fail to achieve urethral continence, even after numerous subsequent bladder outlet procedures, bladder neck/urethral closure is some times used as a last resort treatment. Bladder neck/urethral closure procedure in female is possible either​ by a retropubic or transvaginal approach. The objective of this study is to analyze the outcome of bladder neck/urethral closure as a treatment option for neurogenic and malformative refractory stress urinary incontinence in women with a continent cutaneous diversion (CCD).

This single-center​ historic database included 233 patients (167 females and 66 males) with a CCD, performed between 2001 and 2017. Fourteen female patients underwent a bladder neck/urethral closure. Data on patient and surgical characteristics, previous stress incontinence surgeries and full urethral continence at last follow-up were analyzed.

​A total of 10 transabdominal and 4 transvaginal bladder neck/urethral closure procedures were performed. Seven of the 14 patients failed previous stress urinary incontinence procedure before undergoing bladder neck/urethral closure. From the 7 patients with no prior history of anti-incontinence surgery, 3 presented bladder neck and urethral destruction due to long term indwelling catheter, 2 presented extensive urethral fibrosis owed to multiple reconstructive procedures in childhood and another underwent a previous cervicotomy. Six patients underwent concomitant supratrigonal cystectomy with augmentation cystoplasty and CCD at the time of bladder neck/urethral closure and one underwent a CCD without augmentation cystoplasty, whilst another had a CCD revision. Bladder neck/urethral closure alone was performed in another six patients.
There were no major procedure-related complications. One patient presented an early vesicovaginal fistula 18 days postoperatively. Resolution was achieved after 3 months of conservative management with a suprapubic catheter.
After a median follow-up of 5,4 years, three patients required a CCD revision and 1 patient needed an endoscopic followed by 2 open cystolitholapaxy at a later stage.
At last follow-up, urethral continence was achieved in all 14 patients, with only one necessitating an additional vesicovaginal fistula repair with a Martius flap. A multiple sclerosis patient underwent an ileal conduit due to significant upper limb function loss 7 years after bladder neck closure.

Bladder neck closure with continent cutaneous diversion was mainly studied in the pediatric population and mostly performed by a transabdominal approach. In the adult population, the transvaginal bladder neck closure was mostly used in conjunction with a suprapubic tube placement for treatment of chronic indwelling catheter devastated urethra. Data on transvaginal urethral closure in patients with an augmentation cystoplasty and continent cutaneous diversion is scarce and mostly anecdotal. In our 18 year experience with continent cutaneous diversion, only 14 patients underwent a bladder neck/urethral closure procedure, which accounts for 6% of the patients, confirming the niche character of this treatment.
Nevertheless, when needed, bladder neck/urethral closure provided good long-term results as a treatment option for refractory stress urinary incontinence in female. This was true regardless of the surgical approach. In fact, at last follow-up, all patients achieved full urethral continence and only one patient needed a second procedure in order to achieve this result.

In summary, achieving urethral continence is challenging but crucial for the management of patients with a CCD. Bladder neck/urethral closure seems to be a valid option in females with a continent cutaneous diversion suffering from refractory urinary incontinence or asking for a definitive solution. Before performing such an intervention, patients must be informed about the inherent risks associated with the restricted access to the bladder and upper urinary tract, in case future diagnostic or interventional procedures should be needed.