What Is Bladder Outlet Surgery (Bladder Neck Reconstruction And/Or Sling)?

This type of surgery is done to strengthen a child’s control over the bladder so that urine won’t come out unless the child tries to pee. It may be done when the leak is caused by a lack of muscle support holding the bladder closed between bathroom breaks.

Most children can control bladder leaks with medication or catheterization (inserting a tiny, flexible tube into the urethra). When these do not work, however, bladder outlet surgery may be done. It is most common among children with the following conditions:

• Bladder extrophy
• Spina bifida and myelomeningocele
• Neurogenic bladder
• Non-neurogenic neurogenic bladder (Hinman syndrome)
• Anorectal malformations
• Cloacal malformations

In rare cases, children may have only reconstruction or the sling procedure done to try to stop the leak. This may help some children control urination well enough on their own so that they stay dry. However, the procedures are usually done together with the goal of totally stopping urine from coming out of the urethra. For these children, the bladder neck will be tightened to the point that no urine can get past. In these cases, another operation, such as the Mitrofanoff procedure, is often done at the same time. The Mitrofanoff procedure creates a new tube for urine to exit the body, often through a hole in the belly, specifically the belly button. Children must then drain their bladders by catheterizing through the new hole.

Bladder outlet surgery is not an emergency surgery. You will schedule the operation in advance. A nurse from Nationwide Children’s will call 1-3 days before the operation to give instructions. If your child has constipation problems or if robot-assisted surgery, laparoscopy, or multiple operations will be happening at the same time, he or she will need to arrive a day before the scheduled surgery.

Most children stay in the hospital 3-5 days after the operation. However, your child’s stay may be longer if other operations are being done at the same time.

1. If your child needs to arrive a day early, your child will start a liquid diet at the hospital to help clean out the bowels in time for surgery. This bowel prep may include a feeding tube or enema. This gives more room for the surgeon to work inside the belly.
2. No matter what surgery technique is being done, your child will have to stop eating and drinking by midnight the night before the surgery.
3. Early the next morning, your child will be put to sleep for the operation using medicine (general anesthesia).
4. Your child will be given at least one dose of antibiotics through an IV (a needle and tube going into the arm). This will help lower the chance of infection at the site of the cuts.
5. The surgery will last for several hours. A nurse will come out from time to time to let you know how your child is doing.
6. In the recovery room, your child will be checked for complications and given pain medicine.
7. There will be at least one catheter in place after the surgery to drain your child’s urine from the urethra into a special bag. This will be removed before your child goes home. However, children will have another catheter or two if a Mitrofanoff or Malone procedure is done at the same time. These may stay in place for up to a month after discharge.
8. Your child can drink water the day after the surgery. Your child can start a regular diet and go home once the bowels start working (passing gas) again. In some children, this can take up to a week.

Any catheters your child is discharged with must stay in place for 3-4 weeks after the surgery. This allows the swelling to go down and the body to heal. You will have to return to the hospital for a nurse to remove the catheters. You and your child will also receive training from a nurse to learn how and when to catheterize on your own if the child was also made a catheterizable channel, like a mitrofanoff. The nurse will provide some initial supplies and connect you with resources for home shipping for supplies in the future.

About 6 weeks to 3 months after the operation, your child will get a follow-up ultrasound to check for swelling in the kidneys. This will let the doctor know if the surgery created any problems for the kidneys. Your child will also need an ultrasound 6 months later to re-check your child’s kidneys. In addition, your child will undergo periodic urodynamics to make sure that the bladder function has not changed with surgery.

You should also expect the following after bladder outlet surgery:

• The cut skin is usually closed with internal, absorbable stitches and skin glue. The stitches disappear on their own and don’t require any special removal or care.
• Your child can wash by sponge bath for the 2 days following the surgery. After that, showers are acceptable. Once the catheters are removed, baths may also be okay, depending on whether your child had certain other operations.
• The cuts and any catheters that stay in place may be sore for a few days or weeks.
• Gym class, strenuous activity and heavy lifting should be avoided until any catheters are removed.
• Wheelchair transfers can begin again about 2 weeks after the operation.
• Your child will need to take medicine to soften or stop the body’s natural squeezing of the bladder. This will become part of your child’s new routine. The medicine will keep the pressure lower in the bladder, which should help avoid damage to your child’s kidneys.

You should call the doctor or seek medical attention for your child after bladder outlet surgery if your child:

• Has a fever of 101°F or higher before the first follow-up visit
• Cannot pass urine through the catheter
• Passes blood through the catheter
• Accidentally pulls the catheter out
• Complains of severe pain in the belly, side or back that isn’t helped by the pain medicine they are given at discharge
• Has symptoms of a urinary tract infection (UTI) or kidney infection
• Has ongoing urine leakage

The primary benefit of bladder outlet surgery is that it keeps children dry. When they do not leak urine throughout the day, they can avoid the odor and inconvenience of diapers and bladder accidents. Many children have improved quality of life once they are dry between bathroom breaks or catheterizations.

For children who use wheelchairs, the combination of bladder outlet surgery with another procedure, such as the Mitrofanoff, gives them the ability to stay dry between catheterizations. Girls who use wheelchairs can also catheterize without transferring to a toilet, making it easier for them to be independent.

In general, the risks of bladder outlet surgery include those of any surgery, such as infection, redness, swelling, bleeding, damage to other organs, or reactions to the anesthesia. During surgery on the bladder, urine can also leak into other areas and cause some irritation.

Bladder outlet operations also have their own unique risks:

• The risk of kidney infections may go up because of the increased pressure on the bladder.
• Eventually, your child may need another surgery if there are high pressures in the bladder as this may harm the kidneys.
• The surgery may fail to stop the leak. Another surgery may be needed to re-tighten the bladder neck or close the bladder neck.
• If your child already uses a catheter, he or she may have to catheterize more frequently to adjust to the new pressure on the bladder.
• If the reconstruction or sling creates too much resistance, children who were expecting to pee normally may not be able to pee at all after the surgery. In this case, they may need to catheterize or get an additional operation to urinate from a newly created tube that is catheterized through the belly.

• Why do you recommend bladder outlet surgery?
• What are the alternatives to this surgery?
• Will my child need additional procedures at the same time?
• What surgical techniques are available, and which do you recommend for my child?
• Will my child require a catheter after the operation? If so, what type of schedule will be required?
• What is the long-term impact of this surgery for my child’s ability to be self-sufficient?
• Can you put me in touch with other families who have had this surgery?

Nationwide Children’s is leading the way in minimally invasive bladder outlet surgery. Only a handful of children’s hospitals perform robot-assisted surgery for bladder neck reconstruction or slings.

Our surgeons are among the nation’s leading experts at performing robot-assisted bladder outlet surgery to help your child heal faster, feel less pain, and have less noticeable scars. We welcome you to talk to our urology team to find out if this attractive alternative to open surgery may be a good fit for your child.