The LIO (longitudinal inside-out) technique for bladder neck closure: Early results with an original approach

Managing neurogenic bladder patients with low detrusor leak pressures remains a major challenge in pediatric urology. Bladder augmentation combined with bladder neck resistance procedures is frequently indicated, although outcomes vary according to the technique used. We report early to midterm outcomes of an original bladder neck closure method-the Longitudinal Inside-Out (LIO) technique-used at our center since 2008.

A retrospective review of the bladder reconstruction database at NUPEP/CACAU Pediatric Urology Center (UNIFESP) was performed. All surgeries were conducted by a single senior surgeon. Patients who underwent enterocystoplasty from 2008 onward, those receiving bladder neck procedures were analyzed. Variables included diagnosis, age at surgery, surgical technique, adjunctive procedures, continence outcomes, follow-up duration, and complications. The LIO technique involves a midline cystotomy with Foley traction and inside-out circumferential transection of the bladder neck, creating two longitudinal bladder flaps that are mobilized to the skin level. Closure is performed in two layers. All patients received an ileum-based Macedo pouch and standardized postoperative care, including clean intermittent catheterization (CIC) starting on postoperative day 21. Full continence was defined as a dry interval of at least 4 h.

Of the 73 patients, 35 underwent augmentation alone, 29 had augmentation with bladder neck closure, 6 had augmentation with Pippi Salle, and 3 had augmentation with sling. Mean age at surgery was 10.8 years, with an overall follow-up of 41 months. In the bladder-neck subgroup (n = 38), most patients had spinal dysraphism. Mean detrusor leak point pressure was 26.7 cmH₂O. Urethral continence was achieved in 100% (29/29) of patients undergoing augmentation with bladder neck closure (predominantly LIO), compared to 50% (3/6) with Pippi Salle and 33.3% (1/3) with sling. Mean follow-up in this subgroup was 17.9 months. Complications included urinary stoma stricture (10.5%), colonic stoma stricture (2.6%), urethral false passage (5.2%), and one bladder stone. Additional complications included one enterocutaneous fistula and two cases of colonic channel dehiscence.

The Longitudinal Inside-Out (LIO) technique for bladder neck closure is a simple and promising approach, achieving 100% urethral continence in our initial series after a mean follow-up of 17.9 months. It should be performed with bladder augmentation and a catheterizable reservoir. For families committed to clean intermittent catheterization (CIC) and informed about the risks and benefits of bladder neck closure versus reconstruction, the LIO technique may be considered a primary option to maximize the likelihood of complete continence.