in patients with neurogenic bladders as the result of spinal cord injury or spinal disease , complications such as upper urinary tract damage , infection , stone formation , and incontinence commonly occur . in such patients , procedures that are intended to decrease bladder pressure are required to prevent further deterioration of the upper tract . among such procedures , augmentation cystoplasty ( ac ) incontinence can occur as the result of sphincteric incompetence or bladder factors such as involuntary detrusor contraction ( idc ) or poor compliance . in patients with sphincteric incontinence , pharmaceutical agents can be prescribed as a first - line treatment . when the incontinence is refractory to medication , surgical treatment such as slings , artificial urinary sphincters ( auss ) , or injection of bulking agents can be considered . in many patients , however , consensus over whether concomitant or staged anti - incontinence surgery with ac is advisable in patients with sphincteric incontinence has not yet been established . the surgical management of neurogenic sphincteric incontinence is still under debate , and an effective method for long - term continence in subjects with neurogenic sphincteric incompetence remains to be found . this patient underwent ac for neurogenic bladder and bladder neck suspension for his incompetent urinary sphincter with satisfactory results . also , chartier - kastler et al .   reported lower complication rates in patients who underwent ac and aus implantation simultaneously than in patients who underwent staged operations . dave and salle   analyzed a kropp - salle bladder neck repair performed in 9 children , 6 of whom had myelodysplasia . eighty - nine percent of these patients received concomitant ac , and 88% were dry postoperatively . with concomitant surgery , however , there is a possibility of a higher incidence of morbidities in patients whose incontinence might be resolved with bladder outlet procedures performed as a single procedure . selecting the treatment method for patients with neurogenic sphincter incontinence is a challenging clinical issue . with the goal of obtaining maximal surgical efficacy with the minimum inconvenience to patients , we evaluated patients with sphincteric incontinence who underwent ac as a single procedure at our center . we aimed to determine whether concomitant bladder neck reconstruction was necessary when performing ac in patients with neurogenic bladder . we retrospectively investigated clinical data from 35 patients who underwent ac from january 2006 to september 2010 . medical history , preoperative and postoperative fluoroscopic urodynamic study ( fuds ) parameters , and responses to an incontinence questionnaire ( iciq korean version ) were reviewed . the iciq questionnaires were previously validated linguistically by bilingual translators and were approved for use by the international consultation on incontinence modular questionnaire advisory board ( http://www.iciq.net/index.html ) . we analyzed these patients to see whether ac performed as a single procedure could improve their continence status . of the patients , 24 with urinary incontinence who filled out both a preoperative and a postoperative iciq questionnaire ( 17 males and 7 females ) were eligible for analysis . of these 24 patients , a final analysis was performed on 17 patients who complained of urinary incontinence preoperatively and showed sphincteric incontinence . sphincteric incontinence was primarily determined by a clinical decision made on the basis of the presence or absence of incontinence according to the patients ' symptoms and signs . it was also supported by a low abdominal leak point pressure ( alpp ) , combined with low maximal urethral closure pressure ( mucp ) , and an open bladder neck observed on fuds . because the initial group of 35 patients underwent ac , we assumed that all of the patients had bladder factors related to their symptoms . fluoroscopic images were simultaneously obtained , and vesicoureteral reflux , bladder neck competence , and bladder trabeculation were evaluated . urodynamic parameters including storage phase characteristics , bladder capacity , bladder compliance , cause of incontinence , alpp , mucp , maximum cystometric capacity , and detrusor sphincter dyssynergia were evaluated . fluoroscopic information regarding the bladder neck at filling , trabeculation , and vesico - ureteral reflux ( vur ) was also evaluated . a lower midline abdominal incision was made and subcutaneous tissue and the anterior rectus sheath was divided . the rectus muscle was retracted laterally , and the posterior rectus sheath and peritoneum were transected . after the native bladder was exposed , a 45-cm portion of the ileum was selected , and according to the patient 's condition , the sigmoid colon was used in some cases . ileal end - to - end anastomosis was done by use of 3 - 0 vicryl . the native bladder was dissected and bivalved vertically from the anterodome to the posterodome area . the detubularized ileal segment was sutured with the bivalved bladder by use of 2 - 0 vicryl . a 2-sided chi - square test was performed by use of a commercial analysis program pasw ver . 18.0 ( ibm co. , armonk , ny , usa ) . this study was approved by the institutional review board of seoul national university hospital ( number 1106 - 091 - 366 ) . the average age of the patients was 34.3 years ( standard deviation [ sd ] , 20.76 ) . the average follow - up period was 10.1 months ( sd , 3.9 ) , and postoperative fuds was performed a mean of 7.5 months ( sd , 5.3 ) postoperatively . in 15 patients ( 88.2% ) the ileum was used , and in 2 patients ( 11.8% ) the sigmoid colon was used . postoperatively , 9 of the patients ( 52.9% ) did not have vur , 2 had left vur ( 11.8% ) , and 1 had right vur ( 5.9% ) . among the patients with vur , all of them were grade 2 . both preoperative and postoperative urodynamic parameters were compared ( table 2 ) . among the urodynamic parameters evaluated that were related to the bladder , bladder capacity , bladder compliance , and idc showed significant improvement postoperatively ( p<0.05 ) . the bladder neck was incompetent in all patients preoperatively , but was competent in 83.3% ( 10/12 ) of the 12 patients whose postoperative fuds results were available ( p=0.004 ) ( table 3 , fig . the subjective incontinence status of the patients was evaluated . concerning the pad number , preoperatively , all patients used pads , and the average daily number was 2.2 ( 0.6 ) . postoperatively , the number of pads used decreased significantly to 0.9 ( median ; range 0 to 3 ) pads a day ( p=0.002 ) . significant improvement was shown for questions 1 to 3 on the iciq questionnaire as well as for the total score ( p<0.05 ) . in the analyzed group , all patients had incon tinence preoperatively , and the number who answered that their incontinence disappeared showed statistically significant improvement ( p<0.001 ) . the number of patients who had incontinence when sleeping , those who had nonspecific incontinence , and those who had constant incontinence showed significant improvement ( p<0.05 ) . although postoperatively some patients had incontinence during exercise or when coughing , symptoms disappeared in most patients ( table 4 ) . in patients with a small or poorly compliant bladder or detrusor overactivity , ac is recommended to lower intravesical pressure and to preserve the upper tract . persistent incontinence after ac deserves attention , because it is an important problem that negatively affects the quality of life of the patients . borjeson and lagergren   reported incontinence to be the main reason for social isolation of patients with neurogenic bladder . herschorn and hewitt   reported that 66.6% and 33.8% of patients , respectively , remained incontinent after ac performed as a single procedure . however , in other studies , continence was reported to be achieved after ac as a single procedure . daher et al .   reported improved continence rates after ac performed in a pediatric patient population in a 10-year follow - up study . quek and ginsberg   also reported improvement of urodynamic parameters after ac as a single procedure . venn and mundy   reported a postoperative continence rate of 78% of neurogenic bladder patients who underwent ac only . some studies support bladder neck closure for continence ; however , this can cause deterioration of a pop - off mechanism of the bladder neck . reported that in some patients with neurogenic sphincteric incontinence , an aus can be considered as a treatment option . in pediatric urology , research about the outcome of bladder outlet procedures on children with urinary incontinence with neuropathic bladder dysfunction or structural deficiency is also rare . evaluation of small numbers of patients undergoing ac does not always show improved status on postoperative questionnaires , despite what generally would be considered to be a good surgical outcome . in our study , we evaluated the outcome of ac performed as a single procedure on incontinence caused by sphincteric incompetence . our data suggested that ac as a single procedure improved both subjective continence proven by the korean iciq questionnaire as well as objective continence proven by decreased pad number and fluoroscopically demonstrated bladder neck competence . when selecting patients for analysis in our study , we reviewed the patient 's fluoroscopic images , urodynamic findings , and most importantly , the patient 's history . also , patients whose bladder necks were partially open on cystourethroscopy but showed leaks when strong idcs occurred on filling cystometrograms were also excluded to avoid ambiguity . the fact that both a preoperative and a postoperative iciq evaluation were available in this study is a strong advantage . although the preoperative iciq evaluation was obtained by a postoperative telephone interview , we considered these data reliable . the reason is that although the evaluation was conducted postoperatively , the patients ' recollection of the number of pads they used and the degree of distress caused by incontinence was accurate . these patients had suffered from preoperative incontinence for a long period of time , and their memory was still fresh and the information they provided reliable at the time of data acquisition . the significant improvement of iciq scores shows that ac as a single procedure improves the subjective symptoms of the patients . when incontinence occurs when a patient coughs or sneezes , we consider the patient to have stress urinary incontinence ( sui ) . postoperatively , 3 patients had sui ; however , their iciq total scores decreased from 16 ( sd , 6.2 ) preoperatively to 7.3 ( sd , 6.4 ) postoperatively . in addition , our study had the advantage of both preoperative and postoperative fuds in 12 of the patients analyzed . fuds was performed according to a standardized protocol , and therefore an objective comparison without variation was possible . also , the operations were all performed by a single experienced surgeon , which provided additional strength to the study . according to our data , vur persisted after surgery in 3 patients , which could be attributed to the chimney of the studer - type enterocystoplasty or to excessive filling during the filling cystometrogram . however , the vur was observable only at maximal capacity on fuds and upper - tract follow - up imaging on kidney ultrasound or nonenhanced computed tomography scans showed no hydronephrosis . patients did not suffer from acute pyelonephritis , either , which led us to conclude that the persistent reflux was caused by overfilling . we performed ac on 2 patients who had normal bladder capacity but severe idc who experienced urine leakage whenever there was an idc on fuds . although some patients showed detrusor overactivity postoperatively , the amplitude and duration of the idcs were negligible . first , it was performed in a retrospective nature , and second , it was a short - term study . due to the limited number of patients , further analysis involving the selection criteria of patients who would require bladder neck procedures either concomitantly or in a staged operation was not possible . however , if more data were accumulated , more valuable information could be provided for patients requiring surgery for incontinence . on the basis of the results of this study , we are able to predict that more valuable information can be obtained and that guidelines for the selection of such patients can be established in the future . our study demonstrated that both objective urodynamic parameters and subjective incontinence symptoms improved significantly after ac as a single procedure , even though the patients had sphincteric incompetence . this implies that in patients whose incontinence persists after ac , anti - incontinence bladder outlet procedures can be considered as a staged operation .