The effects of augmentation cystoplasty and botulinum toxin injection on patient-reported bladder function and quality of life among individuals with spinal cord injury performing clean intermittent catheterization

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Bladder-Related Quality of Life After Spinal Cord Injury: Findings from the Neurogenic Bladder Research Group Spinal Cord Injury Registry

The Neurogenic Bladder Research Group (NBRG) was formed with the mission to optimize quality of life (QoL), surgical outcomes, and clinical care of patients with neurogenic lower urinary tract dysfunction. One of the original priorities of the organization was to support creation of the NBRG Spinal Cord Injury (SCI) Registry. The aim of this Registry was to establish a prospective database, in order to study bladder-related QoL after SCI. The study enrolled close to 1500 participants from across North America over an 18 month time-period (January 2016-July 2017).

[Bladder augmentation in the era of botulinum toxin: Indications and results]

AIM

To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection.

MATERIAL

We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context.

RESULTS

We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%).

CONCLUSION

In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team.

LEVEL OF EVIDENCE

Weak.

Variation in Provider Practice Patterns and the Perceived Need for a Shared Decision-making Tool for Neurogenic Lower Urinary Tract Dysfunction

OBJECTIVE

To evaluate neurogenic lower urinary tract dysfunction (NLUTD) care providers' current practice patterns, their perceived need for a shared decision-making tool for NLUTD management.

METHODS

We developed an electronic survey to assess multiple factors surrounding NLUTD management including practice patterns, perceived need for a decision aid and willingness to use it. Prior to survey dissemination, a panel of expert NLUTD care providers reviewed and provided a critique of the survey. It was delivered via email to the members of the Genitourinary Reconstructive Surgeons, and the Society of Urodynamics, female pelvic medicine and urogenital reconstruction between March and May 2022.

RESULTS

A total of 117 NLUTD care providers from 11 countries participated in this survey. Most participants were urologists (n: 109, 93%) working at academic teaching hospitals (n: 82, 70%). The most common treatments the providers had provided for stress urinary incontinence and detrusor overactivity were sling procedures (n: 76, 65%) and anticholinergics (n: 111, 95%). Participants believed that NLUTD management can be highly patient-specific and extensively vary from one individual to another. Most participants believed that patients performing clean intermittent catheterization have better QoL compared to those utilizing indwelling urinary catheters (n: 81, 69%). Participants believed there is a need for a NLUTD decision aid, and they expressed their willingness to use one if available.

CONCLUSION

We found discordances between guideline recommendations, provider practice patterns, and patient-reported outcome measures and essential attributes that indicated the need for a decision aid to improve patient-provider communication and shared decision-making in NLUTD management.

Interventional management and surgery of neurogenic lower urinary tract dysfunction in patients with chronic spinal cord injury: A urologist's perspective

Neurogenic lower urinary tract dysfunction (NLUTD) caused by spinal cord injury (SCI) is challenging for urologists. NLUTD not only affects the quality of life but also endangers the upper urinary tract of patients with chronic SCI. Considering that the bladder and urethral function change with time, regular follow-up of NLUTD is necessary, and any complication should be adequately treated. The first priority of bladder management in patients with chronic SCI manifesting NLUTD should be renal function preservation, followed by the normalization of lower urinary tract function. The quality of life should also be assessed. Patients who have a high risk for impaired renal function should be more frequently identified and investigated. Conservative treatment and pharmacological therapy should be started as early as possible. Intravesical or urethral injections of botulinum toxin A is an alternative treatment for refractory NLUTD. When surgical intervention is necessary, less invasive and reversible procedures should be considered first. Improving patients' quality of life and willingness to undergo bladder management is the most important aspect of treatment.

General and bladder-related quality of life: A focus on women living with spinal cord injury

OBJECTIVE

To compare bladder symptoms, and urinary and overall quality of life (QOL) among women and men after Spinal cord injury (SCI), and to describe specific aspects of QOL among women with SCI.

METHODS

We used data from a prospective, multi-center, and cross-sectional study that was carried out from May 2019 to September 2020. Clinical and demographic details were obtained and participants completed two patient reported outcomes: the neurogenic bladder symptoms score-short form (NBSS-SF, which measures bladder symptoms and QOL) and the SF-12 (which measures overall physical and mental health QOL).

RESULTS

Our cohort included 135 women and 210 men with SCI. Among the women, the median age was 50, and 40% had a cervical SCI. For general QOL, women with SCI had physical functioning scores similar to men, but lower mental health scores on the SF-12 (46.85 vs. 49.76, p = 0.01). Women had significantly worse overall NBSS (10.76 vs. 9.08, p < 0.001) and NBSS continence domain scores (4.71 vs. 3.66, p < 0.001) compared to men. There were significant differences between overall QOL measures, and bladder symptoms based on bladder management techniques among the women. NBSS-SF symptom scores were better among women who used overactive bladder medications compared to women who did not (8.43 vs. 11.9, p = 0.02) and NBSS-SF QOL domain scores were significantly better among women who underwent surgery and those that used overactive bladder medications.

CONCLUSIONS

Women have more bladder symptoms (specifically incontinence) compared to men. Symptom burden and overall QOL vary among women who use different bladder management techniques and treatments.

Video-Urodynamic Characteristics and Predictors of Switching from Botulinum Neurotoxin a Injection to Augmentation Enterocystoplasty in Spinal Cord Injury Patients

Botulinum neurotoxin type A (BoNT-A) injection and augmentation enterocystoplasty (AE) are alternative and effective management strategies for neurogenic detrusor overactivity (NDO) refractory to pharmacotherapy. A great majority of patients with spinal cord injury (SCI) may, however, prefer BoNT-A injections to AE, due to the less invasive characteristics. In this study we evaluated the influence of various video-urodynamic study (VUDS) parameters in SCI patients who continuously received repeat BoNT-A detrusor injections or switched to AE to improve their bladder conditions. We compared the changes in the urodynamic parameters before and after each mode of treatment. In this retrospective study, all SCI patients with refractory NDO who had received at least one BoNT-A injection were enrolled. VUDS was performed before and after both BoNT-A injection and AE. All of the urodynamic parameters of the storage and micturition-including the bladder capacity of every sensation, maximal flow rate (Qmax), post-voiding residual volume, detrusor pressure at Qmax, and bladder contractility index-were recorded. A total of 126 patients, including 46 women and 80 men, with a mean age of 41.8 ± 13.1 years, were recruited for this study. All of the patients receiving either BoNT-A injection or AE had a statistically significant increase of bladder capacity at every time-point during filling and a decrease in detrusor pressure at Qmax during voiding. Patients who switched from BoNT-A to AE had greater improvements in their urodynamic parameters when compared with those who continued with BoNT-A injections. Accordingly, SCI patients receiving BoNT-A injections but experiencing few improvements in their urodynamic parameters should consider switching to AE to achieve a better storage function and bladder capacity.

Effectiveness and Safety of Intradetrusor OnabotulinumtoxinA Injection for Neurogenic Detrusor Overactivity and Overactive Bladder Patients in Taiwan-A Phase IV Prospective, Interventional, Multiple-Center Study (Restore Study)

We conducted a phase IV, pre/post multi-center study to evaluate the efficacy and safety of intradetrusor onabotulinumtoxinA injection in patients with neurogenic detrusor overactivity (NDO, n = 119) or overactive bladder (OAB, n = 215). Patients received either 200U (i.e., NDO) and 100U (i.e., OAB) of onabotulinumtoxinA injection into the bladder, respectively. The primary endpoint for all patients was the change in the PPBC questionnaire score at week 4 and week 12 post-treatment compared with baseline. The secondary endpoints were the changes in subjective measures (i.e., questionnaires: NBSS for patients with NDO and OABSS for those with OAB) at week 4 and week 12 post-treatment compared with baseline. Adverse events included symptomatic UTI, de novo AUR, gross hematuria and PVR > 350mL were recorded. The results showed that compared with baseline, PPBC (3.4 versus 2.4 and 2.1, p < 0.001) and NBSS (35.4 versus 20.4 and 18.1, p < 0.001) were significantly improved at 4 weeks and 12 weeks in NDO patients. In addition, compared with baseline, PPBC (3.5 versus 2.3 and 2.0, p < 0.001) and OABSS (9.1 versus 6.2 and 5.7, p < 0.001) were significantly improved at 4 weeks and 12 weeks in OAB patients. Eight (6.7%) had symptomatic UTI and 5 (4.2%) had de novo AUR in NDO patients. Twenty (9.3%) had symptomatic UTI but no de novo AUR in OAB patients. In conclusion, we found that intradetrusor onabotulinumtoxinA injections were safe and improved subjective measures related to NDO or OAB in our cohort.

Psychosocial aspects of health-related quality of life and the association with patient-reported bladder symptoms and satisfaction after spinal cord injury

STUDY DESIGN

Prospective, multi-centered, observational.

OBJECTIVES

To characterize the relationship between psychosocial aspects of health-related quality of life (HRQoL) and patient-reported bladder outcomes.

SETTING

Multi-institutional sites in the United States, cohort drawn from North America.

METHODS

We performed a cross-sectional analysis of data collected as part of the multicenter, prospective Neurogenic Bladder Research Group Spinal Cord Injury (SCI) Registry. Outcomes were: Neurogenic Bladder Symptom Score (NBSS), Neurogenic Bladder Symptom Score Satisfaction (NBSS-Satisfaction), and SCI-QoL Bladder Management Difficulties (SCI-QoL Difficulties). Adjusted multiple linear regression models were used with variables including demographic, injury characteristics, and the following psychosocial HRQoL measures; SCI-QoL Pain Interference (Pain), SCI-QoL Independence, and SCI-QoL Positive Affect and Well-being (Positive Affect). Psychosocial variables were sub-divided by tertiles for the analysis.

RESULTS

There were 1479 participants, 57% had paraplegia, 60% were men, and 51% managed their bladder with clean intermittent catheterization. On multivariate analysis, higher tertiles of SCI-QoL Pain were associated with worse bladder symptoms, satisfaction, and bladder management difficulties; upper tertile SCI-QoL Pain (NBSS 3.8, p < 0.001; NBSS-satisfaction 0.6, p < 0.001; SCI-QoL Difficulties 2.4, p < 0.001). In contrast, upper tertiles of SCI-QoL Independence and SCI-QoL Positive Affect were associated with improved bladder-related outcomes; upper tertile SCI-QoL Independence (NBSS -2.3, p = 0.03; NBSS-satisfaction -0.4, p < 0.001) and upper tertile SCI-QoL Positive Affect (NBSS -2.8, p < 0.001; NBSS-satisfaction -0.7, p < 0.001; SCI-QoL Difficulties -0.7, p < 0.001).

CONCLUSIONS

In individuals with SCI, there is an association between psychosocial HRQoL and bladder-related QoL outcomes. Clinician awareness of this relationship can provide insight into optimizing long-term management after SCI.

Correction of overactive bladder with botulinum toxin type A (BTX-A)

One of the most common dysfunction is overactive bladder. The clinical symptoms are associated with an involuntary contraction of the detrusor muscle of the urethra. Drugs are the basis of overactive bladder therapy. However, the duration of drug therapy is limited due to the frequent development of side effects. The study aimed to examine the efficacy of using botulinum toxin type A (BTX-A) in patients with overactive bladder. A total of 90 patients with overactive bladder (mean age 39.86 ± 3.47 years; 59 (65.6%) women and 31 (34.4%) men) divided into two groups (45 patients each) were examined: Group 1 included patients without imperative urinary incontinence, and Group 2 included patients with imperative urinary incontinence. Patients in both groups underwent intravesical injection of 200 units of botulinum toxin type A (Xeomin). The BTX- A for treating patients with overactive bladder reduces clinical symptoms, increases the functional volume of the bladder, and facilitates an improvement in the life quality of patients. The use of BTX-A in patients suffering from overactive bladder and not responding to drug therapy with m-cholinolytics is effective and safe, which allows recommending this treatment method to correct the studied bladder dysfunction in such patients.

The Current Positioning of Augmentation Enterocystoplasty in the Treatment for Neurogenic Bladder

Augmentation enterocystoplasty (AEC) is a surgical procedure in which the bladder is enlarged using an intestinal segment in patients with lower urinary tract dysfunction who fail to achieve satisfactory results with all conservative treatments. Currently, surgical materials and procedures, concomitant correction of upper urinary tract abnormalities, or bladder neck reconstruction may vary depending on the experience and preferences of the surgeons. AEC has been proven to be successful with respect to surgical goals, such as achieving urinary continence, improving quality of life, and preserving the upper urinary tract over the long term. The advantage of AEC over intravesical injection of botulinum toxin—a more recent and less invasive procedure—is that the prevention of upper urinary tract damage and the improvement of urinary incontinence are more reliably guaranteed, especially considering that these surgical effects are permanent. Compared to less invasive treatments, the quality of life of patients after surgery is also much higher, and AEC may be more cost-effective in the long run. Thus, in patients with neurogenic bladder, AEC is still the gold standard surgical procedure with strong evidence in support of its efficacy. In this article, the indications, surgical methods, possible complications, long-term follow-up, and current positioning of AEC in lower urinary tract dysfunction is discussed.

Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease

Objective: To provide an overview of clinical assessments and diagnostic tools, self-report measures (SRMs) and data sets used in neurogenic bladder and bowel (NBB) dysfunction and recommendations for their use with persons with spinal cord injury /disease (SCI/D).Methods: Experts in SCI/D conducted literature reviews, compiled a list of NBB related assessments and measures, reviewed their psychometric properties, discussed their use in SCI/D and issued recommendations for the National Institutes of Health (NIH), National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements (CDEs) guidelines.Results: Clinical assessments included 15 objective tests and diagnostic tools for neurogenic bladder and 12 for neurogenic bowel. Following a two-phase evaluation, eight SRMs were selected for final review with the Qualiveen and Short-Form (SF) Qualiveen and the Neurogenic Bowel Dysfunction Score (NBDS) being recommended as supplemental, highly-recommended due to their strong psychometrics and extensive use in SCI/D. Two datasets and other SRM measures were recommended as supplemental.Conclusion: There is no one single measure that can be used to assess NBB dysfunction across all clinical research studies. Clinical and diagnostic tools are here recommended based on specific medical needs of the person with SCI/D. Following the CDE for SCI studies guidelines, we recommend both the SF-Qualiveen for bladder and the NBDS for bowel as relatively short measures with strong psychometrics. Other measures are also recommended. A combination of assessment tools (objective and subjective) to be used jointly across the spectrum of care seems critical to best capture changes related to NBB and develop better treatments.

Reasons for cessation of clean intermittent catheterization after spinal cord injury: Results from the Neurogenic Bladder Research Group spinal cord injury registry

INTRODUCTION

Clean intermittent catheterization (CIC) is recommended for bladder management after spinal cord injury (SCI) since it has the lowest complication rate. However, transitions from CIC to other less optimal strategies, such as indwelling catheters (IDCs) are common. In individuals with SCI who stopped CIC, we sought to determine how individual characteristics affect the bladder-related quality of life (QoL) and the reasons for CIC cessation.

METHODS

The Neurogenic Bladder Research Group registry is an observational study, evaluating neurogenic bladder-related QoL after SCI. From 1479 participants, those using IDC or urinary conduit were asked if they had ever performed CIC, for how long, and why they stopped CIC. Multivariable regression, among participants discontinuing CIC, established associations between demographics, injury characteristics, and SCI complications with bladder-related QoL.

RESULTS

There were 176 participants who had discontinued CIC; 66 (38%) were paraplegic and 110 (63%) were male. The most common reasons for CIC cessation among all participants were inconvenience, urinary leakage, and too many urine infections. Paraplegic participants who discontinued CIC had higher mean age, better fine motor scores, and lower educational attainment and employment. Multivariable regression revealed years since SCI was associated with worse bladder symptoms (neurogenic bladder symptom score), ≥4 urinary tract infections (UTIs) in a year was associated with worse satisfaction and feelings about bladder symptoms (SCI-QoL difficulties), while tetraplegia was associated better satisfaction and feelings about bladder symptoms (SCI-QoL difficulties).

CONCLUSIONS

Tetraplegics who have discontinued CIC have an improved QoL compared with paraplegics. SCI individuals who have discontinued CIC and have recurrent UTIs have worse QoL.

Augmentation cystoplasty in the patient with neurogenic bladder

PURPOSE

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB.

RESULTS

AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel.

CONCLUSIONS

Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Bladder Augmentation (Enterocystoplasty): the Current State of a Historic Operation

PURPOSE OF REVIEW

The goal of this paper was to evaluate the current use of enterocystoplasty, a historical operation for bladder dysfunction but with continued and increasing modern relevance.

RECENT FINDINGS

Since the advent of third line neuromodulation techniques for neurogenic and idiopathic overactive bladder (OAB), the usage of enterocystoplasty has decreased. However, this procedure continues to be utilized in pediatric urology patients and the most refractory OAB patients. Adult urologist should be familiar with this operative technique in an effort to manage pediatric patients transitioning to adulthood. Minimally invasive techniques for this surgical procedure have been described with very limited outcome data. It is important for all urologists to be familiar with enterocystoplasty, both technically and with the unique needs of these patients postoperatively. Further studies evaluating the outcomes of this procedure in idiopathic overactive bladder patients and efforts to standardize recommendations for neurogenic bladder patients will help guide care in the future.

Knowledge Gaps in Urologic Care of Female Spinal Cord Injury Patients

PURPOSE OF REVIEW

We highlight the substantial gaps in knowledge on urologic care of female spinal cord injury (SCI) patients.

RECENT FINDINGS

Males account for approximately 80% of people living with SCI in developed nations. Although there is a robust body of literature in some aspects of urologic care of individuals with SCI, such as treatments for neurogenic detrusor overactivity, there are relatively few studies focusing specifically on females. There are also few studies focusing on other aspects of urologic care of women with SCI such as sexual dysfunction, pelvic organ prolapse, and bladder cancer. Established guidelines for bladder management exist, generally recommending intermittent catheterization, but the fact remains that a substantial number of women with SCI utilize indwelling catheters for bladder management. There remains a paucity of literature using patient-reported measures regarding both outcomes and experiences of urologic management in the SCI population. Bladder management is challenging for many women with SCI. There are few studies on other urologic concerns in women with SCI.