URINARY DIVERSION AND RECONSTRUCTION IN THE PATIENT WITH SPINAL CORD INJURY

Control of urinary bladder function with devices: successes and failures

The management of urinary tract dysfunction is crucial for the health and well-being of people with spinal cord injury. Devices, specifically catheters, play an important role in the daily regime of bladder management for most people with spinal cord injury. However, the high incidence of complications associated with the use of catheters, and the fact that the spinal segments involved in lower urinary tract control remain intact in most cord-injured people, continue to motivate research into devices that could harness the nervous system to provide greater control over lower urinary tract function. Mechanical devices discussed in this review include catheters, artificial urethral sphincters, urethral stents and intraurethral pumps. Additionally, many attempts to restore control of the lower urinary tract with electrical stimulation have been made. Stimulation sites have included: inside the bladder, bladder wall, thigh, pelvic floor, dorsal penile nerve, pelvic nerve, tibial nerve, sacral roots, sacral nerves and spinal cord. Catheters and sacral root stimulators are two techniques whose efficacy is well established. Some approaches have proven less successful and others are still in the development stage. Modifications to sacral root stimulation including posterior root stimulation, anodal blockade and high-frequency blockade as well as new techniques including intraspinal microstimulation, urethral afferent stimulation and injectable microstimulators are also discussed. No single device has yet restored the control and function of the lower urinary tract to the pre-injury state, but new techniques are bringing this possibility closer to reality.

Advantages and risks of ileovesicostomy for the management of neuropathic bladder

OBJECTIVES

To evaluate the efficacy and complications of ileovesicostomy in patients with neurogenic bladder dysfunction.

METHODS

Fifteen consecutive neurologically impaired patients (8 from multiple sclerosis, 4 from spinal cord injury, 3 from other causes) with complications of previous bladder management underwent ileovesicostomy. There were 10 women and 5 men. All patients were either poor candidates for or refused continent urinary diversion or bladder augmentation cystoplasty.

RESULTS

At a mean follow-up of 23.2 months, 14 of 15 patients had low-pressure urine drainage through their ileovesicostomy. Four women with documented preoperative detrusor hyperreflexia had postoperative intermittent mild urge incontinence per native urethra. They did not require any further treatment, except for oral anticholinergic drugs (oxybutynin and tolterodine). Because of persistent severe urge incontinence, 1 woman required conversion of her ileovesicostomy to an ileal conduit with concurrent cystectomy. The ileovesicostomy of another myelodysplastic man who had four failed artificial urinary sphincters in the past was also converted to an ileal conduit because of persistent urethroperineal fistula despite perineal urethral closure. Renal function was preserved in all patients. Long-term complications were stomal stenosis in 2 patients, bladder and kidney stone formation in 5, and symptomatic urinary tract infections in 3.

CONCLUSIONS

Ileovesicostomy can be safely performed in neurologically impaired women and men. Severe preoperative detrusor hyperreflexia with urge incontinence appears to be a risk factor for persistent urge incontinence postoperatively in women. Continued routine urologic surveillance for infection and stones is mandatory. Ileovesicostomy is a versatile procedure for neurologically impaired patients, because it can be converted to a conventional ileal conduit if necessary. In addition, in cases of neural recovery, the ileal "chimney" can be excised and the patient's original lower urinary tract would be preserved.