NEUROGENIC VESICAL DYSFUNCTION

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.

When should video be added to conventional urodynamics in adults and is it justified by the evidence? ICI-RS 2014

AIMS

To debate and evaluate the evidence base regarding the added value of video to urodynamics in adults and to define research questions.

METHODS

In the ICI-RS Meeting 2014 a Think Tank analyzed the current guidelines recommending video urodynamics (VUD) and performed a literature search to determine the level of evidence for the additional value of the imaging with urodynamic assessment of both neurogenic and non-neurogenic lower urinary tract dysfunction.

RESULTS

Current guidelines do not specify the added value of imaging to urodynamics. Recommendations are based on single center series and expert opinion. Standard imaging protocols are not available and evidence regarding the balance between number and timing of pictures, patient positioning, and exposure time on the one hand and diagnosis on the other hand is lacking. On the basis of expert consensus VUD is relevant in the follow-up of patients with spinal dysraphism. Evidence for the value of VUD in non-neurogenic lower urinary tract dysfunction is sparse. There is some evidence that VUD is not necessary in uncomplicated female SUI, but expert opinion suggests it might improve the evaluation of patients with recurrent SUI.

CONCLUSIONS

There is only low level evidence for the addition of video to urodynamics. The ICI-RS Think Tank encourages better reporting of results of imaging and systematic reporting of X-ray doses. Specific research hypotheses regarding the added value of imaging are recommended. The panel suggests the development of standards for technically optimal VUD that is practically achievable with machines that are on the market.

Diagnosing detrusor sphincter dyssynergia in the neurological patient

Detrusor sphincter dyssynergia (DSD) is variant of neurogenic bladder dysfunction caused by suprasacral neurological abnormalities and may be associated with serious complications if unrecognised. This paper focuses on the clinical features as well as challenges and limitations in the diagnosis of DSD.

The neurogenic bladder: an update with management strategies for primary care physicians

Patients with lesions of the central nervous system often have neurogenic bladder dysfunction. Lifelong bladder monitoring and management in these patients is necessary to prevent severe complications, including renal damage. The urodynamic test, performed by neurourologists or other specially trained providers, is the definitive test for diagnosis and management of neurogenic bladder dysfunction. This article describes the indications and technique of urodynamic testing and the interpretation of the results of such testing. The management of patients with neurogenic bladder dysfunction is also discussed.

Neurophysiology in neurourology

The bladder has only two essential functions. It stores and periodically empties liquid waste. Yet it is unique as a visceral organ, allowing integrated volitional and autonomous control of continence and voiding. Normal function tests the integrity of the nervous system at all levels, extending from the neuroepithelium of the bladder wall to the frontal cortex of the brain. Thus, dysfunction is common with impairment of either the central or peripheral nervous system. This monograph presents an overview of the neural control of the bladder as it is currently understood. A description of pertinent peripheral anatomy and neuroanatomy is provided, followed by an explanation of common neurophysiological tests of the lower urinary tract and associated structures, including both urodynamic and electrodiagnostic approaches. Clinical applications are included to illustrate the impact of nervous system dysfunction on the bladder and to provide indications for testing.

Neurogenic bladder management and cutaneous non-continent ileal conduit

STUDY DESIGN

Prospective monocentric follow-up study.

OBJECTIVES

To assess the results of cutaneous non-continent diversion for neurogenic bladder management.

SETTINGS

Department of Urology (Pitié-Salpétrière Hospital), Department of Neurological Rehabilitation (Raymond Poincaré Hospital), Assistance Publique-Hopitaux de Paris, University Paris VI and V.

METHODS

We reviewed the charts of 33 consecutive patients (19 women, 14 men), operated between 1979 and 1999. Twenty-one patients had spinal cord injury (SCI), four had multiple sclerosis, three had various forms of myelitis and five had central neurological diseases. Diversion was indicated for upper urinary tract protection (17), perineal dryness (14) and/or functional or social reasons (20). Before the operation, 20 of the 33 patients (60.6%) presented urologic complications related to bladder management, including triggered micturition, indwelling catheter or intermittent catheterization: urethrocutaneous fistula (4), complicated enterocystoplasty (2), watering pot perineum and severe decubitus ulcerations (14). Ileal conduit (also named ileoureterostomy) was performed alone for 19 patients (57.6%), and in combination with simultaneous cystectomy in 14 patients. We reviewed patient outcome and early and late complications.

RESULTS

Mean follow-up was 48 months (1 to 20 years). All problems related to catheters or incontinence had resolved. There were no deaths or early re-operations. Twelve patients (12 out of 33, 36%) had one or more peri-operative complication, including ileus (1), uretero-ileal anastomosis leak (1) and sepsis (1). During follow-up, four of the 19 patients who did not undergo cystectomy developed pyocystitis (3 secondary cystectomies performed between 6 and 56 months). All patients achieved perineal dryness.

CONCLUSIONS

The ileal conduit procedure is a safe and well-tolerated procedure in neurologically impaired patients. This procedure is suitable for most neurogenic patients with refractory lower urinary tract dysfunctions.

Modulation of insulin-like growth factor-I system of the bladder using a somatostatin analogue in chronic spinalized rats

PURPOSE

We have previously reported the possible role of the insulin-like growth factor-I (IGF-I) system of mitogens in the development of detrusor smooth muscle hyperplasia and hypertrophy after spinal cord injury. We evaluated the in vivo effects of the anti-growth factor somatostatin analogue octreotide on the IGF-I system as well as subsequent changes in bladder smooth muscle hypertrophy and function after spinal cord injury in rats.

MATERIALS AND METHODS

Included in this study were 90 adult female Sprague-Dawley rats weighing 200 to 250 gm. Of the rats 18 served as sham operated controls, while the remaining 72 underwent were spinal cord transection at the level of the T10 vertebra. The spinalized animals were randomly divided into 4 equal groups of 18, of which 1 group served as paraplegic controls. The other 3 groups received octreotide (60 microgram. daily for 4 weeks) delivered via a subcutaneously implanted osmotic pump immediately, 2 and 4 weeks after spinal cord injury. At the end of the experiment (6 to 8 weeks) each group of animals was subdivided into 2 subgroups of 9. In the first group filling cystometrography was done, while in the second subgroup wet bladder weight was estimated and Northern blot analysis was performed.

RESULTS

Mean wet bladder weight plus or minus standard deviation in sham operated and paraplegic controls was 0.11 +/- 0.01 and 0.64 +/- 0.33 gm., respectively (p <0.05). The increase in bladder weight in paraplegic controls was associated with over expression of the IGF-I gene and with marked suppression of IGF binding proteins-3 and 5 compared with sham operated controls. On the other hand, mean wet bladder weight in the animals that received octreotide immediately after spinal cord injury was 0.17 +/- 0.02 gm., which was associated with a dramatic decrease in IGF-I gene expression and increased expression of IGF binding proteins-3 and 5. Mean cystometric bladder capacity in paraplegic controls was 0.48 +/- 0.18 ml. with an associated voiding pressure of 71 +/- 13 cm. water. All paraplegic controls showed detrusor hyperreflexia. In animals that received octreotide immediately after spinal cord injury mean cystometric bladder capacity was 2.49 +/- 1.75 ml. with an associated voiding pressure of 32 +/- 7 cm. water. Detrusor hyperreflexia disappeared in 88.89% of the rats in this group. There were less marked changes in bladder weight (mean 0.24 and 0.29 +/- 0.3 gm.), IGF-I gene expression and its binding proteins and urodynamic parameters when the drug was given 2 and 4 weeks, respectively, after spinal cord injury.

CONCLUSIONS

Modulating the IGF-I system of mitogens in detrusor smooth muscle with consequently decreased bladder hypertrophy and improved urodynamic behavior in spinal cord injured animals using somatostatin analogue could be a possible therapeutic modality in patients with spinal cord injury.

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.