Long-term urological management in spinal injury units in the UK and Eire: a follow-up study

Evaluating Neurogenic Bladder Management in Palestinian Healthcare: A Qualitative Study

BACKGROUND

Neurogenic bladder (NB) is a prevalent urologic condition significantly impacting the health and quality of life of affected individuals. The condition, often resulting from various etiologies such as spinal cord injuries and multiple sclerosis, leads to severe life problems, including pain and impaired physical, mental, social, and emotional functioning. This study aims to explore the medical practices of urologists in the diagnosis, management, and care of NB patients within the Palestinian healthcare context, highlighting the absence of a unified treatment protocol and the reliance on private clinics for care.

METHODS

An exploratory qualitative study design was employed, adhering to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Structured interviews were conducted with 14 urologists and two urology residents across eight different cities in Palestine, including 10 governmental hospitals, two private hospitals, one university hospital, and one charity hospital. Fourteen doctors had private outpatient clinics alongside their work in hospitals. A questionnaire developed by the authors was delivered to specialists and residents to understand the evaluation, management, follow-up practices, and challenges faced in treating NB patients. The study focused on the diagnostic processes, treatment modalities, complications management, and the impact of the lack of standardized protocols on patient care. Our qualitative study consists of six major themes, each theme consisting of multiple sub-themes and different participant responses: (1) diagnosis and follow-up of NB patients; (2) general issues in the management of NB; (3) evaluation and follow-up of upper and lower urinary system function in NB patients; (4) urinary tract infections associated with NB disease and how to deal with it; (5) opinions and future attitudes in the treatment of NB patients; (6) NB in patients with multiple sclerosis.

RESULTS

The study found that urodynamic studies are crucial in NB diagnosis, yet there is no unified management protocol, leading to varied practices. Most participants preferred the American Urological Association (AUA) guidelines in the absence of Palestinian protocols. Six major themes emerged, including diagnosis and follow-up challenges, general issues in NB management, evaluation and follow-up of urinary system function, urinary tract infections management, opinions on future treatment directions, and specific considerations for NB patients with multiple sclerosis.

CONCLUSIONS

The study highlights the need for a unified, standardized protocol for the management of NB patients in Palestine. The reliance on international guidelines, primarily the AUA protocols, underscores the gap in local healthcare policies. The findings call for the establishment of national guidelines and enhanced resources for the effective management of NB, aiming to improve patient outcomes and quality of life.

The Utility of Urodynamic Studies in Neuro-Urological Patients

INTRODUCTION

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review.

METHODS

For this narrative review, a PubMed^® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

ANALYSIS

Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities.

CONCLUSION

Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

A survey of clinical practice concerning long-term follow-up of neurogenic lower urinary tract dysfunction due to spinal cord injury in Italy

CONTEXT/OBJECTIVE

This study aimed to assess the clinical practice for long-term follow-up (FU) of neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) in Italy and compare this practice with the clinical practice in other countries and with the international guidelines.

DESIGN

Data concerning the long-term urological FU of individuals with SCI were collected using a questionnaire and analyzed by means of descriptive and inferential statistics.

SETTING

Twenty-one Italian centers following SCI patients.

PARTICIPANTS

One physician at each center (either a permanent staff member or chief).

OUTCOME MEASURES

Questions addressed the treatment of urinary tract infections (UTI), frequency of visits, urinary tract imaging examinations and urodynamic tests (UD), distinguishing between suprasacral and sacral SCI.

RESULTS

Nineteen out of 21 centers completed the survey. In most centers, patients were recommended to undergo a visit and an ultrasound examination of urinary tract (UT) at least once a year. While the median interval between FU visits was identical (12 months) for individuals with suprasacral and sacral SCI, the two interval distributions were significantly different (suprasacral SCI: min-max 4-18, IQR = 6; sacral SCI: min-max 6-24; IQR = 8.5; P = 0.02), showing people with suprasacral SCI are followed up more often. Approximately 80% of the surveyed centers performed scheduled UD, with a yearly median frequency of 12 months (range 6-36) for patients with suprasacral SCI, as compared to a median frequency of 18 months for sacral SCI (range 0-36, P = 0.04). VideoUD and antibiotic prophylaxis for recurrent UTIs are carried out only by urologists in 63% and 47.4% of the centers, respectively. Overall, Italian centers share common strategies that compare to standards, including yearly visits, yearly UT examinations and stricter follow-up of people with suprasacral SCI, but may not have standard protocols for antibiotic prophylaxis of UTI, and in few cases control visits and UD are carried out too often.

CONCLUSIONS

Even though most Italian centers follow up patients with NLUTD secondary to SCI according to international guidelines, heterogeneity in frequency of FU examinations still exists. A tailored approach to the SCI patient that minimizes unnecessary examinations and groups different tests in a single access could improve patients' compliance with FU and reduce costs for the Health system.

Description of Urological Surveillance and Urologic Ultrasonography Outcomes in a Cohort of Individuals with Long-Term Spinal Cord Injury

Background: Individuals with spinal cord injury (SCI) have an increased risk of developing urological complications. Therefore, long-term routine urological surveillance is recommended. Objective: To describe urological surveillance in individuals with long-term SCI and to determine factors associated with urologic ultrasonography (UU) outcome. Methods: Wheelchair-dependent individuals with an SCI for 10 years or more were included. A medical assessment was done in 8 participating rehabilitation centers. The International Lower Urinary Tract Function Basic SCI Data Set was used to assess bladder-emptying methods and previous surgical procedures on the urinary tract. We studied urological surveillance: whether participants had routine urological checkups (including UU) and when latest urodynamic study was performed. Latest UU (performed <1 year ago) was retrieved or, when lacking, UU was performed as part of our study. Results: Median time since injury (TSI) was 22.0 years. Overall, 39% of the 282 participants did not have routine urological checkups and 33% never had a urodynamic study performed. UU data (N = 243) revealed dilatation of the upper urinary tract (UUT) in 4.5% of the participants and urinary stones in 5.7%. Abnormal UU outcome was associated with increasing TSI, nontraumatic SCI, and previous surgical bladder or UUT stone removal. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Conclusions: Over one-third of Dutch individuals with long-term SCI did not receive routine urological surveillance. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Further research on the indication and frequency of urological surveillance is recommended.

Follow-up urodynamics in patients with neurogenic bladder

INTRODUCTION

Neurogenic bladder patients are at long-term risk of secondary upper urinary tract damage. Symptoms are unreliable and follow-up urodynamics is the only method of ascertaining safety of bladder pressures. This review examines the recommendations, shortcomings and utilization of existing guidelines. The evidence with regard to follow-up urodynamics in different settings relevant to neurogenic bladder is evaluated and an algorithm is proposed.

METHODS

A pubmed search was conducted for studies on follow-up urodynamics in patients with neurogenic bladder. Additional search was made of secondary sources including reviews and guidelines.

RESULTS

The need for follow-up urodynamics should be considered in all patients undergoing an initial assessment and weighed against the risks. Existing guidelines, while unanimous in their recommendation of its utilization, give scant details regarding its incorporation in clinical management. Follow-up urodynamics can document efficacy and identify the need for escalation of therapy in patients on intermittent catheterization and antimuscarinics. Patients with spinal injury, spinal dysraphism and anorectal malformations are at higher risk for upper tract damage. Follow-up urodynamics can help identify patients suitable for intravesical botulinum and mark those destined for failure. Patients undergoing augmentation cystoplasty may be candidates for less aggressive urodynamic follow-up.

CONCLUSIONS

Neurogenic bladder is managed by a broad cross-section of physicians. Clear recommendations and a management algorithm are important for improving patient care. Follow-up urodynamics can identify patients at risk, prevent renal dysfunction and improve the quality of life. There is an urgent need for more evidence on this important subject.

Follow-up of the neuro-urological patient: a systematic review

OBJECTIVES

To systematically review the long-term urological follow-up strategies for patients with neurogenic lower urinary tract dysfunction (NLUTD), focusing on three main groups of neurological diseases: (i) spinal cord injuries, (ii) spinal dysraphism, and (iii) multiple sclerosis.

PATIENTS AND METHODS

Data acquisition comprised electronic search on the Medical Literature Analysis and Retrieval System Online (MEDLINE) database and the EMBASE database in August 2014 to retrieve English language studies. MEDLINE and EMBASE search included the following medical subject heading (MeSH) terms: (i) neurogenic bladder and (ii) neurogenic bladder dysfunction. Each of these terms was crossed with (i) long-term care and (ii) long-term surveillance. Only studies related to NLUTD and urological follow-up were included. Studies were also identified by hand search of reference lists and review articles.

RESULTS

Initial records identified through database searching included 265 articles. In all, 23 articles were included in the quantitative synthesis. The proposed time schedule of investigations as well as the amount and type of investigation were different according to specific neurological lesions. They depend on the dysfunctional pattern of the lower urinary tract (LUT) and its risk profile. However, there is a lack of high-evidence level studies to support an optimal long-term follow-up protocol.

CONCLUSIONS

The goal of neuro-urological management is the best possible preservation of upper urinary tract (UUT) and LUT function in relation to the individual neurological disorder. Regular and risk adapted controls ('urochecks') allow detection of risk-factors in time before irreversible changes of the LUT and UUT have occurred. With risk- and patient-oriented lifelong regular urological care an optimised quality of life and life-expectancy can be achieved, although there is a complete lack of high-evidence level studies on this topic.