Bladder autoaugmentation in adult patients with neurogenic voiding dysfunction

Management of spinal cord injury patients with neurogenic lower urinary tract dysfunction using minimally invasive and surgical therapies in Taiwan

The main problems of neurogenic lower urinary tract dysfunction (NLUTD) in patients with spinal cord injury (SCI) consist of impaired urine storage, impaired bladder emptying, or both. The priorities in the management of SCI-NLUTD should be preservation of renal function, followed by freedom from urinary tract infections and improvement of quality of life. Management of NLUTD in patients with SCI must be based on urodynamic findings rather than clinical evaluations. In the hospital without urodynamic equipment, careful measurement of intravesical pressure and safety functional bladder capacity in conjunction with clinical assessment are also feasible. Identification of high-risk patients is important for preventing urological complications in patients with chronic SCI. The management of NLUTD should start with conservative bladder management and medical treatment. Patients with SCI should be regularly followed up, and any NLUTDs and urological complications should be adequately treated. When surgical intervention is necessary, less invasive and reversible procedures should be considered first, and any unnecessary surgery should be avoided. This article reports the current evidence and expert opinions on the patient-centered bladder management of NLUTD in chronic SCI patients in Taiwan. To avoid renal function deterioration and urological complications, annual active surveillance of bladder and renal function is mandatory, especially for high-risk SCI patients.

Stem Cell Therapy in Spinal Cord Injury-Induced Neurogenic Lower Urinary Tract Dysfunction

Spinal cord injury (SCI) is a devastating condition that enormously affects an individual's health and quality of life. Neurogenic lower urinary tract dysfunction (NLUTD) is one of the most important sequelae induced by SCI, causing complications including urinary tract infection, renal function deterioration, urinary incontinence, and voiding dysfunction. Current therapeutic methods for SCI-induced NLUTD mainly target on the urinary bladder, but the outcomes are still far from satisfactory. Stem cell therapy has gained increasing attention for years for its ability to rescue the injured spinal cord directly. Stem cell differentiation and their paracrine effects, including exosomes, are the proposed mechanisms to enhance the recovery from SCI. Several animal studies have demonstrated improvement in bladder function using mesenchymal stem cells (MSCs) and neural stem cells (NSCs). Human clinical trials also provide promising results in urodynamic parameters after MSC therapy. However, there is still uncertainty about the ideal treatment window and application protocol for stem cell therapy. Besides, data on the therapeutic effects regarding NSCs and stem cell-derived exosomes in SCI-related NLUTD are scarce. Therefore, there is a pressing need for further well-designed human clinical trials to translate the stem cell therapy into a formal therapeutic option for SCI-induced NLUTD.

Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Patients with Chronic Spinal Cord Injury

This study aimed to present a comprehensive literature review of the efforts of a spinal cord injury workgroup in Taiwan regarding urologic surgery for neurogenic lower urinary tract dysfunction (NLUTD) in patients with chronic spinal cord injury (SCI). Surgical procedures should be viewed as a final option for managing patients with SCI who have persistent symptoms and complications that cannot be resolved by other means. Surgeries can be grouped according to their purpose: reducing bladder pressures, reducing urethra resistance, increasing urethra resistance, and urinary diversion. The choice of surgery depends on the type of LUTD based on urodynamic tests. Additionally, cognitive function, hand motility, comorbidities, efficacy of surgery, and related complications should be considered.

Satisfaction with Urinary Incontinence Treatments in Patients with Chronic Spinal Cord Injury

Purpose: To investigate the long-term satisfaction and complications in chronic spinal cord injury (SCI) patients after various bladder management strategies and surgical procedures for the treatment of urinary incontinence. Methods: Patients at a single institution with chronic SCI who received bladder management treatment or surgical procedure to improve urinary continence were retrospectively assessed. Thorough urological examinations and videourodynamic studies were performed. Patients were treated either through conservative approaches including medical treatment, clean intermittent catheterization (CIC), cystostomy, and indwelling urethral catheter, or through surgical procedures including detrusor botulinum toxin (Botox) injections, augmentation, ileal conduit, Kock pouch diversion, continent cystostomy, suburethral sling, and artificial urethral sphincter (AUS) implantation. The patients’ satisfaction with urinary continence improvement, causes of dissatisfaction, long-term complications, and overall satisfaction with bladder and voiding condition were assessed. Results: A total of 700 consecutive patients were enrolled in this study. High satisfaction rates were noted after detrusor Botox injection (81.1%), augmentation enterocystoplasty (91.4%), autoaugmentation (80%), Kock pouch diversion, and continent cystostomy (all 100%). Fair satisfaction rates were noted after ileal conduit diversion (66.7%), suburethral sling (64.3%), and AUS implantation (66.7%). Patients who received conservative treatment with medicines, CIC, cystostomy, or an indwelling urethral catheter all had less-satisfactory outcomes (all < 40%). Conclusion: Overall satisfaction with surgical procedures aimed to improve urinary continence in chronic SCI patients was higher than with conservative bladder management (35.4%). Appropriate surgical procedures for chronic SCI patients with neurogenic lower urinary tract dysfunction (NLUTD) and urological complications yielded satisfaction with both urinary continence improvement and with overall bladder and voiding condition.

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.

Long-term outcomes of urinary tract reconstruction in patients with neurogenic urinary tract dysfunction

The advent of specialized spinal units and better understanding of the pathophysiology of neurogenic urinary tract dysfunction has made long-term survival of these patients a reality. This has, in turn, led to an increase in quality and choice of management modalities offered to these patients including complex anatomic urinary tract reconstructive procedures tailored to the unique needs of each individual with variable outcomes. We performed a literature review evaluating the long-term outcomes of these reconstructive procedures. To achieve this, we conducted a world-wide electronic literature search of long-term outcomes published in English. As the premise of this review is long-term outcomes, we have focused on pathologies where evidence of long-term outcome is available such as patients with spinal injuries and spina bifida. Therapeutic success following urinary tract reconstruction is usually measured by preservation of renal function, improvement in quality-of-life, the satisfactory achievement of agreed outcomes and the prevention of serious complications. Prognostic factors include neuropathic detrusor overactivity; sphincter dyssynergia; bladder over distension; high pressure storage and high leak point pressures; vesicoureteric reflex, stone formation and urinary tract infections. Although, the past decade has witnessed a reduction in the total number of bladder reconstructive surgeries in the UK, these procedures are essentially safe and effective; but require long-term clinical and functional follow-up/monitoring. Until tissue engineering and gene therapy becomes more mainstream, we feel there is still a place for urinary tract reconstruction in patients with neurogenic lower urinary tract dysfunction.

Detrusor myectomy: long-term functional outcomes

OBJECTIVES

Detrusor myectomy is a recognized method of bladder augmentation for treating refractory detrusor overactivity. Herein we report the long-term outcomes of this procedure at the University Hospital of Wales in Cardiff, UK.

METHODS

Detrusor myectomy was carried out in 33 patients (7 males, 26 females) with urodynamically proven detrusor overactivity between 1995 and 2002. The mean patient age was 33 years (range 5-62). A total of 18 patients had idiopathic detrusor overactivity, whereas 15 had neurogenic detrusor overactivity.

RESULTS

A total of 24 patients had a detrusor myectomy alone, whereas eight patients had a detrusor myectomy with implantation of artificial urinary sphincter. One patient had detrusor myectomy with transuretero-ureterostomy. The mean follow up was 148 months (range 108-192). A total of 10 of the 18 patients with idiopathic detrusor overactivity (55.5%) and six of the 15 patients with neurogenic detrusor overactivity (40%) showed marked improvement in symptoms. Detrusor overactivity was completely abolished in 11 patients and significantly reduced in five. Postoperatively, mean cystometric capacity improved from 290 to 458 mL, whereas mean maximum amplitude of detrusor contraction was reduced from 44 cm/H(2) O to 20 cm/H(2) O. An overall success rate of 48.5% (16/33 patients) was achieved. Intermittent self catheterization was needed to achieve bladder emptying in 12 of the 16 (75%) patients. Of the remaining 17 patients who did not improve, six had CLAM enterocystoplasty carried out and two await the operation. An ileal conduit diversion and suprapubic catheter insertion was carried out in one patient each, whereas seven patients declined any further intervention.

CONCLUSIONS

Detrusor myectomy offers a reasonable long-term success rate to patients undergoing surgical treatment for refractory detrusor overactivity.

Neurogenic detrusor overactivity in patients with spinal cord injury: evaluation and management

Lower urinary tract dysfunction can have a significant impact on patients with spinal cord injury. Over the years, many treatment options have become available. This article reviews the assessment and management of neurogenic detrusor overactivity, with a particular focus on articles from the recent literature. Recent guidelines on the subject will be discussed. Management options include antimuscarinics and bladder emptying measures, botulinum toxin A, and neuromodulation in refractory cases and surgery for intractable cases. Recent and relevant publications in these areas will be summarized and discussed.

The past, present and future of augmentation cystoplasty

What's known on the subject? And what does the study add? There is a wealth of evidence on the development, indications, outcomes and complications of augmentation cystoplasty (AC). Over the last decade, new evidence has been emerging to influence our clinical practice and application of this technique. AC is indicated as part of the treatment pathway for both neurogenic and idiopathic detrusor overactivity, usually where other interventions have failed or are inappropriate. The most commonly used technique remains augmentation with a detubularised patch of ileum (ileocystoplasty). Controversy persists over the role of routine surveillance following ileocystoplasty for the detection of subsequent bladder carcinoma; however the indication for surveillance after gastrocystoplasty is clearer due to a rising incidence of malignancy in this group. Despite a reduction in the overall numbers of AC operations being performed, it clearly still has a role to play, which we re-examine with contemporary studies from the last decade.

Use of an inflatable silicone balloon improves the success rate of bladder autoaugmentation at long-term followup

PURPOSE

Most groups have reported disappointing results with autoaugmentation or detrusor myectomy for low capacity/compliance neuropathic bladders. Failure may be due to an ischemic diverticulum or mucosal shrinkage. We investigated whether a Silimed® silicone balloon placed in the bladder after autoaugmentation could prevent these problems, improving surgical results.

MATERIALS AND METHODS

We compared the results of standard bladder autoaugmentation in 12 children (group 1) with those in 10 (group 2) who underwent the same surgery using a bladder conformer. The conformer was a silicone balloon filled with saline that remained in the bladder for 2 weeks. All patients had a neuropathic bladder with poor capacity and compliance, resulting in urinary leakage between catheterizations. Preoperative and postoperative evaluation included a voiding diary, ultrasound, voiding cystourethrogram and urodynamics.

RESULTS

In group 1 only 1 patient became dry, 4 had little improvement in continence, 4 remained unchanged and 3 became worse. In group 2, 6 patients (60%) become continent without medication, 2 (20%) become continent with oxybutynin and 2 remained unchanged. Bladder capacity and compliance did not change significantly in group 1. However, in group 2 capacity changed from a mean of 140 to 240 ml and mean ± SD compliance increased from 15.6 ± 16.8 to 34.3 ± 22.8 ml/cm H(2)O (p = 0.02).

CONCLUSIONS

The inflatable balloon improved our long-term results of bladder auto-augmentation. A larger series may be necessary to confirm procedure efficacy and safety.

Contemporary management of the neurogenic bladder for multiple sclerosis patients

Urinary symptoms related to multiple sclerosis (MS) present a complex challenge for the treating physician. However, several treatment options are available for the symptomatic patient once the physician understands basic MS disease epidemiology and pathophysiology. Depending of disease status and symptoms, MS urinary symptoms may respond to directed behavioral, pharmacologic, intravesical, neuromodulation, or surgical therapies.

EAU guidelines on neurogenic lower urinary tract dysfunction

CONTEXT

Most patients with neurogenic lower urinary tract dysfunction (NLUTD) require life-long care to maintain their quality of life (QoL) and to maximise life expectancy.

OBJECTIVE

To provide a summary of the 2008 version of the European Association of Urology (EAU) guidelines on NLUTD and to assess the effectiveness of currently available diagnostic tools, particularly ultrasound imaging and urodynamics.

EVIDENCE ACQUISITION

The recommendations provided in the 2008 EAU guidelines on NLUTD are based on a review of the literature, using online searches of Medline and other source documents published between 2004 and 2007. A level of evidence and/or a grade of recommendation have been assigned to the guidelines where possible.

EVIDENCE SYNTHESIS

NLUTD encompasses a wide spectrum of pathologies, and patients often require life-long, intensive medical care to maximise their life-expectancy and to maintain their QoL. Treatment must be tailored to the needs of the individual patient and, in many cases, involves a multidisciplinary team of experts. Timely diagnosis and treatment are essential if irreversible deterioration of both the upper and lower urinary tracts are to be avoided. Therapeutic decisions are made on the basis of a comprehensive medical assessment, including urodynamics to identify the type of dysfunction. Advances in investigative technologies have facilitated the noninvasive and conservative management of patients who have NLUTD.

CONCLUSIONS

The diagnosis and treatment of NLUTD, which is a highly specialised and complex field involving both urology and medicine, requires up-to-date expert advice to be readily available. The current guidelines are designed to fulfil this need.

Chapitre C-2 B - Traitement de l’hyperactivité détrusorienne neurologique : détrusoromyomectomie

This article reviews the technical principles and results of bladder auto-augmentation by detrusor myomectomy. This technique has been regularly presented since the 1970s as an alternative to enterocystoplasty, especially in children. This review of the literature demonstrates that the current results of bladder auto-augmentation are highly controversial. Most series of patients with neurogenic bladder with a relatively long mean follow-up (about 6 years) conclude on the inefficacy of this technique on both symptoms and objective parameters (urodynamic results). It therefore seems difficult to recommend bladder auto-augmentation by detrusor myomectomy as a reliable alternative to enterocystoplasty, which remains the reference technique.

Neurourologie

There is no part of urology that has made so much progress in the last 25 years as neurourology. Seminal developments have been made in the selective effectiveness of drugs influencing neurogenic bladder dysfunction but having limited side effects. Additional advances are also likely to be made in the methods of functional electrostimulation and tissue engineering. Neurourology is predominantly influenced by our dynamic-functional understanding and the functionally oriented planning and implementation of treatment. The initial treatment options in many areas of neurourology are conservative, but, when possible, not irreversible. If these are ineffective or lead to late complications (e.g. by congenital paraplegia), there are a series of organ sparing or organ manipulating operations which can restore organ function. These make it possible to save kidney function from continuing damage, and, in many cases, to restore continence. The permanent indwelling catheter should remain excluded from the treatment of neurogenic bladder dysfunction. With adequate treatment, patients with neurogenic bladder dysfunction can be protected from severe complications and reintegrated into their normal social environment. After the acute phase of rehabilitation, urology is the most commonly required specialist area for paraplegic patients. In the past, urological problems have contributed most to the short lifespan of patients with an accident related spinal cord injury. Using modern neurourological treatment strategies, not only is lifespan increased but the quality of life of the patient is permanently improved.

Detrusor myectomy: long-term results with a minimum follow-up of 2 years

OBJECTIVES

To assess the long-term results of detrusor myectomy, which has obvious theoretical advantages over enterocystoplasty for refractory detrusor overactivity (DO), and for which the early results have been encouraging.

PATIENTS AND METHODS

The medical records were reviewed of 30 consecutive patients (median age 33 years, range 10-62) who had a detrusor myectomy between November 1992 and April 2002 in our unit. Twenty-four patients (80%) had idiopathic DO (six males and 18 females) and six (20%) had neurogenic DO (four males and two females). The median (range) follow-up was 79 (28-142) months. All patients were confirmed to have DO on urodynamics before surgery and 26 (87%) had urodynamics afterward.

RESULTS

Nineteen (79%) of those with idiopathic DO and two with neurogenic DO showed a continued overall improvement. The cystometric capacity improved in 80% of patients after surgery, whilst the detrusor pressure at maximum flow and the bladder contractility index decreased in 60% and 78% of the patients, respectively. Ten patients (45%) had to start clean intermittent self-catheterization after surgery.

CONCLUSIONS

Detrusor myectomy is successful in approximately 80% of patients with idiopathic DO, although detrusor contractility is affected in most and almost half of the patients required clean intermittent self-catheterization afterward. This procedure should be offered as an alternative to enterocystoplasty as it is less morbid and does not preclude subsequent surgery if required. However, further evaluation of this technique is required in neuropathic patients.

Success of repeat detrusor injections of botulinum a toxin in patients with severe neurogenic detrusor overactivity and incontinence

OBJECTIVES

Detrusor injections with botulinum toxin type A are an effective treatment for neurogenic detrusor overactivity, lasting for 9-12 months. When the patients develop botulinum resistance, subsequent injections might be less effective. Repeat injections in patients with severe neurogenic detrusor overactivity and incontinence were studied.

METHODS

Patients received Botox (300 UI) or Dysport (750 UI) injections. Clinical variables: satisfaction, anticholinergics use, mean and maximum bladder capacity, continence volume. Cystometric parameters: compliance, cystometric capacity, reflex volume.

STATISTICS

Anova, chi2-tests; t-tests and paired t-tests (p=0.05).

RESULTS

Forty-three men and 23 women (mean age 38.3 years; mean duration of lesion 9.2 years) were included. The interval between subsequent injections (on average 9-11 months) did not change significantly (p=0.5594). The satisfaction was high and anticholinergics use decreased substantially (p=0.0000). Significant improvements were found in clinical parameters and in cystometric capacity, for compliance only at the second treatment. The incidence of reflex contractions was significantly reduced. Four patients had transient adverse events after Dysport.

CONCLUSIONS

Repeat injections with botulinum toxin type A are as effective as the first one. The cause for repeat treatment is relapse of overactive bladder symptoms.

European experience of 200 cases treated with botulinum-A toxin injections into the detrusor muscle for urinary incontinence due to neurogenic detrusor overactivity

OBJECTIVES

To present a comprehensive experience with botulinum-A toxin (BTA) injected into the detrusor muscle in patients with spinal cord injuries/diseases causing neurogenic incontinence.

METHODS

Ten European medical centers provided the results of 231 patients with neurogenic detrusor overactivity who were treated with BTA. 300 units of Botox (Allergan Inc.) were injected cystoscopically into the detrusor muscle at 30 different locations, while sparing the trigonum. Urinary continence status, concomitant anticholinergic medication use and patient satisfaction were recorded. Key urodynamic parameters (reflex volume, maximum detrusor pressure during voiding, detrusor compliance and maximum cystometric bladder capacity) at baseline and at the first and second urodynamic follow-up examinations were analyzed.

RESULTS

By the time of the initial (mean 12 weeks after injection) as well as at the second urodynamic follow-up examinations (mean 36 weeks after injection), the mean cystometric bladder capacity (p < 0.0001) and the mean reflex volume (p < 0.01) increased significantly, while the mean voiding pressure (p < 0.0001) decreased significantly. The mean bladder compliance had increased significantly (p < 0.0001) by the first follow-up examination and non-significantly by the time of the second follow-up. No injection related complications or toxin related side effects were reported. The patients considerably reduced or even stopped taking anticholinergic drugs without recurrence of reflex incontinence and were satisfied with the treatment.

CONCLUSIONS

This retrospective European multicenter study presents the most extensive experience to date with BTA injections into the detrusor muscle to treat neurogenic incontinence due to detrusor overactivity and confirms that this new treatment is safe and valuable. Significant improvement of bladder function corresponds with continence and the subjective satisfaction indicated by the treated patients.

THE OUTCOME OF DETRUSOR MYOTOMY IN CHILDREN WITH NEUROGENIC BLADDER DYSFUNCTION

PURPOSE

We evaluate the outcome of detrusor myotomy for neurogenic bladder dysfunction (NBD) in children.

MATERIALS AND METHODS

A retrospective analysis was performed of data compiled from medical and urodynamic records of children younger than 16 years with NBD who had undergone detrusor myotomy from 1992 to 2000 at our department.

RESULTS

Surgery was performed in 14 children with a mean age +/- SD of 6.7 +/- 4.3 years (range 0.9 to 14.2) and mean followup of 5.9 +/- 1.7 years. All patients were diagnosed with NBD, which was the result of myelomeningocele in 9, sacral agenesis in 2, lumbosacral lipoma in 1, multiple vertebral anomalies in 1 and spinal neuroblastoma in 1. Main indications for surgery included urinary incontinence in 11 cases and high pressure/low capacity bladders with vesicoureteral reflux and impending renal damage in 8. No major postoperative complications were recorded. Although mean maximal cystometric bladder capacity was unchanged 1 month postoperatively (89.7 +/- 70.6 ml) compared to preoperatively (92.5 +/- 75.1 ml, p = 0.87), significant increments of 216%, 237% and 292% were measurable at 3 months, 1 year and 5 years, respectively. Ultimately most of the patients approached age specific capacities. Complete continence on clean intermittent catheterization was achieved by 8 of 11 patients and improved markedly in 1. Reflux was alleviated in 6 cases and improved in 1. Kidney function developed normally in all but 1 patient with persistent reflux.

CONCLUSIONS

When feasible, detrusor myotomy offers a safe and effective alternative for the management of pharmacologically intractable NBD in children.

[Ureterocystoplasty: functional results and possible problem areas]

Surgical procedures such as ileal augmentation cystoplasties are often necessary in neurogenic low-compliance bladders. Whenever possible one should avoid using segments of the GI tract in the urinary tract and preferably use the patient's own ureter for augmentation cystoplasty. This procedure includes transperitoneal nephrectomy of a nonfunctioning kidney with preservation of the renal pelvis and the megaureter, followed by detubularization of the ureter and its integration into the opened urinary bladder. We performed this procedure on four patients, two boys and two girls (aged 6-13 years). In the long-term follow-up they all had good rehabilitation results for their lower urinary tracts with an increase of the storage volume and normalization of their reduced compliance. No deterioration of the remaining upper urinary tract was found. Complications such as partial ureteral necrosis have to be taken into consideration when the vascularization of the ureter is compromised, for example, by multiple prior antireflux procedures.

Neurogenic Bladder, Neurogenic Bowel, and Sexual Dysfunction in People With Spinal Cord Injury

The purpose of this article is to review the literature related to the effects of spinal cord injuries on genitourinary, gastrointestinal, and sexual function. These important areas of function are profoundly affected by spinal cord injuries, with the effects of injury being dependent on the specific level and degree of neurologic dysfunction. Our ability to manage neurogenic bladder dysfunctions and neurogenic bowel dysfunctions has improved over the past few years; however, in general the techniques used have not significantly changed. In contrast, a significant amount of new information has been made available regarding the effects of specific neurologic injuries on sexual response, particularly female sexual response. Moreover, techniques to remediate erectile dysfunction and infertility in the male have vastly improved the fertility potential of men with spinal cord injuries. Further research is warranted in all of these areas.

A long-term follow-up of autoaugmentation in myelodysplastic children

OBJECTIVE

To evaluate the long-term results of patients who underwent bladder autoaugmentation (BA) in whom BA was used to treat a neuropathic bladder secondary to myelomeningocele, and who presented with a high-pressure/poorly compliant bladder.

PATIENTS AND METHODS

Eleven patients (eight girls and three boys, mean age 12.8 years, mean follow-up 6.6 years) were selected who had undergone BA between June 1991 and June 1994. At surgery, the patients had a poorly compliant bladder with a mean leak point volume (LPV) of 94 mL and a mean leak point pressure (LPP) of 58 cmH2O. None of the patients had vesico-ureteric reflux (VUR) at BA; five with grade III or IV VUR had undergone endoscopic correction in a day-surgery procedure using a suburethral collagen injection 1-3 weeks before BA. The patients were evaluated using clinical, urodynamic, radiological and endoscopic assessments. The LPV, LPP and safe bladder capacity (SBC, the cystometric volume at an intravesical pressure of 40 cmH2O) were recorded.

RESULTS

At 1 year after surgery the mean LPV was 297 mL; none of the patients had VUR. The most recent mean LPV was 198 mL and the SBC 167 mL. The mean LPP remained stable at 60 cmH2O. At the last follow-up four patients had recurrent uni- or bilateral grade III-V VUR. At endoscopy the 'augmented' bladder portion had a smooth surface, compared with the grossly trabeculated lower half. From this finding all patients on clean intermittent catheterization were treated with oral oxybutynin. Some patients reported slightly less abdominal pain at maximum bladder volume; four needed pads to treat intermittent incontinence. On voiding cysto-urethrography, one patient had an hourglass-shaped bladder. Five patients recently underwent ileocystoplasty because of recurrent urinary tract infection, high-grade VUR and incontinence.

CONCLUSION

These results do not justify the routine use of BA in hypertonic/poorly compliant bladders secondary to myelomeningocele. The mean follow-up of 6.6 years showed that this procedure failed in seven of 11 patients. Further studies might be able to identify subgroups in which this approach may be more appropriate.

Towards a catheter free status in neurogenic bladder dysfunction: a review of bladder management options in spinal cord injury (SCI)

STUDY DESIGN

Review.

OBJECTIVES

To assess current available options for bladder management in SCI patients the post-acute phase.

METHODS

Relevant articles were extracted from medline and Cinahl between 1966--1999. In addition, references earlier than 1966 that were listed in these articles were identified and extracted.

RESULTS

Catheterisation (indwelling or self intermittent) is still carried out by the majority of SCI patients with more morbidity for indwelling catheterisation. Other methods include condom drainage, suprapubic tapping and supreapubic pressure are used and are associated with less complications. Complicated procedures like sacral anterior root stimulator and entero-cystoplasty are carried out with the onset of or impending complications.

CONCLUSION

Several methods of bladder management are available in the post-acute phase of SCI. The method used has to be based on urodynamic characteristics with the aim of producing a continent bladder with adequate low pressure storage capacity. Modern management of the bladder in SCI has successfully reduced renal related mortality in SCI from 95% in the first half of the 20th century to the present 3%.

Mixed symptomatology

Mixed symptomatology, i.e. both stress and urge incontinence, is reported by patients, either of their own accord or in response to a questionnaire. Our understanding of motor urge incontinence, detrusor instability, stress incontinence and sensory urge incontinence is changing. Detrusor instability is now known to be a urodynamic observation of uncertain clinical significance. Symptoms reported by patients are not equivalent to a urodynamic diagnosis but the problem seems to be more in the urodynamics than in the symptoms. Evidence shows that sensory urge incontinence and motor urge incontinence are probably gradations of the same condition. The relationship between stress incontinence and an overactive bladder is complex. For example, neither detrusor instability nor urge incontinence appear to adversely influence the outcome of surgical treatment for stress incontinence; however, this treatment does not have a good success rate. At present, it is not clear whether this poor outcome reflects a lack of efficacy of the operations used, or their application to inappropriate patients.