Detrusor myotomy: a 5-year review in unstable and non-compliant bladders

Neurogenic bladder in spinal cord injury patients

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

The evolution of bladder augmentation: from creating a reservoir to reconstituting an organ

Bladder augmentation was first described in 1899. The goal at the time was to establish the ideal method to create a simple capacious reservoir for the safe storage of urine. That simple idea has over the last 100 years grown into one of the most dynamic areas in Pediatric Urology. Creative minds and hands from individuals in multiple disciplines have led us from creating a reservoir to the threshold of recreating a functional organ. In this review, we look at the historical evolution of bladder augmentation and how it exponentially grew in scope from those initial descriptions of intestinocystoplasty to the work being reported today in the field of tissue engineering.

Promising long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction

PURPOSE

We evaluated the long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction.

MATERIALS AND METHODS

Data were compiled from the records of 25 children with a median age of 9.3 years (range 0.9 to 14.2) who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end filling pressures, and were unresponsive to clean intermittent catheterization and anticholinergics.

RESULTS

Median followup was 6.8 years (range 0.1 to 15.6). Median postoperative bladder capacity was unchanged or decreased to 95 ml (range 25 to 274) during the first 3 months compared to a median preoperative capacity of 103 ml (14 to 250). At 5 months postoperatively median bladder capacity increased significantly to 176 ml (range 70 to 420, p<0.01). This increase remained significant during the rest of followup. Median bladder compliance doubled after 1 year to 10 ml/cm H2O (range 1 to 31, p<0.05) compared to the preoperative level, and further increased to 17 ml/cm H2O (5 to 55) at 5 years (p<0.05). Median maximal detrusor pressure was 43 cm H2O (range 8 to 140) preoperatively. This value decreased significantly postoperatively (p<0.01) and at final followup it was 26 cm H2O (range 6 to 97). Kidney function developed normally in all patients except 1 with persistent uremia. Reflux was alleviated in 7 of 9 cases. Of the patients 18 became continent on clean intermittent catheterization.

CONCLUSIONS

Bladder autoaugmentation in children with neurogenic bladder dysfunction offers, after a transient decrease in bladder capacity, a long lasting increase in capacity and compliance, while the end filling pressure decreases.

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.

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.

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.

Detrusorectomy with rectus muscle hitch and backing

PURPOSE

Bladder autoaugmentation is a procedure that includes detrusoromyotomy or detrusorectomy with an aim to release intact urothelium, which then prolapses and increases bladder capacity and compliance. Covering of the prolapsed urothelium usually is done by using deepithelialized pedicled colonic or gastric patch. The authors present their first experiences with detrusorectomy using rectus muscle for hitch and backing.

METHODS

Between August 1999 and February 2002, autoaugmentation was performed in 19 patients (12 girls and 7 boys) aged 4 to 12 years (median, 8). All patients had a neurogenic bladder with small capacity and poor compliance. Detrusorectomy usually involves the whole upper half of the bladder to achieve regular shape of the huge prolapsed urothelium. Both rectus muscles are dissected from their anterior and posterior sheaths. Urothelium is sutured to the muscle at several points to prevent its retraction and shrinkage. This way, bladder is fixed and hanged on rectus muscles.

RESULTS

Follow-up was 6 to 35 months (median, 21). The new bladder capacity was increased in all patients and ranged from 190 to 411 ml (median, 313). All patients had clinical improvement and better compliance.

CONCLUSIONS

Detrusorectomy with rectus muscle hitch and backing is a safe and simple procedure. However, long-term results are needed to define value of this procedure.

Detrusorectomy for Neuropathic Bladder in Patients with Spinal Dysraphism

PURPOSE

We assess the outcome of detrusorectomy in 35 patients with spina bifida who were incontinent due to poor bladder volume or poor compliance.

MATERIALS AND METHODS

Of 51 patients requiring bladder augmentation 35 underwent detrusorectomy. In 3 patients ileocystoplasty was later performed as a secondary procedure because of failure of the detrusorectomy.

RESULTS

A total of 35 patients (17 males, 18 females) underwent detrusorectomy. Mean patient age at operation was 9.9 years (range 0.4 to 17.8). Mean followup was 4.9 years (range 1 to 10.5). A continent catheterizable vesicostomy was constructed in 14 patients and ureteral reimplantation was performed in 8. Twenty-five patients also underwent sling and/or Burch cystourethropexy during detrusorectomy, of whom 19 are continent and 5 have some leakage between clean intermittent catheterizations. In 1 girl the sling procedure was not successful, and she was subsequently treated with bladder neck closure. Bladder compliance after operation was improved in 9 cases and unchanged in 10. Of the 16 patients in whom compliance was already acceptable before the operation and was unchanged after detrusorectomy 7 were able to stop antimuscarinic therapy. Compliance became poor in 4 cases, of which 3 required ileocystoplasty. Bladder volume (as a percentage of normal volume for age) was increased after detrusorectomy in 13 patients, unchanged in 11 and decreased in 11. Complications of detrusorectomy included bladder leakage in 2 cases. One patient needed a laparotomy because of urinary ascites shortly after the operation.

CONCLUSIONS

Detrusorectomy may be combined with other procedures such as ureteral reimplantation, slingplasty and continent vesicostomy. Of 35 treated patients compliance improved in 16 (46%),volume improved in 13 (37%), 3 had no change in parameters, and 3 had a slight decrease in volume and compliance. Four patients had poor results, of whom 3 needed a secondary ileocystoplasty. Therefore, it may be concluded that detrusorectomy is a safe and probably useful procedure for improvement of bladder volume and compliance in patients with neurogenic bladder dysfunction, and may obviate the need for ileocystoplasty in a limited number of patients.

Autoaugmentation by Detrusor Myotomy: Its Lack of Effectiveness in the Management of Congenital Neuropathic Bladder

PURPOSE

We present our long-term results in 17 patients with myelomeningocele undergoing autoaugmentation by vesicomyotomy.

MATERIALS AND METHODS

Surgery was performed from 1990 to 1994 on 17 patients with neurogenic bladder due to spinal dysraphism. Indications for autoaugmentation included upper tract deterioration and/or incontinence secondary to hypperreflexia, hypocompliance or low bladder volume. All patients had failed to respond to conservative medical and pharmacological treatments. Median patient age at surgery was 10.2 years (range 2.2 to 13.2). Outcomes were evaluated retrospectively according to changes in upper tract status, continence and urodynamic parameters. Median clinical and urodynamic followup is 75 months (range 4 to 126).

RESULTS

Progressive hydronephrosis developed in 5 patients, which required subsequent enterocystoplasty in 4. Of 13 patients 8 (62%) remain incontinent. Of the 17 cases 12 (71%) were considered clinical failures on the basis of upper tract deterioration and/or ongoing incontinence. There were few clinically significant improvements in urodynamic parameters, as 14 of 15 cases (93%) were considered urodynamic failures on the basis of persistent hypocompliance and/or less than expected gains in safe bladder capacity with somatic growth.

CONCLUSIONS

Although short-term reports of autoaugmentation have been promising, they do not appear durable. This procedure cannot be endorsed for the management of congenital neuropathic bladder.