Bladder neck closure with continent augmentation or suprapubic catheter in patients with neurogenic bladders

Conservative bladder management in advanced multiple sclerosis

Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.

Comparison of transvaginal and retropubic bladder neck closure with suprapubic catheter in women

PURPOSE

Bladder neck closure is an uncommon procedure that is usually reserved for patients with severe urethral incompetence. It may be an acceptable alternative to procedures involving bowel reconstruction. Bladder neck closure can be performed using a transvaginal or a retropubic approach. We compared urethral continence rates, perioperative outcomes, short-term and long-term complications, subsequent procedures and changes in renal function between transvaginal and retropubic bladder neck closure in females at our institution.

MATERIALS AND METHODS

We retrospectively reviewed the records of 64 female patients who underwent bladder neck closure with suprapubic catheter placement from May 1990 to February 2013. Baseline variables and the mentioned outcomes were compared between transvaginal and retropubic bladder neck closure.

RESULTS

There were 35 women in the transvaginal group and 29 in the retropubic group. Urethral erosion due to a chronic indwelling urethral catheter was the most common indication for bladder neck closure. The urethral continence rate after the first bladder neck closure did not significantly differ between the transvaginal and retropubic groups (85.7% vs 81.5%, p = 0.74). The transvaginal group had significantly shorter mean operative time (78.0 vs 137.5 minutes, p = 0.002) and hospital stay (1.5 vs 4.9 days, p = 0.0003), and fewer short-term complications (5.7% vs 31.0%, p = 0.02) than the retropubic group. The remaining outcomes did not differ between the 2 groups.

CONCLUSIONS

There was no difference between transvaginal and retropubic bladder neck closure in achieving urethral continence. Transvaginal bladder neck closure was associated with a shorter operative time and hospital stay as well as fewer short-term complications.

Transvaginal bladder neck closure with posterior urethral flap for devastated urethra

OBJECTIVES

To present a modified transvaginal bladder neck closure (TV BNC) technique using a posterior urethral flap to minimize the potential risk of ureteral injury and fistula formation. Urethral and bladder neck destruction owing to chronic indwelling urethral catheters in female neurogenic patients is a devastating complication.

METHODS

A retrospective review was performed of all patients undergoing TV BNC at a single institution during a 3-year period. All patients had had a nonfunctional or destroyed urethra because of a long-term indwelling urethral catheter. In brief, the devastated outlet was closed using the dorsally bivalved urethra as a flap that was rotated cephalad onto the incised anterior bladder wall for closure, thereby rotating the suture line high into the retropubic space. A postoperative cystogram was obtained at 2-3 weeks.

RESULTS

A total of 11 consecutive female patients with a devastated outlet underwent TV BNC, as described, with placement of a suprapubic tube. One patient experienced failure at 6 weeks postoperatively. The mean follow-up for the entire cohort was 9.6 months (range 1-36). Serial upper tract imaging at the last follow-up visit revealed no new hydroureteronephrosis.

CONCLUSIONS

The results of our study have shown that TV BNC with a posterior urethral flap provides satisfactory early results. This technique creates a suture line far removed from the ureteral orifices, minimizing the risk of upper tract injury during closure. Also, the rotation of the posterior urethra onto the anterior bladder wall secures the suture line high into the retropubic space, minimizing the risk of failure and postoperative fistula formation.

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder

OBJECTIVE

Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients.

METHODS

A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed.

RESULTS

Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts.

CONCLUSIONS

Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.

Bladder neck closure and suprapubic tube placement in a debilitated patient population

AIMS

Bladder neck closure (BNC) with suprapubic tube (SPT) placement is a method of bladder management for patients with neurogenic bladders (NGB). We evaluated our experience at one institution.

METHODS

We conducted a retrospective chart review of patients who received BNC with SPT placement from 1999 to 2008.

RESULTS

Twenty-nine patients (24 females and 5 males, average age 53.4 +/- 9.6 years) underwent BNC with SPT placement. Cause of NGB was multiple sclerosis (48%), spinal injury (28%), or myelodysplasia (17%). All but one were dependent on caregivers for activities of daily living. Preoperative urodynamics studies were performed on 23 patients. Retropubic BNC was performed in 26 of 29 patients. Two females had a transvaginal approach, and one male had a perineal approach. Early (<90 days) postoperative complication rate was 52%. Persistent urine leakage was present in eight patients: two peristomal leakage and six urethral leakage. All three non-retropubic BNC had postoperative fistulas (P = 0.01). Catheter complications were associated with seven of the eight urinary leaks (P = 0.01).

CONCLUSIONS

BNC with SPT is a method of bladder management in the NGB population, particularly suited to those with a low functional status. Fistula rates are significantly higher with non-retropubic BNC (P = 0.01). Poor catheter care in the postoperative period is associated with postoperative urinary leakage (P = 0.01).

Successful Treatment with Intradetrusor Botulinum-A Toxin for Urethral Urinary Leakage (Catheter Bypassing) in Patients with End-Staged Multiple Sclerosis and Indwelling Suprapubic Catheters

OBJECTIVE

To present the initial results of Botulinum-A toxin (BTA) injection in patients with long-standing multiple sclerosis (MS) and urethral leakage of urine in spite of indwelling suprapubic catheters (catheter bypassing).

METHODS

Study of three patients treated with cystoscopic injection of BTA IU (Allergan). Telephone interviews were made at four- to six-week intervals. Continence status and patient satisfaction were recorded before and after treatment.

RESULTS

Patient 1 remained dry at 48 weeks post injection. Patient 2 became incontinent again after 40 weeks. The third patient was continent when interviewed at 27 weeks following injection, but died two weeks later. The patients were very satisfied with the procedure and there were no complications related to BTA.

CONCLUSIONS

Intradetrusor BTA injection is a very effective and safe treatment for intractable catheter bypassing in patients with neurogenic detrusor overactivity.

Physiological principles for surgical correction of detrusor dysfunction

Urinary incontinence may be the result of various forms of detrusor overactivity. Several surgical therapies have been devised, but with the exception of procedures to relieve urethral obstruction, none abolishes the overactivity or restores normal micturition. In general, ablative neurosurgery is considered only in patients with chronic neurologic disease. Bladder augmentation is useful in selected patients. The indications for urinary diversion in patients with detrusor overactivity and urge incontinence are quite limited.