Endoluminal urethral stents: a review

[Ejaculation capacity in spinal cord injured patients carrying an endo-urethral stent for incontinentation: Descriptive study]

OBJECTIVES

To assess the impact of endo-urethral stent (EUP) of incontinentation in spinal cord injured (SCI) men on ejaculation capacity.

FIRST CRITERIA

Presence of ejaculation after EUP.

SECONDARY CRITERIA

Modification on ejaculation type, stimulation mode, possibility of sperm conservation in the same population.

POPULATION AND METHODS

A descriptive monocentric study including SCI subjects which underwent placement or change of temporary (Mémokath™ or Allium™) or definitive (Mémotherm™) EUP between January 2004 and January 2014 with at least one ejaculatory test. Are identified for each patient: the presence of ejaculation, type of ejaculation, stimulation mode used, number of frozen specimen and results from semen analysis.

RESULTS

Over 11 men with tetraplegia, complete for motricity, there were 8 (72%) for whom ejaculation was possible after laying EUP. Of these, 6 (55%) had an antegrade or antero-retrograde ejaculation. It was not possible to make a freezing straw in four of them due to infection of semen (2) or terato-oligo-astenospermia (1) or absence of reproductive project (1).

CONCLUSION

In this small sample, it was found that over 70% ejaculation have been preserved after laying EUP and more than 50% with antegrade or antero-retrograde ejaculation. A larger study would identify how EUP may alter the ejaculatory capacity or quality of the ejaculate.

LEVEL OF EVIDENCE

4.

A 20-year follow-up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury

OBJECTIVE

To assess the long-term (20 years) effectiveness of the UroLume wallstent(TM) (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in patients with spinal cord injury (SCI).

PATIENTS AND METHODS

Twelve patients with quadriplegia secondary to SCI underwent external striated sphincter stenting with the UroLume wallstent in place of sphincterotomy for DESD ≈ 20 years ago. The mean (range) age was 41.8 (26-65) years. Eleven patients had cervical level injury whilst one had a thoracic injury. All the patients were shown to have high-pressure neurogenic detrusor overactivity and DESD with incomplete emptying on preoperative video-cystometrograms (VCMG).

RESULTS

Six of the 12 patients have now been followed-up for a mean (range) of 20 (19-21) years. Of the remaining six, two were lost to follow-up at 1 and 3 years, but both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within 1 year of insertion. Another patient with an adequately functioning stent died 7 years after stent insertion from a chest infection. The twelfth patient developed bladder cancer 14 years after stent insertion and underwent cystectomy with urinary diversion. VCMG follow-up of the six patients showed a significantly sustained reduction of maximum detrusor pressure and duration of detrusor contraction at the 20-year follow-up. Five of these six patients developed bladder neck dyssynergia of varying degrees as shown on VCMG within the first 9 years of follow-up. All were successfully treated with bladder neck incision (BNI) where the last BNI needed was at 12 years. We did not encounter any problem with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia.

CONCLUSION

Urethral stenting using the UroLume wallstent is effective in the management of DESD in patients with SCI and provides an acceptable long-term (20-year follow-up) alternative to sphincterotomy. The failures manifest within the first few years and can be managed easily with stent removal without any significant problems. Bladder neck dyssynergia was the long-term complication which was treated successfully with BNI. It has no significant interference with erectile function, being reversible, minimally invasive and has a shorter hospital stay.

Chapitre B-3 A - Traitement chirurgical des dysfonctions neurologiques des sphincters urinaires

The treatment of neurogenic detrusor-sphincter dyssynergia is primarily medical (drugs and catheterization). Some patients may not be eligible for or fail to respond to these treatment options and endoscopic sphincterotomy or permanent prosthesis may be indicated. In this article, the authors review the indications, results and contraindications of these various treatments.

The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up

OBJECTIVE

To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients.

PATIENTS AND METHODS

Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying.

RESULTS

Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia.

CONCLUSION

Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.

Epithelialization of permanent stents

The permanent Urolume Wallstent has been used for the relief of bladder outlet obstruction (BOO), detrusor-external sphincter dyssnergia (DESD), and recurrent bulbar urethral strictures. Because of its woven construction, it allows ingrowth of urothelial tissue, resulting in complete epithelialization by 6 to 12 months. Certain risk factors are associated with poor epithelialization that may lead to hyperplastic tissue growth and occlusion of the urethral lumen. We review the literature and discuss the 5-year results of the North American Multicenter Urolume Trial with regard to epithelialization, hyperplastic tissue growth, and treatment of hyperplastic growth.

Heat-expansible permanent intraurethral stents for benign prostatic hyperplasia and urethral strictures

We report our experience with the insertion of a new thermoexpansible permanent intraurethral stent, the Memotherm. We treated 49 patients, 25 with benign prostic hyperplasia (BPH), 21 with recurrent urethral strictures (2 cervicourethral and 18 bulbar and 1 of a vescicourethral anastomosis after radical prostatectomy), and 3 with sphincterotomies (2 for dyssynergia and 1 with incontinence plus stenosis). The patients' ages ranged from 24 to 84 (mean 59.7) years. In all patients, stent insertion was achieved without any operative problem. In two patients, stents were removed (one in the BPH group and one in the urethral stricture group), and at long-term follow-up, we have seen two patients with severe mucosal hyperplasia.

Laser prostatectomy: initial experience and urodynamic follow-up

OBJECTIVES

An evolving technology for the treatment of bladder outlet obstruction due to benign prostatic hyperplasia (BPH) is the use of the side-firing neodymium: yttrium-aluminum-garnet (Nd:YAG) laser to achieve prostatic tissue ablation. The purpose of this study was to determine the short-term efficacy of this procedure in both an objective and subjective manner.

METHODS

We examined this technique by carefully evaluating our first 25 men undergoing the procedure. Each patient was subjected to careful symptom score analysis using the American Urological Association symptom index and multichannel urodynamics, including pressure-flow studies both preoperatively and at 3 months postoperatively.

RESULTS

At the 3-month follow-up, symptom scores improved from a preoperative mean of 11.4 to 7.2 and the mean maximum flow rate improved from 6.1 to 14.5 cc/s. These are both significant at P < 0.001. Statistically similar improvement was seen in detrusor pressure at opening and at maximum flow. Eighty percent of the men studied had at least a 50% reduction in symptom score and a 50% improvement in flow rate.

CONCLUSIONS

We conclude that laser prostatectomy is a promising minimally invasive treatment for bladder outlet obstruction secondary to BPH and deserves further evaluation at longer terms of follow-up.

Alternative endoscopic management in the treatment of urethral strictures

Advances in endoscopic instrumentation and techniques have expanded our armamentarium for safe and effective treatment of urethral strictures. Endoscopic incision or dilation should remain the preferred treatment for uncomplicated primary strictures. Balloon dilation can be useful in the treatment of dense strictures. Incision using laser energy has yet to provide better results than procedures employing a cold knife. As such, it would be difficult to justify the added expense of laser urethrotomy. Endoscopic placement of free skin grafts into the bed of the urethra after transurethral resection or deep incision of the stricture is a novel approach that has shown a great deal of promise. Endourethroplasty is a reasonable alternative to open urethroplasty when treating long strictures, as more than 90% of the reported patients have had a successful outcome with no recurrence. However, larger experience with this procedure is necessary to verify its efficacy and for greater acceptance. The placement of indwelling stents is another new promising treatment option. Overall short-term success rates range from 75% to 100%, but the follow-up period is short, and little is known about the long-term risks of an indwelling foreign body in the urethra. Endoscopic incision via "cut-to-the-light" or "core-through" procedures is an excellent alternative in patients with obliterative strictures. Data from several centers reveal that the majority of patients gain relief of obstruction while maintaining continence and erectile potency. However, at least 25% of these patients will need further endoscopic management to maintain urethral patency.