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Doelman AW, Streijger F, Majerus SJA, Damaser MS, Kwon BK. Assessing Neurogenic Lower Urinary Tract Dysfunction after Spinal Cord Injury: Animal Models in Preclinical Neuro-Urology Research. Biomedicines 2023; 11:1539. [PMID: 37371634 DOI: 10.3390/biomedicines11061539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/20/2023] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
Neurogenic bladder dysfunction is a condition that affects both bladder storage and voiding function and remains one of the leading causes of morbidity after spinal cord injury (SCI). The vast majority of individuals with severe SCI develop neurogenic lower urinary tract dysfunction (NLUTD), with symptoms ranging from neurogenic detrusor overactivity, detrusor sphincter dyssynergia, or sphincter underactivity depending on the location and extent of the spinal lesion. Animal models are critical to our fundamental understanding of lower urinary tract function and its dysfunction after SCI, in addition to providing a platform for the assessment of potential therapies. Given the need to develop and evaluate novel assessment tools, as well as therapeutic approaches in animal models of SCI prior to human translation, urodynamics assessment techniques have been implemented to measure NLUTD function in a variety of animals, including rats, mice, cats, dogs and pigs. In this narrative review, we summarize the literature on the use of animal models for cystometry testing in the assessment of SCI-related NLUTD. We also discuss the advantages and disadvantages of various animal models, and opportunities for future research.
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Affiliation(s)
- Adam W Doelman
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Femke Streijger
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Steve J A Majerus
- Department of Electrical, Computer and Systems Engineering, Case Western Reserve University, Cleveland, OH 44106, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH 44106, USA
| | - Margot S Damaser
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH 44106, USA
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Brian K Kwon
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
- Department of Orthopaedics, Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
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Majerus SJA, Offutt SJ, Brink TS, Vasoli V, Mcadams I, Damaser MS, Zirpel L. Feasibility of Real-Time Conditional Sacral Neuromodulation Using Wireless Bladder Pressure Sensor. IEEE Trans Neural Syst Rehabil Eng 2021; 29:2067-2075. [PMID: 34606460 PMCID: PMC9359615 DOI: 10.1109/tnsre.2021.3117518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Continuous sacral neuromodulation (SNM) is used to treat overactive bladder, reducing urine leakage and increasing capacity. Conditional SNM applies stimulation in response to changing bladder conditions, and is an opportunity to study neuromodulation effects in various disease states. A key advantage of this approach is saving power consumed by stimulation pulses. This study demonstrated feasibility of automatically applying neuromodulation using a wireless bladder pressure sensor, a real-time control algorithm, and the Medtronic Summit™ RC+S neurostimulation research system. This study tested feasibility of four conditional SNM paradigms over five days in 4 female sheep. Primary outcomes assessed proof of concept of closed-loop system function. While the bladder pressure sensor correlated only weakly to simultaneous catheter-based pressure measurement (correlation 0.26-0.89, median r=0.52), the sensor and algorithm were accurate enough to automatically trigger SNM appropriately. The neurostimulator executed 98.5% of transmitted stimulation commands with a median latency of 72 ms (n=1,206), suggesting that rapid decision-making and control is feasible with this platform. On average, bladder capacity increased for continuous SNM and algorithm-controlled paradigms. Some animals responded more strongly to conditional SNM, suggesting that treatment could be individualized. Future research in conditional SNM may elucidate the physiologic underpinnings of differential response and enable clinical translation.
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Review of Current Neurogenic Bladder Best Practices and International Guidelines. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00622-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Shang Z, Ou T, Xu J, Yan H, Cui B, Wang Q, Wu J, Jia C, Cui X, Li J. MicroRNA expression profile in the spinal cord injured rat neurogenic bladder by next-generation sequencing. Transl Androl Urol 2020; 9:1585-1602. [PMID: 32944521 PMCID: PMC7475673 DOI: 10.21037/tau-20-415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background An increasing amount of evidence has indicated that microRNAs (miRs) are involved in most biological conditions, including the neurogenic bladder (NB). However, to our knowledge, no studies have investigated these miR expressions in spinal cord-injured (SCI) rat NB. The goal of the study was to explore the miR expression profile in the SCI rat NB by next-generation sequencing (NGS). Methods Female Wistar rats underwent spinal cord transection at T9–10 and were randomly divided into the SCI-1, SCI-2 and SCI-3 groups (n=5 for each group) whose bladder tissues were collected 1, 2, and 4 weeks after transection, respectively. The normal rats were used as the normal control (NC) group. MiRs microarray assays were used to detect the differentially expressed miRs between the groups by NGS, which was then verified by quantitative real-time polymerase chain reaction (qRT-PCR). Those significantly differently expressed miRs were analyzed with Gene Ontology categories and Kyoto Encyclopedia of Genes and Genomes bioinformatical analyses. Results Compared with the NC group, 96, 28 and 51 miRs were downregulated in the rats’ bladder in the SCI-1, SCI-2, and SCI-3 groups, respectively, and 133, 49, and 76 miRs were upregulated respectively. Specifically, miR-21-5p was the most significantly upregulated miR in all SCI groups. Also, 121 miRs (SCI-1 vs. SCI-2), 98 miRs (SCI-1 vs. SCI-3), and 26 miRs (SCI-2 vs. SCI-3) were of significantly different expression. Furthermore, a large set of genes implicated in essential signaling pathways were targeted by these miRs, including PI3K-Akt, MAPK, Rap1, and cGMP-PKG signaling pathways, along with the tight junction and metabolic pathways. Conclusions This is the first demonstration of differentially expressed miRs, which may potentially serve as new molecular targets in the SCI rat NB.
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Affiliation(s)
- Zhenhua Shang
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Tongwen Ou
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jianjun Xu
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Hao Yan
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Bo Cui
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Qi Wang
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jiangtao Wu
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Chunsong Jia
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Xin Cui
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jin Li
- Department of Urology, Xuanwu Hospital Capital Medical University, Beijing, China
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Birkhäuser V, Liechti MD, Anderson CE, Bachmann LM, Baumann S, Baumberger M, Birder LA, Botter SM, Büeler S, Cruz CD, David G, Freund P, Friedl S, Gross O, Hund-Georgiadis M, Husmann K, Jordan X, Koschorke M, Leitner L, Luca E, Mehnert U, Möhr S, Mohammadzada F, Monastyrskaya K, Pfender N, Pohl D, Sadri H, Sartori AM, Schubert M, Sprengel K, Stalder SA, Stoyanov J, Stress C, Tatu A, Tawadros C, van der Lely S, Wöllner J, Zubler V, Curt A, Pannek J, Brinkhof MWG, Kessler TM. TASCI-transcutaneous tibial nerve stimulation in patients with acute spinal cord injury to prevent neurogenic detrusor overactivity: protocol for a nationwide, randomised, sham-controlled, double-blind clinical trial. BMJ Open 2020; 10:e039164. [PMID: 32792454 PMCID: PMC7430472 DOI: 10.1136/bmjopen-2020-039164] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD), including neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, is one of the most frequent and devastating sequelae of spinal cord injury (SCI), as it can lead to urinary incontinence and secondary damage such as renal failure. Transcutaneous tibial nerve stimulation (TTNS) is a promising, non-invasive neuromodulatory intervention that may prevent the emergence of the C-fibre evoked bladder reflexes that are thought to cause NDO. This paper presents the protocol for TTNS in acute SCI (TASCI), which will evaluate the efficacy of TTNS in preventing NDO. Furthermore, TASCI will provide insight into the mechanisms underlying TTNS, and the course of NLUTD development after SCI. METHODS AND ANALYSIS TASCI is a nationwide, randomised, sham-controlled, double-blind clinical trial, conducted at all four SCI centres in Switzerland. The longitudinal design includes a baseline assessment period 5-39 days after acute SCI and follow-up assessments occurring 3, 6 and 12 months after SCI. A planned 114 participants will be randomised into verum or sham TTNS groups (1:1 ratio), stratified on study centre and lower extremity motor score. TTNS is performed for 30 min/day, 5 days/week, for 6-9 weeks starting within 40 days after SCI. The primary outcome is the occurrence of NDO jeopardising the upper urinary tract at 1 year after SCI, assessed by urodynamic investigation. Secondary outcome measures assess bladder and bowel function and symptoms, sexual function, neurological structure and function, functional independence, quality of life, as well as changes in biomarkers in the urine, blood, stool and bladder tissue. Safety of TTNS is the tertiary outcome. ETHICS AND DISSEMINATION TASCI is approved by the Swiss Ethics Committee for Northwest/Central Switzerland, the Swiss Ethics Committee Vaud and the Swiss Ethics Committee Zürich (#2019-00074). Findings will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03965299.
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Affiliation(s)
- Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Sarah Baumann
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Michael Baumberger
- Spinal Cord and Rehabilitation Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Lori A Birder
- Neuro-Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sander M Botter
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, Zürich, Switzerland
| | - Silvan Büeler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Célia D Cruz
- Instituto de Investigação e Inovação em Saúde, Translational Neuro-urology Group, Universidade do Porto, Porto, Portugal
- Faculdade de Medicina, Departemento de Biomedicina, Unidade de Biologia Experimental, Universidade do Porto, Porto, Portugal
| | - Gergely David
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Knut Husmann
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, Zürich, Switzerland
| | - Xavier Jordan
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Eugenia Luca
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sandra Möhr
- Clinic of Neurorehabilitation and Paraplegiology, REHAB Basel, Basel, Switzerland
| | - Freschta Mohammadzada
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jivko Stoyanov
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Cornelia Stress
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Aurora Tatu
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Cécile Tawadros
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jens Wöllner
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Veronika Zubler
- Department of Radiology, Balgrist University Hospital, Zürich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Abstract
PURPOSE OF REVIEW To provide an overview of available electrical stimulation devices in neurogenic patients with lower urinary tract disease. RECENT FINDINGS It is advocated to do more studies in neurogenic patients as results seem promising and useful but most studies did not include neurogenic patients or neurogenic patients were not analyzed or reported separately. Most studies included a small heterogenous neurogenic group with multiple pathophysiologic origin focusing on effect of a treatment instead of results of a treatment in a specific neurogenic group. Neuromodulation or stimulation has the advantage that it acts on different organs, like bladder and bowel, so can treat neurogenic patients, who mostly suffer from multiple organ failure. SUMMARY Brindley procedure, sacral neuromodulation (SNM) and posterior tibial nerve stimulation (PTNS) are available for a while already. The Brindley procedure (including sacral anterior root stimulation in combination with a rhizotomy of posterior sacral roots) is developed for selected spinal cord injury patient with a complete spinal injury, and has shown results for many years in neurogenic patients. An alternative to the rhizotomy is not established yet. SNM and PTNS are other modalities that are used in nonneurogenic patients, but are not yet indicated and much studied in neurogenic patients.
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Lee YJ, Yoon CY, Lee MS, Song BD, Lee SW, Jeong SJ. Effect of Early Sacral Neuromodulation on Bladder Function in a Rat Model of Incomplete Spinal Cord Injury Due to Focal Contusion. Neuromodulation 2018; 22:697-702. [PMID: 30506765 DOI: 10.1111/ner.12895] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 09/23/2018] [Accepted: 10/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Incomplete spinal cord injury (SCI) accounts for two-thirds of all SCIs in clinical practice. Preclinical research on the effect of sacral neuromodulation (SNM) on bladder function, however, has been focused only on animal models of complete SCI. We aimed to evaluate the effect of early SNM on bladder responses in a rat model of incomplete SCI. MATERIALS AND METHODS Altogether, 21 female Sprague-Dawley rats were equally assigned to control (CTR), SCI + sham stimulation (SHAM), and SCI + SNM (SNM) groups. In the SHAM and SNM groups, incomplete SCI was created by producing a moderate contusion with an NYU-MASCIS impactor at the T9-T10 level of the spine, with needle electrodes implanted bilaterally into the S2 or S3 sacral foramen. Only SNM group underwent electrical stimulation for 28 days, beginning on day 7 after SCI. Cystometry was performed 35 days after SCI. RESULTS Although the interval between voiding contractions was significantly longer in the SHAM group than the CTR group (25.5 ± 1.4 vs. 12.5 ± 1.7 min; p < 0.05), there were no significant differences between the SNM group (16.5 ± 1.5 min) and the CTR group. Maximum voiding contraction pressure did not differ among the groups. The SNM group had a significantly lower frequency (3.5 ± 0.5 vs. 14.6 ± 2.0; p < 0.05) and maximum pressure (11.4 ± 6.2 vs. 21.3 ± 1.8 cmH2 O; p < 0.05) of nonvoiding contractions than the SHAM group. CONCLUSIONS Our results provide experimental evidence that early SNM treatment may prevent or diminish bladder dysfunctions (e.g., detrusor overactivity, abnormal micturition reflex) in a clinical condition of incomplete SCI.
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Affiliation(s)
- Young Ju Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Cheol Yong Yoon
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Min Seung Lee
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung Do Song
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sang Wook Lee
- Department of Urology, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Seong Jin Jeong
- Department of Urology, Seoul National University Bundang Hospital, Seongnam, South Korea
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Redshaw JD, Lenherr SM, Elliott SP, Stoffel JT, Rosenbluth JP, Presson AP, Myers JB. Protocol for a randomized clinical trial investigating early sacral nerve stimulation as an adjunct to standard neurogenic bladder management following acute spinal cord injury. BMC Urol 2018; 18:72. [PMID: 30157824 PMCID: PMC6116487 DOI: 10.1186/s12894-018-0383-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background Neurogenic bladder (NGB) dysfunction after spinal cord injury (SCI) is generally irreversible. Preliminary animal and human studies have suggested that initiation of sacral neuromodulation (SNM) immediately following SCI can prevent neurogenic detrusor overactivity and preserve bladder capacity and compliance. We designed a multicenter randomized clinical trial to evaluate the effectiveness of early SNM after acute SCI. Methods/Design The scientific protocol comprises a multi-site, randomized, non-blinded clinical trial. Sixty acute, acquired SCI patients (30 per arm) will be randomized within 12 weeks of injury. All participants will receive standard care for NGB including anticholinergic medications and usual bladder management strategies. Those randomized to intervention will undergo surgical implantation of the Medtronic PrimeAdvanced Surescan 97,702 Neurostimulator with bilateral tined leads along the S3 nerve root in a single-stage procedure. All patients will undergo fluoroscopic urodynamic testing at study enrollment, 3 months, and 1-year post randomization. The primary outcome will be changes in urodynamic maximum cystometric capacity at 1-year. After accounting for a 15% loss to follow-up, we expect 25 evaluable patients per arm (50 total), which will allow detection of a 38% treatment effect. This corresponds to an 84 mL difference in bladder capacity (80% power at a 5% significance level). Additional parameters will be assessed every 3 months with validated SCI-Quality of Life questionnaires and 3-day voiding diaries with pad-weight testing. Quantified secondary outcomes include: patient reported QoL, number of daily catheterizations, incontinence episodes, average catheterization volume, detrusor compliance, presence of urodynamic detrusor overactivity and important clinical outcomes including: hospitalizations, number of symptomatic urinary tract infections, need for further interventions, and bowel and erectile function. Discussion This research protocol is multi-centered, drawing participants from large referral centers for SCI and has the potential to increase options for bladder management after SCI and add to our knowledge about neuroplasticity in the acute SCI patient. Trial registration ClinicalTrials.gov #NCT03083366 1/27/2017.
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Affiliation(s)
- Jeffrey D Redshaw
- Department of Surgery, Division of Urology, University of Utah School of Medicine, 30 N. 1900 E. 3B110, Salt Lake City, UT, 84132, USA.
| | - Sara M Lenherr
- Department of Surgery, Division of Urology, University of Utah School of Medicine, 30 N. 1900 E. 3B110, Salt Lake City, UT, 84132, USA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - John T Stoffel
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey P Rosenbluth
- University of Utah School of Medicine, Physical Medicine and Rehabilitation, Salt Lake City, UT, USA
| | - Angela P Presson
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Department of Surgery, Division of Urology, University of Utah School of Medicine, 30 N. 1900 E. 3B110, Salt Lake City, UT, 84132, USA
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Peh WYX, Mogan R, Thow XY, Chua SM, Rusly A, Thakor NV, Yen SC. Novel Neurostimulation of Autonomic Pelvic Nerves Overcomes Bladder-Sphincter Dyssynergia. Front Neurosci 2018; 12:186. [PMID: 29618971 PMCID: PMC5871706 DOI: 10.3389/fnins.2018.00186] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 03/06/2018] [Indexed: 12/25/2022] Open
Abstract
The disruption of coordination between smooth muscle contraction in the bladder and the relaxation of the external urethral sphincter (EUS) striated muscle is a common issue in dysfunctional bladders. It is a significant challenge to overcome for neuromodulation approaches to restore bladder control. Bladder-sphincter dyssynergia leads to undesirably high bladder pressures, and poor voiding outcomes, which can pose life-threatening secondary complications. Mixed pelvic nerves are potential peripheral targets for stimulation to treat dysfunctional bladders, but typical electrical stimulation of pelvic nerves activates both the parasympathetic efferent pathway to excite the bladder, as well as the sensory afferent pathway that causes unwanted sphincter contractions. Thus, a novel pelvic nerve stimulation paradigm is required. In anesthetized female rats, we combined a low frequency (10 Hz) stimulation to evoke bladder contraction, and a more proximal 20 kHz stimulation of the pelvic nerve to block afferent activation, in order to produce micturition with reduced bladder-sphincter dyssynergia. Increasing the phase width of low frequency stimulation from 150 to 300 μs alone was able to improve voiding outcome significantly. However, low frequency stimulation of pelvic nerves alone evoked short latency (19.9–20.5 ms) dyssynergic EUS responses, which were abolished with a non-reversible proximal central pelvic nerve cut. We demonstrated that a proximal 20 kHz stimulation of pelvic nerves generated brief onset effects at lower current amplitudes, and was able to either partially or fully block the short latency EUS responses depending on the ratio of the blocking to stimulation current. Our results indicate that ratios >10 increased the efficacy of blocking EUS contractions. Importantly, we also demonstrated for the first time that this combined low and high frequency stimulation approach produced graded control of the bladder, while reversibly blocking afferent signals that elicited dyssynergic EUS contractions, thus improving voiding by 40.5 ± 12.3%. Our findings support advancing pelvic nerves as a suitable neuromodulation target for treating bladder dysfunction, and demonstrate the feasibility of an alternative method to non-reversible nerve transection and sub-optimal intermittent stimulation methods to reduce dyssynergia.
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Affiliation(s)
- Wendy Yen Xian Peh
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore
| | - Roshini Mogan
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore
| | - Xin Yuan Thow
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore
| | - Soo Min Chua
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore
| | - Astrid Rusly
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore
| | - Nitish V Thakor
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore.,Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore.,Department of Electrical and Computer Engineering, National University of Singapore, Singapore, Singapore.,Biomedical Engineering, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Shih-Cheng Yen
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore.,Department of Electrical and Computer Engineering, National University of Singapore, Singapore, Singapore
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Bae J, Johnston TA, Chaiittianan R, Sutthanut K, Jay M, Marson L. Characterization and in vivo efficacy of a heptapeptide ODT formulation for the treatment of neurogenic bladder dysfunction. Int J Pharm 2018; 536:397-404. [PMID: 29195918 PMCID: PMC5803421 DOI: 10.1016/j.ijpharm.2017.11.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/13/2017] [Accepted: 11/19/2017] [Indexed: 12/14/2022]
Abstract
The objective of this study was to develop oral disintegrating tablet (ODT) formulations of a heptapeptide, [Lys5,MeLeu9,Nle10]-NKA(4-10), for the treatment of neurogenic bladder dysfunction. A design of experiment approach was applied to determine the optimal ratio of chosen excipients: gelatin (X1), glycine (X2), and sorbitol (X3). These formulations were optimized for efficacy studies to produce ODTs exhibiting rapid disintegration times (Y1) and appropriate structural integrity (Y2) using JMP® 12.0.1 software. Based on theoretically predicted values from 12 experimental runs, the optimal ODT formulation was determined to be 3% (w/v) gelatin, 2% (w/v) glycine, and 1% (w/v) sorbitol in deionized water. Using this formulation, blank and drug-loaded ODTs containing 1.5 mg or 5 mg of [Lys5,MeLeu9,Nle10]-NKA(4-10) were manufactured by a lyophilization process. The peptide-loaded tablets disintegrated in less than 30 s and released 97% of the peptide within 15 min. The peptide was stable for 90 days under 25 °C/60% relative humidity (RH) and 40 °C/75% RH. In vivo efficacy of the peptide-loaded ODTs was confirmed in a rat acute spinal cord injury model under isovolumetric bladder pressure recording conditions, concluding that sublingual administration of peptide-containing ODTs evoke a rapid dose-related neurokinin 2-mediated increase in bladder pressure.
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Affiliation(s)
- Jungeun Bae
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Thomas A Johnston
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Rungsiri Chaiittianan
- Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Khaetthareeya Sutthanut
- Department of Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Michael Jay
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Lesley Marson
- Division of Pharmacoengineering and Molecular Pharmaceutics, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA; Dignify Therapeutics, Research Triangle Park, NC, 27709, USA; Department of Urology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
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11
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Ni J, Wang X, Cao N, Si J, Gu B. Efficacy of different spinal nerve roots for neuromodulation of micturition reflex in rats. Oncotarget 2018; 9:13382-13389. [PMID: 29568364 PMCID: PMC5862585 DOI: 10.18632/oncotarget.23950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 11/16/2017] [Indexed: 12/14/2022] Open
Abstract
Electrical stimulation of peripheral nerves controlling the bladder is an alternative, nondestructive medical treatment for urinary incontinence and retention. In this study, we aimed to identify the most efficient sensory and motor spinal nerve roots involved in the micturition reflex. Unilateral L5-S2 dorsal and ventral roots were electrically stimulated, and bladder reflex contractions were recorded under isovolumetric conditions. Repeated stimulation of the L6 and S1 dorsal roots not only abolished bladder reflex contractions but also induced a poststimulation inhibitory effect, whereas repeated stimulation of the L5 and S2 dorsal roots had no effect. Only the L6 ventral root directly caused bladder contraction when ventral roots L5-S2 were stimulated in sequence. Upon retrograde tracing using pseudorabies virus (PRV), the sacral parasympathetic nucleus of the L6 segment had more PRV-positive cells than the other segments, though the S1 segment of the dorsal root ganglia had the highest density of PRV-positive neurons. These results suggest the L6 ventral root is most efficient in producing detrusor muscle contraction, and the S1 dorsal root best inhibits the micturition reflex.
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Affiliation(s)
- Jianshu Ni
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaohu Wang
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Nailong Cao
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jiemin Si
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Baojun Gu
- Department of Urology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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12
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Bartley JM, Killinger KA, Boura JA, Gupta P, Gaines N, Gilleran JP, Peters KM. The impact of prior back surgery on neuromodulation outcomes: A review of over 500 patients. Neurourol Urodyn 2016; 36:1535-1542. [PMID: 27676460 DOI: 10.1002/nau.23140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 08/31/2016] [Indexed: 11/10/2022]
Abstract
AIMS To evaluate neuromodulation outcomes in patients with prior back surgery. METHODS Adults in our prospective observational sacral/pudendal neuromodulation study were retrospectively evaluated. History and operative details were reviewed, and outcomes were measured at 3, 6, 12, and 24 months with overactive bladder questionnaire (OAB q) symptom severity (SS)/health related quality of life (HRQOL), interstitial cystitis symptom/problem indices (ICSI - PI), voiding diaries, and global response assessments (GRA). Data were examined with Pearson's χ2 , Fisher's exact, Wilcoxon rank sum tests, and logistic regression multivariate analysis. RESULTS Five hundred and sixty patients were evaluated (mean age 58.8 ± 17 years; 83% female; 79% had a sacral lead placed), 109 (19%) had history of back surgery; 66 surgeries were lumbar. Back surgery patients were older (mean 63 ± 15 vs. 58 ± 17 years; P = 0.003) and a higher proportion had urge urinary incontinence (UUI) (64% vs. 50% P = 0.008). Generator implant rates were similar (94% vs. 91%; P = 0.34). OABq-SS and HRQOL and ICSI - PI composite scores did not differ between groups at any time point. On bladder diaries, median incontinence episodes daily at baseline and between stages were worse in the prior back surgery group but all bladder diary parameters improved significantly in both groups with the exception of mean voided volume which only improved significantly in the non-back surgery group. Most patients in both groups reported moderate/marked improvement in overall bladder symptoms. CONCLUSIONS This study suggests that prior back surgery does not appear to impact clinical outcomes; therefore, neuromodulation may be offered in this patient population.
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Affiliation(s)
- Jamie M Bartley
- Beaumont Health System, Royal Oak, Michigan.,Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | | | - Judith A Boura
- Beaumont Health System, Royal Oak, Michigan.,Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | | | | | - Jason P Gilleran
- Beaumont Health System, Royal Oak, Michigan.,Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Kenneth M Peters
- Beaumont Health System, Royal Oak, Michigan.,Oakland University William Beaumont School of Medicine, Rochester, Michigan
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13
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Shi P, Fang Y, Yu H. Bladder response to acute sacral neuromodulation while treating rats in different phases of complete spinal cord injury: a preliminary study. Int Braz J Urol 2016; 41:1194-201. [PMID: 26742980 PMCID: PMC4756948 DOI: 10.1590/s1677-5538.ibju.2014.0144] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/08/2015] [Indexed: 01/16/2023] Open
Abstract
Background: Compared to conventional therapies, sacral neuromodulation (SNM) may offer an alternative, non-destructive treatment for SCI patients with bladder dysfunction. Understanding bladder response to SNM treatment for SCI in different phases may yield new insights for innovative use of this promising technique. Materials and Methods: Female Sprague-Dawley rats were used in this study to examine the effects of acute SNM on bladder reflex in complete SCI rats. All rats were anesthetized and set up for continuous saline infusion. Acute SNM treatment was implemented for about 6 hours for each rat. Cystometric parameters, including time between contractions, contraction duration, bladder peak pressure, and number of uninhibited contractions, were analyzed and compared within rats before and after SNM treatment. Results: For the spinally transected rats during early phase (less than two weeks post spinalization), the time between contractions and contraction duration both increased after SNM treatments, yet the increased amplitude was about or less than 20%. For the spinally transected rats with a longer days survival (about two to four weeks post spinalization), the time between contractions and contraction duration substantially increased after SNM treatment and the changes for their average values were more than 90%. For the spinally transected rats with a much longer days survival (more than five weeks post spinalization), the time between contractions and contraction duration increased after SNM treatments, yet the magnitude of changes were less than 30%. Conclusion: The present study suggested that the significant effectiveness of SNM for complete SCI played its role after the spinal shock phase and prior to the development of detrusor overactivity. It indicated that the time point of SNM treatment is necessary to be paid attention.
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Affiliation(s)
- Ping Shi
- Institute of Rehabilitation Engineering and Technology - University of Shanghai for Science and Technology, Shanghai, China
| | - Youfang Fang
- Institute of Rehabilitation Engineering and Technology - University of Shanghai for Science and Technology, Shanghai, China
| | - Hongliu Yu
- Institute of Rehabilitation Engineering and Technology - University of Shanghai for Science and Technology, Shanghai, China
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14
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Kumsar Ş, Keskin U, Akay A, Bilgilisoy UT, Erdem ŞR, Peşkircioğlu ÇL, Özkardeş H. Effects of sacral neuromodulation on isolated urinary bladder function in a rat model of spinal cord injury. Neuromodulation 2014; 18:67-74; discussion 74-5. [PMID: 24917133 DOI: 10.1111/ner.12189] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/22/2014] [Accepted: 02/28/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Sacral neuromodulation has been considered as an effective treatment option for various types of chronic voiding dysfunction, but the mechanism of action has not been well understood. The aim of this study was to evaluate the effect of chronic sacral neuromodulation on isolated bladder functions in a rat model of spinal cord injury. MATERIALS AND METHODS Female Sprague-Dawley rats (250-300 g; N = 20) were assigned to four groups as follows: 1) control group (N = 6); 2) spinal cord transection group (SCT; N = 5); 3) spinal cord transection + sacral neuromodulation group (SCT + SNM; N = 5); 4) sham (spinal cord transection + electrode wire implantation without sacral neuromodulation; N = 4). The rats in the SCT, SCT + SNM, and sham groups were anesthetized with ketamine (60 mg/kg, i.p.) and xylazine (7 mg/kg, i.p.). The spinal cord was completely transected at T8-T9 level in SCT and SCT + SNM groups. Electrode wires were implanted into S3 dorsal foramina in both sham and SNM groups, but only the SNM group was subjected to electrical stimulation for four hours a day for three weeks. Twenty-one days later, the rats were sacrificed via anesthetic overdose, and isolated longitudinal bladder strip preparations were placed in organ baths for the investigation of their isometric responses to pharmacological agents. RESULTS In isometric contraction experiments, SCT was found to increase the contraction responses of the bladder strips to muscarinic stimulation, and SNM could not prevent this increase. In isometric relaxation experiments, SCT caused a decrease in β-adrenergic relaxation responses, and SNM augmented the bladder's β-adrenergic relaxation responses. Nitric oxide did not affect the relaxation responses. CONCLUSION In our rat model of SCT, SNM seemed to alter adrenergic receptor function in the urinary bladder. Further studies are required to clarify the mechanism of these alterations at the level of bladder receptors following sacral neuromodulation.
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Affiliation(s)
- Şükrü Kumsar
- Urology Department, Sakarya Training and Research Hospital, Sakarya, Turkey
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Collinger JL, Foldes S, Bruns TM, Wodlinger B, Gaunt R, Weber DJ. Neuroprosthetic technology for individuals with spinal cord injury. J Spinal Cord Med 2013; 36:258-72. [PMID: 23820142 PMCID: PMC3758523 DOI: 10.1179/2045772313y.0000000128] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CONTEXT Spinal cord injury (SCI) results in a loss of function and sensation below the level of the lesion. Neuroprosthetic technology has been developed to help restore motor and autonomic functions as well as to provide sensory feedback. FINDINGS This paper provides an overview of neuroprosthetic technology that aims to address the priorities for functional restoration as defined by individuals with SCI. We describe neuroprostheses that are in various stages of preclinical development, clinical testing, and commercialization including functional electrical stimulators, epidural and intraspinal microstimulation, bladder neuroprosthesis, and cortical stimulation for restoring sensation. We also discuss neural recording technologies that may provide command or feedback signals for neuroprosthetic devices. CONCLUSION/CLINICAL RELEVANCE Neuroprostheses have begun to address the priorities of individuals with SCI, although there remains room for improvement. In addition to continued technological improvements, closing the loop between the technology and the user may help provide intuitive device control with high levels of performance.
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