Management options for sphincteric deficiency in adults with neurogenic bladder

Artificial urinary sphincter for neurogenic urinary incontinence: a narrative review

Background and Objective

The artificial urinary sphincter (AUS) is most known for its use in the treatment of moderate to severe post-prostatectomy stress urinary incontinence. However, another lesser-known indication includes stress incontinence related to intrinsic sphincter deficiency (ISD) in the neurogenic bladder population. The purpose of this review is to discuss specific technical considerations related to device implantation in this population, efficacy, durability, and complications.

Methods

We performed a non-systematic literature review using the PubMed Database to identify articles specifically related to treatment of neurogenic urinary incontinence using an artificial urinary sphincter.

Key Content and Findings

More proximal placement of the cuff at the bladder neck is preferred in the neurogenic population due to higher rates of erosion and complications related to frequent clean intermittent catheterization or cystoscopic procedures when placed along the bulbar urethra. Robotic-assisted laparoscopic cuff placement has emerged as a safe and effective alternative to open surgery in select patients. Although continence rates are highly variable due the subjectivity of the term, functional continence (≤1 pad, ± nighttime incontinence) is reported to be between 75-90%. The need for secondary surgery for explanation with or without revision/replacement is higher in neurogenic patients compared to non-neurogenic patients.

Conclusions

Neurogenic urinary incontinence is a complex condition due to the interplay of urethral resistance and bladder function/compliance. While there are a variety of strategies to treat neurogenic incontinence, high quality data from direct comparisons are lacking. Although AUS comes with a high revision rate, functional outcomes for continence with bladder neck placement are promising in this population.

Therapeutic Efficacy of Urethral Sphincter Injections of Platelet-Rich Plasma for the Treatment of Stress Urinary Incontinence due to Intrinsic Sphincter Deficiency: A Proof-of-Concept Clinical Trial

Purpose

The aim of this study was to investigate the efficacy of autologous platelet-rich plasma (PRP) in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) refractory to medical treatment.

Methods

Thirty-five patients with SUI due to urodynamically proven ISD were prospectively enrolled. Five milliliters of PRP (2.5–5 times the platelet concentration in peripheral blood) was injected into the external sphincter at 5 sites; all patients received 4 injections at monthly intervals. The primary end-point was the change in SUI severity as assessed by a visual analogue scale (VAS of SUI). The secondary-endpoints were the Global Response Assessment score and changes in urodynamic parameters from baseline to 3 months after treatment.

Results

The mean age of patients was 68.7±12 years; the median duration of SUI was 4 years. Five patients had neurogenic SUI, while 30 had nonneurogenic SUI (21 with postprostatectomy incontinence, 6 with previous radical cystectomy, and 3 with other etiologies). Complete dryness was achieved in 7 patients (20.0%) while moderate improvement was observed in 14 (40.0%). The mean VAS of SUI score decreased significantly from 6.57±1.89 to 3.77±2.41 after treatment. The abdominal leak point pressure (ALPP) increased significantly from 98.3±55.8 to 157.3±79.3 cm H₂O. There was no increase of ALPP in neurogenic SUI and less increase of ALPP in patients with failed treatment outcomes. No perioperative adverse events or severe complications occurred.

Conclusions

Urethral PRP injection is safe and effective in increasing urethral resistance and improving SUI. PRP could be an alternative treatment modality for male and female patients with moderate SUI due to nonneurogenic causes.

Augmentation cystoplasty in the patient with neurogenic bladder

PURPOSE

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB.

RESULTS

AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel.

CONCLUSIONS

Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Treatment of stress urinary incontinence in men with spinal cord injury: minimally invasive=minimally effective?

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To assess the outcome of minimally invasive treatment of stress urinary incontinence with alloplastic slings in patients with neurogenic lower urinary tract dysfunction.

SETTING

Switzerland.

METHODS

The patient database of a tertiary urologic referral center was screened for male patients with SCI who underwent implantation of a suburethral sling between June 2009 and December 2015. Patient characteristics and bladder management details were collected by chart review.

RESULTS

Sixteen patients were identified. Of those, 13 received a transobturator tape (TOT) and three underwent implantation of an retropubic adjustable system (RAS). In the TOT group, nine patients became continent, one patient was improved and three patients remained unchanged. Three patients underwent minor revisions due to impaired wound healing. In the RAS group, no patient improved and one RAS had to be removed due to severe wound infection; in a second patient, an abscess with destruction of the urethra occurred.

CONCLUSIONS

In our experience, alloplastic slings seem to be an effective minimally invasive treatment option in male patients with SUI due to SCI. TOT seem to be more effective than RAS and was associated with less severe complications. The selection criteria for the optimal patient and the optimal sling have to be further defined.