Radiofrequency sacral rhizotomy for the management of intolerable neurogenic bladder in spinal cord injured patients

Ultrasound-guided continuous erector spinae plane block vs continuous thoracic epidural analgesia for the management of acute and chronic postthoracotomy pain: a randomized, controlled,double-blind trial

Introduction

Postthoracotomy pain (PTP) is a severe pain complicating thoracic surgeries and its good management decreases the risk of PTP syndrome (PTPS).

Objectives

This randomized controlled study evaluated the efficacy of ultrasound-guided continuous erector spinae plane block (ESPB) with or without dexmedetomidine compared with thoracic epidural analgesia (TEA) in managing acute postoperative pain and the possible emergence of PTPS.

Methods

Ninety patients with chest malignancies planned for thoracotomy were randomly allocated into 3 equal groups. Group 1: TEA (20 mL of levobupivacaine 0.25% bolus, then 0.1 mL/kg/h of levobupivacaine 0.1%), group 2: ESPB (20 mL of levobupivacaine only 0.1% bolus every 6 hours), and group 3: ESPB (20 mL of levobupivacaine 0.25% and 0.5 μg/kg of dexmedetomidine Hcl bolus every 6 hours).

Results

Resting and dynamic visual analog scales were higher in group 2 compared with groups 1 and 3 at 6, 24, and 36 hours and at 8 and 12 weeks. Postthoracotomy pain syndrome incidence was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. The grading system for neuropathic pain score was higher in group 2 compared with groups 1 and 3 at 8 and 12 weeks, whereas it was indifferent between groups 1 and 3. Itching, pruritis, and urine retention were higher in group 1 than in ESPB groups.

Conclusion

Ultrasound-guided ESPB with dexmedetomidine is as potent as TEA in relieving acute PTP and reducing the possible emergence of chronic PTPS. However, the 2 techniques were superior to ESPB without dexmedetomidine. Erector spinae plane block has fewer side effects compared with TEA.

Past, Present and Future of Chemodenervation with Botulinum Toxin in the Treatment of Overactive Bladder

PURPOSE

We systematically reviewed preclinical and clinical studies on bladder chemodenervation with onabotulinumtoxin A to highlight current limitations and future drug delivery approaches.

MATERIALS AND METHODS

We identified peer reviewed basic and clinical research studies of onabotulinumtoxin A in the treatment of neurogenic bladder and refractory idiopathic overactive bladder published between March 2000 and March 2016. Paired investigators independently screened 125 English language articles to identify controlled studies on onabotulinumtoxin A administration in the MEDLINE® database and abstracts presented at annual American Urological Association meetings. The review yielded an evidence base of more than 50 articles relevant to the approach of injection-free onabotulinumtoxin A chemodenervation.

RESULTS

The efficacy and safety of intradetrusor injection of onabotulinumtoxin A for the treatment of overactive bladder are sensitive to injection volume and depth, and this issue has motivated researchers to study injection-free modes of drug delivery into the bladder. Urothelial denudation with protamine sulfate or dimethyl sulfoxide, liposome encapsulated onabotulinumtoxin A and other physical approaches are being studied to increase toxin permeability and avoid intradetrusor injections. Liposome encapsulated onabotulinumtoxin A enhances toxin activity while reducing its toxin degradation. The safety and efficacy of liposome encapsulated onabotulinumtoxin A were tested in a multicenter, placebo controlled study. Although this treatment successfully reduced urinary frequency and urgency, it did not significantly reduce urgency urinary incontinence episodes.

CONCLUSIONS

Intradetrusor injection of onabotulinumtoxin A is a safe and effective treatment as reported in several large multicenter, randomized controlled trials. Injection of the toxin into the bladder wall impairs afferent and efferent nerves, but injection-free drug delivery approaches only impair the bladder afferent nerves. Further studies are needed to develop better drug delivery platforms that overcome the drawbacks of intradetrusor injection, increase patient acceptance and reduce treatment costs.

Short-Term Effect of Percutaneous Bipolar Continuous Radiofrequency on Sacral Nerves in Patients Treated for Neurogenic Detrusor Overactivity After Spinal Cord Injury: A Randomized Controlled Feasibility Study

Objective

To investigate the short-term effects of bipolar radiofrequency applied to sacral nerves to treat neurogenic detrusor overactivity in patients with spinal cord injury.

Methods

Ten patients with spinal cord injury with neurogenic detrusor overactivity were recruited. These subjects were randomized to two groups: intervention (n=5) and control (n=5), members of which received conventional treatment. Voiding diary, International Consultation on Incontinence Questionnaire (ICIQ) and the urinary incontinence quality of life scale (IQOL) data were obtained and an urodynamic study (UDS) was performed before and after intervention. In the intervention group, percutaneous bipolar continuous radiofrequency (CRF) was performed on both the S2 and S3 nerves in each patient.

Results

In a comparison of daily frequency and number of urinary incontinence and ICIQ and IQOL scores at baseline and at 1 and 3 months after intervention, all variables achieved a significant effect for time (p<0.05). Regarding UDS parameters, pre/post intervention differences between baseline and 3-month post-intervention for volume at maximal detrusor pressure during filling and reflex detrusor volume at first contraction were significantly different between the two groups (p<0.05). However, pre/post intervention differences in maximum cystometric capacity and maximum detrusor pressure during filling were not significant between the two groups (p>0.05).

Conclusion

Percutaneous bipolar CRF applied to sacral nerves might be an effective therapy for neurogenic overactive bladder that reduces urinary incontinence and improves quality of life.

A microchannel neuroprosthesis for bladder control after spinal cord injury in rat

A severe complication of spinal cord injury is loss of bladder function (neurogenic bladder), which is characterized by loss of bladder sensation and voluntary control of micturition (urination), and spontaneous hyperreflexive voiding against a closed sphincter (detrusor-sphincter dyssynergia). A sacral anterior root stimulator at low frequency can drive volitional bladder voiding, but surgical rhizotomy of the lumbosacral dorsal roots is needed to prevent spontaneous voiding and dyssynergia. However, rhizotomy is irreversible and eliminates sexual function, and the stimulator gives no information on bladder fullness. We designed a closed-loop neuroprosthetic interface that measures bladder fullness and prevents spontaneous voiding episodes without the need for dorsal rhizotomy in a rat model. To obtain bladder sensory information, we implanted teased dorsal roots (rootlets) within the rat vertebral column into microchannel electrodes, which provided signal amplification and noise suppression. As long as they were attached to the spinal cord, these rootlets survived for up to 3 months and contained axons and blood vessels. Electrophysiological recordings showed that half of the rootlets propagated action potentials, with firing frequency correlated to bladder fullness. When the bladder became full enough to initiate spontaneous voiding, high-frequency/amplitude sensory activity was detected. Voiding was abolished using a high-frequency depolarizing block to the ventral roots. A ventral root stimulator initiated bladder emptying at low frequency and prevented unwanted contraction at high frequency. These data suggest that sensory information from the dorsal root together with a ventral root stimulator could form the basis for a closed-loop bladder neuroprosthetic.

Neuromodulation for Neurogenic Bladder

Although neuromodulation is well established for the treatment of non-neurogenic lower urinary tract symptoms, recent literature supports its use in the patient having LUTS associated with a neurologic condition. Sacral neuromodulation, in particular, may see new use as a modality to facilitate neurologic remodeling in spinal cord injured patients as well as children. As a therapeutic option, sacral neuromodulation and dorsal genital nerve stimulation may one day become more effective and more efficient utilizing the concept of closed-loop feedback, where electro-neurogram and bladder pressure data are incorporated into stimulation routines. In addition, some older therapies are reviewed that have recently demonstrated success in this patient population.