Intrinsic neuromuscular defects in the neurogenic bladder. III. Transjunctional,short- and long-term ultrastructural changes in muscle cells of the decentralized feline bladder base following unilateral sacral ventral rhizotomy

We have shown previously that vesicourethral decentralization by unilateral sacral ventral rhizotomy in the cat results in sequential degenerative and regenerative ultrastructural changes in intrinsic nerves of the bladder base. The present study in the same model provides evidence that these neural changes are associated with both degenerative and regenerative ultrastructural changes in smooth muscle cells of the feline base, representing the first example of transjunctional postdecentralization change in an effector tissue to be documented in a mammalian autonomically innervated smooth muscle system. The nature of the observed changes in the sarcoplasm, sarcoplasmic organelles, sarcolemma, and cell-to-cell relationships will be discusssed, and their physiologic significance as well as implications in the phenomenon of neurogenic muscular supersensitivity will be presented.     

The role of botulinum toxin A in treating neurogenic bladder

Neurogenic detrusor overactivity (NDO) can result in lower and upper urinary tract complications and eventually even in end-stage kidney failure. Since the driving force of this clinical cascade is high bladder pressure, controlling intravesical pressure in NDO patients improves both quality of life and life-expectancy in these patients. Botulinum toxin A (BTX-A) has proven its efficacy in reducing intravesical pressure and in reducing incontinence episodes. BTX-A also improves quality of life in patients with NDO. Both onabotulinumtoxinA (Botox^®, Allergan, Irvine, USA) and abobotulinumtoxinA (Dysport^®, Ipsen, Paris, France) have a level A recommendation for NDO-treatment. The recommended dose for intradetrusor injections in NDO patients is 200 U of onabotulinumtoxinA or 500 U of abobotulinumtoxinA. The drug is generally administered extratrigonal in the detrusor muscle, via cystoscopic guided injection at 20 sites in 1 mL injections. Intradetrusor BTX-A injections are safe, with mostly local complications such as urinary tract infection and high post-void residual or retention. The effect of the toxin lasts for approximately 9 months. Repeat injections can be performed without loss of efficacy. Different injection techniques, novel ways of BTX-A administration, eliminating the need for injection or new BTX-A types with better/longer response rates could change the field in the future.     

Urodynamic effects of propiverine hydrochloride in children with neurogenic detrusor overactivity: a prospective analysis

OBJECTIVES: To evaluate prospectively the efficacy and tolerability of propiverine for treating neurogenic detrusor overactivity (NDO) in children. PATIENTS AND METHODS: Twenty children (mean age 8.9 years; median 5.6) with NDO due to an upper motor neurone lesion were enrolled (17 had myelomeningocele). In the urodynamic examination, reflex volume (RV), maximum detrusor pressure (MDP), maximum cystometric bladder capacity (MCBC) and bladder compliance (BC) before and after a twice-daily propiverine hydrochloride regimen were determined. The urodynamic follow-up was after 3-6 months. Incontinence was assessed by an incontinence score. RESULTS: The mean (sem) RV increased from 103.8 (21.3) to 174.5 (33.7) mL (P < 0.005), MDP decreased from 52.5 (7.9) to 40.1 (6.2) cmH(2)O (P < 0.05), MCBC increased from 166 (28.8) to 231.9 (34.8) mL (P < 0.005), and BC improved from 11.2 (2.8) to 30.6 (9.7) mL/cmH(2)O (P < 0.01), with propiverine treatment. The incontinence score (scale 0-3) improved from 2.4 (0.2) to 1.6 (0.3) (P < 0.05). Propiverine was well tolerated, although some children were given higher doses than recommended. CONCLUSIONS: Propiverine hydrochloride is effective and well tolerated in the treatment of children with NDO. Because of its dual mode of action, it is well tolerated even in children who need higher doses. Propiverine hydrochloride is a preferable alternative to oxybutynin, the anticholinergic most frequently used in children with NDO to date.     

Ureteral reimplantation in children with neurogenic bladder.

The treatment of urologic complications from myelomeningocele and especially of vesico-renal reflux is a controversial problem. A series of 26 reimplanted ureters in 17 children, with good results in more than 85%, is reported. Ureteroneocystostomy, carried out with a few technical innovation, may represent a useful method for the treatment of vesico-renal reflux and obstruction of the uretero-vesical junction in neurogenic bladder associated with myelomeningocele. This surgical approach leads to the disappearance of the reflux, decrease of dilatation of the upper urinary tract and preservation of renal function in most cases; moreover, infection can be more easily controlled. Ureteral reimplantation should be preceded by periodic urethral dilatation, external transurethral sphincterotomy, and pharmacologic regulation in order to attempt to decrease urethral resistance. After successful surgery, it is possible to try to reeducate the bladder. Reimplantation should be preferred to permanent urinary diversion even if there is gross reflux.     

逼尿肌漏尿点压在神经原性排尿功能障碍上尿路损害评估中的意义

目的　探讨逼尿肌漏尿点压检测神经原性排尿功能障碍患者上尿路损害功能评估中的诊断价值。　方法　 38例神经原性排尿功能障碍患者行尿动力学检查 ,重点进行逼尿肌漏尿点压测定。　结果　以逼尿肌漏尿点压 4 .0kPa(1kPa=10 .2 0cmH2 O)为界将 38例患者分为高压 (n =2 6 )及低压 (n =12 )两组 ,高压组膀胱容量为 (42 2 .95± 183.2 7)ml,低压组为 (46 4 .83± 10 6 .4 3)ml,高压组逼尿肌顺应性较低压组低 ,逼尿肌尿道括约肌协同失调 (DSD)增高。B超、IVU、血尿素氮及血肌酐检查等临床指标检测显示逼尿肌漏尿点压高者上尿路损害机会较低压组显著增高。　结论　逼尿肌漏尿点压测定对神经原性排尿功能障碍患者上尿路损害状态的评估有较大价值。     

阑尾或肠管可控输出道在神经源性膀胱治疗中的应用

目的：评价阑尾或肠管可控输出道在高反射性神经源性膀胱治疗中的应用价值。方法：采用阑尾输出道（Mitrofanoff法）治疗高反射性神经源性膀胱患者4例,采用回肠腹壁造口（Yang-Monti法）治疗2例。3例采用膀胱自扩大,同时行阑尾输出道2例,回肠腹壁造口1例;3例行回肠膀胱扩大,同时采用阑尾腹壁造口2例,回肠腹壁造口1例。结果：术后随访3～39个月（平均20个月）。1例采用回肠扩大阑尾VZQ造口的患者术后2周造口部皮瓣感染坏死,改行阑尾直接造口;1例阑尾输出道出现造口部位漏尿,缩短导尿间隔为2h,漏尿消失;其他患者控尿良好。5例术后肾功能恢复正常,1例保持稳定。结论：阑尾或回肠可控输出道在高反射性神经源性膀胱治疗中是一种安全可靠的方法。     

Intrinsic neuromuscular defects in the neurogenic bladder. VI. Myofiber ultrastructure in the somatically denervated male feline rhabdosphincter

Ordinary somatic striated muscle with purely somatomotor innervation undergoes atrophy with fibrosis when completely denervated. On this basis, it has been suggested that vesical outlet “obstruction” in voiding dysfunction resulting from lower-motor neural lesions is due to fibrosis of a denervated rhabdosphincter. We have shown previously that: (1) this sphincter has natural triple somatomotor/autonomic, cholinergic/autonomic adrenergic innervation of its myofibers; and (2) following its somatomotor denervation by bilateral sacral ventral rhizotomy, its myofibers lose somatomotor innervation and eventually acquires a purely autonomic innervation that includes autonomic re-innervation of their sole plates. The present study was conducted in 16 adult male cats to define the structural changes in myofibers of the somatically denervated rhabdosphincter. Samples of the sphincter, obtained 1, 2, 4, 6, and 10 weeks after bilaterial sacral ventral rhizotomy, were processed and studied by electron microscopy. In all samples, there was a combination of ultrastructurally normal, degenerative, and regenerative myofiber profiles. Degenerative profiles were most frequent in the 1-week, and regenerative profiles in the 6–10 weeks samples. No atrophic myofibers or interstitial fibrosis were observed in any sample. It is concluded that the somatically denervated male feline rhabdosphincter, unlike ordinary somatic striated muscle, maintains its structural integrity through myofiber regeneration and by not undergoing fibrosis. The somatically denervated rhabdosphincter, with its eventual purely autonomic re-innervation, therefore, can play an important role in lowermotor neurogenic dysfunctions that needs further investigation.     

乙状结肠肌瓣包膀胱术治疗膀胱逼尿肌收缩无力症（附八例报告）

目的 介绍一种治疗膀胱逼尿肌收缩无力的新术式－乙状结肠肌瓣包膀胱术。方法 根据乙状结肠的解剖生理学特性，采用游离的乙状结肠肌瓣包裹膀胱治疗膀胱通尿肌收缩无力症8例。通过临床观察、B超、尿动力学、血液生化及膀胱尿道造影检查对手术效果进行评价。结果 8例病人术后随访1－8年，手术效果良好5例，剩余尿由术前800－1100ml减少至术后的5－50ml，症状改善1例，2例无效。结论 乙状结肠肌瓣包膀胱术是治疗膀胱逼尿肌收缩无力的一种有效方法。     

Changing composition of renal calculi in patients with neurogenic bladder

PURPOSE: Renal calculi are a significant source of morbidity for patients with neurogenic bladder. Calculi from patients with NB have traditionally been composed primarily of struvite and carbonate apatite secondary to chronic urea-splitting bacteriuria. In the current era there have been great improvements in the urological rehabilitation of patients with NB. We defined the composition of renal calculi in a contemporary cohort of patients with NB due to spinal cord injury or myelomeningocele who underwent percutaneous nephrolithotomy. MATERIALS AND METHODS: We performed a retrospective evaluation of all patients with NB due to SCI or MM who underwent PNL between January 2002 and January 2005. RESULTS: A total of 32 patients with NB (14 with SCI, 18 with MM) underwent PNL in this period. Stones were infectious in etiology in 37.5% (12 struvite/carbonate apatite) and metabolic in 62.5% (1 uric acid, 2 calcium oxalate monohydrate, 2 brushite, 6 hydroxyapatite, 9 mixed hydroxyapatite/calcium oxalate). All patients with struvite calculi were infected with urea-splitting bacteria on preoperative urine culture. CONCLUSIONS: Patients with neurogenic bladder are traditionally thought to harbor infection related calculi. These data demonstrate that many contemporary patients will be found to have calculi of a metabolic etiology. Although patients with NB still have renal calculi, advances in urological treatment may have affected the composition of their calculi, as metabolic stones are becoming more commonly identified. When metabolic components are identified, stone activity may be attenuated with appropriate metabolic evaluation, pharmacological therapies and dietary modifications.     

腰骶椎管病变导致神经原性排尿功能障碍的诊断及治疗(附30例报告)

目的　探讨腰骶椎管病变导致神经原性排尿功能障碍患者的病因诊断和治疗方法。　方法　对 1989～ 1999年收治的 30例患者行尿动力学和腰骶椎管磁共振 (MRI)检查并手术治疗。　结果　发现脊髓栓系综合征 (TCS) 2 7例 (90 % ) ,其中合并腰骶脂肪瘤 15例 ,脊髓脊膜膨出 5例、错构瘤 1例、双脊髓畸形 1例、结构正常 5例。椎管内占位 3例。按病因手术治疗 ,术后平均随访 2 7.5个月 ,排尿恢复正常 9例、好转 18例 ,膀胱剩余尿恢复正常 5 /10例 ,好转 2 /10例。逼尿肌无反射好转4/7例 ,低顺行性膀胱好转 2 /8例。　结论　神经原性膀胱应作腰骶椎管检查 ,以便及时诊治     

Erosion of a penile prosthesis due to an indwelling urethral catheter as a late complication

A case of erosion of a penile prosthesis caused by indwelling of a catheter in the urethra is reported. A 73-year-old man had maintained sexual intercourse with penile prostheses (Jonas prosthesis, 19 cm) for 11 years without any complications until he developed cerebral infarction. One month after starting an indwelling urethral catheter in a neurosurgery clinic, the left-side penile prosthesis eroded from the area of the fossa navicularis, and was immediately removed. This type of complication is not unusual in patients with a neurogenic bladder. However, it is not well recognized in patients who suddenly develop a neurogenic bladder following a long-term uneventful period after the implantation of penile prostheses. Therefore, urologists should inform patients who receive this type of treatment that erosion of the prosthesis may develop when they need an indwelling urethral catheter as a late complication.     

Neurogenic bladder treatment by doubling the recommended antimuscarinic dosage

INTRODUCTION AND OBJECTIVES: The dosage of the antimuscarinic drugs: Tolterodine ER or Trospium was increased to a higher-than-recommended dosage in patients where the manufacturer's recommended dosage had failed. All patients were suffering from neurogenic detrusor overactivity incontinence. Tolerability and success were evaluated in the present study. MATERIALS AND METHODS: Twenty-one patients with neurogenic detrusor overactivity were evaluated: 17 with spinal cord injury, 3 with multiple sclerosis, and 1 with a meningomyelocele. All patients catheterized themselves or were catheterized. If neurogenic detrusor overactivity continued and the medication was well tolerated, the dosage was doubled to either 8 mg of Tolterodine ER [2 x 4 mg (n = 11)] or 90 mg of Trospium [3 x 30 mg (n = 10)]. The follow-up was monitored by a bladder diary and urodynamic evaluation. RESULTS: Sixteen patients significantly decreased their incontinence episodes from 8-12 episodes before to 0-2 episodes during the doubled treatment. The reflex volume increased from 202 +/- 68 to 332 +/- 50 ml (P < 0.001). Cystometric capacity enlarged from 290 +/- 56 to 453 +/- 63 ml (P < 0.001). One patient had to stop the medication because of intolerable side effects and five patients did not experience satisfactory benefit. CONCLUSION: The increased dosage of Tolterodine or Trospium is an effective treatment in patients with neurogenic bladder.     

Comparison study of autonomous activity in bladders from normal and paraplegic rats

AIM: To identify differences in the pattern of pressure generated by isolated bladders from normal and paraplegic rats. MATERIALS AND METHODS: Nine female Wister rats were made paraplegic by spinal cord transsection at the vertebral level T8-T9 and sacrificed between D21 and D28. A further group (n = 9) was used as a control group. Each bladder was excised and placed in an organ bath where intravesical pressures were measured. Pressure changes were divided in two well-defined groups: macro-transients and spikes. The effects of intravesical volume load and muscarinic (M) agonists were studied. RESULTS: We demonstrated a higher frequency, a longer duration, and a higher variance of duration in macro-transients in the neurogenic group. Intravesical volume load influenced the amplitude and frequency of macro-transients in both groups similarly. The effects of the muscarinic (M(2))-selective agonist areca?dine were different in neurogenic bladder; the effects of the non-selective muscarinic (M)-agonist carbachol were similar in both groups. CONCLUSION: We showed that the pattern of autonomous activity was significantly different between normal and neurogenic rat bladders. We also found evidence for alterations in the muscarinic response of isolated neurogenic rat bladders. This model offers an exciting new research tool to evaluate the detrusor activity in neurogenic and normal conditions.     

Epidural spinal cord stimulation for the treatment of neurogenic bladder

Summary The effect of percutaneous epidural spinal cord stimulation on neurogenic bladder has been evaluated on the basis of objective clinical and urodynamic criteria. Seven patients suffering from stable bladder and sphincter dysfunction due to spinal cord diseases of different causes of non-evolutive nature were examined. In some of them chronic pain or spasticity, or both, were also present.Spinal cord stimulation substantially improved micturition in six out of seven patients. Complete or almost complete relief of bladder spasticity, marked increase of bladder capacity, and reduction or abolition of residual urine were recorded. The beneficial effect on bladder and sphincter function is strictly dependent on the stimulation, though it can outlast it. It requires some weeks to reach its maximum. It is still obtained after 22 months of treatment (longest present follow-up).No changes of striatal activity and detrusor reflex were produced by spinal cord stimulation in two additional patients, treated for chronic pain but having intact bladder function.Partially supported by Ministry of Public Instruction.     

糖尿病膀胱逼尿肌的病理改变及机制

通尿肌肌源性异常是糖尿病膀胱的重要致病机制之一.其病理变化表现为逼尿肌形态改变、功能改变、能量代谢紊乱.受体与膜通道变化以及自由基损伤等多个方面.     

胸膜外小切口摘除纵隔肿瘤

目的 探讨胸膜外小切口在纵膈肿瘤手术中的应用价值。方法 回顾分析6例纵隔肿瘤经胸膜外小切口手术除的结果。结果 6例手术顺利恢复，无手术合并症和死亡，随诊1月．2年无肿瘤复发或转移。结论 胸膜外小切口手术具有创伤小、恢复快、除彻底等优点，在选择性病人中可替代常规的剖胸切口，达到相同的治疗目的。