Donald Munro Lecture 2003. Neurogenic bladder: past, present, and future

The foundation of the management of neurogenic bladder can be attributed to a pioneer in spinal cord injury medicine. Dr. Donald Munro, a neurosurgeon, who also had experience in urologic surgery, established the first Spinal Cord Injury Service of 10 beds in the Boston City hospital in the 1930s. He later became adviser to the US Army and the Veterans Administration (VA). On his recommendation, paraplegic centers were created in US army hospitals and later in the VA hospitals from 1943 to 1945. This article reviews the evolution of the management of neurogenic bladder in patients with spinal cord injuries from the past century to the present. The role of urodynamics in defining neurologic lesions is critical to the appropriate management of the voiding dysfunction. Key advances, such as the diagnosis of detrusor sphincter dyssynergia (DSD), recognition of its association with autonomic dysreflexia, and its definitive management, have been emphasized. The role of transrectal linear array sonography using a rectal probe was found useful for defining bladder outlet dysfunction during urodynamics. It also helped to recognize secondary bladder neck obstruction and diagnose false passages in the urethra. Clean technique intermittent catheterization (IC) was evaluated and recommended. In about 28% patients with DSD that led to secondary bladder neck obstruction, a consequence of IC was reported. Transurethral laser sphincterotomy (TURS) was first reported by me in 1991, and later, durable 7-year follow-up results were reported in 78% of the first 99 patients. We reported a surgical technique to lengthen the penis. We also reported the long-term success with semirigid implants in 92% of patients with SCI. This technique helped maintain external condom drainage on a small phallus and improved the sex life of patients, as well as their quality of life. The author's pertinent areas of interest in the past one-half century were aimed at recognizing specific urologic problems associated with neurologic impairment. Management was aimed at preventive care, early recognition, and timely management to reduce secondary complications and enhance quality of life.     

Urologic Aspects of Traumatic Central Cord Syndrome

ABSTRACT

Central cord syndrome (CCS) is a subset of spinal cord injury, characterized by more motor involvement of the upper extremities than the lower extremities and sacral sensory sparing. Patients with central cord syndrome have been reported to have a good rehabilitation and urologic outcome. Our purpose was to assess the urologic outcome in a group of patients with central cord syndrome.

We reviewed 23 patients with central cord syndrome who were admitted to Hines VA Hospital between 1983 and 1991, 20 of whom were older than 50 years of age. Urodynamic studies showed detrusor hyperreflexia with a synergistic EMG in 15 patients and detrusor hyperreflexia with external urethral sphincter dyssynergia (DSD) in five patients. Three patients with no urologic problems were not tested. Bladder sensation was preserved during filling in all patients. At follow-up (median = 2–4 months), 16 patients (70 percent) were voiding, seven of whom required either occasional external or intermittent catheterization; nine were voiding independently. The seven other patients (30 percent) required either continuous external or intermittent catheterization (including the five with DSD). Urologic morbidity in the period after SCI included: urinary tract infections (12), renal (2) and bladder calculi (2), superficial bladder cancer (1), epididymitis (1) and none (6). Fifteen patients (65 percent) were ambulatory at follow-up while four patients needed wheelchairs. Data were not available for the other four patients. Urodynamic studies in three of the wheelchair-bound patients showed that two of them had DSD.

Most patients with central cord syndrome have favorable urologic and rehabilitation outcomes and can be managed conservatively. A minority of such patients have DSD and they tend to have a less favorable rehabilitation and urologic outcome. A possible neuroanatomic basis for this observation is that these patients have more extensive central cord damage.     

Long-term follow-up of sphincterotomy in the treatment of autonomic dysreflexia

Autonomic dysreflexia (AD) is a syndrome affecting a majority of patients with high spinal cord lesions. An association between AD and detrusor-sphineter dyssynergia (DSD) is often seen. Between 1980 and 1988 we performed 51 transurethral sphincterotomies in 38 patients. Twelve of these patients underwent procedures primarily for the prevention of AD related to bladder distension. This study presents their long-term follow-up. One patient was lost to follow-up secondary to unrelated death; the remaining 11 patients were followed on average 117.5 months (94–154) after the initial operative procedure. Repeat sphincterotomy was required in 9 of 11 patients (82%) Six (66% ) of these were performed within 24 months. One patient (11%) required delayed sphincterotomy greater than 100 months from the initial procedure. Overall, sphincterotomy was successful in controlling symptoms of AD in 10 of 11 (91%) patients. No major complications were recorded. Sphincterotomy is a sate and effective treatment for AD associated with DSD, however long-term urologic follow-up and management are necessary. © 1995 Wiley-Liss, Inc.     

Efficacy and Safety of Tol Terodine in People With Neurogenic Detrusor Overactivity

Abstract

Objective: To compare tolterodine with oxybutynin and placebo in people with neuragenie detrusor overactivity.

Design: Prospective, randomized, double-blind, crossover trial plus open-label comparative stage.

Participants: Ten participants with neuragenie detrusor overactivity due to spinal cord injury or multiple sclerosis who usedintermittent catheterization.

Methods: Bladder capacity on cystometrogram, a 10-day record of catheterization volumes, number of incontinent episodes perday, and perceived dry mouth using a visual analog scale (VAS) were measured for the following: (a) a blinded comparison:tolterodine, 2 mg twice daily, vs placebo, twice daily; and (b) an unblinded comparison: oxybutynin vs tolterodine, each atself-selected doses (SSDs).

Results: Tolterodine, 2 mg twice daily, was superior to placebo in enhancing catheterization volumes (P<0.0005) and reducingincontinence (P<0.001 ), but was comparable with placebo in cystometric bladder capacity. Efficacy of tolterodine SSD wascomparable with oxybutynin SSD with regard to catheterization volumes, degree of incontinence, and cystometric bladder capacity.The side effect profile (dry mouth) was comparable between tolterodine, 2 mg twice daily, and placebo, but differed significantlywhen comparing tolterodine SSD with oxybutynin SSD (P<0.05).

Conclusion: T olterodine, when used at SSDs, is comparable with oxybutynin at SSDs in enhancing bladder volume and improvingcontinence, but with less dry mouth. T olterodine at the recommended dosage of 2 mg twice daily improves incontinence and bladdervolumes compared with placebo, and without significant dry mouth. Larger doses of tolterodine may be needed to achieve best effectin this population, but further studies are required.     

Evaluation Of Cranberry Supplement For Reduction Of Urinary Tract Infections In Individuals With Neurogenic Bladders Secondary To Spinal Cord Injury.A Prospective,Double-Blinded,Placebo–Controlled,Crossover Study

Abstract

Objective: To determine the effectiveness of cranberry supplement at preventing urinary tract infections (UTis) in persans with spinal cord injury (SCI).

Design: A prospective, double–blinded, placebo–controlled, crossover study.

Participants: 21 individuals with neuragenie bladders secondary to SCI. Main Outcome Measures: Favorable or unfavorable response of cranberry supplement vs placebo on urinary bacterial counts and white blood cell (WBC) counts and the combination of bacterial and WBC counts.

Methods: lndividuals with neuragenie bladders due to SCI were recruited and randomly assigned to standardized 400–mg cranberry tablets or placebo 3 times a day for 4 weeks. After 4 weeks and an additional 1–week “washout period,” participants were crossed over to the other group. Participants were seen weekly, during which a urine analysis was obtained. UTI was defined as significant bacterial or yeast colony counts in the urine and elevated WBC counts (WBC count 2: 1 0 perhigh power field) in centrifuged urine. Participa nts with symptomatic infections were treated with appropriate antibiotics for 7 days and restarted on the cranberry tablet/ placebo after a 7–day washaut period. Urinary pH between the cranberry and placebo groups was compared weekly. Data were analyzed using the Ezzet and Whitehead’s random effect approach.

Results: There was no statistically significant treatment (favorable) effect for cranberry supplement beyond placebo when evaluating the 2 treatment groups for bacterial count, WBC count, or WBC and bacterial counts in combination. Urinary pH did not differ between the placebo and cranberry groups.

Conclusion: Cranberry tablets were not found to be effective at changing urinary pH or reducing bacterial counts, urinary WBC counts, or UTis in individuals with neuragenie bladders. Further Long–term studies evaluating specific types of bladder management and UTis will help to determine whether there is any role for the use of cranberries in individuals with neuragenie bladders.     

Anxiety masquerading as autonomic dysreflexia

Context: Autonomic dysreflexia (AD) is characterized by a sudden onset of hypertension in those with spinal cord injuries (SCI) at T6 or above. Prompt recognition and treatment of AD is important. Herein are two individuals with SCI and acute hypertension due to anxiety that may easily have been confused for AD.

Findings: Case 1: A 77-year-old male with C4 AIS D SCI and a history of anxiety and AD presented for urodynamics to evaluate the effectiveness of onabotulinumtoxinA injections into his urethral sphincter. After lying down on the urodynamics table, his systolic blood pressure (SBP) was noted to rise, from 138 to 170?mmHg over six minutes without any instrumentation or position change. Upon announcing urodynamics would be postponed and preparing for AD management, his SBP returned to below baseline within two minutes. Case 2: A 57-year-old male with T12 AIS A SCI and a history of anxiety presented for routine urodynamics. His baseline SBP was 140?mmHg. During bladder filling, incidental SBP was elevated to 170?mmHg. Filling was stopped and he was told the study was complete. One minute later, prior to draining his bladder, SBP decreased to 150?mmHg.

Conclusions: An individual's psychological state should be considered in addition to traditional management of AD when an individual with SCI presents with hypertension. Moreover, Case 2 may possibly explain reports of individuals presenting with AD with injuries below T6.     

Impacto de la prostatectomía radical en los resultados urodinámicos de pacientes con cáncer de próstata tratados con radioterapia de intensidad modulada

Introduction and objectivesTo evaluate the effect of radical prostatectomy and age on urodynamics before and after intensity-modulated radiation therapy administered to prostate cancer patients.Materials and methodsThe sample consisted of 40 prostate cancer patients, 22 of whom had undergone a radical prostatectomy. Urodynamic parameters before and after an average of 4.2 months of radiotherapy were measured and compared. External radiotherapy was administered via Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Radiation Therapy (IMRT) techniques.ResultsUroflowmetry presented no significant parameters. In the case of Cystomanometry, the data did not show an increase in secondary stress urinary incontinence, although there is 7 percent increase in urge urinary incontinence. There were statistically significant changes in reduced bladder capacity with a strong desire to void, with an urge to void and also in the detrusor pressure with a normal desire to void. Furthermore, pressure/flow analysis revealed a statistically significant reduction of residual urine volume.ConclusionsThe effect of prostatectomy and age varies according to the evolution of urodynamics. There was a significant reduction in terms of residual urine volume and detrusor pressure with a normal desire to void in patients without a prostatectomy and in those under 75 years old. In addition to an increase in urge incontinence, there was also a significant worsening of the bladder filling urodynamics and a decrease in the cystomanometric bladder capacity with a strong desire and an urge to void. None of these were modified by age or prostatectomy.     

Urodynamics in Female Urology

Urodynamics in female urology are often indicated when empiric or conservative treatment does not improve lower urinary tract symptoms. Based on the expected underlying lower urinary tract dysfunction, the urodynamic evaluation is designed by the clinician to reproduce a patient's symptoms and to identify underlying pathophysiological mechanisms, as well as to analyse other functions of the lower urinary tract which may be relevant for planning further (invasive) treatment. In this review, we describe the available urodynamic tests, the normal findings, and the evidence for the role of urodynamics, and on the specific measurements and parameters used to evaluate female lower urinary tract symptoms.In women with a suspected storage dysfunction, filling cystometry allows identification of detrusor overactivity or reduced bladder compliance as possible underlying causation of overactive bladder. Most women with stress incontinence have other storage and/or voiding symptoms and urodynamics should always be performed prior to invasive treatment. In the minority with pure stress urinary incontinence, urodynamic observations can guide the type of surgery chosen, but this has not yet been shown to change treatment outcome.Voiding dysfunction in women has recently received more research attention and various urodynamic parameters are being evaluated on their ability to distinguish detrusor underactivity from bladder outlet obstruction in pressure-flow studies. Video-urodynamics can provide a useful addition when anatomical information is needed in complex patients (eg, prior surgery or neurogenic patients).Finally, ambulatory urodynamics can be used when symptoms cannot be reproduced or explained by conventional urodynamics.     

Urethral pressure changes in women with detrusor instability

Detrusor instability has for years been thought to be due to a primary bladder pathology in 90% of cases. The remaining 10% were attributed to neurologic disorders. The simultaneous measurement of urethral and bladder pressures in patients with detrusor instability revealed two different patterns. The first was characterized by uninhibited bladder contractions followed by urethral relaxation. The second consisted of detrusor contraction preceded by urethral relaxation. The presence of involuntary urethral pressure changes exceeding 15 cmH₂O was defined as urethral instability. These observations have important therapeutic implications. Bladder instability secondary to an unstable urethra does not respond to anticholinergic therapy as well as primary detrusor instability. Better results are obtained by increasing the tone of the urethral sphincter with alpha-adrenergic drugs. Therefore, it is important to identify the chronological sequence of bladder and urethral pressure changes, in order to plan adequate therapy for patients with detrusor instability.     

The effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprung's disease

BACKGROUND/PURPOSE: The aim of this study was to investigate the effect of rectosigmoidectomy and Duhamel-type pull-through procedure on lower urinary tract function in children with Hirschsprungs disease. METHODS: During a 3-year period the authors assessed 11 consecutive children with Hirschsprung's disease prospectively by standard urodynamic investigations, before and after surgery. Urodynamics included simultaneous measurement of abdominal pressure, bladder pressure, detrusor pressure, and pelvic floor electromyography during filling and voiding. All children were submitted to laparoscopic resection of the aganglionic bowel segment below the cul de sac and a Duhamel-type pull-through procedure. Postoperatively, the children were assessed urodynamically and evaluated every 3 months for urologic problems. RESULTS: Mean age at first urodynamic study was 5 months (range, 2 to 10). Postoperative urodynamics were performed at a mean age of 10 months (range, 5 to 159). The mean interval between operation and postoperative urodynamic study was 6 months (range, 2 to 10). No child had structural urologic anomalies or urologic problems before surgery, and all had normal preoperative urodynamic findings. After surgery, urodynamics were considered normal in 3 children. In 7 children cystometric bladder capacity (CBC) was abnormally large, and 6 of these children had significant residuals. However, all had detrusor contractility and were able to void spontaneously. One child had low bladder compliance postoperatively. Despite the urodynamic changes, no child had clinical urologic problems at further follow-up. Mean follow-up after surgery was 24 months. CONCLUSIONS: This study found that after rectosigmoidectomy below the cul de sac alterations of bladder function can be observed. In 7 of the 11 patients studied, mean cystometric bladder capacity was 87% higher than capacity estimated for age. Moreover, postoperative residuals were 156% higher than the preoperative values. These findings suggest that partial detrusor denervation is likely in these patients. However, because detrusor contractility was present, and none of the children had retention or any urologic problems, the findings must be interpreted carefully. Because children with Hirschsprung's disease generally do not have preexisting urologic problems, routine preoperative urodynamic screening is not necessary. However, children with voiding problems after operation should be investigated urodynamically. For legal reasons parents should be informed of possible urologic problems, especially if subtotal resection of the aganglionic bowel segment is planned.     

El cateterismo vesical intermitente en la insuficiencia contráctil del detrusor

ObjectiveTo study the influence of clean intermittent catheterization (CIC) on the lower urinary tract function in patients with urinary retention (UR) due to detrusor underactivity (DU).Material and methodsA longitudinal study was carried out on 49 patients (28 men, 21 women) of mean age 55 years, who underwent CIC for UR secondary to DU. The mean CIC frequency was 3.15 times/day. Patients’ clinical data were collected, and they underwent urodynamic study before and after CIC, with a mean interval of 4 years. Fisher's exact test was used for the analysis of categorical variables and Student's t test for parametric variables. The level of significance was set at 0.05 for a two-tailed test.ResultsThe second urodynamic study showed a significantly increased bladder compliance, the Bladder Outlet Obstruction Index (BOOI) and the Bladder Contractility Index (BCI) also increased but without reaching statistical significance. There was a significantly higher percentage of benign prostatic hyperplasia (BPH) and acontractile detrusor cases among the group of patients whose BCI improved after CIC, with significantly lower CIC time.ConclusionsCIC improved bladder compliance in the patients of our series. The BCI improved in BPH patients and in patients with acontractile detrusor.     

Risk Factors For Osteoporosis at the Knee in the Spinal Cord Injury Population

Abstract

Background: The objective of this study was to determine modifiable and nonmodifiable risk factors for bone loss at the knee in individuals with spinal cord injury (SCI) by examining known risk factors for osteoporosis in the general population and additional, unique nonmodifiable SCI elements including age at injury onset, injury duration, and extent of neurologic injury (Ievei and completeness).

Methods: Risk factors were examined by logistic regression in 152 individuals with chronic SCI. Knees were classified as osteoporoticbased on whether bone mineral density (BMD) of the knee as assessed by dual-energy x-ray absorptiometry feil within the 95%confidence interval of the BMD of the knee of individuals who had experienced fractures at the knee.

Results: Accuracy for predicted membership in the osteoporotic group and nonosteoporotic group were 79.22'7o and 69.33%,respectively. Of all variables included in the analysis, 3 had a significant effect on predicted group membership: completeness ofinjury (P < 0.0001), body mass index (BMI) (P=0.0035), and age (P=0.0394). lndividuals with complete injuries were 6.17times (617'7o) more likely to have BMD of the knee low enough to place them in the osteoporotic category. The odds ratio for BMIindicated that every unit increase in BMIIowered the odds of being in the osteoporotic group by 11.29%. The odds ratio for ageindicated that every 1 -year increase in age increased the odds of being in the osteoporotic group by 3.54%. No other modifiableor nonmodifiable risk factors were significant predictors.

Conclusion: Completeness of injury dictates and overrides most modifiable and nonmodifiable risk factors for bone loss at the kneeleading to pathologic fractures in SCI. SCI osteoporosis may be classifi ed more appropriately as neuragenie in origin.     

Preliminary Observations Of A Synergistic Bladder-Sphincter Relationship Following Spinal Cord Injury In A Quadruped Animal

Abstract

Background/Objectives: High urethral resistance or detrusor-sphincter dyssynergia (DSD) is characterized by obstructed voiding during bladder contractions. DSD is caused by an exaggerated pelvic floor reflex resulting from sensory input from elevated pressure in the bladder that produces reflex constriction of the urethral sphincter. The objective of this study was to determine whether sensory input from the bladder produced synergistic or dyssynergic pelvic floor reflexes following SCI in an animal model.

Methods: A pelvic floor reflex that shares the same motor pathway with DSD is the bulbocavernosus (BC) reflex. The BC reflex was elicited with electrical stimulation in 4 male cats with T1 spinal injury, and recorded as an anal sphincter contraction. Recordings were obtained during control and elevated bladder pressures. Increased bladder pressure was induced with either manual pressure (Crede procedure) or spontaneous contractions resulting from bladder filling.

Results: During the control period, the BC reflex indicated by the peak anal pressure response was 23 ± 6 cmH20. During elevated bladder pressure of 34 ± 18 cmH20, the BC response decreased to 10 ± 3 cmH20 (not significant), showing a synergistic relationship. Anal sphincter tone between BC reflex tests showed a dyssynergic response. All4 animals showed increased tone during elevated bladder pressures that averaged 9 ± 5 cmH2 0 . Because abdominal pressure was not recorded, the significance is not clear. However, there was further support of a dyssynergic relationship based on increases in the anal and urethral electromyography recordings and some pelvic floor spasms during the elevated bladder pressure.

Conclusions: Because 2 different pelvic floor activities were observed during increased bladder pressures, this animal model may be described best as a mixed model. This model shows both synergistic and dyssynergic relationships between the bladder and the BC contractions. Although observed changes were not significant, the unique observations of synergistic bladder-sphincter activity shown by the inhibited BC reflex is in marked contrast to the strictly dyssynergic bladder-sphincter relationship seen in SCI patients.     

Augmentation cystoplasty in neuropathic bladder

Objectives: To look at the changing role of cystoplasty in the neuropathic population.

Design: Retrospective case series.

Setting: Single center over a 10-year period from 2004 to 2014.

Participants and intervention: In 1995, the Princess Royal spinal injuries unit published the outcomes of 78 neuropathic patients who had undergone cystoplasty in the 10-year period from 1982 to 1992. [Singh G, Thomas DG. Enterocystoplasty in the neuropathic bladder. Neurourol Urodyn 1995; 14(1): 5–10.]. In this series, we review 51 consecutive patients undergoing the same operation over a 10-year period from 2004 to 2014 in the same single unit.

Outcome measures: Demographic data were collected to include patient age, condition, and previous treatments. Pre- and post-operative details included sphincter insertions, renal function, continence rates, and complications.

Results: Despite an increase in the number of patients seen at the unit, there were considerably fewer cystoplasty procedures performed in the current series (51 vs. 78 in the 1982–1992 series). There were also significantly fewer patients with spina bifida and fewer concomitant sphincter insertions in the latter series (eight patients vs. 52 in the 82/92 series). Nevertheless, similar outcomes are observed between the current and 1982–1992 series, with continence rates of 93.7 and 93.6%, respectively and low numbers of reported adverse events for both retrospective cohorts.

Conclusions: Cystoplasty remains a safe and effective option for the management of neuropathic bladder in a carefully selected group of patients.     

Emerging genomic biomarkers for improving kidney,prostate, and bladder cancer health disparities outcomes

BackgroundRecent advances in genomic and genetic technologies have facilitated better health outcomes for urologic cancer patients. Genomic and genetic heterogeneity may contribute to differences in tumor biology and urologic cancer burden across various populations.ObjectiveTo examine how emerging genomic and genetic biomarkers, self-reported race, and ancestry-informative markers are associated with kidney, prostate, and bladder cancer outcomes.ResultsGenomic and genetic alterations found in African American kidney cancer patients included distinct somatic mutations, somatic copy number alterations, chromosomal instability, germ-line risk alleles, and germ-line genetic variants. These changes correlated with improved risk prediction, prognosis, and survival; and a predicted decrease in response to targeted therapies. SNP risk alleles and ancestry-informative markers were associated with improved risk prediction in prostate cancer patients of both African and European descent. AKT activation suggest differential response to AKT-targeted therapies in African American, Asian American, and Tunisian bladder cancer patients. Both self-reported race and genetic ancestry predicted urologic cancer risk prediction.ConclusionPrecision medicine approaches that integrate population-specific genomic and genetic information with other known urologic cancer-specific characteristics can improve outcomes and be leveraged to reduce cancer health disparities. Further investigations are necessary to identify novel genomic biomarkers with clinical utility.     

Extent of bladder and ureteric involvement and urologic management in patients with enterovesical fistulas

A retrospective review of hospital charts from 1978-1989 identified 21 patients with acquired enterovesical fistulas. Nine patients with fistulas secondary to benign inflammatory processes required extensive bladder resection; 2 of these had ureteric involvement. Of the 9 patients requiring extensive bladder resection, necrotic and severely inflamed bladder was excised and the bladder was closed in a multilayered fashion with absorbable sutures. An omental flap was used when possible. Postoperative bladder drainage was maintained for seven to fourteen days. Ureteral involvement was managed by stenting in 1 case and ureteroureterostomy in another. No postoperative bladder leaks or recurrent fistulas were reported. Extensive inflammatory involvement of the bladder wall may necessitate a large vesical resection. Excision of diseased bladder tissue, multilayered closure, and the use of omental interposition may help reduce postoperative complications and the risk of recurrence. Associated ureteral involvement may be present in these patients and requires urologic management.     

Urodynamic and rectomanometric findings in patients with spinal cord injury

Patients with spinal cord lesion suffer from complex disorders of bladder and anorectal function. We assessed the value of urodynamics and anorectal manometry as prognostic and diagnostic tools in these patients and evaluated the usefulness of these techniques for the differentiation between complete and incomplete spinal cord lesions. Thirty patients with suprasacral spinal cord injury (six women, 24 men; mean age, 31 years) underwent anorectal manometry and urodynamics within the first 40 days after injury. The findings were compared to the results of a clinical neurologic evaluation. Fifteen patients were classified as complete lesions on their clinical signs, three of these lesions were incomplete according to urodynamic testing and five were incomplete according to visceral sensory testing by anorectal manometry. Despite significant differences in maximum bladder capacity (589 versus 465 mL), maximum detrusor pressure (18 versus 31 cm H2O) was not significantly different between patients with complete and patients with incomplete spinal cord injury. Anorectal manometry did not reveal any significant differences in resting pressure, abdominal pressure, and maximal rectum volume between these groups. Urodynamics and anorectal manometry may be superior to neurologic assessment of completeness of spinal cord lesions. Urodynamics and anorectal manometry were not helpful in the prediction of onset or severity of detrusor hyperreflexia. Thus, we do not regard anorectal manometry as a standard diagnostic tool in spinal cord injury patients.     

Laparoscopy-assisted ileal conduit in sacral agenesis

Sacral agenesis is a rare congenital anomaly. The neurologic deficits are usually static. However, there are reports of progressive neurologic deterioration. They have neurogenic bladder, which usually present late and managed according to the presenting urodynamic pattern. In this paper, we report the urologic management in a 4-and-half-year-old boy with sacral agenesis. He presented with constant dribbling owing to gross instability with a small-capacity bladder. He also had bilateral ureteric obstruction (i.e., stricture at the level of bilateral ureteric reimplantation, which was done at the age of 1 year for high-grade reflux). He was not compliant with intermittent self-catheterization. Various options were discussed with the parents, but they preferred an ileal conduit (which could take care of the leak and avoid complex reconstructive surgery), with an option of reconstruction later. Laparoscopic ileal conduit was performed, with the uretero ileal anastomosis and restoration of ileal continuity performed extracorporeally. Extracorporeal part of the procedure was done without any additional incision (by bringing the ureters and ileal segment outside through the 12-mm port and then pushing it back inside after the completion of the anastomosis). We present this case report for the less-morbid management of a complicated urologic problem.