Vesicoureteral reflux in the early stage of spinal cord injury: a retrospective study

STUDY DESIGN: A retrospective study. OBJECTIVES: To investigate the risk factors of vesicoureteral reflux in the early stage of spinal cord injury. SETTING: Japan. METHODS: Urological evaluation, including cystography and urodynamic study was performed in patients in the early stage of spinal cord injury. The patients were divided into two groups. Group 1 included 13 patients with vesicoureteral reflux. Group 2 included 97 patients without vesicoureteral reflux. We compared Group 1 and Group 2 regarding bladder deformation, the level of spinal cord injury, bladder behaviour, bladder compliance, high urethral closure pressure and method of urine evacuation. RESULTS: The patients injured between Th10 and L2 showed a significantly higher incidence of vesicoureteral reflux than those injured in other areas (P<0.01). Furthermore, bladder compliance among patients with vesicoureteral reflux tended to be low. Other factors showed no differences between patients with and without vesicoureteral reflux. CONCLUSION: Injuries between Th10 and L2 involve the sympathetic nervous system. Patients with such injuries often exhibited vesicoureteral reflux in the early stage of spinal cord injury.     

Relationship among vesicoureteral reflux, urinary tract infection and renal damage in children

PURPOSE: We studied the relationship among vesicoureteral reflux, urinary tract infection and permanent renal damage in children. MATERIALS AND METHODS: We retrospectively analyzed 303 children younger than 2 years with a first time, nonobstructive, culture verified urinary tract infection. The protocol included ultrasonography and voiding cystourethrography within 3 months after urinary tract infection, and (99m)technetium dimercapto-succinic acid scintigraphy after 1 to 2 years. RESULTS: Vesicoureteral reflux was found in 36 of 163 boys (22%) and in 44 of 140 girls (31%). Of the 303 patients 80 (26%) had permanent renal damage according to dimercapto-succinic acid scintigraphy. The rate of abnormality increased significantly with grade of vesicoureteral reflux in boys and girls. The relative risk of renal damage was significantly increased in patients with vesicoureteral reflux grade II and higher. Maximum C-reactive protein concentration, maximum temperature during urinary tract infection, presence of vesicoureteral reflux and febrile recurrences of urinary tract infection were significantly related to permanent renal damage. In stepwise logistic regression vesicoureteral reflux was the only independent variable for boys, while C-reactive protein and vesicoureteral reflux were independent factors for girls. CONCLUSIONS: There was a significant relationship between grade II vesicoureteral reflux and higher and permanent renal damage in boys and girls. However, while the association between renal damage and vesicoureteral reflux was evident in boys, the role of urinary tract infection and renal inflammation seemed to be equally or more important in girls. These findings support the concept that renal damage is associated with vesicoureteral reflux and is often congenital in boys, while in girls it is more related to urinary tract infection with vesicoureteral reflux as a reinforcing factor.     

Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients

PURPOSE: Controversy continues on the optimal method of bladder management in spinal cord injured patients. We investigated the effects of bladder management on bladder compliance and changes in compliance with time. MATERIALS AND METHODS: We retrospectively reviewed the charts, and video urodynamic and upper tract radiographic studies of 316 patients with spinal cord injury. Patients were categorized according to interval since injury and bladder management method, including clean intermittent catheterization, spontaneous voiding and chronic Foley catheterization. Those with upper tract complications were compared with asymptomatic controls at the bladder compliance threshold values of 10.0, 12.5, 15.0 and 20.0 cc/cm. water. RESULTS: No significant differences were noted among bladder management method groups for followup, level, completeness or mechanism of injury. A bladder compliance threshold of 12.5 cc/cm. water was selected for the remaining comparisons based on the frequency of complications compared with asymptomatic controls. Patients using intermittent catheterization had a significantly higher incidence of normal compliance than the Foley management group for suprasacral, complete and incomplete injury (p<0.01). Normal bladder compliance was more common in patients with suprasacral than sacral and incomplete than complete spinal cord injury for each bladder management type. Logistic regression analysis of compliance versus bladder management and age of injury (interval since injury) revealed that intermittent catheterization and spontaneous voiding were associated more with normal compliance than Foley catheterization (RR = 9.2, 5.4 and 1.0, respectively). Combined data showed that each successively older age of injury cohort was at 23% greater risk for loss of normal compliance than the preceding cohort. Low compliance was statistically associated with vesicoureteral reflux, radiographic upper tract abnormality, pyelonephritis and upper tract stones (p<0.01, <0.01, 0.04 and <0.01, respectively). CONCLUSIONS: Clean intermittent catheterization protects bladder compliance in spinal cord injured patients regardless of the level or completeness of injury and helps to prevent low compliance with time. Also, in the population studied low compliance was associated with upper tract complications. Therefore, clean intermittent catheterization is the superior method for preserving bladder compliance and preventing the upper tract complications associated with low compliance.     

Familial vesicoureteral reflux

PURPOSE: Vesicoureteral reflux is known to occur in families. We summarized worldwide data on the incidence and nature of vesicoureteral reflux in siblings of children with vesicoureteral reflux. MATERIALS AND METHODS: We searched MEDLINE using the words siblings vesicoureteral reflux, familial vesicoureteral reflux, offspring vesicoureteral reflux and vesicoureteral reflux screening. All articles that we identified that were published from 1972 to 2002 were analyzed for the incidence of renal damage in siblings of patients with vesicoureteral reflux. RESULTS: Siblings of patients with vesicoureteral reflux have a much higher incidence of reflux than the normal population. There is a direct relationship of patient age to the incidence and severity of reflux. Most investigators advocate screening asymptomatic siblings of patients with vesicoureteral reflux. CONCLUSIONS: The incidence of sibling reflux is significant. When vesicoureteral reflux is discovered in symptomatic siblings, it is usually high grade and associated with a high incidence of reflux nephropathy. Randomized controlled studies are needed to compare renal damage in patients with reflux detected through screening to renal damage in those diagnosed after urinary tract infection to establish how much renal damage may be prevented by screening in asymptomatic siblings.     

Cessation of prophylactic antibiotics for managing persistent vesicoureteral reflux

PURPOSE: We reviewed our experience with patients with vesicoureteral reflux treated off prophylactic antibiotics. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with vesicoureteral reflux treated off prophylactic antibiotics, noting the intervals on and off antibiotics, urinary tract infection, signs and symptoms associated with urinary tract infection, and renal ultrasound and dimercapto-succinic acid scan findings. RESULTS: We identified 196 patients with vesicoureteral reflux treated off prophylactic antibiotics, including 122 who were infection-free while on and 124 who had no urinary tract infection while off prophylactic antibiotics. The infection rate on and off prophylactics was 0.29 and 0.24 urinary tract infections per patient per year, respectively. New scars were identified in 5 patients while on prophylactics and in 7 after antibiotics were discontinued. Comparing different subgroups off prophylactic antibiotics showed that children who presented with scarring had statistically fewer new scars than those with normal initial dimercapto-succinic acid imaging (p <0.043). Girls had significantly more urinary tract infections than boys while off prophylactics (p <0.01) despite the older age at antibiotic cessation. However, after infection occurred while off prophylactic antibiotics, new renal scars developed at about the same rate in boys and girls. Because most patients did not have a urinary tract infection while off prophylactic antibiotics, new renal scars developed in only 2.2% of all boys and 4% of all girls. CONCLUSIONS: Our findings imply that discontinuing antibiotics is reasonable and safe in patients in whom vesicoureteral reflux fails to resolve.     

The impact of contemporary bladder management techniques on struvite calculi associated with spinal cord injury.

OBJECTIVE: To evaluate the incidence, risk factors and complications of upper tract struvite calculi, often associated with spinal cord injury (SCI), as such patients have a high incidence of urinary infection complicating their neurogenic voiding dysfunction, by reviewing a large population of patients with SCI in whom modern techniques of bladder management were used. PATIENTS AND METHODS: Between 1982 and 1996, 1669 patients with SCI were admitted to our institution; 1359 of these patients sustained their injuries during the study period. During this time, their bladder management was based on urodynamic and imaging criteria, using techniques such as early intermittent catheterization, sphincterotomy and bladder augmentation where possible to create a catheter-free, low-pressure reservoir. All instances of upper tract struvite calculi in this population were documented. Risk factors for stone development, presentation and complications, management and recurrence rates were assessed. RESULTS: Over the 15 years, 58 patients (3.5% of the SCI population) were treated for a total of 144 episodes of struvite calculi. The incidence of stones in those injured since 1982 was 1. 5%; 67% of these patients had complete spinal cord lesions, 54% had lesions of the cervical cord and 53% developed their first stone >10 years after injury. Only 22% presented within 2 years of injury. The group of patients developing stones had a significantly higher incidence of indwelling catheters (49%), bladder stones (52%) and vesico-ureteric reflux (28%) than those who were stone-free. The development of recurrent urinary tract infections was the most common mode of presentation. The stone-free rate after treatment was 87%. Normal renal function was preserved in 72% of patients. CONCLUSIONS: In a large population of patients with SCI managed using contemporary bladder techniques the incidence of upper tract calculi was 3.5%; 30% of these stones were complete or partial staghorns. Those patients with complete cord lesions, permanent indwelling catheters and vesico-ureteric reflux were at the highest risk. Stone clearance was 87% and recurrent stones occurred in 69% of patients. Struvite renal calculi continue to be a significant problem in the spinal cord injury population.     

Abnormal dimercapto-succinic acid scans predict an increased risk of breakthrough infection in children with vesicoureteral reflux

PURPOSE: The management of high grade vesicoureteral reflux remains controversial, with breakthrough infections being an indication for surgical repair. We sought to determine if technetium dimercapto-succinic acid (DMSA) scan could help predict which children are at risk for breakthrough urinary tract infection. MATERIALS AND METHODS: A retrospective review was performed on children presenting with a febrile urinary tract infection and prenatal hydronephrosis who were found to have vesicoureteral reflux and underwent a DMSA scan. Reflux was tabulated according to the highest grade. DMSA results were graded as 0-normal, no parenchymal or size defects, grade 1-focal parenchymal defects or less than a quarter of a renal unit involved, or grade 2-severe defects to include at least half of a renal unit, bilateral defects or unilateral atrophy. RESULTS: A total of 120 consecutive patients were evaluated. An abnormal DMSA scan was documented in 57 (33 females and 24 males), and 35 with grade 1 and 22 with grade 2 defects. Of the patients 53 females and 10 males had a normal scan. Of the 57 children with an abnormal DMSA scan 6% presented with grades 1 and 2 vesicoureteral reflux, 24% with grade 3, 38% with grade 4 and 26% with grade 5. Of the children with grades 3 to 5 reflux 60% had a subsequent breakthrough infection. Of the 63 children with a normal DMSA scan 11% presented with grade 1 reflux, 28% with grade 2, 48% with grade 3, 11% with grade 4 and 2% with grade 5. Of these children 5 had a subsequent breakthrough infection. CONCLUSIONS: An abnormality on DMSA scan in the presence of grade 3 to 5 reflux correlates with a greater chance of having a breakthrough infection (60%). We conclude that children with grade 3 to 5 vesicoureteral reflux and an abnormal DMSA scan are at increased risk for breakthrough urinary tract infection.     

Urinary tract infection prophylaxis using Escherichia coli 83972 in spinal cord injured patients

PURPOSE: Escherichia coli 83972 was previously shown to establish bladder colonization in select patient groups. We evaluate the safety and feasibility of using bacterial interference with E. coli 83972 to prevent urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: A total of 21 men and women with neurogenic bladder secondary to spinal cord injury underwent intravesical inoculation with E. coli 83972. Frequency of symptomatic urinary tract infection before and after colonization was compared. RESULTS: Successful long-term bladder colonization was achieved in 13 study participants. Mean duration of colonization was 12.3 months (range 2 to 40). Subjects had no symptoms of urinary tract infection while colonized with E. coli 83972 (0 infection per 18.4 patient-years). Successfully colonized subjects had experienced a mean of 3.1 symptomatic urinary tract infections per year (range 2 to 7) before colonization. Symptomatic infection also occurred in 4 subjects who were not successfully colonized with E. coli 83972 and in 7 others after spontaneous loss of colonization. Colonized subjects reported subjective improvement in quality of life with respect to urinary tract infection while colonized. CONCLUSIONS: E. coli 83972 may be safely used to establish long-term asymptomatic bladder colonization in spinal cord injured subjects. Preliminary findings suggest that colonization with E. coli 83972 may reduce the frequency of urinary tract infection in patients with neurogenic bladder secondary to spinal cord injury.     

Continent lower urinary tract reconstruction in the cervical spinal cord injured population

PURPOSE: Patients with cervical spinal cord injury and upper extremity dysfunction are treated primarily with indwelling or condom catheters. We present our experience with a select group of patients with limited upper extremity function to determine long-term success and patient satisfaction after lower urinary tract reconstruction. MATERIALS AND METHODS: Between May 1988 and November 1996, 28 patients with cervical spinal cord injury underwent lower urinary tract reconstruction. Postoperative information was obtained on 21 patients. Charts were reviewed and patients were contacted by an independent reviewer to ascertain patient satisfaction and quality of life. Patient age was 17 to 51 years (average 34.6). Reconstructive procedures requiring catheterization included augmentation ileocystoplasty in 4 patients plus Mitrofanoff appendicovesicostomy in 7, a Kock ileal reservoir in 8 and an Indiana pouch in 2. RESULTS: Catheterization was regularly performed by 20 of the 21 patients (95%). A total of 12 patients (60%) performed self-intermittent catheterization and 8 (40%) relied on an attendant or family member. Of the patients 80% reported improved quality of life since reconstruction, citing such reasons as lack of a need for urinary drainage bags, increased freedom and an improved sense of body image. Using a visual analog scale to grade satisfaction from 1 to 10 (1-extremely unsatisfied to 10-extremely satisfied) 14 patients (67%) reported a score of 8 or more. CONCLUSIONS: With appropriate preoperative selection of the cervical spinal cord injured patient intermittent catheterization is successfully maintained in the long term, allowing greater flexibility in choice, and a resultant high level of patient satisfaction and improved quality of life.     

Epididymo-orchitis risk factors in traumatic spinal cord injured patients

STUDY DESIGN: Retrospective audit and interview-based study of a traumatic spinal cord injured cohort, assessing the incidence and risk of epididymo-orchitis (E-O). OBJECTIVES: Assess the potential risk factors for E-O in this cohort (spinal cord injured patients). SETTING: Janbazan Clinic for Spinal Cord Injuries, Mashad, Iran. METHODS: A retrospective notes audit of 169 male traumatic spinal cord injured (SCI) patients was performed. In addition, interviews were performed to confirm any equivocal data. The following risk factors were assessed: history of recurrent urinary tract infections (UTIs), urethral stricture, urethral diverticuli, urinary fistula, urinary calculi, spinal injury type, neurogenic bladder type, autonomic dysreflexia, vesico-ureteral reflux, sphincterotomy, vasectomy, marriage status, bladder residual and emptying method, ejaculation, spinal injury level, micturation control, and muscular spasm, which included detrusor, external sphincter or lower limb spasm. RESULTS: A total of 65 patients from our group (38.5%) had suffered E-O at least once. E-O presented on average, 3.9 years after the SCI. Patients with a history of muscular spasm appeared less likely to develop E-O (P<0.05). None of the vasectomised patients developed E-O. The relation between all the other factors and E-O were not significant. CONCLUSIONS: Our study has shown that the presence of muscular spasm decreases the risk of E-O, although the mechanism remains unclear. Surprisingly, the other historical risk factors showed no clear relation with E-O occurrence.     

The predictive factors of hydronephrosis in patients with spina bifida: reports from China

Purpose

To identify the risk factors for hydronephrosis in patients with neurogenic bladder caused by spina bifida.

Methods

A retrospective analysis of 120 patients with hydronephrosis between January 2005 and 2012 was conducted. The patients were evaluated for the following factors: age, sex, voiding symptoms, experience of using clean intermittent catheterization, history of urinary tract infection (UTI), history of one or more tethered spinal cord release surgery, routine urine examination, serum creatinine, ultrasound for kidneys, ureters, bladder, and urodynamic findings by univariate and logistic regression analyses.

Results

Among the 120 patients, 45 (38 %) had unilateral or bilateral hydronephrosis. Univariate analysis indicated that detrusor hyperreflexia, poor compliance (PC), vesicoureteral reflux (VUR), urinary incontinence, high residual urine, and UTI were the significant factors in the incidence of hydronephrosis. Multivariate analysis indicated that PC, VUR, and UTI were the risk factors for hydronephrosis and that detrusor hyperreflexia and urinary incontinence were the protective factors. UTI was the most serious risk factor for hydronephrosis, with an odds ratio of 29.6. Hydronephrosis was not associated with the history of tethered spinal cord release surgery.

Conclusion

This study revealed the prognostic risk factors for hydronephrosis. The medical history of patients, imaging examination, and urodynamic parameters play key roles in identifying the risk factors for hydronephrosis.     

Urolithiasis in patients with spinal cord injuries: risk factors, management, and outcomes

PURPOSE OF REVIEW: Despite major advances in the urological care of spinal cord injury patients, the incidence of urolithiasis has not changed. Although the incidence of kidneys lost to staghorn calculus disease has decreased considerably, stone disease is still a significant cause of morbidity and concern. The purpose of this review is to summarize the risk factors for the development of stone diseases in the spinal cord injury patient population and present the outcomes of current endourologic treatment modalities. RECENT FINDINGS: Recurrent urinary tract infections, indwelling catheters, vesicoureteral reflux, and immobilization hypercalcuria are a few of the major risk factors for the development of urolithiasis among spinal cord injury patients. Retrograde endourologic techniques are often not possible to address stone disease due to lower extremity contractures, spinal curvature, and pelvic tilt. Extracorporeal shockwave lithotripsy success rates vary from 50 to 90%, but clearance rates are often delayed. Success rates for percutaneous nephrolithotomy match those quoted in the general population ( > 90%), but at the expense of a higher rate of complications (6-20%). Meticulous planning with regard to appropriate prophylactic antibiotics and body position will maximize efficacious outcomes. SUMMARY: Early identification and treatment of urolithiasis in spinal cord injury patients will aid in preserving renal function and minimizing associated complications. Despite variation in common urological practices between spinal cord injury units and the lack of clear cut guidelines for follow-up, the increased incidence of risks associated with urolithiasis lends support for routine genitourinary imaging in order to identify and treat those individuals at highest risk.     

脊髓损伤并发上尿路扩张的危险因素分析

目的探讨脊髓损伤患者并发上尿路扩张的尿动力学危险因素。方法随机抽取唐山地震脊髓损伤患者96例,经B超检查并发上尿路扩张16例为A组,无上尿路扩张80例为对照组B组,分别进行尿动力学测定。而后对两组患者间性别、年龄和尿动力学等参数进行单因素和多因素分析。结果男性上尿路扩张发生率明显高于女性,A组残余尿量、最大膀胱容量、逼尿肌漏点压和膀胱低顺应性发生率明显高于B组,而两组年龄、逼尿肌反射亢进发生率、相对安全容量、逼尿肌括约肌协同失调发生率、最大尿流率和最大尿道关闭压差异无统计学意义。Logistic回归分析结果显示,膀胱低顺应性是筛选出的惟一危险因素。结论对脊髓损伤患者及时进行尿动力学检查,阻止或减缓膀胱顺应性的改变,可防止上尿路扩张的发生。     

Changing concepts concerning the management of vesicoureteral reflux

PURPOSE: Conservative estimates indicate that up to 54% of patients who present with vesicoureteral reflux have dysfunction voiding. Children with voiding dysfunction and vesicoureteral reflux historically have a high breakthrough infection rate of 34% to 43%. Breakthrough infection represents significant morbidity and it is the most common indication for surgical intervention for vesicoureteral reflux. Voiding dysfunction is present in 79% of patients who proceed to reflux surgery. We evaluated the impact of pelvic floor muscle retraining combined with a medical program in patients with voiding dysfunction and vesicoureteral reflux. MATERIALS AND METHODS: Children with a history consistent with voiding dysfunction and vesicoureteral reflux were screened by uroflowmetry/electromyography, bladder scan for post-void residual urine, renal ultrasound and voiding cystourethrography. Confirmed cases of voiding dysfunction and vesicoureteral reflux were prospectively enrolled in this study. Children participated in an interactive, computer assisted, pelvic floor muscle retraining program that involved a conservative medical regimen and pelvic floor muscle retraining. All patients received prophylactic antibiotics. We evaluated the rate of breakthrough urinary tract infection, reflux outcome and surgical intervention. A literature review with the key words vesicoureteral reflux, voiding dysfunction and urinary tract infection was performed to identify historical control cases for comparison. RESULTS: Study enrollment criteria were fulfilled by 49 girls and 4 boys 4 to 13 years old (average age 8.8), representing 72 units with low grades I to II (48) and high grades III to V (24) reflux. Mean followup was 24 months. Initial uroflowmetry/electromyography and bladder scan revealed a staccato flow pattern and normal post-void residual urine in 11% of cases, staccato flow pattern and elevated post-void residual urine in 10%, flattened flow pattern and normal post-void residual urine in 28%, and flattened flow pattern and elevated post-void residual urine in 51%. Breakthrough infection developed in 5 patients (10%), including 1 in whom reflux had resolved and 1 with grade I reflux who underwent observation. The parents of 2 patients elected to complete biofeedback without surgical intervention and these patients did not have a repeat infection. Reimplantation was performed in 1 case (2%). There was resolution in 18 low and 7 high grade refluxing units, including 2 older patients with a long history of high grade bilateral disease. Average time to resolution was 7.8 months. We noted elevated post-void residual urine in 88% of the patients with high grade reflux. Average age at resolution was 9.2 years. During a 24-month period one of us (P. H. M.) noted a greater than 90% decrease in surgical intervention. CONCLUSIONS: A combined conservative medical and computer game assisted pelvic floor muscle retraining program appears to have decreased the incidence of breakthrough urinary tract infections and facilitated reflux resolution in children with voiding dysfunction and vesicoureteral reflux. Patients with high grade reflux and voiding dysfunction commonly present with elevated post-void residual urine, contraindicating the indiscriminate administration of anticholinergics. Decreasing the rate of urinary tract infections may have a dramatic impact on the need for surgical intervention and enable the reflux resolution rate to approximate that in patients without voiding dysfunction. Prospective controlled trials are needed to determine whether pelvic floor muscle retraining combined with a conservative medical regimen alters the natural history of vesicoureteral reflux in patients with voiding dysfunction.     

Management of postoperative urinary retention: a randomized trial of in-out versus overnight catheterization

BACKGROUND: There has been no consensus on the best catheterization strategy for the management of postoperative urinary retention. A prospective randomized trial was undertaken to establish the best practice guidelines for the management of postoperative urinary retention. The authors also evaluated the contemporary incidence of urinary retention following different categories of general surgery and examined risk factors associated with its occurrence. METHODS: All patients who underwent elective inpatient surgery between January 2002 and June 2003 were recruited into the study. Patients who developed postoperative urinary retention were randomized to either having in-out catheterization or placement of an indwelling catheter for 24 h after surgery. RESULTS: A total of 1448 patients was recruited. The overall incidence of urinary retention was 4.1% (n = 60). Significant risk factors associated with postoperative urinary retention included old age, anorectal procedures and use of spinal anaesthesia. Comparison of re-catheterization and urinary tract infection rates between patients who were treated with in-out versus overnight catheterization found no significant differences. CONCLUSIONS: Postoperative urinary retention should be managed by in-out catheterization. Indwelling catheterization for 24 h appeared to bestow no additional benefits. The incidence of urinary retention increases with age, anorectal procedures and the use of spinal anaesthesia.     

Complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution (1999–2003)

BACKGROUND: Pseudomonas aeruginosa has been an important uropathogen that causes complicated urinary tract infection. We investigated the clinical characteristics of complicated urinary tract infection caused by Pseudomonas aeruginosa in a single institution. METHODS: We studied those patients who had basal disease in their urinary tract that was diagnosed as urinary tract infection caused by more than 10(4) colony forming units (CFU)/mL of Pseudomonas aeruginosa isolated from their urine. In those patients, we analysed infectious risk factors, treatment methods including the use of antimicrobial agents, the presence of a urinary tract catheter, and the relationship between febrile infection and urinary tract catheter. In addition, we examined the various antimicrobial susceptibilities against Pseudomonas aeruginosa. RESULTS: We studied 76 patients (59 men and 17 women). Of their basal diseases of the urinary tract, bladder tumor was the most prevalent (42.1%). Of the 39 patients who had an indwelling urinary tract catheter, 26 (66.7%) experienced a high-grade fever, a higher rate than that of the 37 patients who were not catheterized (40.5%). Seven patients were treated with anticancer chemotherapy drugs and 31 cases of urinary tract infection caused by Pseudomonas aeruginosa were diagnosed in the perioperative period. Piperacillin showed lower susceptibility against Pseudomonas aeruginosa in these 2 years (P<0.05). CONCLUSIONS: Our results indicated that those patients with urinary tract catheterization had a higher incidence of fever than patients without catheterization. Therefore, we must improve not only the antimicrobial treatment of Pseudomonas aeruginosa but also our management of catheters.     

Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury

AIMS: The vast majority of spinal cord lesions cause neurogenic bladder disorders. Detrusor hyperreflexia presents a major risk factor for renal damage in these patients. We evaluated the long-term results of patients with spinal cord injury treated at our institution. METHODS: Eighty spinal cord injury patients (60 male, 20 female; mean age 29.6 years) with at least one follow-up visit a year for a minimum of five consecutive years, were included in this retrospective analysis. Follow-up included urodynamic evaluation, sonography of the upper and lower urinary tract, urine examination, and evaluation of renal function. Treatment modifications were based on the urodynamic findings. RESULTS: Mean follow-up was 67.3 months (range 60-103 months). At initial presentation, 51 patients performed intermittent catheterization, 7 had indwelling catheters, 10 utilized reflex voiding, 2 patients presented with a Brindley stimulator, 10 patients used abdominal straining. At the end of our study, no patient had signs of renal damage. To achieve that goal, 8 patients underwent sphincterotomy, 3 received a Brindley stimulator, 3 underwent bladder augmentation, one Kock pouch was performed, and 12 patients were treated with botulinum-A-toxin injections in the detrusor. Twenty-two patients received intravesical anticholinergic therapy. In merely three patients, treatment was not modified during the entire follow-up. CONCLUSIONS: In the long term, treatment strategy of neurogenic bladder dysfunction in patients with spinal cord injury had to be modified in almost all patients. 18.8% underwent surgery. For protection of the upper urinary tract and maintenance of continence, regular urodynamic follow-up is warranted.     

Risk factors for urinary stone formation in men with spinal cord injury: a 17-year follow-up study

OBJECTIVE: To establish hazard ratios for risk of urinary stone formation in men with chronic spinal cord injury. PATIENTS AND METHODS: In all, 140 men injured before 1987 were eligible for this investigation and were followed yearly from January 1987 and December 2003. RESULTS: Over the 17 years, 39 patients (28%) and 21 (15%) were diagnosed with bladder and renal stones for a total of 59 and 25 episodes, respectively. In multivariate analysis, bladder stone was more common in patients injured when aged > or = 24 years than in those injured when aged <24 years (odds ratio 2.5; 95% confidence interval 1.1-5.7; P = 0.03). In another model, patients with complete injury had a greater risk of renal stone formation than those with incomplete injury (4.1, 1.3-12.9; P = 0.016). Renal stone was more common for patients with urethral catheterization than for those voiding spontaneously (5.7, 1.3-24.6, P = 0.021) and for patients with bladder stone than for those without (4.7, 1.5-15.1; P = 0.01). CONCLUSION: Injury characteristics are important for the development of urinary stone in chronic traumatic spinal cord injury. In addition, the present findings suggest that in men who cannot use intermittent catheterization or when the bladder cannot empty spontaneously, suprapubic cystostomy is better than urethral catheterization to avoid renal stone formation.     

Vesicoureteral reflux in the Hispanic child with urinary tract infection

PURPOSE: Hispanic individuals have become the largest minority in the United States. Prior studies of minorities revealed real differences in vesicouretal reflux rates between white and black Americans. We studied the incidence of reflux in the Hispanic population to see if the reflux rate was different from that of the white population. MATERIALS AND METHODS: We reviewed the results of voiding cystourethrograms performed in Hispanic children as our normal screening for reflux and compared them to voiding cystourethrograms results in a group of white children. The children were identified as Hispanic or white by their parents on an intake form. RESULTS: Of the Hispanic children 27% had vesicoureteral reflux on voiding cystogram, while 32% of the white children had vesicoureteral reflux. CONCLUSIONS: Hispanic patients presenting with the first urinary tract infection seem to be afflicted with vesicoureteral reflux as often as their white contemporaries. Hispanic children should be screened as aggressively as white children when they present with urinary tract infections.     

Video urodynamic findings in men with the central cord syndrome

PURPOSE: The central cord syndrome reportedly has a favorable prognosis and rehabilitation outcome. However, to our knowledge the status of the lower urinary tract in patients with the central cord syndrome is unclear. We report on 22 men with the central cord syndrome who were evaluated by video urodynamics. MATERIALS AND METHODS: From 1986 to the present we identified 22 men with a mean age of 51 years who had the central cord syndrome and were included in the Houston Veterans Affairs spinal cord registry. All patients underwent video urodynamic evaluation a mean of 34.5 months after injury. RESULTS: Video urodynamic testing for vesicourethral dysfunction was normal in 3 patients, while it showed bladder outlet obstruction secondary to benign prostatic hyperplasia in 2, detrusor areflexia in 4, external detrusor-sphincter dyssynergia in 11, detrusor hyperreflexia with a synergistic external urethral sphincter in 1 and detrusor hypocontractility in 1. Urinary tract infection recurred in 3 patients with external detrusor-sphincter dyssynergia and urolithiasis developed in 2. CONCLUSIONS: Urodynamic testing revealed a high incidence of external detrusor-sphincter dyssynergia in men with the central cord syndrome. Due to the potential for upper tract deterioration all patients with the central cord syndrome should undergo baseline urodynamic studies. Those at high risk for upper tract deterioration with external detrusor-sphincter dyssynergia or a loss of compliance should be treated more aggressively with clean intermittent catheterization and anticholinergic medication when possible.