Memokath stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: the Princess Royal Spinal Injuries Unit 10-year experience

STUDY DESIGN: Medical records review. OBJECTIVE: To assess the effectiveness of the Memokath (Engineers and Doctors A/S, Denmark) thermosensitive stent as a 'nondestructive' means of reducing bladder outlet resistance by treating detrusor sphincter dyssynergia (DSD) of neurogenic bladder dysfunction associated with spinal cord injury. SETTING: Spinal Injuries Unit, Sheffield, England. METHODS: A medical records review was performed to examine our experience of Memokaths over the last 10 years. During this time, 29 patients with spinal cord injury (17 tetraplegic and 12 paraplegic) underwent stenting of the external urethral sphincter either for prevention of dysreflexic symptoms, high residual urine volumes and subsequent urinary tract infection (UTI) or for protection of the upper tracts. RESULTS: A total of 33 stents were inserted into 29 men (25-77 years) with suprasacral spinal cord injury. Initial results showed that the Memokath was effective in almost all for relief of dysreflexic symptoms and elimination of DSD on pressure flow urodynamics. However, to date, 30 of the 33 stents have been removed. The overall mean working life of the Memokath was 21 months. Four stents were removed electively and 23 for complications, which included stent migration (seven) and blockage (14). Single-ended stents were more prone to migration, which was rare after 1 year (1-13 months, median 3 months, mean 5.5 months). Stent blockage by encrustation or prostatic ingrowth did not occur before 12 months (12-45 months, median 30, mean 27.9 months). CONCLUSIONS: In selected patients, temporary, thermo-expandable (Memokath) stents are effective in the treatment of DSD. The 'working life' of a Memokath stent is 21 months; however, complications do occur which may necessitate removal. Our overall experience with Memokath stents was disappointing. In future, Memokath stents will only be inserted after careful consideration in patients with prior 'failed' transurethral sphincterotomy or with caution in patients suitable for reconstructive surgery.     

A 20‐year follow‐up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To assess the long‐term (20 years) effectiveness of the UroLume wallstent^TM (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in patients with spinal cord injury (SCI).

PATIENTS AND METHODS

Twelve patients with quadriplegia secondary to SCI underwent external striated sphincter stenting with the UroLume wallstent in place of sphincterotomy for DESD ≈ 20 years ago. The mean (range) age was 41.8 (26–65) years. Eleven patients had cervical level injury whilst one had a thoracic injury. All the patients were shown to have high‐pressure neurogenic detrusor overactivity and DESD with incomplete emptying on preoperative video‐cystometrograms (VCMG).

RESULTS

Six of the 12 patients have now been followed‐up for a mean (range) of 20 (19–21) years. Of the remaining six, two were lost to follow‐up at 1 and 3 years, but both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within 1 year of insertion. Another patient with an adequately functioning stent died 7 years after stent insertion from a chest infection. The twelfth patient developed bladder cancer 14 years after stent insertion and underwent cystectomy with urinary diversion. VCMG follow‐up of the six patients showed a significantly sustained reduction of maximum detrusor pressure and duration of detrusor contraction at the 20‐year follow‐up. Five of these six patients developed bladder neck dyssynergia of varying degrees as shown on VCMG within the first 9 years of follow‐up. All were successfully treated with bladder neck incision (BNI) where the last BNI needed was at 12 years. We did not encounter any problem with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia.

CONCLUSION

Urethral stenting using the UroLume wallstent is effective in the management of DESD in patients with SCI and provides an acceptable long‐term (20‐year follow‐up) alternative to sphincterotomy. The failures manifest within the first few years and can be managed easily with stent removal without any significant problems. Bladder neck dyssynergia was the long‐term complication which was treated successfully with BNI. It has no significant interference with erectile function, being reversible, minimally invasive and has a shorter hospital stay.     

Outcome of dual flange metallic urethral stents in the treatment of neuropathic bladder dysfunction after spinal cord injury

Abstract Purpose: To review the results of metallic urethral stents used in patients with neuropathic bladder dysfunction after spinal cord injury (SCI). Patients and Methods: In a rehabilitation unit for SCI and stroke in Cape Town, South Africa, we performed a case note review of dual flange Memokath stents placed from March 2008 until October 2011. Stents were placed rather than performing an external sphincterotomy in selected patients. With the patient under deep general anesthesia, a thermosensitive expandable metallic stent was positioned over the internal and external urethral sphincters. Results: In total, 33 stents were placed in 28 male patients. SCI was cervical in 23 patients and thoracic in 5. Average follow-up was 18 months (range 1-40 months, median 18 months). The most common indications were repeated catheter blockage in eight patients and urinary tract infection in six. The average time from SCI to stent insertion was 79 months (range 1-468 months, median 21 months). Severe autonomic dysreflexia was present in 17 cases before stent placement and in 7 after stents were placed (P=0.003). Stents failed in 15 patients (45%) and were removed. The most common reason for failure was stone formation. Comparing the group of patients with stents lasting >20 months (n=11) to the group with stent removal before 20 months (n=10), the mean time between SCI and stent placement was 31 vs 119 months (P=0.057). Medium term results (up to 27 months) were significantly influenced by earlier stent placement (P=0.0484). One major complication was stent migration that caused an urethrocutaneous fistula.     

Long-term result of Memokath urethral sphincter stent in spinal cord injury patients

Background

Memokath urethral sphincter stents are used to facilitate bladder emptying in patients with spinal cord injury, but long term follow-up has not been reported.

Methods

Case series of ten men with spinal cord injury who underwent insertion of Memokath stents and were followed for up to nine years.

Results

Within four years, the stent had to be removed in nine out of ten patients because of: extensive mucosal proliferation causing obstruction to the lumen of the stent; stone around the proximal end of the stent, incomplete bladder emptying, and recurrent urinary infections; migration of the stent into the bladder related to digital evacuation of bowels; large residual urine; concretions within the stent causing obstruction to flow of urine, and partial blockage of the stent causing frequent episodes of autonomic dysreflexia. In one patient the stent continued to function satisfactorily after nine years.

Conclusions

The Memokath stent has a role as a temporary measure for treatment of detrusor-sphincter dyssynergia in selected SCI patients who do not get recurrent urinary infection and do not require manual evacuation of bowels.

     

The treatment of male stress urinary incontinence with polydimethylsiloxane in compliant bladders following spinal cord injury

STUDY DESIGN: Retrospective analysis. OBJECTIVES: To evaluate the safety and efficacy of polydimethylsiloxane (PDS, Macroplastique) submucosal injections, in the treatment of male genuine stress urinary incontinence secondary to spinal cord injury (SCI). SETTING: London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK. PATIENTS AND METHODS: A retrospective analysis identified 14 patients treated with PDS for stress urinary incontinence secondary to SCI between 1997 and 2001. A single surgeon at a specialist spinal injuries unit managed all patients. A total of 13 patients had suffered a traumatic SCI (T11:n=2; T12:n=5; L1:n=5; L2:n=1), while one developed stress incontinence after spinal surgery. The mean age was 41 years (range 26-69 years) and the mean duration of injury was 9.6 years (range 1.5-48 years). The preoperative investigations included video cystometrogram (VCMG) confirming the presence of urodynamically proven stress incontinence without evidence of urge incontinence. Complete cure was defined as a cessation of pad usage with no evidence of leakage on VCMG. Incomplete cure with improvement was defined as a >50% reduction in the number of pads used, with incontinence present on VCMG. RESULTS: The follow-up ranged from 12 to 58 months (mean 34.7 months). Five patients (36%) reported complete success, confirmed by VCMG. Three patients (21%) reported improvement with >50% reduction in the use of pads. The procedure failed completely in six patients (43%). No immediate or late complications were noted with the procedure. CONCLUSIONS: The use of PDS is a safe and minimally invasive treatment for genuine stress urinary incontinence in males following SCI with a stable compliant bladder. We achieved complete cure in 36% of our patients with confirmation on VCMG. A further 21% reported greater than 50% reduction in usage of pads; however, on VCMG stress incontinence was demonstrated in these patients. We suggest that PDS can be used as the first line of treatment in this difficult group of patients with complex problems.     

A urethral stent for the treatment of detrusor-striated sphincter dyssynergia

OBJECTIVE: To assess the technique, efficacy and complications of the Ultraflex urethral stent (Boston Scientific Corp., Boston, MA) for the treatment of detrusor-striated sphincter dyssynergia (DSD). PATIENTS AND METHODS: Forty consecutive patients with DSD who had a Ultraflex stent placed in the membranous urethra were evaluated prospectively. DSD was caused by spinal cord injury in 30, multiple sclerosis in six and other neurological diseases in four. All patients were either tetraplegic or paraplegic and unable to use intermittent self-catheterization. Previous bladder management consisted of an indwelling catheter in 15 patients, chronic suprapubic catheters in two, intermittent catheterization in nine, and trigger reflex micturition in 14. The Ultraflex stent was placed under local anaesthesia. The stents were 50 mm long in 36 patients, 45 mm in two and 40 mm in two. The mean (SD) follow-up was 16.9 (13. 8) months. RESULTS: The mean (SD) residual urine decreased from 245. 9 (117) mL before stenting to 65.2 (19.3) mL at 12 months afterward (n = 19). One stent was removed at 13 months for chronic prostatic and urinary tract infection leading to autonomic dysreflexia. There was no stent stenosis and 17 of 18 stents had > 75% epithelial coverage at one year. None of the stents migrated. Seven patients underwent secondary bladder neck incision through the stent. The stent length was increased in four patients using a second overlapping distal stent, twice during the first procedure and twice within 6 months because the sphincter was inadequately covered. CONCLUSIONS: The Ultraflex stent achieved the expected results for a prosthetic sphincterotomy and appears to be an appropriate but less invasive treatment for DSD.     

Thermo-expandable Intra-prostatic Stent in the Treatment of Acute Urinary Retention in Elderly Patients with Significant Co-morbidities

We assess the use of thermo-expandable intra-prostatic stent (Memokath, Engineers and Doctors A/S, Denmark) for the treatment of acute urinary retention (AUR) in men with significant co-morbidities for transurethral resection of prostate (TURP). We evaluate the pre- and post-operative complications, duration of stents in-situ and patients quality of life after the stent insertion. Patients with significant co-morbidities presenting with AUR were selected, who were unfit for TURP. The co-morbidities included ischaemic heart disease, congestive heart failure, and chronic obstructive pulmonary disease. The exclusion criteria were bladder tumour and atonic bladder. The Memokath stents were inserted using a flexible cystoscope under local anaesthesia. The patients were followed up at 3 and 6 months after the procedure and the ones who remained alive were asked to complete self-administered questionnaires and IPSS scores. Fifteen men with acute urinary retention were recruited for stent insertion with the mean age of 87 years. No peri-operative complications were recorded. Three patients died after the insertion with functional Memokath in-situ. Nine patients had good functioning stents post-operatively, and remain catheter free up to 30 months after the procedure. The mean duration of stent life was 18 months. Three long-term complications were detected, including stent migration and prostate overgrowth. The Memokath is a good option for frail elderly patients presenting with AUR. The procedure is safe and has minimal long term complications. The stent also provides a sustained good quality of life for patients and avoids the necessity of long term catheterisation.     

The mesh wallstent in the treatment of detrusor external sphincter dyssynergia in men with spinal cord injury: a 12-year follow-up

OBJECTIVE: To assess the long-term effectiveness of the UroLume trade mark wallstent (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in quadriplegic patients. PATIENTS AND METHODS: Twelve patients with quadriplegia secondary to spinal trauma underwent external striated sphincter stenting with the UroLume wallstent instead of an external sphincterotomy for DESD (mean age 41.8 years, range 26-65). The level of injury was C4 in two, C5 in four, C6 in four, C7 in one and T6 in one. All patients were shown by preoperative video-cystometrography (VCMG) to have DESD and high-pressure, hyper-reflexic bladders with incomplete emptying. RESULTS: Seven of the 12 patients had a mean (range) follow-up of 12.7 (12.17-13.6) years; two others were lost to follow-up at 1 and 3 years and both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within a year of insertion. Another patient with an adequately functioning stent died 7 years after surgery (chest infection). Urodynamic follow-up of the seven patients showed a significantly sustained reduction in maximum detrusor pressure and duration of detrusor contraction at> 10 years of follow-up. Five of the seven patients developed bladder neck dyssynergia of varying degrees, as shown on VCMG; all were successfully treated with bladder neck incision. There were no problems with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. CONCLUSION: Permanent urethral stenting using the UroLume wallstent is effective in managing DESD and provides an acceptable long-term alternative to sphincterotomy. Subsequent bladder neck dyssynergia is the main complication but this can be managed successfully with bladder neck incision. Importantly, unlike sphincterotomy, there is no significant interference with erectile function. Also, the procedure is reversible, minimally invasive and requires a shorter hospital stay.     

Feasibility of a temporary urethral stent through the striated sphincter in patients in the early phase (6 months) of spinal cord injury

OBJECTIVE: To assess the feasibility of a temporary urethral stent through the striated sphincter in patients in the early phase (before 6 months) of spinal cord injury (SCI) in a department of neurological rehabilitation. METHODS: Fourteen consecutive men with SCI with urinary retention within 6 months after SCI were prospectively treated. Thirteen patients were tetraplegic (C2 to C7) and 1 was paraplegic. All patients were managed with indwelling catheters (10) or intermittent catheterization (4). The Nissenkorn polyurethane urethral stent was inserted across the external sphincter under local anesthesia for an anticipated 4-month duration. RESULTS: No perioperative complications were encountered. Hospital mean stay at the urological department was 1.9 days (range 1-4 days). All patients had good emptying of the bladder (residual urine less than 100 ml) and were free of all types of catheterization. Five stents had to be repositioned in the first 2 weeks, 1 was removed for obstruction at 2.5 months. There was no lithiasis, no upper urinary tract alteration, no symptomatic infection nor local discomfort during follow-up. At a mean of 3.7 months after implantation, 10/14 (71.5%) patients chose sphincterotomy by permanent urethral stent and 4 had stent removal for learning of self-intermittent catheterization (3) and indwelling catheter (1). CONCLUSIONS: The temporary sphincter stent is a new, feasible and reversible technique to manage neuropathic bladder dysfunction in the early phase after SCI. A randomized study on intermittent catheterization should be conducted. It should consider patients' and nursing caregivers' evaluations.     

Intraurethral stent prosthesis in spinal cord injured patients with sphincter dyssynergia

This study is an analysis of the Memotherm prosthesis in spinal cord injured patients with Detrusor-external sphincter dyssynergia (DESD). Twenty-four patients were evaluated urodynamically before and after placement of the intraurethral stent prosthesis. All the patients had been chronically managed with an indwelling urinary catheter, intermittent catheterization or condom catheters. Sixty-six per cent had history of recurrent urinary tract infection, 37% had symptoms of autonomic dysreflexia. Nine patients had previous external sphincterotomy. Follow-up ranged from 3 39 months (mean 15.4 months). After stent insertion all patients were able to achieve spontaneous reflex voiding with the use of condom catheter. Postoperative urodynamics parameters bladder leak point pressure and residual urine volume decreased significantly after stent insertion. Stent insertion was accomplished without any operative complications. In four patients stent migration (16%) required telescoping a new system over the migrated stent. In two patients the stent was removed because of problems of infection and calculus formation. In conclusion, this system (Memotherm) is an attractive, and potentially reversible treatment for DESD in SCI patients.     

An Airway Wallstent for the treatment of tracheobronchial malignancies.

BACKGROUND: The palliative effect of a new Airway Wallstent with a polyurethane covering was tested in patients with inoperable malignant lesions of the central airways. METHODS: Thirty six stents were inserted in 27 patients with obstruction (n = 24) or fistulae (n = 3), 15 of whom later received radiotherapy. The degree of symptom relief was assessed 1, 30, and 90 days after stent insertion. RESULTS: Stent deployment was successful in all patients. Significant improvements were observed one day after placement compared with before placement, with no change at 30 and 90 days, in dyspnoea index (mean (SD) 3.2 (0.7) before stent insertion compared with 1.8 (0.7) one day after insertion); Karnofsky index (32 (18) before insertion compared with 55 (15) one day after insertion); and obstruction of airway diameter (85 (11)% before insertion compared with 10 (12)% on day 1 after stent insertion). Stent-related complications needing later interventions included retained secretions (five patients), granuloma formation at ends of the stent (four patients), and stent migration (four patients). Over a median observation period of two months (range two days to 8.5 months) all stent coverings remained intact without delamination or tumour ingrowth. CONCLUSIONS: The Airway Wallstent provided excellent palliation for malignant obstructions and fistulae of the central airways. Retention of secretions and granuloma formation at the ends of the stent warrant minor technical improvements.     

The thermo-expandable metallic stent for managing benign prostatic hyperplasia: a systematic review

OBJECTIVES: To systematically review published reports of the safety, effectiveness and durability of a self-expanding metallic prostatic stent (Memokath, Engineers & Doctors A/S Ltd., Denmark) in patients with benign prostatic hyperplasia (BPH) who are unfit for surgery. METHODS: We systematically searched the Medline and Embase databases from 1992. The reference lists of included studies and the bibliographies of review articles were also searched. We contacted the manufacturer of Memokath for additional information. The primary outcomes were treatment failure (stent removal, replacement or repositioning) and urological symptom scores. Secondary outcomes were urodynamic indices and minor complications. Two reviewers independently assessed the methodological quality of the studies and extracted data. Data were synthesized using narrative techniques. RESULTS: In all, 14 case series described the use of the Memokath stent in 839 men with BPH. All patients were at high operative risk. Most studies were of poor quality with an inadequate follow-up. Treatment failure rates were 0-48% but the duration of follow-up was often unclear. Five studies reported International Prostate Symptom Scores and found reductions of 11-19 points after stent insertion. All seven studies that reported on maximum urinary flow rates found that these increased, and the four that described residual urine volumes found that these decreased. Minor complications were inconsistently reported. CONCLUSIONS: The Memokath stent can provide an effective treatment for BPH in men at high operative risk; it also appears to be safe, but inadequate follow-up does not allow firm conclusions on stent durability.     

良性前列腺增生患者膀胱出口梗阻及逼尿肌收缩强度对剩余尿的影响

目的　探讨良性前列腺增生 (BPH)患者膀胱出口梗阻 (BOO)及逼尿肌收缩强度与剩余尿的关系。　方法　应用尿动力学方法检测 181例BPH患者BOO情况和逼尿肌收缩强度 ,以导管法结合膀胱灌注量与排出量之差确定剩余尿 ,对相互关系进行统计学分析。　结果　 181例患者剩余尿量 0～ 2 0 0ml。逼尿肌收缩强度减弱 ,剩余尿量增多 (F =12 .14 3,P =0 .0 0 1) ;BOO加重 ,剩余尿量无明显改变 (F =2 .386 ,P =0 .0 71)。 2 5例 (13.8% )患者逼尿肌收缩强度减弱或正常时仍有较多剩余尿(>10 0ml)。　结论　剩余尿增多主要由逼尿肌收缩强度减弱所致 ,而随着BOO加重 ,剩余尿量无明显变化     

Management of Sphincter Dyssynergia Using the Sphincter Stent Prosthesis in Chronically Catheterized SCI Men

Abstract

This effort represents a subset analysis of the long-term Multicenter North American Trial of the UroLume sphincter stent prosthesis to determine the effect of the sphincter stent prosthesis in SCI men afflicted with detrusor-external sphincter dyssynergia (DESD) and chronically managed with an indwelling urinary catheter. Forty-one of 153 male patients in this study were evaluated urodynamically before and after placement of the sphincter stent prosthesis. Of the 41 patients, 34 (81 percent) suffered cervical-level injury while 10 patients (25 percent) had been treated previously with external sphincterotomy. Forty patients (98 percent) were troubled with recurrent urinary tract infections (UTI), with a mean of 4.6±3 episodes of UTI per year. Seven patients (17 percent) demonstrated hydronephrosis prior to stent placement.

Follow-up ranged from six to 44 months. Voiding pressures decreased from a mean of 77±23 cmH20 preoperatively to 35±18 cmH20 at 12 months (n=34) and 33±20 cmH2Û at 24 months (n=22) after stent insertion (p=0.001). Post-void residual urinary volume decreased from 202±187 ml preinsertion to 64±69 ml at 24 months (p=0.001) postinsertion. Maximum cystometric capacity remained constant at 201 ±144 ml preinsertion to 203±79 ml at 24 months (p=0.75) postinsertion. No significant changes in any of the urodynamic parameters occurred after 24 months of follow-up between patients with (n=10) and without (n=31) previous external sphincterotomy.

Neither hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth, stent encrustation or stone formation, nor soft tissue erosion occurred in any patient. No deleterious effects were observed on erectile function. Hydronephrosis resolved in four, and improved in three, of seven patients with hydronephrosis preoperatively. Eighty-two percent of the patients demonstrated complete stent epithelialization after six months, while 96 percent were epithelialized two years after stent insertion. In three patients, stent migration required repositioning or removal within the first month. In another two patients, the stent prostheses were removed one year postinsertion because of problems with condom catheter drainage.

The sphincter stent prosthesis is an attractive, potentially reversible treatment option for DESD in men managed with an indwelling catheter, even if external sphincterotomy has been performed previously. (J Spinal Cord Med;] 8:88–94)     

Ease of removal of thermo-expandable prostate stents

OBJECTIVE: To report the ease of removal of the Memokath 028 prostatic stent (Engineers & Doctors A/S, Hornbaek, Denmark), an important attribute of the 'ideal' prostatic stent. PATIENTS AND METHODS: Data on patients who had had a Memokath 028 stent removed in three different centres in Europe over an 8-year period were collected retrospectively. Standardized forms were used to record relevant information from each physician's patient files. RESULTS: Ninety-three patients had their stents removed at the three reporting centres; the mean indwelling time of their stent was 12.9 months, and most stents were inserted for symptomatic benign prostate disease. Reasons for removal included recurrent outlet or storage-type urinary symptoms, migration of the stent, stent-related pain, recurrent urosepsis and detrusor failure. The stents were removed on a day-case basis in 32% of patients. Topical anaesthesia or no anaesthesia was used in 48%. Of these patients, only 9% described moderate discomfort or worse. The procedure took a mean of 11 min and was felt to be easy or fairly easy in 90% of patients. CONCLUSIONS: These data show the ease of removal of the Memokath 028 stent, reinforce its overall success in achieving the requirements of the ideal intraprostatic stent, and further emphasize the advantages of this implant over the epithelializing, permanent intraprostatic stent.     

SPHINCTERIC STENT VERSUS EXTERNAL SPHINCTEROTOMY IN SPINAL CORD INJURED MEN: PROSPECTIVE RANDOMIZED MULTICENTER TRIAL

PURPOSE: In a prospective randomized multicenter trial we compared the treatment results of conventional external sphincterotomy with those of UroLume sphincteric stent prosthesis placement in men with spinal cord injury and external detrusor-sphincter dyssynergia. MATERIALS AND METHODS: We randomized 57 men with spinal cord injury in whom urodynamics verified external detrusor-sphincter dyssynergia into 2 groups to undergo either sphincter defeating procedure. We compared the primary urodynamic parameter of maximum detrusor pressure, and secondary urodynamic parameters of bladder capacity and post-void residual urine volume in men who underwent sphincterotomy or sphincteric stent placement. Parameters were measured preoperatively, and 3, 6, 12 and 24 months postoperatively. Patients completed questionnaires regarding voiding sensation and quality of life issues at each followup visit. RESULTS: Demographic data of the 26 patients treated with sphincterotomy and the 31 treated with sphincteric stent placement were statistically similar. Preoperatively mean maximum detrusor pressure plus or minus standard deviation in sphincterotomy and stent cases was 98.3 +/- 27.6 and 95.7 +/- 27.7 cm. water, respectively (p = 0.73). At 12 months mean maximum detrusor pressure decreased to 48.9 +/- 16.4 and 52.6 +/- 31.6 cm. water in the sphincterotomy and stent groups, respectively (p = 0). Preoperatively mean bladder capacity in sphincterotomy and stent cases was 245 +/- 158 and 251 +/- 145 ml., respectively (p = 0.87). Bladder capacity did not change significantly in either treatment group throughout followup. Preoperatively mean post-void residual urine volume in the sphincterotomy and stent groups was 212 +/- 163 and 168 +/- 114 ml., respectively (p = 0.33). Residual urine volume decreased in each group at some but not all followup evaluations. The duration of hospitalization was greater for sphincterotomy than stenting (p = 0.036). Six stents required explantation. CONCLUSIONS: The UroLume stent is as effective as conventional external sphincterotomy for treating external detrusor-sphincter dyssynergia. However, sphincteric stent placement is advantageous because it involves shorter hospitalization and is potentially reversible.     

Urethral stent for the treatment of detrusor-sphincter dyssynergia: evaluation of the clinical, urodynamic, endoscopic and radiological efficacy after more than 1 year

PURPOSE: We studied the intermediate-term clinical, urodynamic, endoscopic and radiological efficacy of the Ultraflex urethral stent (Boston Scientific Co., Boston, Massachusetts) for the treatment of detrusor-sphincter dyssynergia (DSD) in spinal cord injured patients. MATERIALS AND METHODS: A total of 47 consecutive men presenting with DSD due to spinal cord injury (39) or various spinal cord diseases (9) were treated with the Ultraflex stent. DSD was demonstrated by urodynamic assessment with electromyographic recording of the striated urethral sphincter muscle activity. RESULTS: Postoperatively, all patients voided by reflex. The number of patients with symptomatic postoperative urinary tract infection decreased significantly (p <0.001). Urodynamic assessment (mean followup +/- SD 2.2 +/- 1.3 years) showed reduction of mean peak detrusor pressure from 65.7 +/- 27.8 to 46.4 +/- 28.8 cm H2O (p <0.005) and reduction of mean residual urine from 231.6 +/- 168.1 to 70.3 +/- 85.6 ml (p <0.0005). Mean urethral closing pressure was markedly reduced from 73.9 +/- 40.9 to 23.8 +/- 25.1 cm H2O (p <0.0005). Mean endoscopic followup was 1.7 +/- 1.1 years. Mean percentage of epithelialization was 90.8% +/- 19.7%, and no obstructive granulation tissue or stone encrustation was observed inside the stent. On ultrasound signs of hydronephrosis persisted in only 1 of 8 patients. There were no immediate postoperative complications. Complementary bladder neck incision was performed in 21% of patients. CONCLUSIONS: The Ultraflex stent appears to be effective for intermediate-term treatment of DSD on the basis of clinical, urodynamic, endoscopic and radiological parameters.     

Experience with the memotherm stent in high-risk urinary retention patients

PURPOSE: We report on our experience with the Memotherm stent implanted in high-risk patients who had an indwelling catheter. PATIENTS AND METHODS: Seventeen patients (mean age 80.6 years, range 55 to 93) who had an indwelling catheter were treated by placement of the Memotherm stent. The mean duration time of indwelling catheter were 12.7 months (range 1 to 60). The methods of implantation was used the special delivery system and treatment can be done with the patient under local anesthesia with non-steroidal anti-inflammatory drug. To assess the efficacy of the treatment we measured urinary peak flow rate (ml/sec), residual urine volume (ml) and residual urine rate (residual urine volume/total urine volume: %). Subjective symptoms were evaluated using the International Prostate Symptom Score (I-PSS). The mean follow-up time was 3.3 months (range 1 week to 8 months). RESULTS: There were no severe medical problems associated with stent placement. Sixteen patients were able to void immediately after insertion of the stent. The remaining 1 required an indwelling catheter to 2 months, however, eventually able to void. Only 7 of the 17 patients can be evaluation for urinary flow and residual urine, nevertheless the mean urinary peak flow rate showed 9.7 ml/sec, the mean residual urine volume was 77.4 ml, and the mean residual urine rate was 27.5%. Also, average I-PSS showed 13.4 in these patients. CONCLUSIONS: As a results of this study, the Memotherm stent is good conservative therapy for high-risk urinary retention patients.     

Long-term urological outcomes in paediatric spinal cord injury

STUDY DESIGN: Retrospective review. OBJECTIVE: This retrospective review observes the evolution of bladder management by time and reports adult urological outcomes and complications in paediatric onset spinal cord injury (SCI). SETTING: Spinal Injuries Unit RNOH Stanmore. METHOD: In total, 10 traumatic SCI patients with mean age at injury of 13.6 years underwent treatment, for a mean period of 13.1 years. Characteristics of injury were noted. Two diagnostic subgroups, neurogenic detrusor overactivity (NDO), and acontractile detrusor were made. Complications, treatment changes, operative procedures with follow-up were noted. RESULTS: In group 1 (6/10 patients) with NDO, five had DSD. Initial bladder management was reflex/urge voiding (n=4), suprapubic catheterisation (SPC), (n=1) and self-intermittent catheterisation (SIC), (n=1). Two patients had multiple upper tract complications with decreased renal function, two recurrent symptomatic urinary infections and one; bladder calculus. In total, 12 operative procedures were performed to treat complications and change bladder management to, SIC+oxybutynin (n=3), ileal conduit (n=1), sacral anterior root stimulator implant (SARSI), (n=1), voiding on urge (n=1). In group 2 (4/10 patients) with a-contractile detrusor two had low compliance. Initial bladder management was SIC (n=3) and voiding on urge/straining (n=1). Two patients converted from SIC to permanent catheter drainage and reported complications. Incidental kidney stone was diagnosed in one. A total of four interventions were carried out with final management of SIC (n=2), voiding on urge/straining (n=1) and Mitrofanoff+ileocystoplasty (n=1). CONCLUSION: Bladder management in paediatric SCI is dependent on neurological level and type of injury; it changes with growth and is affected by changes in bladder management.     

Artificial urinary sphincter insertion in congenital neuropathic bladder

A series of 44 patients with neuropathic bladder dysfunction due to congenital myelodysplasia underwent implantation of an artificial urinary sphincter (AUS); in 26 patients a reconstructive procedure was performed at the same time. Five patients who initially had AUS implantation alone developed detrusor hyper-reflexia and required a clam cystoplasty. Forty patients (90%) are continent, 2 are occasionally damp and 2 are wet and awaiting further surgery; 66% of patients who underwent AUS insertion and reconstruction were found to have significant residual urine and they perform intermittent self-catheterisation (ISC). In patients with a good bladder capacity and normal compliance and detrusor hyper-reflexia controlled by anticholinergic drugs, cystoplasty is not necessary at the time of AUS insertion.