Electroestimulación del nervio tibial posterior para el tratamiento de la vejiga hiperactiva. estudio prospectivo y controlado

The aim of this study was to evaluate the efficacy of the Posterior Tibial Nerve stimulation in women with overactivity bladder symptoms and the impact in the quality of life using the Overactivity Bladder Questionnaire (OABq).Methodsthirty seven women from female urology outpatient clinic of the Hospital das Clínicas de Campinas (HC/UNICAMP) were enrolled in this prospective, controlled and randomized clinical trial. The patients were randomly placed in one of two groups:Treatment grouppatients were submitted to tibial posterior nerve electrical stimulation (n=21) and Sham group: patients had electrodes placed without electricity (n = 16). After informed consent the patients underwent a physiotherapeutic evaluation, that included voiding diary and the overactivity bladder questionnaire(OABq). The treatment schedule included eight sessions of electrical stimulation in the posterior tibial nerve, twice a week.Resultsthere were significant changes in symptoms such as frequency and nocturia (p=0,003 e p=0,001). The urgency and quality of life was improved in both group after treatment.ConclusionThe posterior tibial nerve electrical stimulation is an effective treatment in overactive bladder.     

Efficacy and Safety of Sacral and Percutaneous Tibial Neuromodulation in Non-neurogenic Lower Urinary Tract Dysfunction and Chronic Pelvic Pain: A Systematic Review of the Literature

ContextNeuromodulation is considered in patients with non-neurogenic lower urinary tract dysfunction (LUTD) not responsive to conservative treatment.ObjectiveTo systematically review the available studies on efficacy and safety of sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) in non-neurogenic LUTDs not responsive to conservative treatments.Evidence acquisitionA literature research was conducted in PubMed/Medline and Scopus, restricted to articles in English, published between January 1998 and June 2017, with at least 20 patients and 6 mo of follow-up.Evidence synthesisTwenty-one reports were identified. Concerning SNM, the improvement of ≥50% in leakage episodes ranged widely between 29% and 76%. Overall dry rate ranged between 43% and 56%. Overall success/improvement rate in PTNS varied between 54% and 59%. Symptom improvement or efficacy in interstitial cystitis/bladder pain syndrome patients appeared to be lower compared with other indications in both techniques. Safety data showed fewer side effects in patients submitted to PTNS.ConclusionsNeuromodulation gives good results and is a safe therapy for patients with overactive bladder or chronic nonobstructive urinary retention with long-lasting efficacy. Moreover, PTNS has been shown to have good success rates and fewer side effects compared with SNM. These data have to be confirmed with long-term follow-up.Patient summarySacral neuromodulation can improve low urinary tract symptoms in selected patients; it appears to be a safe therapy for nonresponders to standard medical therapies. Percutaneous tibial nerve stimulation (PTNS) is a less invasive technique that gives good results in short time with fewer side effects. However, we must consider that PTNS has not been tested in the long term and results are lower if compared with SNM.     

Novel technique to enhance bladder neck dissection with traction of Foley catheter during extraperitoneal laparoscopic radical prostatectomy

BackgroundLaparoscopic radical prostatectomy (LRP) is a challenging technique that is associated with a steep learning curve. We describe a novel technique to develop bladder neck traction using a Foley catheter during extraperitoneal LRP to enhance bladder neck dissection, thereby improving patient and procedural outcomes.Materials and methodsThe novel technique employed a four-trocar approach to prostatectomy, which involved the introduction of a 1-0 Vicryl suture into the extraperitoneal space using an Endo Close needle to pull up the Foley catheter tip and make the bladder neck prominent. From June 2006 to November 2012, clinicopathological data of 71 patients who underwent four-port extraperitoneal LRP (modified extraperitoneal LRP, Group 1) were assessed and compared with those from 22 patients who underwent transperitoneal LRP (Group 2) retrospectively.ResultsThe two groups were comparable in terms of pathological staging and Gleason score. The operative time was significantly shorter (p < 0.05) and the total blood loss was less in Group 1 patients (p < 0.05). No patient in either group underwent early reintervention for bleeding or blood transfusion. Bilateral or unilateral nerve sparing surgery was performed in 80.3% and 45.5% of Group 1 and Group 2 patients, respectively. The immediate, 1 month, 3 month, 6 month, and 1 year continence rates were, respectively, 19.7%, 38%, 69%, 91.5%, and 100% in Group 1 and 18.2%, 50.0%, 77.3%, 86.4%, and 95.5% in Group 2. In Group 1, 100% of patients were continent 12 months postprocedure. The potency rate was 71.4% in both groups.ConclusionImproved bladder neck enhancement provides a clearer vision during bladder neck dissection. Similar functional results and cancer control rates were also encountered during modified extraperitoneal radical prostatectomy. This novel technique is a feasible method for performing endoscopic radical prostatectomy using four ports instead of five.     

Inhibition of bladder overactivity by stimulation of feline pudendal nerve using transdermal amplitude-modulated signal (TAMS)

What's known on the subject? and What does the study add? It is known that direct stimulation of pudenal nerve using a cuff electrode can inhibit normal bladder activity. This study further indicates that overactive bladder activity can be inhibited using non‐invasive skin surface electrodes and a transdermal amplitude‐modulated signal (TAMS).

OBJECTIVE

• ? To develop a non‐invasive neuromodulation method targeting the pudendal nerve.

MATERIALS AND METHODS

• ? Bladder overactivity induced by acetic acid (AA) irritation was partially suppressed by electrical stimulation of the pudendal nerve in α‐chloralose anaesthetized cats using a transdermal amplitude‐modulated signal (TAMS).

RESULTS

• ? During cystometrography (CMG), intravesical infusion of 0.25% AA significantly decreased the mean (se ) bladder capacity to 28.8 (5.9)% of the capacity measured during saline infusion.
• ? The TAMS stimulation inhibited AA‐induced bladder overactivity at 5, 7 and 10 Hz, and significantly increased the mean (se ) bladder capacity to 61.8 (9.9)%, 51.3 (14.5)%, 53.6 (14.9)%, respectively, of the control capacity during saline infusion, whereas stimulation at 20–40 Hz had no effect.
• ? Under isovolumetric conditions at a bladder volume ranging between 130 to 160% of the bladder capacity measured during AA infusion, TAMS stimulation at all frequencies (5–40 Hz) significantly suppressed the irritation‐induced rhythmic bladder contractions, reduced the area under the bladder pressure curve, and decreased the frequency of bladder contractions. However, the amplitude of rhythmic bladder contractions was only significantly decreased at stimulation frequencies of 5–20 Hz.
• ? At bladder volumes above the AA control capacity, TAMS stimulation with frequencies of 20–30 Hz had an excitatory effect, resulting in large amplitude (>25 cmH₂O) bladder contractions.

CONCLUSIONS

• ? TAMS stimulation targeting the cat pudendal nerve can inhibit C‐fibre afferent‐mediated bladder overactivity.
• ? Thus, clinical research seems warranted to explore the usefulness of this technology for patients with overactive bladder symptoms.

     

Electrical Stimulation of the Urethra Evokes Bladder Contractions in a Woman With Spinal Cord Injury

Abstract

Objective: Electrical stimulation of pudendal urethral afferents generates coordinated micturition in animals and bladder contractions in men after spinal cord injury (SCI), but there is no evidence of an analogous excitatory urethra-spinal-bladder reflex in women. The objective of this study was to determine whether electrical stimulation of the urethra could evoke bladder contractions in a woman with SCI.

Case Report: A 38-year-old woman with a C6 ASIA A SCI who managed her bladder with clean intermittent catheterization and oxybutynin demonstrated neurogenic detrusor overactivity on urodynamics. Oxybutynin was discontinued 2 days prior to urodynamic testing with a custom 12F balloon catheter mounted with ring-shaped electrodes located in the bladder neck, mid urethra, and distal urethra. The inflated balloon was placed against the bladder neck to stabilize the catheter electrodes in place along the urethra. However, the balloon limited emptying during contractions. Urodynamics were performed at a filling rate of 25 mL/minute until a distention-evoked bladder contraction was observed. The urethra was stimulated over a range of bladder volumes and stimulus parameters to determine whether electrical stimulation could evoke a bladder contraction.

Findings: Electrical stimulation via urethral electrodes evoked bladder contractions that were dependent on bladder volume (>70% capacity) and the intensity of stimulation.

Conclusions: This is the first report of an excitatory urethra-spinal-bladder reflex in a woman with SCI. Future studies will determine whether this reflex can produce bladder emptying.     

Beyond Antimuscarinics: A Review of Pharmacological and Interventional Options for Overactive Bladder Management in Men

ContextThe role of overactive bladder (OAB) treatment in women beyond antimuscarinics has been evaluated extensively. Beta-3 agonists, botulinum toxin-A (BTX-A), and nerve stimulation are indicated in these patients. However, data on male patients in this clinical scenario are scarce.ObjectiveThe aim of this systematic review was to evaluate the evidence on treatment options beyond antimuscarinics in men with OAB.Evidence acquisitionA search of PubMed, EMBASE, Scopus, Web of science, Cochrane Central Register of Controlled Trials, and Cochrane Central Database of Systematic Reviews databases was performed for relevant articles published between January 2000 and October 2020, using the following Medical Subject Headings: “male/man,” “LUTS,” “overactive bladder,” “storage symptoms,” “urgency,” “nocturia,” “incontinence,” “beta-3 agonist,” “PDE-5 inhibitors,” “botulinum toxin,” “sacral nerve stimulation/neurostimulation,” “percutaneous/transcutaneous tibial nerve stimulation,” “PTENS,” and “combination therapy.” Evidence acquisition was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PROSPERO registration number is CRD42020201223.Evidence synthesisOverall, 24 studies were retrieved. In male OAB, mirabegron (MIRA) is the most intensively investigated pharmacological option. A pooled analysis of five randomized clinical trials (RCTs), including 1187 patients, concluded that MIRA 50 mg was associated with a greater reduction in frequency versus placebo (–0.37, 95% confidence interval [CI]: –0.74, –0.01, p < 0.05). A pooled analysis of three RCTs, including 1317 male patients, has also shown that the addition of MIRA 50 mg in men receiving the α₁-blocker tamsulosin improved the mean number of micturitions per day (–0.27, 95% CI: –0.46 to –0.09, p < 0.05), urgency episodes (–0.50, 95% CI: –0.77 to –0.22, p < 0.05), total OAB symptom score (–0.66, 95% CI: –1.00 to –0.38, p < 0.05), and mean volume voided (+10.76 ml, 95% CI: 4.87–16.64, p < 0.05). MIRA treatment is well tolerated in men. Other pharmacological treatment options, such as phosphodiesterase-5 (PDE-5) inhibitors, should be considered investigational. BTX-A seems to be effective as third-line treatment in male OAB patients. A higher rate of intermittent self-catheterization (5–42%) is observed in male than in female patients. Data on nerve stimulation are scarce.ConclusionsMIRA has the most robust data in terms of safety and efficacy in this patient population. Preliminary data in men suggest that BTX-A is indicated as an interventional treatment. Evidence for PDE-5 inhibitors and nerve stimulation is too limited to provide recommendations. Future studies in this population should aim to better define the best treatment sequence and to identify predictors for treatment response and failure, to determine a therapeutic approach tailored to patients’ characteristics.Patient summaryOveractive bladder is highly prevalent in men. Mirabegron 50 mg is the treatment option supported by the highest level of evidence when antimuscarinics failed. Botulinum toxin A injections seems to be an effective treatment as interventional option. Roles of nerve stimulation and phosphodiesterase inhibitors in male OAB patients are still to be defined.     

Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques

Study ObjectiveTo investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop.DesignRandomized-prospective, observational study.SettingUniversity surgical center.Patients100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm.InterventionsPatients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location.MeasurementsData were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia.Main ResultsNo differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 ± 1.2 vs 1.5 ± 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 ± 2.9 vs 2.2 ± 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery.ConclusionsIn trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.     

Peripheral nerve stimulation in the treatment of various types of headache

Background and objectiveHeadache has a great impact on patients quality of life and in industrialized countries there is economic impact as well. One of the pathophysiologic theories to explain headache is activation of afferent C2-C3 nerve fibers. Afferent peripheral nerve stimulation by occipital nerve provocation at C2-C3 seems to alleviate headache by acting on the trigeminocervical complex, which would largely explain the effectiveness of this modality. The aim of this study was to describe peripheral nerve stimulation as an alternative therapy in patients who do not respond to other headache treatments.Material and methodsMulticenter retrospective study between April 2005 and May 2009, analyzing cases of patients treated with nerve stimulation for severe chronic headache. In all patients the medical history included type of headache, intensity of pain on a numerical scale, medical treatment used, and number of headache episodes. We recorded the percentage of patients with negative tests. Patients implanted with a generator assessed effectiveness on the numerical scale; we analyzed the percentage of perceived improvement at 1, 3, 6, and 12 months. We also analyzed the extent of coverage provided by the electrodes, patient satisfaction, reduction in the number of episodes and medication, and complications.ResultsOf 31 patients, 87% had positive results, with a significant decrease in pain from baseline (P <. 001); 85.2% reported sustained improvement of  >50%, and 96.3% reported a decrease of > 2 points on the pain scale. All patients expressed satisfaction during the period of follow-up. Fifty-six percent had no headaches after a year and 47% had stopped taking medication. The most frequent complication was electrode migration.     

超声引导下闭孔神经阻滞在经尿道膀胱肿瘤电切术中预防闭孔神经反射的效果

目的通过对比不同麻醉方式下闭孔神经反射的发生情况,探讨经尿道膀胱肿瘤电切术中预防闭孔神经反射的有效方式。方法选取需行经尿道膀胱肿瘤电切术的膀胱侧壁肿瘤患者160例,男134例,女26例,ASAⅠ~Ⅲ级,随机分为四组:全凭静脉麻醉组(G组),腰-硬联合麻醉组(C组),腰-硬联合麻醉复合静脉麻醉组(V组),腰-硬联合麻醉复合闭孔神经阻滞(obturator nerve block,ONB)组(O组),每组40例。记录不同麻醉方式下闭孔神经反射的发生情况。结果O组闭孔神经反射发生率(7.5%)明显低于C组(32.5%,P=0.005)和V组(40.0%,P=0.001),与G组闭孔神经反射发生率(5.0%)差异无统计学意义(P=0.644)。结论腰-硬联合麻醉复合闭孔神经阻滞与全凭静脉麻醉均可有效预防闭孔神经反射的发生。     

Stoller afferent nerve stimulation in woman with therapy resistant over active bladder; a 1-year follow up

Aim: In this prospective observational study, we investigated the efficacy of Stoller afferent nerve stimulation (SANS) in subjects with overactive bladder who failed anticholinergic treatment.Methods: Thirty-five subjects with overactive bladder who failed therapy with oxybutynin participated in this study. Treatment (n=35) was given once a week for 30 minutes for overall 10 weeks. In treatment, SANS device (Urosurge^®) was used. Subjects were assessed with 3-day voiding diary, SEAPI quality of life questionnaires and cystometry before therapy after completion of therapy and at one-year follow-up.Results: In 54% (n=19) of subjects complete recovery was obtained after treatment. Urgency and SEAPI were reduced significantly whereas urine volume increased significantly (p<0.01). Complete recovery was maintained in eight of the 19 subjects at one year.Conclusions: SANS treatment has a short-term positive effect in patients with resistant overactive bladder. However, it was also established that efficacy was maintained at 1 year in only 23% of subjects.     

Genital nerve stimulation is tolerable and effective for bladder inhibition in sensate individuals with incomplete SCI

Background: Neurogenic detrusor overactivity after spinal cord injury (SCI) causes urinary incontinence and reduces bladder capacity. Surface electrical genital nerve stimulation (GNS) acutely inhibits reflex bladder contractions. The stimulation amplitude selected for GNS is typically twice the amplitude that is required to evoke the pudendal-anal reflex. There is concern about the ability of persons with sensation to comfortably tolerate effective levels of GNS. The objective of this work is to determine if persons with incomplete SCI are able to tolerate acute GNS for bladder inhibition.

Methods: Twenty-four subjects with neurogenic detrusor overactivity, SCI, and pelvic sensation were enrolled in this case series. The setting was the Spinal Cord Injury Service of a Veterans Affairs Medical Center. Primary outcome measures were sensation threshold and tolerable stimulation amplitude; secondary outcome measures were bladder capacity and bladder contraction inhibition.

Results: GNS was tolerable up to 30±16?mA (range 8?mA to ≥60?mA) at amplitudes greater than twice the pudendal-anal (PA) reflex threshold, which was 8±5?mA (range 4?mA to 20?mA). Twelve subjects tolerated GNS at greater than twice the PA, six tolerated 1–1.5 times the PA, and five had no identifiable PA. GNS at tolerable amplitudes inhibited reflexive bladder contractions or increased bladder capacity 135±109?mL (n=23). GNS did not cause autonomic dysreflexia or intolerable spasticity.

Conclusions: GNS is tolerable at amplitudes that effectively inhibit neurogenic detrusor overactivity in individuals with pelvic sensation. GNS therefore is a tool with potential clinical applications for persons with preserved sensation.     

Micturition by Functional Magnetic Stimulation

Abstract

Effectiveness of functional magnetic stimulation (FMS) technology on bladder contraction and bladder emptying was evaluated in twenty-two spinal cord injured subjects. FMS of the bladder was performed by stimulating the sacral nerves or the suprapubic region using a commercially available magnetic stimulator with a round coil. With sacral stimulation, the mean change in bladder pressure (Pves) was 24.4±4.88 cm H2O; with suprapubic stimulation, the mean change in Pves was 16.5±4.44 cm H2O. The change in Pves with sacral stimulation was higher than with suprapubic stimulation (p<.01). Seventeen subjects demonstrated voiding, either with sacral or suprapubic stimulation. Using a water-cooled coil, one subject demonstrated complete bladder emptying. FMS of the bladder has the potential to be a useful non-invasive technology for bladder emptying and bladder training in patients with neurogenic bladders. (J Spinal Cord Med 1997;20:218-226)     

Direct Bladder Stimulation with Percutaneous Electrodes and Impedance Monitoring of Volume in an SCI Animal Model

Abstract

Bladder responses to percutaneous electrodes were investigated with stimulation in three male spinal cats. The animals had been spinalized (T1 level lesion) 10 weeks prior to these studies and had been instrumented with chronic bladder wall electrodes and suprapubic bladder catheters for filling and pressure recording. Percutaneous stimulation in tethered animals was conducted with hook electrodes inserted with a needle in the abdomen bilaterally adjacent to the bladder trigone. Stimulation was conducted with 40 Hz pulse trains of 10 to 30 mA for three seconds. Stimulation with both percutaneous and chronic electrodes induced high bladder pressures and voiding. In addition, with chronically implanted electrodes, impedance monitoring of bladder volume was found to be an effective recording technique. (J Spinal Cord Med; 18:98–102)     

Suppression of bladder overactivity by activation of somatic afferent nerves in the foot

What’s known on the subject? and What does the study add? It is known that electrical stimulation of the sacral root, pudendal nerve, or tibial nerve can inhibit bladder overactivity. These stimulation methods require surgery or repeated clinical visits that are expensive and inconvenient. This study shows for the first time that electrical stimulation of the foot can suppress bladder overactivity. Stimulation of the foot is non‐invasive, easily accessible, and convenient, which could be a widely acceptable treatment for bladder overactivity.

OBJECTIVE

To investigate the possibility of suppressing bladder overactivity by electrical activation of somatic afferent nerves in the foot.

MATERIALS AND METHODS

Cats with an intact spinal cord were studied under α‐chloralose anaesthesia. Bladder pressure was recorded via a urethral catheter. Foot stimulation was applied via surface pad electrodes attached to the skin of the front or hind foot.

RESULTS

Reflex micturition was inhibited by electrical stimulation of the hind foot at either low (5 Hz) or high (20 Hz) frequencies, but stimulation of the front foot was ineffective. The mean (sem ) bladder capacity during a saline infusion cystometrogram (CMG) was significantly (P < 0.05) increased to 153.2 (18.2)% and 136.9 (14.3)% of the control bladder capacity by stimulation at frequencies of 5 Hz and 20 Hz, respectively. Intravesical infusion of 0.25% acetic acid (AA) induced bladder overactivity and reduced bladder capacity to 20.3 (8.9)% of the control capacity measured during saline infusion. Foot stimulation inhibited the AA‐induced bladder overactivity recorded under isovolumetric conditions, and significantly (P < 0.05) increased bladder capacity during AA infusion. However, it only restored the small bladder capacity caused by AA irritation to 40–50% of the control bladder capacity measured during saline infusion. The effect of foot stimulation did not persist after termination of stimulation during repeated CMG tests.

CONCLUSIONS

This study shows the potential of noninvasive transcutaneous electrical stimulation of somatic nerves in the foot to inhibit reflex bladder activity and treat overactive bladder symptoms.     

Bilateral pudendal afferent stimulation improves bladder emptying in rats with urinary retention

Study Type – Therapy (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Previous study demonstrated that unilateral electrical stimulation of the proximal transected sensory pudental nerve during distention‐evoked voiding contractions significantly improved voiding efficiency. The current study extends previous study from unilateral (UniES) to bilateral (BiES) stimulation of pudental afferent nerve fibres to determine whether this approach further enhances the improved voiding efficiency (VE) that we reported previously which unilateral stimulation. Our results show in most instances BiES consistently generated more efficient bladder emptying than did UniES but these differences were not significant.

OBJECTIVE

• ? To determine whether bilateral electrical stimulation (BiES) of the transected pudendal sensory nerves could further enhance the voiding efficiency beyond that produced by unilateral electrical stimulation (UniES) of transected pudendal afferents in rats with urinary retention.

MATERIALS AND METHODS

• ? The efficiency of bladder emptying with either UniES or BiES of pudendal nerve afferents was measured after acute bilateral transection of the sensory branch of the pudendal nerve.
• ? The effects of UniES and BiES on voiding in a partially denervated bladder and acute spinal transection, respectively, were determined.

RESULTS

• ? The voiding efficiency (VE) was reduced from 69 to 22% after bilateral transection of the sensory branch of the pudendal nerve. UniES or BiES increased the VE to 49–62%.
• ? Although in most instances BiES consistently generated more efficient bladder emptying than did UniES, these differences were not significant.
• ? Both UniES and BiES increased VE after unilateral pelvic nerve transection, demonstrating efficacy in a partially denervated bladder.
• ? The enhancement of VE by either UniES or BiES was preserved after acute T₉–T₁₀, demonstrating the spinal origin of this augmenting reflex.

CONCLUSIONS

• ? The results of the present study are consistent with an essential role for pudendal sensory feedback in efficient bladder emptying, and unilateral and bilateral electrical activation of pudendal nerve afferents are equally efficient in improving bladder emptying in an animal model of urinary retention.
• ? This could provide an approach to improve bladder emptying in patients with non‐obstructive urinary retention.

     

Injection of botulinum toxin (BTX-A) in children with bladder dysfunction due to detrusor overactivity

Introductionbladder dysfunction causes urinary incontinence and kidney damage in children. When treatment with anticholinergics and intermittent bladder catheterization fails, the alternative therapy is bladder augmentation.Patients and methodsbetween 2005 and 2009, a prospective study was carried out with Botox^® injected into the detrusor of children suffering from high-pressure bladder despite anticholinergic treatment. We assessed their urodynamic, clinical and radiological evolution prior to and at 4 weeks, 6 months and 1 year after the injection (10 u/kg of weight up to 300 u). Reinjection was indicated in the event of clinical or urodynamic worsening. We employed the Wilcoxom test to statistically analyze the urodynamic parameters.Results12 patients were treated, 11 with neurogenic bladder (91.7%) and 1 with posterior urethral valves (8.4%). The mean age was 12.6 (4.3-17.8) years and follow-up took place after 40.8 (16.9-45-7) months. Bladder capacity, detrusor accommodation and pressure improved after 4 weeks in all the patients except in 2 (16.7%). This improvement decreased after 6 months, although successive injections produced similar changes. One patient (8.3%) received 1 dose, six (50%) two doses and five (41.7%) received three. Clinical and urodynamic improvement in 8 patients (66.7%) prevented bladder augmentation.Conclusionsrepeated botulinum toxin injection in the detrusor is a therapeutic instrument for high pressure and low accommodation bladders in children. It could replace bladder augmentation in some cases, however further studies with long-term follow-up care are required to appropriately evaluate its safety and effectiveness.     

Use of INFIX for managing unstable anterior pelvic ring injuries: A systematic review

IntroductionSubcutaneous screw rod system which is popularly known as Pelvic internal fixator (INFIX) has emerged as an alternative to external fixators in management of unstable pelvic injuries. INFIX has shown various advantages over external fixation such as reduced infection rate and patient morbidity. However, it has its own set of complications such as lateral femoral cutaneous nerve injury, heterotopic ossification, femoral nerve palsy etc. We intended to conduct a systematic review of the current literature to assess outcomes and complications with INFIX technique of fixation.MethodsA comprehensive search of literature was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and online database of EMBASE, PubMed, Medline and Scopus was searched for all studies in English language till March 2020. Included studies were reviewed for demographic data, fracture type/classification, radiological outcome and functional outcomes. The inclusion criteria were: 1. Studies in English language 2. Clinical studies reporting use of INFIX technique in pelvis fracture where clinical and radiological outcomes were reported.ResultsTwenty-two studies fulfilling inclusion and exclusion criteria were included in this systematic review with total of 619 patients. Radiographic parameters and outcome measures were infrequently reported. Fixation with INFIX in these fractures leads to 87% excellent to good radiological results and 84% excellent to good functional results. Complications include lateral femoral cutaneous nerve irritation (25.3%), heterotopic ossification (24.7%), infection (3%), and femoral nerve palsy (1.6%); which is likely related to placing the bar and screws too deep.ConclusionThis analysis supports the use of INFIX in management of unstable pelvis fractures where anterior fixation is required.     

Use of INFIX for managing unstable anterior pelvic ring injuries: A systematic review

IntroductionSubcutaneous screw rod system which is popularly known as Pelvic internal fixator (INFIX) has emerged as an alternative to external fixators in management of unstable pelvic injuries. INFIX has shown various advantages over external fixation such as reduced infection rate and patient morbidity. However, it has its own set of complications such as lateral femoral cutaneous nerve injury, heterotopic ossification, femoral nerve palsy etc. We intended to conduct a systematic review of the current literature to assess outcomes and complications with INFIX technique of fixation.MethodsA comprehensive search of literature was performed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and online database of EMBASE, PubMed, Medline and Scopus was searched for all studies in English language till March 2020. Included studies were reviewed for demographic data, fracture type/classification, radiological outcome and functional outcomes. The inclusion criteria were: 1. Studies in English language 2. Clinical studies reporting use of INFIX technique in pelvis fracture where clinical and radiological outcomes were reported.ResultsTwenty-two studies fulfilling inclusion and exclusion criteria were included in this systematic review with total of 619 patients. Radiographic parameters and outcome measures were infrequently reported. Fixation with INFIX in these fractures leads to 87% excellent to good radiological results and 84% excellent to good functional results. Complications include lateral femoral cutaneous nerve irritation (25.3%), heterotopic ossification (24.7%), infection (3%), and femoral nerve palsy (1.6%); which is likely related to placing the bar and screws too deep.ConclusionThis analysis supports the use of INFIX in management of unstable pelvis fractures where anterior fixation is required.     

Genital nerve stimulation increases bladder capacity after SCI: A meta-analysis

Background: Neurogenic detrusor overactivity (NDO) often results in decreased bladder capacity, urinary incontinence, and vesico-ureteral reflux. NDO can trigger autonomic dysreflexia and can impair quality of life. Electrical stimulation of the genital nerves (GNS) acutely inhibits reflex bladder contractions and can increase bladder capacity. Quantifying the effect of GNS on bladder capacity and determining what study factors and subject factors influence bladder capacity improvements will inform the design of clinical GNS interventions.

Methods: We measured bladder capacity in 33 individuals with NDO, with and without GNS. These data were combined with data from seven previous GNS studies (n=64 subjects). A meta-analysis of the increase in bladder capacity and potential experimental factors was conducted (n=97 subjects total).

Results: Bladder capacity increased 131±101?ml with GNS across subjects in all studies. The number of individuals whose bladder capacity was greater than 300?ml increased from 24% to 62% with GNS. Stimulus amplitude was a significant factor predicting bladder capacity gain. The variance of the bladder capacity gain significantly increased with increasing infusion rate. Other factors did not contribute to bladder capacity gain.

Conclusion: GNS acutely increases bladder capacity in individuals with NDO. The consistent increase in magnitude of bladder capacities across the eight studies, and the lack of dependence on individual-specific factors, provide confidence that GNS could be an effective tool for many individuals with NDO. Studies of the chronic effect of GNS on bladder control, with clinical measures such as urinary continence, are needed.     

A Spinal Cord Injured Animal Model of Lower Urinary Tract Function: Observations Using Direct Bladder and Pelvic Plexus Stimulation With Model Microstimulators

Abstract

Background: Microstimulators are new devices that should be considered for managementof lower urinary tract problems following spinal cord injury (SCI) such as urinary retention. These devices are small(less than 25 mm by 5 mm) with the electrodes located on the ends of the stimulator. However, it is notknown whether the small electrodeson these devices would be effective in stimulating the plexus of nervesthat innervate thebladder. The aim of the present study was to provide preliminary observations with modelmicrostimulators (M-Micro) for inducing bladder contractions in an SCI animal model. Bladder wall andpelvic plexus stimulation sites were compared. Additional investigations evaluated parameters such asstimulation polarity, frequency, and period as well as bladder filling volume.

Methods: In an initial survival surgery, bilateral M-Micros were implanted on the bladderwall and the pelvic plexus along the urethra in 3 female cats. A second survival surgerywas conducted 3 to 5 weeks laterto produce a Tl 0 SCI. Studies are reportedfollowing the second survival surgery. These studies included the effects of stimulation and bladder filling.

Results: The postmortem location of the implanted pelvic plexus M-Micro was previouslydescribed asnear the bladder neck. Therefore, the pelvic plexus location is described in this reportas “pelvic plexus(bladder neck)”stimulation. The observations showed effective stimulation with pelvic plexus (bladder neck)stimulation andvoiding in some cases. Stimulation was limited byside effects of increased abdominalpressure and leg movement. Other factors also affected the response to stimulation, includingthe initial bladder volume and stimulating parameters. Fluoroscopy showed that when stimulation did not inducevoiding the striated urethral sphincter was closed.

Conclusions: This case series of 3 SCI animals showed that the small electrodes on the M-Micro could beused to stimulate the bladder with contractions and voidingin some cases. The pelvic plexus (bladder neck)location for the M-Micro may be a better location than higher on the bladder wall. Limiting side effects ofstimulation included legmovement and increased abdominal pressure. Additional important factors included the stimulation parameters, initial bladder volume, and the function of the skeletal urethral sphincter.