Preoperative prediction of continence after enterocystoplasty or undiversion in children with neurogenic bladder

Fifteen children and young adults with neurogenic bladder undergoing enterocystoplasty were evaluated preoperatively to determine subsequent urinary continence and to establish the need for bladder neck reconstruction. The proximal sphincter mechanism was studied with an erect cystogram under fluoroscopic monitoring and the distal sphincter mechanism was studied with direct electromyography. In 8 patients the distal and proximal sphincters were incompetent, and all underwent a Young-Dees bladder neck reconstruction. In 7 patients 1 or both sphincters were competent and none underwent bladder neck reconstruction during enterocystoplasty. Of the 14 patients followed 13 are continent on intermittent catheterization.     

Assessment of the poorly contractile or acontractile bladder in the older male in the absence of neuropathy

Up to 30% of patients who undergo prostatectomy are left with residual symptoms. Most have persistent detrusor instability, but some have poorly contractile or acontractile bladders. Over a 2-year period, 42 neurologically normal patients were shown to have a hypocontractile or acontractile bladder on urodynamic testing; 27 had undergone outflow tract surgery. Four patients who were totally incontinent had undergone at least 2 transurethral resections. The remainder had severe frequency, urgency and nocturia. Urodynamically, all but 7 patients with poor compliance had normal filling cystometrograms, all but 8 had residual urine volumes less than 100 ml, and 26 had less than 5 ml. Thus their symptoms are difficult to explain. Apart from the insertion of an artificial sphincter in those with total incontinence, treatment did not improve any of these patients.     

Surgical management of the congenital neuropathic bladder

We have previously described 3 types of lower urinary tract dysfunction in the congenital neuropathic bladder--contractile, intermediate and acontractile--accounting for 35, 40 and 25% of patients respectively. Subsequent urodynamic and surgical experience has shown that the intermediate type is commoner and the acontractile type less common than was thought. The contractile group accounts for 31% of patients and rarely requires surgery (a "clam" ileocystoplasty). The acontractile group accounts for only 9% but more commonly requires surgical treatment, usually the implantation of an artificial urinary sphincter (AUS). The intermediate group accounts for 60% of patients and usually requires surgery. If there is no significant sphincter weakness incontinence, a "clam" ileocystoplasty alone is performed; if there is sphincter weakness, a "clam and a cuff" procedure is performed with implantation of the remainder of the AUS at a later date, if required.     

Urological treatment of patients with spinal cord injury in the chronic stage

One hundred eighty patients with spinal cord injury were admitted to our hospital between January, 1980 and June, 1983. Eighty-five of them had cervical lesions, 54 had thoracic lesions and 41 had lumbar lesions. Most of the neurogenic bladders due to spinal cord injury treated in our clinic, could be classified into 3 major patterns: hypoactive detrusor-hypoactive sphincter, hypoactive detrusor-active sphincter, and hyperactive detrusor-hyperactive sphincter. To control the hyperactivity of the detrusor and the sphincter, we employed pharmacotherapy first and then we performed transurethral resection of the bladder neck and prostatectomy (TUR-Bn.P) and nerve block (sacral nerve block, pudendal nerve block, obturator nerve block and lumbar nerve block). In the case of a hypoactive detrusor, we employed TUR-Bn.P, open ileal flap fixation to the bladder and voiding training. Using these procedures, we could make 157 patients catheter-free.     

Dyssynergic vesicourethral responses during bladder rehabilitation in spinal cord injury patients: effects of suprapubic percussion, credé method and bethanechol chloride.

Five normal men and 70 spinal cord injury male patients underwent 100 studies with the multiple pressure recording technique, incorporating the continuous infusion principle for sphincter pressure monitoring. Gross cystosphincteric dyssynergia was noted in the majority of patients with complete upper motor neuron bladders less than 2 years in duration. Some form of synergic voiding patterns was noted, mostly in patients with incomplete upper motor neuron bladders. The external sphincter tends to be synergic in late cases of upper moto neuron bladders. Internal sphincter dyssynergia is uncommon in cases of injuries less than 2 years in duration, with the exception of patients who have autonomic dysreflexia. Bladder neck obstruction seems to be more common in late lesions secondary to global hypertrophy of the bladder. Rehabilitation maneuvers and bethanechol chloride administration may exaggerate detrusor sphincter dyssynergia and injudicious use of such procedures could be detrimental to the urinary tract.     

Peripheral neurology as a predictor of bladder dysfunction in congenital neuropathic bladder

Urodynamic findings and peripheral neurology were correlated in 62 patients with myelomeningocele. The primary motor and sensory levels bore no relation to bladder dysfunction. The ano-cutaneous reflex was a useful predictor, in that where the reflex was positive there was likely to be detrusor hyper-reflexia, a competent bladder neck and absence of sphincter weakness leakage. Where the reflex was absent, detrusor hyper-reflexia was absent or mild, the bladder neck usually incompetent and sphincter weakness leakage common. (Detrusor compliance could not be predicted from peripheral neurological findings). We consider the ano-cutaneous reflex to be a useful indication of bladder dysfunction and urodynamic studies are often unnecessary when it is positive.     

Urinary disturbance due to HTLV-1 associated myelopathy]

Patients with human T-cell lymphotropic virus type 1 associated myelopathy (HAM) have complaints of urinary disturbance frequently. Symptoms and urodynamic examinations were evaluated in untreated twenty-one patients with HAM. Although two cases (11%) had no urinary symptom, nineteen cases (89%) suffered from dysuria, pollakisuria, incontinence or urgency. The combination of irritative and obstructive urinary disturbance was a characteristic symptom in the HAM patients. In three cases the urinary symptoms preceded the gait disturbance which is a main symptom of HAM. In urodynamic study overactive bladder was found in fourteen cases (66%), although three cases (15%) showed underactive or acontractile bladder with disturbance of urinary sensation. There was no abnormal finding by urethral pressure profile (UPP), but detrusor sphincter dyssynergia (DSD) was revealed frequently by EMG. This typical dysfunction of the HAM patients was thought to be caused by destruction of the lateral column of the spinal cord.     

An unusual use of AMS 800 artificial urinary sphincter cuff in the treatment of sphincteric neurogenic incontinence: case report

STUDY DESIGN: Case report of an unusual use of AMS 800 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter cuff in a female patient affected by neurogenic urinary incontinence. OBJECTIVE: To describe this rare surgical solution. SETTING: Department of Urology in Italy. METHODS: A 43-year-old woman affected by flaccid paraplegia, acontractile bladder and incompetent bladder neck, underwent an implantation of an artificial urinary sphincter AMS 800. After 7 years, a mechanical failure of the device occurred and pubovaginal sling (PVS) utilizing the cuff of the sphincter was employed due to the poor quality of rectus fascia and the development of previous allergy for some heterologous materials. RESULTS: At 17 months follow-up, the patient is content and able to empty the bladder by clean intermittent self-catheterization (CIC). CONCLUSION: The risk of developing an allergy reaction due to the employment of heterologous materials and the impossibility to use the rectus fascia obliged us to adopt the pre-existent cuff of the artificial urinary sphincter AMS 800.     

Sphincter stretch: a new technique resulting in continence and complete voiding in paraplegics.

A technique is described to facilitate voiding in the paraplegic, whereby external sphincter spasm is eliminated as a source of obstruction. Digital stretch on the anal sphincter combined with the Valsalva maneuver has resulted in satisfactory bladder emptying in 16 paraplegic patients. The technique has been found unsatisfactory in patients with contracted bladders or with incomplete lesions of the spinal cord.     

PHENOXYBENZAMINE IN THE MANAGEMENT OF NEUROPATHIC BLADDER FOLLOWING SPINAL CORD INJURY

Background : The present study aims to show the clinical and urodynamic effects of phenoxybenzamine on the neuropathic bladder of spinal cord-injured patients who failed to be free of catheter by attaining satisfactory voiding function, despite initial bladder training. Methods : Forty-six spinal cord-injured patients were subjected to pharmacological manipulation with phenoxybenzamine. It was used as an adjunct in the management of neuropathic bladder dysfunction that caused failure of the bladder to empty, by tapping or crede to achieve satisfactory residual urine volume of < 100 mL. Phenoxybenzamine was started with a dose of 10 mg daily, increased by 10 mg every 3 days to a dose of 30 mg daily; this was maintained from 3 weeks to 6 months (mean: 39 days). The pre-treatment residual urine volume ranged between 100 and 1050 mL (mean: 360 mL). Follow-up periods ranged between 12 and 36 months (mean: 16 months). Results : Five patients (11%) were excluded due to either inadequate treatment or inadequate follow-up. Nineteen patients (41%) with reflex (upper motor neurone) bladders showed improvement of bladder evacuation. There was a reduction of the maximum urethral closure pressure, which ranged between 10 and 32 cm of water (mean: 22 cm). Twenty-two patients (48%) did not respond, requiring other measures to be taken which included transurethral surgery (n = 19). Nine of the failures involved areflex (lower motor neurone) bladders, and seven failures involved reflex bladders with an extremely tight outlet and urethral closure pressure of > 50 cm of water. Six failures involved reflex bladders that were lacking strong enough detrusor contractions to attain a balanced bladder responsive to abdominal tapping; response was achieved by administration of a parasympatheticomimetic drug. Neuropathic bladders with uninhibited detrusor contractions responded well to phenoxybenzamine. Conclusions : Phenoxybenzamine proved useful in reducing bladder outlet resistance after spinal cord injury, provided that detrusor bladder contractions were present. It is useful in controlling detrusor–sphincter dyssynergia and autonomic hyperreflexia. It was not useful in areflex bladders, perhaps due to the development of spasticity of the striated muscle component of the external sphincter. The presence of bladder neck (internal sphincter) dysfunction may modify or abolish its effect.     

Urinary dysfunction in transverse myelitis

Six men and 2 women with a history of transverse myelitis and persistent lower urinary tract symptoms underwent neurourological evaluation. Of the patients, 4 were neurologically intact, while the remainder had residual neurological deficits. Urodynamic studies revealed detrusor-external sphincter dyssynergia in 6 patients. Two patients had detrusor hyperreflexia, of whom 1 also had an incompetent sphincter. Erectile or ejaculatory dysfunction was reported by 3 men. We conclude that prolonged bladder and sexual dysfunction, caused by spinal cord inflammatory insult, may persist despite a systemic neurological recovery. Therefore, bladder management guided by initial and followup urodynamics is recommended.     

Puboprostatic sling repair for treatment of urethral incompetence in adult neurogenic incontinence

PURPOSE: An incompetent urethral sphincter can be a significant factor contributing to urinary incontinence in patients with neurogenic bladders. We review our experience with 12 men who underwent a puboprostatic sling. MATERIALS AND METHODS: The study included 12 men (mean age 37.1 years) with neurogenic bladder due to spinal cord injury in 9 and spina bifida in 3. All patients were diagnosed with urethral incompetence based on fluorourodynamic evaluation. Medical therapy failed in all 12 patients and all complained of urine leakage with activity. All patients underwent placement of an autologous fascial sling distal to the prostatic urethra via an abdominal approach. Ten patients also underwent simultaneous bladder augmentation to correct high intravesical pressures. RESULTS: Followup ranged from 1 to 39 months (average 14.25). All patients manage the bladder with intermittent catheterization. Of the patients 8 are completely dry between catheterizations and 2 had significant improvement with only minimal leakage (1 pad per day), with an overall success rate of 83%. One patient improved initially but subsequently underwent placement of an artificial urinary sphincter for residual stress incontinence. In 1 patient several external sphincterotomies failed despite adequate sling placement. There were no complications related to the placement of the sling and all patients are able to perform intermittent catheterization without difficulty. CONCLUSIONS: In select male patients the puboprostatic sling can be an effective and safe method to treat urethral incompetence secondary to neurogenic voiding dysfunction.     

Fascial slings and bladder neck tapering in the treatment of male neurogenic incontinence.

Intractable incontinence in selected male patients with a neurogenic bladder has been treated by increasing bladder compliance with augmentation cystoplasty and increasing urethral resistance with the artificial urinary sphincter. However, there are a number of complications associated with the use of an artificial urinary sphincter. As an alternative, we performed bladder neck tapering and bladder neck slings in 13 men with a neurogenic bladder and an incompetent urethra (10 with spina bifida and 3 with spinal cord injury) undergoing bladder augmentation. Mean patient age was 27 years (range 17 to 40 years) and mean followup was 34.3 months (range 5.5 to 49 months). Postoperatively, there was a 113% increase in mean bladder capacity (from 260 to 550 cc) and a 62% decrease in mean bladder pressure at capacity (from 53 to 20 cm. water). The earliest 2 patients with a Marlex sling suffered erosions that were treated with transurethral excision. As a result, the 11 subsequent patients had a rectus fascial sling. Nine patients (69.2%) are completely dry on self-catheterization, 2 (15.4%) required collagen injections for improved continence and 2 failures (15.4%) required additional procedures. The complications in these patients are comparable to, if not better than, the use of an artificial urinary sphincter. We conclude that a fascial sling with bladder neck tapering is an excellent alternative to the artificial urinary sphincter in the treatment of male neurogenic bladder with an incompetent urethra.     

Phenoxybenzamine in the management of neuropathic bladder following spinal cord injury.

BACKGROUND: The present study aims to show the clinical and urodynamic effects of phenoxybenzamine on the neuropathic bladder of spinal cord-injured patients who failed to be free of catheter by attaining satisfactory voiding function, despite initial bladder training. METHODS: Forty-six spinal cord-injured patients were subjected to pharmacological manipulation with phenoxybenzamine. It was used as an adjunct in the management of neuropathic bladder dysfunction that caused failure of the bladder to empty, by tapping or crede to achieve satisfactory residual urine volume of < 100 mL. Phenoxybenzamine was started with a dose of 10 mg daily, increased by 10 mg every 3 days to a dose of 30 mg daily; this was maintained from 3 weeks to 6 months (mean: 39 days). The pre-treatment residual urine volume ranged between 100 and 1050 mL (mean: 360 mL). Follow-up periods ranged between 12 and 36 months (mean: 16 months). RESULTS: Five patients (11%) were excluded due to either inadequate treatment or inadequate follow-up. Nineteen patients (41%) with reflex (upper motor neurone) bladders showed improvement of bladder evacuation. There was a reduction of the maximum urethral closure pressure, which ranged between 10 and 32 cm of water (mean: 22 cm). Twenty-two patients (48%) did not respond, requiring other measures to be taken which included transurethral surgery (n = 19). Nine of the failures involved areflex (lower motor neurone) bladders, and seven failures involved reflex bladders with an extremely tight outlet and urethral closure pressure of > 50 cm of water. Six failures involved reflex bladders that were lacking strong enough detrusor contractions to attain a balanced bladder responsive to abdominal tapping; response was achieved by administration of a parasympatheticomimetic drug. Neuropathic bladders with uninhibited detrusor contractions responded well to phenoxybenzamine. CONCLUSIONS: Phenoxybenzamine proved useful in reducing bladder outlet resistance after spinal cord injury, provided that detrusor bladder contractions were present. It is useful in controlling detrusor-sphincter dyssynergia and autonomic hyperreflexia. It was not useful in areflex bladders, perhaps due to the development of spasticity of the striated muscle component of the external sphincter. The presence of bladder neck (internal sphincter) dysfunction may modify or abolish its effect.     

The artificial sphincter (AS-800). Experience in children and young adults

From reviewing our experience in the application of the AS-800 sphincter for the management of incontinence in children, we conclude that implantation is indicated after conservative and less invasive therapy has been attempted. The bladder neck is the site of choice for cuff placement in children. Primary deactivation and moderate or low reservoir pressures (61 to 70 and 71 to 80 cm H2O) are indicated, especially in patients with previous bladder neck surgery or an inadvertent bladder neck injury. Excess residual urine should be evacuated by clean intermittent catheterization. The AS-800 is mechanically reliable (9 mechanical failures in 45 sphincters). When the sphincter is implanted in a select group of patients, upper tract function is maintained in a stable state. Detubularized augmentation cytoplasty must be used to supplement the sphincter in patients with low-compliance, low-capacity, and nonresponsive hyperreflexic bladders. In all patients, long and careful follow-up is necessary to identify late changes in bladder function and consequent upper tract damage. An overall satisfactory result (fair to good) was obtained in 88 per cent of patients during an average follow-up period of 35 months, and 0.6 modifying procedure per patient was done in the sphincters.     

Intraoperative urodynamics in spinal cord surgery: a study of feasibility

Intraoperative monitoring (IOM) of bladder function in spinal cord surgery is a challenging task due to vegetative influences, multilevel innervation and numerous supraspinal modulating factors. Despite routine use of urodynamics in neurosurgery for implantation of bladder stimulators or denervation of nerve fibres in spastic reflex bladders, application of IOM in patients with spinal cord tumours or tethered-cord syndrome is not widespread. Combining urodynamics with sphincter electromyography (EMG) in IOM enables identification of bladder efferents responsible for contraction and continence. We monitored four patients with ependymoma of the Cauda equina, one patient with tethered-cord syndrome and two patients with cervical intramedullary tumours. In all patients undergoing operations of the Cauda equina, identification of bladder efferents responsible for detrusor contraction was possible. There was good correlation between preoperative bladder dysfunction, preoperative urodynamics and intraoperative pressure increase by bladder contraction or latency between stimulation and contraction. This method proved unsuitable for intramedullary tumours where no contraction of the bladder could be observed while stimulating the spinal cord. Intraoperative monitoring of urodynamics is an effective tool for identifying bladder efferents in the Cauda equina. Intraoperative conclusions on bladder dysfunction through registration of pressure increase and latency are possible.     

Combined transrectal ultrasonography and urodynamics in the evaluation of detrusor-sphincter dyssynergia

Thirty-one combined transrectal ultrasonographic and urodynamic studies were performed in 24 patients with spinal cord lesions at different levels between C4 and T12. Ultrasonography provided accurate real-time imaging of the bladder neck, prostatic urethra and external sphincter during the bladder filling phase as well as during the voiding phase. Bladder and rectal pressures, sphincter EMG and uroflow were recorded simultaneously. Transrectal ultrasonography contributed significantly to the accuracy of diagnosing detrusor-sphincter dyssynergia. Sphincter contractions were clearly visualised with ultrasonographic video monitoring. This imaging method was especially helpful in sorting out the problems of 3 patients with poor emptying of bladder after endoscopic sphincterotomy. One had a urethral stricture and the other 2 had sphincters that opened adequately but bladders that emptied poorly because of detrusor hypocontractility. Other problems, such as benign prostatic hyperplasia and false passage, were also easily recognised. Transrectal ultrasonography not only provides accurate information but also involves no exposure to radiation and thus precludes the need for costly lead-shielded examination rooms.     

Detrusor behaviour following implantation of the Brantley Scott artificial urinary sphincter for neuropathic incontinence

During a 3-year period, 102 Brantley Scott artificial urinary sphincters were implanted to control urinary incontinence. Nineteen patients underwent endoscopic sphincterotomy and artificial sphincter implantation for the control of sphincter weakness incontinence due to congenital neuropathic bladder dysfunction. None had previous augmentation or substitution procedures. Nine patients (47%) subsequently showed a deterioration in detrusor function, resulting in either recurrent incontinence or upper tract dilatation. Eight of these (89%) had previously been shown to have an intermediate pattern of neuropathic bladder abnormality. All patients implanted with an AUS require long-term surveillance including videourodynamic studies, and patients with intermediate neuropathic bladders should be considered for augmentation or substitution at the time of implantation.     

Bladder neck incompetence in patients with spinal cord injury: significance of sympathetic skin response

PURPOSE: We investigated whether recording the perineal sympathetic skin response, which reflects the sympathetic function of the thoracolumbar spinal cord, represents a reliable and accurate diagnostic tool for assessing bladder neck competence and incompetence. MATERIALS AND METHODS: We compared the sympathetic skin response recorded from the hand, foot and perineal skin with urodynamic findings in 90 patients with neurogenic bladder dysfunction, including 66 with spinal cord injury and 24 with cauda equina lesions. RESULTS: Video urodynamics revealed an incompetent bladder neck in 11 of 32 patients (34%) with complete and 7 of 34 (21%) with incomplete spinal cord injury but in only 1 of 24 (4%) with the conus-cauda equina syndrome. This association significantly correlated with the lesion level at T10 to L2 in 12 of 26 cases (46%) as well as with the loss of perineal but preserved hand and foot sympathetic skin response in 13 of 18 (72%). CONCLUSIONS: Recording the perineal sympathetic skin response in addition to that of the hand and foot represents a sensitive diagnostic tool for assessing sympathetic nerve function within the thoracolumbar spinal cord. It is of diagnostic value for evaluating neurogenic bladder neck incompetence in spinal cord injured patients.     

Smooth muscle membrane organization in the normal and dysfunctional human urinary bladder: a structural analysis

PURPOSE: The decline in contractile properties is a characteristic feature of the dysfunctional bladder as a result of infravesical outlet obstruction. During clinical progression of the disease, smooth muscle cells undergo structural modifications. Since adaptations to constant changes in length require a high degree of structural organization within the sarcolemma, we have investigated the expression of several proteins, which are involved in smooth muscle membrane organization, in specimens derived from normal and dysfunctional organs. MATERIALS AND METHODS: Specimen from patients with urodynamically normal/equivocal (n = 4), obstructed (n = 2), and acontractile (n = 2) bladders were analyzed relative to their structural features and sarcolemmal protein profile. RESULTS: Smooth muscle cells within the normal urinary bladder display a distinct sarcolemmal domain structure, characterized by firm actin-attachment sites, alternating with flexible "hinge" regions. In obstructed bladders, foci of cells displaying degenerative sarcolemmal changes alternate with areas of hypertrophic cells in which the membrane appears unaffected. In acontractile organs, the overall membrane structure remains intact, however annexin 6, a protein belonging to a family of Ca2+-dependent, "membrane-organizers," is downregulated. CONCLUSION: Degenerative changes in smooth muscle cells, which are chronically working against high resistance, are preferentially located within the actin-attachment sites. In acontractile bladders, the downregulation of annexin 6 might have a bearing on the fine-tuning of the plasma membrane during contraction/relaxation cycles.