Sacral neuromodulation in functional urinary retention: an effective way to restore voiding

OBJECTIVE: To determine the long-term efficacy and complications of sacral nerve stimulation as an alternative therapy for functional unobstructive urinary retention, often considered to be psychogenic and effectively treated by clean intermittent catheterization, but for which pelvic floor dysfunction has been recognized as a possible cause. PATIENTS AND METHODS: Twenty patients (17 women and three men, mean age 48 years) with idiopathic, unobstructive functional urinary retention and in whom other forms of therapy had failed, had a pulse generator implanted (Medtronic, Minneapolis, MN, USA) and a sacral nerve implant. Their mean duration of symptoms was 68 months; 13 patients had chronic pelvic and perineal pain associated with their obstructive voiding symptoms. All patients were managed with clean intermittent catheterization and pharmacological therapy (alpha-blockers) before the procedure. All patients had a percutaneous nerve evaluation before the permanent implant, which showed> 50% improvement in their symptoms. All patients were evaluated at 1, 6 12, 18 and 24 months, then yearly thereafter. The results were assessed both subjectively by patient's symptoms and objectively by checking the postvoid residual volume (PVR) and voided volume. RESULTS: Eighteen patients were able to void spontaneously with a mean increase in voided volume from 48 to 198 mL, and a significant decrease in PVR from 315 to 60 mL. Eighteen of the patients had a > or = 50% improvement in their symptoms and said they would recommend the therapy to a friend or relative. Complications occurred in six patients. CONCLUSION: Sacral nerve stimulation is an effective and durable new approach to functional urinary retention, with few associated complications. Test stimulation provides a valuable tool for selecting patients.     

Sacral neuromodulation and lower urinary tract dysfunction in cerebral palsy

Given the emerging role of sacral neuromodulation in treatment of neurogenic voiding dysfunction, the author describes the use of sacral neuromodulation in a patient with voiding dysfunction caused by cerebral palsy (CP). A 45-year-old patient with cerebral palsy presented with progressive complaints of urgency and overflow incontinence and was found to be in retention. She underwent sacral neuromodulation and had complete resolution of her symptoms. The literature of lower urinary tract dysfunction in CP is reviewed. It is concluded that sacral neuromodulation may be a valuable tool in treating storage and voiding disorders associated with CP.     

Sacral neuromodulation for urinary retention in a kidney-transplant patient

Bladder outlet obstruction can negatively affect renal function in the kidney transplant population. Functional obstruction represents a clinical challenge as conventional treatments are either ineffective or not recommended. Sacral neuromodulation was successfully used in functional voiding dysfunction in a kidney transplant patient. This is the first case to be reported in the literature.     

Sacral neuromodulation: an effective treatment for lower urinary tract symptoms in multiple sclerosis

Introduction and hypothesis

Most subjects with multiple sclerosis (MS) suffer from lower urinary tract symptoms (LUTS). Detrusor overactivity, detrusor hypocontractility and detrusor–sphincter dyssynergia are the most common bladder dysfunctions. Management is not straightforward due to the progressive course of the disease. Sacral neuromodulation (SNM) has received increasing attention among new effective treatments for bladder disorders associated with MS. The aim of this study was to review the published literature on the role of SNM in the treatment of LUTS in patients with MS.

Methods

A literature search was carried out up to December 2014, using relevant search terms in MEDLINE and EMBASE databases. The ClinicalTrials.gov and Controlled-trials.com online trial registries and the abstracts from international scientific meetings were searched for English-language studies containing relevant search terms. Relevant reviews and trials and prospective studies were analysed by two independent reviewers.

Results

Two prospective studies and four retrospective studies were included. Overall, MS patients represented small series (4 to 25 subjects). The longest follow-up was 7 years and the evaluation of the treatment outcomes was not homogeneous among the studies. The definition of objective cure was often unclear. The subjective cure rate was 45 %, patients’ reported satisfaction was 85 % and all the results were stable over time.

Conclusions

SNM seems to be a safe and effective treatment for LUTS in MS patients. Further and larger studies as well as randomized controlled trials are needed to confirm its clinical role in patients with MS.

     

Sacral neuromodulation for multiple sclerosis patients with urinary retention and clean intermittent catheterization

Introduction and hypothesis

Multiple sclerosis is a chronic, debilitating, neurological disease with numerous urological manifestations including urinary detrusor overactivity, detrusor sphincter dyssynergia, and urinary retention. Can sacral neuromodulation be successfully implemented for urinary retention in ambulatory women with multiple sclerosis?

Methods

Between January 2002 and January 2008, we conducted an observational retrospective case–control study where 12 of 14 consecutive, ambulatory women with multiple sclerosis had stage 1/2 sacral neuromodulation performed under general anesthesia for urinary retention.

Results

Twelve of 14 patients (86%) were successfully implanted, with a mean follow-up of 4.32?±?1.32 years and mean postvoid residual of 50.5?±?21.18 ml. The mean maximum uroflow was 17.7?±?7.9 ml/s. Two of the 12 patients (17%) required revisional surgeries for lead migration, and 40% needed battery replacement.

Conclusion

Urinary retention in multiple sclerosis female patients can be successfully and safely managed with sacral neuromodulation with few complications with a mean of 4 years follow-up.     

Sacral neuromodulation for refractory detrusor overactivity in women with an artificial urinary sphincter

PURPOSE: We assessed the efficacy of sacral neuromodulation as an alternative therapeutic option in women with an artificial urinary sphincter (AUS) who had de novo irritative urinary symptoms (urgency/frequency) refractory to conventional treatment. MATERIALS AND METHODS: Between 1984 and 2002 we implanted an AUS in 350 women and detrusor overactivity developed in 14. Six of the 14 patients responding positively to a percutaneous nerve evaluation test (greater than 50% subjective/objective improvement) were implanted with an S3 neuromodulator within 42.8 weeks (range 21 to 106) of AUS implantation. Followup included analysis of the voiding diary, a pad test and urodynamic assessment. RESULTS: After 30.5 months followup (range 14 to 40) 1 patient was dry, 4 were improved and treatment failed in 1. At 12 months mean voiding frequency daily had decreased from 17 (range 12 to 23) to 8 (range 4 to 12) and the mean number of leakages episodes daily had decreased from 14.7 (range 8.5 to 17) to 6 (range 4 to 10). Mean voided volume had increased from 121.7 (range 90 to 170) to 180 ml (range 120 to 225), mean first desire to void volume had increased from 117 (range 88 to 190) to 183 ml (range 130 to 275) and mean functional bladder capacity had increased from 325 (range 200 to 530) to 372 ml (range 250 to 580). Uninhibited bladder contractions had resolved in 4 of 5 patients. CONCLUSIONS: In women who already have an AUS with urge incontinence sacral neuromodulation can help resolve symptoms. Because this therapy does not compromise the potential for future treatment, it appears to be an alternative option in these patients. It can postpone or avoid more mutilating surgery and self-catheterization.     

Thulium:yttrium‐aluminium‐garnet laser prostatectomy in men with refractory urinary retention

OBJECTIVE

To evaluate the feasibility and efficacy of thulium:yttrium‐aluminium‐garnet (YAG) laser prostatectomy in patients with an indwelling transurethral catheter due to recurrent urinary retention secondary to benign prostatic obstruction.

PATIENTS AND METHODS

Preoperative data and postoperative outcome, as well as complications, were recorded in 65 patients with a history of recurrent urinary retention before surgery (group A), who were compared with a group of 143 men with no recurrent urinary retention (group B).

RESULTS

The mean (sd ) volume of the prostate was 45.6 (22.5) and 43.1 (24.5) mL in groups A and B, respectively. The respective preoperative prostate‐specific antigen levels were 3.6 (7.8) and 2.8 (6.4) ng/mL, the surgical duration 72.4 (28.9) and 65.6 (28.6) min, the mean laser time and energy 32.5 (11.8) min/140.7 (42.1) kJ and 29.4 (11.6) min/117.6 (11.6) kJ, the maximum urinary flow rate after surgery 19.6 (11.2) and 19.1 (9.6) mL/s, and the postvoid residual urine volume 26.7 (36.3) and 20.6 (27.3) mL. Recorded complications were: bleeding, at 3% in group A and 1.4% in group B; urinary tract infection 15.4% and 4.2%; and a second procedure, 3% and 2.3%. Overall, complications were more frequent in group A (P = 0.02).

CONCLUSION

Thulium:YAG prostatectomy is feasible and effective, even in patients with potentially impaired detrusor function. The long‐term durability of these promising results has yet to be confirmed.     

Fluorescence in situ hybridisation analysis of sex chromosome in non‐obstructive azoospermic men

The aim of this study was to compare results of karyotypes and fluorescence in situ hybridisation (FISH) technique among non‐obstructive azoospermic men and to evaluate feasibility of using FISH to assess the types of major sex chromosome abnormalities. We compared results of karyotypes and FISH technique in those patients, and the association between genetic abnormality and clinical and hormonal parameters was evaluated. We studied 68 non‐obstructive azoospermic men using conventional cytogenetics and FISH. Karyotyping revealed chromosomal abnormalities in 28 males (41%); the most common was Klinefelter syndrome (82%). FISH proved very effective in verifying low level of mosaisim in two cases with Klinefelter syndrome and complex chromosomal rearrangements in four cases with structural sex chromosome abnormalities. Our results indicate that genetic testing and screening is important in men with hypergonadotrophic azoospermia prior to the employment of assisted reproduction techniques. FISH analysis is recommended before discussing the risk of chromosomal aberrations in the offspring of infertile couples.