Clinical usefulness of the transobturator sub-urethral tape in the treatment of stress urinary incontinence in female patients with spinal cord lesion.

OBJECTIVES: To evaluate the clinical usefulness of transobturator sub-urethral tapes for the treatment of stress urinary incontinence in women with spinal cord injury. METHOD AND SUBJECTS: Chart review for all female patients with spinal cord injury who underwent implantation of a transobturator sub-urethral tape for treatment of stress urinary incontinence at our institution. RESULTS: Nine women, median age 45.1 years, received a sub-urethral transobturator tape in the period November 2007 to September 2010. Four patients had paraplegia and five had tetraplegia. Seven women performed intermittent catheterization. At follow up, three of the nine patients were either cured or vastly improved. One major late complication (urethral erosion) occurred. Five of the six patients without treatment success underwent second-line treatment (artificial sphincter or urinary diversion). CONCLUSION: In our case series, implantation of transobturator sub-urethral tapes in women with stress urinary continence due to intrinsic sphincter deficiency and a low leak point pressure led to unfavorable results.

Treatment of urinary tract infection in persons with spinal cord injury: guidelines, evidence, and clinical practice. A questionnaire-based survey and review of the literature.

OBJECTIVES: To investigate current clinical practice in the treatment of urinary tract infections (UTIs) in persons with spinal cord injury (SCI) in SCI centers where German is spoken and to compare it with current guidelines and evidence-based standards evaluated by a literature review. METHODS: A standardized questionnaire was mailed to 16 SCI rehabilitation centers. The results were compared with a literature review RESULTS: Of the 16 centers, 13 responded. Indications for UTI treatment, medications, and treatment duration differed substantially among the individual centers and from the existing guidelines. Antibiotic treatment is regarded as the method of choice. Compared with the existing literature, patients in two center were undertreated, whereas they were overtreated in seven centers. CONCLUSION: Even in specialized centers, treatment of UTI in patients with SCI is based more on personal experience of the treating physicians than on published evidence. This may at least partly be due to the paucity of evidence-based data. The observed tendency toward overtreatment with antibiotics carries substantial future risks, as this strategy may well lead to the induction of multiresistant bacterial strains. Therefore, developing guidelines would be an important step toward a unification of the different treatment strategies, thus reducing unnecessary antibiotic treatment. Furthermore, evidence-based studies evaluating the success of antibiotic treatment as well as the usefulness of alternative strategies are urgently needed.

Clinical usefulness of the memokath stent as a second-line procedure after sphincterotomy failure.

PURPOSE: To assess the clinical usefulness of Memokath® stent placement in the external sphincter region in men with neurogenic bladder dysfunction from spinal cord injury after failed sphincterotomy. PATIENTS AND METHODS: Twenty-two men with elevated (> 100 mL) residual urine and/or voiding difficulties/autonomic dysreflexia were treated with a Memokath stent. Follow-up examinations comprised residual urine, video-urodynamics, renal sonography, and assessment of subjective outcome. RESULTS: No intraoperative complications were observed. Transient autonomic dysreflexia developed in one patient. Stent repositioning from dislocation was necessary in four (18.2%) patients. After a median follow-up of 10.3 months, 18 (81.8%) patients still had a stent in place. In two men, the stents were removed because of newly diagnosed urothelial bladder cancer; in another two patients, they were removed because of lack of success. At follow-up, residual urine was significantly reduced from 229 to 105 mL. Residual urine was < 100 mL in 14 of 18 (77.8%) patients. Changes in bladder capacity, detrusor leak point pressure, bladder compliance, and maximum detrusor pressure were not statistically significant. Renal sonography did not reveal any pathologic findings. CONCLUSIONS: According to our data, the Memokath stent is not only an alternative treatment option to sphincterotomy, but it is a safe and successful second-line treatment after sphincterotomy failure.

Preoperative urodynamic assessment in patients with spinal cord lesions undergoing sphincterotomy: is success predictable?

OBJECTIVE: Sphincterotomy is a well-established therapeutic option in male patients with neurogenic bladder dysfunction and detrusor-sphincter-dyssynergia due to spinal cord lesions. Indication and prediction of treatment outcome, however, are mainly based on clinical parameters. We analyzed the clinical usefulness of preoperative urodynamic evaluation for the prediction of success in patients undergoing external sphincterotomy. MATERIALS AND METHODS: In a retrospective study, residual urine, retrograde perfusion pressure (RESP) and detrusor leak point pressure (DLPP) in 62 male patients with spinal cord injury were assessed before sphincterotomy. Data were compared to surgical success evaluated by postoperative DLPP and residual urine. RESULTS: Sphincterotomy was successful in 85.4% of our patients. In multivariate analysis, both preoperative DLPP and RESP were superior to measurement of residual urine concerning prediction of surgical success. However, these differences were not statistically significant. CONCLUSION: To our knowledge, this is the first study to evaluate preoperative predictors for surgical success in patients undergoing sphincterotomy. Although urodynamic evaluation is strongly advised prior to surgery in patients with spinal cord lesions, it improves prediction of success only marginally.

Subcutaneous tunneling of the temporary testing electrode significantly improves the success rate of subchronic sacral nerve modulation (SNM).

Sacral nerve modulation (SNM) is an effective way to treat non-neurogenic dysfunctions of pelvic organs. For over 20 years, this technique has been used for the treatment of overactive bladder, urinary retention, pelvic pain and even more recently, fecal incontinence and constipation. The objective of the study is to improve the fixation of the temporary testing electrode (TTE) in order to obtain more reliable results in the testing phase which should lead to have a comparable success rate as the two-stage implant for a chronic implant. Twenty-eight patients (ratio of sex women:men = 3:1; with overactive bladder, urinary retention, pelvic pain syndrome and fecal incontinence) were evaluated by the modified temporary test electrode (TTE) placement. With the subcutaneous tunneling technique (mean time of evaluation 8.3 days), it is possible to perform percutaneous nerve evaluation (PNE) more effectively with an objective, reliable and less expensive outcome prior to the implantation of the implantable sacral nerve stimulator in almost 80% of the evaluated patients. Because the costs of therapy are not covered by health insurance in all countries, there is a need for an effective and inexpensive way to test and select patients appropriately. The tunneled TTE maintains its place for consistent amplitude during the entire test duration. The modification of placing the TTE produces repayable results. This technique can be performed on an outpatient basis to evaluate sacral nerve modulation as an early treatment option for non-dysfunctions of pelvic organs before they are forwarded to a specialized center for a chronic SNM implantation.

Reflux of a staple after kock pouch urinary diversion: a nidus for renal stone formation.

A patient with cystectomy and urinary diversion after spinal cord injury had multiple pouch concretements and a kidney stone formed around a staple that apparently had refluxed from the nipple of the pouch. In such cases, the stone and staple should be removed at the same time, either percutaneously or by ureterorenoscopy.

Magnetic resonance imaging of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder.

Fluid-fluid levels have been reported as an extremely infrequent and non-specific condition in many benign and malignant bone lesions. We present the first reported MRI findings of bone marrow metastasis with fluid-fluid levels from small cell neuroendocrine carcinoma of the urinary bladder to the lumbar spine. Radiologists should be aware of the MRI appearance of these extraordinary lesions in order to provide a complete differential diagnosis and to guide clinicians in adequate treatment.

Cowper's syringocele: diagnosis based on MRI findings.

An 8-year-old boy presenting with intermittent haematuria and dysuria was investigated with voiding cystourethrography (VCUG), urethroscopy and perineal MRI. VCUG and urethroscopy did not provide a definitive diagnosis, while MRI clearly demonstrated a homogeneous, oval cystic lesion extending from the bulbourethral glands and slightly impressing the bulbous urethra. The patient was found to have an imperforate Cowper's syringocele. Treatment consisted of marsupialisation and the patient became symptom free. To the authors' knowledge, this is the first description of the MRI characteristics of an imperforate Cowper's syringocele in a paediatric patient.