Treatment of stress urinary incontinence in men with spinal cord injury: minimally invasive=minimally effective?

STUDY DESIGN: Retrospective chart review. OBJECTIVES: To assess the outcome of minimally invasive treatment of stress urinary incontinence with alloplastic slings in patients with neurogenic lower urinary tract dysfunction. SETTING: Switzerland. METHODS: The patient database of a tertiary urologic referral center was screened for male patients with SCI who underwent implantation of a suburethral sling between June 2009 and December 2015. Patient characteristics and bladder management details were collected by chart review. RESULTS: Sixteen patients were identified. Of those, 13 received a transobturator tape (TOT) and three underwent implantation of an retropubic adjustable system (RAS). In the TOT group, nine patients became continent, one patient was improved and three patients remained unchanged. Three patients underwent minor revisions due to impaired wound healing. In the RAS group, no patient improved and one RAS had to be removed due to severe wound infection; in a second patient, an abscess with destruction of the urethra occurred. CONCLUSIONS: In our experience, alloplastic slings seem to be an effective minimally invasive treatment option in male patients with SUI due to SCI. TOT seem to be more effective than RAS and was associated with less severe complications. The selection criteria for the optimal patient and the optimal sling have to be further defined.

Sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction.

STUDY DESIGN: This is a retrospective chart analysis. OBJECTIVES: The objective of this study was to evaluate the effect of sacral neuromodulation (SNM) in patients with neurogenic lower urinary tract dysfunction (NLUTD). SETTINGS: This study was conducted in a spinal cord injury rehabilitation center in Switzerland. METHODS: The charts of all patients who underwent SNM (testing and/or permanent implantation) because of NLUTD at our institution between 2007 and 2013 were evaluated. Treatment outcomes and complications were recorded. RESULTS: A total of 50 patients, 30 women and 20 men, with a mean age of 46 (±14) years, fulfilled the inclusion criteria. The most frequent cause for SNM was spinal cord injury in 35 patients (70%). Median duration of the underlying disease was 9.5 (±9.3) years. In all, 35 patients (70%) received a permanent implant. The complication rate was 16% (8/50). At the last follow-up, SNM was in use in 32 patients. In 26 patients with SNM because of detrusor overactivity, voiding frequency per 24 h was significantly reduced from 9 to 6, and daily pad use rate was significantly improved (2.6 versus 0.6 pads per 24h). On comparing urodynamic assessment of detrusor function before and under SNM, no significant suppression of neurogenic detrusor overactivity (NDO) was detected. In nine patients with chronic neurogenic urinary retention, median postvoid residual urine was significantly reduced from 370 to 59 ml. In all, 94% of the patients were either very satisfied or satisfied with SNM. CONCLUSION: SNM might be an additional therapy option in carefully selected patients with NLUTD. On the basis of our results, urodynamic evaluation before SNM is mandatory, as the procedure does not seem to be suited to significantly alleviate NDO.

[Melanosis of the urinary bladder]. / Melanose der Harnblase.

Melanosis of the bladder is rare. Only 10 cases have been described in the literature. We present the case of an 80-year-old woman with neurogenic lower urinary tract dysfunction due to spinal paralysis. During the diagnostic work-up which included cystoscopy, black spots in the bladder wall were observed. Histopathological evaluation revealed a benign suburothelial melanosis. Thus, with cystoscopic suspicion of a malignancy (melanoma), a biopsy is mandatory and regular cystoscopic follow-up is recommended.

Bladder management in individuals with chronic neurogenic lower urinary tract dysfunction.

STUDY DESIGN: Retrospective investigation. OBJECTIVES: To investigate the association of patient and injury characteristics with bladder evacuation by indwelling catheterization in patients with chronic neurogenic lower urinary tract dysfunction (NLUTD). SETTING: Tertiary urologic referral center. METHODS: The patient database was screened for patients with chronic (>12 months) NLUTD. Patient characteristics and bladder management details were collected. Binary logistic regression analysis was used to investigate the effects of the investigated factors on bladder evacuation by indwelling catheterization. RESULTS: The data of 1263 patients with a median age of 47 years (range 11-89 years) and a median NLTUD duration of 15.2 years (range 1.0-63.4 years) were investigated. The most common bladder evacuation method was intermittent catheterization (IC; 41.3%) followed by triggered reflex voiding (25.7%), suprapubic catheterization (11.8%), sacral anterior root stimulation (7.3%), spontaneous voiding (7.0%), abdominal straining (5.7%) and transurethral catheterization (1.3%). Female gender, tetraplegia, an age older than 45 years and injury duration were significant (<0.001) predictors of indwelling catheterization. The odds of bladder evacuation by indwelling catheterization were increased ~2.5, 3 and 4 times in women, patients older than 45 years and tetraplegics, respectively. CONCLUSIONS: IC is the most common bladder evacuation method. However, the majority of individuals with NLUTD are using other evacuation methods, because factors such as functional deficiencies, mental impairment or the social situation are relevant for choosing a bladder evacuation method. Individuals at risk of indwelling catheterization can be identified based on female gender, age, injury severity and injury duration.

Risk factors for symptomatic urinary tract infections in individuals with chronic neurogenic lower urinary tract dysfunction.

STUDY DESIGN: Retrospective investigation. OBJECTIVES: To investigate the association of patient and injury characteristics, as well as bladder management, with the occurrence of patient-reported, symptomatic urinary tract infection(s) UTI(s) in patients with chronic neurogenic lower urinary tract dysfunction (NLUTD). SETTING: Tertiary urologic referral center. METHODS: The patient database was screened for patients with chronic (>12 months) NLUTD who had presented between 2008 and 2012. Patient characteristics, bladder evacuation management, the annual number of patient-reported, symptomatic UTIs and the type of prophylactic treatment to prevent UTIs were collected. Binary logistic regression analysis was used to investigate the effects of the investigated risk factors on the occurrence of symptomatic UTI(s) and recurrent symptomatic UTIs (⩾3 annual UTIs). RESULTS: The data of 1104 patients with a mean NLTUD duration of 20.3±11.6 years were investigated. The evacuation method was a significant (P⩽0.004) predictor for the occurrence of symptomatic UTI and recurrent symptomatic UTIs. The greatest annual number of symptomatic UTIs was observed in patients using transurethral indwelling catheters, and the odds of experiencing a UTI and recurrent UTIs were increased more than 10- and 4-fold, respectively. The odds of a UTI or recurrent UTIs were also increased significantly (P⩽0.014) in patients using intermittent catheterization (IC). Botulinum toxin injections into the detrusor increased the odds of a UTI ~10-fold (P=0.03). CONCLUSIONS: The bladder evacuation method is the main predictor for symptomatic UTIs in individuals with NLUTD. Transurethral catheters showed the highest odds of symptomatic UTI and should be avoided whenever possible.

Initial experience with the treatment of neurogenic detrusor overactivity with a new ß-3 agonist (mirabegron) in patients with spinal cord injury.

STUDY DESIGN: It is a retrospective chart analysis. OBJECTIVES: In patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI), neurogenic detrusor overactivity (NDO) can cause both deterioration of the upper urinary tract and urinary incontinence. Antimuscarinic treatment is frequently discontinued due to side effects or lack of efficacy, whereas injection of onabotulinumtoxin into the detrusor is a minimally invasive procedure with risks of urinary retention, infection and haematuria. Mirabegron, a new ß-3 agonist, is a potential new agent for treatment of NDO. Aim of the study was to evaluate the efficacy of mirabegron in SCI patients with NLUTD. SETTING: Swiss Paraplegic Center, Nottwil, Switzerland. METHODS: A retrospective chart analysis of SCI patient treated with mirabegron. RESULTS: Fifteen patients with NDO were treated with mirabegron for a period of at least 6 weeks. Significant reduction of the frequency of bladder evacuation per 24 h (8.1 vs 6.4, P=0.003), and of incontinence episodes per 24 h (2.9 vs 1.3, P=0.027) was observed. Furthermore, we observed improvements in bladder capacity (from 365 to 419 ml), compliance (from 28 to 45 ml cm(-1) H(2)0) and detrusor pressure during storage phase (45.8 vs 30 cm H(2)0). At follow-up, 9/15 patients were satisfied with the therapy, 4/15 reported side effects (3 × aggravation of urinary incontinence, 1 × constipation). CONCLUSIONS: Mirabegron may evolve as an alternative in the treatment of NDO. We observed improvements in urodynamic and clinical parameters. Due to the limited number of patients and the retrospective nature of the study, prospective, placebo-controlled studies are necessary.

Urodynamic or video-urodynamic assessment in patients with spinal cord injury: this is not a question!

STUDY DESIGN: Case report. OBJECTIVES: The objective of this study was to demonstrate the additional value of combined video-urodynamic investigations compared with urodynamic investigation alone in patients with neurogenic lower urinary tract dysfunction due to spinal cord injury (SCI). SETTING: The study was conducted in a spinal cord injury rehabilitation center in Switzerland. METHODS: A patient with complete SCI since 1984 evacuated the bladder by reflex voiding. Owing to the lack of clinical symptoms, he refused urologic controls for 15 years. In July 2014, he was referred to our hospital with acute septicemia. RESULTS: The hydronephrosis responsible for the septicemia was successfully treated by intravenous antibiotics and ureteral stenting. Subsequently, a neuro-urologic assessment was performed. Urodynamic examination was normal. Video-urodynamics, however, revealed massive morphologic alterations of the lower and upper urinary tracts, which were responsible for the septicemia. CONCLUSION: Our case demonstrates the necessity of regular video-urodynamic controls even in asymptomatic SCI patients. Persons using triggered voiding may be at a higher risk for secondary changes, as a sustained detrusor pressure is necessary for this technique.

Use of complementary and alternative medicine in persons with spinal cord injury in Switzerland: a survey study.

STUDY DESIGN: Questionnaire-based survey study. OBJECTIVES: To evaluate the use of and the satisfaction with complementary and alternative medicine (CAM) techniques in patients with spinal cord injury (SCI). SETTING: Rehabilitation Center, Switzerland. METHODS: Between May and September 2014, all patients with chronic (>1 year) SCI attending the urologic outpatient clinic were asked to fill in a questionnaire regarding the use of CAM. RESULTS: Of the 103 participants (66 men and 37 women), 73.8% stated that they have used some form of CAM since SCI, with acupuncture and homeopathy being the two techniques that were used most frequently (31% each). The most common indications for CAM use were pain and urinary tract infections (UTIs). CAM was used supplementarily rather than exclusively. Overall satisfaction (85.1%) as well as satisfaction rates for the different indications (pain: 85%; UTI: 90.5%) and for the most frequently used forms of CAM (homeopathy: 90.6%; acupuncture: 78.1%) were high. CONCLUSION: According to our data, there is a demand for adjunctive CAM procedures for the treatment of medical complications by persons with SCI. CAM led to high satisfaction levels. On the basis of these results, future research should systematically evaluate the therapeutic potential of the most popular CAM techniques, for example, acupuncture and homeopathy, for the treatment of secondary medical complications of SCI.

Urethral strictures in men with neurogenic lower urinary tract dysfunction using intermittent catheterization for bladder evacuation.

STUDY DESIGN: Retrospective investigation. OBJECTIVES: To investigate the occurrence, characteristics and clinical consequences of urethral strictures in men with neurogenic lower urinary tract dysfunction (NLUTD) using intermittent catheterization (IC) for bladder evacuation. SETTING: Spinal cord injury rehabilitation center. METHODS: The patient database was screened for men with NLUTD who had presented for a routine video-urodynamic investigation between 2008 and 2012. Patient characteristics, bladder diary details, the occurrence of urethral strictures and performed urethrotomy procedures were collected from patient charts. Urethral strictures were classified using the Wiegand scoring system modified for men with NLUTD. RESULTS: The occurrence rate of urethral strictures (that is, 25% confidence interval (CI) 21-30%) was significantly (P=0.0001) higher in men using IC (n=415) than in men using other bladder evacuation methods (that is, 14% CI 11-17%) (n=629). Urethral strictures had occurred after a median 5.9 years (range 0.5-48.9 years) of IC. There was no significant (P>0.08) effect of tetraplegia or catheter type on the stricture occurrence rate. Approximately one-third of the men suffering from urethral strictures underwent internal urethrotomies. The radiographic stricture severity score was not associated with the need for surgical correction of the stricture. The radiographic recurrence rate of urethral strictures in operated men was 100%, a median 14 years after the first urethrotomy. CONCLUSIONS: The occurrence rate of urethral strictures is significantly higher in men using IC than in men using other bladder evacuation methods. Every fourth men using IC may be affected by urethral strictures. However, only every third stricture may require a surgical intervention.

Bladder stones in patients with spinal cord injury: a long-term study.

STUDY DESIGN: Retrospective follow-up study. OBJECTIVES: To assess the occurrence of bladder stones in patients with spinal cord injury (SCI). SETTING: Single SCI rehabilitation center in Switzerland. METHODS: We searched our database for SCI patients who had undergone surgery due to bladder stones between 2004 and 2012. In all patients retrieved, personal characteristics, bladder management, bladder stone occurrence and time to stone formation/recurrence were recorded. RESULTS: We identified 93 (3.3%) of 2825 patients with bladder stones, 24 women and 69 men, with a mean age 50 years (17-83) years. We observed bladder stones in patients with suprapubic catheter (SPC) in 11% (50/453), transurethral catheter (TC) in 6.6% (5/75), with intermittent catheterization (IC) in 2% (27/1315) and with reflex micturition (RM) in 1.1% (11/982), respectively. The mean time period to stone development was 95 months. The TC group had the shortest time interval (31 months), followed by the SPC group (59 months), individuals performing IC (116 months) and RM (211 months), respectively. Bladder stone recurrence rate was 23%. Recurrences were most frequent in the TC group (40%), followed by SPC (28%) and IC (22%), whereas no recurrences occurred in the RM group. Time to recurrence was shortest in the SPC group (14 months), followed by the IC (26 months) and the TC group (31 months), respectively. CONCLUSION: In SCI patients, bladder management has an important role in the development of bladder stones. Indwelling catheters (TC/SPC) are associated with the highest risk to develop bladder stones and therefore should be avoided if possible. If unavoidable, SPC are superior to TC.

[Extracorporeal magnetic innervation: a non-invasive therapy for urinary incontinence?]. / "Extracorporeal magnetic innervation" : Eine Ergänzung der konservativen Inkontinenztherapie?

OBJECTIVE: Extracorporeal magnetic innervation (ExMI) is a non-invasive therapy for treatment of urinary incontinence (UI). The aim of the current study was to evaluate the efficacy of ExMI in a prospective case series. PATIENTS AND METHODS: Over a period of 1.5 years 63 consecutive patients with a clinically and urodynamically confirmed diagnosis of urinary incontinence were enrolled. All patients requested an additional non-surgical therapy option and the ExMI system (Neo control™, Kitalpha, USA) was used. The therapy consisted of 12 treatment sessions two to three times a week. Primary outcome parameter was reduction of the number of pads per 24 h and secondary outcome parameters were patient satisfaction, adverse events and duration of the therapeutic effect. RESULTS: A total of 63 patients (57 male and 6 female), mean age 68±7.1 years were recruited. After completion a significant (p=0.001) reduction of the number of pads used per 24 h was observed (from 5.4±3.7 to 2.7±2.5) which persisted after a median follow-up of 12.5 months (2.3±2.2 pads per 24 h). Also patients suffering from UI after prostatectomy revealed a significant (p=0.001) reduction in the number of pads from 4.8±2.9 to 2.6±2.6 with persistence at 2.5±2.5 at follow-up. Transient, self-limiting perineal pain in three patients was the only reported side effect. CONCLUSIONS: The ExMI procedure is an additional non-invasive therapy option for patients with urinary incontinence. However, sham-controlled studies are required to corroborate the therapy effect.

[Sacral neuromodulation for neurogenic bladder dysfunction]. / Sakrale Neuromodulation bei neurogenen Blasenfunktionsstörungen.

Sacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patient's activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.

[Complete urethral duplication with dorsal epispadiac urethra: case report]. / Komplette Urethra duplex mit epispader dorsaler Harnröhre : Ein Fallbericht.

Urethral duplication is a rare congenital anomaly with variable clinical presentation. A number of theories have been proposed to describe the embryology of the condition; the actual mechanism of the disorder is still unclear. We present a 2-year-old boy with complete urethral duplication and two functional sphincters. Functional and surgical results were satisfying with good continence.

Continuous, noninvasive measurement of fetal oxygen and carbon dioxide levels in labor by use of mass spectrometry.

Clinical evaluation of the continuous, simultaneous measurement of fetal scalp surface oxygen and carbon dioxide partial pressures by mass spectrometry was undertaken for 52 labors. The mass spectrometer (MM8-80, V.G. Gas Analysis, Winsford, England) was easy to operate and had good long-term stability. The mean drifts for both oxygen and carbon dioxide over the study periods were less than 2 mm Hg. The mean (+/- SD) cervical dilatation at the time of transducer application was 6.1 (+/- 1.9) cm and the mean (+/- SD) duration of the studies was 169 (+/- 122) minutes; 10.5% of the transducer applications were unsuccessful. Falls in fetal scalp surface oxygen levels and rises in carbon dioxide levels were more frequent with late than with variable and with variable than with early fetal heart rate decelerations and with increasing severity and frequency of decelerations. Fetal scalp surface pressure changes also occurred with fetal heart rate variability changes, including some related to behavioral state changes. There was not a constant reciprocal relationship between oxygen and carbon dioxide changes, and fetal heart rate patterns were not related to actual blood gas levels. Fetal scalp surface measurements were related to both fetal blood sample and umbilical artery results. Trends in both oxygen and carbon dioxide levels during the course of labor were compared and related to other fetal variables, and most of the time the scalp surface measurements were an accurate guide to systemic blood gas levels. Maternal oxygen administration resulted in significant increase in fetal scalp surface oxygen levels, and on two of eight occasions it also led to decreases in fetal carbon dioxide levels. Scalp surface gas measurement by means of mass spectrometry is a powerful new method of intrapartum fetal monitoring, which should increase the precision of fetal surveillance as well as allow the accurate assessment of both established and new methods for optimizing labor and delivery.