Long-term outcome of transobturator tape (TOT) for treatment of stress urinary incontinence in females with neuropathic bladders.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVES: Stress urinary incontinence (SUI) is a cause of significant distress in women with neurogenic bladder dysfunction (NBD) due to spinal cord injury (SCI). Transobturator tape (TOT) has not previously been studied in this select group for cure of SUI. We aim to determine the long-term safety and efficacy of TOT in SCI patients with NBD and SUI. SETTING: London, the United Kingdom. METHODS: All patients undergoing TOT between 2005 and 2013 were identified (27 patients). All patients had pre-operative videocystometrogram (VCMG) and all had VCMG-proven SUI. Mean follow-up was 5.2 years. Patient-reported leakage, satisfaction, change in bladder management, complications and de novo overactive bladder (OAB) were recorded. RESULTS: Mean age was 56 years (range 30-82) with complete follow-up. Twenty-two patients (81.5%) reported complete dryness from SUI post surgery. One patient (3.7%) reported SUI only when her bladder was very full but was satisfied. Twenty-three patients (85.2%) were happy. Four patients (14.8%) remained wet. Twenty-five patients (92.6%) had no change in bladder management. Two out of five patients (40%) who voided by straining prior to surgery required clean intermittent self-catheterisation (CISC) post-operatively. Two patients (7.4%) developed de novo OAB. No bladder or vaginal injuries, tape erosions or urethral obstruction were seen. Three patients (11.1%) had transient thigh pain. CONCLUSION: In women with NBD and SUI, TOT should be considered safe and effective with very good medium/long-term outcomes. There may be an increased risk of CISC in women who void by straining pre-operatively.

Long-term urological management in spinal injury units in the U.K. and Eire: a follow-up study.

AIMS: The majority of patients with spinal cord injury (SCI) will develop neurogenic lower urinary tract dysfunction (NLUTD). These patients require a long-term urological follow-up. The follow-up protocol has varied across SCI units in the United Kingdom and Eire. We reviewed the long-term management in the SCI units to identify changes in practice over a decade and compared them to current guidelines. METHODS: We present results of a review of all SCI centres in the United Kingdom and Eire on their long-term urological management before and after the current guidelines and compared the results with European Association of Urology (EAU) Guidelines on NLUTD and the proposed British guidelines for the urological management of patients with SCI. Data were collected through questionnaires posted to SCI units. RESULTS: SCI patients are followed up in outpatients annually in the SCI centres and the frequency of follow-up remains largely unchanged. More SCI units perform renal tract imaging annually as a part of SCI follow-up. Most units follow the proposed British guideline indications for urodynamics and do not perform 'routine urodynamics'. CONCLUSIONS: We conclude that the long-term management of SCI patients in SCI units in the United Kingdom and Eire has changed overtime to follow the proposed British guidelines. EAU guidelines offer a more extensive follow-up regime. Last, there is a continued lack of high-quality evidence to support an optimal long-term follow-up protocol. Importantly, there is a lack of evidence on clinical outcomes when these guidelines have been followed.

Correlation of estimated and measured glomerular filtration rate in patients with interposed bowel in the urinary tract.

OBJECTIVE: Isotope glomerular filtration rate (GFR) measurement is invasive, time-consuming and expensive. Estimated glomerular filtration rate (eGFR) is used as a surrogate, but has not been validated in patients whose lower urinary tract (LUT) is replaced with bowel. This study aimed to evaluate the correlation between the Modification of Diet of Renal Disease (MDRD) eGFR andchromium-51 ethylenediamine tetra-acetic acid (Cr-EDTA) GFR in patients with LUT reconstruction/diversion. MATERIAL AND METHODS: A retrospective chart review was undertaken of 75 consecutive patients with LUT reconstruction/diversion attending scheduled follow-up in a single institutional setting. Cr-EDTA GFR, serum creatinine and eGFR were compared. Routine patient demographics, type of bowel reconstruction/diversionand time since surgery were noted. RESULTS: The correlation between Cr-EDTA GFR and creatinine was poor (r (2) = 0.411) and the limits of agreement between variables were wide (-118 to +102, p = 0.053). The correlation between Cr-EDTA GFR and eGFR was slightly better (r (2) = 0.536), and the limits of agreement narrowed to -39 to +37 (p = 0.0003). The correlation was improved (r (2) = 0.623) when separating patients with renal failure (eGFR ≤ 60 ml/min per 1.73 m(2), n = 21), but the agreement between variables was poor (-20 to +16 ml/min per 1.73 m(2), p = 0.424).Study limitations include the heterogeneous/complex patient population and types of bowel interposition, and asynchronous eGFR and Cr-EDTA GFR measurement (although no clinical events were recorded between measures). These reflect the reality in which eGFR is often used. CONCLUSIONS: There is poor correlation between eGFR and Cr-EDTA GFR in patients with LUT reconstruction/diversion with bowel. eGFR should be used with caution as a surrogate marker for isotope GFR in these patients. Larger prospective studies controlling for the study limitations identified are indicated.

Stress urinary incontinence: current understanding.

Many new concepts were introduced in epidemiology, a etiopathology and treatment of stress urinary incontinence. This review gives a short account of these concepts and compares the results of commonly used treatment options with new ones recently introduced.

Management of oncological and iatrogenic urinary incontinence in malignant disease.

Urinary incontinence can have a major effect on quality of life, and may contribute to overall disability in patients with abdominal and pelvic malignancy. It can lead to isolation and depression, and delay rehabilitation and integration within family and society. With prompt assessment and correct management, urinary leakage can be controlled and many of the problems associated with urinary incontinence can be prevented to the patient's satisfaction. In oncological patients, this is best achieved in a multidisciplinary approach. This involves close co-operation between the oncologist, urologist, specialist nurses and individual patient, setting realistic expectations, guided by the patient's views and wishes. This paper reviews the management of urinary incontinence and its surgical treatment in the palliative setting.

Injection therapy for the treatment of erectile dysfunction: a comparison between alprostadil and a combination of vasoactive intestinal polypeptide and phentolamine mesilate.

OBJECTIVE: To compare two injectable treatments, alprostadil 5-20 microg powder for injection and a combination of vasoactive intestinal polypeptide (VIP) and phentolamine in patients with erectile dysfunction (ED). DESIGN AND METHODS: This was an open multicentre, randomised crossover study comprising two phases. The first phase established the dose of each drug required to produce an erection suitable for sexual intercourse (grade 3 erection). In phase 2, responders to both drugs received, in random order, four doses of VIP/phentolamine, presented as ampoules, and four doses of alprostadil, presented as powder for injection. This was followed by four doses of VIP/phentolamine, presented in an autoinjector. In both phases, patient preference was assessed for each preparation. RESULTS: 187 patients were recruited. In the first phase, both treatments were effective, (83% alprostadil vs. 73% VIP/phentolamine, p = 0.002) but more patients preferred VIP/phentolamine (69 vs. 31%, p = 0.011). In phase 2 (n = 107), the proportion of injections that produced a grade 3 erection was similar for all three treatments (83-85%), but both presentations of VIP/phentolamine (ampoule and auto-injector) were preferred by significantly more patients (p < 0.001). Compared with both presentations of VIP/phentolamine, alprostadil produced a higher frequency of pain (28% of injections vs. 3% for each VIP/phentolamine presentation; p < 0.001) and a lower frequency of facial flushing (3 vs. 16-17%; p < 0.001). CONCLUSIONS: VIP/phentolamine and alprostadil were effective treatments for ED, however the VIP/phentolamine combination was preferred by more patients, which may be because it was much less likely to cause pain.

Long-term efficacy of AMS 800 artificial urinary sphincter in male patients with urodynamic stress incontinence due to spinal cord lesion.

STUDY DESIGN: Retrospective analysis. OBJECTIVES: To evaluate long-term efficacy and complications of AMS 800 (American Medical Systems) artificial urinary sphincter (AUS) in treatment of urodynamic stress incontinence (USI) in male patients with spinal cord lesion (SCL). SETTING: London Spinal Injuries Unit, Stanmore, UK and Institute of Urology and Nephrology, London, UK. PATIENTS AND METHODS: A retrospective analysis identified nine males with SCL (five thoracic, three lumbar, one cervical) with USI, who underwent AMS 800 AUS implantation by a single surgeon at a specialist spinal injuries unit. The mean age was 38.2 years (range 27-47 years), with the mean time since injury of 13.8 years (range 6-26 years). In all, seven were complete and two were incomplete SCL (traumatic spinal injury eight, tranverse myelitis one). All implants were inserted with the urethral cuff around the bulbar urethra with a 61-70 cm water pressure reservoir in the retropubic space. Implant activation was carried out at 6 weeks postoperatively. All patients were regularly followed up in outpatient clinics at the interval of 3 months, 6 months and yearly thereafter. An ultrasound examination for the upper tracts and a video-cystometrogram (VCMG) was carried out at 3 months postsurgery and then yearly. RESULTS: The follow-up ranged from 3 to 133 months (mean 70.2 months). All implants were activated successfully with no intra- or immediate-postoperative complications. At activation all patients reported total urinary continence with seven out of nine implants (77%) currently working well. Two patients reported significant recurrent incontinence at 3 month follow-up, one of whom underwent a removal of the entire implant at the end of 3 months and the other was continent after a pump and cuff revision. The implant removed at 3 months was due to erosion and infection while the second was removed at 24 months due to secondary implant infection. Three out of seven (43%) successful implants required one revision each. One patient continues to report minimal leakage only during transfers with no leak demonstrated on postoperative VCMG. One patient with indwelling urethral catheter, two with suprapubic catheter and one voiding on urge have changed their bladder management to intermittent catheterisations postoperatively. All removals and revision procedures were carried out in the first 53 months of follow-up and four out of seven implants (57%) required no revisions. CONCLUSION: On a long term, AMS 800 is a viable option to treat USI in men with SCL. Mechanical revisions are frequent but effective. Strict patient selection, optimum preoperative bladder management and regular follow-up ensure low complication and high efficacy rates in the long term.

Effects of repeated ejaculations on semen characteristics following spinal cord injury.

STUDY DESIGN: Prospective randomised controlled study. OBJECTIVE: To evaluate the effects of repeated ejaculation on semen characteristics following spinal cord injury (SCI) in a prospective randomised controlled study. SETTING: Spinal Research Centre, Stanmore, UK and Institute of Urology and Nephrology, London, UK. METHODS: A total of 74 patients with SCI above T10 were tested by vibro-ejaculation using a Ferticare penile vibrator (Multicept A/S Horsholm, Denmark) using a standardised technique. The ejaculate was examined according to WHO protocol. The successfully vibro-ejaculated subjects (n = 32) were randomised into a study group (n = 18) and a control group (n = 14). The patients in the study group vibro-ejaculated weekly for 3 months with semen analysis performed at baseline and then monthly. The control group vibro-ejaculated at baseline and at the end of the 3-month period. Two experienced observers performed the semen analysis independently. All measures were compared for statistical significance across the two groups at the beginning and at the end of the 3-month period using a two-tailed student t-test. Significance was determined at the 95% confidence interval (P < 0.05). RESULTS: In total, 10 patients in the study group and nine in the control group have completed the study so far. Six patients have dropped out of the study group and three from the control group for varied reasons. Two patients are currently enrolled in the study and control groups. The morphology and forward progression of sperm shows a statistically significant increase in the study group. The motility improves but is not statistically significant in the study group. No significant adverse effects were reported. CONCLUSIONS: We have shown in this unique randomised controlled study that repeated ejaculation does improve the sperm characteristics in SCI patients. It is suggested that SCI men should undergo repeated ejaculation for at least 3 months before trying intravaginal or intrauterine insemination techniques. If this fails then in vitro fertilisation can be used. This method promotes natural conception, is intimate and cost effective.

Long-term urological outcomes in paediatric spinal cord injury.

STUDY DESIGN: Retrospective review. OBJECTIVE: This retrospective review observes the evolution of bladder management by time and reports adult urological outcomes and complications in paediatric onset spinal cord injury (SCI). SETTING: Spinal Injuries Unit RNOH Stanmore. METHOD: In total, 10 traumatic SCI patients with mean age at injury of 13.6 years underwent treatment, for a mean period of 13.1 years. Characteristics of injury were noted. Two diagnostic subgroups, neurogenic detrusor overactivity (NDO), and acontractile detrusor were made. Complications, treatment changes, operative procedures with follow-up were noted. RESULTS: In group 1 (6/10 patients) with NDO, five had DSD. Initial bladder management was reflex/urge voiding (n=4), suprapubic catheterisation (SPC), (n=1) and self-intermittent catheterisation (SIC), (n=1). Two patients had multiple upper tract complications with decreased renal function, two recurrent symptomatic urinary infections and one; bladder calculus. In total, 12 operative procedures were performed to treat complications and change bladder management to, SIC+oxybutynin (n=3), ileal conduit (n=1), sacral anterior root stimulator implant (SARSI), (n=1), voiding on urge (n=1). In group 2 (4/10 patients) with a-contractile detrusor two had low compliance. Initial bladder management was SIC (n=3) and voiding on urge/straining (n=1). Two patients converted from SIC to permanent catheter drainage and reported complications. Incidental kidney stone was diagnosed in one. A total of four interventions were carried out with final management of SIC (n=2), voiding on urge/straining (n=1) and Mitrofanoff+ileocystoplasty (n=1). CONCLUSION: Bladder management in paediatric SCI is dependent on neurological level and type of injury; it changes with growth and is affected by changes in bladder management.

99mTechnetium-mercaptoacetyltriglycine scintigraphy with full bladder in patients with severe bladder dysfunction.

PURPOSE: We evaluated 99mtechnetium-mercaptoacetyltriglycine scintigraphy for detecting threshold bladder volume at which upper tract obstruction occurs in patients with bladder dysfunction. MATERIALS AND METHODS: A total of 24 patients 19 to 74 years old with severe bladder dysfunction who underwent 99mtechnetium-mercaptoacetyltriglycine scintigraphy and videocystometrogram in a 4-year period were selected for retrospective study. 99mTechnetium-mercaptoacetyltriglycine scintigraphy was done with a full bladder with a mean instilled volume of more than 850 ml saline. In patients in whom an obstructed renal outflow pattern was observed saline was drained at a rate of 100 ml every 5 minutes while dynamic imaging was performed. If results were abnormal, the study was repeated with an empty bladder. Differential function, parenchymal transit time index and outflow efficiency were calculated. RESULTS: Of the 24 patients 15 had an obstructed outflow pattern with a full bladder, which was relieved at a bladder volume of less than 390 ml (median 300, range 250 to 600). Only 2 of these 15 patients had a normal vesical end filling pressure of less than 20 cm H2O. There was no obstruction in 9 patients, of whom 5 had increased vesical end filling pressures. Followup in patients who had normal tracer outflow on a full bladder showed no decrease in renal function, while a small decrease was seen in patients who had obstructed outflow on a full bladder. CONCLUSION: This novel, full bladder 99mtechnetium-mercaptoacetyltriglycine scintigraphic technique provides the ability to detect bladder volumes at which obstructive outflow patterns develop in patients with severe bladder dysfunction.

Autonomic dysreflexia: a medical emergency.

Autonomic dysreflexia is an important clinical diagnosis that requires prompt treatment to avoid devastating complications. The condition may present itself to all members of medical and surgical specialties, who may not be accustomed to treating it. It is the clinician's responsibility to have a basic understanding of the pathophysiology of the condition and the simple steps required to treat it.

Effects of botulinum toxin B on refractory detrusor overactivity: a randomized, double-blind, placebo controlled, crossover trial.

PURPOSE: Open, observational studies of intradetrusor injections of botulinum toxin for detrusor overactivity have reported beneficial effects. We tested the efficacy and safety of botulinum toxin B for the treatment of the overactive bladder in a randomized, double-blind, placebo controlled crossover trial. MATERIALS AND METHODS: A total of 20 patients 18 to 80 years old with detrusor overactivity unresponsive to oral antimuscarinic agents participated in the study. They were injected with either placebo (20 ml normal saline) or botulinum toxin B (5,000 IU diluted up to 20 ml) intravesically in a day case setting. After 6 weeks the treatments were crossed over without washout in line with previous findings. The primary outcome was the paired difference in change in average voided volumes. Frequency, incontinence episodes and paired differences in quality of life measured by the King's Health Questionnaire were the secondary outcome measures. RESULTS: The Wilcoxon signed ranks test was used to test the paired difference in change between treatment phases. Little carryover was noted in the second arm placebo and the placebo data from both arms were included in analysis. There were clinically statistically significant paired differences in the change in average voided volume, urinary frequency and episodes of incontinence between active treatment and placebo (average voided volume: 95% CI difference 16, 122; Z2.5; p = 0.012/weekly frequency: 95% CI -21, -1; Z2.1, p=0.033/weekly incontinence: 95% CI -26, -7; Z3.3; p = 0.001). There were similarly significant paired differences in the change in quality of life affecting 5 domains of the King's Health Questionnaire. CONCLUSIONS: This double-blind, placebo controlled, crossover study provides evidence of the efficacy of botulinum toxin B in the treatment of overactive bladder. Autonomic side effects were observed in 4 patients. The short duration of action will presumably limit the use to patients who have experienced tachyphylaxis with botulinum toxin A.

Penile erosion in spinal cord injury--an important lesson.

STUDY DESIGN: A case report of the complications of a spinal cord injury (SCI) patient alternating between indwelling urethral catheter and a condom drainage system for bladder management. OBJECTIVE: To highlight the importance of penile care for bladder drainage following SCI. SETTING: Spinal Injuries Unit, Stanmore, UK. SUBJECT: A 39-year-old male who sustained a lumbar level SCI in December 2000. He presented acutely with leakage of urine around his condom drainage device. MAIN OUTCOME MEASURE: The examination revealed an eroded area on the ventral aspect of the proximal penile shaft, which corresponded to the site of condom attachment. An indwelling urethral catheter was inserted as a temporary measure before reconstruction. RESULT: At operation, in addition to the preoperatively observed area of erosion, the penile urethra was found to be cleaved for almost its entire length. CONCLUSIONS: The patient had suffered two complications from a combination of two types of bladder management, and surgery was successful in treating both the urethral cleavage and the skin erosion.

Pitfall in insertion of suprapubic catheter in patients with spinal cord injuries.

OBJECTIVE: To report an unusual presentation of a misplaced suprapubic catheter (SPC) in a spinal cord injury (SCI) patient. DESIGN: A case report of a SCI patient in whom a SPC was 'partially misplaced' in an emergency. SETTING: London Spinal Injuries Unit, Stanmore, UK. SUBJECT: A 33-year-old man who sustained a C5 SCI in a road traffic accident 6 months ago. He had an indwelling urethral catheter, which blocked off and repeated attempts to reinsert another one per urethra were unsuccessful. MAIN OUTCOME MEASURE: A SPC was inserted in an emergency at the bedside, as he developed autonomic dysreflexia. The catheter initially drained clear urine but subsequently the flow became intermittent. He also started complaining of lower abdominal discomfort. RESULTS: The abdominal examination was unremarkable without signs of peritonism. An ultrasound scan of the abdomen revealed the eye of the catheter in the bladder but the balloon had been inflated in the subcutaneous tissues. It was reinserted under cystoscopic control in the operating theatre. CONCLUSION: The insertion of a SPC in a neuropathic patient can be a challenge even for an experienced urologist. As these patients often have small capacity bladders, the SPC should be inserted under cystoscopic control wherever possible. However if they are inserted blindly there should be a high index of suspicion for the potential complication of a misplaced catheter. The patient should undergo regular abdominal examination and an ultrasound scan should be performed as soon as possible for confirmation.

Experience of tension-free vaginal tape for the treatment of stress incontinence in females with neuropathic bladders.

STUDY DESIGN: Retrospective. OBJECTIVE: To evaluate the safety and efficacy of the tension-free vaginal tape (TVT) for the treatment of stress incontinence in females with neuropathic bladders. SETTING: London Spinal Injuries Unit, Stanmore & Institute of Urology, London, UK. METHODS: Twelve women (mean age 53.3 years; range 41-80 years) with neuropathic bladder dysfunction and stress urinary incontinence were treated with tension-free vaginal tape (TVT) between November 1997 and December 2000. The group consisted of women with: (i) traumatic spinal cord injuries (n=3); (ii) post lumbar spinal surgery (n=6); (iii) spinal stenosis (n=3). Four of the 12 patients had previously failed surgery for stress incontinence. All patients underwent pre- and post-TVT evaluation with video-urodynamic studies. RESULTS: Mean follow-up was 27.1 months (range 17-54 months). Three patients were voiding spontaneously (stress voiding) before surgery and continued to do so post-operatively. The remaining 9 were performing clean intermittent self-catheterisation before the insertion of TVT and continued to do so after the surgery. At follow up 10 patients (83.3%) were dry. The procedure failed in one patient and the other complained of mild leakage, but she reported a decrease in the number of pads used. One patient developed detrusor hyperreflexia on post-operative video-urodynamics but there was no evidence of stress incontinence. One patient had a bladder perforation on insertion of TVT, managed successfully with extended use of a urethral catheter post-operatively. Three patients developed post-operative urinary tract infection successfully treated with oral antibiotics. CONCLUSIONS: Tension-free vaginal tape insertion is minimally invasive, safe and effective for the treatment of stress incontinence in females with bladder neuropathy with intrinsic sphincter deficiency. Previous surgery for incontinence did not affect post-operative complications or outcome.

Surgical and patient reported outcomes of 'clam' augmentation ileocystoplasty in spinal cord injured patients.

OBJECTIVE: To study the outcomes and effectiveness of 'clam' augmentation ileocystoplasty in the treatment of suprasacral spinal cord injured patients with detrusor hyperreflexia refractory to pharmacological and other conservative therapy. METHODS: A retrospective review of spinal injured patients who had undergone 'clam' augmentation ileocystoplasty was performed, followed by a specifically designed questionnaire/telephone interview to assess patient satisfaction and other issues from this specific group of patients with suprasacral spinal cord lesions. 32 patients were followed up for a mean of 6.0 +/- 3.6 years. RESULTS: Complete continence was found in all patients. There was a significant improvement in bladder capacity from a mean 143 +/- 81 ml pre-operatively to 589 +/- 188 ml post-operatively, and the maximum detrusor pressure fell from a mean of 108 +/- 43 cm H(2)O to 19 +/- 15 cm H(2)O. Pre-operative vesico-ureteric reflux resolved completely in 4 out of 5 patients and improved from grade IV to grade II in one, illustrating the need for achieving low bladder pressures rather than the performance of an anti-reflux procedure at the time of cystoplasty. The use of the questionnaire, designed to evaluate this subset of patients after augmentation cystoplasty, highlighted the high levels of satisfaction with the operation in this group of patients with 96.2% of patients reporting an improvement in quality of life parameters. CONCLUSION: Using an appropriate questionnaire we have found high satisfaction rates, in addition to successful surgical outcomes, in spinal cord injured patients following augmentation cystoplasty. We recommend using this questionnaire as part of the work-up and ongoing assessment of spinal injured patients undergoing 'clam' augmentation ileocystoplasty.