Recommendations of the SUFU/AUGS/ICS Female Stress Urinary Incontinence Surgical Publication Working Group: A common standard minimum data set for the literature.

INTRODUCTION AND OBJECTIVES: Relevant, meaningful, and achievable data points are critical in objectively assessing quality, utility, and outcomes in female stress urinary incontinence (SUI) surgery. A minimum data set female SUI surgery studies was proposed by the first American Urological Association guidelines on the surgical management of female SUI in 1997, but recommendation adherence has been suboptimal. The Female Stress Urinary Incontinence Surgical Publication Working Group (WG) was created from members of several prominent organizations to formulate a recommended standard of study structure, description, and minimum outcome data set to be utilized in designing and publishing future SUI studies. The goal of this WG was to create a body of evidence better able to assess the outcomes of female SUI surgery. METHODS: The WG reviewed the minimum data set proposed in the 1997 AUA SUI Guideline document, and other relevant literature. The body of literature was examined in the context of the profound changes in the field over the past 25 years. Through a DELPHI process, a standard study structure and minimum data set were generated. Care was taken to balance the value of several meaningful and relevant data points against the burden of creating an excessively difficult or restrictive standard that would disincentivize widespread adoption and negatively impact manuscript production and acceptance. RESULTS: The WG outlined standardization in four major areas: (1) study design, (2) pretreatment demographics and characterization of the study population, (3) intraoperative events, and (4) posttreatment evaluation, and complications. Forty-two items were evaluated and graded as: STANDARD-must be included; ADDITIONAL-may be included for a specific study and is inclusive of the Standard items; OPTIMAL-may be included for a comprehensive study and is inclusive of the Standard and Additional items; UNNECESSARY/LEGACY-not relevant. CONCLUSIONS: A reasonable, achievable, and clinically meaningful minimum data set has been constructed. A structured framework will allow future surgical interventions for female SUI to be objectively scrutinized and compared in a clinically significant manner. Ultimately, such a data set, if adopted by the academic community, will enhance the quality of the scientific literature, and ultimately improve short and long-term outcomes for female patients undergoing surgery to correct SUI.

Recommendations of the SUFU/AUGS/ICS Female Stress Urinary Incontinence Surgical Publication Working Group: A Common Standard Minimum Data Set for the Literature.

INTRODUCTION AND OBJECTIVES: Relevant, meaningful, and achievable data points are critical in objectively assessing quality, utility, and outcomes in female stress urinary incontinence (SUI) surgery. A minimum data set female SUI surgery studies was proposed by the first American Urological Association guidelines on the surgical management of female SUI in 1997, but recommendation adherence has been suboptimal. The Female Stress Urinary Incontinence Surgical Publication Working Group (WG) was created from members of several prominent organizations to formulate a recommended standard of study structure, description, and minimum outcome data set to be utilized in designing and publishing future SUI studies. The goal of this WG was to create a body of evidence better able to assess the outcomes of female SUI surgery. METHODS: The WG reviewed the minimum data set proposed in the 1997 AUA SUI Guideline document, and other relevant literature. The body of literature was examined in the context of the profound changes in the field over the past 25 years. Through a DELPHI process, a standard study structure and minimum data set were generated. Care was taken to balance the value of several meaningful and relevant data points against the burden of creating an excessively difficult or restrictive standard that would disincentivize widespread adoption and negatively impact manuscript production and acceptance. RESULTS: The WG outlined standardization in four major areas: 1) study design, 2) pretreatment demographics and characterization of the study population, 3) intraoperative events, and 4) post-treatment evaluation, and complications. Forty-two items were evaluated and graded as: STANDARD - must be included; ADDITIONAL - may be included for a specific study and is inclusive of the Standard items; OPTIMAL - may be included for a comprehensive study and is inclusive of the Standard and Additional items; UNNECESSARY/LEGACY - not relevant. CONCLUSIONS: A reasonable, achievable, and clinically meaningful minimum data set has been constructed. A structured framework will allow future surgical interventions for female SUI to be objectively scrutinized and compared in a clinically significant manner. Ultimately, such a data set, if adopted by the academic community, will enhance the quality of the scientific literature, and ultimately improve short and long-term outcomes for female patients undergoing surgery to correct SUI.

The Association of Physical Activity and Urinary Incontinence in US Women: Results from a Multi-Year National Survey.

OBJECTIVES: To evaluate the relationships between physical activity, both work and recreational, and urinary incontinence among women. METHODS: We assessed women aged 20 years and older in 2008-2018 NHANES (National Health and Nutrition Examination Survey) cycles who answered self-reported urinary incontinence and physical activity questions. Weighted, multivariate logistic regression model was used to determine the association between incontinence and physical activity levels after adjusting for age, body mass index, diabetes, race, parity, menopause and smoking. RESULTS: A total of 30,213 women were included in analysis, of whom 23.15% had stress incontinence, 23.16% had urge incontinence, and 8.42% had mixed incontinence (answered "yes" to both stress and urge incontinence). Women who engaged in moderate recreational activity were less likely to report stress and urge incontinence (OR 0.79, 95% CI 0.62-0.99 and OR 0.66, 95% CI 0.48-0.90, respectively). Similarly, women who engaged in moderate activity work were less likely to report stress, urge and mixed incontinence (OR 0.84, 95% CI 0.70-0.99; OR 0.84, 95% CI 0.72-0.99; and OR 0.66 95% CI 0.45-0.97, respectively). CONCLUSIONS: Moderate physical activity and greater time spent participating in moderate physical activity are associated with a decreased likelihood of stress, urge and mixed incontinence in women. This relationship holds for both recreational and work-related activity. We hypothesize that the mechanism of this relationship is multifactorial, with moderate physical activity improving pelvic floor strength and modifying neurophysiological mediators (such as stress) involved in the pathogenesis of incontinence.

Predictors of Device-related Complications After Exchange of the Pressure-regulating Balloon in Men With an Artificial Urinary Sphincter.

OBJECTIVE: To identify patient and component specific factors that predispose patients to device-related complications when undergoing pressure-regulating balloon (PRB) exchange in men with an artificial urinary sphincter (AUS). METHOD: From 2009 to 2018, 55 patients underwent AUS revision with placement of a higher pressure 71-80 cm H2O PRB to treat recurrent stress incontinence. Patient demographics, perioperative data, and postoperative outcomes were examined and multivariable logistic regression analyses performed to identify predictors of erosion and mechanical failure. RESULT: After a median follow-up of 26.4 months (range: 6-103.7 months), 21 of 55 (38.1%) patients developed a device-related complication that required operative repair or removal of the AUS. Four (7.3%) patients developed erosion after the PRB pressure increase and 5 patients showed evidence of impending erosion on follow-up and underwent successful revision surgery. Twelve patients developed mechanical failure (cuff leak, n = 7; pump malfunction, n =4; unidentified fluid loss, n = 1). Multivariable logistic regression analysis found that increasing body mass index was a predictor of mechanical failure. Hypertension and lower body mass index were found to increase the risk of cuff erosion whereas radiotherapy was not. CONCLUSION: In the carefully selected patient, PRB exchange can be performed to treat recurrent incontinence in patients with an AUS, including those treated with pelvic radiotherapy. Our data suggest that this technique is susceptible to a high rate of revision surgery. As such, when revising a functional AUS system, meticulous preoperative screening, comprehensive informed consent, and follow-up protocols are essential in minimizing adverse events.

Spinal cord stimulation ameliorates detrusor over-activity and visceromotor pain responses in rats with cystitis.

AIM: Interstitial cystitis/painful bladder syndrome/(IC/PBS) results in recurring pain in the bladder and surrounding pelvic region caused by abnormal excitability of micturition reflexes. Spinal cord stimulation (SCS) is currently clinically used for the attenuation of neuropathic and visceral pain. The present study examined whether SCS at upper lumbar segments modulates detrusor overactivity and visceral hyperalgesia associated with cystitis in a rat model of cyclophosphamide (CYP)-induced cystitis. METHODS: Cystitis was induced by intraperitoneal injection of CYP (200 mg/kg) in six adult female Sprague Dawley rats 48 h prior to urodynamic recordings. Another six rats served as-controls with saline injection. Cystometry and the external urethral sphincter (EUS) electromyography during bladder infusion were evaluated under urethane anesthesia. The visceromotor reflexes (VMR) obtained from the external abdominal oblique muscle were quantified during bladder infusion and isotonic bladder distension (IBD), respectively. After baseline recordings were taken, SCS was applied on the dorsal surface of L3 for 25 min. Urodynamic recordings and VMR during bladder infusion and IBD were repeated 2 h after SCS. RESULTS: CYP resulted in detrusor overactivity, stronger EUS tonic contractions, and increased VMR. SCS significantly reduced non-voiding contractions, prolonged EUS relaxation, and delayed VMR appearance during bladder infusion as well as significantly decreased VMR during IBD in cystitis rats. CONCLUSION: SCS improved bladder function and EUS relaxation during bladder infusion and significantly attenuated visceral nociceptive-related VMR during IBD in cystitis rats. SCS may have therapeutic potential for patients with hyperalgesia and IC/PBS.

Mechanical failure rates of artificial urinary sphincter components: Is the 3.5-cm urethral cuff at higher risk?

AIM: We report the rates of artificial urinary sphincter (AUS) mechanical failure in a contemporary cohort of patients stratified by component type and size to determine if the 3.5-cm cuff is at higher risk of failure. METHODS: From 2005-2016, a total of 486 male patients with stress incontinence underwent implantation or revision of an AUS. 993 individual cases were retrospectively reviewed (465 primary placements and 528 revisions). Components were separately tallied and cases of mechanical failure were identified. Multiple variables including duration until failure and follow-up interval were collected and analyzed for each malfunction. RESULTS: After median follow-up of 31.5 months, there were 48 distinct cases of mechanical failure. The urethral cuff was the most common component to fail (n = 27, 56.3%), followed by the pressure regulating balloon (PRB) (n = 6, 12.5%), tubing (n = 6, 12.5%), and the control pump, (n = 5, 10.4%). Four (8.3%) cases did not have the source of malfunction identifiable in available records though fluid loss was evident at the time of device interrogation. Sub-analyses of cuff failure events showed that the 3.5-cm cuff had a statistically significant higher risk of failure (HR: 7.313, (P < .0001) compared to larger cuff sizes. CONCLUSIONS: While each component is prone to malfunction, our study suggests that the 3.5-cm urethral cuff is more susceptible to failure and failure events occur earlier after placement than larger cuff sizes.

Surveillance and management of urologic complications after spinal cord injury.

PURPOSE: Neurogenic bladder due to spinal cord injury has significant consequences for patients' health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management. METHODS: This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs). RESULTS: At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population. CONCLUSIONS: There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

Neobladder-Vaginal fistula: The University of Southern California experience.

AIMS: The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. METHODS: An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. RESULTS: Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). CONCLUSIONS: Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Urologic Management and Complications in Spinal Cord Injury Patients: A 40- to 50-year Follow-up Study.

OBJECTIVE: To assess the management and types of urologic complications in spinal cord injury (SCI) patients and to explore the risk factors for these complications. METHODS: A total of 43 SCI patients with a median follow-up of 45 (range 40-50) years were included in this retrospective study. All medical charts were reviewed for demographics, urologic complications, and bladder management. RESULTS: Recurrent urinary tract infection (UTI) was noted in all patients, with an average incidence of 6.1 cases per 5 years per person. UTI incidence peaked in the 1st and 10th 5-year intervals. Besides UTI, the most common complications were bladder stone (49%), hydronephrosis (47%), and vesicoureteral reflux (33%). Most complications initially occurred during the first 25 years post injury. Male gender, cervical injury, and condom catheter use were closely related to complications, particularly UTI and renal insufficiency. The bladder managements used for the longest period were condom catheter in men (79%) and clean intermittent catheterization in women (33%), with an average maintenance of 23.6 and 38.0 years, respectively. CONCLUSION: With long follow-up, a wide and complex range of urologic complications occurred in SCI patients and continued to do so throughout the period of follow-up. A greater risk of urologic complications may be seen with certain factors (male gender, cervical SCI, and condom catheter use); however, all patients with SCI are at risk of urinary complications over time. Thus, even long-term patients who are thought to be "stable" require regular follow-up and surveillance.

Robotic sacrocolpopexy.

Pelvic organ prolapse (POP) is a prevalent condition with 1 in 9 women seeking surgical treatment by the age of 80 years. Goals of treatment are relief and prevention of symptoms, and restoration of pelvic floor support. The gold standard for surgical treatment of POP has been abdominal sacrocolpopexy (ASC). However, emerging technologies have allowed for more minimally invasive approach including the use of laparoscopic assisted sacrocolpopexy and robotic assisted sacrocolpopexy (RASC). We performed a PubMed literature search for sacrocolpopexy, "robotic sacrocolpopexy" and "RASC" and reviewed all retrospective, prospective and randomized controlled trials. The techniques, objective and subjective outcomes and complications are discussed. The most frequent technique involves a polypropylene Y mesh attached to the anterior and posterior walls of the vagina with the single arm attached to the sacrum. Multiple concomitant procedures have been described including hysterectomy, anti-incontinence procedures and concomitant vaginal prolapse repairs. There are few studies comparing RASC to ASC, with the longest follow-up data showing no difference in subjective and objective outcomes. Anatomic success rates have been reported at 79-100% with up to 9% of patients requiring successive surgery for recurrence. Subjective success is poorly defined, but has been reported at 88-97%. Most common complications are urinary retention, urinary tract infection, bladder injury and vaginal mucosal injury. Mesh exposure is reported in up to 10% of patients. RASC allows for a minimally invasive approach to treatment of POP with comparable outcomes and low complication rates.

Neurogenic bladder: from diagnosis to management.

Patients with spinal cord injury (SCI) present with a wide range and variety of urologic manifestations, depending upon the level of injury. Historically, patients with spinal cord injury experienced significant mortality related to renal failure. Greater knowledge of the pathophysiology of SCI, however, has contributed to a reduction in mortality. It is essential to perform a thorough initial evaluation and regular follow-up of these patients to achieve the primary goal of preservation of renal function, with the secondary goal of optimizing the patient's quality of life.

Long-term efficacy of repeat incisions of bladder neck/external sphincter in patients with spinal cord injury.

OBJECTIVE: To evaluate the efficacy of repeat bladder neck incision (BNI), with or without external sphincterotomy (ES). BNI/ES has been commonly used for management of neurogenic bladder in spinal cord injury (SCI) patients. METHODS: This was a retrospective review of institutional review board-approved SCI database. RESULTS: A total of 97 patients underwent BNI/ES over a period of 40 years. During the period reviewed, a solitary redo BNI/ES was done in 46 patients, a second redo BNI/ES was done in 23 patients, and a third redo BNI/ES was done in 7 patients with success rates of 50%, 68.2%, and 85.7%, respectively. The most common indications for surgery failure and need for repeat surgery were elevated residual for the first repeat BNI/ES, recurrent urinary tract infections for the second, and elevated residual for the third repeat BNI/ES. All patients had a normal serum creatinine level at the end of the follow-up. Mean elapsed follow-up after the last redo BNI/ES was 119 months (range, 6-408 months) for all patients evaluated. Mean durability of successful redo BNI/ES was 109.1 months, which was significantly longer than mean durability of failed redo BNI/ES at 69.4 months (P <.05). CONCLUSION: SCI patients undergoing BNI/ES may require repeat BNI/ES to optimize lower urinary tract management. The success rate ranges from 50% to 85.7% after 3 repeat BNI/ES procedures with acceptable long-term durability and low perioperative complication rates.

Neurogenic lower urinary tract dysfunction: how, when, and with which patients do we use urodynamics?

Neurogenic lower urinary tract dysfunction (NLUTD) affects many patients and requires close monitoring. Initial studies establishing patients at risk for upper tract disease revealed that high detrusor leak point pressures were predictive of upper tract disease. Urodynamics in patients with NLUTD have specific challenges. Initial studies in patients after an acute injury should be delayed until after the spinal shock phase. In children with spinal dysraphism, studies should be done early to established potential risk. The goals are maintaining low bladder pressures, decreasing risk of infection, and maintaining continence.

Potential risk factors and outcomes of artificial urinary sphincter placement after radical cystectomy and orthotopic neobladder urinary diversion.

AIMS: Stress urinary incontinence (SUI) is a known possibility after radical cystectomy (RC) and orthotopic neobladder (ONB) urinary diversion. We retrospectively reviewed the outcomes and complications of patients who underwent artificial urinary sphincter (AUS) placement for treatment of SUI and evaluated potential risk factors (PRFs) for AUS failure. METHODS: Patients who underwent AUS placement after RC/ONB from 1994 to 2009 were identified. Variables evaluated included: demographics, cancer type, AUS characteristics, urinary incontinence (UI), revision procedures data, and PRFs for AUS failure. RESULTS: Demographic data was reviewed on 36 patients. Mean age at AUS placement was 72 (58-79) years. Mean time to AUS after RC/ONB was 28 (2-120) months. Mean follow up after AUS was 40 (2-132) months. TCC was the indication for RC in 94% of patients. The most commonly placed AUS cuff and reservoir size was 4.5 cm and 61-70 H2 O, respectively. Incontinence data was available in 29 patients. Pre-AUS placement 22, 3, and 4 patients were totally, daytime and nighttime only incontinent, respectively. Post-AUS placement, incontinence persisted in 5, 1, and 2 patients with total, daytime and nighttime incontinence, respectively. Prior to AUS placement 11/36 patients received chemotherapy and 10/36 had radiation. Mean time to the first revision/explantation due to UI/erosion/infection/malfunction was an average of 28 (3-96) months after AUS placement and occurred in 21/35 (60%) patients. There was no significant correlation noted between PRFs and UI pre-/post-AUS or between PRFs and the need for AUS revision. CONCLUSIONS: AUS is a safe, effective treatment with an acceptable complication rate for patients after RC/ONB with SUI.

Differences in urodynamic study variables in adult patients with neurogenic bladder and myelomeningocele before and after augmentation enterocystoplasty.

AIMS: To evaluate urodynamic parameters in myelomeningocele patients with native bladders and after augmentation, continence rates and check the longevity of these parameters after lower urinary tract (LUT) reconstruction. METHODS: A retrospective review of adult myelomeningocele patients with UDS. RESULTS: 118 adult patients with NGB secondary to myelomeningocele were identified. 58/118 (49.1%) had UDS performed in our clinic: 18/58 (31%) after prior reconstruction ("Augment" group) and 40/58 (69%) during annual urologic follow up ("NoSx" group). Urodyanmic findings after augmentation included: Pdet@MCC 31.1 (1-95) cmH(2)O, MCC 495.9 ml, NDO in 3/18 (16.7%), mean DLPP 54.0 (48-60) cmH(2)O and mean ALPP 39.6 (20-110) cmH(2)O in 5/18 with an incompetent sphincter. Patients in "NoSx" group had the following findings: Pdet@MCC of 39.6 (1-60) cmH(2)O, MCC 407.5 ml, 18/40 (45%) had NDO, mean DLPP of 48.1 (15-95) cmH(2)O and mean ALPP = 51 (17-78) cmH(2)O in 10/40 with incompetent sphincter. In the "NoSx" group, 19/40 (47.5%) had normal bladder compliance. Mean time from the surgery to UDS was 10.4 years. Continent patients in the "NoSx" group had a significantly higher MCC than incontinent patients in the same group (475 vs. 352 ml, P = 0.029). 8/17 (47.1%) continent patients in "NoSx" group had normal UDS. CONCLUSIONS: Most patients after augmentation maintain low bladder pressures for more than 10 years. Close long-term follow up should be maintained, especially in those patients that have not had prior augmentation. Urinary incontinence may be secondary to poor sphincteric function in patients with and without prior augmentation. Moreover, we should continue to follow patients after reconstruction as elevated detrusor pressures can still be seen. Strict follow up after LUT reconstruction still continues to be important.

Outcomes of artificial urinary sphincter placement in men after radical cystectomy and orthotopic urinary diversions for the treatment of stress urinary incontinence: the University of Southern California experience.

OBJECTIVE: To examine the outcomes of male patients who have undergone artificial urinary sphincter (AUS), AMS-800 (American Medical Systems Minnetonka, MN) placement for iatrogenic stress urinary incontinence after radical cystectomy (RC) and orthotopic neobladder (ONB) diversion in a single institution. MATERIALS AND METHODS: From 2002-2009, patients were prospectively randomized to undergo RC and Studer vs T-pouch neobladder reconstruction. We received IRB- approval to retrospectively review the charts of patients who underwent AUS placement for symptoms of SUI. Patients were mailed 2 validated questionnaires, International Continence Society Male-Short Form, the Incontinence Symptom Severity Index, and a pad questionnaire. RESULTS: Twelve male patients were identified. Average age at time of AUS placement was 73.8 years (range 52-82). Mean time between RC/ONB and AUS placement was 1.53 years (range 1-4). Mean follow-up time after initial AUS placement was 21.7 months (range 12-72). Ten patients (10/12; 83.3%) returned the validated questionnaires. In comparing pre-AUS to post-AUS continence, 90% of patients reported improvement in continence. Three patients deactivated their AUS during the day and activated it at night. There were no erosions (0%) or any mechanical malfunctions of the device (0%) in our cohort. There were no complications or injuries to the ONB during placement of the AUS components. CONCLUSION: AUS is a safe, effective continence procedure for patients with ONB and SUI. Complication rate, urinary symptoms, and quality of life these patients have as determined by validated questionnaires is acceptable.

Augmentation enterocystoplasty in overactive bladder: is there still a role?

Overactive bladder (OAB) is a highly prevalent syndrome defined as "urinary urgency, usually accompanied by frequency and nocturia with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology." It is known to generate a large degree of bother and can lead to significant morbidity. Augmentation cystoplasty (AC) historically has been reserved for patients refractory to conservative management. Over time, the treatment options for OAB have grown. We now have multiple pharmacological agents approved by the US Food and Drug Administration to treat OAB. In addition, neuromodulation and botulinum toxin now are viable options for patients who have suboptimal outcomes after treatment with anticholinergics and/or pelvic floor behavioral therapy. This may suggest that AC no longer is utilized as a mainstay therapy for OAB. However, despite these many possible treatment options, AC remains an important, time-tested tool in the armamentarium of the urologist to combat the patient with refractory OAB.

Comparison of extraperitoneal and intraperitoneal augmentation enterocystoplasty for neurogenic bladder in spinal cord injury patients.

OBJECTIVES: Augmentation enterocystoplasty is the standard treatment for patients with neurogenic bladder who have failed medical management. Our "extraperitoneal" approach involves a small peritoneotomy to obtain the segment of bowel for augmentation, and a standard "clam" enterocystoplasty. We compared operative and postoperative parameters and clinical outcomes of this technique with the standard intraperitoneal technique. METHODS: We retrospectively reviewed charts of 73 patients with neurogenic voiding dysfunction refractory to medical management who underwent augmentation enterocystoplasty alone or in conjunction with additional procedures. A total of 49 patients underwent extraperitoneal augmentation and 24 patients underwent intraperitoneal augmentation. Operative and postoperative parameters including time of surgery, estimated blood loss, need for blood transfusion, time for return of bowel function, and length of hospital stay were examined. Clinical outcomes including early and late postoperative complications, and continence status were also analyzed. RESULTS: Median follow-up was 2.5 years. Patients in the extraperitoneal group had significantly shorter operative time (3.9 vs. 5.6 h, P < 0.0001); shorter hospital stay (8.0 vs. 10.5 days, P = 0.009); and shorter time to return of bowel function (3.5 vs. 4.9 days, P = 0.0005). There was no significant difference in complication rates. Postoperative continence was equally improved in both groups. When only patients with no prior abdominal surgery were compared, the findings were analogous: shorter operative time, shorter length of stay, sooner return of bowel function, and no difference in complication rate. CONCLUSIONS: The extraperitoneal technique provides an equally effective method of bladder augmentation to the standard technique with easier early postoperative recovery.