Temporal trends in the incidence of severe pelvic fracture urethral injuries in the United States from 1998 to 2014.

OBJECT: To use a contemporary population-based cohort to investigate temporal trends in the national incidence of pelvic fracture urethral injuries (PFUIs) in the United States. METHODS: Using the NIS (National Inpatient Sample), we identified patients with a severe PFUI by a combination of an ICD-9 diagnosis code for pelvic fracture (808.xx) and ICD-9 procedure code for suprapubic tube (57.17 or 57.18) from 1998 to 2014. We compared the annual rates of PFUIs and the annual rates of pelvic fractures alone. RESULTS: An estimated total of 6052 ± 347 males with PFUIs were identified. The average age was 38.4 ± 0.5 years. 9.1% ± 0.8% of patients died while hospitalized. In the time frame studied, the rate of PFUI significantly decreased during from 532 patients in 1998 to 255 patients in 2014. Sensitivity analysis excluding patients with bladder repairs identified a similar trend. The annual rate of PFUI per 1000 pelvic fractures has also decreased from 14.6 ± 1.6 in 1998 to 6.5 ± 0.9 in 2014 (p = 0.001). CONCLUSIONS: In this population level study, the number of severe PFUIs has decreased in the United States from 1998 to 2014, which coincides with the implementation and enforcement of seat belt and air bag regulations. Given the rarity of these cases, there is a strong need for collaborative efforts in research and teaching at tertiary care centers for reconstructive urology.

A Critical Analysis of Bulbar Urethroplasty Stricture Recurrence: Characteristics and Management.

PURPOSE: We evaluated the management of recurrent bulbar urethral stricture disease after urethroplasty at our institution. MATERIALS AND METHODS: We performed an institution review board approved, retrospective case study of our urethroplasty database to collect stricture related and postoperative information with an emphasis on bulbar urethral stricture disease recurrence after urethroplasty between 1996 and 2012. Repair types included primary anastomotic, augmented anastomotic and onlay repair. Recurrence, which was defined as the need for intervention, was diagnosed with cystoscopy or retrograde urethrogram. RESULTS: We identified 437 men who underwent urethroplasty of bulbar urethral stricture disease as performed by 2 surgeons from January 1996 to December 2012. Of the men 395 had available followup data. Recurrence was identified in 25 men (6.3%), of whom all presented with symptoms, including a weak stream in 23, urinary tract infection in 1 and pyelonephritis in 1. Median time to recurrence was 10 months. Recurrence was initially treated endoscopically in 23 of 25 cases (92%), dilatation in 12 and visual urethrotomy in 11. In 5 patients (22%) further recurrence developed after endoscopic treatment, which was managed by repeat urethroplasty in 2, self-calibration only in 2 and visual urethrotomy with subsequent self-calibration in 1. We identified 2 distinct phenotypes of recurrent stricture, including type A-short focal recurrence, which may be salvaged with an endoscopic procedure, and type B-the long graft length type, which is less likely to be salvaged with endoscopy. CONCLUSIONS: Recurrence after urethroplasty is most likely to develop within the first 12 months. Type A short focal recurrence may be managed by a salvage endoscopic procedure, including dilation or visual urethrotomy. These data on the phenotype of recurrence may be useful for patient treatment.

Female urethral injuries associated with pelvic fracture: a systematic review of the literature.

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta-analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms 'female pelvic fracture urethroplasty', 'female urethral distraction', 'female pelvic fracture urethral injury' and 'female pelvic fracture urethra girls.' Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty-one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very-low-quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal.

A Critical Evaluation of the Utility of Imaging After Urethroplasty for Bulbar Urethral Stricture Disease.

OBJECTIVE: To determine the incidence of extravasation on initial postoperative pericatheter retrograde urethrogram (pcRUG) after bulbar urethroplasty and the relationship to repair type. MATERIALS AND METHODS: We performed a retrospective review to collect stricture-related and postoperative information with emphasis on pcRUGs. All men had a pcRUG at the initial follow-up appointment. The Foley catheter was removed if no extravasation was seen and left in place for an extra week, with a repeat pcRUG if extravasation was noted. RESULTS: We limited our analysis to men who underwent bulbar urethroplasty from January 1996 to December 2012 (by two surgeons: GDW, ACP). We identified 437 patients and 407 (93%) had follow up data. The mean stricture length was 1.97 cm ± 1.2 cm. In those patients who underwent excision and primary anastomosis (EPA) (n = 232, 57%), we performed the1st pcRUG 1 week earlier compared to those who underwent augmented anastomotic repair (n = 150, 37%) or onlay repair (n = 25, 6%). There was no difference in extravasation rates among all repair types at first pcRUG. The overall rate of extravasation on the first postoperative pcRUG significantly decreased in all patients (0.98% vs 5%, P = .0008) and in those who underwent EPA (5.6% vs 0.4%, P = .0016) when the Foley catheter remained for an extra week. CONCLUSION: Men who undergo bulbar urethroplasty have a low extravasation rate (2.2%) 3 weeks postoperatively and those who underwent EPA benefited from an additional week of catheterization.

Long-term Artificial Urinary Sphincter Outcomes Following a Prior Rectourethral Fistula Repair.

OBJECTIVE: To determine the long-term outcomes of artificial urinary sphincter (AUS) implantation following a successful rectourethral fistula (RUF) repair. MATERIALS AND METHODS: Between January 1, 2006 and January 1, 2012, a total of 26 patients underwent successful repair of an RUF. Stress urinary incontinence was treated in 6 patients (23%) with implantation of an AUS. Preoperative and postoperative evaluation included demographic variables, voiding diaries, 24-hour pad weight, urodynamic characteristics, operative time, estimated blood loss, complication rates, follow-up time, and cuff selection. RESULTS: All 6 patients underwent successful RUF repair using a perineal approach. Mean age was 64.3 years (range 58-74). Mean follow-up after repair was 51.5 months (range 34-64). RUF etiology included radical prostatectomy (4), brachytherapy + external beam radiotherapy (1), and cryotherapy + external beam radiotherapy (1). The median time between RUF repair and AUS placement was 12 months (range 2-41). No intraoperative complications occurred during AUS implantation. The average operative time was 61.8 minutes with an estimated blood loss of 24 mL. The initial cuff size selected was 4.0 or 4.5 cm, and no patient required transcorporal cuff placement. Pad use was reported as ≤1 pad per day in all 6 patients at the initial 3-month follow-up. Median follow-up after AUS placement was 43.5 months (5-55). No patient required revision or removal for mechanical complications, infection, or erosion. No patient had recurrence of their previously repaired RUF or new-onset fecal incontinence. CONCLUSION: Patients who require placement of an AUS after an RUF repair seem to fare just as well as patients who undergo primary AUS implantation with no increased rate of complications postoperatively.

Simple perineal and elaborated perineal posterior urethroplasty.

A pelvic fracture urethral distraction defect (PFUDD) can present in varying lengths and degrees of complexity. In recent decades the repair of PFUDD has developed into a reliance on a perineal anastomotic approach for all but the most complex cases, which might still require an abdominal transpubic approach, or rarely a staged skin-inlay procedure. There is now controversy about the extent to which the perineal repair needs to be elaborated in individual patients. As originally described, the elaborated perineal approach comprises four steps that are used sequentially, as required, depending on the magnitude of the urethral defect. These steps are urethral mobilisation, corporal body separation, inferior wedge pubectomy and supra-crural urethral re-routing to the anastomosis. We present a review of the progressive repair, its reported use and outcomes and our recommendations for its continued use.

The Artificial Urinary Sphincter is Superior to a Secondary Transobturator Male Sling in Cases of a Primary Sling Failure.

PURPOSE: We compared continence outcomes in patients with post-prostatectomy stress urinary incontinence treated with a salvage artificial urinary sphincter vs a secondary transobturator sling. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing salvage procedures after sling failure from 2006 to 2012. Postoperative success was defined as the use of 0 or 1 pad, a negative stress test and pad weight less than 8 gm per day. We performed the Wilcoxon test and used a Cox regression model and Kaplan-Meier survival analysis. RESULTS: A total of 61 men presenting with sling failure were included in study, of whom 32 went directly to an artificial urinary sphincter and 29 received a secondary sling. Of the artificial urinary sphincter cohort 47% underwent prior external beam radiation therapy vs 17% of the secondary sling cohort (p = 0.01). Average preoperative 24 hour pad weight and pad number were higher in the artificial urinary sphincter cohort. Median followup in artificial urinary sphincter and secondary sling cases was 4.5 (IQR 4-12) and 4 months (IQR 1-5), respectively. Overall treatment failure was seen in 55% of patients (16 of 29) with a secondary sling vs 6% (2 of 32) with an artificial urinary sphincter (unadjusted HR 7, 95% CI 2-32 and adjusted HR 6, 95% CI 1-31). CONCLUSION: In this cohort of patients with post-prostatectomy stress urinary incontinence and a failed primary sling those who underwent a secondary sling procedure were up to 6 times more likely to have persistent incontinence vs those who underwent artificial urinary sphincter placement. These data are useful for counseling patients and planning surgery. We currently recommend placement of an artificial urinary sphincter for patients in whom an initial sling has failed.

Critical Analysis of Patient-reported Complaints and Complications After Urethroplasty for Bulbar Urethral Stricture Disease.

OBJECTIVE: To evaluate the full spectrum of postoperative complications and patient-reported complaints after urethroplasty for bulbar urethral stricture disease. MATERIALS AND METHODS: We performed a retrospective review of our institutional database for all patients who underwent urethroplasty from January 1, 2002 to December 1, 2012. We recorded all postoperative complications and patient-reported complaints and grouped them by the Clavien-Dindo classification of surgical complications and into the following categories: perioperative, infectious, anatomic, sexual dysfunction, and voiding related. The Fisher exact test was used to calculate statistical differences among repair types and etiology. RESULTS: Three hundred twenty-five men underwent urethroplasty by 2 surgeons (G.D.W. and A.C.P.) during the period reviewed. Two hundred ninety-two of 325 men (90%) had sufficient follow-up data available. One hundred eleven of 292 men (38%) reported a total of 146 postoperative complications or complaints. Forty-seven of 111 men (42%) were classified as having a perioperative complication, 17 of 111 (15.3%) as infectious, 8 of 111 (7.2%) as anatomic, 29 of 111 (26.1%) as sexual dysfunction, and 32 of 111 (28.8%) as voiding related. The majority of complications were classified as Clavien grade I (87 of 146, 60%). Forty-seven of 146 men (32%) were classified as having Clavien grade II, 9 of 146 (6%) as grade III, and 3 of 146 (2%) as grade IV. There were no grade V complications. Patients with iatrogenic etiology had a higher rate of infectious-related complications when compared with idiopathic or traumatic (17.5% vs 3.7%, 4.8%, respectively; P = .008). CONCLUSION: Urethroplasty continues to have excellent outcomes with acceptable complication rates, the majority of which are self-reported complaints about voiding, scrotal and/or perineal neuralgia, and sexual dysfunction and appear to have minimal long-term sequelae.

Scrotal and perineal sensory neuropathy after urethroplasty for bulbar urethral stricture disease: an evaluation of the incidence, timing, and resolution.

OBJECTIVE: To examine the timing, incidence, and resolution of scrotal and perineal sensory neuropathy after urethroplasty for bulbar urethral stricture disease. MATERIALS AND METHODS: We performed an institutional review board--approved retrospective review of our urethroplasty database with specific attention paid to patient demographics, stricture location, repair type, and postoperative sensory neuropathy defined as the complaint of hypesthesia, anesthesia, paresthesia, hyperesthesia, and pain in the scrotal and perineal region after surgery. Incidence and reported times to onset and resolution of sensory neuropathy were compared among our cohort. RESULTS: A total of 155 men underwent urethroplasty for bulbar urethral stricture disease from January 2007 to December 2012. One hundred forty-three of 155 men (92%) had postoperative data available for analysis. The average age at surgery was 47 ± 15 years and average stricture length was 2.1 ± 1.4 cm. Repair types were excision and primary anastomosis (101 of 143; 71%), augmented anastomotic repair (31 of 143; 22%), onlay repair (4 of 143; 3%), and perineal urethrostomy (7/143, 5%). Twenty of 143 men (14%) experienced postoperative scrotal and perineal neuralgia at a median time of 108 days (range, 18-160 days) from surgery. Fourteen of 20 men (70%) had subsequent follow-up visits, and all of these men had resolution of the pain, without treatment, at a median reported time of 271 days from surgery. There were no significant differences in incidence, resolution, or timing of sensory neuropathy among repair types. CONCLUSION: Our findings indicate that approximately 14% of men who undergo urethroplasty for bulbar urethral stricture disease experience postoperative scrotal and perineal sensory neuropathy. This appears to be transient with 100% resolution in our patients with available follow-up.

The evolution of urethroplasty for bulbar urethral stricture disease: lessons learned from a single center experience.

PURPOSE: We reviewed the evolution of repairs for bulbar urethral stricture disease and analyzed changes in outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of 429 men who underwent urethroplasty for bulbar urethral stricture disease from January 1996 to September 2011. Patient demographics, stricture related details, and intraoperative and postoperative information were collected. We used 1-way ANOVA for differences in age and stricture length, the Fisher exact test for differences in recurrence rates, and the t-test and chi-square test with the Bonferroni correction for subgroup analysis. RESULTS: Of the 429 men 384 (90%) had followup data available. Buccal mucosa surpassed penile skin as our preferred tissue for augmented anastomotic repairs by 1999. It was accompanied by an improved recurrence rate (21.6% vs 5.8%, p = 0.002). The average length of strictures treated with excision and primary anastomosis increased after 2004 (1.29 vs 1.54 cm, p = 0.05) but this was not associated with a significant change in the recurrence rate (3.0% vs 6.9%, p = 0.27). CONCLUSIONS: The transition from penile skin to buccal mucosa for augmented anastomotic repair was relatively abrupt. We have become more aggressive when performing excision and primary anastomosis with respect to stricture length. These changes resulted in improved outcomes. Continuing review of our practices, awareness of results reported by others and intuition contributed to our changes but prospective analysis will be the best way to continually improve outcomes.

The UroLume stent revisited: the Duke experience.

OBJECTIVE: To describe our experience with the UroLume Urethral Stent, showing that it provides a viable option for the devastated, obstructed outlet after prostate cancer treatment. METHODS: We conducted an institutional review board-approved retrospective study of all men at our facility who underwent placement of the UroLume stent from January 2001 to January 2012. Records were reviewed for patient demographics, outcomes, and complications. We specifically evaluated urinary continence, ingrowth of the UroLume stent, need for repeat operations, and complications related to this treatment including artificial urinary sphincter (AUS) erosion. RESULTS: Forty-five men underwent placement of the UroLume stent with an average follow-up of 55.8 months. Of these, 41 had simultaneous or subsequent placement of an AUS with an overall continence rate of 35 of 45 (78%). Ingrowth was seen in 16 of 45 (36%) and AUS erosion in 8 of 41 (19.5%). Of the 16 patients treated for ingrowth, the average number of treatments was 2.7 per patient. There was no association between treatment for ingrowth and rate of AUS erosion (P = .92). CONCLUSION: Although no longer commercially available, our long-term data indicate that the UroLume was a reasonable minimally invasive treatment option for the devastated, obstructed outlet providing a reasonable rate of need for subsequent interventions. The UroLume maintains patency of the urethral lumen, which usually results in incontinence, but this can be managed with placement of the AUS. The alternative open operative reconstructive options have similar limitations with possibly greater morbidity.

Comparison of diary-derived bladder and sleep measurements across OAB individuals, primary insomniacs, and healthy controls.

INTRODUCTION AND HYPOTHESIS: Can diary-derived bladder and sleep measurements differentiate individuals with overactive bladder syndrome (OAB) from individuals with primary insomnia and healthy controls? METHODS: Bladder- and sleep-diary data were compared in nine OAB, ten insomnia, and five control individuals. One-way analysis of variance (ANOVA) was used for normally and Kruskal-Wallis test for nonnormally distributed variables, followed, when significant effects were found, by pairwise comparisons. RESULTS: OAB individuals woke up as frequently as insomniacs, but their awakenings were respectively shorter in duration (18.6 vs. 38.1 min.) and were predominantly initiated by nocturic events (89.2 vs. 23.9 % respectively). Regardless, their reported quality of sleep was as impaired as for the insomniacs. Furthermore, smaller mean volume voided awakenings were evident not only in those with OAB but also in insomniacs compared to controls. CONCLUSIONS: Bladder- and sleep-diary data provide means to differentiate those with OAB from those with insomnia and healthy controls. Awakenings in OAB individuals were shorter than those with insomnia and much more likely due to the need to void. Thus, a reduction in the number of nocturic voids could be the most appropriate sleep-related outcome for nocturia therapy in individuals with OAB. In addition, limited nocturnal bladder capacity, though expected in OAB, was unexpectedly found in insomnia, possibly reflecting the role of consciousness (wakefulness at night) in modulating bladder sensation.

Outcomes following artificial sphincter implantation after prior unsuccessful male sling.

PURPOSE: Despite the proven success and durability of the artificial urinary sphincter many patients elect an AdVance® sling as the initial treatment of male stress incontinence. We determined whether sling placement would change the outcome of an ensuing artificial urinary sphincter. MATERIALS AND METHODS: A total of 29 patients with stress urinary incontinence after failed sling placement were treated with an AMS 800® artificial urinary sphincter between January 2006 and May 2011. A control group of 136 men with a primary artificial urinary sphincter was used for comparison. Preoperative and postoperative evaluation included demographic variables, voiding diary, 24-hour pad weight, urodynamic characteristics, operative time, estimated blood loss, complication rate, followup and cuff selection. RESULTS: There was no statistical difference in urodynamic characteristics, operative variables or the complication rate. Pad use was reported as less than 1 pad daily in 96% of patients (28 of 29) with a secondary artificial urinary sphincter at 3-month followup. At 20.7 months 6.9% of patients (2 of 29) treated with an artificial urinary sphincter after the male sling required revision of the artificial urinary sphincter. The overall complication rate in the control group was 8.8% (12 of 136 patients) with a 2.2% infection rate (3 of 136). The overall complication rate in the artificial urinary sphincter plus male sling group was 6.9% (2 of 29 patients) with a 0% infection rate. CONCLUSIONS: Patients who require an artificial urinary sphincter after an initial male sling seem to fare as well as those who undergo primary artificial urinary sphincter implantation.

Artificial urinary sphincter: lessons learned.

Since its introduction in 1973, the artificial urinary sphincter (AUS) has become widely accepted therapy, particularly for male incontinence. In this article, the authors review their experience with more than 600 artificial urinary sphincter (AUS) devices and discuss practical points concerning surgery and revisions. Their routine surgical approach as a means of reporting on technical lessons learned is also described.

Multiple pudendal sensory pathways reflexly modulate bladder and urethral activity in patients with spinal cord injury.

PURPOSE: Electrical stimulation of pudendal afferents can evoke reflex bladder contractions with relaxation of the external urethral sphincter in cats. This voiding reflex is mediated by pudendal sensory fibers innervating the penile and prostatic urethra that engage spinal and spinobulbospinal micturition pathways, respectively. However, clinical translation of this potential therapy in individuals with spinal cord injury is limited by the lack of evidence showing analogous reflex mechanisms in humans. We investigated excitatory pudendal-to-bladder reflexes in 7 individuals with chronic spinal cord injury. MATERIALS AND METHODS: We recorded isovolumetric bladder pressure and perineal electromyogram in response to intraurethral electrical stimulation at varying amplitudes and frequencies. RESULTS: Selective electrical stimulation of the proximal (29.7 ± 11.6 cm H(2)O) and distal urethral (23.3 ± 9.28 cm H(2)O) segments evoked sustained reflex bladder contractions in different subsets (3 each) of participants. In contrast, the corresponding reflex perineal electromyogram revealed a differential activation pattern between proximal and distal intraurethral stimulation (normalized electromyogram of 1.3 ± 0.2 and 0.3 ± 0.1, respectively, p <0.05). CONCLUSIONS: To our knowledge we report the first clinical evidence of 2 independent excitatory pudendal-to-bladder reflex pathways, which in turn differentially modulate efferent pudendal output. Each reflex mechanism involves complex interaction of multiple sensory inputs and may provide a neural substrate to restore micturition after spinal cord injury.

Detrusor overactivity persisting at night and preceding nocturia in patients with overactive bladder syndrome: a nocturnal cystometrogram and polysomnogram study.

PURPOSE: Nocturia, a common symptom of overactive bladder syndrome, is associated with substantial adverse consequences and yet its pathophysiology has hardly been studied and the capacity to treat it remains limited. We established methods to study the physiology of overactive bladder associated nocturia and better understand this phenomenon. MATERIALS AND METHODS: We recorded simultaneous, time aligned, nocturnal cystometrogram and polysomnogram data during a single night at a sleep laboratory in 9 patients with overactive bladder and detrusor overactivity on daytime cystometrogram, in 10 patients with insomnia and in 5 healthy controls. RESULTS: We safely recorded simultaneous polysomnography/nocturnal cystometrography data accurately during the sleep period. Nocturnal detrusor overactivity occurred significantly less often in patients with insomnia and controls than in patients with detrusor overactivity plus overactive bladder (p = 0.02) and only in the 10 minutes before nocturia events in the latter (0%, 0% and 67%, respectively, p = 0.002). Patients with detrusor overactivity plus overactive bladder were awake for a shorter period before nocturia events (p <0.001) and had a greater percent of nocturia associated awakenings. Patients with insomnia had more awakenings unrelated to nocturia. Nocturnal polyuria, another cause of nocturia, was not significantly associated with nocturnal detrusor overactivity. CONCLUSIONS: Sleep and bladder pressure physiology may be safely monitored during the sleep period accurately. Nocturnal detrusor overactivity occurs in association with nocturia in most patients with detrusor overactivity plus overactive bladder, does not generally occur during sleep and is not due to sleep disturbance or nocturnal polyuria. This study may provide a foundation for research on overactive bladder related nocturia pathophysiology and treatment.

Management of difficult cases in female urology and neurourology at the Reed M. Nesbit society meeting. Festschrift in honor of Edward J. McGuire, MD.

This is a panel discussion of seven complex urologic cases in female urology and neurourology. Differences in diagnosis and management are discussed by this international panel of experts.

Conditional and continuous electrical stimulation increase cystometric capacity in persons with spinal cord injury.

AIMS: Individuals with spinal cord injury (SCI) exhibit neurogenic detrusor overactivity (NDO) causing high intravesicle pressures and incontinence. The first aim was to measure changes in maximum cystometric capacity (MCC) evoked by electrical stimulation of the dorsal genital nerve (DGN) delivered either continuously or conditionally (only during bladder contractions) in persons with SCI. The second aim was to use the external anal sphincter electromyogram (EMG(EAS)) for real-time control of conditional stimulation. METHODS: Serial filling cystometries were performed in nine volunteers with complete or incomplete supra-sacral SCI. Conditional stimulation was delivered automatically when detrusor pressure increased to 8-12 cmH(2)O above baseline. MCCs were measured for each treatment (continuous, conditional, and no stimulation) and compared using post-ANOVA Tukey HSD paired comparisons. Additional treatments in two subjects used the EMG(EAS) for automatic control of conditional stimulation. RESULTS: Continuous and conditional stimulation increased MCC by 63 +/- 73 ml (36 +/- 24%) and 74 +/- 71 ml (51 +/- 37%), respectively (P < 0.05), compared to no stimulation. There was no significant difference between MCCs for conditional and continuous stimulation, but conditional stimulation significantly reduced stimulation time (174 +/- 154 sec, or 27 +/- 17% of total time) as compared to continuous stimulation (469 +/- 269 sec, 100% of total time, P < 0.001). The EMG(EAS) algorithm provided reliable detection of bladder contractions (six of six contractions over four trials) and reduced stimulation time (21 +/- 8% of total time). CONCLUSIONS: Conditional stimulation generates increases in bladder capacity while substantially reducing stimulation time. Furthermore, EMG(EAS) was successfully used as a real-time feedback signal to control conditional electrical stimulation in a laboratory setting.