Surgical management of the neurogenic bladder after spinal cord injury.

PURPOSE: This work represents the efforts of the SIU-ICUD workgroup on this topic and comprehensive literature search of English language manuscripts regarding urologic surgery in spinal cord injury using key words of urologic surgery and spinal cord injury. Articles were compiled, and recommendations in the chapter are based on group discussion and intensive communication. The purpose is to review what has been published during the last decades on urological surgery for neurogenic bladder after spinal cord injury. METHODS: Surgical techniques applied in spinal cord injured patients for neurogenic bladder dysfunction have been reviewed and the published material evaluated. RESULTS: There are several techniques that can be used to treat neurogenic dysfunctions and symptoms in refractory cases where conservative treatment failed. The number of publications is small as are the number of patients with spinal cord injury in which they have been performed. The choice of techniques proposed to the patients depends on the exact functional pathology in bladder, bladder neck and urethral sphincter. The final informed choice will be made by the patient. CONCLUSION: There are surgical urological techniques available to treat neurologic dysfunctions in spinal cord injured patients.

Efficacy and safety of urinary catheters with silver alloy coating in patients with spinal cord injury: a multicentric pragmatic randomized controlled trial. The ESCALE trial.

BACKGROUND: Patients with spinal cord injury (SCI) who carry indwelling urinary catheters have an increased risk of urinary tract infection (UTI). Antiseptic silver alloy-coated (SAC) silicone urinary catheters prove to be a promising intervention to reduce UTIs; however, current evidence cannot be extrapolated to patients with SCI. PURPOSE: This study aimed to assess the efficacy of SAC urinary catheters for preventing catheter-associated urinary tract infections. DESIGN/SETTING: This is an open-label, multicenter (developed in Spain, Portugal, Chile, Turkey, and Italy), randomized clinical trial conducted in 14 hospitals from November 2012 to December 2015. PATIENT SAMPLE: Eligible patients were men or women with traumatic or medical SCI, aged ≥18 years, requiring an indwelling urinary catheter for at least 7 days. OUTCOME MEASURES: The primary outcome was the incidence of symptomatic UTIs. The secondary outcome included bacteremia in the urinary tract and adverse events. MATERIALS AND METHODS: Patients were randomized to receive a SAC urinary catheter (experimental group) or a standard catheter (control group) for at least 7 days. Data were compared using chi-squared test and also calculating the absolute risk difference with a 95% confidence interval. An adjusted analysis including different risk factors of UTI was performed. This study was mainly funded by La Marató de TV3 Foundation (grant number # 112210) and the European Clinical Research Infrastructures Network organization. The funders had no role in the interpretation or reporting of results. RESULTS: A total of 489 patients were included in the study, aged 55 years in the experimental group and aged 57 in the control group (p=.870); 72% were men; 43% were hospitalized patients, and 57% were outpatients (p=1.0). The most frequent cause of SCI was traumatic (73.75%), and the localization was mainly the cervical spine (42.74%). Most of the patients had an A score (complete spinal injury and no motor and sensory is preserved) on the ASIA scale (62.37%). The median time of urethral catheterization was 27 days in the experimental group and 28 days in the control group (p=.202). Eighteen patients (7.41%) in the experimental group and 19 in the control (7.72%) group had a symptomatic UTI (odds ratio [OR] 0.96 [0.49-1.87]). The adjusted analysis revealed no change in the results. Only three patients in the experimental group had bacteremia within the urinary tract. The experimental group presented more adverse events related to the use of a catheter than the control group (OR 0.03 [0.00-0.06]). CONCLUSIONS: The results of this study do not support the routine use of indwelling antiseptic SAC silicone urinary catheters in patients with SCI. However, UTIs associated to long-term urinary catheter use remain a challenge and further investigations are still needed.

Subject-controlled stimulation of dorsal genital nerve to treat neurogenic detrusor overactivity at home.

AIMS: To investigate the effects of subject controlled dorsal genital nerve (DGN) electrical stimulation on neurogenic detrusor overactivity (NDO) in subjects at home. METHODS: Subjects underwent a 5-day study at home with DGN stimulation. Stimulation was provided with surface electrodes placed either on the dorsal penile shaft in males and on or close to the clitoris in females. The days 1 and 5 were with no stimulation whereas days 2-4 were with stimulation. Two urodynamic studies were performed at the beginning and at the end of the study. A bladder diary was obtained. RESULTS: Eleven subjects with NDO and with urge incontinence were included. One subject stopped the protocol before the end of the 5-day trial and two did not undergo the second urodynamic study. The subjects showed a statistically significant increase in bladder capacities compared to baseline (P = 0.047). Mean volume per day voided significantly increased over the study within the subjects. Differences between day 1 and day 5 were statistically significant (P = 0.028). CONCLUSIONS: The feasibility and the globally positive outcomes of the study indicate that the stimulation of the dorsal genital nerve can be an option for the treatment of the NDO.

Effect of sacral anterior root stimulator on bowel dysfunction in patients with spinal cord injury.

PURPOSE: Bowel dysfunction is a problem in patients with spinal cord injury. The sacral anterior root stimulator has been used for neurogenic bladder and has been claimed to be useful for neurogenic bowel. The purposes of this study were to analyze the clinical response of bowel function to the sacral anterior root stimulator and to evaluate physiologic factors that could determine its efficacy. METHODS: Eighteen consecutive patients with spinal cord injury and an implanted sacral anterior root stimulator were evaluated. Clinical assessment, colonic transit time, and anorectal manometry were performed. Patients were evaluated before implantation of the sacral anterior root stimulator and clinically reevaluated after 12 months. RESULTS: Fewer patients required laxatives after implantation of the sacral anterior root stimulator. The mean number of methods used to evacuate was reduced from 2.1 to 1.5 (P < 0.05). Bowel movement frequency was higher (P < 0.05). Time devoted to defecation was reduced, although no statistical significance was achieved. Fecal incontinence did not change, but constipation was reduced (P < 0.05). Most patients reported being more satisfied with bowel function after implantation of the sacral anterior root stimulator. No correlation was found between objective and subjective responses to the sacral anterior root stimulator and manometric or colonic transit times before implantation. CONCLUSION: The sacral anterior root stimulator improves bowel function, and patient satisfaction with this treatment is high. Further studies are needed to evaluate the characteristics of stimulation parameters to achieve better results.

Urethral sphincter EMG as event detector for Neurogenic detrusor overactivity.

The aim of this study was to investigate the feasibility of using external urethral sphincter electromyogram (EMG) (EUSEMG) to detect the onset of detrusor contractions in patients with both neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia (DSD). Detrusor pressure (Pdet) and EUSEMG was recorded in 23 neurogenic patients during slow artificial bladder filling. The time delay between the onset of a detrusor contraction and the onset of EUSEMG activity was calculated together with the detrusor pressure increase related to this delay. Of 23 patients enrolled, 12 patients showed both NDO and DSD. Of these 12 patients, 10 had a strong correlation between detrusor pressure and EUSEMG. One patient in this group was excluded due to a storage pressure above 30 cm H2O. Two detection methods were applied on the remaining 9 patients. Method 1 was a root mean square (RMS)-integrator with simple thresholding. This approach had a good sensitivity but also a poor specificity (many false-positive detections). Detection method 2 included a kurtosis-based scaling function, which was multiplied to a similar RMS-integrator as used in method 1. Onset detection occurred before Pdet exceeded 18 cm H2O with both methods. However, method 1 resulted in 14.1 +/- 12.8 false-positive detections during one bladder filling. Pdet at onset detection was on average 1.0 +/- 1.1 cmH2 0 higher with detection method 2 but the number of false-positives was reduced by 95.8%. This paper demonstrates the feasibility of using EUSEMG to estimate the onset of a detrusor contraction in selected patients.

Intraoperative recording of sacral root nerve signals in humans.

Electroneurographic signals were intraoperatively recorded from the S3 sacral nerve root in two SCI patients. The aim of this study was to record afferent nerve signals in response to mechanical stimulation of the urinary bladder, rectum, and dermatome. Such signals could be used in an implantable neuroprosthesis to treat neurogenic detrusor overactivity. In both patients a neural response was recorded from the dermatome and the rectum, but from the bladder only in one patient. The results were consistent with results from animal and other human studies. Further studies are however, needed because the number of subjects investigated remains low.