Neurostimulation in neurogenic patients.

PURPOSE OF REVIEW: To provide an overview of available electrical stimulation devices in neurogenic patients with lower urinary tract disease. RECENT FINDINGS: It is advocated to do more studies in neurogenic patients as results seem promising and useful but most studies did not include neurogenic patients or neurogenic patients were not analyzed or reported separately. Most studies included a small heterogenous neurogenic group with multiple pathophysiologic origin focusing on effect of a treatment instead of results of a treatment in a specific neurogenic group. Neuromodulation or stimulation has the advantage that it acts on different organs, like bladder and bowel, so can treat neurogenic patients, who mostly suffer from multiple organ failure. SUMMARY: Brindley procedure, sacral neuromodulation (SNM) and posterior tibial nerve stimulation (PTNS) are available for a while already. The Brindley procedure (including sacral anterior root stimulation in combination with a rhizotomy of posterior sacral roots) is developed for selected spinal cord injury patient with a complete spinal injury, and has shown results for many years in neurogenic patients. An alternative to the rhizotomy is not established yet. SNM and PTNS are other modalities that are used in nonneurogenic patients, but are not yet indicated and much studied in neurogenic patients.

Survival of the artificial urinary sphincter in a changing patient profile.

PURPOSE: To examine the functional survival of the artificial urinary sphincter (AUS) AMS800 in a changing patient population. Because of increasing experience and dexterity of the operating team, we hypothesize that patients with known risk factors nowadays have a better survival of their prosthesis. However, due to a change to a more complex case mix, overall results appear to be worse. MATERIALS AND METHODS: All men who underwent implantation of an AUS between 2001 and 2016 because of urethral sphincter deficiency were retrospectively analyzed. Patients were divided in groups based on date of surgery and number of patients: 2001-2009 (G1), 2010-2013 (G2), 2014-2016 (G3). Baseline characteristics and additional therapies prior to implantation were analyzed in all groups. Risk factors for failure only in G1 and G2. Revision or explantation of the AUS was used as endpoint. Kaplan-Meier analysis was used to calculate survival of the device. RESULTS: A total of 129 patients (mean age 72 ± 9 years) underwent 129 primary implants, and 11 secondary implants. Median follow-up was 5.74 years in G1, 3.26 years G2 and 1.54 years G3. Approximately 25% of the patients in G1 had received adjuvant therapy for prostate cancer and 14% underwent previous surgery for incontinence. In G2, 51 and 55% underwent adjuvant therapy for prostate cancer and previous surgery for incontinence, respectively, G3 was comparable. The overall 50% survival improved in patients with radiotherapy and previous incontinence surgery in G2 as compared to G1. CONCLUSIONS: Despite the more complex patient population, the survival of the AUS did not decrease. In some patient categories, the AUS functional survival is even still improving over the past few years.

Clinical results of a brindley procedure: sacral anterior root stimulation in combination with a rhizotomy of the dorsal roots.

The Brindley procedure consists of a stimulator for sacral anterior-root stimulation and a rhizotomy of the dorsal sacral roots to abolish neurogenic detrusor overactivity. Stimulation of the sacral anterior roots enables micturition, defecation, and erections. This overview discusses the technique, selection of patients and clinical results of the Brindley procedure. The Brindley procedure is suitable for a selected group of patients with complete spinal cord injury and detrusor overactivity. Overall, the Brindley procedure shows good clinical results and improves quality of life. However, to remain a valuable treatment option for the future, the technique needs some adequate changes to enable analysis of the implanted parts, to improve revision techniques of the implanted parts, and to abolish the sacral dorsal rhizotomy.

Minimal invasive electrode implantation for conditional stimulation of the dorsal genital nerve in neurogenic detrusor overactivity.

STUDY DESIGN: Experimental. OBJECTIVES: Electrical stimulation of the dorsal genital nerves (DGN) suppresses involuntary detrusor contractions (IDCs) in patients with neurogenic detrusor overactivity (DO). The feasibility of minimal invasive electrode implantation near the DGN and the effectiveness of conditional stimulation to suppress IDCs at different amplitudes in spinal cord injury (SCI) patients with DO were studied. SETTING: Radboud University Nijmegen MC, The Netherlands. METHODS: In eight healthy volunteers, a needle electrode was inserted from both a medial and lateral-to-midline site at the level of the pubic bone. Electrode insertion was guided by the genito-anal reflex (GAR) evoked by electrical stimulation and by sensation to this stimulation. In eight SCI patients with DO, the bladder was repeatedly filled and emptied partially in between. Conditional stimulation using a needle electrode was applied when an IDC was observed at urodynamics. Different amplitudes were used during each filling. Control cystometry was carried out before electrode insertion and after stimulation. RESULTS: The lateral implant approach was preferred, as it was easier to manoeuvre the needle along the pubic bone and fixate the needle. In SCI patients, the electrode was positioned successfully, and IDCs were suppressed (range 1-6 IDC suppressions) with conditional stimulation at maximum tolerable amplitude, except for one patient. Stimulation was less effective at lower amplitudes. Stimulation lowered the intensity of bladder sensations concomitant with IDC. CONCLUSION: The lateral-to-midline implant approach, in combination with GAR and sensation to stimulation, is feasible for electrode implantation near the DGN in SCI patients. Conditional stimulation effectively suppresses IDCs.

No primary role of ambulatory urodynamics for the management of spinal cord injury patients compared to conventional urodynamics.

AIMS: Adequate urodynamic assessment of bladder behavior is essential in spinal cord injury (SCI) patients. Ambulatory urodynamics are more sensitive to detect detrusor overactivity (DO) than conventional urodynamics. The primary objective of this study was to determine the value of ambulatory urodynamics for the diagnosis of DO in SCI patients compared to conventional urodynamics. METHODS: Twenty-seven SCI patients who were suspected of DO underwent both conventional and ambulatory urodynamics at one day. A single involuntary detrusor contraction (IDC) was defined as a detrusor pressure rise of at least 10 cmH(2)O. DO according to the ICS definition was used in addition to minimize the influence of catheter artifacts. Outcome of urodynamics was used for decisions on treatment. RESULTS: Ambulatory urodynamics were more sensitive to diagnose IDC and DO. Conventional urodynamics had a sensitivity of 82% and specificity of 75% for DO diagnosis compared to ambulatory urodynamics. Mean maximum detrusor pressures did not differ significantly between both urodynamics. When the maximum detrusor pressure at conventional urodynamics did not exceed 40 cmH(2)O, 83% (10/12) of patients had a mean maximum detrusor pressure under 40 cmH(2)O at ambulatory urodynamics. Although the inter-individual DO diagnostic agreement was lower for ambulatory than conventional urodynamics (58%, K = 0.201 vs. 77%, K = 0552), the treatment agreement was higher for ambulatory urodynamics (58% vs. 42%). CONCLUSIONS: Ambulatory urodynamics do not seem necessary for diagnosis and risk assessment in SCI patients suspected for DO when conventional urodynamics are done properly. The exact role of urodynamics in treatment decision remains to be determined.

Limited value of bladder sensation as a trigger for conditional neurostimulation in spinal cord injury patients.

AIMS: Conditional stimulation of dorsal genital nerves suppresses undesired detrusor contractions (UDC) and consequently increases bladder capacity and prevents incontinence. No clinically applicable sensor exists for reliable bladder activity monitoring as a trigger for conditional stimulation. Primary objective of this study was to determine whether bladder sensation concomitant with UDC may be used for spinal cord injury (SCI) patients to trigger neurostimulation in daily life. METHODS: Nineteen male and 7 female SCI patients suspected of detrusor overactivity (DO) underwent conventional and 6-hr ambulatory urodynamics. Patients were instructed to do normal daily activities and to activate event buttons of the ambulatory recorder to mark events: physical activity, bladder sensation, micturition or intermittent catheterization, and urinary incontinence. Detection rate was defined as the number of recorded bladder sensation divided by the total number of recorded UDC during ambulatory urodynamics. RESULTS: Bladder sensation was reported by 73% of patients in daily life. Only 41% of patients had analyzable bladder sensation concomitant with UDC during ambulatory urodynamics. For ambulatory and conventional urodynamics, mean detection rates were 23% and 72%, respectively, with mean recording delays of 57 and 16 sec after UDC onset, respectively. CONCLUSIONS: Bladder sensation only occurs in a small group of SCI patients combined with a rather low detection rate and long reaction time. Therefore, bladder sensation as a trigger for conditional stimulation does not seem to be suitable for SCI patients with DO. Reliable techniques for chronic bladder activity monitoring are a prerequisite for successful clinical application of conditional stimulation.

ProACT for stress urinary incontinence after radical prostatectomy.

INTRODUCTION: Stress urinary incontinence is a bothersome complication of radical prostatectomy. Surgical treatment consists of the artificial urinary sphincter (AUS), the male sling and bulk injections. This study presents the results of the first series of implantations of ProACT in the Netherlands. MATERIALS AND METHODS: A non-validated questionnaire was sent to 29 male patients implanted with ProACT to determine Stamey score, pad count and questions about quality of life and satisfaction. Complications, revisions and explantations were registered. RESULTS: Mean follow-up was 41 months. Based on Stamey score four patients are continent at the end and nine patients according to the pad count. The average pad count decreased significantly. Remarkable was the high rate of dislocations and revisions and patients' satisfaction. CONCLUSIONS: ProACT is a less invasive treatment compared to the AUS. However, the procedure is associated with a substantial revision and explantation rate. ProACT can be part of a so-called step-up approach before opting for a more invasive treatment.