A retrospective review of the long term clinical outcomes of patients with neurogenic lower urinary tract dysfunction following transverse myelitis.

AIMS: Transverse myelitis (TM) is an inflammation of the spinal cord which causes neurological deficit in motor, sensory, and autonomic pathways. Persistent neurogenic lower urinary tract dysfunction (NLUTD) is common even where motor and sensory impairment is recovered. Long term follow-up is required to ensure optimal bladder management and protection of the upper tracts. We describe the clinical outcomes for a cohort of patients with TM who have received neurourological follow-up in a specialist center. METHODS: A retrospective review of TM patient records was performed. Current pharmaceutical and surgical management, upper tract status, and patient reported symptoms are reported. Changes in urodynamic parameters and bladder emptying technique between current and baseline were analyzed. RESULTS: Sixty patients with NLUTD following TM were identified. The mean age at onset of NLUTD was 29 years (0-77 years). The mean follow-up was 13 years. 55% of patients were taking antimuscarinic medication, 53% of patients had intradetrusor botulinum toxin injections and 5% had bladder augmentation surgery. Forty-one patients had a baseline and recent urodynamic study which could be compared. Fifty-three of fifty-eight patients with a recent renal ultrasound had normal renal appearance. Four had mild hydronephrosis and one more extensive hydronephrosis. CONCLUSION: TM can have a persistent effect on lower urinary tract function. There is potential for upper tract damage if bladder management is not optimized. We have demonstrated that in a specialist neurourology unit within a tertiary center, one can provide acceptable long term outcomes following international guidelines.

Incidence, type and management of ureteric injury associated with vesicovaginal fistulas: Report of a series from a specialized center.

OBJECTIVES: To report a large series of vesicovaginal fistula, and to assess the incidence of ureteric injury in association with vesicovaginal fistula. METHODS: We retrospectively reviewed a prospective database of patients with vesicovaginal fistula referred to our center between 2004 and 2016. Data on patient demographics, fistula etiology, mode of repair, and any associated ureteric injury and its treatment were noted. RESULTS: Overall, 116 patients (median age 49 years, range 23-88 years) were referred for management of vesicovaginal fistula during the study period. Four of these patients (3.4%) had associated ureteric injury, one of whom had bilateral injury. Ureteric obstruction alone was noted in two patients, ureterovaginal fistula alone in one patient, and bilateral ureteric obstruction and ureterovaginal fistula in one patient. All ureteric injuries were managed with simultaneous reimplantation into the bladder at the time of vesicovaginal fistula repair. Five patients had post-radiotherapy vesicovaginal fistula, and the remainder were post-surgical. Three patients with post-radiotherapy vesicovaginal fistula proceeded to primary diversion. CONCLUSIONS: Ureteric injury is far less common than previously reported, occurring in <5% of patients presenting with vesicovaginal fistula. It can be successfully managed, and it remains the major indication for abdominal repair of vesicovaginal fistula.

Radiotherapy is associated with reduced continence outcomes following implantation of the artificial urinary sphincter in men with post-radical prostatectomy incontinence.

OBJECTIVES: The objective of this study is to present the outcomes of men undergoing implantation of artificial urinary sphincter, after treatment for prostate cancer and also to determine the effect of radiotherapy on continence outcomes after artificial urinary sphincter (AUS) implantation. MATERIALS AND METHODS: A prospectively acquired database of all 184 patients having AUS insertion between 2002 and 2012 was reviewed, and demographic data, mode of prostate cancer treatment(s) before implantation, and outcome in terms of complete continence (pad free, leak free) were assessed. Statistical analysis was performed by Chi-squared and Fisher's exact tests. RESULTS: A total of 58 (32%) men had bulbar AUS for urodynamically proven stress urinary incontinence consequent to treatment for prostate cancer in this period. Median follow-up post-AUS activation was 19 months (1-119). Forty-eight (83%) men had primary AUS insertion. Twenty-one (36%) men had radiotherapy as part of or as their sole treatment. Success rates were significantly higher in nonirradiated men having primary sphincter (89%) than in irradiated men (56%). Success rates were worse for men having revision AUS (40%), especially in irradiated men (33%). CONCLUSION: Radiotherapy as a treatment for prostate cancer was associated with significantly lower complete continence rates following AUS implantation.

A 20-year follow-up of the mesh wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury.

OBJECTIVE: To assess the long-term (20 years) effectiveness of the UroLume wallstent(TM) (Pfizer Inc., UK) in the treatment of detrusor external sphincter dyssynergia (DESD) in patients with spinal cord injury (SCI). PATIENTS AND METHODS: Twelve patients with quadriplegia secondary to SCI underwent external striated sphincter stenting with the UroLume wallstent in place of sphincterotomy for DESD ≈ 20 years ago. The mean (range) age was 41.8 (26-65) years. Eleven patients had cervical level injury whilst one had a thoracic injury. All the patients were shown to have high-pressure neurogenic detrusor overactivity and DESD with incomplete emptying on preoperative video-cystometrograms (VCMG). RESULTS: Six of the 12 patients have now been followed-up for a mean (range) of 20 (19-21) years. Of the remaining six, two were lost to follow-up at 1 and 3 years, but both remained free of complications during that time. Two patients developed encrustation causing obstruction, requiring stent removal within 1 year of insertion. Another patient with an adequately functioning stent died 7 years after stent insertion from a chest infection. The twelfth patient developed bladder cancer 14 years after stent insertion and underwent cystectomy with urinary diversion. VCMG follow-up of the six patients showed a significantly sustained reduction of maximum detrusor pressure and duration of detrusor contraction at the 20-year follow-up. Five of these six patients developed bladder neck dyssynergia of varying degrees as shown on VCMG within the first 9 years of follow-up. All were successfully treated with bladder neck incision (BNI) where the last BNI needed was at 12 years. We did not encounter any problem with stent migration, urethral erosion, erectile dysfunction or autonomic dysreflexia. CONCLUSION: Urethral stenting using the UroLume wallstent is effective in the management of DESD in patients with SCI and provides an acceptable long-term (20-year follow-up) alternative to sphincterotomy. The failures manifest within the first few years and can be managed easily with stent removal without any significant problems. Bladder neck dyssynergia was the long-term complication which was treated successfully with BNI. It has no significant interference with erectile function, being reversible, minimally invasive and has a shorter hospital stay.

Effects of spinal cord injury on semen parameters.

OBJECTIVE/BACKGROUND: Neurogenic reproductive dysfunction in men with spinal cord injury (SCI) is common and the result of a combination of impotence, ejaculatory failure, and abnormal semen characteristics. It is well established that the semen quality of men with SCI is poor and that changes are seen as early as 2 weeks after injury. The distinguishing characters of poor quality are abnormal sperm motility and viability. In the majority of the men with SCI, the sperm count is not abnormal. We elaborate on the effects of the SCI on semen parameters that may contribute to poor motility and poor viability. METHODS: Review. DESIGN: PubMed and MEDLINE databases were searched using the following key words: spinal cord injuries, fertility, sexual dysfunction, and spermatogenesis. All literature was reviewed by the team of authors according to the various stages of sperm development and transport in the male reproductive cycle. FINDINGS: The cause of asthenozoospermia appears to be multifactorial. CONCLUSION: Current literature does not support the preeminence of a single factor relating to neurogenic reproductive dysfunction in men with SCI. After SCI, there is ample evidence of disturbance of sperm production, maturation and storage, and transport due to an abnormal neuroendocrine milieu. Semen quality seems to be primarily affected by changes to the seminal plasma constituents, type of bladder management, and the neurogenic impairment to the ejaculatory function. Further focused and structured studies are required.

An effective day case treatment combination for refractory neuropathic mixed incontinence.

OBJECTIVE: Women with drug refractory neurogenic mixed incontinence (NMI) have limited minimally invasive treatment options and require reconstructive surgery. We examined efficacy of a combination of day case intradetrusor (ID) botulinum toxin (BTX-A) bladder injections and transobturator (TOT) or tension free vaginal tape (TVT). MATERIALS AND METHODS: Eleven women who are pharmacotherapy intolerant or who have drug refractory NMI were treated. Two opted for open surgery and the remaining 9 received 1000 units of Dysport diluted in 30 mL saline cystoscopically at 30 ID sites followed by TOT in 6 or TVT in 3 as a day case combination treatment. Patient demographics, pre and post treatment videocystometrogram (VCMG), pad test and International Committee on Incontinence Questionnaire (ICIQ) scores were recorded. At 6 weeks (repeat ICIQ, pad test and patient satisfaction), at 3 and 12 months (VCMG) and 'current' (ICIQ and patient satisfaction) was recorded. RESULTS: The mean age was 56.7 years (range 41 to 78) with a mean follow up of 19.1 months (range 7 to 33). All women were continent at 3 and 12 months. Quality of life (ICIQ scores) improved at 6 weeks (p > 0.001) and remained stable up to the last follow up (p > 0.001). Eight women have stopped using pads. At 3 months, there was significant improvement in MDP (p > 0.014) and MCC (p = 0.002). Anticholinergics were discontinued in 7 with global high satisfaction with the treatment BTX-A injections were repeated in 4 (mean 13.5 months). CONCLUSION: Anticholinergic refractory women with NMI can be effectively treated as a day case with combination of ID BTX-A injections and TVT or TOT.

An effective day case treatment combination for refractory neuropathic mixed incontinence

OBJECTIVE: Women with drug refractory neurogenic mixed incontinence (NMI) have limited minimally invasive treatment options and require reconstructive surgery. We examined efficacy of a combination of day case intradetrusor (ID) botulinum toxin (BTX-A) bladder injections and transobturator (TOT) or tension free vaginal tape (TVT). MATERIALS AND METHODS: Eleven women who are pharmacotherapy intolerant or who have drug refractory NMI were treated. Two opted for open surgery and the remaining 9 received 1000 units of Dysport diluted in 30 mL saline cystoscopically at 30 ID sites followed by TOT in 6 or TVT in 3 as a day case combination treatment. Patient demographics, pre and post treatment videocystometrogram (VCMG), pad test and International Committee on Incontinence Questionnaire (ICIQ) scores were recorded. At 6 weeks (repeat ICIQ, pad test and patient satisfaction), at 3 and 12 months (VCMG) and 'current' (ICIQ and patient satisfaction) was recorded. RESULTS: The mean age was 56.7 years (range 41 to 78) with a mean follow up of 19.1 months (range 7 to 33). All women were continent at 3 and 12 months. Quality of life (ICIQ scores) improved at 6 weeks (p > 0.001) and remained stable up to the last follow up (p > 0.001). Eight women have stopped using pads. At 3 months, there was significant improvement in MDP (p > 0.014) and MCC (p = 0.002). Anticholinergics were discontinued in 7 with global high satisfaction with the treatment BTX-A injections were repeated in 4 (mean 13.5 months). CONCLUSION: Anticholinergic refractory women with NMI can be effectively treated as a day case with combination of ID BTX-A injections and TVT or TOT.

Lower urinary tract dysfunction in ambulatory patients with incomplete spinal cord injury.

PURPOSE: We evaluated urinary tract dysfunction in individuals with spinal injury who remained able to ambulate. We observed changes with time in urological management. MATERIALS AND METHODS: All patients attending outpatient clinics with traumatic, incomplete (American Spinal Injury Association grades D and E) spinal cord injury during a 2-year period were identified. All patients had their hospital notes reviewed retrospectively and salient urological data extracted. RESULTS: A total of 43 men and 21 women were identified during this period. Mean age was 46 years (range 18 to 70). Mean followup was 7 years (range 1 to 18). At the time of inpatient discharge 40 of the 64 patients (62.5%) could void spontaneously, 20 required CSIC and 4 had a suprapubic catheter. In 19 of these 40 patients (47.5%) who had been initially assessed as having a bladder that was safe to void spontaneously the condition deteriorated, such that CSIC was required. Conversely 5 of 20 patients (25%) who initially required CSIC improved, such that it became redundant. At last followup 68.7% of the patients had abnormal urodynamics and 24 of the 64 (37.5%) required a change in urological management despite no appreciably detectable neurological change. CONCLUSIONS: Despite relatively near total neurological recovery patients with incomplete SCI have neuropathic bladder unless proved otherwise. Salient deterioration in bladder dysfunction is not uncommon. Regular urological monitoring and appropriate treatment changes are required in the long term.

Long-term results of a self-expanding wallstent in the treatment of urethral stricture.

OBJECTIVE: To report the long-term outcome over 12 years of using the urethral Urolume wallstent (AMS, Minnetonka, MI, USA) for treating recurrent bulbar urethral stricture disease. PATIENTS AND METHODS: The case-notes of 60 consecutive men with urethral Urolume wallstents placed for treating recurrent bulbar strictures were reviewed retrospectively. Information was collected on patient demographics, stricture aetiology, stent-related complications and the need for further surgery to treat stent- or stricture-related complications. RESULTS: The mean (range) age of the men was 58 (32-76) years. The most common cause of stricture was iatrogenic, arising after previous endoscopic surgery or after an indwelling catheter (45%). Thirty-five men had complications, with re-operation required in 27 (45%) of them. The most frequent nonsurgical complications were post-micturition dribble (32%) and recurrent urinary tract infections (27%). The most common surgical interventions required were transurethral resection of obstructing stent hyperplasia (32%), urethral dilatation or urethrotomy for stent obstruction or stricture (25%) and endoscopic litholapaxy for stent encrustation or stone (17%). CONCLUSIONS: The Urolume wallstent should only be used in patients who are unfit for or who refuse a bulbar urethroplasty.

Variation in urological practice amongst spinal injuries units in the UK and Eire.

AIMS: To investigate variations in common urological practice between the Spinal Injuries Units (SIU) of UK and Eire. METHODS: In December 2002, each of the 12 SIU in the UK and Eire were sent a questionnaire addressing basic practice relating to urological outpatient follow-up, management of urinary tract infection, upper tract surveillance, and urodynamic studies. RESULTS: Regarding frequency of urological review, two units only saw patients when specifically required. One unit reviewed patients every 6 months and six centres reviewed patients annually. The remaining three units had a patient-specific follow-up protocol. Regarding urinary tract infection, only five units had a unified departmental management protocol. Four units advocated antibiotic prophylaxis for recurrent UTI. Only one unit would routinely treat asymptomatic UTI in individuals using catheters. The range of recommended duration of treatment for symptomatic UTI was 3-14 days (mean 6.3). All units performed routine upper tract screening, ranging from annually to every 3 years. Six units did not perform routine urodynamic studies; in other units the range of frequency of urodynamics was from annually to every 3 years. CONCLUSIONS: The variation in urological practice amongst SIU in the UK and Eire is considerable. This finding supports the need for an increase in the level of collaboration and research.

Management of the neuropathic bladder.

Neurological injury and disease are common, and intimately related to abnormalities of the urinary system. The prevention and treatment of urological sequelae in patients with neurological injury or disease requires a clear multidisciplinary management strategy.