Treatment of neurogenic stress urinary incontinence using an adjustable continence device: 4-year followup.

PURPOSE: We evaluated the long-term safety and efficacy of an adjustable continence device (ACT® or ProACT™) in male and female patients with neurogenic stress urinary incontinence. MATERIALS AND METHODS: Data on patients consecutively treated with implantation of an adjustable continence device due to neurogenic stress urinary incontinence were reviewed from the start of our experience to the current 4-year followup. RESULTS: We reviewed data on 13 male and 24 female patients with neurogenic stress urinary incontinence due to different forms of pelvic nerve or spinal cord lesions. Mean ± SD age at implantation was 46.2 ± 17.4 years. Of the patients 92% performed clean intermittent self-catheterization. The device was implanted bilaterally using general and local anesthesia in 16.2% and 83.8% of cases, respectively. From before implantation to 48-month followup the mean number of urinary incontinence episodes decreased from 6.1 ± 2.4 to 2.8 ± 3.1 and the mean number of pads used per 24 hours decreased from 4.2 ± 2.7 to 2.2 ± 2.2. Of the patients 54.5% indicated more than 50% improvement of stress urinary incontinence symptoms after 48 months, of whom 38.9% indicated complete continence. Adverse events included erosion/migration, device infection or failure, implantation site pain, bladder stone formation and difficult clean intermittent self-catheterization. CONCLUSIONS: Implantation of the ProACT/ACT device in patients with neurogenic stress urinary incontinence is minimally invasive and safe. It can significantly improve neurogenic stress urinary incontinence in the long term. Thus, it might be a reasonable option for patients who are not willing, not suitable or not yet ready for more invasive surgery, such as artificial urinary sphincter or fascial suspension sling placement.

Supratrigonal cystectomy with Hautmann pouch as treatment for neurogenic bladder in spinal cord injury patients: long-term functional results.

AIMS: To study clinical and urodynamic data along with immediate and long-term morbidity of surgical management of neurogenic bladder in spinal cord injury (SCI) patients METHODS: Single-center retrospective study of 61 SCI patients with neurogenic detrusor overactivity (NDO) related urinary incontinence and/or sphincter weakness incontinence who underwent supratrigonal cystectomy with Hautmann pouch ± concomitant stress incontinence procedure (27.9%; n = 17). RESULTS: With a mean follow-up of 5.84 years (range 1-20.5) an improved or total continence rate was achieved in 89.7% and 74.1%, respectively. Surgery failed (incontinence persisted) for six (10.3%) patients, three of which had a simultaneous procedure for stress incontinence. On urodynamics, maximum cystometric capacity (MCC) (ml) increased from 305.2 to 509.4 (P < 0.05), mean compliance (ml/cmH(2) O) increased from 15 to 42.7 (P < 0.05) and mean detrusor pressure at MCC (cmH(2) O) fell from 54.1 to 19.1 (P < 0.05). Persisent NDO occurred in 20.7% compared to 59% pre-operatively (P < 0.05). The overall complication rate was 37.7% but ≤Clavien grade 2 in 82.6%. Notably, the incidence of bowel dysfunction, namely diarrhea and/or fecal incontinence was 27.5%. Concomitant outlet surgery was associated with increased morbidity as three (17.6%) complications led to re-intervention. CONCLUSIONS: Supratrigonal cystectomy with Hautmann pouch is an excellent surgical treatment for SCI patients suffering from refractory NDO incontinence. It achieves the main goals of achieving continence (74% complete), reducing rates of infection and preserving upper tract function, which is reflected in the improvement on urodynamics. The incidence of secondary bowel dysfunction and potential risk of a simultaneous procedure for stress incontinence needs to be discussed.

Functional outcomes after management of end-stage neurological bladder dysfunction with ileal conduit in a multiple sclerosis population: a monocentric experience.

OBJECTIVE: To assess the outcome of cutaneous noncontinent urinary diversion (CNCUD) for neurogenic bladder management in multiple sclerosis (MS) patients. METHODS: We retrospectively reviewed the charts of our MS patients who underwent surgery for CNCUD between 1994 and 2009. To assess the impact of urinary problems on health-related quality of life (HRQOL), a Qualiveen questionnaire was completed by the patients (scale 0 = no impact of urinary problems and 4 = high adverse impact). RESULTS: Overall, 53 patients with a median age of 51 years were included in the study. The mean Expanded Disability Status Scale score before surgery was 7.48 ±1.02 (range 6.5-9). The mean duration of follow-up was 73 months (range 6-168). The complication rate was 55%. Minor postoperative complications (Clavien grades I-II) occurred in 23 cases, and major complications (Clavien grades III-IV) occurred in 6 cases. The mean creatinine levels before surgery and at the last follow-up were 0.63 ± 0.2 mg/dL and 0.73 ± 0.53 mg/dL, respectively. The mean overall HRQOL scores before surgery and at last follow-up, and which assess the impact of the urinary problems on the patient, were 2.1 ± 1.18 and 1.16 ± 0.63 (P = .02), respectively. CONCLUSION: Cystectomy and CNCUD are indicated in MS-impaired patients who are refractory to medical treatment and they can result in disappearance of neurological bladder symptoms. CNCUD appears to be the procedure of choice to improve the quality of life of selected patients, despite the fact that it is associated with high perioperative morbidity.

Transcutaneous posterior tibial nerve stimulation for treatment of the overactive bladder syndrome in multiple sclerosis: results of a multicenter prospective study.

AIMS: Electrostimulation is an established therapeutic option for neurogenic urinary disorders. The aim of this study was to investigate the efficacy of the noninvasive technique of transcutaneous posterior tibial nerve stimulation (TPTNS) in patients with multiple sclerosis (MS) and troublesome symptoms of an overactive bladder (OAB). METHODS: A multicentric study enrolled 70 MS patients, suffering from OAB for a 3-month study period. INTERVENTION: Daily sessions of 20 min of TPTNS were provided. No change of associated treatments during the study period. The primary outcome measurement was Urgency and Frequency reported by bladder diary and symptom score performed before the treatment (Day 0, D0) and at D30 and D90. The secondary outcomes measurements were continence, symptom score, quality of life, psychosocial burden at DO, D30, and D90 and cystometry at baseline, with and without TPTNS and at D90. RESULTS: Clinical improvement of OAB was shown in 82.6% and 83.3% of the patients on D30 and D90, respectively, with significant improvement of primary and secondary outcomes compared to baseline. The initial acute cystometric response to TPTNS was positive in 51.2% of the patients (increase of >30% of cystometric capacity and/or reflex volume), without correlation with TPTNS clinical efficiency. The procedure was well tolerated. CONCLUSIONS: Chronic TPTNS appears to be effective in the management of severe OAB in MS, without compromising bladder emptying or inducing side effect. Treatment may be effective even in the absence of an acute cystometric effect. Additional works are required to demonstrate long-term efficacy of TPTNS.

[Neurogenic bladder]. / Problèmes vésico-sphinctériens de la personne handicapée.

Urinary symptoms are frequent in case of neurologic diseases, symptoms depends on the pathology as well as the extend and the location of the disease. Initial evaluation includes clinical, biological, urodynamic and radiologic assessment in order to precise symptoms quality of life and risk factors of medical complications. Treatment efficacy, adaptation to incapacities, evolution of the disease and complications require close follow up specially in the spinal cord injury and myelomeningocele population. Multidisciplinary approach is often required to optimise treatment strategy.

Evaluation of a stair-climbing power wheelchair in 25 people with tetraplegia.

OBJECTIVE: To compare the performance of a power wheelchair with stair-climbing capability (TopChair) and a conventional power wheelchair (Storm3). DESIGN: A single-center, open-label study. SETTING: A physical medicine and rehabilitation hospital. PARTICIPANTS: Patients (N=25) who required power wheelchairs because of severe impairments affecting the upper and lower limbs. INTERVENTIONS: Indoor and outdoor driving trials with both devices. Curb-clearing and stair-climbing with TopChair. MAIN OUTCOME MEASURES: Trial duration and Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST) tool; number of failures during driving trials and ability to climb curbs and stairs. RESULTS: All 25 participants successfully completed the outdoor and indoor trials with both wheelchairs. Although differences in times to trial completion were statistically significant, they were less than 10%. QUEST scores were significantly better with the Storm3 than the TopChair for weight (P=.001), dimension (P=.006), and effectiveness (P=.04). Of the 25 participants, 23 cleared a 20-cm curb without help, and 20 climbed up and down 6 steps. Most participants felt these specific capabilities of the TopChair--for example, curb clearing and stair climbing-were easy to use (22/25 for curb, 21/25 for stairs) and helpful (24/25 and 23/25). A few participants felt insecure (4/25 and 6/25, respectively). CONCLUSIONS: The TopChair is a promising mobility device that enables stair and curb climbing and warrants further study.

Urethral stent for the treatment of detrusor-sphincter dyssynergia: evaluation of the clinical, urodynamic, endoscopic and radiological efficacy after more than 1 year.

PURPOSE: We studied the intermediate-term clinical, urodynamic, endoscopic and radiological efficacy of the Ultraflex urethral stent (Boston Scientific Co., Boston, Massachusetts) for the treatment of detrusor-sphincter dyssynergia (DSD) in spinal cord injured patients. MATERIALS AND METHODS: A total of 47 consecutive men presenting with DSD due to spinal cord injury (39) or various spinal cord diseases (9) were treated with the Ultraflex stent. DSD was demonstrated by urodynamic assessment with electromyographic recording of the striated urethral sphincter muscle activity. RESULTS: Postoperatively, all patients voided by reflex. The number of patients with symptomatic postoperative urinary tract infection decreased significantly (p <0.001). Urodynamic assessment (mean followup +/- SD 2.2 +/- 1.3 years) showed reduction of mean peak detrusor pressure from 65.7 +/- 27.8 to 46.4 +/- 28.8 cm H2O (p <0.005) and reduction of mean residual urine from 231.6 +/- 168.1 to 70.3 +/- 85.6 ml (p <0.0005). Mean urethral closing pressure was markedly reduced from 73.9 +/- 40.9 to 23.8 +/- 25.1 cm H2O (p <0.0005). Mean endoscopic followup was 1.7 +/- 1.1 years. Mean percentage of epithelialization was 90.8% +/- 19.7%, and no obstructive granulation tissue or stone encrustation was observed inside the stent. On ultrasound signs of hydronephrosis persisted in only 1 of 8 patients. There were no immediate postoperative complications. Complementary bladder neck incision was performed in 21% of patients. CONCLUSIONS: The Ultraflex stent appears to be effective for intermediate-term treatment of DSD on the basis of clinical, urodynamic, endoscopic and radiological parameters.

[Genito-sexual dysfunction in patients with a medullary lesion]. / Les troubles génitosexuels du blessé médullaire.

Multiple dramatic consequences follow medullary lesions. Not only are voluntary motor control and sensitivity of the body segment below the lesion lost, but it also becomes impossible to control erection and ejaculation as well as urinary and faecal continency. The first investigations into genito-sexual function in paraplegics have brought about the idea, commonly admitted in the medical world, that this kind of patient is impotent and sterile. Fortunately this idea is disappearing gradually and many data have demonstrated that appropriate treatment is required and some therapies efficient. This is particularly important in the case of the population concerned, namely young men in 70% of the cases, since the usual age bracket at trauma is between 25 and 35 years old. At this time of life, sexual activity is often at its peak, so that the fertility potential becomes erased.

[Neurogenic bladder: pathophysiology of the disorder of compliance]. / Vessie neurogène : physiopathologie du trouble de compliance.

Bladder compliance is defined by the ratio of the increase of intravesical pressures to the increase of volume (_V/_P). The pathophysiology of disorders of compliance in neurogenic bladder is still poorly elucidated. It can be evaluated in terms of three elements: 1) The natural history of the appearance of these disorders in neurogenic bladders. Clinical experience shows the existence of prognostic factors that determine the development of these disorders, such as the voiding mode adopted (self-catheterization/hetero-catheterization versus indwelling catheter), the level of the spinal cord lesion (suprasacral versus sacral, incomplete versus complete, and cauda equina lesions), and the presence of meningomyelocele. 2). Data derived from conservative management of these disorders in neurogenic bladders: urethral dilatation, various sphincterotomies, bladder disafferentation, alpha-blockers, vanilloids (resiniferatoxin and capsaicin), intra-detrusor botulinum toxin and intrathecal baclofen, have demonstrated a marked improvement of disorders of compliance associated with neurogenic bladder 3). Data derived from experimentations. Morphometric studies on animal or human bladder strips have demonstrated an increased expression of proteolytic enzymes and endogenous tissue inhibitors of metalloproteinases (MMP-1) and type III collagen mRNA in hypocompliant neurogenic bladders. Reduction of bladder wall blood flow, bilateral section of hypogastric nerves in rats, study of the bladders of spinalized rats, and reduction of oestrogenic hormone impregnation, show that these conditions induce loss of the viscoelastic properties of the bladder With the arrival of new treatments, active on afferent and/or efferent pathways or even on the central nervous system, it is very important to further our understanding of the pathophysiology of disorders of compliance in neurogenic bladders. Reversibility of these disorders constitutes a major therapeutic challenge and its functional consequences make it a critical prognostic factor for the outcome of neurogenic bladder