Bladder and Urethral Sphincter Surgery

The association between episodes of AD and the presence of detrusor sphincter dyssynergia, high intravesical pressure and urethral pressure has led to the development of surgical procedures to alleviate voiding dysfunctions and consequently AD.

Discussion

Four surgical studies (Barton et al. 1986; Sidi et al. 1990; Perkash 2007; Ke & Kuo 2010) included indicators of AD (e.g. blood pressure changes). An older study by Barton et al. (1986) demonstrated reduced AD with an external sphincterotomy. A long-term follow-up of patients treated with transurethral sphincterotomies showed the procedure provided subjective relief of AD and was correlated with a significant decrease in blood pressure (Perkash 2007). Additionally, post-void residual urine decreased significantly after surgery (Perkash 2007). Similar results were found by Ke & Kuo in 2010. Patients reported decreased severity in the degree of AD during micturition, as well as significant decrease of post-void residual urine and improvement in quality of life (QoL) index after bladder surgical augmentations.

Sphincterotomies are now rarely performed due to their association with significant risks, including hemorrhage, erectile dysfunction (Ahmed et al. 2006) and the need for repeat procedures (Secrest et al. 2003). Alternatives including intraurethral stents and Botulinum toxin injections have been investigated and shown some success (Ahmed et al. 2006; Seoane-Rodriguez et al. 2007; Pannek et al. 2011; van der Merwe et al. 2012). Augmentation enterocystoplasty has demonstrated long-term success based on urodynamic evaluation and has been found to reduce symptoms of AD (Sidi et al. 1990). Enterocystoplasty with a Mitrofanoff procedure has become a more frequent choice of bladder augmentation in individuals with SCI due to more favorable long-term outcomes. Memokath stent placement in the external sphincter region has demonstrated a significant reduction in post-void residual urine as well as in UTI symptoms (Pannek et al. 2011; van der Merwe et al. 2012). Dual flange Memokath stent placement over the internal and external urethral sphincters in 28 patients with neuropathic bladder dysfunction was shown by van der Merwe et al. (2012) to reduce severe AD from 17 cases to 7 cases after stent placement.

Conclusions

There is level 4 evidence (based on four pre-post/case series studies: Barton et al. 1986; Sidi et al. 1990; Perkash 2007; Ke & Kuo 2010) that urinary bladder surgical augmentations may result in a decrease of intravesical and urethral pressure and therefore diminish or resolve episodes of AD.

There is level 4 evidence (based on 2 case series: van der Merwe et al. 2012; Seoane-Rodriguez et al. 2007) that an intraurethral stent decreases incidence of AD and may be an effective means for the long-term management of detrusor-sphincter dysynergia for SCI patients, including those who have previously undergone sphincterotomy.