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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.

Table 8: Bladder and Urethral Sphincter Surgery

Author Year; Country
Score
Research Design
Sample Size
MethodsOutcome
van der Merwe et al. 2012;

South Africa

Case series

N=28

Population: 28 male patients with neuropathic bladder dysfunction after SCI who had dual flange Memokath stents inserted in the period March 2008 to October 2011; Age in yrs: mean 37.4, range 23-64; Level of injury: 23 cervical, 5 thoracic.

Treatment: Stents were placed rather than performing an external sphincterotomy in selected patients. With the patient under deep general anesthesia, a thermosensitive expandable metallic stent was positioned over the internal and external urethral sphincters; patients were followed-up at 1 month and again between 3 and 6 months.

Outcome Measures: stent failure rate, incidence of AD post-stent placement, complications.

1.     33 stents were placed in 28 patients.

2.     6 patients reported severe autonomic dysreflexia related to poor bladder emptying as their reason for stent placement.

3.     Severe AD decreased significantly from 17 cases before stent placement to 7 after stent placement.

4.     New severe AD was a complication of stent placement in one case, after which the stent was removed.

Ke & Kuo 2010;

Taiwan

Case series

N=22

Population: 19 males; 13 subjects with cervical SCI, 9 with thoracic SCI. 17 subjects reported AD. Mean age at diagnosis of BND = 46.7 years. Lower urinary tract symptoms experienced for mean of 3.8 years.

Treatment: transurethral incision of the bladder neck (TUI-BN)

Outcome Measures: urodynamic parameters; satisfactory outcome (increase of AUA/IPSS quality-of-life index score by ≥2); autonomic dysreflexia occurrence; spontaneous voiding; detrusor pressure; post void residual; Qmax; bladder outlet resistance.

1.   Spontaneous voiding resumed in 19 patients, persistent urinary retention in 3 patients.

2.   Urodynamic parameters:

For patients with a Pdet > 15cmH2O at baseline, after surgery: Pdet and PVR decreased, Qmax increased significantly from 3.7(5.7) to 8.3(5.4)mL/sec;

For patients with a Pdet ≤15cmH2O at baseline, after surgery: Pdet and Qmax increased, PVR decreased significantly from 369(160) to 117(136)mL.

3.   Degree of AD during micturition was less severe or disappeared in 15 patients (88.2%) after surgery.

4.   18 (82%) patients reported satisfactory improvement in QoL index after TUI-BN, and voiding by volitional drills or lower abdominal tapping maneuvers became easier.

Perkash 2007;

USA

Case series

N=46

Population: 46 males; 31 subjects with tetraplegia and 15 with paraplegia; Type of injury: 43 AIS A and B, 3 AIS C.

Treatment: Transurethral sphincterotomy (TURS).

Outcome Measures: Autonomic dysreflexia during cystometrogram (measures the contractile force of the bladder when voiding), blood pressure.

1.     During cystometrogram, mean maximal systolic pressure was 160(23) pre and 108(17) mmHg post. Mean diastolic pressure was 88(15) pre and 62(11) mmHg post.

2.     Mean decrease in systolic BP and diastolic BP after TURS was 55(26) and 30(17) mmHG, respectively.

3.     Amelioration in symptoms of AD.

4.     Mean post-void residual urine decreased significantly from 233(152) to 137(0.35) mL after TURS.

5.     4 patients still exhibited AD within 1 year of laser TURS.

Seoane-Rodriguez et al. 2007;

Spain

Case series

N=47

Population: 47 males; 32 subjects with cervical, 11 with thoracic, and 4 with lumbar injuries; mean post-injury time to stenting was 103.8 months. Mean follow-up time from implantation 67 months. Type of injury: 36 AIS A; 4 AIS B and 7 AIS C.

Treatment: intraurethral stent.

Outcome Measures: Urodynamic parameters; presence or absence of symptomatic UTI; autonomic dysreflexia; appearance of complications of the upper urinary tract (UUT); bladder management before and after surgery; prosthesis complications.

1.     Decrease in symptomatic UTI by 25%.

2.     Decrease in post void residual urine volume by an average of 224.3 cm3.

3.     Episodes of dysreflexia decreased from 35.1% to 16.2%.

4.     Complications in the UUT decreased from 46.8 to 23.4%.

5.     Urodynamic study showed an average reduction of 44.4 cm3 H2O in the maximum detrusor pressure.

6.     Most frequent stent complication was displacement, followed by stenosis, lithiasis (pathological formation of mineral concentrations in the body), and intraprosthetic calcification. 8.5% required stent removal.

Sidi et al. 1990;

USA

Pre-post

N=12

Population: 9 subjects with complete SCI, 3 with incomplete injuries; Level of Injury: C5-T11; 2-27 years post-injury.

Treatment: augmentation enterocystoplasty.

Outcome Measures: functional bladder capacity, levels of blood urea nitrogen, creatinine, electrolytes.

1.    By 4 months post-op, 11/12 patients were totally continent on clean intermittent self-catheterization every 4-6 hours.

2.    Of the 3 patients who had an artificial urinary sphincter, 2 became continent after sphincter activation and 1 had achieved continence without sphincter activation.  No patients experienced symptoms of AD during intermittent catheterization post-operatively.

Barton et al. 1986; USA

Case series

N=16

Population: 5 subjects with thoracic, and 8 with cervical injuries, 47-285 months post-injury.

Treatment: modified transurethral external sphincterotomy with follow-up to 26 weeks.

Outcome Measures: bladder and urethral pressures and volumes, blood pressures.

1.    Intravesical and urethral pressures decreased compared to before sphincterotomy.

2.    Blood pressure responses decreased during urodynamic stimulation.

3.    Other cardiovascular responses related to AD during bladder filling markedly attenuated.

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 andimprovement in quality of life (QoL) indexafter 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.

  • Urinary bladder surgical augmentations may diminish or resolve episodes of AD.