Lower Urinary Tract Denervation, Decentralization, and Neuromodulation

Altering the innervation of the urinary tract is the focus of several strategies for the management of storage failure and is the central mechanism for procedures that vary from sacral rhizotomy to intravesical botulinum toxin. In addition, interventions may involve different levels of the nervous system, such as the spinal cord, nerve roots, or peripheral nerves. Of note, noncentral denervation proximal to the postganglionic neuron is properly termed “decentralization” and because the bladder is innervated by a short-neuron system, almost all denervation procedures outside the central nervous system that we will describe are properly referred to as decentralization. In general, more central procedures would appear more suitable for patients with spinal cord injury (SCI) or neurogenic detrusor overactivity, and although central denervation is theoretically very effective, it may also have a potentially wider range of unintended consequences. Peripheral decentralization is more selective for the bladder and more suitable for idiopathic detrusor overactivity, as other structures innervated by the sacral nerves remain neurologically intact (Madersbacher, 2000). There would seem to be only a small role for most of the procedures discussed in this section, because conservative measures are often sufficient in significantly improving or alleviating storage symptoms in most patients. Although favorable results have been reported with denervation techniques, some of these procedures have been accompanied by significant adverse outcomes that have limited their usefulness. One significant problem with central denervation and decentralization is that neuroplasticity often results in a variable restoration of neurologic function, with an even less desirable result than was present originally in many cases (Madersbacher, 2000). This section will focus on surgical techniques of bladder denervation, both central and peripheral. Sacral neuromodulation is covered in Chapter 70.

Central (Subarachnoid) Block

These procedures, comprise chemical rhizolysis, sacral rhizotomy, and conusectomy, selective anterior sacral rhizotomy, and dorsal rhizotomy are seldom used today and are discussed fully on the Expert Consult website.

Sacral Neuromodulation

Sacral neuromodulation is currently the most commonly used surgical procedure to treat patients with refractory urgency-frequency or urgency incontinence. For more information on the indications, procedural aspects, treatment results, and complications of sacral neuromodulation, see Chapter 70.

Peripheral, Perivesical, and Intravesical Bladder Denervation

Transvaginal Denervation

A number of procedures fall into the category of attempts to achieve a peripheral denervation. The exact nature of these denervations is unclear and may involve interruption of sensory, motor, or both types of innervation. As evident from neuroanatomic considerations, at best, such attempts achieve primarily neurologic decentralization and, at most, partial peripheral denervation. Although many authors report relatively high success rates for these procedures, it is unclear why they are not used more frequently. Because they are primarily used for detrusor overactivity, it is likely that many clinicians use nonsurgical methods first and are often successful in managing detrusor overactivity with fewer side effects. Also, because these procedures are uncommonly performed, many clinicians are unfamiliar with how to perform the procedure, and the success rate is likely much lower than when performed by clinicians who commonly perform these procedures. Lastly, many clinicians have begun to use neuromodulation or botulinum toxin injections to treat refractory overactive bladder, leaving the role of transvaginal denervation in question.

Regarding the literature on transvaginal denervation, in many articles, there is little description of what “success” actually means. In addition, there are few studies with long-term follow-up, and “postoperative assessment” often means a few months of follow-up. A comprehensive summary of the surgical treatment of detrusor overactivity by peripheral denervation was reported by Mundy in 1985; however, many reports have been published since that time.

Transvaginal partial denervation of the bladder was originally described by Ingelman-Sunberg in 1959. The original procedure, which was an extensive denervation, was used mostly for the treatment of refractory urge-urinary incontinence, and in the originator’s hands, success rates of up to 80% were achieved. Mundy (1985) reported that other investigators found success in 50% to 65% of cases, and Torrens (1985) noted that “the technique has not found favor with other workers.”

More recently, Cespedes and associates (1996) described McGuire’s modification (limited lateral vaginal dissections) of the Ingelman-Sundberg procedure in 25 women with urinary urgency incontinence and detrusor overactivity who had failed behavioral and medical therapy (Fig. 75–1). Transvaginal local anesthesia was used as a test to determine which patients would benefit from the procedure, with significant improvement of urgency symptoms considered a positive test. Twenty-five patients were found to have a positive test; the number of patients unsuccessfully tested was not reported. Sixteen (64%) of these patients were cured of urgency incontinence at a mean follow-up of 14.8 months. Of the 16 patients cured, 9 patients required one medication, and 2 required two medications. Madersbacher (2000) comments that a follow-up period of 15 months is too short to determine long-term effects.

Figure 75–1 Terminal pelvic nerve branches enter the bladder near the trigone. A, To assess preoperatively in clinic whether the patient would benefit from the procedure, local anesthetic (0.25% bupivacaine) is injected subtrigonally to block the nerves which would be denervated by the operative procedure. B, Normal saline is injected submucosally to facilitate dissection of the vaginal mucosa off the bladder. C, Position of the trigone outlined by a catheter balloon inflated to 30 mL. D, Inverted-”U” vaginal incision is made. E, Dissection of the vaginal mucosa and deeper tissues off the underlying bladder. F, Completed dissection.

Long-term follow-up was reported by Westney and associates (2002), who retrospectively reviewed 28 patients with refractory urgency incontinence, having undergone the modified procedure with a mean follow-up of 44.1 months. Of these, 68% were cured (54%) or improved (14%). Based on these results and the prior series, the authors concluded that the modified Ingelman-Sundberg procedure is an efficacious, minimally invasive option for this difficult-to-treat patient population.

Acupuncture

The use of acupuncture as a therapeutic treatment modality is described in Chinese medical texts as early as 300 BC. Acupuncture is a form of somatic sensory stimulation using a variety of procedures that involve stimulation of specific anatomical locations by insertion of thin, solid, metallic needles into the skin. In the classic forms of acupuncture, needles are stimulated manually to achieve the desired effects. In more modern forms of acupuncture, heat or electrical stimulation may be provided by the addition of an energy source or be performed needleless, as in laser acupuncture. Indeed, McGuire and coworkers’ (1983) developed transcutaneous posterior tibial nerve stimulation for bladder inhibition that was based on the acupuncture points. The use of acupuncture has been described for a number of urologic symptoms, including urinary urgency, frequency, incontinence, nonobstructive urinary retention, enuresis, and neurogenic detrusor overactivity. Acupuncture is generally a well-tolerated procedure, and although side effects are generally uncommon and minimal in nature, treatment may occasionally result in localized pain, hematoma, infection, and even organ puncture. Several treatment sessions are usually required.

There has been much interest in determining the mechanism by which acupuncture exerts its beneficial effects. According to traditional Chinese medicine, concepts such as the meridian system, circulation of Qi, and other related theories remain difficult to define and characterize. Sato (1997) has shown somatovisceral reflexes evoked from somatic afferent stimulation may induce either excitatory or inhibitory changes in bladder function and sphincter activity. Bergström and associates (2000) hypothesized any one or a combination of (1) endorphinergic effects at the sacral spinal cord level or above, (2) inhibitory somatovisceral reflexes, and (3) increase in peripheral circulation as possible mechanisms of action. The true nature of how acupuncture exerts its beneficial effects remains incompletely understood.

Bergström and associates (2000) reported on the results of classic acupuncture performed twice weekly in a group of 15 elderly women with urgency or mixed incontinence. In this open, uncontrolled study, subjective assessments of improvement and objective measurements in the form of grams of leakage over 48 hours were encouraging, not only at the end of the study but also after 1 and 3 months. More recently, Emmons and Otto (2005) compared acupuncture versus placebo acupuncture in the treatment of women with overactive bladder and urinary urgency incontinence. The number of incontinent episodes decreased by 59% in the treatment group compared with 40% in the placebo group. The treatment group had a significant improvement in bladder capacity, urgency, frequency, and quality-of-life scores compared with the placebo group.

Many studies have been performed to determine the efficacy of acupuncture; however, the level of evidence continues to be limited secondary to difficulties in performing adequate placebo controlled, double-blind studies. In addition, acupuncture requires extensive training, is performed by few clinicians, and few teachers exist. Overall, the importance of acupuncture may not just be in learning or performing the procedure; it may be more important to learn the mechanisms by which it achieves these results, in order to develop easier and less invasive methods of achieving the same (or better) clinical results.

Bladder Distention Therapy

Initially described by Helmstein in 1972 for the treatment of patients with bladder carcinoma, this treatment modality has undergone several modifications. Bladder overdistention, most familiar for its use in the treatment of interstitial cystitis (see Chapter 12), has also been used for other diverse indications, including nocturnal enuresis, irritative symptoms following radiation or BCG, and for patients with overactive bladder.

No standard technique has been clearly defined for this procedure and, as such, several variations exist. Bladder distention may be performed under regional or general anesthesia. The bladder is then distended by either a balloon catheter or more commonly by saline infused cystoscopically or through a urethral catheter. The ideal pressure and duration needed to distend the bladder has not been well defined. Dunn and colleagues (1974) described prolonged bladder distention of several hours at a pressure equal to the patients’ systolic blood pressure. At this pressure, therapeutic benefit is thought to derive from ischemic changes induced in submucosal afferent nerve endings and stretch receptors (Dunn et al, 1977). In a primarily interstitial cystitis population, Hanno and Wein (1991) described distending the bladder to 80 cm H₂O for several minutes with good results. Bladder rupture, historically as high as 5% to 10%, is the most significant complication after bladder distention therapy. Other possible complications include hematuria, back pain, and urinary retention.

Ramsden and colleagues (1976) reported good to excellent results in the treatment of patients with detrusor overactivity, while most others have reported inferior results with this treatment modality. In this same patient population, Jorgensen and coworkers (1985) reported a success rate of only 1 in 15 (6%) patients. In a retrospective review by Taub and Stein (1994), 8 of 22 (36%) of patients with frequency and urgency of various etiologies had subjective improvement, while no patient with detrusor overactivity improved. They also demonstrated that short duration distention therapy (15 to 30 minutes) was as efficacious as prolonged therapy (6 hours). Lloyd and colleagues (1992) reported that only 6 of 29 women with severe irritative symptoms, including 6 patients with interstitial cystitis and none with neurogenic detrusor overactivity, had a good response to treatment. In a study of 26 women with frequency and urgency, Liapis and associates (2001) found a statistically significant increase in bladder capacity after treatment; however, only 4 (15%) had any improvement in symptoms beyond 9 months. Although largely regarded as an ineffective procedure in patients with storage failure secondary to neurogenic detrusor overactivity, bladder overdistention may provide substantial, but usually temporary, improvement to some patients with non-neurogenic storage symptoms who have failed medical therapy.

Nonsurgical Compressive and Occlusive Devices

Urethral compression devices have been used to successfully control urinary incontinence in males for over 250 years, with little change in their construction during this time. Indeed, the Heister penile clamp was described in Institutiones Chirurgicale, a surgical textbook published in 1750. This device closely resembles the Cunningham clamp, a device commonly used today (Madjar et al, 2001). These devices are primarily used to treat patients with pure sphincteric incontinence, most commonly postprostatectomy incontinence (PPI), because normal bladder capacity and storage pressures are a relative requirement. Continence is achieved by mechanically compressing the urethra between two foam pads. The device is adjusted by slowly increasing the level of compression until continence is attained, because this allows the lowest pressure to be applied, keeping obstruction of blood flow to a minimum. Regardless, these devices should be unclamped regularly at 3- to 4-hour intervals, because prolonged or excessive compression can cause pressure-related injury to the penis. Additionally, these devices should not be worn during an erection or while sleeping. Pressure-related injuries may also be more prevalent in patients with impaired sensation or cognition; therefore penile clamp usage in this population should be considered a relative contraindication. Several other compression devices are available and are similar in both design and function to the Cunningham clamp. Moore and colleagues (2004) reported efficacy, comfort, and patient satisfaction with three penile compression devices: the Cunningham clamp, the C3, and the U-Tex. The study population included 12 men with postprostatectomy incontinence requiring continuous pad protection. Over 4 consecutive days, patients were randomly assigned to use either one of the three devices, or pads alone as a control group. Each group wore the device or pads continuously for 4 hours (maximum time recommended for continuous usage), and pad weights were obtained before and after the study period to quantify leakage. Additionally, patients were asked to complete a questionnaire at the conclusion of the study. Urine leakage was significantly reduced by all three devices evaluated; however, the Cunningham clamp was the most efficient of the three devices tested, reducing urine leakage by nearly 85%. The Cunningham clamp was also noted to reduce cavernosal blood flow significantly more than the other devices. Overall, patients rated the Cunningham clamp the most acceptable and preferable of the devices evaluated.

Although these devices manage sphincteric incontinence relatively well, they are rarely used today because they are inconvenient, and many minimally invasive options for male sphincteric incontinence now exist. These devices remain useful for patients who cannot undergo surgical therapy due to medical conditions, and for patients who have severe leakage during the early postprostatectomy period, while surgical treatment is contraindicated.

The renewed interest in conservative management of female sphincteric incontinence, and lower urinary tract symptoms associated with pelvic organ prolapse, has prompted the development and investigation of several nonsurgical devices. Unfortunately, due to the location and anatomy of the female urethra, no compressive or occluding device has been introduced that successfully treats sphincteric incontinence without causing significant side effects or patient discomfort. In addition, reliable external urinary collection devices do not exist for females, making the Foley catheter the most common method of treatment for intractable sphincteric incontinence. Therefore the role of these devices in the algorithm of conservative management of female sphincteric incontinence remains unclear. A more thorough description of these devices, along with the indications and efficacy, are discussed in Chapter 69.

Pelvic organ prolapse may be associated with sphincteric incontinence, overactive bladder symptoms, and/or urinary retention due to anatomic urethral obstruction. Vaginal support devices that support the anterior vaginal wall, thereby supporting the bladder neck and proximal urethra, should theoretically improve both stress incontinence due to urethral hypermobility and allow normal voiding by reducing urethral obstruction. Some devices may even improve stress incontinence due to intrinsic sphincter deficiency, if the urethra is sufficiently compressed. Intravaginal devices, such as tampons, contraceptive diaphragms, pessaries, and pessary-like devices specifically designed for bladder neck support have all been used with variable results. The issues that exist with these devices include the need for intermittent removal and cleaning, problems with device placement, and dislodgement due to the variable anatomy of the vagina, and patient discomfort.

Female urethral occlusive devices may be external or internal, depending on whether the device occludes the urethra or bladder neck from the outside or must be inserted into the urethra. Examples of these devices include urethral meatal occlusive devices and urethral inserts. These devices are most useful in patients with mild to moderate sphincteric incontinence without significant detrusor overactivity or decreased compliance. The characteristics of an ideal occlusive or supportive device include (1) efficacy, (2) comfort, (3) ease of application/insertion/removal, (4) no interference with voiding, (5) lack of tissue damage, (6) no increase of infection risk, (7) no compromise of subsequent therapy, (8) cosmetic acceptance, and (9) no interference with sexual activity. Unfortunately, no occlusive or supportive device currently fulfills all these requirements.

Sphincteric Injection Therapy

Injection therapy is commonly employed as a minimally invasive treatment option for male and female stress incontinence. Although it is theoretically a temporary treatment, typically lasting only 6 to 12 months, the ease of reinjection in a clinical setting renders it a potentially permanent solution in selected patients. Injectables treat stress incontinence by increasing the abdominal leak point pressure by several mechanisms, including increased mucosal sealing pressure and improvement in the mucosal seal mechanism (Appell, 2002). Females most likely to benefit from this procedure have intrinsic sphincter deficiency (ISD), a normally contractile bladder, and a well-supported urethra. This constellation of requirements is most commonly fulfilled by elderly females; however, several authors have demonstrated improvement in younger patients with stress urinary incontinence (SUI) due primarily to urethral hypermobility (Appell, 2009). The rarity of injectable use in this population really reflects the efficacy and widespread use of the newer minimally invasive slings, compared with the relative ineffectiveness of injectables.

The lack of standardization in defining success, largely attributable to the nonpermanent nature of this treatment, makes it difficult to accurately assess the true cure and improved rates after treatment. Nevertheless, the most extensively studied injectable, glutaraldehyde cross-linked (GAX) collagen, has consistently resulted in improvement and/or cure in 60% to 80% of selected female patients. Most patients will require two injections to achieve dryness and will require reinjection every 6 to 12 months to maintain continence. The injections can be performed indefinitely without any apparent side effects. If the patient fails injection therapy, it does not hinder other surgical procedures.

In males, postprostatectomy incontinence can also be managed with injection therapy. The best results are obtained with patients with mild incontinence (one to three pads per day), while patients who have undergone radiation, bladder neck incision, or cryotherapy have less favorable responses (Cespedes, 2000). Most patients require four to five injections, with reinjections every 6 to 12 months to maintain dryness (Cespedes, 2000). Westney and colleagues (2005) reported their results of collagen injection in 322 men with ISD after therapy for prostate carcinoma or benign prostatic hyperplasia. The authors reported that after a mean of 4.37 injections, and irrespective of therapy, overall improvement was approximately 50% with a mean duration of 6 months.

The ideal bulking agent should be durable, biocompatible, should not migrate, or cause significant inflammatory reaction at the injection site. Unfortunately, no current injectable has all of these qualities. In the future, advances in the field of tissue engineering, including autologous chondrocytes and cultured myoblasts, may offer new and exciting options in the treatment of stress urinary incontinence using injectables. For a more thorough discussion of the history, indications, techniques, and results of bulking procedures, including a review of the injectable agents currently available, refer to Chapter 77.

Vesicourethral Suspension and Prolapse Repair (Female)

Vesicourethral suspension procedures, such as the Burch and MMK (Marshall-Marchetti-Krantz) procedures, have been successfully used for many years to treat stress incontinence secondary to urethral hypermobility, most commonly defined as stress incontinence occurring with an abdominal leak point pressure (ALPP) greater than 100 cm H₂O. More recently, with the increasing popularity of the minimally invasive mesh slings, their use has diminished substantially, and they are rarely used unless a simultaneous abdominal procedure, such as a hysterectomy or abdominal sacral colpopexy, is planned. In addition, the Burch colposuspension was recently shown to be inferior to the autologous pubovaginal sling in a randomized, controlled study (Albo et al, 2007). Although vaginal prolapse does not, per se, cause urinary continence, a deficiency of vaginal support is shared by both conditions. Therefore, urinary incontinence secondary to hypermobility would imply that vaginal prolapse, especially the anterior wall, likely coexists and should be repaired at the same time. Severe vaginal wall prolapse has also been associated with occult urinary incontinence, defined as stress incontinence that only occurs with reduction of the prolapse. Patients with severe vaginal prolapse, with or without complaints of incontinence, should be carefully assessed preoperatively by reduction of the prolapse during the stress incontinence evaluation (see Fig. 75–2). This condition and additional descriptions of these procedures are further discussed in Chapters 71 and 72.

Pubovaginal Slings and Tension-Free Tape Procedures

Autologous fascia pubovaginal slings, popularized by McGuire in the 1980s, were originally used for female patients with poor sphincteric function. Historically, female patients with stress incontinence have been divided into groups based on etiologies of either urethral hypermobility or intrinsic sphincter deficiency (ISD). It has become clearer over time that almost all patients leak due to a combination of hypermobility and intrinsic sphincter deficiency, with each component of incontinence on a continuum. Using this logic, a sling would be the ideal treatment because it successfully corrects both urethral hypermobility and ISD. More recently, pubovaginal slings have been supplanted by a wide variety of minimally invasive tension-free mesh sling procedures. These procedures, although less invasive, have never shown success rates superior to the 90% cure rate of the original pubovaginal slings, which are still considered by most to be the gold standard therapy. Autologous or cadaveric fascial slings are still commonly used in situations where the sling must be pulled more tightly, as with the obstructing slings sometimes used in patients with neurogenic incontinence. Theoretically, mesh slings are “tension- free” slings and therefore would be much more likely to erode into the urethra if pulled tightly. In cases where mesh is preferred, a “spiral” or “circumferential” sling, which wraps completely around the urethra, can be used; however, this requires a urethrolysis to gain access to the retropubic space and passage of the needles from the abdomen to the opposite side of the vagina to gain circumferential compression. This procedure and many others are more fully described in Chapter 73.

Artificial Urinary Sphincter and Male Perineal Sling

The introduction by Scott and coworkers (1974) of the artificial urinary sphincter (AUS) signified a major advancement in the treatment of sphincter-related incontinence. The AUS has been successfully used in the management of stress incontinence of various etiologies and can be implanted in adults and children of both sexes. Postprostatectomy incontinence remains the most common indication for AUS insertion, with female patients accounting for only 1% of the patients in whom the devices are implanted yearly, typically for neurogenic disease (Lee et al, 2009). Although the AUS is commonly used in patients with neurogenic incontinence, it is important to remember that because of the ability of the AUS to greatly increase outlet resistance, social continence may be gained at the expense of renal deterioration in patients with poor detrusor compliance. In general, storage pressures and bladder capacities should be normalized prior to placement of an AUS.

For treatment of PPI, the AUS has been quite successful and remains the gold standard therapy. Nevertheless, revisions may be necessary due to atrophy, infections, erosions, or mechanical problems. In addition, some patients are reluctant to have the AUS placed for a variety of reasons, including the desire to “void normally” without having to manipulate a device. More recently, the male sling has had a resurgence of popularity in the search for a minimally invasive, efficacious, “natural voiding” alternative to treat PPI. The male sling is a passively obstructive device that appears to function by increasing the urethral closure pressure and functional sphincteric length, thereby augmenting existing sphincteric function. This may be why it does not work as well in patients with severe sphincteric incontinence. Male slings are easily placed using a perineal approach and can be fixated using either bone anchors (into the inferior pubic ramus) or a transobturator approach. Although slings are more commonly used in patients with mild to moderate PPI, and the AUS with more severe PPI, high rates of continence and patient satisfaction have been reported using both the male sling and AUS in properly selected patients (Rajpurkar et al, 2005; Gallagher et al, 2007). A more thorough and in-depth discussion of the male sling and artificial urinary sphincter are covered in Chapter 79.

Closure of the Bladder Outlet

Complete closure of the bladder neck is rarely necessary, because a compressive bladder neck sling is more easily performed, is less morbid, and allows transurethral access if necessary. The main indication for bladder outlet closure is urethral destruction secondary to prolonged catheter drainage in neurogenic bladder patients. The clinical course is typically a progressive worsening of leakage around the catheter, requiring progressively larger-bore catheters and larger volumes of fluid in the balloon, ultimately resulting in a dilated, nonfunctional urethra and bladder neck. It is thought that a long-term Foley catheter and balloon can cause pressure necrosis and bladder neck erosion, especially in the setting of recurrent bladder spasms. In these patients, an obstructing sling or AUS is rarely feasible. For patients with some residual normal urethra, Chancellor and colleagues (1994a) reported on the use of a combined “tight” autologous pubovaginal sling and lower urinary tract reconstruction in 14 female patients with urethras destroyed by long-term Foley use. At 24 months, they reported excellent results with minimal incontinence or other complications. They concluded that at least 1 cm of normal urethra was required for proper functioning of the sling. For patients without residual normal urethra, management options include transvaginal, transabdominal, or combined closure of the bladder neck with simultaneous continent or incontinent urinary diversion, incontinent ileovesicostomy, or suprapubic catheter placement.

Feneley (1963) reported on 24 female patients with neurologic disease who underwent transvaginal bladder neck closure and suprapubic tube placement. Overall results were good; however, a vesicovaginal fistula developed in 4 patients, resulting in persistent incontinence. Zimmern and associates (1985) reported on 6 female patients using a transvaginal closure. At 21 months of follow-up, all patients were cured with no fistulas or incontinence reported. Levy and colleagues (1994) reported a 40% success rate using a transvaginal bladder neck closure. They subsequently modified the approach, using a combined transvaginal-transabdominal approach, and reported a 100% success rate at a mean 16-month follow-up for the subsequent 10 patients. Shpall and Ginsberg (2004) reported on 39 patients who underwent a combined transabdominal bladder neck closure and various continent and incontinent diversions. At a mean of 37 months, 6 patients (15%) developed fistulas; however, 4 patients were successfully repaired, for an overall 95% cure rate. Most recently, O’Connor and colleagues (2005) reported on 35 patients with a mean 79-month follow-up who underwent a transabdominal bladder neck closure for refractory incontinence. They were initially successful in 28 (83%) patients with an overall 94% cure rate after one revision.

As illustrated in this historical perspective, the risk of complications, specifically a vesicovaginal fistula, is relatively common and can be difficult to repair. It is important to remember that a bladder neck closure is much more difficult than a simple closure of the bladder wall. The bladder neck is usually hyperactive in patients with neurologic disease, and every voiding reflex includes active opening and closing of the bladder neck, which forcibly attempts to destroy the bladder neck closure. To reduce this risk, postoperative suppression of the voiding reflex using prolonged continuous catheter drainage (3 weeks) and liberal use of anticholinergics is imperative. In addition, to reduce the risk of fistula, the repair must be watertight from the beginning, and this requires a precise mucosal closure using a running suture and multiple additional layers of muscle to reinforce the strength of the repair (see Fig. 75–3). Lastly, a drain should be used to minimize fistula formation should suture line leakage occur. When performed correctly, a bladder neck closure with simultaneous lower urinary tract reconstruction remains an excellent treatment option in those patients with a destroyed bladder neck or urethra.

Bladder Outlet Reconstruction

Sphincteric incontinence with a fixed, nonvolitional, open bladder outlet may be congenital or acquired. In most cases, the sphincteric musculature is insufficient and denervated and therefore does not provide sufficient closure pressure to prevent incontinence. Techniques have been developed that concentrate on increasing urethral resistance by either tightening or lengthening the urethral segment, such as the Kropp and Pippi-Salle procedures (see Chapter 129) or by constructing a mechanism more similar to the native sphincter. In 1919, Hugh Hampton Young first described a technique to reconstruct the bladder outlet to improve sphincteric continence. Originally, the procedure included resecting a portion of bladder neck and reconstructing the bladder outlet with constricting sutures to effectively narrow its caliber. This technique was further modified by Dees (1949) and Leadbetter (1964). In theory, circularly arranged muscle fibers located in close proximity to the bladder neck are used to re-create a functional, tubularized neourethra that replicates the outlet resistance of a normal sphincteric outlet, but with variable volitional control. The Leadbetter modification involves proximal reimplantation of the ureters to allow more extensive tubularization of the trigone and, theoretically, improved outlet resistance. The construction of this neourethra may be formed from tissue of the anterior bladder neck as described by Tanagho (1981), or from the posterior surface of the bladder wall and trigone, according to any of the variations of the Young-Dees-Leadbetter technique. Leadbetter (1985) reported long-term success rates of 60% to 70% in 34 patients; however, the exact definition of success in this paper is unclear. Clinically, these procedures are most useful for patients with a good-capacity, acontractile bladder and who are mentally and physically able to perform CIC on a regular basis. In addition, care should be taken in the setting of poor bladder compliance or significant detrusor overactivity, because these patients commonly need bladder augmentation. For further discussion regarding the original technique described by Young, and its several variations, refer to Chapters 124 and 129.

Myoplasty for Functional Sphincter Reconstruction

The Holy Grail for sphincteric incontinence may well be the replacement of the dysfunctional sphincter with a new, functional native replacement. The first attempt at this type of sphincteric replacement was a skeletal muscle transposition reported by Deming (1926). He used unstimulated gracilis muscle wrapped around the urethra, which reportedly did improve sphincteric continence; however, the unstimulated skeletal muscle required the patient to voluntarily contract (adduct) the leg for prolonged periods to provide outlet resistance. Additional problems with the use of unstimulated graciloplasty include (1) poor sustainability of the contraction due to the fast twitch, non–fatigue-resistant fibers of the gracilis, (2) high passive resistance resulting in urethral obstruction, (3) postsurgical changes resulting in the loss of resting tension and reduced contractility, (4) the potential for fibrosis due to segmental vascularization (Stenzl, 1998). The next improvement in functional sphincteric replacement was the development of external stimulation of the gracilis using implanted electrodes (Janknegt et al, 1995). They developed an electrical stimulation program that was able to transform fatigable type 2 skeletal muscle fibers to the slow type I fibers that were able to sustain a long-lasting contraction. This early report described three patients who achieved “good results” and one patient who became dry at night. Two years later, Chancellor and colleagues (1997) reported their series using a gracilis urethral wrap in five men with neurogenic bladder dysfunction and severe sphincteric stress incontinence. The procedure was considered successful in four patients; however, three required CIC, and two of these patients had persistent stress incontinence.

The shortcomings of using the gracilis was noted by Stenzl (1998), who commented that the electrically stimulated gracilis muscle was an improvement over the unstimulated muscle; however, the bulky musculature and propensity for stricture formation caused an inherent passive obstruction. This shortcoming was scientifically overcome by Palacio and coworkers (1998) in an animal model using a free but innervated flap of well-vascularized proximal gracilis muscle in female dogs. The smaller size of the graft allowed it to be more easily transposed around the urethra while stimulation of the sphincter was carried out using the graft’s own motor innervation. Unfortunately, this apparently successful animal model has never been reported in a human clinical study.

The most recent twist in an attempt to improve the function of a neurologically damaged sphincter includes injecting allogenic muscle–derived progenitor cells (MDPC) directly into the sphincter (Cannon et al, 2003). The authors used a rat model in which the urethra was mechanically denervated and subsequently injected with MDPCs, which dramatically improved the fast-twitch muscle contraction amplitude from 8.8% to 87% (compared with normal amplitude). Although promising, this innovative and minimally invasive option for sphincteric incontinence has not yet been proven in follow-up human clinical studies.

Augmentation Cystoplasty

Bladder augmentation offers the best chance to construct a “normal” urinary system and, as such, should be considered before attempting urinary diversion. The ability to void without self- catheterization is not guaranteed, especially in men; therefore, this procedure should only be considered for patients who have the ability and motivation to perform CIC, because bladder rupture can be a life-threatening complication. CIC performed by a caretaker is rarely adequate and makes the patient dependent on a caretaker. If the urethra is not a reliable conduit—due to urethral stricture, or access to the native urethra is limited by spasticity, obesity, or contracture—a continent abdominal stoma or alternate procedure should be considered.

Originally, augmentation cystoplasty was used for the treatment of bladder fibrosis secondary to tuberculous cystitis (Smith et al, 1977). More recently, augmentation has been used for the treatment of other conditions associated with bladder fibrosis and limited bladder capacity, such as in patients with end-stage interstitial cystitis, neurogenic bladder or, less often, patients who have undergone pelvic radiation. Neurogenic bladder patients are a special group because they often have hydronephrosis, vesicoureteral reflux secondary to chronic elevated storage, and voiding pressures due to poor detrusor compliance and detrusor sphincter dyssynergia. Augmentation cystoplasty in this group can preserve renal function, whereas typically it serves to improve the quality of life in the other groups. Augmentation should also be considered for patients with incontinence secondary to intractable neurogenic detrusor overactivity (Linsenmeyer et al, 2006). Because no effective external collecting device exists for females, bladder augmentation has been used in female paraplegics, with encouraging results (Venn and Mundy, 1998), to treat incontinence due to poor compliance or neurogenic detrusor overactivity. Although augmentations are invasive, the value of these procedures cannot be discounted, because they are generally very effective, with significant improvement reported in up to 90% of patients with neurogenic lower urinary tract dysfunction or limited-capacity bladders due to other causes (Barrett, 1999).

Ureterocystoplasty and autoaugmentation are alternatives to conventional bladder augmentation. Autoaugmentation, as it was initially described by Cartwright and Snow (1989), involves excising the detrusor muscle over the bladder dome and leaving the urothelial mucosa intact. Since the original description in 1989, several modifications have been used. A review by Gurocak and associates (2007) summarizes these modifications and provides a good review of the ongoing research with the autoaugmentation procedure. The results after autoaugmentation are less favorable and of shorter duration than after conventional enterocystoplasty; however, some patients may benefit by avoiding the use of intestinal segments and from the lower morbidity associated with this procedure. In most cases, detrusor compliance can be reliably improved; however, the overall increase in bladder capacity is usually nominal. Patients most likely to benefit are those with poor compliance with a reasonable bladder capacity, usually over 200 mL. The specific issues regarding the type of procedure to be performed (enterocystoplasty, autoaugmentation, or ureterocystoplasty), the amount (if any) of bladder to be removed in different disease states, the effect of the loss of the bowel segment on the individual patient’s physiology, and the question of whether to perform a simultaneous procedure to increase the resistance of the bladder outlet is described more fully in Chapter 129.

Urinary Diversion

Supravesical diversion is a treatment modality common to disorders of both storage and emptying failure. Although it has been commonly used in the past for the treatment of neurogenic voiding dysfunction, it is now rarely indicated in any patient with voiding dysfunction alone. Indications may include (1) progressive, medically refractory hydronephrosis, commonly caused by obstruction at the ureterovesical junction from a thickened bladder or by vesicoureteral reflux; (2) recurrent episodes of urosepsis; and (3) intractable storage or emptying failure when CIC is impossible.

Both patient- and disease-related factors should be considered when deciding the type of urinary diversion to perform. The healthy, 60-year-old male with muscle-invasive bladder cancer clearly has more options for reconstruction than a bedridden spinal cord–injured patient. In addition, the decision to perform a continent or incontinent diversion is often fraught with physician bias and emotional preconception on the part of the patient. Continent reconstruction has been shown in some studies to result in a high level of patient satisfaction and improved quality of life in select patients (Zommick et al, 2003); however, the generalized notion that continent diversion is superior to any other form of urinary diversion has not been supported in the literature (Porter and Penson, 2005). Other potential complications include neobladder rupture and increased risk of upper tract deterioration secondary to high-pressure storage, with or without vesicoureteral reflux. In some cases, a continent orthotopic diversion may be considered; however, this procedure should rarely ever be performed in the neurologically impaired patient but is a reasonable option in patients who desire to avoid CIC, although normal voiding is not guaranteed.

The incontinent ileovesicostomy or “bladder chimney” is an excellent method for managing patients with neurogenic bladder who are unable to perform CIC independently (Mutchnik et al 1997; Leng et al 1999). This procedure avoids the complications of long-term indwelling catheters and maintains the native antireflux and urethral sphincteric mechanisms. In addition, this procedure may be reversed if necessary.

Overall, with all the possible choices for a diversion, an ileal conduit is still the most commonly performed. Most urologists are very familiar with this procedure and a conduit gives the patient the best chance of maintaining a system with low pressure while providing a reliable method of urine collection.

Perhaps one of the most controversial issues is what to do with the bladder that remains in situ. Pyocystis remains a potentially fatal condition, especially in the spinal cord–injured population. For in-depth discussions regarding patient selection, technique, postoperative care, and complications of urinary diversions refer to Chapters 85, 86, and 87.

The Artificial Bladder and Tissue Engineering

Prosthetic organs have been successful in many regions of the body, and it would seem to be a simple matter to replace a biologic reservoir such as urinary bladder with a mechanical storage/emptying device. Unfortunately, despite numerous attempts over the past 50 years, we are still far from achieving this goal. Desgrandchamps and Griffith (1999) described the overall goals to include providing adequate storage with complete volitional evacuation of urine while preserving renal function. The structure of the artificial bladder must be biocompatible and resistant to urinary encrustation and tolerant to bacterial infection. There have been numerous alloplastic materials (nonbiologicals) considered for such use, along with the consideration of various (mostly failed) design concepts for total artificial bladder replacement. The desirable qualities for future designs would include:

Presently, incorporation of intestinal segments in urologic reconstruction will continue to serve an important role, but the benefits obtained with their use must be weighed against the associated physiologic effects and complications that accompany those procedures. Further advances in the development of tissue-engineered bladders will likely make them a potential treatment option in the near future. As progress continues in the development of this new technology, it is fascinating to realize the implications it might have regarding our current methods of reconstruction. The processes involved in tissue engineering may include selective cell transplantation, expansion in culture, attachment to a support matrix, and reimplantation after expansion. These topics as well as other options in bladder substitution are discussed in Chapter 19.

Clean Intermittent Catheterization (CIC)

CIC has proved to be the most effective and practical means of attaining a catheter-free state in the majority of patients with acute spinal cord lesions. CIC has revolutionized the treatment of difficult cases of neuromuscular dysfunction of the lower urinary tract by providing a safe and effective method that preserves the independence of the patient to empty the lower urinary tract in cases in which continence has been achieved pharmacologically or surgically, producing total or partial urinary retention. For example, without CIC, the successful outcomes achieved using augmentation cystoplasty or continent urinary diversion would have never been achieved. CIC is based on a theory proposed by Lapides that high intravesical pressure or bladder overdistention is primarily responsible for the development of UTI, not the bacteruria itself. Theoretically, reduced blood flow to the bladder can lead to increased host susceptibility to bacterial invasion and UTI. Bacteria introduced by CIC would be neutralized by the host, and relatively sterile urine would be maintained as long as bladder distention and high intraluminal pressures were avoided. The long-term efficacy and safety of such a program has been demonstrated by Lapides and others (Weld and Dmochowski, 2000).

Whereas indwelling catheter drainage requires little input from the patient, a cooperative, well-motivated patient or family is a requirement for CIC. The patient must have adequate hand control, or a family member must be willing to perform the catheterization. In addition, there must be adequate urethral exposure. Graham (1989) reported on the factors required to successfully develop a catheterization program for patients with functional limitations, which commonly exists in patients with neurogenic bladder dysfunction. It is advantageous to have a dedicated nurse who instructs the patients and families in the catheterization regimen; provides them with understandable written instructions to refresh their memory regarding technique, precautions, and danger signals; and provides continuing support for patients and families who call with questions or problems regarding their regimen. Many patients are initially reluctant to perform any procedure on their own genitalia. Patients need a thorough explanation of the advantages of CIC along with assurances that it is simple and that it will not tie them to their houses or to an absolute time schedule. Additionally, proper selection of equipment for the patient’s intelligence and financial level will increase patient acceptance of and compliance with a self-catheterization program. Patients who are reticent initially are continually amazed by the ease with which such a regimen is established. Successful CIC is intimately associated with patient compliance, and therefore patients should be monitored periodically to ensure catheterization is performed properly. Of note, CIC should be used cautiously in patients known to have autonomic dysreflexia.

Intermittent catheterization may be performed by clean, aseptic, or sterile techniques (Hudson and Murahata, 2005). Clean intermittent catheterization often includes reusing a catheter several times before disposal. It is washed, generally with soap and water, and allowed to air dry prior to storage. When reusing catheters, some have advocated boiling or microwaving for sterilization (Douglas et al, 1990). In April 2008, in an attempt to decrease the incidence of UTIs in patients performing intermittent catheterization, Medicare policy regarding intermittent catheterization changed. Any patient requiring intermittent catheterization may obtain up to 200 sterile catheters per month for one-time use. This change in policy has negated the need for reusing catheters in most patients, but it still may be necessary in patients without insurance coverage or other financial limitations. For adult patients, catheterization is typically performed at a minimum of every 4 to 6 hours to minimize bacterial dwell time. CIC may need to be more frequent if large volumes of fluid are ingested. In most cases, catheterizations should be timed to maintain bladder volumes below the normal 400- to 500-mL capacity to minimize bladder wall pressure. Even smaller volumes may be required if they have poor detrusor compliance. Catheter choice is variable, but a 12- to 16-Fr soft catheter may be used for males and short (6-inch “female”) 12- to 16-Fr catheters for females. Note that rigid catheters have the potential to injure the urethra in insensate males because they may not “make the bend” at the prostate, causing a false passage such that CIC may be quite difficult or impossible. Larger catheters may be required in patients with a prior bowel augmentation or those who require bladder irrigation. In men, hydrophilic coated catheters have been found to reduce the incidence of UTI and hematuria and have higher patient satisfaction rates than conventional plastic catheters (Vapnek et al, 2003; De Ridder et al, 2005). Patients with recurrent UTIs, despite the use of single-use sterile catheters, may obtain sterile catheter kits for sterile intermittent catheterization (IC). Anticholinergic medication should be considered when urine leakage occurs between catheterization intervals or if high storage pressures develop. Wyndaele (2002) reported that trauma from catheterization occurs frequently, but effects are usually not long standing, and urethral stricture and false passages are more common the longer that CIC is employed.

Continuous Catheterization

Long-term indwelling catheters should be considered when anatomical, functional, or familial limitations prohibit performance of intermittent catheterization. Continuous catheterization may also be indicated in patients with complications from persistent incontinence or autonomic dysreflexia, despite therapy or when a small bladder capacity prohibits effective CIC. Long-term catheterization may be accomplished by either a urethral or suprapubic catheter. The basics of urethral catheterization, including the technique of suprapubic tube (SPT) insertion are covered in Chapter 7.

In males, the benefits of an indwelling SPT over urethral catheterization include a lower incidence of epididymitis and urethral stricture disease (Weld and Dmochowski, 2000) and preserved sexual function (Rutkowski et al, 1995) (see Fig. 75–4). Overall, suprapubic catheters have been associated with high rates of patient satisfaction. Barnes and associates (1993) concluded that long-term suprapubic catheters were well tolerated by patients with neuropathic bladders. Based on the replies of 32 patients who expressed an opinion, 84% were satisfied; however, the follow-up was short (mean 23 months), and in 2 of 12 patients assessable at over 2 years, creatinine levels increased. Other problems occurred, including recurrent catheter blockage in 38%, recurrent symptomatic urinary infections in 23%, and displaced catheters requiring reinsertion in the operating room in 15%. Urethral leakage occurred in 8 of 14 females with a suprapubic catheter alone and in 6 of 16 males. Patients using a suprapubic catheter must be warned that urinary incontinence may commence or worsen in the setting of sphincteric incontinence or reflex detrusor overactivity, because active opening of the sphincteric unit will occur in the absence of dyssynergia. Sheriff and associates (1998) discussed the clinical outcome in a satisfaction survey of 185 patients with neuropathic bladder dysfunction treated with long-term suprapubic catheterization (follow-up, 3 to 68 months; mean, 24 months). The authors reported an 82% satisfaction rate; however, the main reason for this procedure was failed CIC from poor hand function. In addition, only 103 of the 185 patients filled out the satisfaction questionnaire, and only 8 patients had a suprapubic catheter for longer than 2 years. Complications in this group included 5 patients with a small-bowel injury during insertion, 2 developing significant hemorrhage, 2 requiring catheter repositioning, 1 requiring reinsertion because of dislodgement, 8 with persistent incontinence, and 18% with recurrent catheter blockage. Bacteriuria existed in 98% of the patients, but recurrent symptomatic infection occurred in only 4%. More recently, Ahluwalia and colleagues (2006) reported a satisfaction rating of 71% among 219 patients having indwelling suprapubic catheters for greater than 50 months.

A controversial issue, common to all long-term indwelling catheters, is the development of bladder cancer. The long-term risk of carcinoma in the SCI patient with a chronic catheter has been estimated to be 8% to 10% (Locke et al, 1985; Delnay et al, 1999). Kaufman and colleagues (1977) were among the first to recognize that patients with SCI and chronic indwelling catheters had an increased incidence of bladder cancer, particularly squamous cell carcinoma (SCC). Several others have reported similar findings (Chao et al, 1993; Stonehill et al, 1996). Since this report, the association between chronic indwelling catheterization and the development of bladder carcinoma has been debated. No associations with intermittent catheterization have been identified. Chronic inflammation is the most likely causative factor and may be caused by the indwelling catheter itself, bladder calculi, and/or recurrent infections. It is not clear whether earlier treatment of these conditions or better follow-up will lessen the risk for bladder carcinoma. A mechanism for the development of bladder carcinoma secondary to long-term inflammation was described by Wall and colleagues (2001). According to their report, inducible nitric oxide synthase expressed by inflammatory macrophages in areas of chronic inflammation may lead to the formation of potentially carcinogenic nitrosamines in the bladder. For more on the development of carcinoma and the associations with spinal cord injury and chronic catheterization, see Chapter 65.

When SCC is identified in SCI patients, it is often advanced and commonly fatal; however, routine screening cystoscopy for SCI patients at risk is controversial. Although some authors suggest that screening cystoscopy conveys a survival advantage by identifying bladder cancer at an earlier stage (Navon et al, 1997), others have found no advantage for screening (Yang and Clowers, 1999; Hamid et al, 2003). Cytology, although commonly obtained, is not useful for detecting squamous cell carcinoma (Bejany et al, 1987). Additionally, SCC may not always be cystoscopically detectable (Kaufman et al, 1977). For this reason, routine random biopsies have been advocated by some (Stonehill et al, 1996). Despite the lack of data in non-SCI patients, most urologists recommend all patients with chronic catheters undergo annual screening, generally starting after 8 years (Stonehill et al, 1996). Gross hematuria has been reported by several investigators as the most common presenting symptom for patients eventually diagnosed with bladder cancer (Hess et al, 2003). Despite the disparate opinions regarding screening, certainly all would agree that patients with new-onset gross hematuria should be evaluated with upper tract imaging, urinary cytology, cystoscopy, and perhaps random biopsies. Other patients to consider for close surveillance should include patients with known risk factors for the development of carcinoma, such as recurrent UTIs or recurrent bladder stones.

External Collecting Devices

Despite the numerous patents for prospective female collection devices, no device has yet to perform effectively enough to distinguish itself as a reliable method of urine collection. Problems in application and failure of leak-proof collection have often limited the success and widespread use of these devices. As a result, females must often make due with pads, diapers, or other absorbent products. On the contrary, external collection devices for the male—the condom catheter, penile sheath or Texas catheter—are generally successful regarding urine collection. Unfortunately, they are also unacceptable to some patients because the device is visible (sometimes through their clothing) and due to odor issues secondary to leakage of often foul-smelling urine. Condom catheters are available in various sizes, and some include a measuring guide to assist in catheter selection. The inappropriate sizing of the condom catheter is often responsible for dislodgment and leakage of these catheters.

Condom catheters are generally perceived as more comfortable, less painful, and less restrictive on daily activities than indwelling catheters (Saint et al, 2006). Saint and colleagues (2006) reported the results of a prospective, randomized, controlled trial of 75 hospitalized men requiring a urinary collection device. In this study, condom catheters were associated with a lower incidence of complications, including bacteruria, symptomatic urinary tract infection, and death, than with use of indwelling catheters. It should be emphasized that despite the reduced incidence of these adverse outcomes, the use of external collection devices and absorbent products is associated with a higher risk for UTIs compared with cases where no appliances are used (Sturman et al, 1989). It is generally recommended that condom catheters be changed daily, because the risk for UTI is increased when catheters are changed less frequently (Waites et al, 1993; Zimakoff et al, 1996). The use of this device is not free of complications; it can cause allergic reactions, skin maceration, and/or penile edema. Furthermore, the penile skin and glans should be examined at every catheter change to ensure no skin breakdown or contact reactions have occurred (Newman, 1999). These devices have the potential to cause pressure necrosis of the penis and, when severe, may even damage the urethra (Golji, 1981). Pressure-related complications are more likely to occur in patients with impaired sensation, such as those with neurogenic lower urinary tract dysfunction (Golji, 1981). The authors suggest that many of these problems may be due to the hard ring on the condom catheter. Maintaining an external urinary collecting device can also be a major problem for patients with SCI. The inability to maintain a device during a vigorous voiding contraction, inadequate penile length (often due to obesity), or recurrent lacerations of the penile skin may dictate temporary use of an indwelling catheter. Van Arsdalen and coworkers (1981) described the use of a noninflatable penile prosthesis in this type of patient, because it increases the ease of applying and maintaining such a common catheter. This is also advantageous for those patients who are interested in a prosthesis for reasons of potency. Initial studies reported up to a 25% penile implant loss in these patients; however, more recent data have shown much lower rates of implant loss. Zermann and associates (2006) reported on the long-term follow-up of penile prosthetic surgery for neurologically impaired patients. Indications for implantation included erectile dysfunction, urinary management, or both. After a mean follow-up of 7.2 years, the overall infection rate was 5%, and the rate of explantation was 7.7%. This is not much higher than the explantation rate in non-neurologic patients. In addition, the rate of perforation was different depending on the model used, with the semirigid device having the highest occurrence (18.1%), the self-contained inflatable 2.4%, and 0% for the three-piece inflatable. The authors attribute these improvements to changes in antibiotic prophylaxis and the introduction of new softer implant materials. For similar problems resulting from a “receding phallus,” Binard and colleagues (1993) described a penoplasty procedure that basically lengthens the shortened penis. Early results are encouraging; however, no long-term results of this procedure have been reported.

Absorbent Products

Patients with incontinence are more likely to suffer from depression or anxiety (Shaw, 2001) and may adjust their lifestyle by limiting social activities for fear of odor, discovery, and embarrassment. Eventually, many patients will initially manage their urine leakage by wearing absorbent products. It is not known how many patients use this method to control incontinence, but consumers spend billions of dollars annually on these products (Getliffe et al, 2007; Erekson et al, 2008). Depending on the type of product used, the average patient may spend $40 to $150 a month, none of which is covered by Medicare, HMOs, or insurance companies (Newman, 1999). Consumers may be overwhelmed by the numerous brands and types of products available; options include pads, shields, drip collectors, guards, undergarments, briefs, diapers, or underpads. Further, products may be disposable or reusable. For the majority of patients, selection is often a matter of trial and error and is based on personal opinion, manufacturers’ claims, convenience of the caregiver, or product cost ( Baker and Norton, 1996; Fantl et al, 1996). Very few studies are available that provide evidence-based recommendations for any specific brand or type of product, and therefore choosing the most appropriate absorbent product is not a simple matter. The ideal substance for absorptive devices is one that is highly permeable and absorbent. Generally, a layer of hydrophobic material is immediately next to the patient’s skin. Through this layer, urine passes into an absorbent pad, which is, in turn, surrounded by a waterproof material to keep clothing dry. Ideally, the hydrophobic material next to the skin keeps the patient relatively dry and reduces chafing as much as possible. There is no standardization in the absorbent capacity or quality of materials used to construct these products (Newman et al, 2004). Also, several factors may influence a patient’s satisfaction, such as shape or contour of the pad, their capacity and speed of absorbency, amount of core fluff, fit, and comfort when dry or wet (Newman et al, 2004). Erekson and colleagues (2008) examined the difference in cost and performance of brand name and generic incontinence pads. The authors concluded that brand name products generally cost more, but often perform better than generic products. They also found that neither the cost nor the size of the pad significantly affects product performance. The authors acknowledge the limitations of the study, stating that pad performance was not always reliable and that it may be attributed to errors in measurement or product inconsistencies. To guide patient selection, Fader and associates (2007, 2008) compared the performance and cost-effectiveness of different designs of absorbent products. The authors concluded that although there are significant differences between designs of absorbent products, there is considerable individual variability in preferences. The authors also suggest that, depending on the degree of the patient’s incontinence, some designs may function better than others. Selection of the ideal absorbent product continues to be inadequately assessed and studied. Only recently have researchers started to investigate the factors that influence patients’ selections. In addition, results from any study must be interpreted in the context of the population that was evaluated, making widespread recommendations to the wide variety of patients with incontinence difficult. Indeed, as reported by Fader and associates (2008), there is no single-best design that is significantly better than all other designs and applicable to all users.

Often recognized as the authority in the management of the incontinent patient, urologists should acknowledge the basic nursing principles and skin care recommendations that may significantly contribute to patient care. Absorbent products should be changed frequently to help avoid buildup of odor and to limit the exposure of the skin to urine. Prolonged exposure of the skin to a wet environment may lead to supersaturation and disruption of the skin’s protective barriers, promoting skin maceration, dermatitis, and possibly infection. Incontinence-associated dermatitis (IAD) can be defined as inflammation of the surface of the skin with redness, edema, and, in some cases, bullae containing clear exudate (Gray et al, 2007). IAD predominately occurs in skin folds and may promote candidiasis or bacterial skin infections. Gray and associates (2007) published an excellent review of the epidemiology, pathophysiology, and management of IAD with recommendations for prevention and treatment of incontinence-associated dermatitis.

Further information regarding the types of absorbent products available for males and females, including a review of skin care management, external collection, and urethral compression devices can be found in the book by Newman and Wein (2009) and the 2008-to-2009 catalogue available from the National Association for Continence (2004) (http://www.nafc.org).

Increasing Intravesical Pressure or Facilitating Bladder Contractility

Transurethral Resection or Incision of the Bladder Neck

The first transurethral bladder neck resection for neurogenic lower urinary tract dysfunction was performed by Emmett in 1937 (Wein and Barrett, 1988). Originally, the procedure had two main indications: a hypocontractile (or atonic bladder) and anatomic (or functional) obstruction at the level of the bladder neck and/or proximal urethra that prevented emptying despite abdominal straining or a sustained detrusor contraction. It was also used in areflexic bladder patients with sacral spinal cord lesions who could not adequately empty by straining or Credé maneuver; however, this simply created progressively severe stress incontinence. In these instances, other alternatives for improving bladder emptying should be sought first (Wein et al, 1976).

The most common modern indication for transurethral resection (TURBN) or incision (TUIBN) of the bladder neck is a urodynamic-confirmed anatomic or functional obstruction at the bladder neck or proximal urethra. Primary bladder neck obstruction (PBNO) is a videourodynamically diagnosed condition, characterized by high-pressure, low-flow voiding, with radiographic evidence of obstruction at the bladder neck, without striated sphincter contraction or distal obstruction (Padmanabhan and Nitti, 2007) (Fig. 75–6). Alternatively, the diagnosis can be made by a micturitional urethral profile (McGuire et al, 1984). The true prevalence and etiology of PBNO is unknown. The highest reported incidence is in younger males with severe lower urinary tract symptoms (LUTS) and ranges from 33% to 54% in this population (Huckabay and Nitti, 2005). Much lower incidences have been reported for females (4.6% to 8.7%). For more on bladder neck dysfunction refer to Chapter 65.

Figure 75–6 During urodynamics in a young male with severe lower urinary tract symptoms, a primary bladder neck obstruction was found. The bladder neck obstruction was accentuated by having the patient tighten his voluntary sphincter during voiding.

Currently, the preferred technique is incision of the bladder neck at the 5-o’clock and/or 7-o’clock positions. A single full-thickness incision is extended from 1 cm distal to each ureteral orifice and continued through the bladder neck and prostatic fossa to just proximal to the verumontanum. The incision is deepened until no ridge is visible at the bladder neck, and fat is visualized through the capsular fibers (Huckabay and Nitti, 2005). Other techniques include a limited resection of the dorsal tissue from the 3-o’clock to the 9-o’clock position and a resection limited to the posterior lip. In women, incisions may be performed at the same anatomic location as in men and extended from just inside the vesical neck through the proximal third of the urethra (Blaivas et al, 2004). Overly aggressive technique should be avoided in females, because of the risk of stress incontinence.

In this predominately young male population, one of the most significant concerns with bladder neck incision or resection is the development of retrograde ejaculation. A reduction in the incidence of retrograde ejaculation has been reported with the performance of a unilateral TUIBN (Kaplan et al, 1994; Kochakarn et al, 2003). Earlier studies reported the incidence of diminished ejaculate volume ranging from 10% (Turner-Warwick, 1984) to as high as 50% (Norlen and Blaivas, 1986). More recently, a 27% incidence was reported with bilateral incisions (Trockman et al, 1996), while antegrade ejaculation was preserved in all patients who underwent a unilateral incision (Kaplan et al, 1994).

Significant improvements in symptom relief and maximum flow rate have been reported with these techniques (Huckabay and Nitti, 2005). Norlen and Blaivis (1986) reported subjective improvement in 18 men with PBNO, with an increase in Q_max from 9.1 mL/sec to 26.1 mL/sec. Kaplan and colleagues (1994) performed a unilateral incision in 31 men, 30 of 31 had subjective improvement and a mean increase in Q_max from 9.2 to 15.6 mL/sec. Peng and Kuo (2005) reported their experience with TUIBN in 11 women with urodynamically confirmed bladder neck obstruction. After a mean follow-up of 10 months, significant urodynamic improvements were reported in Q_max (3.8 to 12.0 mL/sec), residual urine (355.5 to 84.5 mL), and voiding pressure (86.5 to 59.1 cm H₂O). A similar study of 11 women with PBNO was reported by Goldman and Zimmern (2006). Ten had improvement or resolution of symptoms, and one developed mild SUI postoperatively.

YV-Plasty of the Bladder Neck

The objective of the YV-plasty is to reduce bladder outlet resistance by revision of the anterior bladder neck; however, this technique is now rarely performed. Bladder neck resection or incision performed endoscopically is now the preferred procedure and is capable of achieving the same objectives as the YV-plasty but with less morbidity. It would only seem appropriate to consider this method when a concurrent open procedure is already required for a concomitant urologic disorder. Significant incontinence may result following this procedure and, at times, was the intended consequence, especially when it was performed radically or in the setting of a refractory, poorly emptying bladder. Due to the infrequency and short-lived use of this procedure, the efficacy of YV-plasty and incidence of postoperative complications have not been reported.

Surgical Sphincterotomy

Therapeutic destruction of the external urethral sphincter was initially performed in 1936, but the first large clinical series was not reported until 1958 by Ross and colleagues (Wein and Barrett, 1988). Several techniques have been described; however, the 12-o’clock sphincterotomy, as originally proposed by Madersbacher and Scott (1975), remains the procedure of choice for a number of reasons. The anatomy of the striated sphincter is such that its main bulk is anteromedial. With the blood supply primarily lateral, a 12-o’clock incision is least likely to cause hemorrhage, with reported rates of 5% to 20%. The rate of postoperative erectile dysfunction with this incision is approximately 5% compared with a 5% to 30% incidence with a 3-o’clock and 9-o’clock technique. Significant urinary extravasation has also been reported. Sphincterotomy can be performed using a knife electrode, resection with a loop electrode, or laser ablation. The incision must extend from the level of the verumontanum at least to the bulbomembranous junction. Gradual deepening of the incision allows good visual control and minimizes the chance of significant hemorrhage and extravasation. An external collecting device is usually necessary postoperatively, precluding usage in females. Vapnek and associates (1994) reported that conversion to suprapubic bladder drainage was most commonly attributed to difficulty with the collection device. Continuous sphincteric incontinence or severe stress incontinence is uncommon, unless the urethra or bladder neck has been compromised by prior surgery or preexisting pathology. Noll and colleagues (1995) reported that laser sphincterotomy seems to have an advantage over conventional diathermy procedures, after finding that only 15.1% of laser-treated patients required resphincterotomy compared with 30% of those treated with a conventional procedure. Further advantages of laser sphincterotomy were reported by Perkash (1996) with the finding of less bleeding following procedures performed in this manner.

When early failure occurs, it is generally attributable to an inadequate surgical procedure (either not deep enough or not extensive enough), inadequate detrusor function, and bladder neck or prostatic obstruction. Late failure may occur because of fibrosis somewhere along the extent of the sphincterotomy, a change in detrusor function, the development of prostatic obstruction, or a change in neurologic status such that smooth sphincter dyssynergia develops (Lockhart and Pow-Sang, 1989). Yang and Mayo (1995) defined failure as (1) the presence of large postvoid residual urine volumes associated with urinary tract infections, (2) autonomic hyperreflexia symptomatology associated with bladder overdistention or high voiding pressures, and/or (3) progressive upper tract deterioration from persistent reflux or poor bladder emptying.

Failure rates following sphincterotomy have been reported to be as high as 40% to 50% in some series (Santiago, 1993; Vapnek et al, 1994; Yang and Mayo, 1995). In addition, the incidence of failure increases with time from the initial procedure (Vapnek et al, 1994; Yang and Mayo, 1995). In a more recently reported series, Pan and colleagues (2009) reported only a 32% primary success rate following external sphincterotomy, with eventual failure occurring in 57 of 84 (68%) patients at a mean of 42.7 months from the initial procedure. Of the 57 patients that failed, 30 underwent a repeat sphincterotomy with a mean response of 56 additional months. Kim and colleagues (1998) reported a significantly higher incidence of upper tract damage and persistent sphincter dyssynergia with detrusor leak point pressures of greater than 40 cm H₂O. Juma and associates (1995) considered detrusor leak point pressure as the most reliable urodynamic parameter to predict the risk of upper tract complications after sphincterotomy. The authors reported a 30% incidence of significant upper tract complications (half of which developed more than 2 years after sphincterotomy), in their series of 63 patients with a mean follow-up of 11 years. Lower urinary tract complications (recurrent infection, calculi, urethral diverticula, stricture, bladder neck stenosis, and recurrent epididymitis) occurred in 48% of patients.

Urethral Stenting

The use of a urethral stent to bypass the striated sphincter was suggested by Shah and associates (1990). Chancellor and Rivas (1995) reported the initial multicenter North American data using the UroLume stent (American Medical Systems, Minnetonka, MN) in 153 patients at 15 centers. A significant decrease in detrusor leak pressure and residual urine volume was seen; however, 18% of patients required more than one procedure to adequately open the sphincter, hyperplasia within the lumen was seen in 42 patients (33.3%) at 3 months, and 10 devices were removed (7 for migration) and 7 were replaced. Bladder neck obstruction requiring treatment was seen in 13 patients (4 with α blockers, 7 with incision, 2 with CIC), and when removal was required (in 4) this was not a problem up to 12 months. Rivas and coworkers (1994) concluded that a stent prosthesis is as effective, easier, less morbid, and less expensive than a sphincterotomy.

Chancellor and colleagues (1999b) reported the long-term follow-up of the UroLume stent in for striated sphincter dyssynergia in a group of 160 men with SCI at 15 centers in North America. Mean voiding pressure decreased from 75.1 cm H₂O to 37.4 cm H₂O at year 1 and was maintained for up to 5 years. Residual urine volume also decreased and was maintained for 5 years; however, the residual urine volume was not less than 105 mL in any group, and mean cystometric bladder capacity did not change. Symptoms of autonomic hyperreflexia after stent placement were reduced in 53 of 89 patients at 1 year and 37 of 72 at 2 years. De novo detrusor overactivity developed in only 1 of 36 patients in the 1-year follow-up group and only 3 of 30 in the 2-year group. One obvious advantage using a sphincteric stent is that it is potentially reversible. Fifteen percent of patients (24 patients) required stent removal; another stent was implanted in 4 of these. Stent migration occurred in 12.4% of patients at 3 months after implantation and in 5% at 6 months, with correspondingly decreased percentages up to 4 and 5 years. Forty-seven patients (26.3%) were diagnosed with bladder neck obstruction after stent placement, and were managed by bladder neck incision in 20, α blockade in 10, CIC in 8, and watchful waiting in 9. The authors commented that in those patients who required stent removal, the procedure could be accomplished despite epithelialization but that a learning curve certainly exists before one becomes comfortable removing the stent.

Chancellor and colleagues reported a prospective, randomized, multicenter trial of sphincteric stent placement versus external sphincterotomy (Chancellor et al, 1999a). Fifty-seven men were randomized; the primary outcome indicator was maximum detrusor pressure. At 12 months, there was no significant difference; however, at 24 months, maximum detrusor pressure had decreased from 90.6 cm H₂O to 41.6 cm H₂O in the sphincterotomy group and from 101.9 cm H₂O to 71.6 cm H₂O in the stent group. Whether this is meaningful is uncertain. At 24 months, residual urine volume had decreased from 218 to 112 mL in the sphincterotomy group and from 164 to 132 mL in the stent group. Cystometric capacities did not appear to change up to 24 months. Bladder neck obstruction requiring treatment developed in 6 patients in each group. Six of the 31 stent patients required stent removal, all without difficulty.

The use of temporary urethral stents in 147 men with DSD was reported by Gamé and colleagues (2008). Patient satisfaction and treatment efficacy was assessed every 3 months postoperatively until a mean of 10 months after insertion. After the initial period of temporary stenting, patients who were subjectively satisfied with this treatment modality, who also had a significant decrease in urinary complications and in postvoid residual, went on to permanent urethral stenting, 70.7% in this case. Seven (4.7%) recovered enough neurologically to perform CIC upon removal of the temporary stent. The authors state that the use of temporary urethral stents allows identification of patients who are unlikely to benefit from permanent stent insertion.

The ideal patient and therapeutic role for urethral stenting remains controversial (Boone, 2009; Perkash, 2009). The reversibility of this procedure is attractive to some; however, stent removal, when necessary, may be difficult. Complications include obstruction by urothelial ingrowth, stent encrustation, stricture, stent migration, and UTI. Similar to sphincterotomy, a collection device is required with urethral stenting, precluding use in females.

An intraurethral sphincter prosthesis with a self-contained urinary pump has been developed for use in women with a hypocontractile or acontractile bladder (“inflow” intraurethral insert). Schurch and associates (1999) reported on the use of this device in 18 women with neurogenic voiding dysfunction and a hypocontractile bladder. Sixteen months after placement, only 6 of the women were still using the implant and were satisfied. In 10 patients, severe incontinence around the catheter or irritation necessitated removal. In 2 patients, the device was removed because the patients could not transfer to the toilet to empty their bladder. Fourteen of the devices had to be replaced early because of device dysfunction, and three external remote control units malfunctioned. At that time, the authors considered the device unsuitable for long-term use.

Madjar and colleagues (2000) reported on 92 women, having the device, who were followed for periods of longer than 1 year. Early removal of the device (<14 days) was required in 56.5% of patients, mostly because of local discomfort and urinary leakage. In an additional 20.6% of patients, the device was removed between 2 and 16 months after placement. Only 21 patients (22.8% of the original group) with the device still in place after more than 1 year (mean, 24.6 months) were being followed. In these patients, six device removals in 4 patients were required because of migration into the bladder, asymptomatic bacteriuria developed in 15 patients, and symptomatic urinary tract infections developed in 4 patients. The authors’ conclusion that further studies are necessary to compare this treatment with CIC and other modalities seems justified.

Pharmacologic Sphincterotomy

Botulinum toxin is a protein neurotoxin produced by the bacterium Clostridium botulinum. Urologic use of botulinum toxin for the treatment of detrusor striated sphincter dyssynergia was first reported by Dykstra and colleagues (Dykstra and Sidi, 1990; Dykstra et al, 1998). Further experiences followed, with several reports of botulinum toxin usage in diverse groups with voiding dysfunction (Schurch et al 1996; Gallien et al, 1998; Petit et al, 1998). Fowler and coworkers (1992) injected botulinum toxin into six women with difficult voiding/urinary retention secondary to what is now called the Fowler syndrome (manifested by abnormal myotonus-like electromyographic activity in the striated urethral sphincter). Kuo (2003) reported periurethral injections of botulinum A toxin in 103 patients with lower urinary tract dysfunction due to a number of different causes, including detrusor sphincter dyssynergia, dysfunctional voiding, nonrelaxing urethral sphincter, cauda equina lesion, peripheral neuropathy, and idiopathic detrusor underactivity. As the role of botulinum toxin in the treatment of sphincteric obstruction continues to evolve, its use remains uncommon and unclear. A more detailed discussion of the role of botulinum toxin in urologic practice is covered in Chapter 68.

Theoretically, any agent that promotes striated sphincter relaxation in a uroselective manner could be used to decrease outlet resistance and facilitate voiding dysfunction. Yoshiyama and associates (2000) reported improved voiding in rats with SCI by using intravenously administered α-bungarotoxin. This compound is a toxin, extracted from the venom of a Formosan snake, that selectively blocks nicotinic receptors without influencing transmission in autonomic ganglia. The nicotinic receptors in the striated sphincter have been shown to be a potential target for drug therapy for striated sphincter dyssynergia.

Urethral Overdilatation

Urethral overdilatation to 40 to 50 Fr in females can achieve the same objective as external sphincterotomy in males (see Wein and Barrett, 1988) but is rarely performed because of the lack of a suitable external collecting device. In young boys, a similar stretching of the posterior urethra can be performed using a perineal urethrostomy, obviating or postponing the need for a surgical sphincterotomy. Wang and associates (1989) reported the results of urethral dilatation, using sounds or balloon procedures, to 22 to 28 Fr in 11 myelodysplastic children with high intravesical pressures refractory to traditional forms of treatment. After dilatation, the intravesical pressures decreased, and upper tract function and bladder compliance improved. There was no discernible effect on continence. These observations demonstrated that urethral dilation can decrease outlet resistance and improve compliance without deterioration in urinary control beyond preoperative conditions.

Balloon dilatation of the external urethral sphincter was reported by Werbrouck and associates (1990). Using balloon dilatation to 90 Fr at 3 atm, Chancellor and colleagues (1994b) compared balloon dilatation (20 patients), sphincterotomy (15 patients), and stent placement (26 patients) in the treatment of striated sphincter dyssynergia. A significant decrease in detrusor leak point pressure and residual urine occurred in all three groups. Bladder capacity remained constant, renal function stabilized or improved, and autonomic hyperreflexia improved. Balloon dilatation and stent placement were associated with a significantly shorter surgery and hospitalization times and less blood loss. In the dilatation group, 3 patients developed recurrent obstruction (at 3, 8, and 12 months), 1 required transfusion, and 1 developed a 1-cm bulbar stricture. In the surgical sphincterotomy group, 2 patients required transfusion, 2 developed a stricture with obstruction, and 1 developed erectile dysfunction. In the stent group, 3 patients had migration requiring adjustment (1 had the stent replaced, 2 had a second overlapping stent), and 2 developed bladder neck obstruction requiring transurethral incision. McFarlane and colleagues (1997) reported on the use of balloon dilatation of the striated sphincter as an alternative to sphincterotomy in 14 patients followed for a mean of 55.5 months (8 to 68 months). Sphincter activity was initially abolished in all patients, and reflux, which was present in 1 patient, resolved. Long term, however, 62% failed within 1 year, and overall 85% failed. The authors concluded that this is an ineffective long-term treatment for striated sphincter dyssynergia in the majority of patients, thus recommending either surgical sphincterotomy or stenting as the surgical treatments of choice for this condition.

Pudendal Nerve Interruption

Relief of obstruction at the level of the striated sphincter can also be achieved by pudendal neurectomy, first described in 1899 by Rocket (see Wein and Barrett, 1988). This method is seldom used today due to potential undesirable effects, even after a unilateral nerve section. Bilateral nerve section results in an extremely high rate of impotence and may result in significant fecal and stress urinary incontinence. If this procedure is contemplated, the results of a block should precede the formal procedure, which should be performed only unilaterally. More recently, Changfeng and colleagues (2004) reported on the use of high-frequency electrical stimulation to provide a reversible pudendal nerve block in cats. The authors stated that the goal of this approach is to relax the external urethral sphincter only at the time of voiding, allowing normal function between voids to maintain continence. No human studies have been reported at this time.