Reversible Clinical Outcome After Sphincter Stent Removal

Chapitre B-3 A - Traitement chirurgical des dysfonctions neurologiques des sphincters urinaires

The treatment of neurogenic detrusor-sphincter dyssynergia is primarily medical (drugs and catheterization). Some patients may not be eligible for or fail to respond to these treatment options and endoscopic sphincterotomy or permanent prosthesis may be indicated. In this article, the authors review the indications, results and contraindications of these various treatments.

Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia

STUDY DESIGN

Retrospective study.

OBJECTIVES

To assess in the long-term clinical and urodynamic results of intraurethral stents in a group of patients with spinal cord injury.

SETTING

Spinal Cord Injury Unit, Juan Canalejo Hospital, A Coruña, Spain.

METHODS

Forty-seven consecutive male patients were studied from 1993 to 2002. All of them suffered from hyperreflexia with detrusor-sphincter dyssynergia (DSD) owing to spinal cord injury, and were treated by means of the placement of an intraurethral stent at the external sphincter.

RESULTS

After surgery, significant decreases in all the parameters studied were observed. The number of patients with symptoms of urinary tract infection decreased by 25% (P<0.031). Post-void residual urine volume experienced an average decrease of 224.3 cm(3) (P=0.001). Episodes of dysreflexia decreased from 35.1 to 16.2% (P=0.039). The urodynamic study showed an average reduction of 44.36 cm H(2)O in the maximum detrusor pressure (P<0.0001). Complications in the upper urinary tract descended from 46.8 to 23.4% after placing the stent (P=0.013). The most frequent stent complication was displacement, followed by stenosis, lithiasis and intraprosthetic calcification. In all, 8.5% required the stent removal.

CONCLUSIONS

Intraurethral stent is a good choice for the long-term management of DSD in spinal cord-injured patients, even in those who had been previously submitted to prior sphincterotomy. It has the advantage of being a potentially reversible procedure, so patients prefer it to more invasive therapies such as sphincterotomy.

Extraction of UroLume endoprostheses with one-stage urethral reconstruction

We describe a technique for transperineal excision of UroLume endoprostheses with one-stage urethral reconstruction. We have used this technique in 3 patients with occluded urethral stents placed for bulbar stricture disease. All patients experienced acceptable outcomes.

Temporary urethral stenting for membranous urethral stricture helps complete healing without compromising continence

We report the case of a patient with a recurrent membranous urethral stricture who was treated with temporary implantation of a UroLume endoprosthesis and recovered completely, without any sphincteric insufficiency or stricture recurrence, during a 1-year follow-up period.

Experience with urethral stent explantation

PURPOSE

We examined the timing, causes and results of the explantation of UroLume (American Medical Systems, Minnetonka, Minnesota) urethral stents.

MATERIALS AND METHODS

The North American Study Group enrolled 465 patients in a trial of UroLume stent placement, including 69 (14.8% of the series) who required removal of a total of 73 stents (15.6% of stents) in 7 years. The time of explantation, reason for stent removal and local histological findings were determined from patient charts and reviewed in relation to the indication for stent placement.

RESULTS

In patients treated for bladder outlet obstruction secondary to benign prostatic hyperplasia 23% of the stents were removed, as were 5% of those implanted in patients with bulbar urethral stricture and 22% of those in patients with detrusor-sphincter dyssynergia (see figure). Of the explantations 43.8% were done during year 1. Migration and/or inappropriate placement was the cause in 38.4% of cases. The most common stent site tissue finding was focal inflammation with a hyperplastic tissue response. Stent specific malignant changes were not observed. Stent removal was feasible with no sequelae. CONCLUSIONS When used appropriately, the UroLume endoprosthesis has a low incidence of failure. Stent removal is technically feasible and options are available for subsequent therapy. Local tissue reaction is minimal.

Removal of UroLume endoprosthesis: experience of the North American Study Group for detrusor-sphincter dyssynergia application

PURPOSE

We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis.

MATERIALS AND METHODS

A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively.

RESULTS

Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion.

CONCLUSIONS

While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.