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Wilkins NL, Medina Aguinaga D, Hoey R, Fell J, Harkema SJ, Hubscher CH. Bladder responses to thoracolumbar epidural stimulation in female urethane-anesthetized rats with graded contusion spinal cord injuries. J Neurotrauma 2024. [PMID: 39264865 DOI: 10.1089/neu.2024.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2024] Open
Abstract
Spinal cord epidural stimulation (scES) is a therapeutic option that promotes functional improvements in sensory, motor, and autonomic functions following spinal cord injury (SCI). Previous scES mapping studies targeting the lower urinary tract (LUT) in rats demonstrated functional response variability based upon lumbosacral level, parameters used, extent of injury (spinally intact versus chronic anatomically complete spinal transections), and sex. In the current study, female rats with clinically relevant graded incomplete T9 contusion injuries were mapped with scES at 60 days-post-injury at three spinal levels (T13, L3, L6) with a novel miniature 15-electrode array designed to deliver optimal specificity. The results obtained during bladder fill and void cycles conducted under urethane anesthesia indicate frequency dependent sub-motor threshold effects on LUT function with a single row of electrodes positioned across the full medio-lateral extent of the dorsal cord. The findings of improved storage and emptying, represented by significantly longer inter-contractile intervals with T13 scES and L3 scES and by a significantly increased estimated void efficiency with L6 scES, respectively, is consistent with previous studies using intact and chronic complete transected male and female rats. The data support the efficacy of selective spinal network stimulation to drive functionally relevant networks for storage versus emptying phases of the urinary cycle. The current findings further demonstrate the translational promise of scES for SCI individuals with LUT dysfunctions, regardless of injury severity.
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Affiliation(s)
- Natasha L Wilkins
- University of Louisville School of Medicine, Anatomical Sciences & Neurobiology, Louisville, Kentucky, United States;
| | - Daniel Medina Aguinaga
- University of Louisville School of Medicine, Anatomical Sciences & Neurobiology, Louisville, Kentucky, United States;
| | - Robert Hoey
- MetroHealth Medical Center, Physical Medicine and Rehabilitation , Cleveland, Ohio, United States;
| | - Jason Fell
- University of Louisville School of Medicine, Anatomical Sciences & Neurobiology, Louisville, Kentucky, United States;
| | - Susan J Harkema
- University of Louisville School of Medicine, Neurological Surgery, Louisville, Kentucky, United States;
| | - Charles H Hubscher
- University of Louisville School of Medicine, Anatomical Sciences & Neurobiology, Louisville, Kentucky, United States;
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Yeh SD, Khasanah N, Gustafson KJ, Sun C, Tsai ML, Lin BS, Wu CW, Peng CW. Beneficial carry-over effects of chronic at-home genital nerve stimulation on incontinence in individuals with spinal cord injury: A pragmatic trial. Ann Phys Rehabil Med 2024; 67:101799. [PMID: 38128350 DOI: 10.1016/j.rehab.2023.101799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 06/30/2023] [Accepted: 09/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Genital nerve stimulation (GNS) is a promising, but under-researched, alternative treatment for neurogenic detrusor overactivity (NDO) in those with spinal cord injury (SCI). OBJECTIVES To investigate the urodynamic, quality-of-life (QOL) and carry-over effects of GNS when applied at home for 2 weeks by participants with incomplete SCI and NDO during activities of daily living. METHODS Seven men and 1 woman participated in this 1-month protocol study. Urodynamic and QOL data were gathered during week 1 (baseline measurements), followed by 2 weeks of daily GNS at home using a portable device. GNS was applied either on-demand or thrice daily, depending on the individual's sensation. At week 4, post-stimulation tests were repeated to record any carry-over effect from the GNS. Participants maintained voiding diaries throughout the study. Assessments were carried out at the end of each protocol period in a randomized order. Clinical procedures were conducted at Taipei Medical University Hospital (Taipei, Taiwan). RESULTS Everyone completed the study but only 7 of the 8 participants completed their voiding diary. Two weeks after GNS, average cystometric bladder capacity was increased by 30 % compared to baseline (P< 0.05). A 1-week carry-over effect was demonstrated as this capacity remained, on average, 35 % greater than baseline in week 4 after GNS was stopped (P< 0.05). Incontinence frequency significantly decreased by the end of week 3 (P< 0.05) but no significant improvements were recorded for either detrusor pressure or bladder compliance. CONCLUSIONS Chronic at-home GNS improved cystometric bladder capacity and reduced urinary incontinence for individuals with incomplete SCI and NDO. A carry-over effect of 1 week was observed following GNS treatment. The use of portable GNS treatment that can be applied by the individual at home merits further investigation as alternative treatment for NDO in those with SCI.
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Affiliation(s)
- Shauh-Der Yeh
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan, ROC; Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan, ROC
| | - Nurida Khasanah
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan, ROC; Department of Obstetrics and Gynecology, Faculty of Medicine Public Health and Nursing, Universitas Gadjah Mada-Dr Sardjito General Hospital, Yogyakarta, Indonesia
| | - Kenneth J Gustafson
- Louis Stokes Cleveland VAMC, Cleveland, OH, USA; Cleveland FES Center, Cleveland, OH, USA; Departments of Biomedical Engineering & Urology, Case Western Reserve University, Cleveland, OH, USA
| | - Chi Sun
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan, ROC
| | - Mei-Lin Tsai
- Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan, ROC; Department of Urology, Taipei Medical University Hospital, Taipei 11031, Taiwan, ROC
| | - Bor-Shing Lin
- Department of Computer Science and Information Engineering, National Taipei University, New Taipei City, Taiwan, ROC
| | - Chun-Wei Wu
- School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan, ROC
| | - Chih-Wei Peng
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan, ROC; School of Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, 250 Wuxing Street, Taipei 11031, Taiwan, ROC; School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei 11031, Taiwan, ROC; Research Center of Biomedical Device, Taipei Medical University, Taipei 11031, Taiwan, ROC.
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Garrod H, Khadr RN, Floyd MS. Letter to the Editor RE: Urodynamic findings and urologic management of central cord syndrome, J Clin Urol 11 September 2019. JOURNAL OF CLINICAL UROLOGY 2020. [DOI: 10.1177/2051415819889263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Huw Garrod
- Departments of Urology and North West Regional Spinal Cord Injury Unit, Southport and Ormskirk NHS Foundation Trust, United Kingdom
| | - Rauf N Khadr
- Departments of Urology and North West Regional Spinal Cord Injury Unit, Southport and Ormskirk NHS Foundation Trust, United Kingdom
| | - Michael S Floyd
- Departments of Urology and North West Regional Spinal Cord Injury Unit, Southport and Ormskirk NHS Foundation Trust, United Kingdom
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Sarı İF, Köklü K, Özişler Z, Özel S. A comparison of urodynamic findings between patients with complete and incomplete traumatic spinal cord injuries. J Spinal Cord Med 2020; 43:449-454. [PMID: 30540550 PMCID: PMC7480453 DOI: 10.1080/10790268.2018.1533317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Objective: To compare urodynamic findings between patients with complete and incomplete traumatic spinal cord injuries (SCI) and to determine whether it is important to test with urodynamic study in patients with incomplete SCI. Design: Retrospective study Setting: Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey Participants: A total of 66 patients with 36 complete and 30 incomplete traumatic SCI were included in the study, from July 2012 to September 2014. Interventions: Urodynamic study Outcome Measures: Maximum cystometric capacity (MCC) , vesicle pressure at MCC, detrusor function (detrusor overactivity or not), bladder complience, bladder storage and emptying disorders, post-void residual volume (PVR) and bladder emptying method were recorded. It was also recorded whether the patients used anticholinergic drugs before urodynamic study. Results: In urodynamic findings MCC, vesicle pressure at MCC, PVR, there was no statistically significant difference between complete and incomplete traumatic SCI patients. Also there was no statistically significant difference in low-compliance of detrusor frequency and bladder storage and emptying disorder frequency. Clean intermittent catheterization (CIC) was the most commonly recommended method after urodynamic studies in both groups of patients with SCI. Conclusions: In urodynamic study findings, there was no statistical difference between complete and incomplete traumatic SCI patients. The present study demonstrate that even if patients with incomplete SCI appear to be functionally better than the patients with complete SCI, urodynamic studies should still be performed in patients with incomplete SCI to identify bladder characteristics and to identify appropriate treatment.
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Affiliation(s)
- İlker Fatih Sarı
- The Department of Physical Medicine and Rehabilitation, Konya Training and Research Hospital, University of Health Sciences, Konya, Turkey,Correspondence to: İlker Fatih Sarı, The Department of Physical Medicine and Rehabilitation, Konya Education and Research Hospital, University of Health Sciences, Yazır Mahallesi Turgut Özal Caddesi No:10 Selçuklu/KONYA, Konya, Turkey.
| | - Kurtuluş Köklü
- The Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Zuhal Özişler
- The Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Sumru Özel
- The Department of Physical Medicine and Rehabilitation, Hitit University Medical School, Çorum, Turkey
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Stampas A, Gustafson K, Korupolu R, Smith C, Zhu L, Li S. Bladder Neuromodulation in Acute Spinal Cord Injury via Transcutaneous Tibial Nerve Stimulation: Cystometrogram and Autonomic Nervous System Evidence From a Randomized Control Pilot Trial. Front Neurosci 2019; 13:119. [PMID: 30837835 PMCID: PMC6390711 DOI: 10.3389/fnins.2019.00119] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 02/01/2019] [Indexed: 01/24/2023] Open
Abstract
Aim: Percutaneous tibial nerve stimulation is used to decrease incontinence in chronic neurogenic bladder. We report the findings from a subset of patients in a randomized control trial of transcutaneous tibial nerve stimulation (TTNS) for bladder neuromodulation in acute spinal cord injury (SCI) in whom heart rate variability (HRV) was recorded before and after cystometrogram (CMG). The aim was to correlate autonomic nervous system (ANS) changes associated with the CMG changes after the trial using HRV analyses. Methods: The study was a double-blinded sham-controlled 2-week trial with consecutive acute SCI patients admitted for inpatient rehabilitation, randomized to TTNS vs. control sham stimulation. Pre- and Post- trial CMG were performed with concurrent 5-min HRV recordings with empty bladder and during filling. Primary outcomes were changes with CMG between/within groups and associations to the HRV findings. Results: There were 10 subjects in the TTNS group and 6 in the control group. Pre-trial baseline subject characteristics, blood pressures (BPs), and CMG were similar between groups. In both groups, the pre-trial systolic BP increased during filling CMG. After the trial, the control group had significantly increased detrusor pressure and counts of detrusor-sphincter dyssynergia on CMG, not seen in the TTNS group. Also, the control group did not maintain rising BP post-trial, which was observed pre-trial and remained in the TTNS group post-trial. HRV was able to detect a difference in the ANS response to bladder filling between groups. Post-trial HRV was significant for markers of overall increased parasympathetic nervous system activity during filling in the controls, not seen in the TTNS group. Conclusion: Preliminary evidence suggests that TTNS in acute SCI is able to achieve bladder neuromodulation via modulation of ANS functions. Clinical Trial Registration:clinicaltrials.gov, NCT02573402.
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Affiliation(s)
- Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Kenneth Gustafson
- Department of Bioengineering, Case Western Reserve University, Cleveland, OH, United States
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Christopher Smith
- Department of Urology, Baylor College of Medicine, Houston, TX, United States
| | - Liang Zhu
- Biostatistics and Epidemiology Research Design Core, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sheng Li
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston, TX, United States
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Liu L, Zhao K, Chen F, Wu J, Yang Z, Chen M, Mao L, Han J. Testing of a New Portable Device for Dynamic Bladder Pressure Monitoring. Low Urin Tract Symptoms 2018; 10:193-197. [PMID: 29664238 DOI: 10.1111/luts.12146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/11/2016] [Accepted: 05/30/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop a portable dynamic bladder pressure monitoring device for facilitating the monitoring of bladder detrusor pressure in patients with neurogenic bladder (NB) caused by spinal cord injury and further compared the effect with traditional urodynamics devices. METHODS Portable dynamic bladder pressure monitoring device was implemented by software and hardware. The hardware was mainly composed of seven parts, such as micro liquid pressure sensor, electric bridge amplifying circuit, clock module, SD card storage circuit, liquid crystal display circuit, touch circuit, controller circuit and so on. The main program of the software included system initialization, data acquisition, storage, display, alarm, etc. A total of 45 patients with neurogenic bladder caused by spinal cord injury were enrolled in the study. Detrusor pressure was measured with the portable device and traditional urodynamics device. RESULTS The test-retest reliability of the portable device was modest in two times test (intra-class correlation coefficient (ICC) = 0.852), no significant difference was found in the results of volume perfusion evaluation between our device and conventional urodynamic (each P > 0.05). CONCLUSION The portable dynamic bladder pressure monitoring device is conducive to the dynamic monitoring of bladder pressure in patients with neurogenic bladder caused by spinal cord injury.
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Affiliation(s)
- Lingfeng Liu
- Department of Rehabilitation Medicine, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jingjiang, China
| | - Kang Zhao
- Physics Teaching and Research Section, School of Physics Science and Technology, Yangzhou University, Yangzhou, China
| | - Fan Chen
- Physics Teaching and Research Section, School of Physics Science and Technology, Yangzhou University, Yangzhou, China
| | - Jian Wu
- Department of Rehabilitation Medicine, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jingjiang, China
| | - Zhaofeng Yang
- Department of Rehabilitation Medicine, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jingjiang, China
| | - Ming Chen
- Department of Rehabilitation Medicine, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jingjiang, China
| | - Linbo Mao
- Department of Rehabilitation Medicine, Jingjiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, Jingjiang, China
| | - Jiurong Han
- Physics Teaching and Research Section, School of Physics Science and Technology, Yangzhou University, Yangzhou, China
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Przydacz M, Chlosta P, Corcos J. Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury. Int Urol Nephrol 2018; 50:1005-1016. [PMID: 29569211 DOI: 10.1007/s11255-018-1852-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/19/2018] [Indexed: 12/30/2022]
Abstract
PURPOSE To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice. METHODS Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR). RESULTS Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy. CONCLUSION Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.
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Affiliation(s)
- Mikolaj Przydacz
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Canada
- Department of Urology, Jagiellonian University, Medical College, Kraków, Poland
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Medical College, Kraków, Poland
| | - Jacques Corcos
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Canada.
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Schurch B, Iacovelli V, Averbeck MA, Carda S, Altaweel W, Finazzi Agrò E. Urodynamics in patients with spinal cord injury: A clinical review and best practice paper by a working group of The International Continence Society Urodynamics Committee. Neurourol Urodyn 2017; 37:581-591. [DOI: 10.1002/nau.23369] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 06/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Brigitte Schurch
- Department of Clinical Neurosciences; Neuropsychology and Neurorehabilitation Service; Vaudois University Hospital of Lausanne; Lausanne Switzerland
| | - Valerio Iacovelli
- Department of Experimental Medicine and Surgery; Unit of Functional Urology; Tor Vergata University Hospital; University of Rome Tor Vergata; Rome Italy
| | | | - Stefano Carda
- Department of Clinical Neurosciences; Neuropsychology and Neurorehabilitation Service; Vaudois University Hospital of Lausanne; Lausanne Switzerland
| | - Waleed Altaweel
- King Faisal Specialist Hospital and Research Centre; Alfaisal University; Riyadh Saudi Arabia
| | - Enrico Finazzi Agrò
- Department of Experimental Medicine and Surgery; Unit of Functional Urology; Tor Vergata University Hospital; University of Rome Tor Vergata; Rome Italy
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9
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Cohn JA, Kaufman MR, Dmochowski RR, Kowalik CG, Milam DF, Reynolds WS. Early Sacral Neuromodulation in Spinal Cord Injury—Can It Regenerate Nerves? CURRENT BLADDER DYSFUNCTION REPORTS 2016. [DOI: 10.1007/s11884-016-0382-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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10
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Matillon X, Terrier JE, Arnouil N, Lalloue F, Pic G, Ruffion A. [Temporary urethral stents ALLIUM BUS "BULBAR URETHRAL STENT" for the treatment of detrusor sphincter dyssynergia]. Prog Urol 2016; 26:532-7. [PMID: 27567746 DOI: 10.1016/j.purol.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 07/11/2016] [Accepted: 07/22/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The temporary prosthetic sphincterotomy is a possible treatment for neurologic detrusor sphincter dyssynergia (DSD). The purpose of the study was to verify the feasibility and effectiveness of the urethral stent (US) Temporary ALLIUM BUS "BULBAR URETHRAL STENT". PATIENTS AND METHODS A prospective, non-comparative, single-center starting in 2015 was conducted. Were included patients over 18 years, with a neurologic DSD proved urodynamically for which medical treatment was not indicated or failed. The primary endpoint was the percentage of patients who had a voiding method considered as improved or much improved at 1 month and the feasibility of the procedure. RESULTS From January to June 2015, 7 patients, (mean age 47.9 years [24-76 years]) were prospectively enrolled. One patient was lost to sight at one month and therefore excluded. The median follow-up was 8.1 months (1-10 months). All procedures were technically successful. At 1 month, there were 57% of grade 2 complications (Clavien-Dindo), 1 of 6 patients had a migration of the US. At one month, quality of life and the urologic situation was considered good in 3 patients, unchanged in 2 patients and decreased in 1 patient. The study was stopped after the inclusion of seven patients. At the date of the latest news, 5 of 6 patients had a migrated or an explanted US. CONCLUSION The temporary urethral stent ALLIUM BUS does not seem to be a possible surgical alternative for the treatment of detrusor sphincter dyssynergia. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- X Matillon
- Service d'urologie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France.
| | - J-E Terrier
- Service d'urologie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France.
| | - N Arnouil
- Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France; Service d'urologie et de chirurgie de la transplantation, hôpital Edouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France.
| | - F Lalloue
- Service d'urologie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France.
| | - G Pic
- Service d'urologie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France.
| | - A Ruffion
- Service d'urologie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Hospices civils de Lyon, centre hospitalier universitaire, 69002 Lyon, France; Université Claude-Bernard Lyon 1, 69100 Villeurbanne, France.
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Welk B, Liu K, Winick-Ng J, Shariff SZ. Urinary tract infections, urologic surgery, and renal dysfunction in a contemporary cohort of traumatic spinal cord injured patients. Neurourol Urodyn 2016; 36:640-647. [PMID: 26928899 DOI: 10.1002/nau.22981] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/04/2016] [Indexed: 02/06/2023]
Abstract
AIMS The objective of this study was to measure the incidence of urinary tract infections (UTIs), urologic reconstruction/urinary diversion, and renal dysfunction after a traumatic spinal cord injury (TSCI). METHODS Retrospective cohort study using administrative data from Ontario, Canada. All incident adult TSCI patients (2002-2013) admitted to a rehabilitation center were included. The impact of lesion level on each outcome was assessed. The rate of outcomes was further compared to an age and sex matched sample from the general population. RESULTS A total of 2,023 incident TSCI patients were identified (median follow-up of 4.8 years). Most patients (73%) were male and median age was 50 years. Lesion level included cervical (39%), thoracolumbar (44%), and unknown (17%). The incidence of serious UTIs (requiring emergency room visit or hospital admission) was 40%. Thoracolumbar lesion TSCI patients had significantly greater risk of serious UTIs (HR 1.3, 95%CI 1.1-1.7, P < 0.01) compared to those with a cervical lesion. Urologic reconstruction/urinary diversion was carried out on 2.4% of patients. New onset renal dysfunction was identified in 4.2% (84) TSCI patients. The rate ratios for serious UTIs (10.59, 95%CI 8.71-12.89), urologic reconstruction/urinary diversion (6.48, 95%CI 3.07-13.68), and renal dysfunction (2.55, 95%CI 1.70-3.83) were significantly increased among TSCI patients compared to matched controls. CONCLUSIONS Urologic disease is still an important source of morbidity for contemporary TSCI patients, and is more common compared to the general population. Neurourol. Urodynam. 36:640-647, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Institute for Clinical Evaluative Sciences-Western (ICES Western), London, Ontario, Canada
| | - Kuan Liu
- Institute for Clinical Evaluative Sciences-Western (ICES Western), London, Ontario, Canada
| | - Jennifer Winick-Ng
- Institute for Clinical Evaluative Sciences-Western (ICES Western), London, Ontario, Canada
| | - Salimah Z Shariff
- Institute for Clinical Evaluative Sciences-Western (ICES Western), London, Ontario, Canada
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Cameron AP, Lai J, Saigal CS, Clemens JQ. Urological Surveillance and Medical Complications after Spinal Cord Injury in the United States. Urology 2015; 86:506-10. [PMID: 26123520 PMCID: PMC4979001 DOI: 10.1016/j.urology.2015.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/02/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the national patterns of urologic follow up after spinal cord injury (SCI) and the occurrence and predictors of urological complications. MATERIALS AND METHODS This retrospective cohort study used a 5% sample of Medicare data 2007-2010. The minimum adequate urologic surveillance was defined as a urologist visit, serum creatinine evaluation, and upper urinary tract imaging study within the 2-year period. Patients were classified to their most severe complication in a multivariate linear regression model. RESULTS Among the 7162 patients with SCI, the majority were functionally paraplegic (82.4%) and Caucasian (80.9%). Among them, 4.9% received no screening studies over the 2-year period; 70.5% received some, but not all screening; and 24.6% received all three screening tests. Patients traveled a mean of 21.3 ± 27.5 miles to receive care. A total of 35.7% of patients saw a urologist during the 2-year period; 48.6% had some form of upper tract evaluation, with the majority being computed tomography scans; and 90.7% had serum creatinine evaluation. Of all patients, 35.8% had a minor complication during their 2-year follow up, 17.1% had a moderate complication, and 8.0% had a severe complication. In our prediction model, patient factors that correlated with increased complications included male gender, African American race, paraplegia, and receiving some or all of the neurogenic bladder recommended screening. Patients' distance of travel to their treating physician (urologist or physiatrist) did not affect the rate of complications. CONCLUSION Urological complications are common in patients with SCI who receive Medicare. Most of these patients with SCI are not receiving even the minimum recommended surveillance for these urological complications.
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Affiliation(s)
- Anne P Cameron
- Department of Urology, University of Michigan, Ann Arbor, MI.
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Afsar SI, Sarifakioglu B, Yalbuzdağ ŞA, Saraçgil Coşar SN. An unresolved relationship: the relationship between lesion severity and neurogenic bladder in patients with spinal cord injury. J Spinal Cord Med 2015; 39:93-8. [PMID: 26322550 PMCID: PMC4725797 DOI: 10.1179/2045772315y.0000000011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES We aimed to investigate the relationship between the severity of the spinal lesion and urodynamic findings, bladder drainage method at discharge, and incidence of renal calculi in patients with spinal cord injury (SCI). STUDYDESIGN: Retrospective. SETTING In-patient rehabilitation unit of a tertiary research hospital. METHODS A total of 131 patients who were admitted to our clinic with a diagnosis of SCI and placed into a rehabilitation program were included in the study. The severity of the lesion was determined according to the American Spinal Injury Association Impairment Scale (AIS). We evaluated the relationship between the severity of the lesion and the detrusor hyperactivity and compliance as determined by urodynamic investigation, the bladder drainage method used at discharge, and the renal calculi rate as determined by ultrasonography. RESULTS While no difference was found between the patients with complete and incomplete injuries in terms of age, sex, disease duration, detrusor hyperactivity and compliance, the bladder drainage method was found to show a significant change according to the severity of the lesion. None of the patients were found to have hydronephrosis and the rate of renal calculi showed no statistically significant difference according to the severity of the lesion. CONCLUSIONS We concluded that urodynamic examination is required in each patient with SCI as the severity of the lesion is not sufficient to determine the bladder type, and patients with complete and incomplete injuries should be monitored with the same sensitivity in terms of complications.
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Affiliation(s)
- Sevgi Ikbali Afsar
- Department of Physical Medicine and Rehabilitation,Baskent University, Faculty of Medicine, Ankara, Turkey
| | - Banu Sarifakioglu
- Department of Physical Medicine and Rehabilitation, Namık Kemal University, School of Medicine, Tekirdağ, Turkey
| | | | - Sacide Nur Saraçgil Coşar
- Department of Physical Medicine and Rehabilitation,Baskent University, Faculty of Medicine, Ankara, Turkey
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Schurch B, Tawadros C, Carda S. Dysfunction of lower urinary tract in patients with spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 130:247-67. [PMID: 26003248 DOI: 10.1016/b978-0-444-63247-0.00014-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Over the past 50 years, the mortality for urorenal cause in patients with spinal cord injuries (SCI) has decreased from over 75% to 2.3%, as a result of dramatic improvements in the diagnosis and management of lower urinary tract dysfunction (LUTD). The aims of this chapter are to assess the physiopathology of upper and lower motor neuron lesion on bladder and sphincter function after SCI, to give an overview of required clinical and instrumental examination and to discuss treatment modalities. Videourodynamic examination plays a key role in the assessment and follow-up of LUTD in SCI patients, in conjunction with neurophysiological and radiological examinations. The cornerstone of bladder management in SCI is clean intermittent self-catheterization, but often other treatments are needed to achieve full continence, to reduce infections and stone formation, to protect the upper urinary tract from excessive bladder pressure, and to prevent chronic renal failure. Treatments may be pharmacologic (i.e., anticholinergic drugs and botulinum toxin) or surgical (by enterocystoplasty or urinary diversion). In selected cases, neuromodulation and sacral root stimulation can be used to reduce detrusor overactivity and empty the bladder. Management of LUTD in SCI patients requires a deep knowledge of spinal cord medicine and functioning of patients with neurologic disability.
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Affiliation(s)
- Brigitte Schurch
- Neuropsychology and Neurorehabilitation Service, Department of Clinical Neuroscience, Lausanne University Hospital, Lausanne, Switzerland.
| | - Cécile Tawadros
- Urology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Carda
- Neuropsychology and Neurorehabilitation Service, Department of Clinical Neuroscience, Lausanne University Hospital, Lausanne, Switzerland
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Abstract
INTRODUCTION Neurogenic bladder is one of the most common complications following spinal cord injury (SCI). In China, acupuncture therapy is a common treatment for neurogenic bladder due to SCI, but its effects and safety remain uncertain. A protocol is described for a systematic review to investigate the beneficial effects and safety of acupuncture for neurogenic bladder due to SCI. METHODS AND ANALYSIS Eight databases will be searched from their inception: the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, the China National Knowledge Infrastructure (CNKI), the VIP database, the Wanfang database, the China Doctoral Dissertations Full-text Database (CDFD) and the China Master's Theses Full-text Database (CMFD). Any clinical randomised controlled trials (RCTs) and the first period of randomised cross-over studies related to acupuncture for neurogenic bladder due to SCI will be included. Outcomes will include change in urinary symptoms, urodynamic tests, clinical assessment and quality of life (QoL). The incidence of adverse events will be assessed as the safety outcome. Study selection, data extraction and quality assessment will be performed independently by two reviewers. Assessment of risk of bias, data synthesis and subgroup analysis will be carried out using Review Manager software. ETHICS AND DISSEMINATION Ethics approval is not required as this is a protocol for a systematic review. The findings of this systematic review will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER PROSPERO (CRD42014010448).
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Affiliation(s)
- Tao Zhang
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Huilin Liu
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Zhishun Liu
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linpeng Wang
- Department of Acupuncture and Moxibustion, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
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Burki JR, Omar I, Shah PJR, Hamid R. Long-term urological management in spinal injury units in the UK and Eire: a follow-up study. Spinal Cord 2014; 52:640-5. [DOI: 10.1038/sc.2014.90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 05/03/2014] [Indexed: 11/10/2022]
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Gupta A, Taly AB. Urodynamic profile of patients with neurogenic bladder following non-traumatic myelopathies. Ann Indian Acad Neurol 2013; 16:42-6. [PMID: 23661961 PMCID: PMC3644780 DOI: 10.4103/0972-2327.107693] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 11/27/2011] [Accepted: 07/19/2012] [Indexed: 11/11/2022] Open
Abstract
Objective: To observe the urodynamic profile of the patients following non-traumatic myelopathies (NTMs) with neurogenic bladder. Setting: Neurological rehabilitation department of university tertiary research hospital. Materials and Methods: Seventy-nine patients (44 men) with monophasic NTM, with the age range 8-65 years (31.0 ± 16.0 years), were admitted for inpatients’ rehabilitation. Length of stay in rehabilitation ranged from 6 to 120 days (32.0 ± 24.8 days). Fifty-six patients (70.9%) had spinal lesion above D10, 17 had lesion between D10 and L2 (21.5%), and 6 (7.6%) had cauda equina syndrome. All patients had neurogenic bladder with urinary complaints. Urodynamic study (UDS) was performed in all patients. Results: UDS showed 71.4% patients (40/56) had neurogenic detrusor overactivity (NDO) with or without sphincter dyssynergy (DSD) with lesion above D10; only 52.9% patients (9/17) had NDO with or without DSD detrusor with lesion between D10 and L2; and majority (5/6 patients) had underactive detrusor in the cauda equina group. Bladder management was based on the UDS findings. No significant correlation was found (P > 0.05) between detrusor behavior and the level, severity (ASIA Impairment Scale) of spinal injury, or gender using chi-square test. Conclusions: Neurogenic bladder following NTM was observed in all patients. UDS suggested predominantly NDO in lesions above D10 and mixed pattern in between D10 and L2 lesions. No significant correlation was found between detrusor behavior and the level or severity of NTM in the study.
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Affiliation(s)
- Anupam Gupta
- Department of Neurological Rehabilitation, NIMHANS, Bangalore, Karnataka, India
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Affiliation(s)
- Heinrich Binder
- Department of Neurology, Otto Wagner Hospital, Vienna, Austria.
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19
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20
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Gohbara A, Tanaka K, Kawaji K, Yokomizo Y. Urinary tract management in patients with incomplete cervical cord injury during the recovery phase. Spinal Cord 2012. [PMID: 23184025 DOI: 10.1038/sc.2012.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
PURPOSE For patients with incomplete cervical cord injuries, appropriate urinary management based on an assessment of voiding and storage function of the bladder is necessary for a better prognosis, especially during the recovery phase. In our review of medical records of such patients, we identified factors related to recovery of bladder function and parameters for predicting prognosis. METHODS In this study, we included 234 patients with incomplete cervical cord injuries admitted to Kanagawa Rehabilitation Hospital. Their medical records were retrospectively reviewed for various parameters related to final urinary management measures at discharge. Parameters included age, severity of paralysis, bladder function over time, urinary sensation and cystometry results. RESULTS Patients were managed using urethral catheterization, suprapubic cystostomy, clean intermittent catheterization (CIC) by oneself or care givers, CIC with occasional spontaneous voiding, or spontaneous voiding alone. Bladder function improved in majority of the patients during hospitalization. The severity of paralysis and urinary sensation are predictive parameters for improvement in voiding function. In patients who were admitted with catheterization but were discharged with spontaneous voiding, the period for recovery was 85.2 days on average (range 16-142 days). CONCLUSIONS Selection of urinary management measures for patients with incomplete cervical cord injuries can be performed adequately by considering the severity of paralysis and urinary sensation.
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Affiliation(s)
- A Gohbara
- Department of Urology, Kanagawa Rehabilitation Hospital, Atsugi, Japan
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21
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Acute spinal cord injury--do ambulatory patients need urodynamic investigations? J Urol 2012; 189:1369-73. [PMID: 23069382 DOI: 10.1016/j.juro.2012.10.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2012] [Indexed: 11/22/2022]
Abstract
PURPOSE We compared the urodynamic parameters of ambulatory vs nonambulatory acute spinal cord injured patients. MATERIALS AND METHODS A total of 27 women and 33 men (mean age 58 years) with neurogenic lower urinary tract dysfunction due to acute spinal cord injury (duration of injury less than 40 days) were prospectively evaluated. The patients were dichotomized according to the mobility for moderate distances subscale of the SCIM (Spinal Cord Independence Measure) version III into ambulatory (score of 3 or greater) and nonambulatory (score less than 3). Videourodynamic parameters including maximum detrusor pressure during the storage phase, bladder compliance, detrusor overactivity, detrusor external sphincter dyssynergia and vesicoureterorenal reflux were compared between the groups. RESULTS Of the 60 patients with acute spinal cord injury 17 were ambulatory and 43 were nonambulatory. Mean ± SD duration of injury at urodynamic investigation was 30 ± 8 days. The lesion level was cervical in 14 patients, thoracic in 28 and lumbar/sacral in 18. Comparing unfavorable urodynamic parameters, no significant differences were found between ambulatory vs nonambulatory patients in terms of a high pressure system during the storage phase (29% vs 33%, p = 0.81), a low compliance bladder (12% vs 7%, p = 0.54), detrusor overactivity (24% vs 47%, p = 0.1), detrusor external sphincter dyssynergia (18% vs 21%, p = 0.77) and vesicoureterorenal reflux (0% vs 5%, p = 0.36). CONCLUSIONS Ambulatory and nonambulatory patients with acute spinal cord injury have a similar risk of unfavorable urodynamic measures. Thus, we strongly recommend the same neurourological assessment including urodynamic investigations in all acute spinal cord injury patients independent of the ability to walk.
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Abstract
This review sets out to provide an overview of the author's approach to the management of the urinary tract in the patient who has suffered from an injury to their spinal cord. Emphasis is given to the need to understand the fundamental pathophysiological patterns that are seen with injuries that involve the sacral segments of the cord (the conus) and those that spare the conus but interrupt communication between the sacral parasympathetic and somatic centers and the brain (supraconal lesions). The importance of patient participation in management decisions is highlighted by considering the different ways in which the urinary tract can be managed and how the clinician needs to try to meet patient expectations and requirements while establishing safe urological management. Finally, consideration is given to the importance of establishing an appropriate follow up regime and managing urinary tract complications effectively.
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Affiliation(s)
- Simon C W Harrison
- Department of Urology, Pinderfields Hospital, Wakefield, West Yorkshire, UK
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23
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Neurogenic Bladder: Current Pharmacologic Trends. CURRENT BLADDER DYSFUNCTION REPORTS 2010. [DOI: 10.1007/s11884-010-0046-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Moslavac S, Dzidic I, Kejla Z. Neurogenic detrusor overactivity: comparison between complete and incomplete spinal cord injury patients. Neurourol Urodyn 2008; 27:504-6. [PMID: 18508334 DOI: 10.1002/nau.20575] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
AIMS To compare leak-point intravesical pressure and cystometric capacity in complete and incomplete spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO). METHODS Retrospective study of filling cystometry at non-physiological filling rate in 80 SCI patients at rehabilitation or annual check-up using Dantec Etude urodynamic machine. RESULTS Fifty neurologically complete (ASIA (American Spinal Injury Association) A) and 30 incomplete (ASIA B-E) were diagnosed with neurogenic detrusor overactivity, all with suprasacral level of injury. Mean Pves leak-point pressure (Pves LPP) at cystometric capacity for ASIA A group was 79 +/- 30 cmH(2)O (range 26-140) and mean Pves LPP for ASIA B-E group was 70 +/- 29 cmH(2)O (range 25-130). There was no significant difference between groups (P = 0.234). Mean CC (cystometric capacity) for ASIA A group was 239 +/- 107 ml (range 47-526) and mean CC for ASIA B-E group was 227 +/- 125 ml (range 42-500). Again, no significant difference was found (P = 0.655). CONCLUSIONS No difference in cystometric capacity and intravesical leak point pressure at terminal detrusor overactivity was shown between complete and incomplete spinal cord injury patients in our survey, that is, represented findings are equally unfavorable for both groups. Incomplete SCI patients with NDO should be tested with cystometry and observed with same caution as we proceed in complete SCI patients.
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Affiliation(s)
- S Moslavac
- Spinal Unit, Special Medical Rehabilitation Hospital, Varazdinske Toplice, Croatia.
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Scivoletto G, Cosentino E, Morganti B, Farchi S, Molinari M. Clinical prognostic factors for bladder function recovery of patients with spinal cord and cauda equina lesions. Disabil Rehabil 2008; 30:330-7. [PMID: 17852204 DOI: 10.1080/09638280701265596] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To investigate the relationship between lesion severity and other clinical factors and bladder function recovery. PATIENTS AND METHODS The charts of 269 patients with traumatic and non traumatic spinal cord lesion (SCL) were reviewed and the following information was recorded: lesion to admission time, injury variables, length of stay and neurological status. At five months, urological outcome was assessed by voiding modalities, and urodynamics according to International Continence Society. Logistic approach with univariate and multivariate analysis. RESULTS Both ASIA impairment at admission and age were significantly correlated with bladder function outcome. None of the patients with ASIA A impairment at admission reached volitional voiding at five months. ASIA B patients had a 90% lower probability of achieving good bladder control and ASIA C ones a 65% lower than ASIA D patients (p < 0.05). Older patients had a significant lower probability (60%) of achieving volitional voiding than younger ones (p < 0.05). Of the 121 patients with ASIA D impairment at discharge only 78 voided spontaneously and showed a higher frequency of cervical lesions and a lower frequency of detrusor-external sphincter dyssynergia. DISCUSSION AND CONCLUSION Bladder recovery in patients with complete SCL is limited. ASIA B patients showed a better neurological recovery and, concurrently, better bladder function recovery than ASIA A patients, thus demonstrating the importance of sensation preservation for recovery. Younger patients show better bladder recovery than older ones, probably because of different efficiency of spinal cord plasticity. Finally, patients with good neurological recovery may not achieve volitional voiding. Patients with bladder function recovery show a higher frequency of central cord and Brown-Sequard syndromes (with better prognosis) and a lower frequency of detrusor-sphincter dyssynergia.
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Affiliation(s)
- G Scivoletto
- Spinal Cord Unit, IRCCS Foundation S. Lucia, Rome, Italy.
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