Bladder autoaugmentation in myelodysplastic children

Management of spinal cord injury patients with neurogenic lower urinary tract dysfunction using minimally invasive and surgical therapies in Taiwan

The main problems of neurogenic lower urinary tract dysfunction (NLUTD) in patients with spinal cord injury (SCI) consist of impaired urine storage, impaired bladder emptying, or both. The priorities in the management of SCI-NLUTD should be preservation of renal function, followed by freedom from urinary tract infections and improvement of quality of life. Management of NLUTD in patients with SCI must be based on urodynamic findings rather than clinical evaluations. In the hospital without urodynamic equipment, careful measurement of intravesical pressure and safety functional bladder capacity in conjunction with clinical assessment are also feasible. Identification of high-risk patients is important for preventing urological complications in patients with chronic SCI. The management of NLUTD should start with conservative bladder management and medical treatment. Patients with SCI should be regularly followed up, and any NLUTDs and urological complications should be adequately treated. When surgical intervention is necessary, less invasive and reversible procedures should be considered first, and any unnecessary surgery should be avoided. This article reports the current evidence and expert opinions on the patient-centered bladder management of NLUTD in chronic SCI patients in Taiwan. To avoid renal function deterioration and urological complications, annual active surveillance of bladder and renal function is mandatory, especially for high-risk SCI patients.

Total endoscopic and anal irrigation management approach to noncompliant neuropathic bladder and bowel in children: A long-term follow-up

Purpose:

To evaluate the long-term efficacy and durability of combined intradetrusor botulinum-A toxin (BTX-A), endoscopic treatment of vesicouerteral reflux and anal irrigation for stool incontinence (SI) via a total endoscopic and anal irrigation management (TEAM^®) approach in patients with myelomeningocele and neuropathic bladder and bowel who did not respond to conservative measures.

Materials and Methods:

Fourteen myelomeningocele patients with at least 3 years follow-up were included in the study. All patients have urinary and SI not responded to conservative management. All patients received a cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) BTX-A. There was vesicoureteral reflux in 22 ureters, and a Deflux^® injection was completed during the same procedure. SI was managed using trans-anal irrigation, either with a fleet enema or Peristeen^® system regularly.

Results:

After at least 3 years of follow-up, mean maximum bladder capacity increased significantly from 78 ± 36 ml to 200 ± 76 ml (P < 0.0001) and the maximum detrusor pressure decreased from 56 ± 12 cm H₂O to 29 ± 7 cm H₂O (P < 0.001). Twenty-one refluxing ureters (95%) showed complete resolution and one persisted. Ten patients (72%) achieved complete dryness between catheterizations. Four patients (28%) went for augmentation cystoplasty, due to progressive hydronephrosis and/or persistent urinary incontinence. Thirteen patients achieved complete stool continence.

Conclusions:

Over long-term follow-up, major reconstruction surgery can be avoidable or delayable; the TEAM^® approach is a minimally invasive, safe, simple, and effective way to achieve upper urinary tract protection and provide urinary and stool continence.

The evolution of bladder augmentation: from creating a reservoir to reconstituting an organ

Bladder augmentation was first described in 1899. The goal at the time was to establish the ideal method to create a simple capacious reservoir for the safe storage of urine. That simple idea has over the last 100 years grown into one of the most dynamic areas in Pediatric Urology. Creative minds and hands from individuals in multiple disciplines have led us from creating a reservoir to the threshold of recreating a functional organ. In this review, we look at the historical evolution of bladder augmentation and how it exponentially grew in scope from those initial descriptions of intestinocystoplasty to the work being reported today in the field of tissue engineering.

Alternatives to conventional enterocystoplasty in children: a critical review of urodynamic outcomes

Alternatives to conventional enterocystoplasty have been developed in order to avoid the most common complications derived from contact of the urine with intestinal mucosa. In this article critically we review the literature on the topics: ureterocystoplasty, detrusorectomy, detrusorotomy, seromuscular gastroenterocystoplasty, use of off the shelf biomaterials, and bladder augmentation by bioengineering. Recognizing the difficulty of deciding when a child with a history of posterior urethral valves requires and augmentation and that the development of a large megaureter in cases of neurogenic dysfunction represents a failure of initial treatment, we conclude that ureterocystoplasty can be useful in selected cases when a large dilated ureter is available. Seromuscular colocystoplasty lined with urothelium (SCLU) has been urodynamically effective in several series when the outlet resistance is high and no additional intravesical procedures are necessary. Seromuscular gastrocystoplasty lined with urothelium seems to offer no distinct advantages and involves a much more involved operation. The use of seromuscular segments without urothelial preservation, with or without the use of an intravesical balloon has been reported as successful in two centers but strict urodynamic evidence of its effectiveness is lacking. The published evidence argues strongly against the use of detrusorectomy or detrusorotomy alone because of the lack of significant urodynamic benefits. Two recent reports discourage the use of small intestinal submucosa patches because of a high failure rate. Finally, research into the development of a bioengineered bladder constructed with cell harvested from the same patient continues but is fraught with technical and conceptual problems. In conclusion of the methods reviewed, only ureterocystoplasty and SCLU have been proven urodynamically effective and reproducible.

Promising long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction

PURPOSE

We evaluated the long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction.

MATERIALS AND METHODS

Data were compiled from the records of 25 children with a median age of 9.3 years (range 0.9 to 14.2) who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end filling pressures, and were unresponsive to clean intermittent catheterization and anticholinergics.

RESULTS

Median followup was 6.8 years (range 0.1 to 15.6). Median postoperative bladder capacity was unchanged or decreased to 95 ml (range 25 to 274) during the first 3 months compared to a median preoperative capacity of 103 ml (14 to 250). At 5 months postoperatively median bladder capacity increased significantly to 176 ml (range 70 to 420, p<0.01). This increase remained significant during the rest of followup. Median bladder compliance doubled after 1 year to 10 ml/cm H2O (range 1 to 31, p<0.05) compared to the preoperative level, and further increased to 17 ml/cm H2O (5 to 55) at 5 years (p<0.05). Median maximal detrusor pressure was 43 cm H2O (range 8 to 140) preoperatively. This value decreased significantly postoperatively (p<0.01) and at final followup it was 26 cm H2O (range 6 to 97). Kidney function developed normally in all patients except 1 with persistent uremia. Reflux was alleviated in 7 of 9 cases. Of the patients 18 became continent on clean intermittent catheterization.

CONCLUSIONS

Bladder autoaugmentation in children with neurogenic bladder dysfunction offers, after a transient decrease in bladder capacity, a long lasting increase in capacity and compliance, while the end filling pressure decreases.

Detrusorectomy reduces the need for augmentation and use of antimuscarinics in children with neuropathic bladders

OBJECTIVE

To assess bladder behaviour and long-term outcome after detrusorectomy in children.

MATERIAL AND METHODS

Between 1990 and 2001, 49 detrusorectomies were performed (mean follow-up: 9.6 years) in children with neuropathic bladders (mean age at surgery: 9.8 years). Urodynamic study (UDS) was done before surgery (pre-UDS) and after surgery (UDS-1 and UDS-2). Bladder behaviour was assessed as good, fair or poor depending on the volume and intravesical pressure. In all patients, oxybutynin and clean intermittent catheterization were used preoperatively. In 24 patients, good bladder compliance and capacity were seen before detrusorectomy.

RESULTS

Good and fair outcomes were observed in 35 (71%) patients at 1 year and in 39 (79%) patients 6 years after detrusorectomy. In 30 (60%) patients, there was hardly any difference between the first and second follow-up. In 9 (18%) patients, formal bowel bladder augmentation was necessary: in 6 (12%) because of poor compliance and in 3 because of small bladder volume and incontinence. Seven patients improved during follow-up, 5 of them after resuming oxybutynin. In 11 patients, oxybutynin could be stopped, and in 2 the dosage could be reduced to once daily.

CONCLUSIONS

The good short-term results of detrusorectomy generally remain unchanged at long-term follow-up. Detrusorectomy can reduce the need for antimuscarinics, and the need for formal bladder augmentation in selected cases.

Long-term follow-up after botulinum toxin A (BTX-A) injection into the detrusor for treatment of neurogenic detrusor hyperactivity in children

Purpose

To prove the long-term efficacy of BTX-A injection in the management of children with neurogenic detrusor hyperactivity.

Materials and methods

28 out of 145 children with neurogenic bladder (15 male and 13 female, mean age 10.7 years) who were treated between 2002 and 2010 and became non-responders to conservative treatment were included into the retrospective study.

We injected 10-12 U/kg of BTX-A (Botox^®) into the detrusor at 20-30 sites, sparing the trigone. The mean follow-up was 48 months (range 6-84 months).

Results

Group 1. 14 patients had a single injection of BTX-A. Five of them were successful.

Mean bladder reflex volume increased (from 62.9 to 117.5 ml), maximum detrusor pressure decreased (from 59 to 37.5 cm H₂O), detrusor compliance increased (from 4.8 to 9.5 ml/cm H₂O), and leak-point-pressure decreased (from 46.5 to 24.2 cm H₂O). Four patients did not respond and were treated by ileocystoplasty. Another five were lost to follow-up. Group 2. 14 patients had repeated (mean 2.5) injections of BTX-A with a mean interval of 13.7 months. In thirteen patients, urodynamic parameters of the first and last injection were similar to those obtained in Group 1, showing a good response. One patient received an ileocystoplasty.

Conclusion

BTX-A is a safe alternative in the treatment of detrusor hyperactivity in children with myelomeningocele (MMC). The efficacy lasted a mean of 12 months and urodynamic response was unchanged even after several injections. In our series, 21.7% of children with severe low-compliance bladders were non-responders.

Use of an inflatable silicone balloon improves the success rate of bladder autoaugmentation at long-term followup

PURPOSE

Most groups have reported disappointing results with autoaugmentation or detrusor myectomy for low capacity/compliance neuropathic bladders. Failure may be due to an ischemic diverticulum or mucosal shrinkage. We investigated whether a Silimed® silicone balloon placed in the bladder after autoaugmentation could prevent these problems, improving surgical results.

MATERIALS AND METHODS

We compared the results of standard bladder autoaugmentation in 12 children (group 1) with those in 10 (group 2) who underwent the same surgery using a bladder conformer. The conformer was a silicone balloon filled with saline that remained in the bladder for 2 weeks. All patients had a neuropathic bladder with poor capacity and compliance, resulting in urinary leakage between catheterizations. Preoperative and postoperative evaluation included a voiding diary, ultrasound, voiding cystourethrogram and urodynamics.

RESULTS

In group 1 only 1 patient became dry, 4 had little improvement in continence, 4 remained unchanged and 3 became worse. In group 2, 6 patients (60%) become continent without medication, 2 (20%) become continent with oxybutynin and 2 remained unchanged. Bladder capacity and compliance did not change significantly in group 1. However, in group 2 capacity changed from a mean of 140 to 240 ml and mean ± SD compliance increased from 15.6 ± 16.8 to 34.3 ± 22.8 ml/cm H(2)O (p = 0.02).

CONCLUSIONS

The inflatable balloon improved our long-term results of bladder auto-augmentation. A larger series may be necessary to confirm procedure efficacy and safety.

Botulinum toxin in the treatment of OAB, BPH, and IC

Botulinum neurotoxins (BoNTs) are well known for their ability to potently and selectively disrupt and modulate neurotransmission. BoNT is currently undergoing regulatory evaluation for urological disorders in the United States and the European Union and is not FDA approved for urologic use. Overactive bladder (OAB) and benign prostatic hyperplasia (BPH) are common urologic conditions characterized by urinary frequency, urgency, nocturia, urge incontinence and, in the case of BPH, decreased urine flow that are currently being evaluated in clinical trials with BoNT-A. Interstitial cystitis (IC) is a chronic condition in which patients describe urinary frequency, urgency and associated bladder/pelvic pain. In the two former conditions, BoNT-A is currently being evaluated in Phase II or Phase III clinical trials as a therapeutic agent. Evidence for BoNT in the treatment of IC is limited to small case series. The purpose of this article is to provide up to date clinical evidence regarding the use of BoNT to treat these three urologic problems. For the sake of clarity, BoNT-A describes the use of Botox unless otherwise specified. In addition, when describing OAB, two sub-populations exist: those with OAB of neurogenic origin (NDO) and those with OAB of unknown (idiopathic) origin (IDO).

Bladder augmentation without integration of intact bowel segments: critical review and future perspectives

PURPOSE

We evaluated the long-term results of autoaugmentation in the pediatric age group and summarized technical adaptations, experimental options and future perspectives for treating these patients.

MATERIALS AND METHODS

A directed MEDLINE literature review was performed to assess different techniques and alternative options in autoaugmentation procedures. Of 150 studies 49 in the subgroup with the longest duration of followup to show the long-term outcome of the autoaugmentation procedures were chosen for this review. Information gained from these data was reviewed and new perspectives were summarized.

RESULTS

Enterocystoplasy is an effective mode of therapy with acceptable morbidity and satisfactory clinical results, although it is major intraperitoneal surgery with various complications and patients need prolonged convalescence to adapt to these surgical procedures. On the other hand, patient selection seems to be the most crucial step for the success of autoaugmentation procedures because the clinical outcome does not appear to be durable.

CONCLUSIONS

Achievement of better compliance after autoaugmentation procedures seems to be less pronounced and of shorter duration than that of conventional enterocystoplasty. On the other hand, the low morbidity and lack of side effects of bowel integration into the urinary tract are the definite advantages of this technique. It is the responsibility of the physician to determine the balance between the limited efficacy of the procedures vs the definite advantages. Although functionally improved parameters are obtained in tissue engineered autologous bladders, there is an absolute need for additional studies before this challenging technique could be applied widely.

Repeated Intradetrusor Botulinum Toxin Type A in Children With Neurogenic Bladder Due to Myelomeningocele

PURPOSE

We evaluated the effect of repeated intradetrusor injections of BTA in pediatric myelomeningocele not responding to medical management.

MATERIALS AND METHODS

After baseline history, physical examination and urodynamic assessment BTA was injected (5 IU/kg body weight, maximum 300 IU) at 10 to 30 sites. Clinical and urodynamic assessment was performed at 3 months after each injection. Re-treatment was offered when clinical symptoms returned.

RESULTS

A total of 20 patients (average age 13 years) received BTA injections. Of the patients 13 became continent. MBC increased from 215.6 +/- 58.8 cc to 338.3 +/- 98.4 cc (p < 0.01), MDP decreased from 43 +/- 13.7 cm H2O to 21.6 +/- 10.5 cm H2O (p < 0.01) and compliance increased from 5.2 +/- 2.6 ml/cm H2O to 13 +/- 6.9 ml/cm H2O (p < 0.01). At an average of 8.1 months after the first injection all 13 patients received a second injection, which led to similar improvement, ie MBC increased from 200.5 +/- 41.6 cc to 404.2 +/- 57.8 cc (p < 0.001), MDP decreased from 48.18 +/- 6.1 cm H2O to 27.8 +/- 3.7 cm H2O (p < 0.01) and compliance increased from 6.0 +/- 3.1 ml/cm H2O to 15.1 +/- 5.2 ml/cm H2O (p < 0.01). Among the responders 3 received 3 injections and 1 received 4 injections, all of whom exhibited improvement similar to that seen initially. Among our initial cohort of 20 patients 7 failed to improve initially and 6 failed to improve after a second injection.

CONCLUSIONS

BTA seems to be a simple and safe way to postpone or avoid invasive procedures in two thirds of children with myelomeningocele not responding to usual medical treatment.

Detrusor myectomy: long-term results with a minimum follow-up of 2 years

OBJECTIVES

To assess the long-term results of detrusor myectomy, which has obvious theoretical advantages over enterocystoplasty for refractory detrusor overactivity (DO), and for which the early results have been encouraging.

PATIENTS AND METHODS

The medical records were reviewed of 30 consecutive patients (median age 33 years, range 10-62) who had a detrusor myectomy between November 1992 and April 2002 in our unit. Twenty-four patients (80%) had idiopathic DO (six males and 18 females) and six (20%) had neurogenic DO (four males and two females). The median (range) follow-up was 79 (28-142) months. All patients were confirmed to have DO on urodynamics before surgery and 26 (87%) had urodynamics afterward.

RESULTS

Nineteen (79%) of those with idiopathic DO and two with neurogenic DO showed a continued overall improvement. The cystometric capacity improved in 80% of patients after surgery, whilst the detrusor pressure at maximum flow and the bladder contractility index decreased in 60% and 78% of the patients, respectively. Ten patients (45%) had to start clean intermittent self-catheterization after surgery.

CONCLUSIONS

Detrusor myectomy is successful in approximately 80% of patients with idiopathic DO, although detrusor contractility is affected in most and almost half of the patients required clean intermittent self-catheterization afterward. This procedure should be offered as an alternative to enterocystoplasty as it is less morbid and does not preclude subsequent surgery if required. However, further evaluation of this technique is required in neuropathic patients.

A case for botulinum toxin-A in idiopathic bladder overactivity

Botulinum toxin (BTX) has been shown to be an effective agent in suppressing detrusor overactivity due to neurogenic causes. Similar to results obtained with traditional agents to treat bladder overactivity (ie, antimuscarinic medications), the use of BTX has been extended to patients with idiopathic detrusor overactivity. This article briefly reviews the use of BTX to treat disorders of detrusor overactivity and, based on early clinical and laboratory results, establishes the case for its use as a therapeutic modality to treat idiopathic detrusor overactivity.

The spectrum of urological disease in patients with spina bifida

BACKGROUND

[corrected] Urological complications are the major cause of ill health during childhood and adult life of patients with spina bifida but the significance of urinary tract disease on the individual and the healthcare services is underemphasised.

AIM

To assess the effects of spina bifida on the individual and the healthcare services.

METHODS

A retrospective review was performed to assess the frequency and significance of urological conditions requiring hospital attendance in patients with spina bifida currently attending a specialised multidisciplinary clinic over a period of six months.

RESULTS

Urinary sepsis accounted for the majority of admissions (62%), while 38 of 62 patients required 60 surgical procedures. Targeting the primary urological abnormality (the dysfunctional and usually poorly compliant bladder) allows implementation of effective treatments, including regular intermittent bladder catherisation (52%) in order to preserve upper renal tract function. Associated postural abnormalities complicated both conservative and interventional therapies.

CONCLUSION

This study highlights the surgical commitment for units caring for patients with spina bifida, the important considerations for the future healthcare services, and the range and severity of urological diseases encountered by these patients.

Autoaugmentation by Detrusor Myotomy: Its Lack of Effectiveness in the Management of Congenital Neuropathic Bladder

PURPOSE

We present our long-term results in 17 patients with myelomeningocele undergoing autoaugmentation by vesicomyotomy.

MATERIALS AND METHODS

Surgery was performed from 1990 to 1994 on 17 patients with neurogenic bladder due to spinal dysraphism. Indications for autoaugmentation included upper tract deterioration and/or incontinence secondary to hypperreflexia, hypocompliance or low bladder volume. All patients had failed to respond to conservative medical and pharmacological treatments. Median patient age at surgery was 10.2 years (range 2.2 to 13.2). Outcomes were evaluated retrospectively according to changes in upper tract status, continence and urodynamic parameters. Median clinical and urodynamic followup is 75 months (range 4 to 126).

RESULTS

Progressive hydronephrosis developed in 5 patients, which required subsequent enterocystoplasty in 4. Of 13 patients 8 (62%) remain incontinent. Of the 17 cases 12 (71%) were considered clinical failures on the basis of upper tract deterioration and/or ongoing incontinence. There were few clinically significant improvements in urodynamic parameters, as 14 of 15 cases (93%) were considered urodynamic failures on the basis of persistent hypocompliance and/or less than expected gains in safe bladder capacity with somatic growth.

CONCLUSIONS

Although short-term reports of autoaugmentation have been promising, they do not appear durable. This procedure cannot be endorsed for the management of congenital neuropathic bladder.

Botulinum-a toxin detrusor injection as a novel approach in the treatment of bladder spasticity in children with neurogenic bladder

OBJECTIVES

Children with neurogenic hyper-reflexive bladder in whom classical therapy with anticholinergic drugs and intermittent catheterization fails are threatened by high intravesical pressure, vesicoureteral reflux, and impairment of kidney function. Surgery, such as bladder augmentation, is often necessary in such cases. To obviate surgery in these high-risk children, we investigated the use of detrusor injection of botulinum-A toxin (Botox).

METHODS

Our subjects were 20 children with hyper-reflexive detrusor muscle and high bladder pressure, over 40 cmH(2)O despite anticholinergic therapy. After baseline urodynamic measurements, we injected botulinum-A toxin into the detrusor muscle at 30-50 sites at 12 U/kg of body weight up to a maximum of 300 U. Follow-up cystometric measurements were taken two to four weeks and three and six months after injection.

RESULTS

From basic measurements to follow-up cystometry, mean reflex volume changed from 97.1 ml before injection to 178.6 ml after four weeks (p<0.01) and to 162.8 ml after three months (p<0.01). After six months mean reflex volume returned to 119.3 ml (n.s.). Maximal bladder capacity changed from 163.1 ml to 219.9 ml (p<0.01), to 200.6 ml (p<0.01) and to 222.4 ml (p<0.01), respectively, and maximal detrusor pressure changed from 59.6 cmH(2)O to 34.9 cmH(2)O (p<0.01), to 46.7 cmH(2)O (n.s.) and to 61.8 cmH(2)O (n.s.), respectively.

CONCLUSION

Botulinum-A toxin (Botox) is effective when injected into the hyper-reflexive detrusor muscle. It is a valuable treatment option in the management of neurogenic bladder. The effect lasts about six months, and then reinjection is necessary.

A long-term follow-up of autoaugmentation in myelodysplastic children

OBJECTIVE

To evaluate the long-term results of patients who underwent bladder autoaugmentation (BA) in whom BA was used to treat a neuropathic bladder secondary to myelomeningocele, and who presented with a high-pressure/poorly compliant bladder.

PATIENTS AND METHODS

Eleven patients (eight girls and three boys, mean age 12.8 years, mean follow-up 6.6 years) were selected who had undergone BA between June 1991 and June 1994. At surgery, the patients had a poorly compliant bladder with a mean leak point volume (LPV) of 94 mL and a mean leak point pressure (LPP) of 58 cmH2O. None of the patients had vesico-ureteric reflux (VUR) at BA; five with grade III or IV VUR had undergone endoscopic correction in a day-surgery procedure using a suburethral collagen injection 1-3 weeks before BA. The patients were evaluated using clinical, urodynamic, radiological and endoscopic assessments. The LPV, LPP and safe bladder capacity (SBC, the cystometric volume at an intravesical pressure of 40 cmH2O) were recorded.

RESULTS

At 1 year after surgery the mean LPV was 297 mL; none of the patients had VUR. The most recent mean LPV was 198 mL and the SBC 167 mL. The mean LPP remained stable at 60 cmH2O. At the last follow-up four patients had recurrent uni- or bilateral grade III-V VUR. At endoscopy the 'augmented' bladder portion had a smooth surface, compared with the grossly trabeculated lower half. From this finding all patients on clean intermittent catheterization were treated with oral oxybutynin. Some patients reported slightly less abdominal pain at maximum bladder volume; four needed pads to treat intermittent incontinence. On voiding cysto-urethrography, one patient had an hourglass-shaped bladder. Five patients recently underwent ileocystoplasty because of recurrent urinary tract infection, high-grade VUR and incontinence.

CONCLUSION

These results do not justify the routine use of BA in hypertonic/poorly compliant bladders secondary to myelomeningocele. The mean follow-up of 6.6 years showed that this procedure failed in seven of 11 patients. Further studies might be able to identify subgroups in which this approach may be more appropriate.

Efficacy of botulinum-a toxin in children with detrusor hyperreflexia due to myelomeningocele: preliminary results

OBJECTIVES

The established treatment of children with neurogenic bladder consists of the use of anticholinergic drugs, such as oxybutynin and tolterodine, and clean intermittent catheterization four or five times a day. If anticholinergic drugs and clean intermittent catheterization fail, surgery is often necessary. With the intent of avoiding surgery, we investigated the effect of botulinum-A toxin for treating detrusor hyperreflexia in this group of patients.

METHODS

The subjects were 17 children (average age 10.8 years) who had detrusor hyperreflexia and were using clean intermittent catheterization four or five times a day. Urodynamic studies were followed by injection of 85 to 300 U of botulinum-A toxin into 30 to 40 sites in the detrusor muscle. Urodynamic follow-up was done 2 to 4 weeks after injection.

RESULTS

The mean reflex volume increased by 112.1%, from 95.00 plus minus 34.54 mL (range 47 to 147) to 201.45 plus minus 68.57 mL (range 77 to 310) (P <0.005). The maximal bladder capacity increased by 56.5%, from 137.53 plus minus 59.96 mL (range 59 to 242) to 215.25 plus minus 96.36 mL (range 60 to 380) (P <0.005). The maximal detrusor pressure decreased by 32.6%, from 58.94 plus minus 32.32 cm H(2)O (range 19 to 149) to 39.75 plus minus 26.12 cm H(2)O (range 7 to 100) (P <0.005). Detrusor compliance increased by 121.6%, from 20.39 plus minus 26.5 mL/cm H(2)O (range 4.5 to 40) to 45.18 plus minus 45.4 mL/cm H(2)O (range 5.3 to 100) (P <0.01).

CONCLUSIONS

Botulinum-A toxin injection into the hyperreflexive detrusor muscle seems to be very effective and might be a therapeutic alternative to anticholinergic drugs.

Orthotopic bladder augmentation and substitution

Orthotopic bladder augmentation or substitution using intestinal segments has become a standard procedure for many disorders that cause a loss of functional or anatomical bladder capacity. From the technical point of view, reservoir configuration by detubularizing the intestinal segments is the general practice. Various techniques exist, depending which types of segments and which techniques of ureteral implantation are used. Common problems include urinary incontinence, retention, metabolic disorders, and the possibility of secondary malignancies. As a result, research has been conducted into utilizing tissues other than intestine for bladder augmentation or substitution.

Neurogenic bladder dysfunction

Urodynamics are still essential for diagnosis and prognosis of neurogenic lower urinary tract-dysfunction and can not be replaced by other means of investigation so far, neither by a thorough clinical investigation nor by sophisticated means like magnetic resonance imaging. The findings with clinical investigations are specific, but not sensitive enough, and the spinal cord lesions may sometimes be beyond the resolution of magnetic resonance-scanning. Pharmacotherapy is still the corner stone in the management of detrusor hyperreflexia. Further studies with tolterodine, oxybutynin, trospiumchloride and propiverine have increased our knowledge about these substances. Capsaicin was proved to be the effective substance and not the alcoholic solution, which serves as a carrier. Intrathecal clonidine may represent a new conservative reversible alternative treatment for detrusor hyperreflexia. Experiments with detrusor strips from end-stage MMC-patients may explain the relative resistance of the low compliant bladder to the common anticholinergic/spasmolytic therapy. The differential indication for bladder augmentation, either using segments of the gastrointestinal-tract or performing a partial detrusor myectomy is ongoing, favourable results are reported for both techniques. Sacral posterior root rhizotomy is able to abolish detrusor hyperreflexia and therefore recommended for tetra- and paraplegics, however autonomic dysreflexia, if present, can not be totally abolished. Collagen injections for neuropathic sphincter incompetence can not be recommended as demonstrated in children with congenital neuropathy, a new design of an artificial sphincter must stand the test of time.