Safety and efficacy of a patient-controlled bladder management system for treating urinary retention in men

AIMS

The CymActive™ Bladder Management System (BMS) is a self-retaining, intraurethral catheter with a patient-controlled magnetic valve that allows cyclical bladder filling and emptying, without external appliances. We determined the safety and efficacy of the BMS in men with urinary retention who required catheterization for more than 7 days.

METHODS

Men requiring continuous drainage, bladder capacity less than 300 ml, history of prostatic or urethral surgery, or urethral length outside of defined limits, were excluded. Data were collected from patient diaries and weekly visits during catheterization for up to 30 days. The primary composite endpoint assessed four outcomes: placement, post-void residual volume (PVR) of 75 ml or less, adverse device-related events requiring early removal, and removal.

RESULTS

Nine of 23 patients met all four criteria: eight of 18 non-neurogenic (7/11 prior Foley users and 1/7 without Foley experience) and one of five neurogenic spinal cord injury (SCI) patients. Secondary outcomes in non-neurogenic patients included: 17/18 successful insertions; of these, 16/17 average PVR of 75 ml; successful valve openings and closings ≥ 95% of more than 1,400 voids; and minimal leakage. Four of five SCI patients discontinued within 7 days. Cystourethroscopy after removal revealed no marked inflammation or mucosal changes.

CONCLUSIONS

This pilot study demonstrated the BMS is potentially useful, convenient, and safe for appropriate patients. A follow-up study will better define the characteristics of patients who benefit from this device and examine whether the use of antimuscarinic agents improves outcomes. Neurourol. Urodynam. 35:630-635, 2016. © 2015 Wiley Periodicals, Inc.

Current and future techniques of neuromodulation for bladder dysfunction

Recent increase in the use of neuromodulation for the treatment of urinary urgency and frequency, urge incontinence, and nonobstructive urinary retention has coincided with improved knowledge of micturition physiology and concurrent technologic advances in nerve stimulation. Currently, the most common technology for bladder neuromodulation involves stimulation through the S3 foramen, or sacral neuromodulation, although other techniques of neuromodulation continue to be explored. Despite many advances in neuromodulation, the exact mechanism of action remains uncertain. Additionally, which patients will respond to neuromodulation remains unclear, and although there is a standard method for testing, this procedure is invasive and expensive. As we continue to improve patient selection criteria and better understand the mechanism of action, the efficacy and patient satisfaction should continue to increase. Currently, most patients considered for implantation with a neuromodulator are those unresponsive to other conservative treatments for bladder dysfunction.

The effect of bulbar urethroplasty on erectile function

PURPOSE

Theoretically bulbar urethroplasty has the potential to adversely affect potency, involving as it does dissection in proximity to the corporeal bodies and erectile neurovascular structures. We prospectively examined the effect of various bulbar urethroplasties on erectile function.

MATERIALS AND METHODS

Prior to undergoing urethroplasty, patients completed an International Index of Erectile Function questionnaire. Each patient repeated the International Index of Erectile Function at least 3 months postoperatively. One-sided t and Fisher's exact tests were used to compare preoperative and postoperative erectile function.

RESULTS

A total of 25 men with an average age of 39 years (range 26 to 66) completed the study. Etiology of stricture was idiopathic in 20 patients and traumatic in 5. Stricture location was panbulbar in 5 patients, mid to posterior bulbar in 13 and mid to distal bulbar in 7. Eight men underwent anastomotic urethroplasty, 15 underwent augmented anastomotic repair using a buccal mucosal graft and 2 underwent a dorsal onlay. At a mean of 6.2 months of followup, average total International Index of Erectile Function went from 62.6 to 59.6 of 75 possible points and the average erectile function domain score went from 26.9 to 24.8 of 30 possible points. Neither of these differences attained significance (p = 0.29 and 0.13, respectively). A total of 25 men had an erectile function domain postoperative score of greater than 20 and 8 had a score of 20 or less. Men with a score of 20 or less were older (47 vs 36.8 years, p = 0.17) and had worse preoperative erectile function (20 vs 29, p = 0.11) than those with erectile function scores greater than 20, although these differences did not achieve significance.

CONCLUSIONS

We report on men undergoing 4 variations of bulbar urethroplasty. Although the numbers are small, we found that such surgery had an insignificant effect on erectile function. Surgical complexity with long stricture excision and the use of a buccal graft did not influence outcome.

A statistical comparison of pad numbers versus pad weights in the quantification of urinary incontinence

AIMS

Pad per day (PPD) usage is a frequently utilized measure of urinary incontinence. The 24-hour pad weight test (24PWT) is a reproducible test for quantifying incontinence volumes. We investigated whether PPD validly reports the magnitude of urinary incontinence.

METHODS

This was a retrospective review of patients undergoing stress incontinence surgery from July 2002 to 2005. Inclusion criteria were a documented 24PWT and patient-reported PPD usage. Grams of urine loss per pad (GPP) provided a third measure of incontinence. Descriptive statistics and correlations between all variables and significance were noted. Factor analysis was performed on the three measures of leakage and age for all patients over age 50.

RESULTS

One hundred forty-five male and 116 female patients met inclusion criteria. Correlated against 24PWT, GPP has the strongest association with a correlation of 0.80 for males and 0.88 for females. PPD has a weaker correlation of 0.64 for males and 0.61 for females (R2 = 0.38 overall). Factor analysis identified two components associated with incontinence. A "leakage" component correlated best with 24PWT and GPP. Additionally, an "age" component implies that despite stable 24PWT values, older patients increase GPP while PPD decreases.

CONCLUSIONS

Self-reported PPD is an unreliable measure of incontinence as this variable only measures 38% of the variation of urinary incontinence volume. Patients at a given PPD level present with a wide range of 24PWT values. Older patients have higher per-pad leakage. Future incontinence studies should report 24PWT to ensure the most reliable and uniform data.

The current use of neuromodulation for bladder dysfunction

Neuromodulation utilizes electrical stimulation to alter the function of an organ. Recent advances in technology and improved knowledge of micturition physiology have coincided with the growth of neuromodulation for the treatment of urinary urgency/frequency, urge incontinence and non-obstructive urinary retention. Currently, the most common modality for bladder neuromodulation involves stimulation through the S3 foramen, or sacral neuromodulation. This review will highlight the current indications, patients selection, implantation options/techniques, outcomes and complications of sacral neuromodulation. In addition, other methods of neuromodulation will be discussed.

Sacral neuromodulation for the treatment of refractory urinary urge incontinence after stress incontinence surgery

OBJECTIVE

This study was undertaken to evaluate the response to sacral neuromodulation in women with refractory, nonobstructive urinary urge incontinence after stress incontinence surgery.

STUDY DESIGN

We reviewed the medical records of women in whom sacral neuromodulation was performed for worsening or de novo urinary urge incontinence after a stress incontinence procedure. All patients had undergone preliminary test stimulation. Demographics, surgical and urogynecologic history, including bladder diary and pad weight test, and urodynamic parameters were evaluated.

RESULTS

Of 34 women, 22 (65%) responded to the test stimulation and underwent permanent lead implant. There was no difference between responders and nonresponders with respect to type of stress incontinence surgery. Incontinence or urodynamic parameters were not different between responders and nonresponders. Factors that were predictive of a positive response were women aged less than 55 years (P = .01), the test stimulation performed within 4 years of the stress incontinence procedure (P = .01), and evidence of pelvic floor muscle activity (P = .03).

CONCLUSION

Sacral neuromodulation is a viable option for the treatment of refractory urinary urge incontinence that occurs after stress urinary incontinence surgery. Older women with no pelvic floor activity who are remote from their incontinence surgery may have a suboptimal response.

Management of male incontinence following artificial urinary sphincter failure

PURPOSE OF REVIEW

The artificial urinary sphincter has been used successfully for the treatment of stress urinary incontinence in both male and female patients. Its most common use, however, is in men suffering from postprostatectomy incontinence.

RECENT FINDINGS

The success rates, long-term durability, and patient satisfaction for the artificial urinary sphincter are high. The incidence of complications and adverse events remains low although they are sometimes unavoidable.

SUMMARY

We believe that continence can be salvaged in the majority of men in whom the device fails or requires explantation and we present the logical analysis for device revision and relocation in this review.

Bladder Dysfunction After Bilateral Ectopic Ureterocele Repair

PURPOSE

We examined postoperative outcome, with emphasis on bladder function, in pediatric patients who underwent bilateral ectopic ureterocele repair.

MATERIAL AND METHODS

We reviewed the records of 117 patients with orthotopic and ectopic ureteroceles treated between 1977 and 2000. Twelve of these patients had bilateral ectopic ureteroceles. All patients with bilateral ureteroceles were females 1 day to 2 years old at referral. Initial treatment was transureteral puncture in 6 cases, transurethral unroofing in 2 and extravesical bilateral reimplantation in 1. Of the remaining 3 patients the initial treatment was unilateral heminephroureterectomy in 1 and bilateral heminephroureterectomy in 2. Definitive treatment included bilateral upper to lower ureteroureterostomy, ureterocelectomy with trigonal and bladder neck reconstruction, and bilateral ureteroneocystotomy with or without tapering of the recipient ureter. In patients who underwent upper pole partial nephrectomy the distal upper pole ureter was removed in conjunction with trigonal surgery and ureteroneocystotomy.

RESULTS

There was significant morbidity in this group of patients, including voiding dysfunction and poor bladder emptying with residual urine greater than 20% of bladder capacity in 7 of 10 patients studied by serial bladder ultrasonography. Urodynamic evaluation in 3 patients revealed increased bladder compliance and large volume residual urine. Of these 3 patients 2 perform clean intermittent catheterization. Recurrent symptomatic bacteruria was noted in 7 of the 12 patients.

CONCLUSIONS

Patients undergoing bilateral ectopic ureterocele repair are at increased risk for postoperative voiding dysfunction. Whether this risk is present preoperatively or is a result of trigonal surgery is unclear.