Spastic Bladder and Spinal Cord Injury: Seventeen Years of Experience with Sacral Deafferentation and Implantation of an Anterior Root Stimulator

Abstract

Artif Organs, 29: 239 -241, 2005 Introduction: Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The hyperreflexia of the detrusor and the external sphincter causes incontinence and threatens those patients with recurrent urinary tract infections (UTI), renal failure, and autonomic dysreflexia. All of these severe disturbances may be well managed by sacral deafferentation (SDAF) and implantation of an anterior root stimulator. Material and Method: Between September 1986 to December 2002, 464 paraplegic patients (220 female, 244 male) received a SDAF-SARS. Almost exclusively the SDAF was done intradurally, which means with one operation field there can be done two steps (SDAF and SARS). Results: 440 patients have a follow-up with 6.6 years (at least 6 months-17 years) The complete deafferentation was successful in 94.1%. A total of 420 paraplegics may use the SARS for voiding (frequency 4.7 per day) and 401 use it for defecation (frequency 4.9 per week). Continence was achieved in 364 patients (83%). UTI declined from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function presented stable. Early complica- tions were 6 CSF leaks, 5 implant infections. Late complications with receiver or cable failures made us do surgical repairs in 34 paraplegics. A step-by-step program for trouble-shooting differentiates implant failure and myogenic or neurogenic failure. Conclusion: SDAF is able to restore the reservoir function of the urinary bladder and to achieve continence. Autonomic dysreflexia disappeared in most of the cases. By means of an accurate adjustment of stimulation parameters it is possible to accomplish low resistance micturition. The microsurgical technique requires an education. One has to be able to manage late implant complications. Editorial Comment: This is a very extensive and most impressive experience with a technique that is confined in usage to a very few centers. Perhaps this is because of the intensive education that the authors state is required in the microsurgical technique. In addition to what is described in the abstract, the following data from the short, sparsely referenced article are relevant: 1) 8 patients required a second deafferentation at the conus level to achieve a complete interruption of hyperreflexia; 2) in 22 of the 364 patients achieving continence the additional implantation of an artificial sphincter was required and 3) autonomic dysreflexia disappeared in all but 2 of 187 cases. The authors also state that implants with cable plugs could make repair procedures easier and the development of microelectronic devices without cables could help to avoid implant complications. The authors conclude by stating ...the satisfaction of our para- plegic patients with the outcome after SDAF and (sacral anterior root stimulation) is very high and they improve in independence and in quality of life. Sexual aspects are not considered in this article, but it can be assumed that reflex erections, where present, were lost with the complete transection of the afferent dorsal roots S2 to S5.