Detrusor Myectomy Research Articles

Traumatic pediatric spinal cord injury: long-term outcomes of lower urinary tract function.

Long-term urodynamic and urological outcomes were evaluated in pediatric patients following traumatic spinal cord injury (SCI). The medical charts of three pediatric patients following traumatic SCI were retrospectively reviewed. The level of the injury was cervical in two patients and thoracic in one. Two patients, whose initial urodynamics demonstrated voluntary or reflex detrusor contraction with synergic sphincter relaxation, managed to void; however, urinary management was switched in one of these patients from voiding to clean intermittent catheterization (CIC) with anti-cholinergic agents because of a treatment for urinary incontinence. There were also no episodes of hydronephrosis, vesicoureteral reflux (VUR) or renal dysfunction in these two patients. Although one patient with hyperreflexic bladder was initially managed with CIC and anti-cholinergic agents, detrusor myectomy was ultimately performed because of severe VUR associated with the progressive worsening of lower urinary tract (LUT) function. Careful follow-ups including urodynamics are mandatory for children with progressively deteriorated LUT function or problematic urinary incontinence.

Detrusor myectomy: Long‐term functional outcomes

Detrusor myectomy is a recognized method of bladder augmentation for treating refractory detrusor overactivity. Herein we report the long-term outcomes of this procedure at the University Hospital of Wales in Cardiff, UK. Detrusor myectomy was carried out in 33 patients (7 males, 26 females) with urodynamically proven detrusor overactivity between 1995 and 2002. The mean patient age was 33 years (range 5-62). A total of 18 patients had idiopathic detrusor overactivity, whereas 15 had neurogenic detrusor overactivity. A total of 24 patients had a detrusor myectomy alone, whereas eight patients had a detrusor myectomy with implantation of artificial urinary sphincter. One patient had detrusor myectomy with transuretero-ureterostomy. The mean follow up was 148 months (range 108-192). A total of 10 of the 18 patients with idiopathic detrusor overactivity (55.5%) and six of the 15 patients with neurogenic detrusor overactivity (40%) showed marked improvement in symptoms. Detrusor overactivity was completely abolished in 11 patients and significantly reduced in five. Postoperatively, mean cystometric capacity improved from 290 to 458 mL, whereas mean maximum amplitude of detrusor contraction was reduced from 44 cm/H(2) O to 20 cm/H(2) O. An overall success rate of 48.5% (16/33 patients) was achieved. Intermittent self catheterization was needed to achieve bladder emptying in 12 of the 16 (75%) patients. Of the remaining 17 patients who did not improve, six had CLAM enterocystoplasty carried out and two await the operation. An ileal conduit diversion and suprapubic catheter insertion was carried out in one patient each, whereas seven patients declined any further intervention. Detrusor myectomy offers a reasonable long-term success rate to patients undergoing surgical treatment for refractory detrusor overactivity.

Use of an Inflatable Silicone Balloon Improves the Success Rate of Bladder Autoaugmentation at Long-Term Followup

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

Management of overactive bladder

Many people are affected by urinary urgency, which can be highly bothersome. Urgency is the cornerstone symptom of overactive bladder (OAB), commonly occurring in conjunction with urinary frequency and nocturia. Once other medical causes of similar symptoms have been excluded, first-line OAB management comprises fluid intake advice and bladder training, supplemented by antimuscarinic drugs if necessary. Urodynamic confirmation of the diagnosis is required for OAB patients whose symptoms are refractory to first-line interventions. If patients are severely bothered by OAB despite optimization of medical treatment, they may proceed to invasive treatments, including neuromodulation, enterocystoplasty, detrusor myectomy, or urinary diversion. Our burgeoning understanding of the complex cellular, neural and integrative physiology of the bladder offers new insights into the causative mechanisms of OAB, and reasons why patients sometimes fail to respond to treatment. Study of sensory information pathways in the lower urinary tract has led to identification of the urothelium, afferent nerves and interstitial cells as key cellular elements in OAB. In-depth knowledge of the hierarchy of central nervous system control is lacking, but functional imaging is beginning to elucidate the challenges that lie ahead. New treatments under investigation include botulinum neurotoxin-A injection, oral β(3)-adrenergic agonists, and novel modalities for nerve stimulation. The subjective nature of urinary urgency, the lack of animal models and the multifactorial pathophysiology of OAB present significant challenges to effective clinical management.

The overactive bladder.

Urinary urgency and the associated symptoms which comprise overactive bladder are prevalent amongst the general population and adversely affect quality of life. Disease management consists of a sequential series of options starting with behavioural and lifestyle techniques, pharmacological management (antimuscarinics) and, in severe cases, surgical treatment (urinary diversion, neuromodulation, augmentation cystoplasty and detrusor myectomy). There is increasing recognition of pathophysiological mechanisms in the urothelium, interstitial cells and afferent neurons allowing the importance of peripheral integrative interaction to be identified. The hierarchy of the central nervous system control adds additional complexity to understanding the oflower urinary tract function. Some newer methods of treatment include Botulinum toxin A intramural injections, oral beta-3 adrenergic agonists and rho-kinase inhibitors. The lack of a disease generating hypothesis, the lack of animal models for disease and the subjective nature of the central symptom (urgency) still pose considerable theoretical and scientific hurdles that need to be overcome in the treatment of this condition.

559: A Comparison of Detrusor Myectomy and Enterocystoplasty in the Surgical Treatment of Refractory Idiopathic Overactive Bladder

559: A Comparison of Detrusor Myectomy and Enterocystoplasty in the Surgical Treatment of Refractory Idiopathic Overactive Bladder

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

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. 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. 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. 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.

Enterocystoplasty or detrusor myectomy? Comparison of indications and outcomes for bladder augmentation

Enterocystoplasty or detrusor myectomy? Comparison of indications and outcomes for bladder augmentation

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.

ENTEROCYSTOPLASTY OR DETRUSOR MYECTOMY? COMPARISON OF INDICATIONS AND OUTCOMES FOR BLADDER AUGMENTATION

Purpose We review our experience with enterocystoplasty and detrusor myectomy to delineate clinical indications and compare operative outcomes with both types of bladder augmentation. Materials and Methods Retrospective analysis of 61 patients who had undergone a total of 37 detrusor myectomies and 32 enterocystoplasties was performed. The patients were categorized into 6 diagnostic subsets representative of the clinical spectrum of indications for bladder augmentation. Results For most clinical indications detrusor myectomy offered comparable success or significant improvement in bladder function without incurring the significant complication rate of enterocystoplasty. Conclusions Detrusor myectomy is a safe, successful method of bladder augmentation for most clinical indications. Myectomy does not hinder subsequent creation of an enterocystoplasty.

Detrusor myectomy (autoaugmentation) in the treatment of hyper-reflexive low compliance bladder

After unsuccessful medical treatment of a neurogenic hyperreflexive bladder dysfunction further treatment options are the ileal bladder augmentation, the detrusor-myectomy (bladder auto-augmentation) and the sacral root deafferentation. All techniques lead to a low-pressure bladder with enlarged storage volume. The authors here report about their personal experience with the detrusor myectomy in 62 patients with hyperreflexive neurogenic bladder dysfunction from 1989 until 1998. Indication, surgical technique, and long-time results are presented.

Detrusor myectomy for detrusor overactivity: A minimum one-year follow-up: K.S. Swami, R.C.L. Fenely, J.C. Hammonds, et al. Br J Urol 81:68–72, (January), 1998

Detrusor myectomy for detrusor overactivity: A minimum one-year follow-up: K.S. Swami, R.C.L. Fenely, J.C. Hammonds, et al. Br J Urol 81:68–72, (January), 1998

Detrusor myectomy for detrusor, overactivity: a minimum 1‐year follow up

Detrusor myectomy for detrusor, overactivity: a minimum 1‐year follow up

Detrusor myectomy for detrusor overactivity: a minimum 1-year follow-up.

To evaluate the clinical and urodynamic outcome of partial detrusor myectomy in patients with idiopathic detrusor instability and neuropathic hyper-reflexia. Seventeen patients with idiopathic detrusor instability and 10 with hyper-reflexia and symptoms not responding to non-surgical treatment underwent partial detrusor myectomy. The clinical and urodynamic results before and after myectomy were compared and the patient's subjective assessment of the outcome documented. There was an overall improvement in 17 of 27 patients (63%) but the success rate was higher in those with idiopathic instability (12 of 17) than in those with neuropathy (five of 10). There was urodynamic evidence of reduced bladder contractility and an improvement in the storage characteristics of the bladder in most of the patients treated. Partial detrusor myectomy is relatively simple and is associated with minimum morbidity and an acceptable success rate. The procedure alters the urodynamic behaviour of the bladder and leads to symptomatic and objective improvement, giving better results with idiopathic than with neuropathic detrusor overactivity. Detrusor myectomy may be offered to patients with detrusor overactivity unresponsive to conventional management. The option of enterocystoplasty is still open to patients with an unsuccessful outcome. However, the long-term results and surgical variations of the technique should be evaluated further.

Tumors in Bladder Remnant After Augmentation Enterocystoplasty

We attempted to determine the tissue of origin of tumors after augmentation enterocystoplasty. We retrospectively reviewed the histological findings of 4 tumors that developed after clam ileocystoplasty. Tumors were primarily adenocarcinoma that originated on the bladder side of the anastomosis. The urothelium showed glandular metaplasia and dysplasia with intestinalization overlying normal detrusor muscle. These changes were also present in the renal pelvis in 1 patient with ureteral reflux. Bowel mucosa was normal except for inflammation. These tumors are derived from urothelium, which may be due to elevated urinary nitrosamines in this group of patients.