Treatment Of Detrusor Sphincter Dyssynergia Research Articles

The Role of Chemical Sphincterotomy with Urethral Botulinum Toxin Injection in Patients with Neurogenic and Non-neurogenic Failure to Empty

This review focuses on the evidence for injection of botulinum A toxin (BTX) to the external urinary sphincter for management of impaired bladder emptying secondary to neurogenic conditions such as detrusor sphincter dyssynergia (DSD) and non-neurogenic conditions such as dysfunctional voiding (DV). The application of urethral BTX for patients with impaired emptying secondary to detrusor underactivity will also be discussed. The goal of the review is to comprehensively analyze the evidence surrounding urethral BTX in this context and help guide decision-making. A robust body of literature including case series, a randomized control trial (RCT), and a meta-analysis support the use of urethral BTX for the treatment of DSD in spinal cord injury (SCI) patients, with documented improvement in urethral pressure and post-void residual urine volume (PVR). A second RCT among patients with DSD and MS demonstrated no improvement in urethral pressure, PVR, or maximum urine flow rate following urethral BTX relative to control. For non-neurogenic conditions like DV and pelvic floor spasticity, there are mixed data regarding the efficacy of urethral BTX. Small series have reported improvement in PVR and urethral pressure, but a RCT in this patient population demonstrated no benefit of urethral BTX relative to control. Urethral BTX effectively lowers urethral pressure and PVR in SCI patients with DSD, though the long-term impact on renal function requires further study. For patients with MS and those with non-neurogenic conditions like DV, pelvic floor spasticity, and detrusor under activity, the role of urethral BTX is not well defined. Further study in these patient populations should be undertaken prior to widespread utilization.

Botulinum toxin a external urethral sphincter quadrant injection guided by transrectal ultrasound for treatment of detrusor sphincter dyssynergia

Detrusor sphincter dyssynergia (DSD) causes impaired micturition and high intra-vesical pressure that leads to potentially life-threatening urological complications. Botulinum toxin A (BTX-A) is an inhibitor of acetylcholine release at the neuromuscular junction, which can decrease muscle contractility. It has been used successfully in the treatment of focal dystonia and spasticity of skeletal muscles. This study investigates the effectiveness of BTX-A injection to the external urethral sphincter guided by transrectal ultrasound in the treatment of spinal cord injury (SCI) patients with DSD. A total of 18 patients with DSD (15 men and 3 women) were caused by SCI. BTX-A (100μ) was injected into external urethral sphincter(EUS) respectively in four sites at 12.3,6.9 o’clock guided by transrectal ultrasound. Clinical effects and urodynamic parameters were compared at baseline and after treatment one month. The EUS was clearly identified as a neatly hypoechoic area extending from the prostatic apex to the levator ani muscle in men patients, but not in women patients. After treatment, the urinary function and urodynamic parameters is improved significantly compared with the baseline ( P < 0.05), and at 4 week up to a maximum efficacy. In total, 6 (33.3%) patients had an excellent result and had 5 (27.7%) significant improvement. Relatively poor bladder contractility tended to be more frequent in the unimproved patients. However, the catheter insertion becomes easier in patients with failed treatment. Stress urinary incontinence was reported in 4 patient. There was no other obvious side effects occurred in patients. Transrectal ultrasound is an effective method to visualize the lower urinary tract and allows for the accurate targeting of the EUS. It is a simple and repeatability method for the treatment of DSD. BTX-A injection to the EUS guided by transrectal ultrasound is an effective method in the treatment of SCI patients with DSD.

Use of botulinum toxin for voiding dysfunction.

The use of botulinum toxin A (BoNT-A) has expanded across a range of lower urinary tract conditions. This review provides an overview of the current indications for BoNT-A in the lower urinary tract and critically evaluates the published evidence within each area. The classic application of BoNT-A has been in the management of refractory neurogenic detrusor overactivity (NDO) and overactive bladder (OAB). There is a large volume of high-quality evidence, including numerous randomized placebo-controlled trials, which demonstrate the efficacy of BoNT-A over a long follow-up period. The culmination of this robust evidence-base has led to onabotulinumtoxin A (onaBoNT-A) receiving regulatory approval as a second-line treatment for NDO at a dose of 200 U and OAB at dose of 100 U. Other applications for BoNT-A are used on an off-license basis and include interstitial cystitis/bladder pain syndrome (IC/BPS), benign prostatic hyperplasia (BPH), and detrusor sphincter dyssynergia (DSD). These applications are associated with a less mature evidence-base although the literature is rapidly evolving. At present, the results for painful bladder syndrome (PBS) are promising and BoNT-A injections are recommended as a fourth line option in recent international guidelines, although larger randomized study with longer follow-up are required to confirm the initial findings. As a treatment for DSD, BoNT-A injections have shown potential but only in a small number of trials of limited quality. No definite recommendation can be made based on the current evidence. Finally, the results for the treatment of BPH have been variable and recent high quality randomized controlled trials (RCTs) have suggested no benefit over placebo so at present it cannot be recommended for routine clinical practice. Future advances of BoNT-A include liposome encapsulated formulations which are being developed as an alternative to intravesical injections.

Intérêt des endoprothèses urétrales ALLIUM BUS « BULBAR URETHRAL STENT » pour le traitement de la dyssynergie vésico-sphinctérienne

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". 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. 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. The temporary urethral stent ALLIUM BUS does not seem to be a possible surgical alternative for the treatment of detrusor sphincter dyssynergia. 4.

Chapter 5: Clinical data in neurogenic detrusor overactivity (NDO) and overactive bladder (OAB).

Following use of botulinum toxin in the 1980s for the treatment of detrusor sphincter dyssynergia in patients with spinal cord injury (SCI), the potential therapeutic value of this neurotoxin in urology has been the subject of much interest. The DIGNITY (Double-blind InvestiGation of purified Neurotoxin complex In neurogenic deTrusor overactivitY) clinical research program aimed to compare onabotulinumtoxinA with placebo in terms of efficacy and safety in patients with neurogenic detrusor overactivity (NDO) due to SCI or multiple sclerosis. The EMBARK clinical research program mirrored these aims in patients with overactive bladder with urinary incontinence (UI). Each program comprised two phase III, randomized, placebo-controlled studies. In all four trials, primary efficacy endpoints were met, and significant benefits of onabotulinumtoxinA versus placebo were demonstrated across a range of secondary endpoints, including measures of health-related quality of life. The most common adverse event across both programs was urinary tract infection. Interim analyses of data from ongoing long-term extensions to these phase III trials have provided promising evidence for the efficacy of repeated injections. While further investigation is recommended to enrich the dataset, the available evidence indicates that onabotulinumtoxinA provides an effective treatment option for these two populations, which were previously considered very difficult to treat.

Therapeutic outcome and quality of life between urethral and detrusor botulinum toxin treatment for patients with spinal cord lesions and detrusor sphincter dyssynergia

Patients with spinal cord lesions and detrusor sphincter dyssynergia (DSD) may be treated with urethral sphincter botulinum toxin A (BoNT-A) injection for difficult urination or detrusor BoNT-A injection for incontinence. Although objective data showed improvement, patients might not be satisfied with the result especially in quality of life (QOL) issue. This study investigated the therapeutic results and QOL and patients' satisfaction to these two treatments. Patients with spinal cord lesion and DSD were treated with urethral sphincter injection of 100 U of BoNT-A for main symptoms of difficult urination and detrusor injection of 200 U of BoNT-A for main symptom of incontinence. The urodynamic parameters, QOL scores using UDI-6 and IIIQ-7 and general satisfaction were compared between two groups. The overall satisfactory result was perceived in 60.6% and 77.3% in patients who received urethral and detrusor BoNT-A injection, respectively. Urodynamic parameters showed significant improvement in both groups. Urethral injection group had improvement in IIQ-7, but not in UDI-6 scores whereas detrusor injection group had improvement in all scores. The improvement of UDI-6 and IIQ-7 was significantly greater in detrusor than urethral injection group. Increase in incontinence grade was the major cause of dissatisfaction in urethral injection group, whereas increase in difficult urination and needing catheterisation were the main dissatisfaction causes in detrusor injection group. There was discrepancy between the objective urodynamic results and patient satisfaction in treatment of DSD by BoNT-A injection. Patients with DSD and treated with detrusor BoNT-A had greater QOL improvement than those treated with urethral injection.

Management of the Detrusor Sphincter Dyssynergia

Detrusor sphincter dyssynergia (DSD) is a disturbance of the normal synergistic coordination between bladder contraction and external urethral sphincter muscles relaxation during voiding. In patients with neurogenic bladder, the urethral sphincter muscle contracts during voiding instead of completely relaxing. This results in alteration of the normal flow and rising of the bladder pressure. The voiding dysfunction and the subsequent dysfunction of the emptying phase of micturition represent a high risk of complications for patients with neurogenic bladder, in relation with high intra-vesical pressure and lack of complete bladder emptying such as: lithiasis, urinary tract infection (UTI), vesico-ureteral reflux, hydronephrosis, and renal failure. Therefore, management of DSD requires a multidisciplinary and careful follow-up to prevent complications. Various physicians should be involved including surgeon, rehabilitation physician, neurologist. Treatment of DSD is a moving field with new emerging approaches and therapies such as botulinum toxin, urethral stent, and promising pharmacological treatment. Therapeutics are often highly specific and should be individually tailored, but with always the same aim: to prevent complications which can impact quality of life, and life expectancy of patients. Here we propose a therapeutic approach to DSD, based on a review of the recent literature and our personal experience. At the end, we try to summarize recommendations for managing DSD in neurogenic bladder.

Uroflowmetry Nomograms for Healthy Children 5 to 15 Years Old

We determined flow rates and generated flow rate-voided volume nomograms based on healthy children 5 to 15 years old voiding spontaneously in their natural environment. A total of 824 healthy school children of both genders were enrolled. A single uroflow record from each child was evaluated. A total of 103 children with a voided volume of less than 50 ml and/or a staccato/interrupted uroflow pattern were excluded, and 721 records were analyzed. Data were evaluated using several mathematical formulas and goodness of fit was determined. Linear regression analysis was used to generate nomograms. Flow rates and voided volumes increased with increasing age, with the effect being more pronounced in girls. No significant difference was noted in uroflow rates from 5 to 10 years, but significant differences (p <0.001) started appearing at 11 to 15 years. Also no significant difference was noted in uroflow rates among children 11 to 15 years. Therefore, 2 age groups were designated, with group 1 consisting of patients 5 to 10 years old and group 2 consisting of patients 11 to 15 years old. There were 222 boys and 122 girls in group 1 and 240 boys and 137 girls in group 2. In group 1 the maximum and average ± SD flow rates were 15.26 ± 4.54 ml per second and 7.68 ± 3.26 ml per second, respectively, for boys and 17.98 ± 6.06 ml per second and 9.19 ± 4.23 ml per second, respectively, for girls. In group 2 these rates were 22.50 ± 7.24 ml per second and 10.78 ± 4.03 ml per second, respectively, for boys and 27.16 ± 9.37 ml per second and 13.48 ± 5.21 ml per second, respectively, for girls. This large study, which expands the scant existing literature on uroflow parameters in healthy children, will hopefully promote wider application of uroflowmetry testing in the pediatric population.

Transperineal Injection of Botulinum Toxin A for Treatment of Detrusor Sphincter Dyssynergia: Localization With Combined Fluoroscopic and Electromyographic Guidance

Tsai S-J, Ying T-H, Huang Y-H, Cheng J-W, Bih LI, Lew HL. Transperineal injection of Botulinum Toxin A for treatment of detrusor sphincter dyssynergia: localization with combined fluoroscopic and electromyographic guidance. Objective To determine the effectiveness of a combined method for localizing external urethral sphincter for transperineal injection of botulinum toxin A (BTX-A) in the treatment of detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury (SCI). Design A prospective, open-label trial. Setting A rehabilitation hospital affiliated with a medical university. Participants Eighteen SCI patients with voiding dysfunction resulting from urodynamically confirmed DSD. Interventions 100 units of BTX-A injected transperineally into the external urethral sphincter, which was localized using combined fluoroscopic and electromyographic guidance, using a Foley catheter inserted for visualization of vesicourethral anatomy. Main Outcome Measures (1) postvoid residual volume, (2) leak point pressure, (3) maximal intravesical pressure, (4) maximal urethral pressure, (5) quality of life measures for urination, quantified by the Quality of Life Index (QLI). Results Positive clinical outcomes were observed in all 18 patients in this study. The mean reductions in postvoid residual volume, leak point pressure, maximal intravesical pressure, and maximal urethral pressure before and after BTX-A injection were 183ml, 37cm H 2O, 45cm H 2O, and 92cm H 2O, respectively (all P values <.05). The mean QLI significantly improved from −0.68±0.27 to 0.66±0.19 ( P<.01). No significant side effects were noted after injection. The clinical therapeutic effects have shown reductions in occurrence and degree of autonomic dysreflexia, vesicoureteral reflux, hydronephrosis, and urinary tract infection. The bladder management programs also obtained improvements in our patients, either doing intermittent catheterizations less frequently, or resuming spontaneous voiding without indwelling catheters. Conclusion With this combined method for localization of the external urethral sphincter, transperineal injection of BTX-A was safe, accurate, easy to perform, and effective for treatment of DSD in patients with SCI.

Transurethral Sphincterotomy

No AccessJournal of UrologyOpposing Views1 Apr 2009Transurethral Sphincterotomy Inder Perkash Inder PerkashInder Perkash More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2009.02.014AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Transurethral Sphincterotomy." The Journal of Urology, 181(4), pp. 1539–1540 References 1 : Use of the Memokath for detrusor-sphincter dyssynergia after spinal cord injury—a cautionary tale. Spinal Cord1998; 36: 39. Google Scholar 2 : Long-term follow-up study of intraurethral stents in spinal cord injured patients with detrusor-sphincter dyssynergia. Spinal Cord2007; 45: 621. Google Scholar 3 : The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience. Eur Urol2003; 43: 539. Google Scholar 4 : Detrusor-sphincter dyssynergia and detrusor hyperreflexia leading to hydronephrosis during intermittent catheterization. J Urol1978; 120: 620. Link, Google Scholar 5 : The various types of neurogenic bladder dysfunction: an update of current therapeutic concepts. Paraplegia1990; 28: 217. Google Scholar 6 : Contact laser sphincterotomy: further experience and longer follow-up. Spinal Cord1996; 34: 227. Google Scholar 7 : Transurethral sphincterotomy provides significant relief in autonomic dysreflexia in spinal cord injured male patients: long-term followup results. J Urol2007; 177: 1026. Link, Google Scholar 8 : Use of penile prostheses to maintain external condom catheter drainage in spinal cord injury patients. Paraplegia1992; 30: 327. Google Scholar 9 : Bladder leak pressure: the measure for sphincterotomy success in spinal cord injured patients with external detrusor-dyssynergia. J Urol1998; 159: 493. Link, Google Scholar Surgical Service, VA Palo Alto and Stanford University, Stanford, California© 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4April 2009Page: 1539-1540 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Inder Perkash More articles by this author Expand All Advertisement PDF DownloadLoading ...

The lowest effective dose of botulinum toxin in detrusor sphincter dyssynergia

Detrusor sphincter dyssynergia is a spastic condition due to lack of coordination between the bladder and the external sphincter. It results in excessive bladder pressures and inability to empty the bladder completely. Botulinum toxin type A has been injected either transurethrally via cystoscope or transperineally under electromyographic control. The dose and dilution volume vary from author to author. This was a prospective, randomized, double-blind, dose-ranging clinical trial to define the lowest effective dose of botulinum toxin type A and safety in the treatment of detrusor sphincter dyssynergia. Twelve adult patients with detrusor sphincter dyssynergia are randomly divided into three groups by a random table, four patients in each group. Depending on randomization, BOTOX 50,75 or 100 U will be administered. The results indicate that BOTOX 75 and 100 U statistically reduce postvoiding residual urine and detrusor pressure at P Conclusion:The lowest effective dose of BOTOX in the treatment of detrusor sphincter dyssynergia is 75–100 U, which is slightly lower than in other studies.

Outcome after treatment of detrusor–sphincter dyssynergia by temporary stent

To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent. Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case. The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD). After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.

Possible Role of Large Fluid Intake in Delaying Formation of Encrustations and, thereby, Prolonging Working Life of Memokath Stent for Nearly 14 Years in a Spinal Cord Injury Patient

The Memokath stent has been used in spinal cord injury patients as a reversible alternative to external urethral sphincterotomy, but the stent has a finite lifetime of <2 years before failure in the majority of patients. We report an unusual case of a spinal cord injury patient in whom memokath stent was functioning for almost 14 years. The long life span of the Memokath in this patient was probably due to this person's habit of drinking around 5 l of fluids a day. Large fluid intake resulted in high urine output and, consequently, deceased the risk of urine infections and delayed formation of encrustations around the stent. Although this case represents an unusual length of time for a Memokath stent to have been in place and functioning, caution should be exercised against the long-term use of Memokath stents. Memokath stents do not get absorbed into the mucosa unlike urolume stents and, therefore, are prone to stone formation. Further, Memokath stents have not yet been approved in the U.S. either for bladder outlet obstruction or detrusor-sphincter dyssynergia. This case is also a reminder to health professionals that if a tetraplegic patient, in whom a Memokath stent has been deployed for treatment of detrusor-sphincter dyssynergia, presents with autonomic dysreflexia, encrustations blocking the lumen of the stent or calculus formation around the stent should be considered as possible reasons for autonomic dysreflexia.

Treatment of detrusor sphincter dyssynergia with baclofen and doxazosin

Detrusor sphincter dyssynergia (DSD) is an involuntary contraction of the external urethral sphincter during detrusor contraction. A high proportion of patients needing repeat surgery and long term failure have both been described in the literature. In the present study, we evaluated clinical characteristics, underlying disorders and outcomes of conservative medical treatment in 21 female patients. Two patients were newly diagnosed multiple sclerosis. Urodynamic studies were performed in all symptomatic patients, and consisted of measurement of post-micturition residuals, urethral pressure profilometry and EMG cystometry according to the criteria of the International Continence Society. All patients were treated with baclofen 15 mg/day and doxazosin 4 mg/day. Seven patients received tolterodine 4 mg/day in addition to baclofen and doxazocin because they had detrusor hyperreflexia (DH). In conclusion, treatment with either combined baclofen and doxazosin or anticholinergic agent tolterodine appeared to be effective. In addition, it should be kept in mind that DSD could be the first sign to any neurologic diseases.

Experience With 100 Cases Treated With Botulinum-A Toxin Injections in the Detrusor Muscle for Idiopathic Overactive Bladder Syndrome Refractory to Anticholinergics

In this prospective, nonrandomized, ongoing study we evaluated the efficacy and safety of botulinum-A toxin injections in the detrusor muscle to treat patients with idiopathic overactive bladder resistant to conventional treatment, such as anticholinergic drugs. A total of 23 men and 77 women with a mean age of 63 years (range 24 to 89) with nonneurogenic overactive bladder, including urgency-frequency syndrome, and incontinence despite the administration of maximal doses of anticholinergics were consecutively treated with injections of 100 U botulinum-A toxin in the detrusor muscle at 30 sites under cystoscopic guidance. Micturition diary, full urodynamics, neurological status and urine probes were performed in all participants before treatment. Bladder biopsies were done only in cases of suspected bladder fibrosis or unclear findings. Special attention was given to reflex volume, maximal bladder capacity, detrusor compliance, post-void residual urine, urgency and frequency/nocturia. Clinical, urodynamic and quality of life assessments were performed at baseline, and 4, 12 and 36 weeks after botulinum-A toxin treatment. Overall after 4 and 12 weeks 88% of our patients showed significant improvement in bladder function in regard to subjective symptoms, quality of life and urodynamic parameters (p <0.001). Urgency disappeared in 82% of the patients and incontinence resolved in 86% within 1 to 2 weeks after botulinum-A toxin injections. Mean frequency decreased from 14 to 7 micturitions daily (-50%) and nocturia decreased from 4 to 1.5 micturitions. Mean maximal bladder capacity increased 56% from 246 to 381 ml, mean detrusor compliance increased from 24 to 41 ml/cm H(2)O and pretreatment detrusor instability (mean reflex volume 169 ml) resolved in 74% of patients. Mean volume at first desire to void increased from 126 to 212 ml and mean urge volume increased from 214 to 309 ml. There were no severe side effects except temporary urine retention in 4 cases. Only in 8 patients was the clinical benefit poor and analysis revealed preoperative low detrusor compliance. Mean efficacy duration +/- SD was at least approximately 6 +/- 2 months and then symptoms began to increase. Our results show that intradetrusor botulinum-A toxin injections may be an efficient and safe treatment option in patients with severe overactive bladder resistant to all conventional treatments.

Memokath® stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: the Princess Royal Spinal Injuries Unit 10-year experience

Memokath ® stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: the Princess Royal Spinal Injuries Unit 10-year experience

Placebo controlled, randomised, double blind study of the effects of botulinum A toxin on detrusor sphincter dyssynergia in multiple sclerosis patients

Objective: The purpose of the study was to evaluate the efficacy and safety of botulinum A toxin in the treatment of detrusor sphincter dyssynergia in multiple sclerosis patients. Methods: This...

Memokath® stents for the treatment of detrusor sphincter dyssynergia (DSD) in men with spinal cord injury: The Princess Royal Spinal Injuries Unit 10-year experience

Medical records review. To assess the effectiveness of the Memokath (Engineers and Doctors A/S, Denmark) thermosensitive stent as a 'nondestructive' means of reducing bladder outlet resistance by treating detrusor sphincter dyssynergia (DSD) of neurogenic bladder dysfunction associated with spinal cord injury. Spinal Injuries Unit, Sheffield, England. A medical records review was performed to examine our experience of Memokaths over the last 10 years. During this time, 29 patients with spinal cord injury (17 tetraplegic and 12 paraplegic) underwent stenting of the external urethral sphincter either for prevention of dysreflexic symptoms, high residual urine volumes and subsequent urinary tract infection (UTI) or for protection of the upper tracts. A total of 33 stents were inserted into 29 men (25-77 years) with suprasacral spinal cord injury. Initial results showed that the Memokath was effective in almost all for relief of dysreflexic symptoms and elimination of DSD on pressure flow urodynamics. However, to date, 30 of the 33 stents have been removed. The overall mean working life of the Memokath was 21 months. Four stents were removed electively and 23 for complications, which included stent migration (seven) and blockage (14). Single-ended stents were more prone to migration, which was rare after 1 year (1-13 months, median 3 months, mean 5.5 months). Stent blockage by encrustation or prostatic ingrowth did not occur before 12 months (12-45 months, median 30, mean 27.9 months). In selected patients, temporary, thermo-expandable (Memokath) stents are effective in the treatment of DSD. The 'working life' of a Memokath stent is 21 months; however, complications do occur which may necessitate removal. Our overall experience with Memokath stents was disappointing. In future, Memokath stents will only be inserted after careful consideration in patients with prior 'failed' transurethral sphincterotomy or with caution in patients suitable for reconstructive surgery.

The use of the Memokath stent in the treatment of detrusor sphincter dyssynergia in spinal cord injury patients: a single-centre seven-year experience.

A retrospective analysis of our seven-year experience with the Memokath urethral stent for the treatment of detrusor sphincter dyssynergia (DSD) in spinal cord injured (SCI) patients. Twenty five patients with SCI underwent rhabdosphincter Memokath stent insertion. The mean age was 45.5 years (range 32-65 years). The level of injury was cervical in 14 and thoracic in 11 patients. All patients were shown to have neurogenic detrusor overactivity with DSD associated with high detrusor pressures and incomplete emptying on pre-operative video-cystometrograms (VCMG). The Memokath stent was inserted using a standardized protocol. Follow-up assessment included blood chemistry, ultrasound scan (upper tracts and residual urine) at one and three months after insertion, and a follow-up VCMG at six months. The pre-operative and six-month post-operative VCMG results were analysed by the paired t-test and p value <0.05 was taken as significant. There was a significant reduction in maximum detrusor pressure, duration of contraction and residual urine volume (p<0.05) on the VCMG six months after insertion of the stent. At present six patients have a Memokath stent in situ at a mean of 34.7 months (range 6-86 months). Nineteen stents were removed for several reasons at a mean of 20.3 months (range 0.25-41 months). These include, exacerbation of autonomic dysreflexic symptoms (n=3); stent migration (n=7); encrustation and stone formation (n=5); incomplete bladder emptying without obstruction (n=3); entrance into fertility program (n=1). The Memokath stent is safe, easy and quick to insert with minimal trauma to the urethra. It is effective in the management of DSD and decreasing the detrusor pressure and residual urine volume in SCI patients. Moreover the ease of its removal in a non-traumatic fashion makes this stent an attractive option when patients are still contemplating the method of bladder management, in those wishing to be involved in fertility program and in recently SCI patients who may recover some manual dexterity to perform clean intermittent self-catheterisation. It must be remembered that this is a temporary stent, as our study clearly shows that the majority are removed within two years of insertion.

Lack of Efficacy of Botulinum A Toxin in The Treatment of Detrusor Sphincter Dyssynergia in Multiple Sclerosis Patients

Clinical Pharmacology &amp; Therapeutics (2003) 73, P37–P37; doi: