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Background Urological dysfunction in patients with multiple system atrophy (MSA) is one of the main manifestations of autonomic failure. Urodynamic examination is clinically relevant since underlying pathophysiology of lower urinary tract (LUT) dysfunction can be variable. Objective Evaluation of the pathophysiology of urological symptoms and exploration of differences in urodynamic patterns of LUT dysfunction between MSA‐P and MSA‐C. Methods Retrospective study of patients with possible and probable MSA who were referred for urodynamic studies between 2004 and 2019. Demographic data, medical history, physical examination and urodynamic studies assessing storage and voiding dysfunction were obtained. Results Seventy‐four patients were included in this study (MSA‐P 64.9% n = 48; median age 62.5 (IQR 56.8–70) years). Detrusor overactivity during filling phase was noted in 58.1% (n = 43) of the patients. In the voiding phase, detrusor sphincter dyssynergia and detrusor underactivity were observed in 24.6% (n = 17) and in 62.1% (n = 41) of the patients, respectively. A postmicturition residual volume of over 100 ml was present in 71.4% (n = 50) of the patients. Comparison of MSA subtypes showed weaker detrusor contractility in MSA‐P compared to MSA‐C [pdetQmax 26.2 vs. 34.4 cmH20, P = 0.04]. In 56.2% (n = 41) of patients pathophysiology of LUT dysfunction was deemed to be neurogenic and consistent with the diagnosis of MSA. In 35.6% (n = 26) urodynamic pattern suggested other urological co‐morbidities. Conclusion Urodynamic evaluation is an important tool to analyze the pattern of LUT dysfunction in MSA. Impaired detrusor contractility was seen more in MSA‐P which needs to be investigated in further studies.

Die Therapie der neurogenen Blasenfunktionsstorung (nBFS) bei Querschnittlahmung (SCI) und Myelomeningozele (MMC) ist primar konservativ und setzt am unteren Harntrakt an. So gilt heute z. B. die orale antimuskarinerge Medikation als Standardtherapie der neurogenen Detrusoruberaktivitat. In den letzten Jahren stehen jedoch zunehmend Behandlungsoptionen, welche direkt oder indirekt Einfluss auf die Innervation des Harntrakts nehmen, im Fokus des Interesses. Die aktuelle Evidenzlage rechtfertigt den Einsatz von Nervenumleitungsoperationen bis heute nicht. Die vorliegenden praliminaren Daten sind fur MMC-Patienten deutlich positiver als fur Personen mit traumatischer SCI. Die sakrale Neuromodulation stellt bei inkomplett querschnittgelahmten Patienten mit neurogener Blasenfunktionsstorung schon heute eine Therapieoption dar. Erste Daten weisen darauf hin, dass ein Einsatz bereits im spinalen Schock auch bei kompletter SCI die Entwicklung einer nBFS verhindern kann. Die Zulassung von Onabotulinumtoxin (Botox®) erleichtert den Einsatz dieser Substanz zur Therapie der nBFS, allerdings nur fur die Indikation der neurogenen Detrusoruberaktivitatsinkontinenz in der Dosierung von 200 IE. Die genannten unkonventionellen Behandlungsverfahren stellen somit, obwohl z. T. kontrovers diskutiert, vielversprechende neue Behandlungsoptionen der nBFS dar.

Context Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear. Objective To assess the efficacy and safety of SNM for neurogenic LUTD. Evidence acquisition Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis. Evidence synthesis Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half ( n =13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase ( n =4) or permanent SNM ( n =9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50–87) and 92% (95% CrI, 81–98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0–2%) for the test phase and 24% (95% CrI, 6–48%) for permanent SNM. Conclusions There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.

Prolonged sacral neuromodulation (SNM) testing is more reliable for accurate patient selection than the usual test period of 4-7 days. However, prolonged testing was suspected to result in a higher complication rate due to infection via the percutaneous passage of the extension wire. Therefore, we prospectively assessed the complications associated with prolonged tined lead testing.A consecutive series of 44 patients who underwent prolonged tined lead testing for at least 14 days between May 2002 and April 2007 were evaluated. Complications during prolonged tined lead testing, during and after tined lead explantation and during follow-up after implantation of the implantable pulse generator (IPG) were registered prospectively.Four patients suffered from urgency-frequency syndrome, 13 from urge incontinence, 18 from non-obstructive chronic urinary retention and nine from chronic pelvic pain syndrome. The median test phase was 30 days (interquartile range [IQR] 21-36). Thirty-two of the 44 patients (73%) had successful prolonged tined lead testing and 31 of these (97%) underwent the implantation of the IPG. The median follow-up of the IPG implanted patients was 31 months (IQR 20-41). The complication rate was 5% (2/44) during prolonged tined lead testing and 16% (5/31) during follow-up of the IPG implanted patients, respectively. None of the complications could be attributed to prolonged testing. No infections were observed during the study period.This prospective, observational non-randomised study suggests prolonged SNM tined lead testing is a safe procedure. Based on the low complication rate and the increased reliability for accurate patient selection, this method is proposed as a possible standard test procedure, subject to confirmation by further randomised, controlled clinical studies.

The primary goal in neurourologic management of patients with myelomeningocele is the preservation of renal function. In addition, achieving continence or at least improving urinary incontinence becomes imperative given the impact of continence on quality of life. Initial neurourologic and urodynamic examination of children with myelomeningocele is strongly recommended as early as possible, ideally on the day of birth or within 2 weeks after closure of the myelomeningocele defect. Examination is decisive for the therapeutic strategy as it allows definition of the dysfunctional pattern of the lower urinary tract and detection of risk factors (low bladder compliance, intravesical pressure > 40 cm H2O, detrusor sphincter dyssynergia) before major upper urinary tract changes occur. Thereby, the appropriate treatment can be initiated to preserve both upper and lower urinary tract function and to achieve urinary continence.

Objective: To assess the effect of prolonged sacral neuromodulation testing using permanent leads comparing the usual evaluation period of 4 to 7 days to a prolonged evaluation period of a minimum of 14 days. Patients and Methods: A consecutive series of 20 patients (16 females and 4 males) undergoing prolonged sacral neuromodulation testing using permanent leads between September 2000 and March 2004 were evaluated retrospectively. 10 suffered from urgency-frequency syndrome, 3 from urge incontinence and 7 from non-obstructive chronic urinary retention. Key bladder diary variables at baseline, after the usual and prolonged evaluation period and at the last follow-up were compared. Results: The median age was 52 years (interquartile range (IQR) 38–59) and the median evaluation period 28 days (IQR 18–29). 16 of the 20 patients (80%) had successful prolonged sacral neuromodulation testing and underwent the implantation of the IPG that was placed in the anterior abdominal wall in 6 and in the upper buttock in 10 patients. The eligibility for IPG implantation was significantly ( p =0.031) increased from 50% after the usual to 80% after the prolonged evaluation period. At a median follow-up of 22 months (IQR 12–34), sacral neuromodulation was successful in 14 (88%) of the 16 IPG implanted patients but failed in 2. Conclusions: Prolonged sacral neuromodulation testing using permanent leads is more reliable for accurate patient selection than the usual evaluation period. Therefore, this method is strongly recommended and suggested to become the standard test procedure.

This chapter describes the different surgical procedures for managing a neurogenic bladder. The procedures include electrical stimulation, bladder and urethral reconstructive surgery, bladder outlet obstruction management and the treatment of stress urinary incontinence. Electrical stimulation to manage bladder dysfunction in patients with neurological disorders has been used since 1950. Electrical stimulation therapies include intravesical electrostimulation, sacral neuromodulation and sacral anterior root stimulation with selective sacral rhizotomy. Cutaneous continent diversions may be performed in neurological patients, mainly in the young myelomeningocele patient or those with spinal cord injury (SCI) who cannot perform clean intermittent self-catheterization (CISC) via the urethra because of congenital abnormalities, urethral pain, obesity, strictures or poor hand mobility. Finally, the chapter describes the suprapubic catheter (SPC), and sphincter surgery, which relieves bladder outlet obstruction due to external urethral sphincter contraction.

OBJECTIVE To investigate whether prolonged sacral neuromodulation (SNM) testing induces a substantial risk of infection because of the percutaneous passage of the extension wire. PATIENTS AND METHODS A consecutive series of 20 patients with negative prolonged SNM testing for ≥14 days who underwent tined-lead explantation were prospectively evaluated. The explanted tined leads were sent for microbiological examination. The tined lead, gluteal, and extension wire incision sites were investigated for clinical signs of infection according to the Centers for Disease Control and Prevention classification system. RESULTS In all, 17 patients had bilateral and three unilateral implanted tined leads. The median (range) test period was 30 (21–62 days). Bacterial growth (Staphylococcus species) was detected in four of 20 (20%) patients on seven of 37 (19%) explanted tined leads. There were clinical signs of infection in one of 20 (5%) patients at none of 37 tined lead, one of 20 (5%) gluteal, and none of 20 extension wire incision sites. There were no clinical signs of infection in the remaining three of four patients with bacterial growth. CONCLUSIONS After prolonged tined-lead testing, we found an infection rate comparable to that reported with the usual short test period. In addition, most patients with bacterial growth on tined leads showed no clinical signs of infection. Thus, prolonged tined-lead testing does not seem to induce clinically relevant infection, warranting randomized trials.

Context The intraprostatic injection of botulinum neurotoxin type A (BoNT-A) is a minimally invasive but still-experimental treatment of lower urinary tract symptoms (LUTS) due to benign prostatic enlargment (BPE) based on an off-label use of the drug. Objective Report the mechanisms of action of BoNT-A on the prostate as well as the efficacy and safety of intraprostatic BoNT-A injection according to various injection protocols. Evidence acquisition We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE) database and the abstract volumes of the 2005, 2006, and 2007 European Association of Urology (EAU), American Urological Association (AUA) and International Continence Society (ICS) meetings for studies on intraprostatic BoNT-A injection. Evidence synthesis Five experimental studies and 10 clinical studies were found. The level of evidence is 1b for one study and 3 for the other studies, with grades of recommendation of A and C, respectively. The experimental studies report induced relaxation of the prostate, atrophy, and reduction of its size through inhibition of the trophic effect of the autonomic system on the prostate gland. In the clinical studies, all patients had LUTS due to BPE and prostate volume varied from 80ml. The dose varied from 100U to 300U of Botox ® . The injection was performed transperineally, transrectally, or transurethrally under general, local, or without anesthesia. The follow-up period ranged from 3 mo to 19.8 mo. All studies reported an improvement of maximum urinary flow rate, quality-of-life index and reduction of International Prostate Symptoms Score, prostate-specific antigen (PSA) level, post-void residual volume, and prostate volume. Local or systemic side effects were rare. Only patients with retention needed a urethral drainage catheter. Conclusions BoNT-A intraprostatic injection provides improvement in patients with LUTS due to BPE refractory to medical treatment. However, there is a need for large placebo controlled-studies and long-term results. So far the therapy is still experimental.

Aims To investigate whether upper urinary tract function and the need for surgery in patients with myelomeningocele depends on the timing of initiating neurourological management. Patients and Methods One hundred thirty-three patients with myelomeningocele were included in our retrospective study. The patients were divided based on age at the initial evaluation into three categories: from day of birth to age 2 (group 1, n = 67), from age 3 to age 10 (group 2, n = 44), and after age 10 (group 3, n = 22). Upper urinary tract function and the need for surgery with the intention to preserve or normalize the upper urinary tract function were compared between the three groups. Results Mean follow-up was 11, 10, and 9 years in group 1, 2, and 3, respectively. The upper urinary tract function was normal in 91%, 80%, and 82% at the initial evaluation (P = 0.194) and in 99%, 86%, and 86% at the last follow-up (P = 0.012) in group 1, 2, and 3, respectively. Following failure of conservative therapy only, the proportions of patients undergoing surgical interventions with the intention to preserve or normalize the upper urinary tract function was significantly (P = 0.0002) different among the three groups: 15%, 34%, and 59%, respectively. Conclusions Early proactive management improves upper urinary tract function and reduces the need for surgery in patients with myelomeningocele in the long-term. Therefore, initiation of proactive neurourological management as early as possible, ideally from the day of birth, is strongly recommended. Neurourol. Urodynam. 25:758–762, 2006. © 2006 Wiley-Liss, Inc.

Aims To investigate whether the initial urodynamic pattern may predict urinary continence and the need for adjunctive incontinence surgery in patients with myelomeningocele. Patients and Methods One hundred and twenty-three patients with myelomeningocele were included in our retrospective study. The patients were divided based on the urodynamic pattern at initial evaluation into four categories: overactive detrusor with overactive (spastic) sphincter (group 1, n = 43), overactive detrusor with underactive/acontractile sphincter (group 2, n = 37), underactive/acontractile detrusor with overactive (spastic) sphincter (group 3, n = 8), and underactive/acontractile detrusor with underactive/acontractile sphincter (group 4, n = 35). Urinary continence status at the last follow-up and the need for adjunctive incontinence surgery were compared between the four groups. Results Mean follow-up was 10 years and mean age at the last follow-up 17 years. A socially acceptable continence status (continent or socially dry) was achieved in 74% and was significantly different among the four groups (P = 0.023): 86% and 87% of the patients in group 1 and 3 became continent or socially dry, but only 57% and 74% of those in group 2 and 4, respectively. Although none of the patients in group 3 underwent adjunctive incontinence surgery compared to about 25% in the other groups, statistically the difference was not significant (P = 0.48). Conclusions The initial urodynamic pattern is very useful in counseling families by predicting urinary continence in patients with myelomeningocele. The chances of becoming continent or at least socially dry are best for patients with overactive (spastic) sphincter. Neurourol. Urodynam. 25:361–367, 2006. © 2006 Wiley-Liss, Inc.

Sacral neuromodulation is becomingincreasing ly popular in the urological community for the treatment of refractory overactive bladder, nonobstructive chronic urinary retention and the chronic pelvic pain syndrome. Recently, Spinelli et al presented promisingresults with a new self-blockingtined lead designed to allow minimally invasive percutaneous placement requiringno additional fascial anchoring. 1 To our knowledge no displacement of a sacral neuromodulation tined lead has been reported in the literature. We describe bilateral migration of tined leads implanted in a thin patient for sacral neuromodulation treatment of overactive bladder refractory to conservative therapy. CASE REPORT