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Ralf Böthig,1 Burkhard Domurath,2 Johannes Kutzenberger,3 Jörn Bremer,4 Ines Kurze,5 Albert Kaufmann,6 Jana Pretzer,7 Jens-Peter Klask,8 Birgitt Kowald,9 Christian Tiburtius,1 Klaus Golka,10 Sven Hirschfeld,11 Roland Thietje11 1Department of Neuro-Urology, Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Hamburg, Germany; 2Centre for Neuro-Urology, Kliniken Beelitz, Neurologische Rehabilitationsklinik, Beelitz-Heilstätten, Germany; 3Department of Neuro-Urology, Kliniken Hartenstein UKR, Bad Wildungen, Germany; 4Centre for Spinal Cord Injuries, BDH-Klinik Greifswald, Greifswald, Germany; 5Centre for Spinal Cord Injuries, Department of Paraplegiology and Neuro-Urology, Zentralklinik Bad Berka, Bad Berka, Germany; 6Department of Neuro-Urology, Kliniken Maria Hilf GmbH, Mönchengladbach, Germany; 7Department of Urology and Neuro-Urology, BG Trauma Hospital Berlin, Berlin, Germany; 8BG Trauma Hospital Duisburg, Duisburg, Germany; 9Biomechanical Laboratory, BG Klinikum Hamburg, Hamburg, Germany; 10Leibniz Research Centre for Working Environment and Human Factors at TU Dortmund(IfADo), Dortmund, Germany; 11Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Hamburg, GermanyCorrespondence: Ralf BöthigDepartment of Neuro-Urology, Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Bergedorfer Str. 10, Hamburg 21033, GermanyTel +49 40 7306 2608Fax +49 40 7306 2621Email r.boethig@bgk-hamburg.dePurpose: For successful long-term rehabilitation of patients with neurogenic lower urinary tract dysfunction (NLUTD), it is necessary to define the objective requirement for urological aids based on a scientifically validated basis.Methods: This was a cross-sectional multicenter study, based on a questionnaire. Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD in a community setting were collected through a standardized survey.Results: Seven hundred and sixty-seven records were analyzed: 543 males, 221 females (N/A = 3). Patients using intermittent catheterization (n= 608) required 5.06 (mean) single-use catheters per day. Out of them, 94 (15.5%) required additional pads (mean: 2.29 per day), 34 patients (5.6%) additionally used pants (mean: 2.55 per day) and 46 patients (7.6%) utilized condom catheters (mean: 3.81 per day) between catheterizations. Among all, 126 patients (16.4%) used pads (mean: 5.03 per day), and 51 patients (6.6%) used pants (mean: 3.03 per day). Women needed both pads (p

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Background: In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare., Methods: The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, β3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%)., Conclusion: Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Spinal cord injury (SCI) is a highly devastating injury with a variety of complications; among them are neurogenic bladder, bowel, and sexual dysfunction. We aimed to evaluate the effect of sacral anterior root stimulation with sacral deafferentation (SARS-SDAF) on neurogenic bladder and sexual dysfunction in a large well-defined spinal cord injury cohort., Methods: In the manner of cross-sectional study, subjects undergone SARS-SDAF between September 1986 and July 2011 answered a questionnaire concerning conditions before and after surgery in the department of Neuro-Urology, Bad Wildungen, Germany., Results: In total 287 of 587 subjects were analyzed. Median age was 49 years (range 19-80), median time from SCI to surgery was 10 years (range 0-49), and from surgery to follow-up 13 years (range 1-25). Of the analyzed subjects, 100% of both gender used SARS for bladder emptying. On the visual analogue scale (VAS) ranging from 0 to 10 (best), satisfaction with SARS-SDAF was 10 concerning bladder emptying, however 5 and 8 regarding sexual performance, for female and male users, respectively. Baseline and follow-up comparison showed a decline in self-intermittent catheterization (p < 0.0001), partial catheterization by attendant (p = 0.0125), complete catheterization and suprapubic catheterization (p < 0.0001), transurethral catheterization (p < 0.0011), and fewer cases of involuntary urine leakage (p < 0.0001)., Conclusions: The SARS-SDAF is a beneficial multi-potential treatment method with simultaneous positive effect on multi-organ dysfunction among SCI subjects.

Purpose: To evaluate treatment outcomes and resource consumption of patients with neurogenic detrusor overactivity (NDO) before and after botulinum toxin A (Botox) therapy in Germany., Methods: In a multi-center, cross-sectional, retrospective cohort study, data of patients with NDO 12 months before and after the first Botox therapy were analyzed., Results: 214 patients (mean age 38 +/- 14.8 years, 145 male, 69 female) with NDO due to spinal cord injury (81%); myelomeningocele (14%), or Multiple Sclerosis (5%) from seven hospitals were included. Mean interval between treatments was 8 months. Following treatment, mean maximum detrusor pressure, maximum cystometric capacity and detrusor compliance improved significantly. Prior to Botox therapy, 68% reported urinary tract infections (UTI), 63% had incontinence episodes, and 58% used incontinence aids. These numbers decreased significantly (p < 0.05) after treatment to 28, 33, and 28%, respectively. In patients using incontinence aids, mean costs per patient decreased from 2euro to 1euro per day, whereas the mean cost of drugs to treat UTIs per patient decreased from 163euro to 80euro per year, respectively., Conclusion: This is the first study demonstrating the clinical usefulness of Botox therapy in clinical practice. Successful treatment resulted in lower costs for NDO associated morbidity due to less need for incontinence aids and UTI medication.

Damage to the CNS, the cauda equina, and the pelvic nerval structures causes neurogenic bladder dysfunction with neurogenic urinary incontinence (NUI). The definitive diagnosis of NUI is made with urodynamic examination methods. The most frequent cause of NUI is neurogenic detrusor overactivity (NDO). The treatment concept must take into account the physical and emotional restrictions. The treatment of NUI due to NDO is a domain of conservative therapy, i.e., mostly antimuscarinics and intermittent catheterization (IC). In about 30%, there is a good chance for therapy failures. An advancement in therapy is the injection of BTX-A into the detrusor. The missing drug approval is a disadvantage.Operative treatments are considered if conservative and minimally invasive therapies are unsuccessful. Sacral deafferentation (SDAF) and sacral anterior root stimulator implantation (SARSI) are available as organ-preserving techniques only for paraplegics with NDO and reflex urinary incontinence and neuromodulation for the other forms of NDO provided that a successful percutaneous nerve evaluation (PNE) test has previously taken place. Augmentation cystoplasty is indicated if SDAF and neuromodulation cannot be used and the bladder wall is damaged irreversibly by fibrosis. Kidney function of at least 25% and acceptance of IC are prerequisites. Myectomy (autoaugmentation) has an indication similar to augmentation cystoplasty but there must not be any fibrosis. Bladder neck insufficiency (BNI) caused by paralysis or iatrogenically can be treated by the implantation of an alloplastic sphincter high at the bladder neck. A stable reservoir function is required. If not all methods are possible, the ileum conduit or the suprapubic bladder fistula can be the last resort.

Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The neurogenic detrusor overactivity (NDO) and the overactive external sphincter cause incontinence and threaten these 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 a sacral anterior root stimulator (SARS). Since September 1986 to December 2002, 464 paraplegic patients (220 females, 244 males) received a SDAF-SARS. The SDAF was done intradurally in almost all cases, which means that we used a single operation field to do a two-stages procedure (SDAF and SARS). The results include data on 440 patients with a mean follow-up of 8.6 years (18 months to 18 years) until December 2004. The complete deafferentation was successful in 95.2%. Of these patients, 420 paraplegics use the SARS for voiding, (frequency 4.7 per day) and 401 for defecation (frequency 4.7 per week). Continence was achieved in 364 patients (83%). UTIs decreased from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function remained stable. Early complications were 6 CSF leaks and 5 implant infections. Late compli cations included receiver or cable failures and required surgical repair in 44 patients. A step-by-step program for trouble-shooting distinguishes implant failure from myogenic or neurogenic failure. SDAF is able to restore the reservoir function of urinary bladder and makes the patient achieve continence. Autonomic dysreflexia disappeared in most cases. By accurate adjustment of stimulation parameters, it is possible for the patient to have a low resistance micturition. The microsurgical technique requires intensive education. In addition, the therapist should be able to manage late complications.

Purpose: Penile prosthetics are a viable option for erectile dysfunction in neurologically impaired patients. Penile implants can also be used to facilitate the management of urinary drainage when penile retraction has made this difficult., Materials and Methods: Between 1980 and 1996, 245 neurologically impaired patients with a mean age of 40.8 years (range 16 to 75), including 188 with paraplegia, 57 with quadriplegia and 197 with spinal cord injuries, were treated for erectile dysfunction and/or urinary incontinence with penile prosthesis implantation. The mean history of paralysis was 11.2 years (range 1 to 52). After neuro-urological evaluation all patients included in this study were considered candidates for penile prosthesis implantation. A followup program for treatment success, patient satisfaction, problems and complications was subsequently initiated., Results: During 17 years a total of 293 surgical procedures in 245 patients were done with the implantation of 147 semirigid (Jonas), 113 self-contained inflatable (Dynaflex) and 33 inflatable 3-piece (AMS 700) prostheses. There were 3 patient groups based on the indication for penile prosthetic surgery, namely group 1-134 patients with urinary management only, group 2-60 with erectile dysfunction only, and group 3-51 with urinary management and erectile dysfunction. At a mean followup of 7.2 years (maximum 17) 195 patients were reevaluated in clinic. In 122 patients (90.3%) urinary management problems were resolved. Erectile dysfunction treatment was successful in 76 patients (82.6%). There were 43 revisions for technical reasons and infections. The infection rate was 5% (12 patients). The perforation rate was different for different implant devices, that is 18.1% (15 of 83 cases) for semirigid devices, 2.4% (2 of 84) for self-contained inflatable devices and 0% (0 of 28) for inflatable 3-piece devices., Conclusions: The implantation of a penile prosthesis is a safe procedure for erectile dysfunction and/or urinary incontinence in neurologically impaired patients. Based on technical advances the complication rates significantly decreased during the years. The implantation of an inflatable 3-piece penile prosthesis in a neurologically impaired patient is a safe and viable procedure. Indications include the management of erectile dysfunction and problematic urinary collection.

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 complications 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 intensive education. One has to be able to manage late implant complications.