The bladder evacuation method is the main predictor for symptomatic UTIs in individuals with NLUTD. Transurethral catheters showed the highest odds of symptomatic UTI and should be avoided whenever possible.

Sensory evoked potentials can be reliably recorded from different lower urinary tract locations after 0.5 Hz stimulation with a characteristic negativity at about 130 milliseconds. These latencies are compatible with a conduction velocity in the range of 3 to 10 m per second, corresponding to transmission by A-δ fibers. The inability to retrieve reliable responses at 3 Hz stimulation might potentially be related to less involvement of fast conduction fibers, ie A-β, in afferent sensation along the human lower urinary tract. The value of a more distinct diagnosis of sensory sensation in lower urinary tract disorders must be evaluated in further studies.

Initial experience with the treatment of neurogenic detrusor overactivity with a new β-3 agonist (mirabegron) in patients with spinal cord injury J Wöllner and J PannekStudy design: It is a retrospective chart analysis. Objectives: In patients with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI), neurogenic detrusor overactivity (NDO) can cause both deterioration of the upper urinary tract and urinary incontinence. Antimuscarinic treatment is frequently discontinued due to side effects or lack of efficacy, whereas injection of onabotulinumtoxin into the detrusor is a minimally invasive procedure with risks of urinary retention, infection and haematuria. Mirabegron, a new β-3 agonist, is a potential new agent for treatment of NDO. Aim of the study was to evaluate the efficacy of mirabegron in SCI patients with NLUTD. Setting: Swiss Paraplegic Center, Nottwil, Switzerland. Methods: A retrospective chart analysis of SCI patient treated with mirabegron. Results: Fifteen patients with NDO were treated with mirabegron for a period of at least 6 weeks. Significant reduction of the frequency of bladder evacuation per 24 h (8.1 vs 6.4, P = 0.003), and of incontinence episodes per 24 h (2.9 vs 1.3, P = 0.027) was observed. Furthermore, we observed improvements in bladder capacity (from 365 to 419 ml), compliance (from 28 to 45 ml cm − 1 H 2 0) and detrusor pressure during storage phase (45.8 vs 30 cm H 2 0). At follow-up, 9/15 patients were satisfied with the therapy, 4/15 reported side effects (3 × aggravation of urinary incontinence, 1 × constipation). Conclusions: Mirabegron may evolve as an alternative in the treatment of NDO. We observed improvements in urodynamic and clinical parameters. Due to the limited number of patients and the retrospective nature of the study, prospective, placebo-controlled studies are necessary.

Study design: Retrospective follow-up study. Objectives: To assess the occurrence of bladder stones in patients with spinal cord injury (SCI). Setting: Single SCI rehabilitation center in Switzerland. Methods: We searched our database for SCI patients who had undergone surgery due to bladder stones between 2004 and 2012. In all patients retrieved, personal characteristics, bladder management, bladder stone occurrence and time to stone formation/recurrence were recorded. Results: We identified 93 (3.3%) of 2825 patients with bladder stones, 24 women and 69 men, with a mean age 50 years (17-83) years. We observed bladder stones in patients with suprapubic catheter (SPC) in 11% (50/453), transurethral catheter (TC) in 6.6% (5/75), with intermittent catheterization (IC) in 2% (27/1315) and with reflex micturition (RM) in 1.1% (11/982), respectively. The mean time period to stone development was 95 months. The TC group had the shortest time interval (31 months), followed by the SPC group (59 months), individuals performing IC (116 months) and RM (211 months), respectively. Bladder stone recurrence rate was 23%. Recurrences were most frequent in the TC group (40%), followed by SPC (28%) and IC (22%), whereas no recurrences occurred in the RM group. Time to recurrence was shortest in the SPC group (14 months), followed by the IC (26 months) and the TC group (31 months), respectively. Conclusion: In SCI patients, bladder management has an important role in the development of bladder stones. Indwelling catheters (TC/SPC) are associated with the highest risk to develop bladder stones and therefore should be avoided if possible. If unavoidable, SPC are superior to TC.

Study design: Retrospective investigation. Objectives: To investigate the occurrence, characteristics and clinical consequences of urethral strictures in men with neurogenic lower urinary tract dysfunction (NLUTD) using intermittent catheterization (IC) for bladder evacuation. Setting: Spinal cord injury rehabilitation center. Methods: The patient database was screened for men with NLUTD who had presented for a routine video-urodynamic investigation between 2008 and 2012. Patient characteristics, bladder diary details, the occurrence of urethral strictures and performed urethrotomy procedures were collected from patient charts. Urethral strictures were classified using the Wiegand scoring system modified for men with NLUTD. Results: The occurrence rate of urethral strictures (that is, 25% confidence interval (CI) 21-30%) was significantly (P = 0.0001) higher in men using IC (n = 415) than in men using other bladder evacuation methods (that is, 14% CI 11-17%) (n = 629). Urethral strictures had occurred after a median 5.9 years (range 0.5-48.9 years) of IC. There was no significant (P40.08) effect of tetraplegia or catheter type on the stricture occurrence rate. Approximately one-third of the men suffering from urethral strictures underwent internal urethrotomies. The radiographic stricture severity score was not associated with the need for surgical correction of the stricture. The radiographic recurrence rate of urethral strictures in operated men was 100%, a median 14 years after the first urethrotomy. Conclusions: The occurrence rate of urethral strictures is significantly higher in men using IC than in men using other bladder evacuation methods. Every fourth men using IC may be affected by urethral strictures. However, only every third stricture may require a surgical intervention.

Study design: This is a retrospective chart analysis. Objectives: The objective of this study was to evaluate the effect of sacral neuromodulation (SNM) in patients with neurogenic lower urinary tract dysfunction (NLUTD). Settings: This study was conducted in a spinal cord injury rehabilitation center in Switzerland. Methods: The charts of all patients who underwent SNM (testing and/or permanent implantation) because of NLUTD at our institution between 2007 and 2013 were evaluated. Treatment outcomes and complications were recorded. Results: A total of 50 patients, 30 women and 20 men, with a mean age of 46 (±14) years, fulfilled the inclusion criteria. The most frequent cause for SNM was spinal cord injury in 35 patients (70%). Median duration of the underlying disease was 9.5 (±9.3) years. In all, 35 patients (70%) received a permanent implant. The complication rate was 16% (8/50). At the last follow-up, SNM was in use in 32 patients. In 26 patients with SNM because of detrusor overactivity, voiding frequency per 24 h was significantly reduced from 9 to 6, and daily pad use rate was significantly improved (2.6 versus 0.6 pads per 24h). On comparing urodynamic assessment of detrusor function before and under SNM, no significant suppression of neurogenic detrusor overactivity (NDO) was detected. In nine patients with chronic neurogenic urinary retention, median postvoid residual urine was significantly reduced from 370 to 59 ml. In all, 94% of the patients were either very satisfied or satisfied with SNM. Conclusion: SNM might be an additional therapy option in carefully selected patients with NLUTD. On the basis of our results, urodynamic evaluation before SNM is mandatory, as the procedure does not seem to be suited to significantly alleviate NDO. INTRODUCTIONThe physiological function of the lower urinary tract (LUT) is storage and controlled evacuation of urine. The LUT is controlled by spinal, supraspinal and cerebral networks. 1-3 Because of the complexity of the neural interactions, damage of at least one of the components can cause LUT dysfunction (NLUTD). 4 Depending on the neurologic disease and the location of the lesion, various forms of NLUTD can occur. Depending on the type of dysfunction, NLUTD can affect the upper urinary tract with the risk of renal failure, and it can impair the quality of life. 5,6 Therefore, treatment of NLUTD is not based on symptoms alone, but it should focus on the results of urodynamic testing.Sacral neuromodulation (SNM) is a minimally invasive approach for the treatment of LUT dysfunction. The mechanism of action is not completely clarified, but a central modulation of afferent and efferent signals in the spinal cord and the supraspinal areas seems to have a crucial role. 2 Although the efficacy and safety of SNM in patients with idiopathic LUT dysfunction has been frequently demonstrated, its effectiveness in patients with NLUTD is not well documented. [7][8][9][10] In particular, there is a lack of clinical studies reporting urodynamic results after SNM.The aim of th...

Study Design: Retrospective investigation. Objectives: To investigate the association of patient and injury characteristics with bladder evacuation by indwelling catheterization in patients with chronic neurogenic lower urinary tract dysfunction (NLUTD). Setting: Tertiary urologic referral center. Methods: The patient database was screened for patients with chronic (412 months) NLUTD. Patient characteristics and bladder management details were collected. Binary logistic regression analysis was used to investigate the effects of the investigated factors on bladder evacuation by indwelling catheterization. Results: The data of 1263 patients with a median age of 47 years (range 11-89 years) and a median NLTUD duration of 15.2 years (range 1.0-63.4 years) were investigated. The most common bladder evacuation method was intermittent catheterization (IC; 41.3%) followed by triggered reflex voiding (25.7%), suprapubic catheterization (11.8%), sacral anterior root stimulation (7.3%), spontaneous voiding (7.0%), abdominal straining (5.7%) and transurethral catheterization (1.3%). Female gender, tetraplegia, an age older than 45 years and injury duration were significant (o0.001) predictors of indwelling catheterization. The odds of bladder evacuation by indwelling catheterization were increased~2.5, 3 and 4 times in women, patients older than 45 years and tetraplegics, respectively. Conclusions: IC is the most common bladder evacuation method. However, the majority of individuals with NLUTD are using other evacuation methods, because factors such as functional deficiencies, mental impairment or the social situation are relevant for choosing a bladder evacuation method. Individuals at risk of indwelling catheterization can be identified based on female gender, age, injury severity and injury duration.

BackgroundSacral neuromodulation has become a well-established and widely accepted treatment for refractory non-neurogenic lower urinary tract dysfunction, but its value in patients with a neurological cause is unclear. Although there is evidence indicating that sacral neuromodulation may be effective and safe for treating neurogenic lower urinary tract dysfunction, the number of investigated patients is low and there is a lack of randomized controlled trials.Methods and designThis study is a prospective, randomized, placebo-controlled, double-blind multicenter trial including 4 sacral neuromodulation referral centers in Switzerland. Patients with refractory neurogenic lower urinary tract dysfunction are enrolled. After minimally invasive bilateral tined lead placement into the sacral foramina S3 and/or S4, patients undergo prolonged sacral neuromodulation testing for 3–6 weeks. In case of successful (defined as improvement of at least 50% in key bladder diary variables (i.e. number of voids and/or number of leakages, post void residual) compared to baseline values) prolonged sacral neuromodulation testing, the neuromodulator is implanted in the upper buttock. After a 2 months post-implantation phase when the neuromodulator is turned ON to optimize the effectiveness of neuromodulation using sub-sensory threshold stimulation, the patients are randomized in a 1:1 allocation in sacral neuromodulation ON or OFF. At the end of the 2 months double-blind sacral neuromodulation phase, the patients have a neuro-urological re-evaluation, unblinding takes place, and the neuromodulator is turned ON in all patients. The primary outcome measure is success of sacral neuromodulation, secondary outcome measures are adverse events, urodynamic parameters, questionnaires, and costs of sacral neuromodulation.DiscussionIt is of utmost importance to know whether the minimally invasive and completely reversible sacral neuromodulation would be a valuable treatment option for patients with refractory neurogenic lower urinary tract dysfunction. If this type of treatment is effective in the neurological population, it would revolutionize the management of neurogenic lower urinary tract dysfunction.Trial registrationTrial registration number:http://www.clinicaltrials.gov; Identifier: NCT02165774.