Study design: Laboratory investigation using serial slow-®ll cystometrograms. Objectives: To examine the acute e ects of di erent modes of dorsal penile nerve stimulation on detrusor hyperre¯exia, bladder capacity and bladder compliance in spinal cord injury (SCI). Setting: Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. Methods: Fourteen SCI patients were examined. Microtip transducer catheters enabled continuous measurement of anal sphincter, urethral sphincter and intravesical pressures. Control cystometrograms were followed by stimulation of the dorsal penile nerve at 15 Hz, 200 ms pulse width and amplitude equal to twice that which produced a pudendo-anal re¯ex. Stimulation was either continuous or in bursts of one minute triggered by a rise in detrusor pressure of 10 cm water (conditional). Further control cystometrograms were then performed to examine the residual e ects of stimulation. Results: Bladder capacity increased signi®cantly during three initial control ®lls. Continuous stimulation (n=6) signi®cantly increased bladder capacity by a mean of 110% (+Standard Deviation 85%) or 173 ml (+146 ml), and bladder compliance by a mean of 53% (+31%). Conditional stimulation in a di erent group of patients (n=6) signi®cantly increased bladder capacity, by 144% (+127%) or 230 ml (+143 ml). In the conditional neuromodulation experiments, the gap between suppressed contractions fell reliably as bladder volume increased, and the time from start of stimulation to peak of intravesical pressure and 50% decline in intravesical pressure rise was 2.8 s (+0.9 s) and 7.6 s (+1.0s) respectively. The two methods of stimulation were compared in six patients; in four out of six conditional neuromodulation resulted in a higher mean bladder capacity than continuous, but the di erence was not signi®cant. Conclusions: Both conditional and continuous stimulation signi®cantly increase bladder capacity. The conditional mode is probably at least as e ective as the continuous, suggesting that it could be used in an implanted device for bladder suppression. Spinal Cord (2001) 39, 420 ± 428

We report on the clinical outcome and satisfaction survey of long-term suprapubic catheterisation in patients with neuropathic bladder dysfunction. Between early 1988 and later 1995, 185 suprapubic catheters were inserted under direct cystoscopic vision. Anticholinergic therapy was given to all patients with signi®cant detrusor hyper-re¯exia; the catheters clamped daily for two hours and changed every six weeks. Ultrasonography and assessment of the serum creatinine were used to assess the upper renal tracts, and the results of the pre-and post-catheter video-cystometrography was used to evaluate bladder morphology, cystometric capacity, maximum detrusor pressure and the presence of vesico-ureteric re¯ux. There were equivalent numbers of males and females. The follow-up ranges from 3 ± 68 months. Following catheterisation, there was a 50% reduction in the average maximum detrusor pressure, bladder morphology improved in 85% of the cases; the bladder capacity and upper renal tracts remained unchanged. Vesico-ureteric re¯ux was abolished in 33% of the cases. Complaints were common consisting of recurrent catheter blockage, persistent urinary leakage and recurrent urinary tract infections. There was a 2.7% incidence of small bowel injury with one fatality. However, the general level of satisfaction was high. It is concluded that suprapubic catheterisation is an e ective and well tolerated method of management in selected patients with neuropathic bladder dysfunction for whom only major surgery would otherwise provide a solution to incontinence. We are encouraged to ®nd preservation of renal function with maintained bladder volumes and reduced maximum detrusor pressures thus justifying the policy of catheter clamping and anti-cholinergic therapy in the presence of signi®cant detrusor hyper-re¯exia. However, even in expert hands this procedure is not without hazards.

Study design: Investigation of ®ve patients receiving an implant, using laboratory cystometry and self-catheterisation at home. Objectives: To use the established Finetech-Brindley sacral root stimulator to increase bladder capacity by neuromodulation, eliminating the need for posterior rhizotomy, as well as achieving bladder emptying by neurostimulation. Setting: Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. Methods: Five patients underwent implantation of a Finetech-Brindley stimulator without rhizotomy of the posterior roots. This was either a two channel extradural device (four cases) or a three channel intrathecal device (one case). In each patient, the implant was con®gured as a Sacral Posterior and Anterior Root Stimulator (SPARS). Postoperatively, repeated provocations using rapid instillation of 60 ml saline were used to determine the relative thresholds for neuromodulation using each channel. The eect of continuous neuromodulation was examined in the laboratory using slow ®ll cystometrograms, and conditional stimulation was also studied (neuromodulation for 1 min to suppress hyperre¯exic contractions as they occurred). In one patient, neuromodulation was applied continuously at home, and volumes at self catheterisation recorded in a diary. Results: Re¯ex erections were preserved in each patient. In three patients, detrusor hyperre¯exia persisted postoperatively and neuromodulation via the implant was studied. In these three patients, the con®guration was: S2 mixed roots bilaterally (channel B), and S34 bilaterally (channel A). Both channels could be used to suppress provoked hyperre¯exic contractions, with the S2 channel eective at a shorter pulse width than S34 in a majority of cases. Continuous stimulation more than doubled bladder capacity in two out of three patients during slow ®ll cystometry. Conditional stimulation was highly eective. In the one patient who used continuous stimulation at home, bladder capacity was more than doubled and the eect was comparable with anticholinergic medication. Bladder pressures 470 cm water could be achieved with intense stimulation in three patients, but detrusor-external urethral sphincter dyssynergia (DSD) prevented complete emptying. Conclusions: Neuromodulation via a SPARS was eective and may replace the need for posterior rhizotomy. However, persisting DSD may prevent complete bladder emptying and warrants further investigation.

In this section, many different issues are written about by authors from the UK, France, the Netherlands, the USA and Denmark, respectively. Topics covered are botulinum toxin in drug‐resistant neurogenic detrusor overactivity in spinal cord injury, dutasteride and BPH, the effect of childbirth on bothersome LUTS, female urethral strictures, and a new bulking agent in treating female stress urinary incontinence. OBJECTIVES To assess, in a prospective study, whether botulinum toxin‐type A (BTX‐A) injected into the detrusor muscle, can be used as a day‐case treatment for drug‐resistant neurogenic detrusor overactivity (NDO) in patients with spinal cord injury (SCI). PATIENTS AND METHODS BTX‐A (Dysport, Ipsen, Luxembourg; 1000 units) was injected cystoscopically into the detrusor muscle of 37 patients with drug‐resistant NDO and SCI, as a day‐case procedure. The maximum cystometric capacity (MCC), maximum detrusor pressure (MDP), NDO, continence, and anticholinergic requirement were used as outcome variables. The International Consultation on Incontinence questionnaire (ICIQ) was used to assess the patient’s quality of life before and after the BTX‐A injection. RESULTS The mean follow‐up was 7 months. The MCC increased from a mean of 259 to 522 mL, and the MDP decreased from a mean of 54 to 24 cmH2O. Incontinence and NDO were abolished in 82% and 76% patients, respectively. In all, 86% of the patients were able to stop or reduce anticholinergics, with a similar proportion of patients scoring favourably on the ICIQ. The mean duration of improvement was 9 months. CONCLUSIONS Injection with BTX‐A is an effective day‐case treatment that bridges the gap between oral and invasive surgical treatment of drug‐resistant NDO in patients with SCI.

Objective To investigate the acute effects of functional Results Following FMS there was an obvious acute suppression of detrusor hyper-reflexia. There was a magnetic stimulation (FMS) on detrusor hyper-reflexia using a multi-pulse magnetic stimulator.profound reduction in detrusor contraction, as assessed by the area under the curves of detrusor Patients and methods Seven male patients with established and intractable detrusor hyper-reflexia following pressure with time. Conclusions Functional magnetic stimulation applied spinal cord injury were studied. No patient was on medication and none had had previous surgery for over the sacrum can profoundly suppress detrusor hyper-reflexia in man. It may provide a non-invasive detrusor hyper-reflexia. After optimization of magnetic stimulation of S2-S4 sacral anterior roots by recording method of assessing patients for implantable electrical neuromodulation devices and as a therapeutic option toe flexor electromyograms, unstable detrusor activity was provoked during cystometry by rapid infusion of in its own right. Keywords Detrusor hyper-reflexia, neuromodulation, fluid into the bladder. The provocation test produced consistent and predictable detrusor hyper-reflexia. On functional magnetic stimulation some provocations, supramaximal FMS at 20 pulses/s for 5 s was applied at detrusor pressures which were >15 cmH 2 0.renal failure was the commonest late cause of death

OBJECTIVE To review the outcomes of all patients referred with vesico‐vaginal (V VF) and urethro‐vaginal (UVF) fistulae to a tertiary centre, and to investigate the patient, fistula and surgical factors relevant to success. PATIENTS AND METHODS We reviewed retrospectively the case‐notes of 41 consecutive patients (32 with V VF; nine with UVF) treated between January 2000 and January 2006. RESULTS All patients were tertiary referrals, eight after failed local repairs. Four patients were unsalvageable and had a supravesical diversion. In all there were 47 repairs (23 transvaginal; 24 transabdominal) on 37 patients by two specialist surgeons. The fistula was closed in 92%; five V VF and one UVF required a second procedure, and one V VF a third procedure. One patient with a V VF awaits a second attempt at repair. In one V VF (one attempt) and one UVF (three attempts) the procedure failed and the patient had a diversion. A transvaginal approach cured all 11 patients with a V VF and eight of nine with a UVF, whilst an abdominal approach used for larger/complex fistulae was successful in 18 of 24 (75%) attempts (P = 0.13). The major determinants of success were fistula size (>3 cm; P = 0.02) and the availability of tissue for interposition. V VF repairs using Martius/omental interposition were mostly successful, whilst abdominal repairs in which omentum was unavailable tended to fail (37.5% cure; P = 0.002). CONCLUSIONS Despite varied aetiology, V VF/UVF were repaired successfully in 92% of patients. Complex (V VF) fistulae were challenging and a quarter of these required more than one attempt. Failure of repair was more likely in larger fistulae (>3 cm) requiring an abdominal approach, if omental interposition was not possible. Good‐quality tissue interposition for complex fistula is essential for a successful outcome.

This double-blind, placebo controlled, crossover study provides evidence of the efficacy of botulinum toxin B in the treatment of overactive bladder. Autonomic side effects were observed in 4 patients. The short duration of action will presumably limit the use to patients who have experienced tachyphylaxis with botulinum toxin A.

Sixty-one male patients with urodynamically proven outflow obstruction took part in a study of phenoxybenzamine (PBZ), the initial phase of which was double-blind (41 patients). The double-blind phase of the trial showed an overall symptomatic improvement in the PBZ patients. The symptoms of slow stream and hesitancy were significantly improved. The urethral pressure profile features of prostatic plateau height and prostatic plateau area were significantly decreased in the PBZ group. Dizziness was the commonest side effect of PBZ but was well tolerated by most patients. This study shows that PBZ has an effect on bladder outflow obstruction by reducing pressure in the proximal urethra and that the drug has a place in the management of patients with symptoms attributable to such obstruction, especially where operative treatment has to be delayed.