Diagnóstico.

duced in 1989 by two separate research teams, one concentrating on children, and the other on adults. The treatment is intended to allow the bladder to enlarge when the functional capacity is reduced by detrusor overactivity or low compliance, in patients with neuropathology, who are refractory to anticho- linergic medication. Patients have been followed for up to ten years [49, 50].

In this technique, a large part of the detrusor muscle is excised, leaving the mucosa intact and thereby creating an “artificial diverticulum”. As a result the emptying contraction is reduced, and thus patients must use intermittent catheterisation.

Bladder enlargement following detrusorectomy

develops relatively slowly, taking about 1-2 years. During this period medical treatment with anticholi- nergics (mostly in a much lower dose then before surgery) may be beneficial [51]. Occasionally, late reduction of capacity, caused by fibrosis, has been reported. Securing omentum to cover the serosal side of the mucosa after the detrusorectomy has been des- cribed to avoid this. However, results do not confirm that this maneuver makes any difference [52 to 54]. A study on 62 adult patients with various neuropa- thies (about 75% traumatic spinal cord injury) and a minimum follow-up of 2 years has been reported [55]. The average follow-up was two and a half years. The only complication noted was intra-opera- tive mucosal perforation in one third of patients. Fol- lowing the procedure, most patients required no or significantly reduced anticholinergic use. Sixteen failures were reported: In those patients who respon- ded well to auto-augmentation, most reported a much better quality of life (LOE 4).

It has been suggested that this procedure may be used prior to enterocystoplasty and would not pre- clude the use of this modality if required later. It is of interest however, that there have not been any reaso- nable studies on the use of this technique in adult neurologic patients, since 1999 and also that this technique has not achieved wide acceptance in prac- tise.

c) Denervation or neurologic decentralization tech- niques

Historically many techniques have been used and described in the literature to try and convert the ove- ractive neurologic bladder (upper motor neuron lesion) to an underactive bladder (lower motor neu- ron lesion). These methods will be briefly described. In general they are rarely used now because of poor long-term results, and significant complications. • Bladder distention (Helmstein’s technique): suc- cessful outcome of up to 70% has been reported. This has never been reproduced in the long term and the occasional reports of bladder rupture have dis- couraged the establishment of this technique [56]. • Cystolysis:mostly used for the treatment of inter-

Conclusions

• Alternatives to enteroplasty have been little documented. Some data exist on auto-aug- mentation but these are also limited and evi- dence remains low (LOE 4)

Recommendation

• Enterocystoplastie has passed the test of time in achieving a low pressure reservoir but complications and reinterventions are common (Grade C)

stitial cystitis and other sensory conditions, with a few series including patients with hyperreflexic neu- rologic bladder. Short term results reported as good, but no long term results available. The late compli- cation of bladder contracture in 10% has precluded its further use [57].

• Inglemann Sundberg procedure: transvaginal denervation has been used in patients with overacti- ve bladder with some short term success. Series are all relatively small and there is no experience of this technique in the neurologic population [58].

• Bladder transection:various techniques have been described ranging from circumferential incision to an endoscopic supratrigonal technique. Patients in these small series were generally suffering from detrusor overactivity (non-neurologic) or had senso- ry disorders (interstitial cystitis) [59].

• Subtrigonal injection:the logical extension of the above was the use of phenol or alcohol injected trans-trigonally to effect a denervation of the blad- der. Little experience is reported in neuropaths and effects were usually short lived. The occasional com- plication of fistula formation has further doomed these procedures to the ‘history’ books [60].

• Sacral rhizotomy: Of all the techniques used to denervate the hyperreflexic bladder, sacral rhizoto- my has achieved the best success. In most series, pre- sently, it is combined with implantation of sacral anterior root stimulator. In this way the hyperreflexia is significantly reduced and functional bladder capa- city is increased [6, 7, 9, 10]. The stimulator allows the patient to empty the bladder without resorting to catheterisation. The rhizotomy also reduces the development of sphincter dyssynnergia during ante- rior root stimulation.

Rhizotomy is conventionally performed via a limited lumbo-sacral laminectomy to expose S2-S4 nerve roots bilaterally (L4/5- S1/2). Visual magnification and continuous cystometry aid identification of the appropriate nerve roots. The nerves that evoke an adequate detrusor contraction when stimulated are selected and severed.

Complications frequently referred to are fecal incon- tinence and erectile dysfunction. The latter may be overcome by using the anterior root stimulator for this purpose. Fecal incontinence is rarely reported in published series [7, 8, 10, 61] (LOE 4).

Recent developments focus on techniques to reversi- bly block the posterior roots during stimulation so that formal rhizotomy can be avoided.

d) Sacral nerve stimulation / neuromodulation. Suppressing detrusor overactivity using a neuromo- dulation approach has been in the development stage for many years. Presently several clinical studies are available to demonstrate the efficacy of this techno- logy. Unfortunately there are no good studies on its use in the neurologic bladder patient. The exact mechanism, by which sacral nerve stimulation inhi- bits bladder contraction, is not fully understood. However it is thought that sacral nerve stimulation induces reflex mediated inhibitory effects on the detrusor through afferent and or efferent stimulation of the sacral nerves. In addition, activation of the pel- vic floor muscles may occur via stimulation of the somatic fibers of the nerves, causing further detrusor inhibition [62].

The technique of initial percutaneous nerve stimula- tion to assess efficacy, followed by surgical implan- tation of the sacral nerve stimulator is well known. Several reasonable clinical studies are available sho- wing significant reduction in incontinence episodes etc. Unfortunately, as stated, the majority of patients in these studies, suffered from refractory urge incon- tinence, and those with neurological conditions were specifically excluded. Complications of the tech- nique included pain at implant site, infection, change in bowel habit and technical problems including lead migration [63].

This technique is certainly a promising development in a difficult group of patients. Technical details still need to be improved and results are mixed [64, 65]. In this most recent report [65] only 8 out of 12 implanted patients had any therapeutic benefit, for a maximum of 96 months for 7 of them. The compli- cation rate was high with side effects in 4 and early removal in 1. It remains to be seen if this will be appropriate for neurologic patients. (LOE 4)

Conclusions

• In general, surgical intervention to decrease detrusor contractility should only be used when all conservative measures have failed. • Choice of intervention at present will depend

on many factors including the underlying pathogenesis of the condition, its natural his- tory, the patients’ mobility, motivation, age and home support to name the most signifi- cant.

• Although augmentation cystoplasy gives the most reproducible results its complication rate is still relatively high.

2. S