DETRUSOR EXTERNAL SPHINCTER DYSSYNERGIA Sphincterotomy OR Stent? Saleh A.A.Binsaleh

DESD-Background Defined as involuntary external urethral sphincter contractions during involuntary detrusor contractions. These results in a high bladder pressure with subsequent back pressure effects. The rate of urological complications from DESD with no intervention is 50% These include: sepsis,hydronephrosis,VUR,nephrolithiasis,renal insufficiency and even failure.

Treatment Options Current treatment options aim to minimize intravesical pressure and its detrimental effect on the upper urinary tract. These includes: 1-Chronic indwelling catheterization. 2-Intermittent self catheterization. 3-Pharmacological therapy. 4-Bladder reconstruction and urinary diversion.

Treatment Options (cont.) 5-External sphincterotomy. 6-Urolume stent. 7-Sphincter ablation with Botulinum toxin inj. 8-Intrathecal continous baclofen infusion. 9-Balloon dilatation. 10-Laser sphincter ablation.

External Sphincterotomy A surgical incision into the sphincter muscle to open it, then urine drains out and collected by condom drainage. Unfortunately,the female anatomy does not allow for condom drainage as an alternative. Usually requires a few days of hospital admission.

External Sphincterotomy (cont.) Complications include: 1- Reoperation in 12-26% of cases. 2- Hemorrhage requiring transfusion in 5-23% of cases. 3- Erectile dysfunction (complete or partial) in 3-64% of cases. 4- Irreversible.

The Urolume It is a metal flexible mesh prosthesis, that is inserted into the urethra and placed over the external sphincter, holding it open with a constant force. Over a few months, a layer of tissue grows over the wall of the Urolume making a smooth, open passageway to allow urine to pass freely. Large lumen(42F) allowing. Can be done as an outpatient bases. Minimal bleeding over 2-3 days.

The Urolume (cont.) Potentially reversible. 10 % rejection rate. (uncovered Urolume need to be removed). Stenosis in 3%. Best candidates for this procedure are individuals who have strong detrusor contractions and good emptying under high pressure.But in patient with borderline bladder pressure, the emptying may not be adequate and I.C. might be necessary 1-2 times daily.

The Urolume (cont.) Patients with previous sphincterotomy are not suitable for Urolume stent because the scar tissue at the site of the sphincterotomy does not allow the epithelial tissues to cover the Urolume properly.

The Urolume (cont.)

Sphincterotomy vs. Stent Review Long term follow up in external urethral sphincterotomy. -YANG et al. University of Washington. -neurourology urody. Journal male spinal cord injury pts underwent sphincterotomy from operations were failure. -19 operations were successful. -reoperation rate was 32% *the external sphincterotomy even in appropriately selected pts, can have a high failure rate over time.

Review (cont.) Is sphincterotomy the best management of the spinal cord injured bladder. -VAPNEK et al. University of California. -J.of urology reviewed 16 cases of sphincterotomy done over 8 years period. -8/16 still manage the bladder with a condom catheter,while 8 have an indwelling suprapubic tube. Reasons? * Sphincterotomy is generally effective in decreasing outlet resistance and voiding efficiency initially but careful pts selection and long term follow up are necessary.

Review (cont.) Urolume stent in treatment of DSD. -JUMA et al. University of California. -J. paraplegia experience with 10 patients. *insertion technique was simple, short hospitality, and low morbidity. However long term safety not yet established.

Review (cont.) Long term follow up of the North American multicenter Urolume trial for treatment of DSD. -CHANCELLOR et al. University of Pittsburgh,Pennsylvania. -J. of urology, cases spinal cord injured pts follow up for 5 years. *Urolume stent demonstrates long term safety and efficacy for treatment of DSD.

-mean voiding pressure decrease from 75 cm.water pre treatment up to 44.2 at 5 years. -residual urine volume decreased. -bladder capacity remained constant. -hydronephrosis and autonomic dysreflexia improved or stabilized in most patients.

Review (cont.) Prospective comparison of external sphincter prosthesis and external sphincterotomy in men with spinal cord injury. -RIVAS et al, Thomas Jefferson University, Philadelphia. -J. endourology * The sphincter prosthesis is as effective as sphincterotomy in the treatment of DSD, while being technically easier, less morbid and less expensive.

Review (cont.) Sphincteric stent versus external sphincterotomy in spinal cord injured men. Prospective randomized multicenter trial. -CHANCELLOR et al, University of Pittsburgh, Pennsylvania. -J.of urology, men with spinal cord injury and urodynamics verified EDSD divided into two groups - parameters taken including: maximum detrusor pressure, bladder capacity, PVR urine volume, pre and post op. till two years.

* The Urolume stent is as effective as conventional external sphincterotomy for treating EDSD. However, stent placement is advantageous because it involves shorter hospitalization and is potentially reversible.

Conclusion -The Urolume stent is as effective as traditional sphincterotomy. -Less side effects. -Reversible.

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