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651Results of sacral root neuromodulation in neurogenic voiding dysfunction
649 N E U R O G E N I C BLADDER TREATMENT BY PERMISSIBLE ANTICHOLINERG1C DOSAGE
DOUBLING
THE
650 P E R I P H E R A L NEUROPATHY INCONTINENCE
IN
FEMALE
STRESS
URINARY
Pinggera G.M., Rehder E, Gozzi C., Herwig R., Bektic J., Spranger R., Strasser H., Bartsch G.
Horstmann M. Schaefer T., Aguilar Y., Stenzl A., Sievert K.D. University Hospital, Urology, Tuebingen, Germany
Medical University Innsbruck, Department of Urology, Innsbruck, Austria
INTRODUCTION & OBJECTIVES: Patients with neurogenic bladder and suffering with urgency incontinence were initially treated with the recommended dosage of an anticholinergic drug. If tolerated, without any or reasonable side effects and without the aspired effect, the dosage was increased. The tolerability and the success of the higher than recommended dosage of the drug was evaluated. MATERIAL & METHODS: Of the 21 patients (9 women, 12 men) 17 had spinal cord injury, 3 had multiple sclerosis and t had meningomyelocele. The patients were either treated with Tolterodin extended release or Yrospiumchloride. The initial dosage was with 1 x 4 mg of Tolterodin extended release and Trospiumchloride (3 x 15 rag). If well tolerated and there was still sign of bladder overactivity, the dosage was increased to a maximum of Tolterodin extended release (2x4 mg (n=l 1)) or Trospiumchloride (3x30 mg (n=10)). The follow-up was monitored by a voiding/catheter diary and urodynamic evaluation as well as noted new or increased side effects. When side effects increased or the bladder overactivity was not sufficiently suppressed, the therapy was stopped.
INTRODUCTION & OBJECTIVES: Urogenital neuropathy has not been considered so far to play a major role in female stress incontinence. It was our aim to assess and quantify genital neural function in patients with stress incontinence in order to provide the basis for new diagnostic approaches. MATERIAL & METHODS: This pilot study included 15 female patients (mean age: 53.1 years; range: 34 to 80 y) with stress incontinence (11 grade lI, 4 grade III). 11/15 patients had a history of up to 4 vaginal deliveries, 5 patients had undergone hysterectomy and 10 patients had up to 6 previous pelvic operations including anti-incontinence procedures. Thorough physical examination, perineal ultrasound, videourodynamics, cystoscopy, cough stress test and genital neurosensory evaluation were performed. To quantify suspected genitourinary neuropathic malfunction, repeated genital sensory testing with a thermal/vibratory Genital Sensory Analyzer system (TSA-3000 and VSA-3000 GSA, Medoc, Israel) was performed-starting at 37 ° C (maximum: 50°C;minimum: 20°C) at the site of the anterior vaginal wall. Vibratory sensation was provoked with a second internally rotating probe (with a constant frequency of 100 MHz and increasing amplitude from 0.5 gm to 25 gin).
RESULTS: With a mean follow-up of 7 months (4-18 months), 16 patients had a significant decrease in incontinence episodes (from 8-12 before treatment to 0-2 after treatment). The reflex volume increased from 140+/-30 to 350+/-40. The bladder capacity enlarged from 170+/-30 to 370+/-40. Five patients (3 with Trospiumchloride, 2 with Yolterodin) did not demonstrate any satisfactory benefit. One patient treated with Tolterodin experienced side effects and stopped the taking of the drug.
RESULTS: The mean perceived warm sensation level was 48.6 °C (SD 2.92) in the subjects, compared to the mean value of 37.6 °C (SD 0.05) in 89 healthy volunteers reported in a previous study. The calculated p value was statistically significant (p = 0.048). Cold perception at 22.9 °C (SD 4.9) was lower in comparison to 34.4 °C in healthy volunteers (p = 0.017). Assessment of vibratory perception showed altered sensibility (mean value: 20.5), whereas in the healthy controls the range was 7 to 12.
CONCLUSIONS: An increased dosage of Tolterodin or Trospiumchloride is an effective treatment in patients with neurogenic bladder. In our experience, an 8 mg dosage of Tolterodin extended release is slightly more effective than Trospiumchloride (90 rag). Most patients tolerated the dosage well and reported no or only a moderate increase of side effects.
CONCLUSIONS: The present pilot study demonstrates the presence of severe vaginal neuropathy (altered vaginal, thermal and vibratory sensibility) in incontinent females irrespective of the number or method of previous pelvic operative procedures suggesting a neuropathological cause of this disorder. Ongoing studies will determine the feasibility and utility of GSA measurement as a non-invasive diagnostic procedure.
651
652
RESULTS OF SACRAL ROOT NEUROMODULATION IN NEUROGENIC VOIDING DYSFUNCTION
SACRAL NERVE STIMULATION: "TWO-STAGE-IMPLANTATION" VS. "CONVENTIONAL" PERIPHERAL NERVE EVALUATION
Gain6 X., Sarramon J.E, Mallet R., Mouzin M., Berrogain N., Malavaud B., Rischmann E
Bannowsky A., Wefer B., B6hler G., Seif C., Jfinemann K.E, Braun EM.
CHU de Toulouse, Urology, Toulouse, France
INTRODUCTION & OBJECTIVES: Prior to implantation of a chronicle sacral neurostimulator, it is important to establish which patients might profit from this kind of therapy in order to ensure, by means of a PNE (peripheral nerve evaluation) test, that the implantation of a permanent stimulating device is effective. In a retrospective study we compared the two different techniques used in our department (implantation of the permanent neurostimulation electrodes so-called "two-stage-implantation" vs. conventional PNE).
INTRODUCTION & OBJECTIVES: To assess the results of sacral root neuromodulation in neurogenic voiding dysfunction. MATERIAL & METHODS: Between January 1998 and March 2004, a stimulation test was performed in 23 patients, 17 women, 6 men, with neurogenic voiding dysfunction. The mean age was 47.4 4- 13.5 years. The neurologic disease was a multiple sclerosis in 6 cases, an incomplete spiual cord injury in 5 cases, a peripheral neuropathy in 3 cases, a Canda equina syndrome in 2 cases, an encephalomyelitis in 2 cases, a Parkinson disease in 2 cases, a myelitis in 1 case, a Brown-Sequard syndrome in 1 case and a head trauma in 1 case. The urinary symptoms were an overactive bladder in 15 cases and a chronic urinary retention in 8 cases. A detrusor-sphincter dyssynergia was associated in 7 cases. Before and during the stimulation test, each patient had had an urodynamic evaluation and had performed a voiding diary. The test was considered as positive if the patients were improved of more than 70%. After implantation, the patients were reviewed at 1 month and every 6 months. RESULTS: Out of the 23 patients, the test was considered as positive in 16 (69%) patients. Fourteen were implanted. With a mean follow-up of 34.9 i 25.2 months, the patients were cured in 11 (79%) cases and not cured in 2 cases. The implant has been removed for infection in 1 case. The electrode was changed in two cases, for displacement in 1 case and section in 1 case. Out of the 2 patients who were not cured, the failure was related to a new attack of a multiple sclerosis in one case. CONCLUSIONS: Sacral root neuromodulation is an effective treatment of neurogenic voiding dysfunction.
University Hospital Schleswig-Holstein, Campus Kiel, Urology, Kiel, Germany
MATERIAL & METHODS: We performed a sacral nerve stimulation in 53 patients (mean age: 49.7 yrs (14-75 yrs); 31 with neurogenic or ideopathic urinary retention, 13 with a hyperactive detrusor and 9 with sensory urge or pelvic pain) over a minimum of 5 days. In 42 patients we performed a conventional PNE, 11 patients received "two-stage-implantation" with implantation of the permanent electrodes. RESULTS: 52 of 53 patients received bilateral test stimulation (9% at $2, 91% at $3). One patient underwent unilateral PNE ($3) because of anatomical deformity of the os sacrum. In 20 cases the conventional PNE-test (cPNE) was successful according to standard criteria (47.6% of all cPNE). 12 of these patients suffered from a neurogenic bladder dysfunction, in 8 cases the causes were idiopathic; 9 patients suffered from retention, 7 from overactive bladder symptoms and 4 patients from sensory urge or pelvic pain. The response rate of "two-stageimplantation" with implantation of the permanent electrodes was 81.8% (9 of 11 patients). 7 patients with neurogenic and 2 with idiopathic bladder dysfunction; 3 patients suffered from retention, 4 from overactive bladder symptoms and 2 patients from sensory urge. CONCLUSIONS: Success rate of implantation of permanent neurostimulation electrodes in selecting patients for the permanent implant is significantly higher than the conventional PNE. In this group patients with neurogenic and overactive bladder dysfunctions showed the highest response rates to sacral nerve stimulation and are the most likely to benefit from sacral neuromodulation.
European Urology Supplements 4 (2005) No. 3, pp. 165
DOUBLING
THE
650 P E R I P H E R A L NEUROPATHY INCONTINENCE
IN
FEMALE
STRESS
URINARY
Pinggera G.M., Rehder E, Gozzi C., Herwig R., Bektic J., Spranger R., Strasser H., Bartsch G.
Horstmann M. Schaefer T., Aguilar Y., Stenzl A., Sievert K.D. University Hospital, Urology, Tuebingen, Germany
Medical University Innsbruck, Department of Urology, Innsbruck, Austria
INTRODUCTION & OBJECTIVES: Patients with neurogenic bladder and suffering with urgency incontinence were initially treated with the recommended dosage of an anticholinergic drug. If tolerated, without any or reasonable side effects and without the aspired effect, the dosage was increased. The tolerability and the success of the higher than recommended dosage of the drug was evaluated. MATERIAL & METHODS: Of the 21 patients (9 women, 12 men) 17 had spinal cord injury, 3 had multiple sclerosis and t had meningomyelocele. The patients were either treated with Tolterodin extended release or Yrospiumchloride. The initial dosage was with 1 x 4 mg of Tolterodin extended release and Trospiumchloride (3 x 15 rag). If well tolerated and there was still sign of bladder overactivity, the dosage was increased to a maximum of Tolterodin extended release (2x4 mg (n=l 1)) or Trospiumchloride (3x30 mg (n=10)). The follow-up was monitored by a voiding/catheter diary and urodynamic evaluation as well as noted new or increased side effects. When side effects increased or the bladder overactivity was not sufficiently suppressed, the therapy was stopped.
INTRODUCTION & OBJECTIVES: Urogenital neuropathy has not been considered so far to play a major role in female stress incontinence. It was our aim to assess and quantify genital neural function in patients with stress incontinence in order to provide the basis for new diagnostic approaches. MATERIAL & METHODS: This pilot study included 15 female patients (mean age: 53.1 years; range: 34 to 80 y) with stress incontinence (11 grade lI, 4 grade III). 11/15 patients had a history of up to 4 vaginal deliveries, 5 patients had undergone hysterectomy and 10 patients had up to 6 previous pelvic operations including anti-incontinence procedures. Thorough physical examination, perineal ultrasound, videourodynamics, cystoscopy, cough stress test and genital neurosensory evaluation were performed. To quantify suspected genitourinary neuropathic malfunction, repeated genital sensory testing with a thermal/vibratory Genital Sensory Analyzer system (TSA-3000 and VSA-3000 GSA, Medoc, Israel) was performed-starting at 37 ° C (maximum: 50°C;minimum: 20°C) at the site of the anterior vaginal wall. Vibratory sensation was provoked with a second internally rotating probe (with a constant frequency of 100 MHz and increasing amplitude from 0.5 gm to 25 gin).
RESULTS: With a mean follow-up of 7 months (4-18 months), 16 patients had a significant decrease in incontinence episodes (from 8-12 before treatment to 0-2 after treatment). The reflex volume increased from 140+/-30 to 350+/-40. The bladder capacity enlarged from 170+/-30 to 370+/-40. Five patients (3 with Trospiumchloride, 2 with Yolterodin) did not demonstrate any satisfactory benefit. One patient treated with Tolterodin experienced side effects and stopped the taking of the drug.
RESULTS: The mean perceived warm sensation level was 48.6 °C (SD 2.92) in the subjects, compared to the mean value of 37.6 °C (SD 0.05) in 89 healthy volunteers reported in a previous study. The calculated p value was statistically significant (p = 0.048). Cold perception at 22.9 °C (SD 4.9) was lower in comparison to 34.4 °C in healthy volunteers (p = 0.017). Assessment of vibratory perception showed altered sensibility (mean value: 20.5), whereas in the healthy controls the range was 7 to 12.
CONCLUSIONS: An increased dosage of Tolterodin or Trospiumchloride is an effective treatment in patients with neurogenic bladder. In our experience, an 8 mg dosage of Tolterodin extended release is slightly more effective than Trospiumchloride (90 rag). Most patients tolerated the dosage well and reported no or only a moderate increase of side effects.
CONCLUSIONS: The present pilot study demonstrates the presence of severe vaginal neuropathy (altered vaginal, thermal and vibratory sensibility) in incontinent females irrespective of the number or method of previous pelvic operative procedures suggesting a neuropathological cause of this disorder. Ongoing studies will determine the feasibility and utility of GSA measurement as a non-invasive diagnostic procedure.
651
652
RESULTS OF SACRAL ROOT NEUROMODULATION IN NEUROGENIC VOIDING DYSFUNCTION
SACRAL NERVE STIMULATION: "TWO-STAGE-IMPLANTATION" VS. "CONVENTIONAL" PERIPHERAL NERVE EVALUATION
Gain6 X., Sarramon J.E, Mallet R., Mouzin M., Berrogain N., Malavaud B., Rischmann E
Bannowsky A., Wefer B., B6hler G., Seif C., Jfinemann K.E, Braun EM.
CHU de Toulouse, Urology, Toulouse, France
INTRODUCTION & OBJECTIVES: Prior to implantation of a chronicle sacral neurostimulator, it is important to establish which patients might profit from this kind of therapy in order to ensure, by means of a PNE (peripheral nerve evaluation) test, that the implantation of a permanent stimulating device is effective. In a retrospective study we compared the two different techniques used in our department (implantation of the permanent neurostimulation electrodes so-called "two-stage-implantation" vs. conventional PNE).
INTRODUCTION & OBJECTIVES: To assess the results of sacral root neuromodulation in neurogenic voiding dysfunction. MATERIAL & METHODS: Between January 1998 and March 2004, a stimulation test was performed in 23 patients, 17 women, 6 men, with neurogenic voiding dysfunction. The mean age was 47.4 4- 13.5 years. The neurologic disease was a multiple sclerosis in 6 cases, an incomplete spiual cord injury in 5 cases, a peripheral neuropathy in 3 cases, a Canda equina syndrome in 2 cases, an encephalomyelitis in 2 cases, a Parkinson disease in 2 cases, a myelitis in 1 case, a Brown-Sequard syndrome in 1 case and a head trauma in 1 case. The urinary symptoms were an overactive bladder in 15 cases and a chronic urinary retention in 8 cases. A detrusor-sphincter dyssynergia was associated in 7 cases. Before and during the stimulation test, each patient had had an urodynamic evaluation and had performed a voiding diary. The test was considered as positive if the patients were improved of more than 70%. After implantation, the patients were reviewed at 1 month and every 6 months. RESULTS: Out of the 23 patients, the test was considered as positive in 16 (69%) patients. Fourteen were implanted. With a mean follow-up of 34.9 i 25.2 months, the patients were cured in 11 (79%) cases and not cured in 2 cases. The implant has been removed for infection in 1 case. The electrode was changed in two cases, for displacement in 1 case and section in 1 case. Out of the 2 patients who were not cured, the failure was related to a new attack of a multiple sclerosis in one case. CONCLUSIONS: Sacral root neuromodulation is an effective treatment of neurogenic voiding dysfunction.
University Hospital Schleswig-Holstein, Campus Kiel, Urology, Kiel, Germany
MATERIAL & METHODS: We performed a sacral nerve stimulation in 53 patients (mean age: 49.7 yrs (14-75 yrs); 31 with neurogenic or ideopathic urinary retention, 13 with a hyperactive detrusor and 9 with sensory urge or pelvic pain) over a minimum of 5 days. In 42 patients we performed a conventional PNE, 11 patients received "two-stage-implantation" with implantation of the permanent electrodes. RESULTS: 52 of 53 patients received bilateral test stimulation (9% at $2, 91% at $3). One patient underwent unilateral PNE ($3) because of anatomical deformity of the os sacrum. In 20 cases the conventional PNE-test (cPNE) was successful according to standard criteria (47.6% of all cPNE). 12 of these patients suffered from a neurogenic bladder dysfunction, in 8 cases the causes were idiopathic; 9 patients suffered from retention, 7 from overactive bladder symptoms and 4 patients from sensory urge or pelvic pain. The response rate of "two-stageimplantation" with implantation of the permanent electrodes was 81.8% (9 of 11 patients). 7 patients with neurogenic and 2 with idiopathic bladder dysfunction; 3 patients suffered from retention, 4 from overactive bladder symptoms and 2 patients from sensory urge. CONCLUSIONS: Success rate of implantation of permanent neurostimulation electrodes in selecting patients for the permanent implant is significantly higher than the conventional PNE. In this group patients with neurogenic and overactive bladder dysfunctions showed the highest response rates to sacral nerve stimulation and are the most likely to benefit from sacral neuromodulation.
European Urology Supplements 4 (2005) No. 3, pp. 165