CLINICAL FEATURES AND TREATMENT OUTCOMES OF ADULT TETHERED CORD SYNDROME

Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008

1291 “ADD-ON” TOLTERODINE EXTENDED RELEASE IMPROVES OVERACTIVE BLADDER SYMPTOMS IN MEN RECEIVING Į%/2&.(57+(5$3< Sender Herschorn*, Paul Abrams, Christopher R Chapple, Franklin Sun, Marina Brodsky, Zhonghong Guan. Toronto, ON, Canada, %ULVWRO8QLWHG.LQJGRP6KHI¿HOG8QLWHG.LQJGRPDQG1HZ
Source of Funding:3¿]HU,QF

1292 EFFECT OF SYSTEMIC NITRIC OXIDE AUGMENTATION IN PATIENTS WITH BLADDER OUTLET OBSTRUCTION DUE TO SPASTIC BLADDER NECK Sharmistha G Roy-Guggenbuehl, Michael Muntener, Tullio Sulser, Brigitte Schurch, Daniel M Schmid*. Zurich, Switzerland. INTRODUCTION AND OBJECTIVE: Nitric oxide (NO) is an important neurotransmitter in the lower urinary tract and there is raising evidence that alterations in the NO-cGMP pathway plays an important role in the development of bladder outlet obstruction and lower urinary tract symptoms. Exogenously applied NO-donors have been shown

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to effectively relax pre-contracted smooth musle preparations from the bladder neck and urethra. In humans, sublingual administration of isosorbide dinitrate to healthy males was shown to reduce resting pressure of the external urethral sphincter. In this study we investigated WKHLPPHGLDWHLQÀXHQFHRIDV\VWHPLF12DXJPHQWDWLRQRQWKHEODGGHU outlet resistance due to bladder neck spasticity in patients with LUTS. METHODS: Ten male patients (mean age 47.9 y.) with LUTS due to a spastic bladder neck were included in the study. All patients had KLVWRU\RIIUHTXHQF\DQGQRFWXULDZLWKRUZLWKRXWVLJQL¿FDQWSRVWYRLGLQJ residual volume (PVR >80 ml). All had IPSS lesser than 17 and were treated with alpha-1-adrenoceptorblockers. Bladder neck obstruction was morphologically judged by cystoscopy before urodynamics tested WKH IXQFWLRQDO DVSHFW 7KH F\VWRPHWU\ DQG SUHVVXUH ÀRZ VWXG\ ZDV conducted twice, once before and 30 min. after sublingual administration of 20mg ISDN. PVR was checked sonographically and the pressure catheter was left in place for the second recording after administration of ISDN. Baseline values were compared to the values after ISDN DGPLQLVWUDWLRQE\WKHRQHVDPSOHWWHVWOHYHORIVLJQL¿FDQFHS  5(68/767KHPHDQHQG¿OOLQJGHWUXVRUSUHVVXUHGHFUHDVHG IURPWRFP+2S  WKHPHDQHQG¿OOLQJXUHWKUDOSUHVVXUH decreased from 70.0 to 45.27 cmH2O (p=0.045) and the maximum cystometric capacity increased from 598.6 to 758.3 ml(p=.0001). The mean maximum detrusor pressure decreased from 62.5 to 45.2 cmH2O S  PD[LPXPÀRZUDWHLQFUHDVHGIURPWRPOVS   and mean PVR decreased from 230 to 155 ml (p=.001) after intake of NO-donor. None of the patients experienced any adverse reactions to the ISDN. CONCLUSIONS: Within 30 min. of sublingual administration of a NO- donor in men with spastic bladder neck we observed a statistically significant change of objective urodynamic parameters defining functional bladder neck obstruction such as a reduction of Pdet max during voiding, an increase of Qmax and a reduction of PVR. Whether or not a future NO-donor based treatment may also continuously improve subjective symptoms still remains to be elucidated. Source of Funding: None

1293 CLINICAL FEATURES AND TREATMENT OUTCOMES OF ADULT TETHERED CORD SYNDROME Wesley M White*, Regula Doggweiler, Todd Abel, Frederick A Klein. Knoxville, TN. INTRODUCTION AND OBJECTIVE: Occult tethered cord V\QGURPH7&6 LVDZLGHO\UHFRJQL]HGEXWSRRUO\GHVFULEHGFDXVHRI voiding and bowel dysfunction in the adult population. Scant literature LVDYDLODEOHFRQFHUQLQJLWVQDWXUDOKLVWRU\DQGWKHEHQH¿WRIRSHUDWLYH intervention. We present a series of adult patients with occult TCS. METHODS: A retrospective study was performed to demonstrate the clinical manifestations and operative outcomes among patients with adult TCS. All patients with a history of voiding and/or bowel dysfunction without a known etiology were evaluated with history and physical examination, lumbar magnetic resonance imaging (MRI), and urodynamics (UDS). Patients with clinical and MRI evidence of occult TCS were offered cord sectioning via a limited lumbar laminectomy. Patients were followed postoperatively, salient data was recorded, and statistical analysis performed. RESULTS: From March 2006 to March 2007, 20 (14 female and 6 male) patients with a mean age of 55 years demonstrated clinical and MRI evidence of occult TCS. All patients demonstrated clinical symptoms of overactive bladder, 3 of which exhibited urge incontinence. Seventeen of 20 patients demonstrated bowel dysfunction manifested as chronic constipation (7 of 17), bowel irritability (9 of 17), and/or incontinence of stool (1 of 17). Eighteen of 20 patients reported chronic leg pain and all patients reported chronic low back pain. UDS demonstrated a small bladder capacity with elevated urethral sphincter pressures in 18 patients while the remaining 2 patients had large capacity, hyposensitive bladders. All patients underwent sectioning of WKH¿OXPWHUPLQDOHZLWKRXWRSHUDWLYHFRPSOLFDWLRQV0HDQSRVWRSHUDWLYH follow-up was 12 months (range 6 - 23 months). Of the 20 patients with YRLGLQJG\VIXQFWLRQUHSRUWHGFRPSOHWH RUVLJQL¿FDQW V\PSWRP improvement. All patients with incontinence reported resolution. Of the 17 patients with existing bowel dysfunction, 14 reported complete (7) or

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VLJQL¿FDQW V\PSWRPLPSURYHPHQW%DFNSDLQZDVFRPSOHWHO\ RU VLJQL¿FDQWO\ LPSURYHGLQRISDWLHQWV/HJSDLQZDVFRPSOHWHO\  RUVLJQL¿FDQWO\ LPSURYHGLQRISDWLHQWV7KHUHZDVRQH postoperative wound infection requiring drainage. CONCLUSIONS: Among patients with chronic leg/low back pain and voiding and/or bowel dysfunction, neurologic examination and lumbar MRI is appropriate to evaluate for occult TCS. Based on our experience, operative intervention appears to offer a durable improvement in clinical symptoms. Source of Funding: None

1294 LONG TERM OUTCOMES OF AUGMENTATION CYSTOPLASTY IN THE NEUROGENIC PATIENT Sanjeev Pathak, Thomas Watcyn-Jones, Eshan Senanayake*, Paul 7RSKLOO6KHI¿HOG8QLWHG.LQJGRP INTRODUCTION AND OBJECTIVE: The goals involved in the mangement of the hostile bladder is creating low compliance and adequate capacity for socially acceptable continence. Augmentation cystoplasty is the principle surgical option used in patients with neurogenic bladder dysfunction refractory to medical therapies. Few studies exist with long term follow up data of such patients. We present our results of augmentation cystoplasties performed in the last 10 years. METHODS: A retrospective study was carried out for patients ZLWKVSLQDEL¿GDDQGVSLQDOFRUGLQMXU\ZKRXQGHUZHQWDXJPHQWDWLRQ cystoplasty at our tertiary referral spinal injuries unit between 1996-2006. 3DWLHQWVZHUHLGHQWL¿HGIURPWKHRSHUDWLRQWKHDWUHOLVWVDQGFDVH notes were reviewed. Demographic data was recorded. Indications for surgery, peri-operative and long term post-operative complications were evaluated. Preservation of renal function, increased post-operative bladder capacity and overall patient satisfaction were deemed successful outcomes. RESULTS: Augmentation cystoplasty was performed in 30 DQGSDWLHQWVZLWKVSLQDEL¿GDDQGVSLQDOFRUGLQMXU\UHVSHFWLYHO\7KH mean age was 33 years (17-69), with 64 male and 20 female patients. Ileum and sigmoid segments were used in 57 and 27 augmentations, UHVSHFWLYHO\$UWL¿FLDOXULQDU\VSKLQFWHUVZHUHLQVHUWHGLQSDWLHQWV Indications for surgery included incontinence (74%), urinary tract infections (46%) and detrusor sphincter dyssynergia (42%). Mean preoperative detrusor pressure was 66 cm H2O (5-200). Mean total bladder capacity ± SD increased from 324 ± 219 to 785 ± 286 ml (p < 0.01, by student t-test). Mean follow up was 6.6 years. Long term complications included stones (23%), urinary tract infections (66%) and continuing incontinence (22%). Deterioration in renal function occurred in 2 patients with 1 patient progressing to renal replacement therapy. All patients performed intermittent self catheterisation on average 4/daily. CONCLUSIONS: The long term results of our study show that augmentation cystoplasty remains a safe and effective treatment for the hostile bladder. High levels of patient satisfaction were recorded. Although, adverse peri-operative events were minimal, long term FRPSOLFDWLRQVZHUHVLJQL¿FDQW7KHUHIRUHFDUHIXOSDWLHQWVHOHFWLRQDQG effective counselling are vital to improve long term outcomes. Source of Funding: None

1295 INCONTINENT ILEOVESICOSTOMY: LONG-TERM COMPLICATIONS AND OUTCOMES Nicholas J Hellenthal*, Scott S Short, Stanley A Yap, Jonathan A Eandi, Anthony R Stone. Sacramento, CA, and Philadelphia, PA. INTRODUCTION AND OBJECTIVE: Incontinent LOHRYHVLFRVWRP\ZDVSRSXODUL]HGLQWKHPLGVDVDVXUJLFDORSWLRQ for patients with neurogenic bladder dysfunction who lack the dexterity to SHUIRUPFOHDQFDWKHWHUL]DWLRQ:KLOHVHYHUDOSXEOLVKHGUHSRUWVDGYRFDWH use of the incontinent ileovesicostomy, few studies review the long-term complications associated with this procedure. METHODS: We review the outcomes of twelve patients who underwent incontinent ileovesicostomy for management of neurogenic bladder dysfunction since its introduction at our institution in 1998. We GLVFXVVWKHVSHFL¿FFRPSOLFDWLRQVSHUWDLQLQJWRWKHLOHRYHVLFRVWRP\DQG

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report on the number of patients who subsequently elected to undergo conversion to ileal conduit. RESULTS: Of the twelve patients who underwent incontinent ileovesicostomy over the aforementioned time frame, two patients have been converted to ileal conduit, and an additional three patients have continued vesicostomy drainage problems necessitating indwelling FDWKHWHUL]DWLRQ )LYH SDWLHQWV FRQWLQXH WR KDYH XSSHU WUDFW SUREOHPV pertaining to recurrent stones and infection. CONCLUSIONS: Incontinent ileovesicostomy is an option for patients with lower urinary tract dysfunction who are unable to perform FOHDQLQWHUPLWWHQWFDWKHWHUL]DWLRQ+RZHYHUWKHFOLQLFLDQDQGWKHSDWLHQW must be aware of the long-term complications associated with the procedure before incontinent ileovesicostomy is chosen for bladder management. Traditional conduit diversion may be more appropriate in this group of patients. Incontinent Ileovesicostomy Complications Bladder Stones 3 (25%) Renal Stones 3 (25%) Urinary Tract Infection 5 (42%) Urethral Leakage 3 (25%) Stomal Stenosis 1 (8%) Hydronephrosis 1 (8%) Conversion to Ileal Conduit 2 (17%)

Source of Funding: None

Urodynamics/Incontinence/Female Urology: Pelvic Prolapse Podium Session 28 Tuesday, May 20, 2008

8:00 - 10:00 am

1296 FUNCTIONAL AND ANATOMICAL PHENOTYPE IN LYSYL OXIDASE LIKE-1 KNOCKOUT MICE RESEMBLES THE NATURAL HISTORY OF PELVIC ORGAN PROLAPSE IN HUMANS Una J Lee*, A Marcus Gustilo-Ashby, Firouz Daneshgari, Mei Kuang, Drina Vrubic, DanLi Lin, Chris Flask, Tiansen Li, Margot S Damaser. Cleveland, OH, and Boston, MA. INTRODUCTION AND OBJECTIVE: Mice lacking the protein, lysyl oxidase-like 1 (LOXL1 KO) develop pelvic organ prolapse (POP) and demonstrate voiding dysfunction after pregnancy and delivery. )XUWKHU FKDUDFWHUL]DWLRQ RI WKH /2;/ .2 PRGHO LV LPSRUWDQW WR determine its relevance to FPFD in humans. The objective of this study was to compare the anatomy and function of the lower urogenital tract (LUT) of LOXL1 KO mice with and without POP. METHODS: 62 LOXL1 KO mice were observed for POP. 'HJUHHRI323ZDVTXDQWL¿HGXVLQJWKH0234V\VWHP/87DQDWRP\ LQOLYHDQHVWKHWL]HGPLFHZDVDVVHVVHGXVLQJD7HVOD05,VFDQQHU to produce high resolution T1-weighted, fat-suppressed images. Age and parity-matched LOXL1 KO mice were divided into prolapsed (n=11) and non-prolapsed (n=6) groups. LUT function was evaluated using conscious cystometry (CMG) and leak point pressure (LPP) testing. Quantitative histologic analysis was performed on mid-urethra samples stained with von Gieson (elastin) stain. Kaplan Meier curves were used to describe the development of POP over time with differences determined using chi-square tests. Statistical analysis included: univariate analysis using t-test on normally distributed data, Wilcoxon rank sum test on nonnormally distributed data, multivariate analysis using two-way ANOVA, and pairwise multiple comparisons using the Tukey test. P < 0.05 was FRQVLGHUHGVLJQL¿FDQW RESULTS: By 25 weeks of age, 50% of parous LOXL1 KO PLFH GHYHORSHG 323 3DULW\ VLJQL¿FDQWO\ DIIHFWHG WKH DJH DW ZKLFK POP developed (p=0.016). With each delivery, the age at development of POP decreased by 25%. MRI showed that LOXL1 KO mice with 323KDGYDULDELOLW\LQWKHVL]HDQGORFDWLRQRIWKHEODGGHUDQGYDJLQD compared with mice without POP. Multivariate analysis revealed lower LPP in the prolapsed mice compared with non-prolapsed mice when FRQWUROOHGIRUSDULW\S  7KHUHZDVDVLJQL¿FDQWLQFUHDVHLQWKH number of elastin clusters in the external urethral sphincter of LOXL1