More than 1 year after the original surgery, the patient self-catheterizes about 4 to 5 times daily via the catheterizable channel using a single-use catheter. His bladder holds at least 500 mL. The patient does not have significant leakage from the channel or the penis. He is no longer dependent on a chronic indwelling catheter and is free of the problems associated with severe UI, including foul odor, UTIs, and social isolation.
Discussion
Patients with spinal cord or pelvic nerve injury often develop spastic bladders with low capacities. This is similar to muscle spasticity that may occur with a neurologic injury, below the level of the injury, such as in the lower extremities. The powerful uncontrolled bladder spasms and small bladder capacity most often lead to incontinence. Additionally, neurologic control of the urinary sphincter is affected, leading to either uncontrolled spasms or poor tone. Patients with these injuries have no volitional control of bladder functions and are forced to catheterize intermittently, use a condom-type catheter, or have a chronic indwelling catheter (a Foley catheter or suprapubic catheter).
Intermittent catheterization is the preferred management option for neurogenic bladder. When compared with chronic indwelling catheters, intermittent catheterization is associated with lower rates of UTI and upper tract abnormalities and with the loss of renal function.5 Unfortunately, patients do not often stay on intermittent catheterization. A recent study showed that up to 70% of patients with spinal cord injuries who used clean intermittent catheterization when discharged from acute rehabilitation discontinue use and are subsequently managed by chronic indwelling catheters.6 Although the reasons why intermittent catheterization is discontinued are unclear, patient dissatisfaction with catheterization, anatomic problems, such as urethral scarring, or continued leakage despite medical treatments, such as anticholinergic medicines, may be factors.
Uncontrolled leakage and UI significantly impacts QOL and may cause patients to choose chronic indwelling catheters over intermittent catheterization. Several treatments are available to control incontinence associated with intermittent catheterization. Anticholinergic medications and more recently onabotulinum toxin A may help improve bladder spasticity. In 2011, the FDA approved onabotulinum toxin A for transurethral bladder injections. It has been shown to increase functional bladder capacity and decrease spasticity.7,8 Onabotulinum toxin A treatment will not enlarge a small, contracted bladder.
Onabotulinum toxin A treatment would not be ideal for the patient in this case study. His absolute bladder capacity was 200 mL, and onabotulinum toxin A treatment would not significantly improve capacity or make intermittent catheterization practical. Additionally, the patient had poor urinary sphincter function, and he would continue to leak regardless of improvements in the bladder spasticity or tone.
Augmentation enterocystoplasty is surgical enlargement of the bladder, using a piece of the bowel and is indicated in patients with low bladder volumes. With this procedure the native bladder becomes defunctionalized, and patients experience a dramatic improvement in bladder volumes and a reduction in bladder spasms and leakage. The use of the colon and terminal ileum for bladder augmentation, or CCIC, was first reported by Sarosdy in 2 patients in 1992.9 In 1996, King and colleagues demonstrated successful outcomes with CCIC in a cohort of 8 patients after 34 months of follow-up.10 Seven patients successfully used clean intermittent catheterization, and 1 patient chose an indwelling catheter because of progressive upper extremity weakness. No patients experienced worsened renal function or pyelonephritis suggestive of upper urinary tract deterioration. A single patient had mild stomal stenosis, which was successfully revised under local anesthesia.
In another study, Sutton and colleagues reported at 27 months an improvement of 276 mL in bladder capacity, no metabolic complications, and a 95% continence rate in a cohort of 23 patients with neurogenic bladder who underwent CCIC.4 Sutton and colleagues later reported outcomes for 34 patients with a median of 31 months follow-up.11 The most common complications were recurrent UTIs (12%) and stomal stenosis (12%). Only 3 patients (9%) required surgical revisions for stomal stenosis.
Altered bowel function and metabolic abnormalities are a concern after bowel resection and reconstruction. However, a study has found no subjective change in bowel function following ileal resection of up to 60 cm for urinary diversion for bladder malignancy.12 Rates of hyperchloremic hypokalemic metabolic acidosis are low, and most changes in electrolytes are subclinical.13,14 Long-term vitamin B12 deficiency is seen with larger (> 50 cm) ileal resections but is rare with CCIC, given the small segment used for reconstruction.15 Overall, CCIC is shown to have excellent surgical outcomes in carefully selected patients with neurogenic bladder.
In addition to low bladder capacity, the case study patient also had intrinsic sphincteric deficiency (very low urinary sphincter tone), which is common with pelvic nerve injury but unusual with spinal cord injury. He initially received a suburethral mesh sling that supported and compressed the urethra and buttressed the natural urinary sphincter. However, patients can develop catheterization issues with a suburethral sling due to mechanical compression of the urethra and traversing the compressed area with a urinary catheter. Given the indication for augmentation cystoplasty in this patient, he additionally elected to undergo catheterization channel creation to avoid long-term issues of urethral catheterization through the urethra compressed by the sling.
Unfortunately, this patient had postoperative issues with his suburethral sling, and a modified AUS was inserted rather than a second sling. Normally, an AUS is attached to a pump mechanism in the scrotum. The pump allows the patient to cycle fluid from the sphincter cuff to a reservoir in the abdomen, removing compression on the urethra and allowing normal urination. Because this patient could not effectively urinate from the penis, the authors wanted to obstruct the urethra to prevent leakage without closing it permanently. The AUS was connected to a tissue expander port placed subcutaneously in the lower abdomen rather than to a pump mechanism. This modified approach used fewer mechanical parts compared with the pump mechanism, possibly reducing rates of mechanical failure. Additionally, a lower cuff pressure could be used to obstruct the urethra and prevent leakage, reducing the likelihood of urethral atrophy. Fewer mechanical parts and a lower cuff pressure could theoretically improve longevity of the AUS (Figure 3). This modified method of AUS placement has been described in patients with sphincteric deficiency and spinal cord injury.16
These 2 reconstructive surgeries freed the patient from indwelling catheter dependence and significantly improved his incontinence and QOL. Many patients with spinal cord injury or pelvic injury could benefit from similar reconstructive surgeries if conservative measures such as anticholinergic medications or onabotulinum toxin A treatments do not control incontinence.
Conclusion
Blast injuries in soldiers often cause pelvic and genitourinary injuries. These injuries can lead to chronic urinary problems and profound social and physical disability. These young veterans need innovative, individualized approaches to best manage their long-term urinary issues. Reconstructive surgery may improve QOL and decrease disability from bladder dysfunction for carefully selected patients. Clinicians caring for veterans with pelvic and genitourinary injury should strive to create a system where these options are available when they are appropriate.