Eiji Iwatsubo

Sports-related spinal cord injury in Japan (From the nationwide spinal cord injury registry between 1990 and 1992)

The Injury Prevention Committee of the Japan Medical Society of Paraplegia (JMSoP) conducted a nationwide epidemiological survey on spinal cord injury (SCI) using postal questionnaires for 3 years periods from 1990 to 1992, and the annual incidence of the spinal cord injury was estimated as 40.2 per million. From this registry, we investigated SCI related to sports activities.In 3 years, 528 patients were registered and 374 of them had neurological deficits. The incidence was 1.95 per million per annum. Mean age at injury was 28.5 years (10-77), and 88.1% of the patients were males. Diving was the commonest cause of SCI (21.6%), which was followed by skiing (13.4%), football including rugby, American football and soccer (12.7%), sky sports (7.0%), judo (6.8%) and gymnastics (6.6%). Mean age at injury was higher than 30 years in skiing (38.6 years) and sky sports (38.2 years). Cervical injury was predominant in all but sky sports and accounted for 83.5% of SCI. Motor complete paralysis was reported in 35.0% of the patients. Bony injury was observed in 55.9% of the patients; most of the patients who sustained the SCI in diving and sky sports had bony injury, and no bony injury was detected in more than a half of the patients who sustained injuries in skiing, judo or gymnastics.Although the percentage of sports-related SCI was small in the present study as compared to the data from previous reports, it is not difficult to imagine the increase in the number of sports-related SCI. We have launched an injury prevention campaign and are planning to conduct a similar study in future to evaluate the effect of the campaign as well as the changes in the incidence and pattern of SCI.

Non-inflatable penile prosthesis for the management of urinary incontinence and sexual disability of patients with spinal cord injury

During the last 5 years non-inflatable penile prostheses were implanted in 37 patients with spinal cord injury. Operation was done to provide adequate stability of the penis in order to hold an external urinary device, to help erectile impotence and to make self-catheterisation easier. A pair of Shirai-type silicone penile implants were inserted into the corpora cavernosa through a dorsal skin incision at the penile base. In 37 patients 33 had excellent results. Extrusion of the prosthesis occurred in two cases due to infection. Removal of the prosthesis was necessary in a patient who had causalgia in the lower extremities. Posterior migration of the prosthesis was noted in a tetraplegic patient who used to turn on his stomach when he changed clothes. Anterior sphincterotomy which was performed during the surgery in one case and after the surgery in another two cases did not affect the prosthesis. Questionnaire survey revealed that 32 (86%) were satisfied with the procedure which provided better condom fitting and easier intermittent catheterisation whereas only 5 (14%) were dissatisfied. The prosthesis improved sexual function in 15 (41%) patients, 18 (48%) patients were unchanged and four (11%) patients were dissatisfied. Penile prosthesis is an effective manoeuvre for the treatment of urinary incontinence and sexual disability of patients with spinal cord injury provided that the special aspects of the spinal cord injury is taken into consideration.

Urinary tract infection in neurogenic bladder

The most frequent medical complication in patients with neurogenic bladder dysfunction is urinary tract infection (UTI). In the acute phase of neurogenic bladder, aseptic intermittent catheterization should be applied. After this phase, patients are subject to UTIs leading to febrile diseases. In the chronic phase of neurogenic bladders, febrile infections are often accompanied with hypertonic bladder. Some causes or symptoms prior to febrile attack are recognized in many of the cases. Antimicrobial chemotherapy has to be started in time without delay. Newer generation cephalosporins and carbapenems may shorten the febrile period. We report our experience with 229 patients treated between January 1993 and December 1998.

Non-Obstructive Vesicoureteral Reflux in Adults: Value of Conservative Treatment

Chronic or recurrent non-obstructive urinary tract infection was investigated in 158 adult patients, 39 of whom had vesicoureteral reflux. Conservative, long-term chemotherapy did not eradicate the reflux in these patients. The characteristics of reflux in adults were studied with cystograms, excretory urograms, cystoscopic findings of the ureteral orifices or trigones and the clinical histories of the patients. These data were evaluated and compared to data obtained from adults with chronic or recurrent uncomplicated urinary tract infection and from children with vesicoureteral reflux who were referred to us during the same period. Non-obstructive vesicoureteral reflux in adults may be considered to be congenital in most cases, since the proportion of trigonal anomalies in adults with reflux is equal to that in children and the frequency of abnormalities at the ureteral orifice and trigonal region is significantly more than the frequency noted in control patients with uncomplicated pyelonephritis. Characteristically, excretory urography revealed caliceal scarring in adults with reflux in contrast to children, in whom a normal or dilated pattern of the upper tract was prominent. Recurring renal infection, for which this congenital defect of the ureterovesical valve must be responsible, produces progressive renal damage. Prolonged conservative treatment is of little use and is often destructive in adults with reflux.

Selective intrathecal phenol block to improve activities of daily living in patients with spastic quadriplegia. A preliminary report

To eliminate severe leg spasms of 15 quadriplegics, 0.3 ml 10% phenol-glycerin was injected into the subarachnoid space at the T12/L1 interspace. The effectiveness for leg spasm was evaluated by the Penn spasticity and Ashworth rigidity scales. Three patients remained completely flaccid; however three had slight, six had moderate and three had complete recurrence of spasms in a follow up period of observation for 1 to 22 (average 13) months. The result of selective intrathecal phenol block was significantly valuable, improving the activities of daily living (ADL) of quadriplegic patients. There were no systemic side effects nor disturbance of bladder, bowel or sexual functions.

Over-distension therapy of the bladder in paraplegic patients using self-catheterisation: a preliminary study.

Over-distension therapy was performed in 60 patients during the period of spinal shock after complete spinal cord injury.Forty-five developed upper motor neurone (UMN) hypo-active decompensated bladder function and 39 achieved satisfactory social activity without urinary incontinence using self-catheterisation. Self catheterisation appeared a safer and more comfortable means of urinary management than trigger voiding in paraplegics with complete spinal cord injury. This is a preliminary communication as it is hoped that a comparative study will follow in due course.

Bladder recovery in patients with traumatic cervical cord injury evaluated by voiding synchronous cystosphincterometry with uroflowmetry.

Voiding synchronous cystosphincterometry with uroflowmetry was used in 16 patients with traumatic cervical cord injury to evaluate bladder recovery. This method was shown to be reliable since the statistical analysis of the voiding responses showed the same values with repeated tests. A total of 14 patients with such injuries recovered from shock in 6 weeks and 10 acquired mature bladder contraction with a synergic external sphincteric urethra approximately 13 weeks after spinal cord injury. Bladders in patients with cervical cord injury usually recover from a state of inactive detrusor to that of a mature contraction by way of immature small and/or sustained contractions. Pressure measurements revealed 7.1 plus or minus 3.7 cm. water in the empty bladder and 74 plus or minus 20.5 cm. water (43 plus or minus 13.3 seconds in duration) in the recovered bladder contraction. Resting pressure in the external sphincteric urethra was 70 plus or minus 25.3 cm. water. The dyssynergic sphincter coexists with immature sustained bladder contraction and it usually improves to the synergic state, according to the degree of maturity of bladder contraction. The bladder and external urethral sphincter recover independently and a synergic response develops even in cases of complete lesions. Thus, synergy can be accomplished by regulatory mechanisms at the sacral cord level. Surgical intervention should be postponed if the maturity of bladder contraction is not yet established. More precise objective information in the dyssynergic bladder caused by cervical cord injury can be obtained when voiding synchronous cystosphincterometry with uroflowmetry is used.

Closure of a Vesicovaginal Fistula Using a Vaginal Flap

Abstract Use of a vaginal flap method to repair a vesicovaginal fistula is reported. This highly successful and less traumatic method of repair can be performed easily by urologists who are less accustomed to the transvaginal procedure.

An Evaluation of Average Flow Rate in Traumatic Neurogenic Bladder Dysfunction

The average flow rate of 60 male patients with spinal cord injuries was studied in a simplified method with a urine cup and a stopwatch. Results were based on the level of the lesion, course of injury, sensation of micturition, cystometric type and cystographic change. The average flow rate of 60 patients with traumatic spinal cord injury was 10.62 plus or minus 5.37 ml. per second, while that of 10 normal adult male patients was 15.70 plus or minus 3.10 ml. per second. The average flow rate was better in patients who had normal or nearly normal proprioceptive sensation than in those without this sensation. Bladder deterioration was not noted on the cystograms of patients who had normal proprioceptive sensations. Therefore, patients with traumatic cord bladders with normal urinary sensation may have a good prognosis, while those with disturbed proprioceptive sensation may require some urological manipulation to reduce urethral resistance.

Followup Study After Conservative and Surgical Treatment of Vesicoureteral Reflux

Our series of 94 cases (145 ureters) of vesicoureteral reflux is reviewed. The occasional disappearance of reflux during conservative treatment should not be mistaken for cure because of its variable nature. To avoid such a mistake voiding cystography under fluoroscopic monitoring is repeated indefinitely. Those patients who were treated surgically were followed for at least 2 to 3 years before cure was established. Transient ureteral dilatation after reimplantation was eradicated within 3 months. Postoperative urinary infection was observed at various intervals, ranging from 1 week to 5 months, and the erythrocyte sedimentation rate was likely to be influenced by infection. Postoperative chemotherapy was continued until the erythrocyte sedimentation rate was normal and there was no infection and/or dilatation of the upper tract.