Marko Kozomara

Acute Spinal Cord Injury—Do Ambulatory Patients Need Urodynamic Investigations?

PURPOSE We compared the urodynamic parameters of ambulatory vs nonambulatory acute spinal cord injured patients. MATERIALS AND METHODS A total of 27 women and 33 men (mean age 58 years) with neurogenic lower urinary tract dysfunction due to acute spinal cord injury (duration of injury less than 40 days) were prospectively evaluated. The patients were dichotomized according to the mobility for moderate distances subscale of the SCIM (Spinal Cord Independence Measure) version III into ambulatory (score of 3 or greater) and nonambulatory (score less than 3). Videourodynamic parameters including maximum detrusor pressure during the storage phase, bladder compliance, detrusor overactivity, detrusor external sphincter dyssynergia and vesicoureterorenal reflux were compared between the groups. RESULTS Of the 60 patients with acute spinal cord injury 17 were ambulatory and 43 were nonambulatory. Mean ± SD duration of injury at urodynamic investigation was 30 ± 8 days. The lesion level was cervical in 14 patients, thoracic in 28 and lumbar/sacral in 18. Comparing unfavorable urodynamic parameters, no significant differences were found between ambulatory vs nonambulatory patients in terms of a high pressure system during the storage phase (29% vs 33%, p = 0.81), a low compliance bladder (12% vs 7%, p = 0.54), detrusor overactivity (24% vs 47%, p = 0.1), detrusor external sphincter dyssynergia (18% vs 21%, p = 0.77) and vesicoureterorenal reflux (0% vs 5%, p = 0.36). CONCLUSIONS Ambulatory and nonambulatory patients with acute spinal cord injury have a similar risk of unfavorable urodynamic measures. Thus, we strongly recommend the same neurourological assessment including urodynamic investigations in all acute spinal cord injury patients independent of the ability to walk.

Neurogenic Lower Urinary Tract Dysfunction—Do We Need Same Session Repeat Urodynamic Investigations?

PURPOSE We investigated whether same session repeat urodynamic investigations are needed in patients with neurogenic lower urinary tract dysfunction. MATERIALS AND METHODS A consecutive series of 226 patients with neurogenic lower urinary tract dysfunction who underwent same session repeat urodynamic investigation was prospectively investigated at a single university spinal cord injury center. Urodynamics were done according to the good urodynamic practices recommended by the International Continence Society. All 226 patients underwent same session repeat consecutive filling cystometry and 88 also underwent pressure flow studies if they could void spontaneously. Repeatability of the 2 measurements was assessed using the Bland and Altman 95% limits of agreement, and the κ statistic. RESULTS Mean age of the 226 patients enrolled was 52 years (range 18 to 90). Of the patients 94 (42%) were women and 132 were (58%) men. Detrusor overactivity repeatability was excellent between the 2 urodynamic investigations (κ=0.87, 95% CI 0.80-0.94). For all other urodynamic parameters assessed there were wide 95% limits of agreement for differences in the parameters, indicating poor repeatability. CONCLUSIONS In same session repeat urodynamic investigations of patients with neurogenic lower urinary tract dysfunction detrusor overactivity demonstrates excellent repeatability but all other urodynamic parameters show insufficient agreement. Thus, we strongly recommend that clinical decision making not be based on a single urodynamic investigation since repeat measurements may yield completely different results.

External Urethral Sphincter Pressure Measurement: An Accurate Method for the Diagnosis of Detrusor External Sphincter Dyssynergia?

Background Combined pelvic floor electromyography (EMG) and videocystourethrography (VCUG) during urodynamic investigation are the most acceptable and widely agreed methods for diagnosing detrusor external sphincter dyssynergia (DESD). Theoretically, external urethral sphincter pressure (EUSP) measurement would provide enough information for the diagnosis of DESD and could simplify the urodynamic investigation replacing combined pelvic floor EMG and VCUG. Thus, we evaluated the diagnostic accuracy of EUSP measurement for DESD. Patients & Methods A consecutive series of 72 patients (36 women, 36 men) with neurogenic lower urinary tract dysfunction able to void spontaneously was prospectively evaluated at a single university spinal cord injury center. Diagnosis of DESD using EUSP measurement (index test) versus combined pelvic floor EMG and VCUG (reference standard) was assessed according to the recommendations of the Standards for Reporting of Diagnostic Accuracy Initiative. Results Using EUSP measurement (index test) and combined pelvic floor EMG and VCUR (reference standard), DESD was diagnosed in 10 (14%) and in 41 (57%) patients, respectively. More than half of the patients presented discordant diagnosis between the index test and the reference standard. Among 41 patients with DESD diagnosed by combined pelvic floor EMG and VCUR, EUSP measurement identified only 6 patients. EUSP measurement had a sensitivity of 15% (95% CI 5%–25%), specificity of 87% (95% CI 76%–98%), positive predictive value of 60% (95% CI 30%–90%), and negative predictive value of 56% (95% CI 44%–68%) for the diagnosis of DESD. Conclusions For diagnosis of DESD, EUSP measurement is inaccurate and cannot replace combined pelvic floor EMG and VCUR.

Sakrale Neuromodulation bei neurogenen Blasenfunktionsstörungen

ZusammenfassungDie sakrale Neuromodulation (SNM) stellt bei therapierefraktären neurogenen Blasenfunktionsstörungen eine vielversprechende Therapieoption dar. Es bleibt allerdings zu zeigen, welche Typen der neurogenen Blasenfunktionsstörungen und welche zugrunde liegenden neurologischen Erkrankungen am besten auf die SNM ansprechen. Die SNM wurde ständig weiterentwickelt und ist heute ein minimal-invasives, in Lokalanästhesie durchführbares Therapieverfahren, das vor größeren rekonstruktiven Eingriffen zumindest erwogen werden sollte. Es wird eine Elektrodenimplantation ins Sakralforamen S3 oder S4 durchgeführt und in einer Testphase über Tage bis Wochen unter Führen eines Blasentagebuches geprüft, ob die SNM dem Patienten einen relevanten Nutzen bringt. Wenn sich eine positive Testphase zeigt, wird der Neuromodulator gluteal (oder seltener in die Bauchdecke) implantiert.Der Wirkmechanismus der SNM ist nicht gänzlich geklärt, doch Afferenzen dürften eine Schlüsselrolle spielen. So scheint die SNM via periphere Afferenzen eine Modulation von Rückenmarkreflexen und Gehirnzentren zu bewirken. Das implantierte Neuromodulationssystem führt zu keiner Einschränkung der Aktivitäten der Patienten. Allerdings gilt es zu beachten, dass bei Neuromodulatorträgern Hochfrequenzwärmetherapie und unipolare Elektrokauterisation kontraindiziert sind, dass bei einer extrakorporellen Stoßwellenlithotripsie der Brennpunkt nicht in unmittelbarer Nähe des Neuromodulators oder der Elektrode liegen darf, dass Ultrasonographie und Strahlentherapie im Bereich der Implantatkomponenten vermieden werden sollten, dass bei Schwangerschaft der Neuromodulator auszuschalten ist und dass MR-Untersuchungen nur bei zwingender Indikation und bei ausgeschaltetem Neuromodulator durchgeführt werden sollen.AbstractSacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patient’s activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.Sacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patients activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.

Sacral neuromodulation for neurogenic bladder dysfunction

ZusammenfassungDie sakrale Neuromodulation (SNM) stellt bei therapierefraktären neurogenen Blasenfunktionsstörungen eine vielversprechende Therapieoption dar. Es bleibt allerdings zu zeigen, welche Typen der neurogenen Blasenfunktionsstörungen und welche zugrunde liegenden neurologischen Erkrankungen am besten auf die SNM ansprechen. Die SNM wurde ständig weiterentwickelt und ist heute ein minimal-invasives, in Lokalanästhesie durchführbares Therapieverfahren, das vor größeren rekonstruktiven Eingriffen zumindest erwogen werden sollte. Es wird eine Elektrodenimplantation ins Sakralforamen S3 oder S4 durchgeführt und in einer Testphase über Tage bis Wochen unter Führen eines Blasentagebuches geprüft, ob die SNM dem Patienten einen relevanten Nutzen bringt. Wenn sich eine positive Testphase zeigt, wird der Neuromodulator gluteal (oder seltener in die Bauchdecke) implantiert.Der Wirkmechanismus der SNM ist nicht gänzlich geklärt, doch Afferenzen dürften eine Schlüsselrolle spielen. So scheint die SNM via periphere Afferenzen eine Modulation von Rückenmarkreflexen und Gehirnzentren zu bewirken. Das implantierte Neuromodulationssystem führt zu keiner Einschränkung der Aktivitäten der Patienten. Allerdings gilt es zu beachten, dass bei Neuromodulatorträgern Hochfrequenzwärmetherapie und unipolare Elektrokauterisation kontraindiziert sind, dass bei einer extrakorporellen Stoßwellenlithotripsie der Brennpunkt nicht in unmittelbarer Nähe des Neuromodulators oder der Elektrode liegen darf, dass Ultrasonographie und Strahlentherapie im Bereich der Implantatkomponenten vermieden werden sollten, dass bei Schwangerschaft der Neuromodulator auszuschalten ist und dass MR-Untersuchungen nur bei zwingender Indikation und bei ausgeschaltetem Neuromodulator durchgeführt werden sollen.AbstractSacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patient’s activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.Sacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patients activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.

Effects of onabotulinumtoxinA on cardiac function following intradetrusor injections.

OnabotulinumtoxinA intradetrusor injections are considered a highly effective localized therapy for refractory detrusor overactivity. However, despite evidence for distant systemic effects of onabotulinumtoxinA, little is known on potential systemic side effects following intradetrusor injections. Given that onabotulinumtoxinA is a highly potent toxin this is an important safety issue specifically with regard to repeat injections and parallel treatments with botulinum toxin. Hence, it was the purpose of this prospective study to investigate, using heart rate variability (HRV) analysis, whether onabotulinumtoxinA causes systemic effects on cardiac function following intradetrusor injections. Patients with neurogenic detrusor overactivity (NDO) and age-matched healthy controls were recruited. Concomitant medication and diseases affecting the cardio-vascular system were exclusion criteria. A 3-channel resting electrocardiogram (ECG) was recorded in supine position for 15min during four consecutive visits: 1) 2weeks prior onabotulinumtoxinA intradetrusor injections, 2) 10min prior injections, 3) 30min after injections, and 4) 6weeks after injections. NDO patients received intradetrusor injections (300units Botox®) between visits 2 and 3. The control group had no intervention. Short-term (5min) HRV analysis included assessment of frequency and time domain parameters. Statistical analysis was performed using ANOVA with repeated measures and the t-test. Due to multiple comparisons, α was corrected to 0.0125 (Bonferroni method). Twelve healthy volunteers (5♀, 7♂; 46±12years old) and 12 NDO patients (5♀, 7♂; 46±13years old) completed all measurements. Comparing both groups, resting heart rate was significantly higher in the patients group at visit 4 only. No further significant differences in time and frequency domain parameters were discovered. Within the NDO group, standard deviation of the normal to normal intervals (SDNN) in the ECG demonstrated a significant decrease (1.70 to 1.53ms, p=0.003) from visit 3 to 4, whereas the total power (TP) significantly increased (3.05 to 3.29ms2, p=0.009) from visit 2 to 3. This increase subsided until visit 4. STUDY LIMITATIONS single treatment investigation under resting conditions only. In conclusion, onabotulinumtoxinA intradetrusor injections do not seem to affect resting state cardiac function. Short-term changes such as total power might rather result from natural cardio-vascular responses to the procedure itself (e.g. discomfort, stress). Further detailed investigations also under physical stress and repeated injections are necessary to fully exclude systemic cardiac side effects of onabotulinumtoxinA intradetrusor injections.

Is Detrusor Contraction during Rapid Bladder Filling Caused by Cold or Warm Water? A Randomized, Controlled, Double-Blind Trial

Purpose We investigated whether detrusor contraction during rapid bladder filling is provoked by cold or warm water. Materials and Methods Patients with neurogenic lower urinary tract dysfunction were included in this randomized, controlled, double‐blind trial. At the end of a standard urodynamic investigation patients underwent 2 bladder fillings using a 4C ice water test or a 36C warm water test saline solution at a filling speed of 100 ml per minute. The order was randomly selected, and patients and investigators were blinded to the order. The primary outcome measure was detrusor overactivity, maximum detrusor pressure and maximum bladder filling volume during the ice and warm water tests. Results Nine women and 31 men were the subject of data analysis. Neurogenic lower urinary tract dysfunction was caused by spinal cord injury in 33 patients and by another neurological disorder in 7. Irrespective of test order detrusor overactivity occurred significantly more often during the ice water test than during the warm water test (30 of 40 patients or 75% vs 25 of 40 or 63%, p = 0.02). When comparing the ice water test to the warm water test, maximum detrusor pressure was significantly higher and maximum bladder filling volume was significantly lower during the ice water test (each p <0.001). The order of performing the tests (ice water first vs warm water first) had no effect on the parameters. Conclusions Our findings imply that the more frequent detrusor overactivity, higher maximum detrusor pressure and lower bladder filling volume during the ice water test compared to the warm water test were caused by cold water. This underlies the theory of a C‐fiber mediated bladder cooling reflex in humans.

Sakrale Neuromodulation bei neurogenen Blasenfunktionsstörungen@@@Sacral neuromodulation for neurogenic bladder dysfunction

ZusammenfassungDie sakrale Neuromodulation (SNM) stellt bei therapierefraktären neurogenen Blasenfunktionsstörungen eine vielversprechende Therapieoption dar. Es bleibt allerdings zu zeigen, welche Typen der neurogenen Blasenfunktionsstörungen und welche zugrunde liegenden neurologischen Erkrankungen am besten auf die SNM ansprechen. Die SNM wurde ständig weiterentwickelt und ist heute ein minimal-invasives, in Lokalanästhesie durchführbares Therapieverfahren, das vor größeren rekonstruktiven Eingriffen zumindest erwogen werden sollte. Es wird eine Elektrodenimplantation ins Sakralforamen S3 oder S4 durchgeführt und in einer Testphase über Tage bis Wochen unter Führen eines Blasentagebuches geprüft, ob die SNM dem Patienten einen relevanten Nutzen bringt. Wenn sich eine positive Testphase zeigt, wird der Neuromodulator gluteal (oder seltener in die Bauchdecke) implantiert.Der Wirkmechanismus der SNM ist nicht gänzlich geklärt, doch Afferenzen dürften eine Schlüsselrolle spielen. So scheint die SNM via periphere Afferenzen eine Modulation von Rückenmarkreflexen und Gehirnzentren zu bewirken. Das implantierte Neuromodulationssystem führt zu keiner Einschränkung der Aktivitäten der Patienten. Allerdings gilt es zu beachten, dass bei Neuromodulatorträgern Hochfrequenzwärmetherapie und unipolare Elektrokauterisation kontraindiziert sind, dass bei einer extrakorporellen Stoßwellenlithotripsie der Brennpunkt nicht in unmittelbarer Nähe des Neuromodulators oder der Elektrode liegen darf, dass Ultrasonographie und Strahlentherapie im Bereich der Implantatkomponenten vermieden werden sollten, dass bei Schwangerschaft der Neuromodulator auszuschalten ist und dass MR-Untersuchungen nur bei zwingender Indikation und bei ausgeschaltetem Neuromodulator durchgeführt werden sollen.AbstractSacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patient’s activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.Sacral neuromodulation (SNM) represents a promising option for managing treatment-refractory neurogenic bladder dysfunction. It remains to be seen, however, which types of neurogenic bladder dysfunction and which underlying neurological disorders best respond to SNM. Constant improvements in SNM have been achieved and it is now a minimally invasive approach performed under local anesthesia which should be considered before undertaking larger reconstructive procedures. An electrode is implanted in the S3 or S4 sacral foramen and during a test phase lasting for days to weeks the patient keeps a bladder diary to determine whether SNM has provided a relevant benefit. If the results of the test phase are positive, a neuromodulator is implanted in the gluteal area (or more rarely in the abdominal wall).The mechanism of action of SNM has not been completely clarified, but the afferent nerves most likely play a key role. It appears that SNM produces a modulation of medullary reflexes and brain centers by peripheral afferents. The implanted neuromodulation system does not lead to limitation of the patients activities. However, it should be noted that high-frequency diathermy and unipolar electrocauterization are contraindicated in patients with neuromodulators, that during extracorporeal shock wave lithotripsy the focal point should not be in the direct vicinity of the neuromodulator or the electrode, that ultrasound and radiotherapy in the region of the implanted components should be avoided, that the neuromodulation should be discontinued in pregnancy, and that MRI examinations should only be conducted when urgently indicated and the neuromodulator is turned off.