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. 2014 May 24;2014(5):CD004927.
doi: 10.1002/14651858.CD004927.pub4.

Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction

Elaine Utomo  1 , Jan Groen, Bertil F M Blok
Affiliations

Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction

Elaine Utomo et al. Cochrane Database Syst Rev. .

Abstract

Background: The most common type of functional bladder outlet obstruction in patients with neurogenic bladder is detrusor-sphincter dyssynergia (DSD). The lack of co-ordination between the bladder and the external urethral sphincter muscle (EUS) in DSD can result in poor bladder emptying and high bladder pressures, which may eventually lead to progressive renal damage.

Objectives: To assess the effectiveness of different surgical therapies for the treatment of functional bladder outlet obstruction (i.e. DSD) in adults with neurogenic bladder dysfunction.

Search methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, and handsearching of journals and conference proceedings (searched 20 February 2014), and the reference lists of relevant articles.

Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing a surgical treatment of DSD in adults suffering from neurogenic bladder dysfunction, with no treatment, placebo, non-surgical treatment, or other surgical treatment, alone or in combination.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data.

Main results: We included five trials (total of 199 participants, average age of 40 years). The neurological diseases causing DSD were traumatic spinal cord injury (SCI), multiple sclerosis (MS), or congenital malformations.One trial compared placement of sphincteric stent prosthesis with sphincterotomy. For urodynamic measurements, results for postvoid residual urine volume (PVR) and cystometric bladder capacity were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy at three, six, 12, and 24 months. Results for maximum detrusor pressure (Pdet.max) were also inconclusive at three, six, and 12 months; however, after two years, the Pdet.max after sphincterotomy was lower than after stent placement (mean difference (MD) -30 cmH2O, 95% confidence interval (CI) 8.99 to 51.01).Four trials considered botulinum A toxin (BTX-A) injection in the EUS, either alone or in combination with other treatments. The comparators included oral baclofen, oral alpha blocker, lidocaine, and placebo. The BTX-A trials all differed in protocols, and therefore we did not undertake meta-analysis. A single 100 units transperineal BTX-A injection (Botox®) in patients with MS resulted in higher voided urine volumes (MD 69 mL, 95% CI 11.87 to 126.13), lower pre-micturition detrusor pressure (MD -10 cmH2O, 95% CI -17.62 to -2.38), and lower Pdet.max (MD -14 cmH2O, 95% CI -25.32 to -2.68) after 30 days, compared to placebo injection. Results for PVR using catheterisation, basal detrusor pressure, maximal bladder capacity, maximal urinary flow, bladder compliance at functional bladder capacity, maximal urethral pressure, and closure urethral pressure at 30 days were inconclusive and consistent with benefit of either BTX-A injection or placebo injections. In participants with SCI, treatment with 200 units of Chinese manufactured BTX-A injected at eight different sites resulted in better bladder compliance (MD 7.5 mL/cmH2O, 95% CI -10.74 to -4.26) than participants who received the same injections with the addition of oral baclofen. Results for maximum uroflow rate, maximal cystometric capacity, and volume per voiding were inconclusive and consistent with benefit of either BTX-A injection or BTX-A injection with the addition of oral baclofen. However, the poor quality of reporting in this trial caused us to question the relevance of bladder compliance as an adequate outcome measure.In participants with DSD due to traumatic SCI, MS, or congenital malformation, the results for PVRs after one day were inconclusive and consistent with benefit of either a single 100 units transperineal BTX-A (Botox®) injection or lidocaine injection. However, after seven and 30 days of BTX-A injection, PVRs were lower (MD -163 and -158 mL, 95% CI -308.65 to -17.35 and 95% CI -277.57 to -39.03, respectively) compared to participants who received lidocaine injections. Results at one month for Pdet.max on voiding, EUS activity in electromyography, and maximal urethral pressure were inconclusive and consistent with benefit of either BTX-A or lidocaine injections.Finally, one small trial consisting of five men with SCI compared weekly BTX-A injections with normal saline as placebo. The placebo had no effect on DSD in the two participants allocated to the placebo treatment. Their urodynamic parameters were unchanged from baseline values until subsequent injections with BTX-A once a week for three weeks. These subsequent injections resulted in similar responses to those of the three participants who were allocated to the BTX-A treatment. Unfortunately, the report presented no data on placebo treatment.Only the trial that compared sphincterotomy with stent placement reported outcome measures renal function and urologic complications related to DSD. Results for renal function at 12 and 24 months, and urologic complications related to DSD at three, six, 12, and 24 months were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy.Adverse effects reported were haematuria due to the cystoscopic injection and muscle weakness, of which the latter may be related to the BTX-A dose used.All trials had some methodological shortcomings, so insufficient information was available to permit judgement of risk of bias. At least half of the trials had an unclear risk of selection bias and reporting bias. One trial had a high risk of attrition bias, and another trial had a high risk of reporting bias.

Authors' conclusions: Results from small studies with a high risk of bias have identified evidence of limited quality that intraurethral BTX-A injections improve some urodynamic measures after 30 days in the treatment of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. The necessity of reinjection of BTX-A is a significant drawback; a sphincterotomy might therefore be a more effective treatment option for lowering bladder pressure in the long-term.However, because of the limited availability of eligible trials, this review was unable to provide robust evidence in favour of any of the surgical treatment options. More RCTs are needed, measuring improvement on quality of life, and on other types of surgical treatment options for DSD since these are lacking. Future RCTs assessing the effectiveness of BTX-A injections also need to address the uncertainty about the optimal dose and mode of injection for this specific type of urological condition.

PubMed Disclaimer

Conflict of interest statement

Elaine Utomo: none stated. Jan Groen: none stated. Bertil FM Blok: none stated.

Figures

1
1
PRISMA study flow diagram
2
2
'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
3
3
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
1.1
1.1. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 1 urodynamic measurement: postvoid residual urine.
1.2
1.2. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 2 urodynamic measurement: cystometric bladder capacity.
1.3
1.3. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 3 urodynamic measurement: maximum detrusor pressure.
1.4
1.4. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 4 renal function: vesico‐ureteric reflux per ureter.
1.5
1.5. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 5 renal function: hydronephrosis per ureter.
1.6
1.6. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 6 urinary tract infection: positive urine culture.
1.7
1.7. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 7 urinary tract infection: presence of symptoms relating to positive urine culture.
1.8
1.8. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 8 autonomic dysreflexia symptoms: participant‐reported disappearance of symptoms at 24 months.
1.9
1.9. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 9 catheterisation rates.
1.10
1.10. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 10 bladder symptoms: participant‐reported improved bladder‐emptying ability.
1.11
1.11. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 11 surgical outcome: hospitalisation 2 or more days.
1.12
1.12. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 12 surgical outcome: bladder neck obstruction requiring treatment.
1.13
1.13. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 13 surgical outcome: 1 day postoperative bleeding as quantified by haemoglobin value.
1.14
1.14. Analysis
Comparison 1 Implantable urethral stent versus sphincterotomy, Outcome 14 surgical outcome: urethral stricture requiring urethrotomy at 2 years.
2.1
2.1. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 1 postvoiding residual urine volume using catheterisation at 30 days.
2.2
2.2. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 2 voiding volume at 30 days.
2.3
2.3. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 3 urodynamic measurement: detrusor pressure at 30 days.
2.4
2.4. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 4 urodynamic measurement: maximal bladder capacity at 30 days.
2.5
2.5. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 5 urodynamic measurement: maximal urinary flow at 30 days.
2.6
2.6. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 6 urodynamic measurement: bladder compliance at functional bladder capacity at 30 days.
2.7
2.7. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 7 urodynamic measurement: urethral pressure at 30 days.
2.8
2.8. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 8 multiple sclerosis attack.
2.9
2.9. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 9 participant‐reported outcome: International Prostate Symptom Score at 30 days.
2.10
2.10. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 10 quality of voiding: assessed using 10 cm visual analogue scales at 30 days.
2.11
2.11. Analysis
Comparison 2 Botulinum A toxin injection versus placebo, Outcome 11 surgical outcome measures.
3.1
3.1. Analysis
Comparison 3 Botulinum A toxin injection combined with non‐surgical therapy, Outcome 1 urodynamic measurement: maximum uroflow rate at 1 month.
3.2
3.2. Analysis
Comparison 3 Botulinum A toxin injection combined with non‐surgical therapy, Outcome 2 urodynamic measurement: maximal cystometric capacity.
3.3
3.3. Analysis
Comparison 3 Botulinum A toxin injection combined with non‐surgical therapy, Outcome 3 urodynamic measurement: volume per voiding.
3.4
3.4. Analysis
Comparison 3 Botulinum A toxin injection combined with non‐surgical therapy, Outcome 4 urodynamic measurement: bladder compliance.
3.5
3.5. Analysis
Comparison 3 Botulinum A toxin injection combined with non‐surgical therapy, Outcome 5 amelioration degree.
4.1
4.1. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 1 postvoid residual urine measured by catheterisation.
4.2
4.2. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 2 urodynamic measurement: maximal detrusor pressure on voiding at 1 month.
4.3
4.3. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 3 urodynamic measurement: maximal ureteral pressure at 1 month.
4.4
4.4. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 4 urodynamic measurement: decrease EUS activity in EMG at 1 month according to Blaivas' classification.
4.5
4.5. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 5 satisfactory score at 1 month.
4.6
4.6. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 6 autonomic dysreflexia symptoms at 1 month: patient reported disappearance of symptoms.
4.7
4.7. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 7 need to reinject at 1 month.
4.8
4.8. Analysis
Comparison 4 Botulinum A toxin injection versus other surgical therapy, Outcome 8 surgical outcome: tolerance score.
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