Urinary diversion/reconstruction for cases of catheter intolerant secondary progressive multiple sclerosis with refractory urinary symptoms.
ABSTRACT We assessed surgical outcomes for patients intolerant of catheters with secondary progressive multiple sclerosis undergoing urinary diversion/reconstruction for refractory urinary symptoms.
Patients with secondary progressive multiple sclerosis treated with ileovesicostomy, enterocystoplasty and ileal loop surgeries were reviewed for demographic, operative and postoperative data. All patients had attempted maximal conservative therapy, including catheterization options. Evaluated outcome measures included incidence of postoperative urinary incontinence, urinary tract infections and Clavien grade 3 or higher complications.
A total of 26 patients (22 female) with secondary progressive multiple sclerosis underwent 15 ileovesicostomy, 7 enterocystoplasty and 4 ileal loop procedures. All patients had significant neurological impairment (mean Expanded Disability Status Scale 7), and the most common indications for surgery were chronic urinary tract infection (77%) and refractory incontinence (77%). Maximum preoperative bladder capacity was 185 cc and mean bladder compliance was 5.7 cc/cm H(2)O. After a mean followup of 16 months 63% of patients were continent (p = 0.01) and 58% had no further urinary tract infections (p = 0.03). The type of diversion/reconstruction was not associated with significantly improved continence or urinary tract infection reduction. No new upper tract changes developed in any patients. There were 11 high grade complications, and patients with a preoperative indwelling catheter (HR 5.89, p = 0.024), diabetes (HR 5.60, p = 0.009) and increasing blood loss during surgery (HR 1.09, p = 0.014) were at greatest risk for significant complications.
Patients with secondary progressive multiple sclerosis treated with urinary diversion/reconstruction who cannot tolerate catheters had improved continence and fewer urinary tract infections. However, patients with secondary progressive multiple sclerosis with preoperative indwelling catheters, diabetes, increased body mass index and increasing operative blood loss were at greatest risk for postoperative morbidity.
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ABSTRACT: AimsSince lower urinary tract dysfunction (LUTD) related to multiple sclerosis (MS) has a different behavior pattern than other types of neurogenic voiding dysfunction, we aimed to prepare a national consensus report for the management of LUTD due to multiple sclerosis in light of available literature. MethodsA search of available databases yielded an evidence base of 125 articles after the application of inclusion/exclusion criteria. When sufficient evidence existed, recommendations A (high), B (moderate), or C (low) were made according to the strength of evidence; recommendation D was provided when insufficient evidence existed. ResultsAvailable data did not support the use of invasive urodynamics in the initial evaluation of patients with MS and LUTD. Clinical studies on the safety and efficacy of antimuscarinics and alpha-blockers in these patients were scarce and low quality. Desmopressin could be used in MS-related overactive bladder symptoms owing to its short-term effects as an adjunctive treatment. Intravesical botulinum toxin type A treatment in patients with MS and detrusor overactivity was recommended in cases of medical treatment failure or severe side effects due to antimuscarinics. Pelvic floor rehabilitation together with neuromuscular electrical stimulation was also recommended as it increased symptomatic treatment success. This systematic review was not able to find any evidence-based cut off post-void residual value for the recommendation to start clean intermittent catheterization in MS-related LUTD. Conclusions Patients with MS and LUTD could be best managed through the use of this consensus report. Neurourol. Urodynam. 32:1047-1057, 2013. (c) 2013 Wiley Periodicals, Inc.Neurourology and Urodynamics 11/2013; 32(8). DOI:10.1002/nau.22374 · 2.67 Impact Factor
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ABSTRACT: Multiple sclerosis is commonly associated with bladder dysfunction, which is frequently reported to be the worst aspect of the disease. Patients may experience bothersome bladder symptoms early in the course, and this should be explored. If necessary, a formal evaluation of the lower urinary tract should be offered. The type of bladder dysfunction may also change with time, which highlights the need for continual follow-up assessments. Anticipated problems are incomplete bladder emptying and disorders with urine storage, which may occur simultaneously. This may lead to symptoms of overactive bladder and recurrent urinary tract infections. Conservative measures for management should be used initially while other sinister pathology is excluded. Newer treatments such as botulinum toxin A and neural stimulation techniques are replacing more invasive surgical procedures. Treatment approaches have been described and should be offered by teams who are familiar with patients having uro-neurological complaints.Current Bladder Dysfunction Reports 06/2012; 7(2). DOI:10.1007/s11884-012-0129-8