Accepted Manuscript Title: Detrusor-External Sphincter Dyssynergia: Review of Minimally Invasive and Endoscopic Management Author: Yanina Barbalat, Matthew Rutman PII: DOI: Reference:
S0090-4295(16)00083-2 http://dx.doi.org/doi: 10.1016/j.urology.2015.11.049 URL 19591
To appear in:
Urology
Received date: Accepted date:
31-7-2015 30-11-2015
Please cite this article as: Yanina Barbalat, Matthew Rutman, Detrusor-External Sphincter Dyssynergia: Review of Minimally Invasive and Endoscopic Management, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2015.11.049. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Detrusor-external sphincter dyssynergia: Review of minimally invasive and endoscopic management
1
Yanina Barbalat, M.D. Matthew Rutman
1
Fellow in Voiding Dysfunction and Female Pelvic Medicine Corresponding Author E-mail: [email protected] 161 Fort Washington Avenue, HIP 11 New York, NY, USA 10032 Telephone: 212-305-0144
Key Words: Detrusor-external sphincter dyssynergia, neurogenic bladder, external urethral sphincterotomy, laser, endoscopic surgery
Abstract Word Count: 77 Manuscript Word Count: 2,915
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Acknowledgements/Conflict of Interest: Yanina Barbalat: None Matthew Rutman: Lecturer for American Medical Systems
Abstract Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. Management of this condition includes the use of antimuscarinic agents in combination with intermittent catheterization, indwelling urethral catheterization, suprapubic catheterization, and a variety of surgical options, depending on patient and physician preference. This paper will review the current literature and data on minimally invasive and endoscopic management of DSD.
Introduction:
Bladder storage and emptying requires continual coordination of the detrusor and external urinary sphincter, both mediated by the central and peripheral nervous systems1. Various neurologic conditions such as traumatic spinal cord injury (SCI), multiple sclerosis, myelodysplasia and other forms of transverse myelitis may lead to abnormalities in coordination between the detrusor muscle and the external urethral sphincter.
Detrusor sphincter dyssynergia (DSD) is defined by the International Continence Society2 as “detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle” and is characterized by involuntary
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contractions of the external urethral sphincter (EUS) during an involuntary detrusor contraction. In the absence of neurological abnormality, impaired coordination of bladder contraction and sphincter relaxation is more appropriately referred to as dysfunctional voiding (DV)1.
Up to 50% of patients with DSD develop serious urological complications. Untreated DSD has been associated with reduced bladder compliance, bladder outlet obstruction with possible bladder calculi formation, elevated upper tract pressures, vesico-ureteral reflux (VUR), hydronephrosis and renal failure. In those patients with lesions above T6, DSD with its accompanying urinary retention may lead to autonomic dysreflexia, resulting in dangerously elevated blood pressure. If this is not promptly managed, it can lead to stroke, seizures and even death3.
Methods:
A PubMed search for papers from 1970 to 2015 was conducted using the words “detrusor external sphincter dyssynergia treatment”. A total of 191 papers were obtained. After case reports, abstracts only, and papers not in English were excluded, 102 articles remained. We reviewed all case series, review papers, cohort studies, and retrospective and prospective studies which were relevant to the topic covered in this review. In addition, we searched and reviewed all relevant articles on the topic of detrusor external sphincter dyssynergia in “Neurourology and Urodynamics” from 20002015.
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Diagnosis of DSD
The diagnosis of DSD should be suspected in any patient with a neurologic lesion involving the spinal cord. The correct diagnosis is best attained by videourodynamic evaluation with EMG monitoring but in patients with incomplete injuries who spontaneously void, the condition can be initially screened for by performing uroflowmetry and a post void residual. Cystometry allows evaluation of the storage phase during bladder filling by measuring the change in intravesical pressure with changes in bladder volume. Cystometry also assesses detrusor leak point pressure, a direct reflexion of the resistance of the external sphincter. This allows a clinician to assess the volume of the bladder at which the detrusor pressure reaches dangerous levels. Other abnormal cystometric findings in patients with DSD include decreased bladder compliance and a steeply rising detrusor pressure curve on the cystometrogram4. McGuire at al showed that sustained pressures of 40 cm of H20 or higher during storage phase can lead to upper tract damage5.
Normally, voluntary voiding is preceded by complete relaxation of the external sphincter on EMG. In DSD the onset of the detrusor contraction is typically preceded by an increase in sphincter EMG activity. If EMG is unavailable, fluoroscopy during videourodynamics can be used to detect external sphincter contraction during an elevation in detrusor pressure in the pressure-flow phase of the study3. Classic fluoroscopic findings would include a narrowing at the membranous urethra with
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contrast pooling in the prosthatic urethra during the voiding phase. Vesico-ureteral reflux and a “Christmas tree” bladder may also be seen, suggesting long-term obstruction.
Management of DSD
Therapy for DSD is designed to eliminate or significantly lessen the resistance of the external sphincter or circumvent it altogether. The goal is to lessen storage and voiding pressure to below 40 cm of H2O in order to prevent long term complications 6. In patients with sufficient manual dexterity the most reasonable treatment option is to abolish involuntary detrusor contractions and then to institute intermittent selfcatheterization in order to empty the bladder and circumvent the sphincter. The bladder may be paralyzed pharmacologically using antimuscarinic agents. However, antimuscarinic agents are not exclusively selective for the bladder and may cause intolerable side effects. In addition, for patients in whom intermittent catheterization is not possible, an indwelling catheter to ensure adequate drainage may be required. However, permanent catheterization carries many complications such as urethral erosion formation, calculus formation, recurrent gross hematuria, and recurrent urinary tract infections. A systemic review looked at noninfectious complication of indwelling catheterization in patients with spinal cord injury and found a 13% pooled frequency of gross hematuria in patients with spinal cord injury and long-term indwelling catheters. They also found a 27.2% frequency of bladder stones and 8.7% pooled frequency of urethral stricture or erosion in male patients with indwelling catheters and spinal cord
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injury. Results of studies that included women were too variable for pooling but also included the same set of complications7. Groah et al8 showed that after controlling for
age at injury, gender, level and completeness of SCI, history of bladder calculi, and smoking, those patients using solely indwelling catheters had a significantly greater risk of bladder cancer (relative risk [RR] = 4.9; 95% CI, 1.3-13.8) than those using non-indwelling methods8. Although suprapubic catheterization eliminates the risk of urethral erosion and stricture, it is often complicated by calculus formation, blockage, infection and also carries a risk of metaplasia and carcinoma4.
Due to complications associated with indwelling catheters, external sphincterotomy in male patients has been the traditional management route in patients with DSD who are unable to catheterzie and do not desire a diversion. This procedure eliminates the resistance of the external sphincter, causing incontinence, which is then managed with an external urinary appliance such as a condom catheter. The goals of external sphincterotomy are to stabilize or improve renal function, prevent urosepsis, lower detrusor leak point pressure, stabilize or eliminate VUR and eliminate the need for indwelling catheters.
Following a successful sphincterotomy, improvement in bladder emptying and stabilization of the upper urinary tract can be achieved in 70% to 90% of patients. This procedure is primarily performed in male tetraplegics and in individuals with increased residual urine and high pressure voiding following failure of conservative management 6.
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Techniques for Performing an External Urethral Sphincterotomy
In 1956 Ross et al9 reported the results of 10 cases in which the external sphincter was deliberately divided in spinal cord injured patients with bladder outlet obstruction. A cold punch was used to remove tissue posteriolaterally at the level of the external sphincter. No electrocoagulation was used and a large bore catheter was inserted to tamponade bleeding. Blood transfusions were given routinely. One patient died from bleeding and one from uremia. Since then, this technique has been refined.
Currently, the most established technique for performing a sphincterotomy involves using a Colling’s electrocautery knife to make an anterior (11, 12 or 1 o’clock) incision beginning at the level of the proximal part of the verumontanum and ending in the corpus spongiosum of the bulbar urethra6. The resection can also be performed using a loop electrode10.
According to many studies, this technique is very effective. Although the majority of patients in published series did not have hydronephrosis or VUR prior to the surgery, external urethral sphincterotomy was effective in curing reflux in 75% of the patients that presented with VUR11. Febrile and recurrent urinary tract infections resolved in 74-77% of the patients12,13. Autonomic dysreflexia resolved in 93-100% of patients12,13. Mean residual urine volume fell from 210 ml pre-operatively to 100 ml following sphincterotomy, in one of the largest patient series (n=92)13.
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Persistence of hydronephrosis or VUR, continued recurrent urinary infection or autonomic dysreflexia represent a failure of external sphincterotomy. The reasons for failure may be inadequate sphincterotomy with persistent DSD or impaired detrusor contractility resulting in poor bladder emptying and thus persistent UTIs, and/or urethral stricture. Management of failed sphincterotomy consists of either repeat sphincterotomy or catheter drainage. Persistent obstruction due to bladder neck obstruction can be managed by a trial of alpha adrenergic blocking drugs or by bladder neck incision or resection11.
Because the depth of the incision during external sphincterotomy can be difficult to gauge, heavy bleeding may be encountered11. Hemorrhage with blood transfusion has been reported in 0-23% of patients, depending on the location of the incision11. Impotence rate of 7% has been reported after anterior sphincterotomy14,15 and a urethral stricture rate of 3-13% 15,16,17 was reported in most recent series. Overall, 15 - 40% of patients subsequently require a repeat sphincterotomy11.
Laser Sphincterotomy with Neodymium: yttrium-aluminum-garnet (Nd: YAG) Laser
In an effort to minimize peri-operative blood loss, external sphincterotomy has also been performed using a laser. Perkash et al performed a laser sphincterotomy with a sapphire tip contact Neodymium: yttrium-aluminum-garnet (Nd:YAG) laser in 76 spinal cord injured men. Blood loss was less than 50 ml in 97.4% of patients18. An indwelling
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Foley catheter was left in place for about 24 hours and the majority of the patients were discharged the next day. All patients were followed for at least 6 months for a mean period of 27 months. Sixty-nine patients (92%) had adequate voiding, minimal to absent autonomic dysreflexia and no significant symptomatic urinary tract infections. There were seven patients who required repeat laser surgery within 2 to 5 months 18.
Rivas et al19 used a Nd:YAG laser for external sphincterotomy in 22 spinal cord injured men with DSD (and three men with concurrent bladder neck obstruction). Mean duration of surgery was 45 min and mean hospitalization was 2.7 days. No blood transfusions were required. At 12 months of follow-up mean voiding pressure had fallen from 87 to 47 cm H2O and residual urine volume from 122 to 33 ml. Recurrent sphincter obstruction at 12 months occurred 14% of the patients19.
Other Endoscopic Options for Relieving Urethral Pressure in Patients with DSD
Implantable Stents and Balloon Dilation
Implantable stents are also an alternative treatment to a traditional external sphincterotomy and are thought to achieve a similar effect. Chancellor et al showed the implantable UroLume® stent to be equally effective as traditional external sphinterotomy in a prospective randomized multicenter trial20. At 12 months voiding pressures in both treatment arms were reduced by 50% and patients reported somewhat to much better emptying with either technique. Autonomic dysreflexia improved in nine out of 16 (56%)
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patients in the external sphincterotomy group and in 13 out of 18 men (72%) after stent insertion. UroLume stent placement was associated with less morbidity and this option made it an attractive alternative to conventional sphincterotomy. Six out of 31 stents had to be removed, most commonly for stent migration, and was accomplished easily in all cases20.
Sauerwein et al used the UroLume stent in 51 patients with SCI and DSD. The patients were followed between 12 and 36 months and improvements in bladder compliance, detrusor voiding pressure, and autonomic dysreflexia were seen21.
After longer term follow of up to 5 years, stent migration in 12% of the patients, insufficient coverage of the external sphincter with a single stent in 28% of the patients, and encrustation and obstruction with urothelial hyperplasia within the stent lumen were complications most commonly reported with UroLume stents22.
Recently, another group looked at 20 year follow up data of 12 patients who underwent UroLume stent placement for DSD23. This is the longest follow up data available. Six patients were lost to follow up. Two out of the 12 patients developed stent encrustation causing obstruction. The stents were removed in these patients without difficulty. In the six patients, there was a significantly sustained reduction of maximum detrusor pressure (94 to 67 cm H2O) and duration of detrusor contraction (130 to 69 seconds) at the 20year follow-up. Five of these six patients developed bladder neck dyssynergia within the first 9 years of follow-up causing UTIs, VUR, and bladder stones. All were successfully
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treated with bladder neck incision without further complications23.
Chancellor et al15 also compared balloon dilatation of the sphincter using the OptiLume Prostate Dilator to 3 atm pressure against 12 o'clock sphincterotomy and the Urolume stent. Each patient selected his own treatment. Forty percent of those who elected to undergo sphincterotomy had undergone a prior sphincterotomy, while only 27% and 15% of those who elected to undergo stent placement or balloon dilation, respectively, had had a prior sphincterotomy. In theory, failure to respond to a previous sphincterotomy might have reduced the chance of subsequent successful sphincterotomy, thus introducing bias into the study and potentially making the results of balloon dilatation and stenting seemingly more favorable. Allowing for this, the results suggested that both balloon dilatation and stenting were comparable with sphincterotomy as far as resolution of urinary tract infections and hydronephrosis as well as a reduction in post void residual of urine and maximum voiding pressures at 12 months post treatment. Blood transfusion was required in 5% of the patients in the balloon dilation group. No repeat sphincterotomies were required at up to 12 months of follow-up15. However, other authors reported an 85% failure rate after balloon dilation after 55 months of follow up and concluded that balloon dilatation `cannot be recommended for the treatment of DESD’24.
Intersphincteric Injection of Botulinum-A toxin
Botulinum toxin (BTX-A) is an inhibitor of acetylcholine release at the neuromuscular
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junction, which can decrease muscle contractility for 3–6 months. It was first reported as a treatment for DSD by Dykstra et al in 11 patients with SCI, with reduction of urethral pressure and PVR25. Schurch and co-workers later reported that in 21 of 24 patients with DSD, a significant reduction of 48% in maximum urethral pressure was observed. Nine out of 24 patients had a mean decrease in PVR of 130 ml, although in eight patients the PVR remained high. PVR remained unchanged in the remaining seven patients, in which it was less than 50 ml before treatment. Bladder neck dyssynergia is independent of DESD and may explain why PVR remained high in some patients. In the subset of patients with autonomic dysreflexia, no improvement in their condition was seen26.
De Seze et al performed a randomized, double blind, lidocaine- controlled study evaluating 13 patients with DSD and spinal cord injury. They used 100 units of Botulinum- A toxin vs. 4 ml of lidocaine and found a significant decrease in PVRs as well as maximal urethral pressure at 1 month follow up27. An overall satisfaction rate of 60.6% was reported with BTX-A treatment28.
A recent study by Chen et al29 prospectively evaluated 20 patients with SCI who were injected with a single dose of 100 u BTX-A. There were significant reductions in integrated electromyography and static and maximal urethral pressure, but not in maximal detrusor pressure and detrusor leak point pressure after treatment. Because of this, some authors proposed the treatment with concomitant BTX-A injection to the detrusor and EUS for those with both DSD and detrusor hyper-reflexia26. PVRs were
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significantly decreased up to 6 months after treatment. No adverse effects were noted29.
Future Prospects
Sacral Dermatome Neuromodulation
Recently, McCoin et al30 showed that patterned stimulation of sacral afferent pathways may reduce abnormal EUS reflexes in cats. Four adult cats were implanted with sacral root electrodes and underwent subsequent spinal cord transection. Although abnormal reflexive EUS contractions were seen in all 4 animals prior to stimulation, following patterned sacral dermatome stimulation, EUS reflex rate and amplitude in two out of four animals was reduced. Unfortunately, recent studies in humans were not as promising31. Ten subjects with chronic SCI underwent S2 and S3 dermatome stimulation during bladder filling and sphincter pressures were recorded. Differences in bladder and sphincter pressures were compared between control and afferent stimulation periods. No significant reduction in sphincter or bladder pressures were observed for any stimulus location or pattern tested. The group concluded that stimulation parameters and locations effective in suppressing urethral reflex mechanisms in animals were not effective in human subjects. Additionally, it is likely that a larger range of stimulus patterns and/or locations are necessary to determine if urethral reflex suppression can be achieved in humans31.
Pudendal Nerve Block
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Tsai et al32 recently showed that pudendal nerve block may be effective potential treatment for DSD in both animals and humans. Twenty-two male patients with SCI were injected with 5% phenol into the pudendal nerve. Urodynamics were performed 1 month post procedure and all outcome measures significantly improved in these patients, including a decrease in PVR (242.8 ml), decrease in leak point pressure, maximal detrusor pressure, and increase in Quality of Life Index. Decrease in frequency and amplitude of autonomic dysreflexia was also observed in 5 out of 6 patients. Results were maintained for 3 months. Another group also showed that high frequency, biphasic stimulation of the pudendal nerve causes a reversible block of EUS contractions in cats and may be a potential method for suppressing DSD in SCI patients33.
Conclusion:
DSD is a complex problem in neurogenic patients and can have profound effects on renal function, quality of life, and even life expectancy. There are multiple medical and minimally invasive surgical options for managing DSD depending on patient’s physical abilities, social situation and physician preference. Unfortunately, prospective studies and studies with long term follow up are lacking in patients with DSD. Furthermore, because neurogenic patients are a very heterogeneous group in terms of their comorbidities, follow up, and social situations, it becomes very difficult to conduct sound studies in this patient population. Although external sphincterotomy using a cold knife
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has traditionally been a gold standard procedure for patients with DSD, laser sphincterotomy and intersphincteric botulinum A toxin injection may be appropriate alternatives that carry less morbidity with similar efficacy. However, once more data is available, even less invasive therapies such as pudendal nerve block and neuromodulation may play a greater role in the management of patients with DSD in the future.
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sphincter balloon dilatation and prosthesis placement with external sphincterotomy in spinal cord injured men. Arch Phys Med Rehabil. 1994; 75: 297-305. 16.
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Rivas DA, Chancellor MB, Staas WB JR, et al. Contact neodymium:yttrium-
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American multicenter UroLume trial for the treatment of external detrusor-sphincter dyssynergia. J Urol. 1999; 161(5):1545-50. 23.
Abdul-Rahman A, Ismail S, Hamid R, et al. A 20-year follow-up of the mesh
wallstent in the treatment of detrusor external sphincter dyssynergia in patients with spinal cord injury. BJU Int. 2010; 106(10):1510-3. 24.
McFarlane JP, Foley SJ, Shah PJR. Long-term outcome of permanent urethral
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sacral dermatomes suppress urethral sphincter reflexes in individuals with spinal cord injury? Neurourol Urodyn. 2015; 34(3):219-23. 32. Tsai SJ, Lew HL, Date E, et al. Treatment of detrusor-sphincter dyssynergia by pudendal nerve block in patients with spinal cord injury. Arch Phys Med Rehabil. 2002;
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83(5):714-7. 33. Tai C, Roppolo JR, de Groat WC. Response of external urethral sphincter to high frequency biphasic electrical stimulation of pudendal nerve. J Urol. 2005; 174(2):782-6.
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Editorial Comment: Detrusor-external sphincter dyssynergia: Review of minimally invasive and endoscopic management
Jerry G. Blaivas, M.D. Clinical Professor of Urology, Weill Cornell Medical College Adjunct Professor of Urology, SUNY Downstate Medical School 445 E 77th St New York, NY 10075 Office: (212) 772 3900 Fax: (212) 772 1919 Cell: (917) 273 6563
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This review by Barbalat and Rutman nicely summarizes the state of the art of minimally invasive therapies for detrusor sphincter dyssynergia (DSD). DSD is an abnormal voiding reflex, seen almost exclusively in patients with suprasacral neurologic lesions of the spinal cord. It is characterized by an involuntary contraction of the striated urethra sphincter and an involuntary detrusor contraction (1,2,3). The net result is that the patient is obstructed by the sphincter contraction and incontinent when the detrusor contraction overpowers the sphincter or when the sphincter relaxes. Because of the obstruction, untreated patients with DSD are at risk for serious upper tract deterioration, stones and infection. As the authors correctly point out, DSD should be distinguished from dysfunctional voiding which has similar urodynamic findings, but is seen in neurologically normal people who have a maladapted response to lower urinary tract symptoms. The ideal treatment for DSD is to abolish the abnormal dyssynergic voiding reflex and replace it with a normal micturition reflex. To date, this goal has not been achieved and the objective of contemporary treatment has been to either relieve the obstruction and manage the incontinence or abolish the involuntary detrusor contractions and manage the urinary retention. The authors review modern techniques designed to relieve the urethral obstruction including external sphincterotomy, urethral stents, balloon dilation, and intrasphincteric injection of Botulinum toxin (BTX-A). In their conclusion, they bemoan the poor quality of the studies – an opinion that we sadly share. The prospective studies are few, the numbers are small, follow up is short, and many are lost to followup. So, conclusions and recommendations are largely anecdotal. In our judgment, the most practical approach to treatment of DSD is to abolish or abort the involuntary detrusor contractions with anticholinergic medications, intradetrusor Botox injections or augmentation enterocystoplasty and manage the retention with intermittent self-catheterization. When that is not practical, external sphincterotomy and condom catheter should be considered the gold standard (perhaps bronze standard would be a better term considering the fact that 15 to 40% of patients require another sphincterotomy). Despite some promising reports, in our judgment, neither urethral stents nor balloon dilation are very good treatments, The former come with too many reported and unreported long term complications and the latter is simply ineffective. External sphinterotomy, in the hands of an expert surgeon, has minimal morbidity and can be safely performed in well under an hour. Several technical features should be kept in mind. The authors recommend a standard technique of external sphincterotomy “beginning at the level of the proximal part of the verumontanum and ending in the corpus spongiosum of the bulbar urethra.” While this serves as a general guide, in many patients the obstruction begins more proximally, as far back as the bladder neck, and the sphincter contraction may extend further into the bulb. Rather than using arbitrary anatomical landmarks, we rely on two parameters- the proximal extent of obstruction
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seen on the voiding cystourethrogram and the distal extent of sphincter contraction noted by performing a bulbocavernosus reflex which is done both during the surgery and diagnostic cystoscopy. We prefer electrocautery using a Collings knife to laser sphincterotomy because we believe that the former allows much more precision as to the length and depth of the incision. For the sphincterotomy, we recommend a 12 o’clock incision down to the tunica albuginea of the corpora cavernosum. During surgery, the left hand presses down on the shaft of the resectoscope so that the tip of the Collings knife can be kept in view at all times and does not get buried in the muscle. The Collings knife is moved back and forth with a scratching kind of motion as the fibers of the urethral sphincter are seen to retract laterally until the shiny white surface of the tunica is seen. In our judgment, this technique offers the best chance of success, but the ravages of time may take their toll and recurrent obstruction due to the prostate, bladder neck or urethral stricture are not uncommon. So, what of the future? We are not yet there and we see little on the horizon. The problem is the wiring and until there is a way to restore a normal micturition reflex, treatment will be relegated to circumventing the problem. 1) Blaivas, J. G., Sinha, H. P., Zayed, A. A. H., Labib, K. B., Detrusor-external sphincter dyssynergia, J. Urol., 125:541, 1981. 2) Blaivas, J. G., Sinha, H. P., Zayed, A. A. H., Labib, K. B.,Detrusor external sphincter dyssynergia: a detailed EMG study, J. Urol, 125: 545, 1981. 3) Blaivas, J. G., The Neurophysiology of Micturition: A clinical study of 550 patients, J. Urol., 127:958, 1982.
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S0090-4295(16)00083-2 http://dx.doi.org/doi: 10.1016/j.urology.2015.11.049 URL 19591
To appear in:
Urology
Received date: Accepted date:
31-7-2015 30-11-2015
Please cite this article as: Yanina Barbalat, Matthew Rutman, Detrusor-External Sphincter Dyssynergia: Review of Minimally Invasive and Endoscopic Management, Urology (2016), http://dx.doi.org/doi: 10.1016/j.urology.2015.11.049. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Detrusor-external sphincter dyssynergia: Review of minimally invasive and endoscopic management
1
Yanina Barbalat, M.D. Matthew Rutman
1
Fellow in Voiding Dysfunction and Female Pelvic Medicine Corresponding Author E-mail: [email protected] 161 Fort Washington Avenue, HIP 11 New York, NY, USA 10032 Telephone: 212-305-0144
Key Words: Detrusor-external sphincter dyssynergia, neurogenic bladder, external urethral sphincterotomy, laser, endoscopic surgery
Abstract Word Count: 77 Manuscript Word Count: 2,915
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Acknowledgements/Conflict of Interest: Yanina Barbalat: None Matthew Rutman: Lecturer for American Medical Systems
Abstract Detrusor-external sphincter dyssynergia (DSD) is a debilitating problem in patients with spinal cord injury. DSD carries a high risk of complications, and even life expectancy can be affected. Management of this condition includes the use of antimuscarinic agents in combination with intermittent catheterization, indwelling urethral catheterization, suprapubic catheterization, and a variety of surgical options, depending on patient and physician preference. This paper will review the current literature and data on minimally invasive and endoscopic management of DSD.
Introduction:
Bladder storage and emptying requires continual coordination of the detrusor and external urinary sphincter, both mediated by the central and peripheral nervous systems1. Various neurologic conditions such as traumatic spinal cord injury (SCI), multiple sclerosis, myelodysplasia and other forms of transverse myelitis may lead to abnormalities in coordination between the detrusor muscle and the external urethral sphincter.
Detrusor sphincter dyssynergia (DSD) is defined by the International Continence Society2 as “detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle” and is characterized by involuntary
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contractions of the external urethral sphincter (EUS) during an involuntary detrusor contraction. In the absence of neurological abnormality, impaired coordination of bladder contraction and sphincter relaxation is more appropriately referred to as dysfunctional voiding (DV)1.
Up to 50% of patients with DSD develop serious urological complications. Untreated DSD has been associated with reduced bladder compliance, bladder outlet obstruction with possible bladder calculi formation, elevated upper tract pressures, vesico-ureteral reflux (VUR), hydronephrosis and renal failure. In those patients with lesions above T6, DSD with its accompanying urinary retention may lead to autonomic dysreflexia, resulting in dangerously elevated blood pressure. If this is not promptly managed, it can lead to stroke, seizures and even death3.
Methods:
A PubMed search for papers from 1970 to 2015 was conducted using the words “detrusor external sphincter dyssynergia treatment”. A total of 191 papers were obtained. After case reports, abstracts only, and papers not in English were excluded, 102 articles remained. We reviewed all case series, review papers, cohort studies, and retrospective and prospective studies which were relevant to the topic covered in this review. In addition, we searched and reviewed all relevant articles on the topic of detrusor external sphincter dyssynergia in “Neurourology and Urodynamics” from 20002015.
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Diagnosis of DSD
The diagnosis of DSD should be suspected in any patient with a neurologic lesion involving the spinal cord. The correct diagnosis is best attained by videourodynamic evaluation with EMG monitoring but in patients with incomplete injuries who spontaneously void, the condition can be initially screened for by performing uroflowmetry and a post void residual. Cystometry allows evaluation of the storage phase during bladder filling by measuring the change in intravesical pressure with changes in bladder volume. Cystometry also assesses detrusor leak point pressure, a direct reflexion of the resistance of the external sphincter. This allows a clinician to assess the volume of the bladder at which the detrusor pressure reaches dangerous levels. Other abnormal cystometric findings in patients with DSD include decreased bladder compliance and a steeply rising detrusor pressure curve on the cystometrogram4. McGuire at al showed that sustained pressures of 40 cm of H20 or higher during storage phase can lead to upper tract damage5.
Normally, voluntary voiding is preceded by complete relaxation of the external sphincter on EMG. In DSD the onset of the detrusor contraction is typically preceded by an increase in sphincter EMG activity. If EMG is unavailable, fluoroscopy during videourodynamics can be used to detect external sphincter contraction during an elevation in detrusor pressure in the pressure-flow phase of the study3. Classic fluoroscopic findings would include a narrowing at the membranous urethra with
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contrast pooling in the prosthatic urethra during the voiding phase. Vesico-ureteral reflux and a “Christmas tree” bladder may also be seen, suggesting long-term obstruction.
Management of DSD
Therapy for DSD is designed to eliminate or significantly lessen the resistance of the external sphincter or circumvent it altogether. The goal is to lessen storage and voiding pressure to below 40 cm of H2O in order to prevent long term complications 6. In patients with sufficient manual dexterity the most reasonable treatment option is to abolish involuntary detrusor contractions and then to institute intermittent selfcatheterization in order to empty the bladder and circumvent the sphincter. The bladder may be paralyzed pharmacologically using antimuscarinic agents. However, antimuscarinic agents are not exclusively selective for the bladder and may cause intolerable side effects. In addition, for patients in whom intermittent catheterization is not possible, an indwelling catheter to ensure adequate drainage may be required. However, permanent catheterization carries many complications such as urethral erosion formation, calculus formation, recurrent gross hematuria, and recurrent urinary tract infections. A systemic review looked at noninfectious complication of indwelling catheterization in patients with spinal cord injury and found a 13% pooled frequency of gross hematuria in patients with spinal cord injury and long-term indwelling catheters. They also found a 27.2% frequency of bladder stones and 8.7% pooled frequency of urethral stricture or erosion in male patients with indwelling catheters and spinal cord
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injury. Results of studies that included women were too variable for pooling but also included the same set of complications7. Groah et al8 showed that after controlling for
age at injury, gender, level and completeness of SCI, history of bladder calculi, and smoking, those patients using solely indwelling catheters had a significantly greater risk of bladder cancer (relative risk [RR] = 4.9; 95% CI, 1.3-13.8) than those using non-indwelling methods8. Although suprapubic catheterization eliminates the risk of urethral erosion and stricture, it is often complicated by calculus formation, blockage, infection and also carries a risk of metaplasia and carcinoma4.
Due to complications associated with indwelling catheters, external sphincterotomy in male patients has been the traditional management route in patients with DSD who are unable to catheterzie and do not desire a diversion. This procedure eliminates the resistance of the external sphincter, causing incontinence, which is then managed with an external urinary appliance such as a condom catheter. The goals of external sphincterotomy are to stabilize or improve renal function, prevent urosepsis, lower detrusor leak point pressure, stabilize or eliminate VUR and eliminate the need for indwelling catheters.
Following a successful sphincterotomy, improvement in bladder emptying and stabilization of the upper urinary tract can be achieved in 70% to 90% of patients. This procedure is primarily performed in male tetraplegics and in individuals with increased residual urine and high pressure voiding following failure of conservative management 6.
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Techniques for Performing an External Urethral Sphincterotomy
In 1956 Ross et al9 reported the results of 10 cases in which the external sphincter was deliberately divided in spinal cord injured patients with bladder outlet obstruction. A cold punch was used to remove tissue posteriolaterally at the level of the external sphincter. No electrocoagulation was used and a large bore catheter was inserted to tamponade bleeding. Blood transfusions were given routinely. One patient died from bleeding and one from uremia. Since then, this technique has been refined.
Currently, the most established technique for performing a sphincterotomy involves using a Colling’s electrocautery knife to make an anterior (11, 12 or 1 o’clock) incision beginning at the level of the proximal part of the verumontanum and ending in the corpus spongiosum of the bulbar urethra6. The resection can also be performed using a loop electrode10.
According to many studies, this technique is very effective. Although the majority of patients in published series did not have hydronephrosis or VUR prior to the surgery, external urethral sphincterotomy was effective in curing reflux in 75% of the patients that presented with VUR11. Febrile and recurrent urinary tract infections resolved in 74-77% of the patients12,13. Autonomic dysreflexia resolved in 93-100% of patients12,13. Mean residual urine volume fell from 210 ml pre-operatively to 100 ml following sphincterotomy, in one of the largest patient series (n=92)13.
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Persistence of hydronephrosis or VUR, continued recurrent urinary infection or autonomic dysreflexia represent a failure of external sphincterotomy. The reasons for failure may be inadequate sphincterotomy with persistent DSD or impaired detrusor contractility resulting in poor bladder emptying and thus persistent UTIs, and/or urethral stricture. Management of failed sphincterotomy consists of either repeat sphincterotomy or catheter drainage. Persistent obstruction due to bladder neck obstruction can be managed by a trial of alpha adrenergic blocking drugs or by bladder neck incision or resection11.
Because the depth of the incision during external sphincterotomy can be difficult to gauge, heavy bleeding may be encountered11. Hemorrhage with blood transfusion has been reported in 0-23% of patients, depending on the location of the incision11. Impotence rate of 7% has been reported after anterior sphincterotomy14,15 and a urethral stricture rate of 3-13% 15,16,17 was reported in most recent series. Overall, 15 - 40% of patients subsequently require a repeat sphincterotomy11.
Laser Sphincterotomy with Neodymium: yttrium-aluminum-garnet (Nd: YAG) Laser
In an effort to minimize peri-operative blood loss, external sphincterotomy has also been performed using a laser. Perkash et al performed a laser sphincterotomy with a sapphire tip contact Neodymium: yttrium-aluminum-garnet (Nd:YAG) laser in 76 spinal cord injured men. Blood loss was less than 50 ml in 97.4% of patients18. An indwelling
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Foley catheter was left in place for about 24 hours and the majority of the patients were discharged the next day. All patients were followed for at least 6 months for a mean period of 27 months. Sixty-nine patients (92%) had adequate voiding, minimal to absent autonomic dysreflexia and no significant symptomatic urinary tract infections. There were seven patients who required repeat laser surgery within 2 to 5 months 18.
Rivas et al19 used a Nd:YAG laser for external sphincterotomy in 22 spinal cord injured men with DSD (and three men with concurrent bladder neck obstruction). Mean duration of surgery was 45 min and mean hospitalization was 2.7 days. No blood transfusions were required. At 12 months of follow-up mean voiding pressure had fallen from 87 to 47 cm H2O and residual urine volume from 122 to 33 ml. Recurrent sphincter obstruction at 12 months occurred 14% of the patients19.
Other Endoscopic Options for Relieving Urethral Pressure in Patients with DSD
Implantable Stents and Balloon Dilation
Implantable stents are also an alternative treatment to a traditional external sphincterotomy and are thought to achieve a similar effect. Chancellor et al showed the implantable UroLume® stent to be equally effective as traditional external sphinterotomy in a prospective randomized multicenter trial20. At 12 months voiding pressures in both treatment arms were reduced by 50% and patients reported somewhat to much better emptying with either technique. Autonomic dysreflexia improved in nine out of 16 (56%)
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patients in the external sphincterotomy group and in 13 out of 18 men (72%) after stent insertion. UroLume stent placement was associated with less morbidity and this option made it an attractive alternative to conventional sphincterotomy. Six out of 31 stents had to be removed, most commonly for stent migration, and was accomplished easily in all cases20.
Sauerwein et al used the UroLume stent in 51 patients with SCI and DSD. The patients were followed between 12 and 36 months and improvements in bladder compliance, detrusor voiding pressure, and autonomic dysreflexia were seen21.
After longer term follow of up to 5 years, stent migration in 12% of the patients, insufficient coverage of the external sphincter with a single stent in 28% of the patients, and encrustation and obstruction with urothelial hyperplasia within the stent lumen were complications most commonly reported with UroLume stents22.
Recently, another group looked at 20 year follow up data of 12 patients who underwent UroLume stent placement for DSD23. This is the longest follow up data available. Six patients were lost to follow up. Two out of the 12 patients developed stent encrustation causing obstruction. The stents were removed in these patients without difficulty. In the six patients, there was a significantly sustained reduction of maximum detrusor pressure (94 to 67 cm H2O) and duration of detrusor contraction (130 to 69 seconds) at the 20year follow-up. Five of these six patients developed bladder neck dyssynergia within the first 9 years of follow-up causing UTIs, VUR, and bladder stones. All were successfully
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treated with bladder neck incision without further complications23.
Chancellor et al15 also compared balloon dilatation of the sphincter using the OptiLume Prostate Dilator to 3 atm pressure against 12 o'clock sphincterotomy and the Urolume stent. Each patient selected his own treatment. Forty percent of those who elected to undergo sphincterotomy had undergone a prior sphincterotomy, while only 27% and 15% of those who elected to undergo stent placement or balloon dilation, respectively, had had a prior sphincterotomy. In theory, failure to respond to a previous sphincterotomy might have reduced the chance of subsequent successful sphincterotomy, thus introducing bias into the study and potentially making the results of balloon dilatation and stenting seemingly more favorable. Allowing for this, the results suggested that both balloon dilatation and stenting were comparable with sphincterotomy as far as resolution of urinary tract infections and hydronephrosis as well as a reduction in post void residual of urine and maximum voiding pressures at 12 months post treatment. Blood transfusion was required in 5% of the patients in the balloon dilation group. No repeat sphincterotomies were required at up to 12 months of follow-up15. However, other authors reported an 85% failure rate after balloon dilation after 55 months of follow up and concluded that balloon dilatation `cannot be recommended for the treatment of DESD’24.
Intersphincteric Injection of Botulinum-A toxin
Botulinum toxin (BTX-A) is an inhibitor of acetylcholine release at the neuromuscular
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junction, which can decrease muscle contractility for 3–6 months. It was first reported as a treatment for DSD by Dykstra et al in 11 patients with SCI, with reduction of urethral pressure and PVR25. Schurch and co-workers later reported that in 21 of 24 patients with DSD, a significant reduction of 48% in maximum urethral pressure was observed. Nine out of 24 patients had a mean decrease in PVR of 130 ml, although in eight patients the PVR remained high. PVR remained unchanged in the remaining seven patients, in which it was less than 50 ml before treatment. Bladder neck dyssynergia is independent of DESD and may explain why PVR remained high in some patients. In the subset of patients with autonomic dysreflexia, no improvement in their condition was seen26.
De Seze et al performed a randomized, double blind, lidocaine- controlled study evaluating 13 patients with DSD and spinal cord injury. They used 100 units of Botulinum- A toxin vs. 4 ml of lidocaine and found a significant decrease in PVRs as well as maximal urethral pressure at 1 month follow up27. An overall satisfaction rate of 60.6% was reported with BTX-A treatment28.
A recent study by Chen et al29 prospectively evaluated 20 patients with SCI who were injected with a single dose of 100 u BTX-A. There were significant reductions in integrated electromyography and static and maximal urethral pressure, but not in maximal detrusor pressure and detrusor leak point pressure after treatment. Because of this, some authors proposed the treatment with concomitant BTX-A injection to the detrusor and EUS for those with both DSD and detrusor hyper-reflexia26. PVRs were
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significantly decreased up to 6 months after treatment. No adverse effects were noted29.
Future Prospects
Sacral Dermatome Neuromodulation
Recently, McCoin et al30 showed that patterned stimulation of sacral afferent pathways may reduce abnormal EUS reflexes in cats. Four adult cats were implanted with sacral root electrodes and underwent subsequent spinal cord transection. Although abnormal reflexive EUS contractions were seen in all 4 animals prior to stimulation, following patterned sacral dermatome stimulation, EUS reflex rate and amplitude in two out of four animals was reduced. Unfortunately, recent studies in humans were not as promising31. Ten subjects with chronic SCI underwent S2 and S3 dermatome stimulation during bladder filling and sphincter pressures were recorded. Differences in bladder and sphincter pressures were compared between control and afferent stimulation periods. No significant reduction in sphincter or bladder pressures were observed for any stimulus location or pattern tested. The group concluded that stimulation parameters and locations effective in suppressing urethral reflex mechanisms in animals were not effective in human subjects. Additionally, it is likely that a larger range of stimulus patterns and/or locations are necessary to determine if urethral reflex suppression can be achieved in humans31.
Pudendal Nerve Block
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Tsai et al32 recently showed that pudendal nerve block may be effective potential treatment for DSD in both animals and humans. Twenty-two male patients with SCI were injected with 5% phenol into the pudendal nerve. Urodynamics were performed 1 month post procedure and all outcome measures significantly improved in these patients, including a decrease in PVR (242.8 ml), decrease in leak point pressure, maximal detrusor pressure, and increase in Quality of Life Index. Decrease in frequency and amplitude of autonomic dysreflexia was also observed in 5 out of 6 patients. Results were maintained for 3 months. Another group also showed that high frequency, biphasic stimulation of the pudendal nerve causes a reversible block of EUS contractions in cats and may be a potential method for suppressing DSD in SCI patients33.
Conclusion:
DSD is a complex problem in neurogenic patients and can have profound effects on renal function, quality of life, and even life expectancy. There are multiple medical and minimally invasive surgical options for managing DSD depending on patient’s physical abilities, social situation and physician preference. Unfortunately, prospective studies and studies with long term follow up are lacking in patients with DSD. Furthermore, because neurogenic patients are a very heterogeneous group in terms of their comorbidities, follow up, and social situations, it becomes very difficult to conduct sound studies in this patient population. Although external sphincterotomy using a cold knife
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has traditionally been a gold standard procedure for patients with DSD, laser sphincterotomy and intersphincteric botulinum A toxin injection may be appropriate alternatives that carry less morbidity with similar efficacy. However, once more data is available, even less invasive therapies such as pudendal nerve block and neuromodulation may play a greater role in the management of patients with DSD in the future.
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83(5):714-7. 33. Tai C, Roppolo JR, de Groat WC. Response of external urethral sphincter to high frequency biphasic electrical stimulation of pudendal nerve. J Urol. 2005; 174(2):782-6.
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Editorial Comment: Detrusor-external sphincter dyssynergia: Review of minimally invasive and endoscopic management
Jerry G. Blaivas, M.D. Clinical Professor of Urology, Weill Cornell Medical College Adjunct Professor of Urology, SUNY Downstate Medical School 445 E 77th St New York, NY 10075 Office: (212) 772 3900 Fax: (212) 772 1919 Cell: (917) 273 6563
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This review by Barbalat and Rutman nicely summarizes the state of the art of minimally invasive therapies for detrusor sphincter dyssynergia (DSD). DSD is an abnormal voiding reflex, seen almost exclusively in patients with suprasacral neurologic lesions of the spinal cord. It is characterized by an involuntary contraction of the striated urethra sphincter and an involuntary detrusor contraction (1,2,3). The net result is that the patient is obstructed by the sphincter contraction and incontinent when the detrusor contraction overpowers the sphincter or when the sphincter relaxes. Because of the obstruction, untreated patients with DSD are at risk for serious upper tract deterioration, stones and infection. As the authors correctly point out, DSD should be distinguished from dysfunctional voiding which has similar urodynamic findings, but is seen in neurologically normal people who have a maladapted response to lower urinary tract symptoms. The ideal treatment for DSD is to abolish the abnormal dyssynergic voiding reflex and replace it with a normal micturition reflex. To date, this goal has not been achieved and the objective of contemporary treatment has been to either relieve the obstruction and manage the incontinence or abolish the involuntary detrusor contractions and manage the urinary retention. The authors review modern techniques designed to relieve the urethral obstruction including external sphincterotomy, urethral stents, balloon dilation, and intrasphincteric injection of Botulinum toxin (BTX-A). In their conclusion, they bemoan the poor quality of the studies – an opinion that we sadly share. The prospective studies are few, the numbers are small, follow up is short, and many are lost to followup. So, conclusions and recommendations are largely anecdotal. In our judgment, the most practical approach to treatment of DSD is to abolish or abort the involuntary detrusor contractions with anticholinergic medications, intradetrusor Botox injections or augmentation enterocystoplasty and manage the retention with intermittent self-catheterization. When that is not practical, external sphincterotomy and condom catheter should be considered the gold standard (perhaps bronze standard would be a better term considering the fact that 15 to 40% of patients require another sphincterotomy). Despite some promising reports, in our judgment, neither urethral stents nor balloon dilation are very good treatments, The former come with too many reported and unreported long term complications and the latter is simply ineffective. External sphinterotomy, in the hands of an expert surgeon, has minimal morbidity and can be safely performed in well under an hour. Several technical features should be kept in mind. The authors recommend a standard technique of external sphincterotomy “beginning at the level of the proximal part of the verumontanum and ending in the corpus spongiosum of the bulbar urethra.” While this serves as a general guide, in many patients the obstruction begins more proximally, as far back as the bladder neck, and the sphincter contraction may extend further into the bulb. Rather than using arbitrary anatomical landmarks, we rely on two parameters- the proximal extent of obstruction
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seen on the voiding cystourethrogram and the distal extent of sphincter contraction noted by performing a bulbocavernosus reflex which is done both during the surgery and diagnostic cystoscopy. We prefer electrocautery using a Collings knife to laser sphincterotomy because we believe that the former allows much more precision as to the length and depth of the incision. For the sphincterotomy, we recommend a 12 o’clock incision down to the tunica albuginea of the corpora cavernosum. During surgery, the left hand presses down on the shaft of the resectoscope so that the tip of the Collings knife can be kept in view at all times and does not get buried in the muscle. The Collings knife is moved back and forth with a scratching kind of motion as the fibers of the urethral sphincter are seen to retract laterally until the shiny white surface of the tunica is seen. In our judgment, this technique offers the best chance of success, but the ravages of time may take their toll and recurrent obstruction due to the prostate, bladder neck or urethral stricture are not uncommon. So, what of the future? We are not yet there and we see little on the horizon. The problem is the wiring and until there is a way to restore a normal micturition reflex, treatment will be relegated to circumventing the problem. 1) Blaivas, J. G., Sinha, H. P., Zayed, A. A. H., Labib, K. B., Detrusor-external sphincter dyssynergia, J. Urol., 125:541, 1981. 2) Blaivas, J. G., Sinha, H. P., Zayed, A. A. H., Labib, K. B.,Detrusor external sphincter dyssynergia: a detailed EMG study, J. Urol, 125: 545, 1981. 3) Blaivas, J. G., The Neurophysiology of Micturition: A clinical study of 550 patients, J. Urol., 127:958, 1982.
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