Urethral Surgeries


Q: I am C5-6 complete quad. Up until now I have been voiding naturally and using convenes (external catheters) with no problems since my injury eight years ago. Recently I started getting recurring UTIs. A urodynamics test last week confirmed that something needs to be done. The urologist gave me a choice of either a surgical sphincterotomy or a suprapubic catheter, neither of which I am keen on. My wife is now doing intermittent catheters every night and morning for me until I can get something done.
 
I read about a urethral sphincter stent and am wondering if this may be an option for me. Other than this, I feel my preferred choice would be to try the chemical sphincterotomy. However, would either of these options shrink my bladder?
— David

A: David, your question is a good reminder to those of us with spinal cord injuries to continue regular follow-up visits with a urologist. The fact that your bladder situation changed eight years after injury underscores this. Your question also points out the importance of doing research and discussing pros and cons (including possible complications) with your urologist before having any type of procedure. I suggest you read about the suprapubic catheter option in the August Bladder Matters. In this column I will discuss pros and cons of the other three procedures you mention.

All three procedures — sphincterotomy, chemical sphincterotomy, and sphincter stent — open up the urethral sphincter (the muscle that holds the urine in the bladder). When researching information about bladder management and SCI you will come across an important term: detrusor-sphincter dyssynergia (DSD). In layperson’s terms DSD means the detrusor muscle (the muscle that contracts the bladder in order to void) contracts — but the sphincter muscle remains tight and doesn’t release urine, which creates high bladder pressure — not good. High bladder pressure causes bladder scarring, and reflux — urine backing up into the kidneys, which can cause permanent kidney damage. And dyssynergia means impairment of voluntary movement — meaning you can’t voluntarily contract detrusor muscle and relax the sphincter muscle to void.

The goal of each of these procedures is to achieve low Leak Point Pressure (LPP) and low residual volume of urine in the bladder. LPP is the pressure in the bladder when urine starts to flow. A tight sphincter muscle causes LPP to go up. Even if the detrusor muscle isn’t contracting the bladder, a tight sphincter muscle without catheterization enables the bladder to overfill which can result in scarring and reflux.

Residual volume is the amount of urine left in the bladder after voiding. If there is bacteria in the bladder, most of it gets flushed out each time the bladder empties. On the other hand, residual volume of urine in the bladder is like a stagnant pond — it gives bacteria a place to multiply and make a stronghold.

Of the three procedures you mentioned, chemical sphincterotomy is the least invasive and easiest to try (assuming that your insurance gives you pre-authorization). Since chemical sphincterotomy is temporary — lasting around 6 months — you are not locked into it if you don’t like the results. We also covered this procedure in the August Bladder Matters column.

Now on to surgical sphincterotomy, also known as external sphincterotomy or transurethral sphincterotomy. Surgical sphincterotomy remains a viable option in the treatment of DSD — especially when somebody has limited hand function. On the plus side, when it works it is convenient: All you have to deal with is management of your external catheter and emptying your leg bag. Journal articles define surgical sphincterotomies as successful when they reduce incidence of UTI, reduce urinary retention, lower bladder pressure, lower LPP, and prevent pressure-induced kidney damage.

On the downside, journal articles say that a significant number of men (around 25 percent) continued to have one or more of these symptoms following the procedure. In some cases the problem was resolved with a follow-up sphincterotomy. In some cases it turned out there were obstructions in other areas like the bladder neck, and some people ended up going with other options, such as a suprapubic catheter.

Dr. Mark Fredrickson, a physical medicine and rehab doc and residency program head and at University Hospital in San Antonio, Texas, says that if you are considering the procedure it is important to find a skilled surgeon that has plenty of experience in the procedure. The procedure itself is done through a cystoscope — a catheter with a camera on the end. A tiny electrocautery scalpel is passed through the cystocsope and the sphincter is cut at the 12 o’clock position to make the sphincter “incompetent.” After the area is cauterized to stop the bleeding, a large Foley catheter is placed to make sure there is a wide passage and to minimize any bleeding. The Foley is usually removed within 24 to 48 hours after the procedure.

Possible complications include blood loss, and the possibility of a blood transfusion if the surgeon cuts too deep. The procedure can also be done with a laser, which reduces the chances of blood loss dramatically. Historically, the risk of losing reflex erection capability was about 30 percent; however, the current technique of cutting the sphincter at the 12 o’clock position, rather than the previous technique of cutting at the 3 and 9 o’clock position, greatly reduces the possibility this side effect.

Dr. Fredrickson also points out that a surgical sphincterotomy doesn’t last a lifetime. It will usually scar up, or the sphincter itself will heal over time. You may need another one 4 to 5 years down the road. He says that with a sphincterotomy it is important to come in for a yearly urodynamic follow-up to make sure the bladder pressure isn’t getting too high and there is no urine reflux.

A urethral stent is a braded wire mesh tube that can be inserted in the urethra to hold the sphincter open. The stent is put in place and over time it becomes epithelialized (covered with skin). The surgery required to place the stent is minimally invasive and the stent can be removed — but removal may not be easy if epithelization is extensive.

Journal studies on stents report they work well in the short term but have a high rate of complication over the long term. Two years ago Dr. Fredrickson published a poster presentation on stents. At the time San Antonio Hospital had seen a 100 percent complication rate in stents. He says that they no longer offer stents as a first or second option for bladder management. They will still use them when appropriate but try other options first.

Complications in stents include the stent migrating; scarring or encrustation of the stent; or having a kidney stone plug the stent. Any of these complications can cause a life-threatening emergency. You can’t pass a catheter through a stent, so if it gets clogged you would need to go to an emergency room immediately. If doctors weren’t able to clear the blockage they would need to put in an emergency suprapubic catheter. By contrast, if a chemical or surgical sphincterotomy stops working you would still have the option of using an intermittent catheter.

To answer your question about any of these procedures causing your bladder to shrink: Urologists say there is no scientific evidence that this occurs. Bladder shrinkage happens more because of bladder over-activity and high bladder pressure (as scar tissue builds up, the bladder becomes less elastic, i.e. smaller). This is another reason to continue regular urological follow-up visits.

I hope this helps. Best of luck with your choice and please keep us posted.


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