The following article appears in the March 1998 issue of Outspoken and is reprinted here with permission from The Robson Clinic and The Canadian Paraplegic Association of Ontario. A spotlight on the Charles J. Robson Clinic, Lyndhurst Spinal Cord CentreThe Urolume Urethral Stent (American Medical Systems Inc.)
Detrusor External Sphincter DyssynergiaHigh pressure bladder secondary to Detrusor External Sphincter Dyssynergia (DESD) is a very common problem experienced by individuals who have damage to the spinal cord. After trauma to the spinal cord, the sphincter control may be spastic, resulting in the sphincter staying snug even though the bladder contracts, causing a very high bladder pressure. If the bladder pressure is allowed to remain high, it can ultimately force the urine in the bladder to back up, causing damage to the kidneys, renal failure and infections in some people.
What are the Options?
Initially, most patients try a combination of intermittent catheterization and Ditropan, a medication used to lower bladder pressure. This is not always successful however, especially if the patient can not do their own IC due to poor hand function. A surgical option in the past has been a sphincterotomy, which is an incision into the sphincter muscle to open it up. The urine drains out and is collected by condom drainage. (Unfortunately, the female anatomy does not allow for condom drainage as an alternative!) The sphincterotomy usually requires a few days admission to a general hospital, and often is accompanied by rather significant bleeding, and an indwelling catheter until healing occurs in about 1 - 2 weeks. Impotency may result and the failure rate is as high as 40 - 50 %.
At the Robson Clinic, we feel that the Urolume is an easier and safer alternative to the sphincterotomy. The Urolume is a metal flexible mesh prosthesis that is inserted into the urethra and placed over the external sphincter, holding it open with a constant, gentle force. Over a few months, a layer of tissue grows over the wall of the Urolume making a smooth, open passageway to allow urine to pass freely. This is performed on an outpatient basis. Generally there is only minimal bleeding over the first 2 -3 days. Some activities must be modified or held for the first week to minimize bleeding. For example, digital bowel stimulation must not be aggressive, and no "rough" transfers.
The Urolume - Robson Clinic Experience
Since 1991, Dr. MacMillan has inserted over 70 Urolumes for DESD, which is the highest number in North America. We have found the Urolume to be highly successful in lowering bladder pressures thereby reducing the risk of urine backing up into the kidneys, as shown through urodynamic testing.
Our experience has demonstrated less than a 10% rejection rate, where the Urolume began to "uncover" and needed to be removed. Most of the failures were early in our experience when we used a shorter prosthesis, ie: we're getting better at this! Rarely, a second or third Urolume had to be used to cover the length of the sphincter if the Urolume was too short. The best candidates for this procedure are individuals who have strong detrusor contractions and good emptying under high pressure. Unfortunately we have found that if the bladder pressures were borderline before the Urolume, the emptying may not be adequate and a catheterization performed once or twice a day may be necessary. Now individuals with this pattern must be considered very carefully to determine whether or not they are appropriate for it. In addition to these criteria, we have found that people who have had previous sphincterotomies are not suitable because the scar tissue at the site of the sphincterotomy does not allow the epithelial tissue to cover the Urolume properly.
In summary, this is a very good alternative for individuals that cannot do intermittent catheterization throughout the day because of limited hand function, or failure to keep the bladder pressure low. Certainly, the majority of individuals who have had the Urolume inserted say it has been very successful and that it has made life a lot easier for them! Please don't have a sphincterotomy until you consider a Urolume! We have models available to explain the whole thing better to you, plus a list of satisfied customers you can call.
Please call the Robson Clinic for further information, at 416 597-3422 ext. 6218.
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