132 VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY

Re: US Pilot Study of Lumbar to Sacral Nerve Rerouting to Restore Voiding

and Bowel Function in Spina Bifida: 3-Year Experience

K. M. Peters, H. Gilmer, K. Feber, B. J. Girdler, W. Nantau, G. Trock, K. A. Killinger

and J. A. Boura
Beaumont Health System, Royal Oak and Oakland University William Beaumont School of Medicine, Rochester, Michigan,
and Urology Center of the Rockies, Fort Collins, Colorado
Adv Urol 2014; 2014: 863209. doi: 10.1155/2014/863209.

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24987412

Editorial Comment: The idea of a skinecentral nervous systemebladder reflux arc creation in
patients with spina bifida was first reported in the American literature in 2005, after animal
experimentation.1 Peters et al report their experience in creating such an arc with an intradural
lumbar-to-sacral motor route microanastomosis to restore bladder/bowel function in these patients.
Three-year data are presented, with 3 cases lost to followup being counted as failures. Of the 10
patients who returned 7 were labeled treatment responders and 9 had discontinued
antimuscarinics, “most” of whom still leaked urine. Only 2 of 8 patients with baseline neurogenic
detrusor overactivity (NDO) still had NDO. All 3 patients with compliance less than 10 ml/cm H2O
had normalized, 7 considered their bowels normal, 5 were continent of stool and 8 said they would
undergo the procedure again. Treatment success was defined as voiding with at least 50%
efficiency on uroflowmetry, using clean intermittent catheterization once per day, stable renal
ultrasound and renal function studies, and no worsening of motor function from baseline.
Secondary outcomes included evidence of a new neural pathway to elicit voiding, demonstrable by
at least 2 detrusor contractions during the same urodynamic study of at least 10 cc water detrusor
pressure while performing cutaneous stimulation of the operative dermatone. Other secondary
outcomes were changes in bladder compliance, neurogenic detrusor overactivity, and overall
changes in urinary and bowel function on questionnaires.
The 3 patients who did not return for followup included 1 with permanent foot drop, and all were
considered nonresponders because of a lack of positive response at their 2-year visit. Of the remaining
10 subjects only 4 were able to void at baseline and 8 were voiding at 3 years.
Using the definition of treatment success, nerve rerouting was successful in only 7 of the original
13 patients since 1 was voiding with only 47% efficiency. Of the 8 patients who were voiding at
3 years only 4 reported that their stream was strong, and all but 1 used Valsalva to initiate voiding.
One scratched the operative dermatone. Of the original cohort 2 of 8 patients with NDO still had
this at 3 years. Eight patients from the original cohort had demonstrated reproducible sustained
detrusor contractions with cutaneous stimulation at 12 months but only 2 still had reproducible
contractions at 3 years. Only 1 patient at 3 years was dry and the remainder had persistent stress
incontinence.
Five of 10 patients reported at least some improvement on a global response assessment. At 3 years
7 of 10 patients considered their bowels normal (compared to 4 of 13 at baseline), 5 of 10 were
continent of stool (compared to 2 of 13 at baseline). There was 1 patient with persistent foot drop. Two
patients had suspected cerebrospinal fluid leaks requiring another surgical procedure at 25 and
37 days postoperatively, and 12 of 13 patients had transient lower extremity weakness that resolved
by 12 months. Eight patients were able to void at 3 years (compared to 4 of 13 at baseline).
It appears that 1 of the original 13 patients was dry at 3 years (the 3 who did not return for followup
were nonresponders at their 2-year visit and were properly counted as failing treatment, and thus the
persistent use of the number 10 as the denominator in some of the results is a bit confusing). Prior
intrauterine closure became an exclusionary condition as the trial progressed, since the 1 patient
with foot drop had undergone intrauterine closure and 2 others did not achieve treatment success,
and it was felt by the surgeons that there was more scarring, making the surgery more difficult.
The clinical significance of not being able to demonstrate a cutaneous-to-bladder reflux arc on
urodynamic studies is difficult to understand. At 1 year 8 of 13 patients had a reproducible reflex. By
3 years this was demonstrated in only 2 patients, yet most could void efficiently using a degree of
Valsalva.
The authors themselves point out certain caveats regarding interpretation, including 1) there was
no control series, but the authors pointed out that such controls would be susceptible to the negative
 VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY 133

effects of growth spurts or tethered cord syndrome, and 2) it is possible, but the authors consider it
unlikely, that the outcomes may be related to coincidental cord detethering during the procedure.
Finally, the authors point out, and rightly so, that this is a very complex patient population, and
absolute normalization of bowel and bladder function is not a realistic goal. They further point out
that neurogenic dysfunction can be safely controlled with the use of pharmacological management
and intermittent catheterization, along with augmentation and a bowel regimen. They further point
out that in underdeveloped countries intermittent catheterization and antimuscarinics are not
readily available. They conclude, “Even though more data are needed to fully understand the impact
of this procedure, nerve rerouting has the potential to change how patients with neurogenic bladder
are managed.”

Alan J. Wein, MD, PhD (hon)

1. Xiao CG, Du MX, Li B et al: An artificial somatic-autonomic reflex pathway procedure for bladder control in children with spina bifida. J Urol 2005; 173: 2112.

Re: Does Cystocele Repair Improve Overactive Bladder Symptoms?

C. S. Fok
Department of Urology, University of Minnesota, Minneapolis, Minnesota
Curr Bladder Dysfunct Rep 2015; 10: 1e5. doi: 10.1007/s11884-014-0284-1

Abstract available at http://link.springer.com/article/10.1007%2Fs11884-014-0284-1

Editorial Comment: This is a review article regarding the apparent connection between the 2 topics
in the title. Although there is no mechanism that is agreed on consistently, there are data to
show that overactive bladder symptomatology may be related to anatomical changes in any vaginal
compartment. There are no data that correlate prolapse symptoms, degree of prolapse, or any uro-
dynamic test parameters to predict the occurrence or resolution of overactive bladder symptom-
atology. The author summarizes that anywhere from 50% to 90% of patients with concomitant
overactive bladder symptoms and pelvic organ prolapse will show improvement in their overactive
bladder symptomatology after prolapse repair. There is no evidence that types of prolapse repair,
suture vs mesh use or any other factor regarding the repair is related to the degree of improvement.
It is also noted that there have been very few long-term studies to show, in those who do
experience improvement, the duration of the improvement and whether the overactive bladder
symptoms occur.

Alan J. Wein, MD, PhD (hon)

Re: Vaginal Estrogen Use in Postmenopausal Women with Pelvic Floor

Disorders: Systematic Review and Practice Guidelines

D. D. Rahn, R. M. Ward, T. V. Sanses, C. Carberry, M. M. Mamik, K. V. Meriwether,

C. K. Olivera, H. Abed, E. M. Balk and M. Murphy; Society of Gynecologic
Surgeons Systematic Review Group
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
Int Urogynecol J 2015; 26: 3e13. doi: 10.1007/s00192-014-2554-z.

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25392183

Editorial Comment: This is a report by the Society of Gynecologic Surgeons Systematic Review
Group assessing the literature on vaginal estrogen and the management of pelvic floor disorders in
postmenopausal women. Of 1,805 abstracts they identify 12 eligible papers. They labeled evidence as
generally poor to moderate quality. Their conclusions included 1) vaginal estrogen before pelvic
organ prolapse surgery improved the maturation index and increased vaginal epithelial thickness;