4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 with adverse urodynamic parameters, we typically recommend clinical reassessment includingurodynamic evaluation 3 months after the first injection. Other preparations of botulinum toxin, while less commonly utilized, appear to offer similar outcomes. AbobotulinumtoxinA (Dysport) is generally used at a dose of 750 IU. In one study, it was used as successful salvage therapy in over half of patients after failed treatment with onabotulinumtoxinA. 18 Surgical management of NDO Surgical management of NDO with either bladder augmentation or urinary diversion is generally reserved for situations where medical methods have failed to achieve acceptable continence. Surgical intervention is also indicated in situations where ongoing adverse urodynamic findings, such as poor bladder compliance, risks progressive upper urinary tract deterioration that may progress to renal failure. Bladder augmentation is the preferred method of surgical treatment of NDO. It provides the advantage of keeping the native urinary tract otherwise intact as access to the upper tracts via preservation of the native ureteral orifices. This is important as this populationhas a higher risk of upper tract urolithiasis. The functional and clinical outcomes of bladder augmentation using a bowel segment in patients with NDO are consistent and predictable. 19 Reliable improvements in bladder compliance, urinary incontinence, and quality of life are consistent. 20 Although any bowel segment may be used, ileum and colon are most commonly chosen in clinical practice. There are a number of absolute and relative contraindications to bladder augmentation. The most important absolute contraindication is inability to perform intermittent catheterization, such as those with quadriplegia, or those unwilling to perform intermittent catheterization. Bladder augmentation should not be considered in patients with a history of bladder cancer. Metabolic alterations may result when augmented bowel segments are exposed to urine as these segments have preserved absorptive and secreting properties. Evaluation for chronic kidney disease remains important in order to minimize the risk of clinicallymeaningful hyperchloremic metabolic acidosis that may develop in patients undergoing bladder augmentation with ileal or colonic segments. In general, candidates for bladder augmentation should have a creatinine clearance over 40 mL/min. Other patient specific factors include inflammatory bowel disease or prior extensive bowel resection. Functional bowel loss may affect absorption of not only nutrients, but also water from small and large bowel. A change in bowel habits in this population, particularly loose or frequent bowel movements, may dramatically impact quality of life. While metabolic complications are uncommon in properly selected patients, there are several long term complications of bladder augmentation including the formation of bladder stones, intraperitoneal bladder rupture, and the development of adenocarcinoma or urothelial carcinoma. The risk of bladder stone formation canbeminimizedby implementing a bladder irrigation regimen to prevent mucus accumulation. Intraperitoneal bladder rupture is uncommon in adult patients with bladder augmentation. Great care with patient selection to assure compliance with recommended catheterization regimens and prompt attention to difficulty with catheterization minimizes this potentially life-threatening complication. Incontinent or continent urinary diversion may be offered as a final option for patients who have failed more conservative management. In patients able to do intermittent catheterization through a catheterizable, abdominal stoma, continent diversion may be considered. This option carries many of the same long term risks as bladder augmentation including metabolic complications and urolithiasis. 21 Continent diversion should only be offered in patients with adequate renal function due to the large segment of intestine exposed to urine. Other potential complications include ureteral-intestinal anastomotic stricture, stomal stenosis, stomal incontinence, peristomal hernias, and urolithiasis. Incontinent urinary diversion is usually considered a last resort option. In properly selected andmotivated patients, urinary diversion can offer significant improvement in long term quality of life. The ileal conduit is the most commonly utilized form of incontinent urinary diversion. Although it generally allows preserved renal function in the short tomedium term period, patients with longstanding incontinent urinary diversionwith ileal conduits may see a gradual decline in renal function. The incontinent ileovesicostomy also allows continuous drainage of urine using an intestinal stoma. Advantages of this reconstruction is that it avoids the need for cystectomy and maintains normal anatomy of the ureterovesical junction allowing access to the upper tracts for endoscopic management of stones. 22 Disadvantages include the potential increase of malignancy due to preservation of the bladder segment as well as the potential for urethral incontinence. The ileovesicostomy is effective in preserving renal function by allowing low-pressure storage and Clark ET AL. 36