Surgical Options

Surgical Procedures for Managing Detrusor Overactivity and Bladder Sphincter Dysfunction

Below is a list of surgical procedures that may be performed to manage issues with detrusor overactivity and bladder sphincter dysfunction. This is not a complete list of surgical options, and it is best to discuss any procedures with the treating Urologist or Spinal Injuries rehabilitation medical specialist. A specialist or GP can send a referral to the Spinal Injuries Unit outpatient to for any discussion for the following surgical options.

Sphincterotomy

A sphincterotomy is the transurethral resection of the external urethral sphincter. It requires the use of an external drainage device (urinary sheaths). This use of an external device means it was only used for males. This procedure is not performed as frequently anymore.

The risks with this method are:

• the need to have further procedures to maintain patency
• incomplete emptying
• detrusor changes from overdistension
• potential ureteric reflux.

Other issues with this management are related to skin irritation from sheath usage and issues with application due to reduced penile length.

A further complication with this method is perineal pressure

Mitrofanoff

The Mitrofanoff surgery involves forming a stoma connected to the bladder. The appendix is used to form a continent valve usually located over the umbilicus, making it discreet. This allows the person to pass an intermittent catheter directly into the bladder and remain continent with ease of access. It can be combined with a bladder augmentation (see below). The principles of intermittent clean self catheterisation (ICSC) should be adhered to.

Bladder Augmentation

Surgical augmentation of the bladder is performed to enhance bladder capacity. It is typically considered when conservative approaches to manage detrusor overactivity have failed and there is ongoing incontinence or renal deterioration. One method is the "clam-shell" ileocystoplasty, in which the bladder is opened like a clam and an isolated segment of intestine (ileum) is used to create a patch that is then sewn into the bladder. The outcome of having a bladder augmentation is the production of mucous from using a part of the bowel. To manage the mucous, the person may need to attend frequent high volume bladder washouts. This procedure is outlined in the bladder washout procedure.

Artificial Urinary Sphincter

The artificial urinary sphincter is an implantable device for males to resolve urethral leaking which can be common with lower motor neuron e.g. cauda equina injuries and mixed upper and lower motor neuron injuries e.g. Conus medullaris injuries. Risks with this can be device failure, infection and erosion of tissue around the device.

Image of an artificial urinary sphincter. The artificial sphincter wraps around and closes off the urethra. It is activated by a pump in the scrotum.

Mid-Urethral Sling

A mid-urethral sling is performed to resolve stress urinary incontinence in women. This risk in increased with women after a spinal cord injury due to the pelvic floor dysfunction. A sling helps re-establish the position of the urethra to gain closure and stop ongoing urinary leakage.

For more generic information on slings

Ileal Conduits or Bladder Stomas

An ileal conduit, bladder stoma or urostomy is surgery where a section of the intestine is used to create an attachment to the ureters and is formed as a stoma on the abdomen. This method of management means the bladder is no longer connected or used. The reason for choosing this procedure is because of ongoing leakage, sphincter dysfunction and possible renal complications. The bladder can be left in place or removed. This will be determined by the surgeon. Please see information on the bladder washout procedure if the bladder remains insitu.