Is it necessary to perform surveillance investigations for long term follow up of spinal cord injury patients? Rizwan Hamid MBBS, FRCSEd, FRCS(Urol), MD(Res) Honorary Senior Lecturer & Consultant Urologist London Spinal Injuries Centre & University College London Hospitals 1 Introduction Bladder dysfunction in SCI patients Aims of treatment / follow-up in SCI population The investigations for urinary tract monitoring Current surveillance study Similar studies for long term follow-up International Guidelines Summary Future Conclusions Prevalence Europe: 252 per million 1 SCI with Bladder Dysfunction: Vast majority with SCI have voiding dysfunction 2 Total with UI Europe: ~19% 3 Type of Disease: Majority are a result of trauma 2 Age of Onset: Majority 30 40 years old and male 4 Life Expectancy: Spinal Cord Injury (SCI) Spinal cord lesions can be traumatic, vascular, medical or congenital 5 Related to severity of injury 4 1. Wyndaele M et al. Spinal Cord. 2006;44:523-529. 2. Bladder Management for Adults with Spinal Cord Injury. Consortium for Spinal Cord Medicine. August 2006. 3. Guly HR. Resuscitation. 2008;76(1):57-62. 4. Foundation for SCI Prevention, Care & Cure. Spinal Cord Injury Facts. Available at: www.fscip.org/facts.htm. Accessed April 2013. 5. Pannek J. European Association of Urology. Guidelines on neurogenic lower urinary tract dysfunction. 2011. http://www.uroweb.org/gls/pdf/17_neurogenic%20luts.pdf. Accessed April 2013. 4 1
Bladder symptoms in neurogenic diseases Frequency, urgency & incontinence are commonly reported in NDO population 10% of patients with stroke develop NBD 1 in 10 patients present with bladder symptoms at time of MS diagnosis 2 Up to 75% of MS patients report some form of UI 3 Vast majority of SCI patients have NBD 4 Aims of treatment of NBD Protection of the upper urinary tract Achieving urinary continence Improvement in QoL Restoration of LUT function Avoiding complications Cost effectiveness of treatment 1. Patel et al Stroke 2001; 32: 122-127; 2. McCombe PA et al. Expert Rev Neurotherap. 2009;9:331-340 5; 3. Mahajan ST et al. J Urol. 2010;183:1432-1437 4. Bladder Management for Adults with Spinal Cord Injury. Consortium for Spinal Cord Medicine. August 2006 1. Stohrer M. Eur Urol 2009;56:81 8. 2. Pannek J. European Association of Urology. Guidelines on neurogenic lower urinary tract dysfunction. 2011. Available from http://www.uroweb.org/gls/pdf/17_neurogenic% 20LUTS.pdf. Spinal Cord Injury: survival The consequence of effective therapy Long Term Survival 20 year survival First world war (1914-1918) <5% Second World war (1939-1945) 29% Korean war (1950-1953) 64% Present day 85% Improved life expectancy Compared to general population Cervical lesions 79% Thoracic/lumbar lesions 86% Complete lesion: mean life expectancy 70% for tetraplegics 84% for paraplegics Incomplete lesions: mean life expectancy More than 90% for both tetra & paraplegics JD Yeo et al, spinal cord. 1998 May; 36(5) 2
Post SCI causes of death Main causes of death post SCI are: -Septicaemia -Pneumonia -Urinary tract disease -Suicide However, the Major cause of death in 1 st two years post SCI is urinary tract disease Surveillance investigations of SCIP Video urodynamics studies Renal ultrasound scans Screening cystoscopy for Ca bladder to detect any significant urinary tract abnormalities The protocol for undertaking these studies is not standardised but it is generally agreed that SCI patients do need a life long follow-up Soden RJ, Walsh J. Causes of death after spinal cord injury: Spinal Cord:2000 Oct;38(10):604-10. 10 Current Study The aim of this study was to assess if there is a need for regular imaging studies in follow up of SCI patients Methods We evaluated the role of VCMG or USS in influencing the management decisions of SCI patients with a minimum of 5 years follow up All patient admitted to our SCI centre in a single year (2005) were included in the study All VCMG or USS undertaken as part of patient s bladder rehabilitation programme were evaluated All follow up changes were recorded during the 5 year period to 2010 11 12 3
Results A total of 23 patients were identified There were 15 male and 8 females All had a traumatic SCI 18 were upper motor neuron lesion 5 had a lower motor neuron lesion The patients had an average of 2.5 USS Results All but three patients underwent VCMG The remaining 3 patients did not complain of any urinary symptoms and had a normal flow rate with no significant residual urine Patients had an average of 2.1 (0-4) VCMG 13 14 Results Seventeen (74%) otherwise asymptomatic patients had a change in their management instituted as a result of these investigations Results Pts required surgical change Pts required medical change Pts required no changes VCMG USS VCMG USS 9 of them underwent a surgical intervention Botox injection to bladder STING procedure Anti-incontinence operations UMNL LMNL 7/18 (33.3) 1/5 (20) 1/18 (5.5) 0/5 7/18 (38) 1/5 (20) 0/18 0/5 3/18 (16.6) 3/5 (60) 15 16 4
Summary of study Bladder dysfunction after SCI is a dynamic process Most of these changes occur in patients with UMNL The changes in lower & upper tract can be insidious and a high index of suspicion is required We feel a proactive approach with regular VCMG and USS in asymptomatic patients is necessary to keep the urinary tract safe in this patient group 17 Lisenmeyer TA, J Spinal Cord Med:2013:36:420-26 Urodynamic changes were compared with their previous annual urodynamic evaluation The main outcome measure was whether or not there was a need for an intervention based on the urodynamics Impact of type of bladder management & level of injury was evaluated Ninety-six consecutive individuals with SCI undergoing annual urodynamic evaluations were enrolled over a 5-month period 47.9% of individuals required at least one type of intervention based on urodynamic studies 82.6% were urological interventions The need for interventions did not appear to be influenced by the type of bladder management or level of injury Annual urodynamic evaluation plays an important role in guiding bladder management following SCI Patki P, Hamid R. et al:j Urol:2006:175:1784-87 Patients attending with isci during a 2-year period were identified At the time of discharge 40/64 patients (62.5%) could void spontaneously 19/40 patients (47.5%) who had been initially assessed as having a bladder that was safe to void spontaneously required SIC Conversely 5/20 patients (25%) who initially required CSIC improved At last follow-up 68.7% of the patients had abnormal urodynamics 24/64 (37.5%) required a change in urological management despite no appreciably detectable neurological change Despite relatively near total neurological recovery patients with incomplete SCI have neuropathic bladder unless proved otherwise Salient deterioration in bladder dysfunction is not uncommon Regular urological monitoring and appropriate treatment changes are required in the long term 5
Longitudinal cohort study spanning 6 years, studying patients with SCI for at least 20 years Structural/ functional renal deficits accumulate over time for all management methods High proportion of patients change bladder management method over time Indwelling catheters are the method of last resort Spinal Cord:2010:48:257-61 SCI is known risk factor for Ca bladder (16-28) All CaB in SCI patients over 14 years 32 identified 46.9% SCC Primary bladder management was urethral in 44% Mean duration was 33.3 years 42% detected on screening cystoscopy 36 SCI patients with long tern SPC Mean duration 12.1 years Yearly screening bladder biopsies No tumors identified SCI is a risk factor and long term screening is required for all 6
Guidelines for follow up of patients with Neurogenic bladder Summary Bladder management in SCI patients is a dynamic process Lifelong follow up is essential It appears that surveillance investigations should be undertaken regularly to optimise the function of LUT EAU Guidelines 2012 edition Future High quality trials are required & possible Multicentre studies to be undertaken MS/ SCI predominance; what about other conditions - stroke, dementia, Parkinson s? Problems caused by the heterogeneous population Neurological variability Confounded by non-neurological processes; aging, childbirth Achieving equipoise; e.g. urodynamics in MS Methodological flaws e.g. cross-sectional cohorts Conclusions Bladder dysfunction after SCI is a dynamic process Most of these changes can occur in patients with UMNL The changes in lower & upper tract can be insidious and a high index of suspicion is required A proactive approach with regular VCMG and USS in asymptomatic patients is necessary to keep the urinary tract safe in this patient group Life long follow-up of SCI patients is recommended 27 28 7
Thank you 29 8