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Fifty years of ICS: A Brief History of Neurourology

Wednesday 05 Aug 2020 {{NI.ViewCount}} Views {{NI.ViewCount}} Views

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Knowledge accumulated over more than two millennia provided the foundations for rapid advancements in Neuro-Urology that have occurred over the last century. Descriptions of the urinary bladder have been recorded in ancient Egypt (16th Century BC), India (Sushruta, Surgeon, 6th Century BC) and Greece (5th Century BC). References to herbal treatment for neurodegenerative disorders can be found in Ayurvedic texts from the 6th to 12th Century BC (Murthy, 2010). Dissection techniques progressively refined by Galen, Al-Baghdadi, Lucci, Vesalius and other ancient scientists helped define human anatomy. Modern day pioneers such as Tanagho and Elbadawi applied advancements in technology to study the urinary tract in microscopic detail to improve our fundamental understanding of Neuro-Urology.

The beginnings of modern day Neuro-Urology can be traced back to the early part of the 20th century that saw a surge in such patients due to spinal injury sustained during the world wars. Most patients who survived the initial trauma died eventually of urinary tract complications chiefly sepsis and renal failure until Guttman (1949) demonstrated the transformative role of sterile intermittent catheterization (IC). Later Lapides (1972) in what became the 20th most cited paper in Urology over half a century (Heldwin 2010) simplified the technique by introducing the concept of clean IC.

IC proved to be a simple yet revolutionary technique in Neuro-Urology. It provided an alternative to expression techniques. IC also avoided the damaging impact of voiding against elevated outlet resistance in patients with detrusor sphincter dyssynergia, a condition that was increasingly recognized as a marker for high-risk neurogenic bladder (Bors and Comarr, 1971; Bradley 1973). However, IC solved only one part of the Gordian knot of neurogenic lower urinary tract dysfunction, namely intractable voiding abnormality. While the fact that renal deterioration occurred with the passage of time in patients with spinal cord injury was well recognized (Bors and Comarr, 1971), the precise importance of safe storage was not well understood. Recognition of the importance of storage pressure in determining safety of the lower urinary tract proved to be a milestone.

One of the earliest publications was by Light (1978) who described deterioration of the upper tracts in children with myelodysplasia. This paper was published in the South African Journal of Surgery and did not receive wide attention. McGuire (1981) subsequently published his landmark paper on detrusor leak point pressure and while the precise threshold of safety described in his paper may no longer be regarded as appropriate, the article continues to be widely cited. Since then antimuscarinics have become standard of care for patients with storage pressure abnormalities, typically neurogenic detrusor overactivity. A progressive improvement in our understanding of the autonomic nervous system (Belt 1949, Gjone 1965, ElBadawi 1966) and its role in lower urinary tract function provided a foundation to these conceptual changes.

Over the last 50 years, the widespread use of urodynamics and the standardization of protocols championed by ICS have transformed management and follow-up of neurogenic lower urinary tract disease. The recognition that neurogenic dysfunction may evolve with time, especially in children, has led to universal guideline recommendations for follow up. In turn, this has led to a remarkable reduction in secondary chronic kidney disease. The concept of regular follow-up with appropriate monitoring of the upper and lower urinary tracts in now well established.

For management of storage phase, oral medications are effective and generally well tolerated but many patients fail to respond or tolerate these drugs. Augmentation cystoplasty, originally described by Von Mikulicz (1889) became the treatment of choice for such patients. Surgical techniques devised for alternative catheterizable conduits (Mitrofanoff, 1980; Yang and Monti, 1993, 1997) were a critical improvement for patients in whom urethral IC was not feasible. Augmentation was noted to be very effective at lowering storage pressures to an acceptable level and remains a valuable option to this day. However, the introduction of bowel into the urinary tract brought with it a new possible set of problems, including metabolic problems and the increased risk for neoplasms. Augmentation remains a valuable option in patients with intractable storage abnormalities but these problems present an unsolved challenge for future Neuro-Urology.

It is in this context that one must view the discovery of botulinum toxin injection therapy for the urinary tract. The underpinnings of this treatment were long in the making, starting with the identification of botulinum by Justinus Kerner in 1793 (Hanchanale 2010). Dyskstra (1981) injected the molecule into the sphincter of patients with detrusor sphincter dyssynergia. However, it was the large multicentric randomized trial reported by Schurch (2005) that paved the way for widespread use of intravesical botulinum injection for neurogenic detrusor overactivity.

All this while, the utopian (and largely elusive) goal for neurogenic bladders has always been restoration of spontaneous voiding. The earliest efforts in this direction can probably be traced back to 1878 when Saxtorph attempted direct stimulation of the bladder via a catheter (Madersbacher, 1999). Work by Brindley on sacral root stimulation (1972-77) and de Groat (1975-1997) as well as experiments by Tanagho and Schmidt (1982-1989) laid the foundations for neuromodulation. Currently, neuromodulation has limited role for patients with spinal injury or other forms of high-risk neurogenic bladder and is primarily used for improving intractable storage dysfunction in individuals with intact spinal reflexes.

The ICS has been at the forefront of promoting the understanding and teaching of Neuro-Urology and has helped advance it as a sub-specialty. To achieve this objective, the Neuro-Urology Promotion Committee (NUPC) was set up in 2004 by the strenuous efforts of Jacques Corcos, its first Chair. The aim of this Committee is to disseminate the knowledge of pathophysiology, diagnostic procedures and therapeutic interventions related to neuro-urologic conditions, and to assist centres requesting help in setting up, developing and promoting Neuro-Urology.

An ICS Fellowship in Neuro-Urology was set up specifically to support candidates from developing countries. The first fellowship in Neuro-Urology was successfully completed by Dr. Jianguo Wen, a urologist from China, under the supervision of Jacques Corcos in Montreal from January to March 2009.

The NUPC has gone from strength to strength and holds workshops and meetings all over the world. Under the present Chair (2015-2020), Emmanuel Chartier Kastler, the NUPC has recorded a series of lectures at the annual meetings from 2016-2019 that serve as an invaluable resource for teaching Neuro-Urology all over the world.

ICS supported the NUPC to publish the standardization of terminology in Neuro-Urology in 2017 under the direction of Jerzy Gajewski as Chair with Brigitte Schurch and Rizwan Hamid as Co-Chairs. This has been widely received as an excellent source by the membership and beyond.

The field of Neuro-Urology continues to evolve with new challenges from an ageing global population. Functional MR imaging of the central nervous system is a promising field that could yield new approaches to managment. Geriatric and neurodegenerative diseases require innovative new research. It is a sobering thought that the newest challenges faced by Neuro-Urology are where we began our journey millennia ago.

The Neuro-Urology committee of the ICS is exclusively devoted to the advancement in knowledge and clinical practice of Neuro-Urology. Toward these goals, the Institute is the latest initiative from ICS to facilitate worldwide teaching and training. The School of Neuro-Urology under Rizwan Hamid is setting up multiple teaching aids including videos, lectures and presentations to share the understanding of Neurourology with colleagues across the globe.

We look forward in anticipation to the next 50 years of ICS support in the advancement of our understanding of Neuro-Urology for improved patient care.

Sanjay Sinha and Rizwan Hamid, on behalf of the Neurourology Promotion Committee, International Continence Society

Picture: NeuroUrology Promotion Committee taken at ICS 2019 in Gothenburg

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