An interesting recent paper from Rotterdam addresses an important clinical problem for urologists and neurourologists. We commonly face patients with bladder outlet obstruction. In the neurologic population, obstruction is often linked to detrusor sphincter dyssynergia, the most frequent etiology. However the progressive aging of both the general population and the neurologic population increases the prevalence of anatomic obstruction. A recent article by B. Blok et a l reviews the literature on this topic attempting to identify a guideline for the management of bladder outlet obstruction in this very particular and increasing population.
The authors of this article systematically reviewed, for the first time in the literature, all publications on surgical treatment of bladder outlet obstruction caused by BPH, urethral stricture or bladder neck stricture in male patients with neurogenic bladder dysfunction due to Multiple Sclerosis, Parkinson’s Disease, spinal cord injury, spina bifida and stroke. The different types of procedures were TURP, open prostatectomy, endoscopic urethrotomy , urethroplasty, bladder neck resection or any other surgical treatment of functional bladder outlet obstruction. Overall after reviewing more than 930 abstracts, only 8 studies were included, as they were the only ones meeting specific criteria (eg procedure previsouly described in patients 18 and over affected with neurogenic bladder). The principal findings of the review were the following :
- Concerning TURP, de novo urinary incontinence occured in up to 20% of patients with Parkinson’s Disease. Bladder function improved in more than 76% of patients treated with this method concomitantly with spinal cord injury. In stroke patients, poorer results regarding bladder function were seen in case of of more severe neurological impairment. Therefore the main message was the high variability of surgical outcome in neurological patients confirming the absolute need of preoperative urodynamics
- Concerning bladder neck resetions and urethrotomy in spinal cord injury patients, good results were seen. However, there was a high rate of reintervention due to recurence. Compared to repeated urethral dilation and urethrotomy, outcomes were similar. The best results were seen with urethroplasty procedures.
Overall, the authors conclude that the available data in literature is insufficient to determine the optimal practice in neurological patients with bladder outlet obstruction.
This paper provides a significant contribution to the literature because :
- It gives an overview of the current literature on this topic emphasizing the fact that the only studies available are of poor scientific quality
- It underlines the need and urgency for valid trials in order to support a group of patients which is increasing in number
Article by Julien Renard on behalf of the Publications and Communications Committee
Surgical Management of Anatomic Bladder Outlet Obstruction in Males with Neurogenic Bladder Dysfunction : A Systematic Review. T.C. Noordhoff, J. Grien, J. Scheepe, B. Blok European Urology (2018) Ahead of print