Sometimes conservative or minimally invasive treatment will not control the symptoms or the risk of kidney damage. In this case, your doctor will suggest more invasive surgical treatment. Depending on the problem, several procedures can be performed.
Bladder neck and urethral procedures
Some procedures may be recommended to increase bladder neck or sphincter resistance for continence. This should be attempted only after careful study of the bladder and urethra. Several procedures are available and your doctor may recommend a particular technique based on your situation (Table 1).
Sacral anterior root stimulation, sacral rhizotomy and sacral neuromodulation
In patients with a complete spinal lesion, the nervous system cannot send signals below the level of the injury. A device can be implanted that is connected to parts of the spinal cord below the lesion to stimulate the bladder and cause urination if activated.
This is called sacral anterior root stimulation. It can also be used to induce defecation or erection. This approach has been used successfully in some patients. The severing of other nerves, called sacral rhizotomy, is used mostly in support of this procedure but also can reduce overactive bladder.
Sacral neuromodulation is a less invasive technique. Small electrodes are implanted next to the sacral nerves and modulate nerve activity. This technique is widely used in patients without neurological disease. It also might help neurourological patients, but its role has not been well established.
Bladder covering by striated muscle
Covering the bladder with muscle tissue from the belly or the back can strengthen the bladder. It can establish a new way to control urinary function (voluntarily or by electrical stimulation) This complex surgical procedure has been used successfully in some neurourological patients.
Bladder capacity may be increased and overactivity reduced by surgical expansion of the bladder. This may be achieved by surgery using part of the bladder muscle (autoaugmentation) or intestine or other expandable tissue. The procedure is called augmentation cystoplasty. It has possible complications such as infections that come back, formation of stones in the urinary tract, and tissue perforation. Patients should be chosen carefully to undergo such major reconstructive surgery.
Urinary diversion means creating an artificial way to pass urine from the kidneys without going through the bladder. When all other therapies have failed, this option can protect the kidneys and improve quality of life. Although a diversion can be undone, it may be technically difficult. Discuss this treatment in detail with your doctor before choosing this option.
A pouch can be constructed in the body for intermittent catheterisation. Frequent complications may occur such as leakage or narrowing of the tube that carries urine (stenosis).
The surgeon will create a stoma, which is a small portal in the belly. The urine flows through the stoma to an attached collecting bag. This is technically easier to achieve than a continent diversion and usually has fewer complications. Incontinent diversion cannot be used if you are not able to catheterise or already have severe kidney damage.
Table 1: Procedures used to increase the resistance in the bladder neck and urethra
|Urethral slings (synthetic, autologous)||A piece of material is placed as a sling in women to compress the bladder neck and increase resistance to urine flow; material can be man-made (synthetic) or tissue taken from another part of the patient’s body (autologous)|
|Artificial urinary sphincter||This device is composed of a cuff that compresses the urethra, a balloon that prevents urine from leaking, and a pump that controls the release of urine; it is surgically implanted|
|Bladder neck and urethral surgical reconstruction||Surgical reconstructions may be an alternative only in selected cases and generally after failure of more conservative techniques|