http://www.icsoffice.org/Documents/Documents.aspx?FolderID=107
Dubai Education Course Handouts, February 2011
Handouts from the PACS/ICS/ICCS Education Course held in Dubai, 3-5 February. The handouts are from the ICS speakers only.

http://www.icsoffice.org/Documents/Documents.aspx?DocumentID=897
K Peters, Nerve Rerouting
Friday 4th February 2011
International Continence Society

36-Month Update
[] Recently finished 3 year follow-up
[] 7 of 9 returned for follow-up
[] 1 (37 yo male) no change in symptoms
[] 2 subjects not returning considered non-responders
[] Bowels improved 5/7 on GRA
[] Bladder improved 4/7 on GRA
[] Incontinence still problem in most
[] 6/7 would undergo surgery again
[] Success? Not Sure

36-Month Catheterization
[] Baseline all subjects were on clean intermittent catheterization
[] 36-months: 4 (5) of 7 off catheterization
- One subject’s mother had her restart ISC prior to 36-month visit due to a single UTI
– Patient is sexually active teen with a PVR<50cc
- Now off ISC
[] 1 subject catheterizes only 1 x/day
[] 1 subject (37 year old male) had no change in bladder from surgery and on ISC

Voiding
Void Diary
[] Baseline 2/9 voided some
– Mean voided volume 27cc
[] 36-month 6/7 voided (without scratching)
- Mean voided volume 156cc
Uroflow-36 Month n=6 (37 yo male could not void)
[] Mean voided volume: 248 cc (without scratching)
[] Mean PVR: 93 cc
[] Voiding efficiency: 73%

Voiding Pattern at 36 Months
[] 6/7 leak urine, all with stress incontinence
[] 2/7 occasionally start stream by thinking
[] 1/7 no valsalva to void, 4/7 valsalva void greater than 1/2 time and 1/7 valsalva void always
[] Urine stream described as: Strong-2, Weak-3 and dribble in 2
[] Daytime continence: 1-dry, 3 occasional leak and 3 frequent leak
[] Sensation of bladder fullness: Yes-7, No-0
[] Improvement in bladder sensation: Yes-4, No-3

3-year Compliance Data (n=7)
[] Median compliance 15.2 ml/cmH20 baseline vs 28.4 ml/cmH20 at 36 months
[] 3 children had compliance less than 10 at baseline:
– All normalized at 36 months
- 7.0 -> 34.3
- 9.4 -> 21.2
- 8.3 -> 28.4

3-year Bladder MCC and NDO (n=7)
[] Baseline MCC: Mean=210 cc; Median=200 cc
[] 36-month MCC: Mean=293 cc; Median=316 cc
– *Children are 3-years older
[] Baseline: 4/7 had NDO on UDT
[] 36-month: 1/7 had NDO on UDT*
– All patients off Antimuscarinics except 1*
* persistent DO-37 year old male

Reflex
[] By 12 months 7/9 had cutaneous to bladder reflex defined as at least a 10 cm/H20 pressure rise with stimulating dermatome on side of surgery (range 11-30 cm/H20
[] At 36 months only ONE had reflex remaining and much weaker than earlier
[] ? Suppression of reflex by CNS

Adverse Events
[] No new long-term adverse events
[] Stable renal function
[] Stable renal ultrasounds

UPDATE
[] 2009 added Holly Gilmer, MD a pediatric neurosurgeon as part of our team
[] Dr. Xiao returned to Beaumont and proctored Dr. Gilmer on the rerouting procedure on 4 children with SB
[] Transient weakness, no foot drop
[] 2 subjects had dural leak
[] At 1 year, 2/4 off catheter and meds

2009年
Conclusions
[] Neurogenic bladder and bowel remains a significant clinical challenge
[] Developed countries with adequate resources can often manage the patient with CIC and medications thus preventing significant infections, renal failure and death
[] The concept of nerve rerouting to restore bladder and bowel function was popularized by CG Xiao from China
[] Successful reinnervation of the bladder and bowel may not only improve QOL but also be life-saving in countries where catheterization and/or antimuscarinics are not readily available or affordable
[] In the spina bifida population, our pilot trial demonstrated 6/9 (66%) had clinical improvement at 36 months
[] A risk of lower extremity weakness is evident in that 1/9 subjects had a permanent foot-drop
[] No other long-term adverse events were identified
[] Defining clinical success is a difficult challenge in a disease state that impacts many aspects of bladder and bowel function
[] In this study, stress incontinence remained a problem, although NDO and antimuscarinic use were reduced
[] We feel strongly that multicenter clinical trials are needed to determine the utility of nerve rerouting in the neurogenic patient
[] We should better define the ideal patient population, refine the surgical procedure, improve the evaluation of the urinary and bowel sphincters and assess quality of life