F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
373
(a)
4: Operations for electric detrusor stimulation
Operations designed to implant electrodes for direct electric stimulation of the destrusor
muscle have been performed in spinal cord patients in recent years by various authors
(Bradley
et
a/., 1963; Bunts, 1964; Scott, 1965; Susset, 1966, 1968; Hagman
et
a/., 1966
and others) to overcome retention of urine. A review of the literature shows that so far
about 50 patients were subjected to this operation. However, so many methodical and
technical imperfections have been described that this operation cannot be considered
so far of practical use in spinal cord lesions. The implantation of detrusor stimulators
demands a large uncovering of the bladder because of the impossibility of assessing the
full detrusor contraction from one optimal single point. Failures in the implanted receiver
have occurred, and the receiver had to be removed and replaced by another in a second
operation. Furthermore, rupture of the electrodes, infection and necrosis of the tissues,
surrounding the implanted apparatus or spreading of the electric current, causing pain
and contractions of the muscles of the pelvic floor and adjacent skeletal muscles were
other undesirable side-effects of this method. Above all the therapeutic results of this
procedure, in particular, their permanence, are unsatisfactory so far. It is obvious that
this surgical procedure is contra-indicated in the immediate and early stages of paraplegia
and tetraplegia and, if at all contemplated in future, should be the last resort, provided
its failure can be avoided by further research.
(a) 5: Muscle transplantation to increase detrusor function
Transplantations of the rectus abdominis (Boshamer, 1951, 1960) or of the gracilis
(Ingelman-Sundberg, 1957) into the bladder wall have been used in some cases of lower
motor neuron lesions to increase voiding pressure and to overcome urinary retention.
Although the authors claim satisfactory results, reports of long-term detailed follow up
of the patients are not available. The value of this surgical approach in the treatment
of retention seems very doubtful and was never used at Stoke Mandeville.
(a) 6: Urinary diversion
While suprapubic cystostomy, as mentioned before, has very
rare
indications
and, as a rule, as a temporary measure only in cases with local uncontrollable damage of
the urethra by strictures or fistulae, it has no place in the treatment of persistent vesical
urinary retention in view of the better understanding of the vesical pathophysiology and
the advances made in the more adequate methods of treatment of this condition in spinal
cord lesions, such as TUR and resection of the external urethral sphincter. However,
from all experiences gained, cutaneous vesicostomy and urethrostomy are contra-
indicated in the treatment of paraplegics and tetraplegics in both early and late stages
of spinal paraplegia and tetraplegia.
Supravesical diversions by ileal or colonic conduits are also deprecated in the treat
ment of vesical urinary retention. Their indication in urinary incontinence, ureteric
reflux and hydronephrosis with renal deficiency will be discussed in the following
chapters.
