Neurogenic bladder includes lower urinary tract problems that occur as a result of damage to the nerves that affect bladder functions. Complaints vary according to the type of disease, the location and degree of damage. Normally, there is a harmony between the bladder muscle and the urinary retention mechanism (sphincter). They contract and relax in a coordinated way, and in this way, normal urination takes place. When this mechanism is damaged for any reason, urination problems occur. Nerve damage may develop due to trauma or chronic systemic diseases such as diabetes. A detailed examination and questioning, urodynamic, radiological, endoscopic and neurological evaluation are important in the diagnosis of the disease.

In this article, I will try to summarize the surgical treatment methods in neurogenic bladder patients based on the current literature and our own experience.

What are neurogenic bladder types/types?

There are two main forms (types) of neurogenic bladder. Complaints also differ according to the type of disease. Types of neurogenic bladders include:

• Spastic neurogenic bladder: Here are the main complaints (symptoms) of overactive bladder. Patients urinate at very frequent intervals and complain of urinary incontinence when it is late.
• Flask type neurogenic bladder: In this type of neurogenic bladder disease, the problem is mainly in the bladder muscle. The bladder muscle cannot contract and pass urine. Over time, excess urine accumulates in the bladder.

When is surgery performed in neurogenic bladder patients?

Depending on the degree and level of neurogenic bladder nerve damage, it impairs bladder functions and causes serious problems. The main purpose in the treatment of these patients is to keep the intravesical pressure at normal levels, to prevent damage to the upper urinary system, namely the kidney, and to keep the patient dry by treating urinary incontinence. Surgery is the last option in the treatment of neurogenic bladder. If no results can be obtained with drug therapy and other preventive methods, then surgical treatment, that is, surgical options, should be considered.

What problems will occur if neurogenic bladder is not treated?

Patients with neurogenic bladder are chronic patients. These are patients who need to be followed and treated very closely. If these patients are not treated appropriately, serious urological problems will occur. Urinary system complications that may occur in neurogenic bladder patients if appropriate treatment is not performed are as follows:

• Urinary tract infection
• Urinary system stone disease (bladder, kidney, ureteral stones): Stone formation is more common in spinal cord injuries in the sacral region.
• Urinary incontinence (incontinence), especially in cervical and thoracic spine injuries, is common.
• Kidney damage and future kidney failure
• Development of bladder cancer: Bladder stones may occur as a result of frequent catheterization and trauma due to bladder stone formation.

Why is surgery performed in the treatment of neurogenic bladder?

Bladder nerves are damaged due to spinal cord injury and this causes serious urinary problems in patients. Surgical procedures in neurogenic bladder patients should be performed by considering functional pathologies in the bladder, bladder neck and urethral sphincter. It is possible to collect the urinary bladder problems that occur in these patients in 3 groups:

• Bladder storage problem
• Bladder emptying problem
• Combined closure and emptying problem of the bladder

The aims of the surgical treatment of these patients can be summarized as follows:

• Reducing intra-bladder pressure
• Reducing urethral pressure
• Increasing urethral pressure
• Urinary diversion

What are the surgical methods in neurogenic bladder disease?

Symptoms in neurogenic bladder patients usually manifest as lower urinary tract dysfunctions. In the surgical treatment of patients whose conservative treatments could not yield results, the main malfunctioning mechanism should be determined and appropriate action should be taken. While doing this, it is essential to evaluate the intra-bladder pressure, the conditions that prevent urine flow after the bladder and the sphincter in a healthy way.

We can list the surgical methods used in the treatment of neurogenic bladder as follows:

Operations to reduce intra-bladder pressure: The main purpose here is to normalize and reduce the increased pressure in the bladder. It is extremely important for the upper urinary system (kidneys and ureters) to have normal intra-bladder pressure. The main function of the bladder is to store the urine filtered from the kidneys until urination. During this period, the urine in the bladder does not escape back to the ureters and kidneys. This happens thanks to the mechanism in the part where the ureters open to the bladder (ureterovesical junction). In the case of chronically increased intra-bladder pressure, this mechanism is disrupted and as a result, urine in the bladder escapes to the ureters and kidneys. We call this vesicoureteral reflux (VUR). As a result, ureter and kidney functions are adversely affected. If effective and correct treatment is not performed on time, kidney damage leading to kidney failure occurs. The surgical methods that are effective by reducing the intra-bladder pressure and protecting the kidneys are as follows:

• Augmentation cystoplasty (ileocystoplasty) surgery)
• Bladder auto augmentation surgery
• Sacral anterior nerve root stimulation Posterior sacral root rhizotomy
• Sacral neuromodulation

Operations to reduce urethral resistance: The main purpose here is to correct the pathology/factor in the infravesical region after the bladder. Normally, during bladder contraction, the bladder neck and external sphincter (urinary-holding mechanism) relax and the person urinates normally. In some cases, this mechanism is broken. These factors usually cause increased pressure in the part after the bladder, leading to urinary problems. Pathologies in this region mainly originate from the bladder neck and external sphincter. Surgical methods to reduce urethral resistance in patients with neurogenic bladder problems are as follows:

• Cutting the external sphincter (sphincterotomy)
• Putting a stent in the urethra
• Transurethral bladder neck incision (endoscopic bladder neck incision)
• Transurethral prostate resection (TUR-P, TURP) in male patients

Operations to increase urethral resistance: In some of the patients with lower urinary tract dysfunction, the problem is the decrease in pressure after the bladder, that is, at the infravesical level. The main complaint in these patients is the inability to control urine, that is, the problem of urinary incontinence. The surgical procedures/applications to be performed for these patients are mainly aimed at bringing the decreased pressure back to normal. The main surgical methods we apply to patients with urinary incontinence due to decreased pressure in the urinary system after the bladder are the following techniques:

• Insertion of artificial urinary sphincter
• Urethral sling surgeries (autologous, synthetic)
• Urethral bulking agents (submucosal bulking injections)
• Adjustable continence treatment methods

Urinary diversion surgeries: If neurogenic bladder patients do not give positive results to classical conservative treatments, one of the surgical options to be performed is urinary diversion surgeries. Urinary diversion surgeries are our last preferred surgical procedures for these patients. The methods we frequently use in these surgeries are ileal loop surgery and continent urinary diversion surgeries. In ileal loop (ileal condiut) surgery, the thin bladder is removed. A piece of 15-20 cm long is taken from the small intestines and the ureters are connected here and the other end is attached to the abdominal wall. The urine of the patients is collected in a bag attached to the abdominal wall and this bag is emptied at regular intervals. In continent diversions, after the bladder is removed, a new bladder is made from the small intestines and put in place of the bladder. Or the created reservoir is placed in the abdomen, and one end is attached to the anterior abdominal wall. Urine is emptied with a catheter at regular intervals from the stoma placed on the abdominal wall. Important urinary diversion methods used for surgical purposes in the treatment of neurogenic bladder are:

• Continent urinary diversion surgeries
• Ileal conduit (ileal loop) surgery
• Other diversion methods

What are the complications that can be seen after neurogenic bladder surgery?

As with any surgery, some complications may occur after the surgical treatment of this disease. These complications vary according to the experience of the surgeon and the operation performed. The disadvantages we frequently encounter can be as follows:

• Wound infection
• Bleeding
• Anastomotic strictures
• Urinary system stones
• Inability to urinate and need for self-catheterization
• Urethral erosion
• Deterioration in kidney functions in the late period

In which cases should a doctor be called after surgery?

Patients should be followed closely after neurogenic bladder surgery. Patients should be told in detail about the issues to be considered. Patients who have undergone surgery due to neurogenic bladder problem should definitely call their doctor in the following cases:

• Inability to urinate
• If there are signs of infection such as high fever, chills, chills
• If you have frequent and little urination

In summary: Neurogenic bladder is a chronic disease. Serious complications develop in patients who do not receive proper care and treatment. Surgery is an appropriate option in the treatment of neurogenic bladder that cannot be improved with current treatments. There are different methods in the surgical treatment of this disease. The type of disease should be determined by evaluating the patients in detail. As a result of the necessary examinations, the most appropriate surgical method should be applied to the patient. The aim of surgical treatment is to reduce the intra-bladder pressure, to remove the obstruction in the bladder outlet, and to increase the urethral pressure if there is urinary incontinence. In this way, problems such as damage to the upper urinary system, namely kidneys, urinary tract infections, stone formation and urinary incontinence are prevented. The patients’ quality of life improves significantly. In patients who will undergo surgery, attention should be paid to issues such as the intellectual level of the patients and their ability to use their hands actively. Urinary diversion surgeries are our last preferred surgical methods.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY