Neural reconstruction methods of restoring bladder function

Key Points

  • Neurogenic bladder dysfunction, such as detrusor muscle hyperactivity and dyssynergia with the external urethral sphincter (EUS), are common long-term consequences affecting the wellbeing of patients with spinal cord injury (SCI)

  • Various studies have investigated surgical strategies to restore function of a decentralized bladder after SCI via repair of the original roots or by transferring new axonal sources

  • The Finetech-Brindley stimulation device is effective in triggering bladder contraction in patients with neurogenic bladder dysfunction caused by upper motor neuron lesion

  • Surgical techniques for restoring bladder volume, without also inducing a high increase in bladder pressure, are needed to promote efficient storage and continence

  • Development of surgical techniques to reinnervate both the detrusor muscle and the EUS are needed to promote coordinated detrusor–EUS function

  • Comprehensive assessment of the effectiveness of surgical procedures can guide future research and potential clinical application

Abstract

During the past century, diverse studies have focused on the development of surgical strategies to restore function of a decentralized bladder after spinal cord or spinal root injury via repair of the original roots or by transferring new axonal sources. The techniques included end-to-end sacral root repairs, transfer of roots from other spinal segments to sacral roots, transfer of intercostal nerves to sacral roots, transfer of various somatic nerves to the pelvic or pudendal nerve, direct reinnervation of the detrusor muscle, or creation of an artificial reflex pathway between the skin and the bladder via the central nervous system. All of these surgical techniques have demonstrated specific strengths and limitations. The findings made to date already indicate appropriate patient populations for each procedure, but a comprehensive assessment of the effectiveness of each technique to restore urinary function after bladder decentralization is required to guide future research and potential clinical application.

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Figure 1: Spinal cord neuroanatomy and bladder innervation in humans and other mammals.
Figure 2: Homotopic root repair.23,25,26,36
Figure 3: Heterotopic root repair.15,35
Figure 4: Extradural-to-intradural transfer of spinal nerves to sacral roots.24,27,30
Figure 5: Intradural-to-extradural transfer of lumbar or sacral roots to sacral spinal nerves.37,38,40,41
Figure 6: Transfer of peripheral nerves to pelvic nerves.17,29,33,34,35
Figure 7: Direct detrusor muscle reinnervation by somatic nerve transfer.32
Figure 8: Artificial skin–CNS–bladder reflex pathway methods.43,44,45,46,47

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Acknowledgements

The projects described were supported by Award Number R01NS070267 and NS070267-S1 to M.F.B. and M.R.R. from the National Institute of Neurological Disorders and Stroke. The content of this Review is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Neurological Disorders and Stroke or the National Institutes of Health.

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S.M.G.-A. and M.F.B. are joint first authors on this manuscript. S.M.G.-A., M.F.B. and M.R.R. researched data for and wrote the article. All authors contributed to discussion of the content. M.F.B., W.C.d.G., J.M.B. and M.R.R. reviewed/edited the manuscript before submission.

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Correspondence to Michael R. Ruggieri Sr.

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Gomez-Amaya, S., Barbe, M., de Groat, W. et al. Neural reconstruction methods of restoring bladder function. Nat Rev Urol 12, 100–118 (2015). https://doi.org/10.1038/nrurol.2015.4

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