The Stockholm spinal cord uro study

Abstract

Aims: To evaluate urinary tract function and complications in a regional population with chronic traumatic spinal cord injury (SCI), to estimate risk profiles for recurring complications and improve follow-up for neurogenic lower urinary tract dysfunction (NLUTD) after SCI.

Materials and methods: 412 patients were included in the study as they consecutively attended an annual check-up visit at the regional out-patient centre the Spinalis clinic. A regional programme for follow-up of NLUTD after SCI was applied, including S-creatinine, S-cystatin-C, urine culture, residual urine, renal ultrasound, and urodynamics. A study specific questionnaire was used for patient-reported data of complications during the preceding year. A national programme for medical follow-up after SCI was applied registering data on autonomic dysfunctions such as spasticity, autonomic dysreflexia, neuropathic pain, and pressure ulcers. A study-specific database was created. Information was added from retrospective reviews of patient files on urine cultures and antibiotics prescriptions during the preceding year (paper II), primary urodynamic observation after SCI and bladder management through the following years (paper III), and urologic surgical interventions and outcomes (paper IV). A re-analysis was undertaken of all urodynamic graphs (paper III).

Results: The male/female distribution was 320(78%)/ 92(22%). The mean age/ mean SCI duration was 49.1/16.4 years. All neurological levels and severity of SCI and all types of bladder management were represented. Signs of renal complications were present in one-fourth. Nearly half of all patients reported complications during the preceding year. Urinary tract infection (UTI) was the most frequent problem, reported by 44%. 15.3% had >3 infections and 5% had a febrile UTI requiring hospital treatment. There was no relationship between residual urine or use of preventive medications/ vitamins/ health foods and the number of reported UTIs. Urodynamic studies were completed by 211 patients. There was a statistically significant relationship between a duration of detrusor overactivity during more than one-third of the filling phase and signs of renal complications among patients with an SCI duration 11-20 years. Among patients with a current underactive/acontractile or normal detrusor, a primary observation of neurogenic overactive detrusor and a previous history of voiding by bladder reflex triggering emerged as an important factor for renal impairment. Urological surgical interventions had been carried out in 137 patients with a total/ mean of 262/ 1.9 procedures. Follow-up was a mean 10-19 years for the various types of surgery. Imperative surgery due to urinary stones, severe infections, and to ensure voiding via a suprapubic catheter constituted half of all procedures and were mostly carried out within two years after SCI. Reconstructive surgery was performed to improve long-term voiding and continence. One-fourth of all patients had >3 urological procedures and among them 59% had developed signs of renal complications. Risk profiles for renal complications, more frequent/more severe UTIs, and imperative or repeated surgery overlapped to a great extent. They were identified as a cervical-thoracic neurological level of SCI, AIS grades A-C, and a duration of detrusor overactivity of more than one-third during bladder filling. Further risk factors for UTIs included an SCI-duration >10 years, catheter-assisted voiding, and having a neurogenic overactive detrusor. Patients with an AIS D lesion had a lower frequency of UTIs. However, three-fifths had neurogenic detrusor overactivity, and one-fifth had signs of renal complications.

Conclusions: Overall, the regional population had a relatively stable and healthy situation regarding the urinary tracts. However, signs of renal complications were frequent and nearly half of all patients had UTIs during the preceding year. Risk profiles for more frequent and more severe complications were identified. Follow-up programmes for NLUTD after SCI can be improved taking these risk profiles into account. Prior to urologic surgical interventions risk indicators for renal complications must be observed and further exposure prevented.