Bladder Managment for Adults with Spinal Cord Injury - 34

BLADDER MANAGEMENT FOR ADULTS WITH SPINAL CORD INJURY

urinary tract infection immediately before surgery, the failure rate has been about 8 percent (Perkash et al., 1992). 3. Advise males with SCI of the potential for complications of a sphincterotomy, such as: Significant intraoperative and perioperative bleeding. Clot retention. Prolonged drainage with a large diameter catheter. Urethral stricture. Erectile dysfunction. Ejaculatory dysfunction. Reoperation in 30 percent to 60 percent of cases.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Rationale: Several complications have been reported following electrosurgical TURS: (a) significant intraoperative and perioperative bleeding, (b) clot retention, (c) prolonged drainage with a large diameter catheter, (d) urethral strictures, (e) impotence, and (f) reoperation in 30 percent to 60 percent of cases (Juma, Mostafavi, and Joseph, 1995; Vapnek, Couillard, and Stone, 1994). In 14 percent of the initial TURS failures, an additional bladder neck incision or a transurethral resection of the prostate was performed to improve urodynamic parameters (Noll, Sauerwein, and Stohrer, 1995). The majority of failures of TURS have been attributed to inadequate surgery, postdiathermy TURS strictures of the bulbous urethra, and poor detrusor contractility. 4. Consider laser sphincterotomy the procedure of choice for transurethral sphincterotomy, depending upon the availability of laser equipment.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Stohrer, 1995; Perkash, 1996). Both contact and beam lasers have been applied through the standard cystoscope (Perkash, 1996). The laser energy is delivered fiber optically through a reusable contact laser probe screwed on to the tip of a rigid fiber, or through almost the direct contact of end fiber or side fire through a side firing probe for the delivery of Holmium laser (HO:YAG). A usual setting of 1.5 JX15 or 20 hertz seems ideal. Free beam laser leads to coagulative necrosis; therefore, it is not a suitable choice for TURS. Contact laser, an end fiber, or a side fiber delivering HO:YAG is similar to using a knife: It requires repeated passes to cut and vaporize all fibers just short of cutting spongy tissue, as is also done using a diathermy knife, to prevent perforation of the urethra. Research findings indicate a significantly reduced incidence of operative and perioperative bleeding as well as a reduced incidence (about 7 percent to 15 percent) of repeat sphincterotomy following use of the contact laser (Noll, Sauerwein, and Stohrer, 1995; Perkash, 1996), compared to a repeat rate of more than 30 percent following the use of electrocautery in the reported series mentioned above. Laser sphincterotomy is, therefore, the procedure of choice depending upon the availability of laser equipment. Following TURS, an indwelling catheter may be placed instead of external condom drainage. Leakage of urine around an indwelling catheter may occur, which happens more often if a simultaneous transurethral resection of the prostate also has been performed. This leaves a wide open prostatic fossa where collection of urine evokes the urethra-urethral reflex with almost constant leakage of urine around the catheter. There is a significantly higher incidence of upper tract damage and of persisting externaldetrusor sphincter dyssynergia in individuals with bladder leak point pressure greater than 40 cm water following surgery (Kim, Kattan, and Boone, 1998). Thus, a bladder leak point pressure below 40 cm water seems to be a useful urodynamic parameter for the successful outcome of TURS (Juma, Mostafavi, and Joseph, 1995; Vapnek, Couillard, and Stone, 1994).

Rationale: Transurethral external sphincterotomy can be performed with either a diathermy electrode (knife) or with a laser at the 12 o’clock position (Perkash, 1996). Incision usually starts just proximal to the verumontanum and extends into the proximal bulbous urethra. It is deepened until all muscle fibers have been cut. Significantly reduced morbidity and minimal to nil blood loss have been reported following laser sphincterotomy (Noll, Sauerwein, and

Nursing Considerations for Tr a n s u re t h r a l S p h i n c t e ro t o m y
Individuals need to be aware that this irreversible surgical procedure will render them incontinent of urine, that urine will be contained in a bag on the outside of the body, and that erectile function may be affected. A thorough assessment for appropriateness of the procedure is essential.

Bladder Managment for Adults with Spinal Cord Injury

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