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Alsulihem et al. Neuroimmunol Neuroinflammation 2019;6:13 I http://dx.doi.org/10.20517/2347-8659.2019.007 Page 9 of 13

urodynamic evaluation 2-3 months after the first injection and then if there is a change of clinical course
and recurrence of symptoms despite recent injection [12,40] .

Sacral nerve stimulation
Several retrospective and observational studies have evaluated the role of dorsal rhizotomy (sacral
deafferentation S2-S4/5), combined with anterior sacral root stimulation in the treatment of NDO [42-45] . This
treatment has been shown to effectively reduce elevated detrusor pressure, improve compliance, increase
bladder capacity, improve urinary incontinence, and achieve voluntary bladder and bowel emptying in
patients with complete SCI [41-44] . This technique has a variable success rate in specialized centers but is
limited by long-term complications and a high rate of surgical revision. It might be offered by experienced
centers and in highly selected patients as a third-line option after failure of previous medical and minimally
invasive options [8,13] .

Surgical treatment of NDO
Surgical treatment options are considered when all medical and minimally invasive treatment options have
failed to eliminate poor urodynamic parameters [Table 1]. Surgical options include bladder augmentation
and urinary diversion.

Bladder augmentation, using a bowel segment, should be considered in patients who failed all medical
and minimally invasive management for reduced bladder capacity and NDO [8,13] . It can eliminate urinary
incontinence in 75%-100%, improve bladder compliance in 69%-100%, and improve quality of life in
[8]
90% of patients . The addition of a continent catheterizable channel might be considered if the patient
cannot catheterize through the urethra [8,46] . Contraindications to performing bladder augmentation
include bladder malignancy, Chronic kidney disease (creatinine clearance less than 40 mL/min),
bowel disease, previous significant bowel resection, inability to do CISC (such as quadriplegia), or
unwillingness to perform CISC [8,46] . Long term complications include bladder stone formation, metabolic
complications, intraperitoneal bladder perforation, urosepsis, vesicoureteric reflux, recurrence of NDO and
adenocarcinoma or urothelial carcinoma in up to 6% [8,46-48] . Therefore, lifelong surveillance with cystoscopy
is recommended. In case of recurrence of incontinence, video urodynamic is recommended, and in the
presence of NDO, treatment with Botox injection into the augmented bladder can be tried before surgical
[49]
revision or urinary diversion .

Urinary diversion, is considered as last resort option in the management of NDO if the patient is unfit or
not a candidate for bladder augmentation. Urinary diversion options include continent and incontinent
[46]
diversion .
Continent urinary diversion with continent catheterizable channels is performed when the patient can
catheterize but cannot use native bladder due to a severely contracted bladder with severe vesicoureteral
reflux or devastated bladder outlet, or bladder malignancy [8,47] . It carries a higher risk of long-term
metabolic complications. It is contraindicated in patients with chronic kidney disease (creatinine clearance
less than 40 mL/min) and in a patient who are not fit for CISC [8,48] .

Incontinent urinary diversion is a last resort option [8,13,49] , in which urine is diverted to the skin by using
bowel segment (usually ileum) in patients who cannot perform CISC and in patients who are unfit
or failed other surgical options [8,13,46] . An ileal conduit is a familiar procedure to urologists, the most
commonly performed incontinent urinary diversion procedure, and the preferred incontinent urinary
diversion procedure [8,46,50] . It results in renal function preservation in 88% to more than 90% of patients [8,50] .
Possible complications include ureteral anastomotic stenosis, stomal or incisional hernia, stomal stenosis,
bowel obstruction, urinary tract infections and pyelonephritis, urine leak, urolithiasis, and metabolic
[8]
complications (acidosis) [46,51] . Overall major complications can reach up to 11% .