If drug therapy measures are unsuccessful, the following surgical measures are used:
- Unmanageable detrusor hypertrophy (trabeculation and pseudodiverticulum formation of the bladder):
- Urinary bladder augmentation (bladder enlargement) with small bowel or an incontinent (ileal conduit)/continent (catheterizable reservoir) drainage system
- Dorsal rhizotomy – surgical transection of the sensory nerve roots in the region of the lower spinal cord.
- Unmanageable sphincter externus spasticity:
- Incision (cutting into) the sphincter externus.
- Stent implantation (small, lattice-shaped support that serves to dilate) to widen the sphincter externus (external sphincter)
- Injection of botulinus toxin into the sphincter.
- Detrusor overactivity
- Urinary bladder augmentation with small bowel or an incontinent (ileum conduit)/continent (catheterizable reservoir) diversion
- Urinary diversion via ileum conduit (ureters are anastomosed with a short ileum loop)/continent catheterizable reservoir
- Detrusor-sphincter dyssynergia (DSD; bladder dysfunction characterized by impaired interaction of anatomic structures involved in bladder emptying).
- Sacral anterior root stimulation (combined with dorsal rhizotomy: see below) Prerequisite for this procedure: complete spinal cord injury that has been present for at least 1 year, but preferably no longer than 5 years.
- Complete sphincterotomy, i.e., a nick of the sphincter (sphincter muscle) transurethrally (“through the urethra“).
- Urinary bladder augmentation with small bowel or an incontinent (ileum conduit)/continent (catheterizable reservoir) diversion
- Hypoactive sphincter (loss of reflex contraction of the sphincter with increase in abdominal pressure).
- Artificial sphincter system (artificial sphincter system).
- Transurethral injection of the sphincter with so-called “bulking agents” (silicone, Teflon, fat, collagen); procedure can be performed using local anesthesia (local anesthesia).
- Hypocontractile detrusor
- Suprapubic urinary diversion* for at least 12 weeks. Thereafter, determine whether there is sufficient speech tonification of the detrusor with adequate bladder emptying.* Bladder catheter inserted above the pubic bone through the abdominal wall into the urinary bladder to drain urine bypassing the urethra.
- Sacral neuromodulation (SNM; synonyms: pelvic floor pacemaker, so-called “bladder pacemaker“): minimally invasive procedure to inhibit the micturition reflex and thus reduce autonomic contractions and incontinence (bladder weakness) by electrical stimulation of the posterior root S3 (sacral nerve stimulation, SNS). Advantage of the procedure compared to external electrostimulation is the greater proximity to the nerve and permanent modulation.
- Persistent stress incontinence (formerly stress incontinence):
- Insertion of a hydraulic sphincter system.
Patients with neurogenic bladder dysfunction require long-term/ongoing observation to avoid complications (see under sequelae).