Is sphincterotomy the best management of the spinal cord injured bladder?

Transurethral incision of the external urinary sphincter with condom catheter drainage has long been used in the management of the male quadriplegic or high thoracic level paraplegic with neurogenic bladder. The decrease in outlet resistance is believed to lower the high intravesical pressures associated with detrusor-sphincter dyssynergia and obviate the need for an indwelling catheter, with its associated infectious complications. We reviewed 16 consecutive cases of sphincterotomy performed at our institution during the last 8 years to determine the long-term success rate and outcome of this mode of bladder management. Of the patients 13 are cervical level quadriplegics and 3 are thoracic level paraplegics who were unable to perform self-catheterization. Preoperative urodynamics most commonly demonstrated detrusor external sphincter dyssynergia, moderate to severe hyperreflexia and decreased compliance. Followup ranged from 3 months to 8 years (median 39 months). Only 8 of 16 patients still manage the bladder with a condom catheter, while 8 have an indwelling suprapubic cystostomy tube. Only 1 patient followed for more than 4 years postoperatively still uses condom catheter drainage. The most common reason for conversion to suprapubic drainage was difficulty with the external appliance but other reasons included desire for increased independence, high post-void residual volumes and renal deterioration. We conclude that sphincterotomy is generally effective in decreasing outlet resistance and improving voiding efficiency initially but that careful patient selection and close long-term followup are necessary to guarantee long-term success.