Die sakrale Nervenstimulation zur Behandlung von Blasenfunktionsstörungen nach Rückenmarksverletzungen: aktueller Stand und Perspektiven

Zusammenfassung

Neben sozialen und bekannten medizinischen Problemen können Rückenmarksverletzungen zahlreiche urologische Funktionsstörungen verursachen. Neben einer Detrusorhyperreflexie entwickelt sich zusätzlich eine Detrusor-Sphinkter-Dyssenergie, die mit rezidivierenden Harnwegsinfekten, Urolithiasis, vesikoureteralem Reflux, und konsekutiv mit zum Teil irreversiblen Nierenparenchymschädigungen einhergehen kann. Während des letzten Jahrzehntes wurden mit unterschiedlichen Erfolgsraten zahlreiche neue experimentelle Techniken für die Neurostimulation der Sakralwurzeln entwickelt. Die Neuromodulation der Sakralwurzel ist eines der innovativen Konzepte zur Behandlung diverser Blasenspeicher- und Blasenentleerungsstörungen. Die Indikationen zur Neuromodulation werden dabei ständig erweitert und modifiziert, so dass viele diagnostische Entitäten wie Urge- und sensorische Inkontinenz, idiopathische chronische Harnretention, Beckenschmerzen und interstitielle Zystitis erfasst werden können. Trotz der erheblichen Menge an Beiträgen aus der Forschung und der Klinik, welche die verschiedenen Modalitäten in der Anwendung der Elektrostimulation oder -modulation zur Behandlung von Blasenentleerungsstörungen untersuchen, erscheinen die Daten noch immer unvollständig. Die Neurostimulation der Sarkralwurzeln ist eine einfache Technik mit hoher Selektivität, die ein hohes Potential für zukünftige klinische Anwendungen hat. Weitere Untersuchungen zu den neuropathologischen Veränderungen nach Diskonnektion des sakralen Miktionszentrums vom höher gelegenen Zentrum, und stetige Verbesserungen der Stimulationssysteme werden dieser Technik in der Zukunft zum Erfolg verhelfen.

Abstract

Spinal cord injury, beside its social and medical problems, has many urologic complications. Detrusor hyperreflexia and detrusor sphincter dyssynergia develop with repeated urinary tract infection, stone formation, vesicoureteral reflux, renal parenchymal loss and renal failure. Over the last decade, there are many reports about new experimental techniques for application of neurostimulation to the sacral roots with variable success rate. Sacral root neuromodulation is one of the relatively recent concepts for the treatment of various voiding and storage dysfunctions. The indications of neuromodulation have been extended to include many diagnostic entities including urge and sensory incontinence, idiopathic chronic urinary retention, pelvic pain and interstitial cystitis. Despite the extensive amount of research and clinical papers cited in this article and others concerning the different modalities for application of electrostimulation or electromodulation to recuperate the bladder function and decrease its outlet resistance, the overall results are still supoptimal. We believe that a simple technique of sacral root neurostimulation with high selectivity and long term results will be optimal for future human application. Further exploration of neuropathological changes and understanding the possible reflex mechanism after disconnection of sacral micturition center from its higher control with continous improvement of the stimulation system and electric waveforms will help solve many current problems.

Urinary tract - Spinal cord injuries - Sacral - Neurostimulation

Literatur

• 1 Schmidt R A. Application of neurostimulation in urology.  Neurourol Urodyn. 1988;  7 585-592
• 2 Schmidt R A. Advances in genitourinary neurostimulation.  Neurosurg. 1986;  19 1041-1044
• 3 Hassouna M, Li J S, Elhilali M M. Dog as an animal model for neurostimulation.  Neurourol Urodyn. 1994;  13 159-167
• 4 Boyce W H, Lathem J E, Hundt L D. Research related to the development of an artificial electrical stimulator for the paralyzed human bladder: a review.  J Urol. 1964;  91 41-51
• 5 Hald T, Freed P S, Agrawal G, Kantrowitz A. Urethral resistance during electrical stimulation.  Invest Urol. 1966;  4 247-256
• 6 Stenberg C C, Burnette H, Bunts R C. Electrical stimulation of human neurogenic bladders: experience with four patients.  J Urol. 1967;  97 79-84
• 7 Susset J G, Boctor Z N. Implantable electrical vesical stimulator: Clinical experience.  J Urol. 1968;  98 673-678
• 8 Halverstadt D B, Parry W L. Electronic stimulation of the human bladder: nine years later.  J Urol. 1975;  113 341-344
• 9 Magasi P, Simon S Z. Electrical stimulation of the bladder and gravidity.  Urol Int. 1986;  41 241-245
• 10 Decter R M, Snyder P, Rosvanis T K. Transurethral electrical bladder stimulation: Initial results.  J Urol. 1992;  148 651-653
• 11 Decter R M, Snyder P, Laudermilch C. Transurethral bladder stimulation: A follow up report.  J Urol. 1994;  152 812-814
• 12 Friedman H, Nashold B S, Senechal P. Spinal cord stimulation and bladder function in normal and paraplegic animals.  J Neurosurg. 1972;  36 430-437
• 13 Jonas U, Heine J P, Tanagho E A. Studies on the feasibility of urinary bladder evacuation by direct spinal cord stimulation. I. Parameters of most effective stimulation.  Invest Urol. 1975;  13 142-150
• 14 Jonas U, Tanagho E A. Studies on the feasibility of urinary bladder evacuation by direct spinal cord stimulation. II. Post stimulus voiding: a way to overcome outflow resistance.  Invest Urol. 1975;  13 151-153
• 15 Carter R R, McCreery D B, Woodford B J, Agnow W F. Micturition control by microstimulation of the sacral spinal cord of the cat: acute studies.  IEEE Trans Rehabil Eng. 1995;  3 206-214
• 16 Woodford B J, Carter R R, McCreery D, Bullara L A, Agnow W F. Histopathological and physiologic effects of chronic implantation of microelectrodes in sacral spinal cord of the cat.  J Neuropathol Exp Neurol. 1996;  55 982-291
• 17 Holmquist B, Olin T. Electromicturation in male dogs at pelvic nerve stimulation: a urethrocystographic study.  Scan J Urol Nephrol. 1968;  2 115-127
• 18 Holmquist B, Olin T. Electromicturation in female dogs at pelvic nerve stimulation: a urethrocystographic study.  Scan J Urol Nephrol. 1968;  2 129-135
• 19 Holmquist B, Staubitz W J, Greatbatch W. The significance of voltage and wave duration of stimuli in electrostimulation, induced by pelvic nerve stimulation in dogs.  Scan J Urol Nephrol. 1968;  2 137-142
• 20 Habib H N. Experience and recent contribution in sacral nerve stimulation for voiding in both human and animal.  Brit J Urol. 1967;  39 73-83
• 21 DeAraujo C G, Schmidt R A, Tanagho E A. Neural pathways to the lower urinary tract identified by retrograde axonal transport of horseradish peroxidase.  Urology. 1982;  19 290-295
• 22 Hassouna M, Li J S, Sawan M, Duval R, Latt R, Elhilali M M. Effect of early bladder stimulation on spinal shock: Experimental approach.  Urology. 1992;  40 563-573
• 23 El-Rifaei M, Hassouna M, Fouda A, Latt R, Sawan M, Duval R, Elhilali M M. The effect of early bladder stimulation on spinal shock: A preliminary report.  J Urol. 1989;  141 1010-1013
• 24 Li J S, Hassouna M, Sawan M, Duval R, Elhilali M M. Electrical stimulation induced sphincter fatigue during voiding.  J Urol. 1992;  148 949-952
• 25 Li J S, Hassouna M, Sawan M, Duval R, Elhilali M M. Long-term effect of sphincteric fatigue during bladder neurostimulation.  J Urol. 1995;  153 283-242
• 26 Meirowsky A M, Scheibert D C, Hinchey T R. Studies on the sacral reflex arc in paraplegic I. Response of the bladder to surgical elimination of sacral nerve impulses by rhizotomy.  J Neurosurg. 1950;  7 33-38
• 27 Brindley G S. The Ferrier Lecture, 1986. The actions of parasympathetic and sympathetic nerve in human micturition, erection and seminal emission, and their restoration in paraplegic patients by implanted electrical stimulators.  Proc R Soc London (Bio). 1988;  235 111-120
• 28 Tanagho E A, Schmidt R A. Electrical stimulation in the clinical management of the neurogenic bladder.  J Urol. 1988;  140 1331-1339
• 29 Thüroff J W, Schmidt R A, Bazeed M A, Tanagho E A. Chronic stimulation of sacral roots in dogs.  Eur Urol. 1983;  9 102-108
• 30 Bindley G S, Polkey C E, Rushton D N. Sacral anterior root stimulation for bladder control in paraplegia.  Paraplegia. 1982;  20 365-381
• 31 Schurch G, Rodic B, Jeanmond D. Posterior sacral rhizotomy and intradural anterior sacral root stimulation for treatment of the spastic bladder in spinal cord injury.  J Urol. 1997;  157 610-614
• 32 Schurch G, Knapp P A, Jeanmondo E, Rodic B, Rossier A B. Does sacral posterior rhizotomy suppress autonomic hyper-reflexia in patients with spinal cord injury.  Brit J Urol. 1998;  81 73-82
• 33 Van Kerrebroeck Koldewijn E L, Rosier P FWM, Wijkstra H, Debruyne F MJ. Results of the treatment of neurogenic bladder dysfunction in spinal cord injury by sacral posterior root rhizotomy and anterior sacral root stimulation.  J Urol. 1996;  155 1378-1381
• 34 Creasey G H. Electrical stimulation of sacral roots for micturition after spinal cord injury.  Urol Clin North Am. 1993;  3 505-515
• 35 McDonagh R P, Forster D M, Thomas D G. Urinary continence in spinal injura patients following complete sacral posterior rhizotomy.  Br J Urol. 1990;  66 618-622
• 36 Sauerwein D H, Domurath K H, Kutzenberger J F. Experience with sacral deafferentation and implantation of an anterior root stimulator following in 294 spinal-cord injury patients.  J Urol. 1999;  (Suppl) 161 274
• 37 Madersbacher H G, Kofler A, Fischer J, Strasser F, Haring B, Spanudakis S. Early temporary and late permanent loss of electromicturition through an anterior sacral root stimulator (Nrindley)- A 12 year's experience. European Urology 1999; 35/S2/99 XIV Congress of the European Association of Urology, April 7 - 11. Stockholm; Abstract 1999: 60
• 38 Hohenfellner M, Piack J S, Trigo-Rocha F, Schmidt R A, Kaula N F, Thüroff J W, Tanagho E A. Site of deafferentation and electrode placement for bladder stimulation: clinical implications.  J Urol. 1992;  147 1665-1670
• 39 Haleem A S, Boehm F, Legatt D, Kantrowitz A, Stome A, Melman A. Sacral root stimulation for controlled micturition: prevention of detrusor external sphincter dyssynergia by intraoperative identification and selective section of sacral nerve branches.  J Urol. 1993;  149 1607-1612
• 40 Brindley G S, Craggs M D. A technique for anodally blocking large nerve fibers through chronically implanted electrodes.  J Neuro Neurosurg and Psych. 1980;  43 1083-1090
• 41 Koldewijn E, Rickhoff N, Holsheimer J, van Kerrebroeck P EV, Debruyne F MJ, Wijkastra H. Selective sacral root stimulation for bladder control: Acute experiment in an animal model.  J Urol. 1994;  151 1674-1679
• 42 Rickhoff N JM, Koldewijn E L, van Kerrebroeck P EV, Debruyne F MJ, Wijkastra H. Acute animal studies on the use of an anodal block to reduce urethral resistance in sacral root stimulation.  IEEE Trans Rehab Eng. 1994;  2 92-94
• 43 Rickhoff N JM, Wijkastra H, van Kerrebroeck P EV, Debruyne F MJ. Selective detrusor activation by electrical sacral nerve root stimulation in spinal cord injury.  J Urol. 1997;  157 1504-1508
• 44 Mortimer J T. Electrical excitation of the nerve. In: Agnew WF, McCreery DB (Eds) Neural protheses. Fundamental studies. Prentice Hall; Englewood Cliffs 83
• 45 Grünewald V, Bhadra N, Creasey G H, Mortimer J T. Functional conditions of micturition induced by selective sacral anterior root stimulation: experimental results in aq canine animal mode.  Word J Urol. 1998;  16 329-336
• 46 Tanner J. Reversible blocking of nerve conduction by alternating current excitation.  Nature. 1962;  195 712-713
• 47 Solomonow M. External control of the neuromuscular system.  IEEE Trans Biomed Eng. 1984;  31 752-763
• 48 Baratta R, Ichie M, Hwang S, Solomonow M. Method for studying muscle properties under orderly stimulated motor units with tripolar nerve cuff electrode.  J Biomed Eng. 1989;  11 141-147
• 49 Zang T, Jiang D. Selective stimulation in a nerve trunk and ist application in urology.  Proc 9thAnnual Int Conf IEEE-EMBS, Boston. 1987;  pp 1040-1041
• 50 Shaker H S, Tu L M, Robin S, Arabi K, Hassouna M, Sawan M, Elhilali M M. Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: An acute study.  J Urol. 1998;  160 901-907
• 51 Sawan M, Hassouna M, Li J S, Duval F, Elhilali M M. Stimulator Design and Subsequent Stimulation Parameters Optimization for Controlling Micturition and Reducing Urethral Resistance.  IEEE Trans Rehab Eng. 1996;  4 39-46
• 52 Schumacher S, Bross S, Scheepe J R, Stief C, Junemann P P, Alken P. Extradural cold block for selective neurostimulation of the bladder: Development of a new technique.  J Urol. 1999;  161 950-954
• 53 Dahms S E, Tanagho E A. The impact of sacral root anatomy on selective electrical stimulation for bladder evacuation.  World J Urol. 1998;  16 322-328
• 54 Hassouna M M, Elhilali M M. Role of the sacral root stimulator in voiding dysfunction: Preliminary report.  World J Urol. 1991;  9 145-148
• 55 Elabbady A A, Hassouna M M, Elhilali M M. Neural stimulation for chronic voiding dysfunction.  J Urol. 1994;  152 2076-2080
• 56 Bosch J LHR, Groen J. Sacral (S3) segmental nerve stimulation as a treatment as for urge incontinence in patients with detrusor instability: results of chronic electrical stimulation using an implantable neural prosthesis.  J Urol. 1995;  154 504-507
• 57 Everaert K, Plancke H, Oosterlinck W. The urodynamic evaluation of neuromodulation in patients with voiding dysfunction.  Br J Urol. 1997;  79 702-707
• 58 Shaker H S, Hassouna M. Sacral root neuromodulation in idiopathic nonobstructive chronic urinary renteition.  J Urol. 1998;  159 1476-1478
• 59 Shaker H S, Hassouna M. Sacral nerve root neuromodulation: an effective treatment for refractory urge incontincence.  J Urol. 1998;  159 1516-1519
• 60 Janknegt R A, van Kerrebroeck P HEV, Lycklama a Nijeholt A, Schmidt R A, Hassouna M M, Siegel S W. Sacral nerve modulation for urge incontinence: A multinational, multicenter randomized study.  J Urol. 1997;  157 1237
• 61 Hassouna M. and the Sacaral Nerve Stimulation Group .Effect of sacral neuromodulation on urinary urgency-frequency. AUA 94thannual meeting Dallas, Texas; May 1 - 6, 1999