Intradetrusor onabotulinumtoxinA injections have revolutionized the treatment of refractory neurogenic detrusor overactivity. As a consequence, bladder augmentation and urinary diversion for neuro-urological indications have almost disappeared from the operating theatres and many urologists will no longer be confronted with patients undergoing such reconstructive procedures for refractory neurogenic lower urinary tract dysfunction (NLUTD) during their careers. With this background assumption we assessed if there is still a place for bladder augmentation and urinary diversion in modern neuro-urology.

Between January 2011 and October 2017, a total of 51 patients underwent bladder augmentation (n=12) or urinary diversion (ileal conduit: n=31, continent catheterisable reservoir, n=8) for NLUTD.

Of the 51 patients, mean age was 47 years (standard deviation ±16 years) and 25 (49%) were women. 20 patients suffered from spinal cord injury, 14 from multiple sclerosis, 8 from spina bifida, and 9 from other neurological disorders. Before bladder augmentation, patients were treated with 2 to 3 different antimuscarinics and with 2 to 16 intradetrusor onabotulinumtoxinA injection cycles. All patients with urinary diversion underwent cystectomy. Reasons for ileal conduit and decisions against continent catheterisable reservoir were severely impaired hand (n=18) or cognitive (n=8) function making intermittent self-catheterization impossible, renal failure in 3 and patients’ preference in 2 patients.

Looking at our cohort, all patients had a long history of suffering behind them with repetitive outpatient visits and hospitalizations as well as several unsuccessful conservative / minimally invasive treatments, before the decision for a surgical solution was made. In modern neuro-urology, a careful assessment together with the patient and their caregivers must be made to guarantee an optimal customized treatment protecting the upper and lower urinary tract and improving health-related quality of life.

Despite the triumphal era of onabotulinumtoxinA treatment in neuro-urology, there is still a place for bladder augmentation and urinary diversion in very selected patients with refractory NLUTD. Thus, meticulous knowledge transfer to upcoming neuro-urologists is of utmost importance to guarantee optimal treatment for prospective neuro-urological patients.