Spinal cord injury (SCI) results in neurogenic dysfunction of the lower urinary tract. Depending on the degree and level of paralysis, individuals may develop detrusor overactivity and detrusor sphincter dyssynergia or detrusor acontractility. Bladder management in patients with tetraplegia can be challenging as intermittent catheterization may not be feasible due to limited hand function. Reflex voiding is an option that avoids long-term indwelling catheters, which carry risks such as recurrent infection, occlusion, stone formation, and tumour development. However, some centres do not perform this method due to the high pressure during reflex voiding, which is discussed to be a risk factor for renal function. Long-term, data, however, are missing. The aim of this study was to demonstrate that triggered reflex voiding with sphincterotomy is a feasible long-term technique for bladder management in tetraplegic patients and does not pose a risk to the upper urinary tract.

In a retrospective analysis of medical records, we analysed the data sets of men who underwent sphincterotomy. The minimum follow-up was 10 years. Renal function (cystatin C), sonography and the presence of reflux were analysed as outcome parameters. In addition, video urodynamic data and postvoid residual urine were analysed over the long term. Descriptive statistics were used to analyse the data (SPSS).

We identified 176 patients with a minimum follow-up of 10 years, the mean age was 54.1 years (ranged 28-89), most patients had SCI (84%), the remaining patients had meningomyelocele, multiple sclerosis, or anterior spinal artery syndrome. The median disease duration was 23 years (quartiles 19/33), the level of lesion was cervical in 52% and thoracic in 34%. At 10-year follow-up the cystatin level was 0.91 mg/dl (0.80-1.49 ng/ml SD 0.20). In 5% of patients, unilateral grade I reflux was detected. Urodynamics showed no change in bladder capacity (326.9 ml ±167.9 ml) after sphincterotomy (390.6 ±170.8 ml at 10-year follow-up), and residual urine volume remained stable from 185.8 ml ±134.2 to 144.8 +178.7 at 10-year follow-up.

Renal function and urodynamic parameters remained stable in the long-term follow-up. The increase in patients with suprapubic catheters can be explained by aging and the development of comorbidities. As this is a retrospective study, there are some methodologic drawbacks. Nonetheless, we could demonstrate that sphincterotomy in men with tetraplegia is a safe procedure, which, like all bladder management in persons with SCI, should be followed by video-urodynamic controls.

Sphincterotomy remains an important part of the neuro-urologist's toolbox. With regular video urodynamic monitoring, this procedure preserves upper urinary tract function as well as independence of the tetraplegic patients, as neither caregivers to perform catheterization nor long-term indwelling catheters are required.