SPHINCTEROTOMY - LONG-TERM COMPLICATIONS AND WARNING SIGNS

Transurethral sphincterotomy is a commonly performed operation in spinal cord injury patients. Sixty-three patients who have had transurethral sphincterotomy were evaluated at our spinal cord injury unit for the risk and possible predictors of long-term outcome associated with this procedure. In addition to history and physical examination, all patients had urine culture, blood urea and creatinine, intravenous pyelogram and/or KUB with renal ultrasound, 4 channel videourodynamics, voiding cystourethrogram, and cystoscopy when indicated. Their mean age was 53 years, and their level of injury was cervical 32, thoracic 25, and lumbar 6. The mean time since injury was 27 years (3-50), and the mean follow-up since their last sphincterotomy was 11 years (2-30). The mean number of sphincterotomies was 1.74 (1-4). Urine culture revealed bacteruria (asymptomatic) in 48 and sterile urine in 15 patients. Renal function was normal in 61 patients and abnormal in 2 patients. Videourodynamics revealed detrusor hyperreflexia in 60, detrusor areflexia in 3, abnormal detrusor compliance in 9, and detrusor sphincter dyssynergia in 34 patients. The mean Leak point pressure was 36.4 cm H2O (5-100), and the mean maximum detrusor pressure was 54.7 cm H2O (12-100). Nineteen (30%) patients had significant upper tract complications including; renal calculi, atrophic kidney, vesicoureteral reflux, and renal scarring with impaired renal function. Fifty percent of upper tract complications developed more than 2 years after sphincterotomy. Thirty patients had lower tract complications including; recurrent symptomatic urinary tract infection, bladder stones, urethral diverticulum, urethral stricture, bladder neck stenosis, and recurrent epididymitis. Leak point pressure was the most reliable urodynamic parameter to predict the risk of upper tract complications after sphincterotomy. The risk of these complications were 25% when LPP < 40 cm H2O and 50% when LPP > 70 cm H2O. Maximum detrusor pressure did not correlate with the risk of these complications. The risk of upper tract complications in the presence and absence of abnormal detrusor compliance was 32 and 33%, respectively, and in the presence and absence of detrusor sphincter dyssynergia was 32 and 39%, respectively. Bacteriuria was associated with increased risk to the upper tracts in this study. In conclusion, the risk of significant upper tract complications after sphincterotomy is 30%, and the reoperation rate is 1.74. This risk remains at 25% even when the leak point pressure is less than 40 cm H2O. Fifty percent of upper tract complications occur more than 2 years after sphincterotomy, thus continued follow-up of these patients is necessary. Leak point pressure is the most reliable urodynamic parameter to predict upper tract complications after sphincterotomy. Detrusor compliance, maximum detrusor pressure, and EMG patterns as independent variables did not predict the risk of upper tract complications after sphincterotomy. Asymptomatic bacteriuria is associated with increased risk of upper tract complication, although the exact mechanism is unclear. (C) 1995 Wiley-Liss, Inc.