SPHINCTEROTOMY - LONG-TERM COMPLICATIONS AND WARNING SIGNS

Transurethral sphincterotomy is a commonly performed operation in spin al cord injury patients. Sixty-three patients who have had transurethr al sphincterotomy were evaluated at our spinal cord injury unit for th e risk and possible predictors of long-term outcome associated with th is procedure. In addition to history and physical examination, all pat ients had urine culture, blood urea and creatinine, intravenous pyelog ram and/or KUB with renal ultrasound, 4 channel videourodynamics, void ing cystourethrogram, and cystoscopy when indicated. Their mean age wa s 53 years, and their level of injury was cervical 32, thoracic 25, an d lumbar 6. The mean time since injury was 27 years (3-50), and the me an 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. Ren al function was normal in 61 patients and abnormal in 2 patients. Vide ourodynamics revealed detrusor hyperreflexia in 60, detrusor areflexia in 3, abnormal detrusor compliance in 9, and detrusor sphincter dyssy nergia 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 in cluding; renal calculi, atrophic kidney, vesicoureteral reflux, and re nal scarring with impaired renal function. Fifty percent of upper trac t complications developed more than 2 years after sphincterotomy. Thir ty patients had lower tract complications including; recurrent symptom atic urinary tract infection, bladder stones, urethral diverticulum, u rethral stricture, bladder neck stenosis, and recurrent epididymitis. Leak point pressure was the most reliable urodynamic parameter to pred ict the risk of upper tract complications after sphincterotomy. The ri sk of these complications were 25% when LPP < 40 cm H2O and 50% when L PP > 70 cm H2O. Maximum detrusor pressure did not correlate with the r isk of these complications. The risk of upper tract complications in t he 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 w ith increased risk to the upper tracts in this study. In conclusion, t he risk of significant upper tract complications after sphincterotomy is 30%, and the reoperation rate is 1.74. This risk remains at 25% eve n when the leak point pressure is less than 40 cm H2O. Fifty percent o f upper tract complications occur more than 2 years after sphincteroto my, thus continued follow-up of these patients is necessary. Leak poin t 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. As ymptomatic bacteriuria is associated with increased risk of upper trac t complication, although the exact mechanism is unclear. (C) 1995 Wile y-Liss, Inc.