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CUA: Neurogenic Lower Urinary Tract Dysfunction (2019): Difference between revisions

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'''See Original Guideline'''
'''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570608/ Original Guideline]'''


== Definitions ==
== Definitions ==
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#'''<span style="color:#0000ff">U</span><span style="color:#ff0000">pper urinary tract deterioration (UUTD)'''
#'''<span style="color:#0000ff">U</span><span style="color:#ff0000">pper urinary tract deterioration (UUTD)'''


=== <span style="color:#ff0000">Infection ===
=== Infection ===


* '''Sepsis'''
* '''Sepsis'''
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**'''<span style="color:#ff0000">Diagnosis and Evaluation'''
**'''<span style="color:#ff0000">Diagnosis and Evaluation'''
***'''The accepted definition of UTI in persons with NLUTD requires the presence of (3):'''
***'''The accepted definition of UTI in persons with NLUTD requires the presence of (3):'''
****'''Leukocyturia'''
***#'''Leukocyturia'''
*****Consensus cut-off for leukocyturia is 100 leukocytes/mL or any leukocyte esterase activity on dipstick
***#*Consensus cut-off for leukocyturia is 100 leukocytes/mL or any leukocyte esterase activity on dipstick
****'''Bacteriuria'''
***#'''Bacteriuria'''
*****No evidence-based cut-off values for bacteriuria; '''generally accepted guidelines:'''
***#*No evidence-based cut-off values for bacteriuria; '''generally accepted guidelines:'''
******'''Any detectable concentration for suprapubic aspirate'''
***#**'''Any detectable concentration for suprapubic aspirate'''
******'''>102 cfu/ml (clean catheterized sample)'''
***#**'''>102 cfu/ml (clean catheterized sample)'''
******'''>104 cfu/ml (clean voided)'''
***#**'''>104 cfu/ml (clean voided)'''
****'''Clinical symptoms'''
***#'''Clinical symptoms'''
*****'''<span style="color:#ff0000">Signs and symptoms of UTI in SCI'''  
***#*'''<span style="color:#ff0000">Signs and symptoms of UTI in SCI'''  
*****#'''<span style="color:#ff0000">Fever'''
***#*#'''<span style="color:#ff0000">Fever'''
*****#'''<span style="color:#ff0000">Cloudy urine'''
***#*#'''<span style="color:#ff0000">Cloudy urine'''
*****#'''<span style="color:#ff0000">Malodorous urine'''
***#*#'''<span style="color:#ff0000">Malodorous urine'''
*****#'''<span style="color:#ff0000">Dysuria'''
***#*#'''<span style="color:#ff0000">Dysuria'''
*****#'''<span style="color:#ff0000">Urinary incontinence/failure of control or leaking around catheter'''
***#*#'''<span style="color:#ff0000">Urinary incontinence/failure of control or leaking around catheter'''
*****#'''<span style="color:#ff0000">Increased spasticity'''
***#*#'''<span style="color:#ff0000">Increased spasticity'''
*****#'''<span style="color:#ff0000">Malaise'''
***#*#'''<span style="color:#ff0000">Malaise'''
*****#'''<span style="color:#ff0000">Lethargy or sense of unease'''
***#*#'''<span style="color:#ff0000">Lethargy or sense of unease'''
*****#'''<span style="color:#ff0000">Back pain'''
***#*#'''<span style="color:#ff0000">Back pain'''
*****#'''<span style="color:#ff0000">Bladder pain'''
***#*#'''<span style="color:#ff0000">Bladder pain'''
*****#'''<span style="color:#ff0000">Autonomic dysreflexia'''
***#*#'''<span style="color:#ff0000">Autonomic dysreflexia'''
***'''Urine cultures should always be obtained prior to antimicrobial therapy due to the increased risk of nosocomial and multidrug-resistant microorganisms'''
***'''Urine cultures should always be obtained prior to antimicrobial therapy due to the increased risk of nosocomial and multidrug-resistant microorganisms'''
**'''<span style="color:#ff0000">Management'''
**'''<span style="color:#ff0000">Management'''
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****'''<span style="color:#ff0000">Bladder management'''
****'''<span style="color:#ff0000">Bladder management'''
***** '''<span style="color:#ff0000">When possible, CIC should be used over other methods'''
***** '''<span style="color:#ff0000">When possible, CIC should be used over other methods'''
***** '''Risk of UTI: Transurethral indwelling catheterization carries >5x risk of recurrent UTIs when compared to suprapubic catheterization and CIC'''. '''Risk of UTI comparable between suprapubic, condom catheter, and CIC.'''
****** '''Risk of UTI: Transurethral indwelling catheterization carries >5x risk of recurrent UTIs when compared to suprapubic catheterization and CIC'''. '''Risk of UTI comparable between suprapubic, condom catheter, and CIC.'''
****** '''Condom catheters are effective and safe in select NLUTD patients''' (low PVRs and bladder storage pressures) '''but are significantly associated with Pseudomonas and Klebsiella bacteriuria and an incidence of UTI comparable to CIC'''.
******* '''Condom catheters are effective and safe in select NLUTD patients''' (low PVRs and bladder storage pressures) '''but are significantly associated with Pseudomonas and Klebsiella bacteriuria and an incidence of UTI comparable to CIC'''.
***** '''Risk of stones: CIC and condom catheter lower risk than indwelling transurethral or suprapubic'''
****** Risk of stones: CIC and condom catheter lower risk than indwelling transurethral or suprapubic
***** <span style="color:#ff0000">'''Indwelling catheters should be changed every 2–4 weeks, with monthly being the most common interval.'''
***** <span style="color:#ff0000">'''Indwelling catheters should be changed every 2–4 weeks, with monthly being the most common interval'''
**** '''Antimicrobial prophylaxis'''
**** '''Antimicrobial prophylaxis'''
***** '''Routine antimicrobial prophylaxis for NLUTD UTI is not recommended for most patients'''
***** '''Routine antimicrobial prophylaxis for NLUTD UTI is not recommended for most patients'''
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*#*# '''<span style="color:#ff0000">Known high-risk features'''
*#*# '''<span style="color:#ff0000">Known high-risk features'''
*#*# '''<span style="color:#ff0000">Considering more invasive treatment options'''
*#*# '''<span style="color:#ff0000">Considering more invasive treatment options'''
*'''See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6570608/figure/f2-cuaj-6-e157/ Figure 2] (Initial investigations and risk stratification for neurogenic lower urinary tract dysfunction (NLUTD) patients) from Original Guideline'''


=== History and Physical Exam ===
=== History and Physical Exam ===
Line 274: Line 275:


=== Other ===
=== Other ===
*'''PVR'''
 
** To address potential UTI risk and overflow incontinence; may prompt screening for upper tract deterioration
==== PVR ====
** In the non-NLUTD population, a value >300 mL is used to define chronic urinary retention. The need to treat PVR should be based on patient symptoms rather than an absolute number.
* '''To address potential UTI risk and overflow incontinence; may prompt screening for upper tract deterioration'''
* '''Urodynamics'''
* In the non-NLUTD population, a value >300 mL is used to define chronic urinary retention.
** '''Gold standard for evaluating NLUTD and are necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.'''
*'''The need to treat PVR should be based on patient symptoms rather than an absolute number.'''
** '''VideoUDS are preferred, as the additional correlation with imaging allows assessment of (3):'''
 
**# '''VUR'''
==== Urodynamics ====
**# '''Abnormal bladder morphology'''
* '''<span style="color:#ff0000">Gold standard for evaluating NLUTD'''
**# '''Behaviour of the urinary sphincters during voiding'''
*'''<span style="color:#ff0000">Necessary due to the absence of normal lower urinary tract sensation and the poor ability of symptoms to predict high-risk features.'''
*** The availability of videoUDS is not universal; a voiding cystogram is an acceptable alternative in some cases
* '''<span style="color:#ff0000">VideoUDS are preferred, as the additional correlation with imaging allows assessment of (3):'''
** Urodynamic diagnoses, such as neurogenic detrusor overactivity (NDO), impaired compliance, reduced bladder capacity, or a high detrusor leak point pressure (DLPP, defined as the lowest detrusor pressure at which urine leaks from the bladder in the absence of a detrusor contraction or increased abdominal straining) can identify a patient with potentially higher risk of urological complications (such as renal dysfunction, urinary infections, and incontinence).
*# '''<span style="color:#ff0000">VUR'''
*** A DLPP of >40 cm H2O has traditionally been cited as the cutoff above which a patient has a high risk of renal deterioration; however, this is based on a historical study of children with SB, and may not be applicable to adult NLUTD.
*# '''<span style="color:#ff0000">Abnormal bladder morphology'''
*** As DLPP increases, so too does the risk of renal dysfunction due to an increased resting pressure in the bladder being transmitted to the kidneys.
*# '''<span style="color:#ff0000">Behaviour of the urinary sphincters during voiding'''
*** '''If a high DLPP only occurs at a volume greater than the usual capacity during the normal daily voiding pattern, then this DLPP may not be physiologically relevant.'''
** The availability of videoUDS is not universal; a voiding cystogram is an acceptable alternative in some cases
*** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence.
* '''<span style="color:#ff0000">Urodynamic findings associated with increased risk of urological complications (such as renal dysfunction, urinary infections, and incontinence) (4):'''
** '''Other potential UDS findings, such as the duration of the NDO contraction, may also predict renal deterioration.'''
*#'''<span style="color:#ff0000">Neurogenic detrusor overactivity (NDO)'''
* '''Cystoscopy'''
*#*'''Duration of the NDO contraction''' may predict renal deterioration
** Should be reserved for situations where there is a clinical indication to assess either the urethra or bladder (such as suspicion of urethral strictures or false passages, bladder stones, or bladder cancer)
*#'''<span style="color:#ff0000">Impaired compliance'''
* '''Voiding diaries'''
*#'''<span style="color:#ff0000">Reduced bladder capacity'''
** '''Should be considered for all patients'''
*#'''<span style="color:#ff0000">High detrusor leak point pressure (DLPP)'''
** Allows the patient to self-reflect on their urinary habits and the physician to measure changes over time in a non-invasive manner and interpret urodynamic findings in the context of the patient’s day-to-day urinary patterns.
*#*DLPP: defined as the lowest detrusor pressure at which urine leaks from the bladder in the absence of a detrusor contraction or increased abdominal straining
* '''Validated questionnaires'''
*#** A DLPP of >40 cm H2O has traditionally been cited as the cutoff above which a patient has a high risk of renal deterioration; however, this is based on a historical study of children with SB, and may not be applicable to adult NLUTD.
** Optional; generally used for research purposes in the NLUTD population
*#** As DLPP increases, so too does the risk of renal dysfunction due to an increased resting pressure in the bladder being transmitted to the kidneys.
*#** '''If a high DLPP only occurs at a volume greater than the usual capacity during the normal daily voiding pattern, then this DLPP may not be physiologically relevant.'''
*#** A low DLPP maintains low pressure drainage from the kidneys, however, this often results in urinary incontinence.
 
==== Voiding diaries ====
* '''Should be considered for all patients'''
* Allows the patient to self-reflect on their urinary habits and the physician to measure changes over time in a non-invasive manner and interpret urodynamic findings in the context of the patient’s day-to-day urinary patterns.
 
==== Validated questionnaires ====
* '''Optional'''
*Generally used for research purposes in the NLUTD population
 
==== Cystoscopy ====
* Should be reserved for situations where there is a clinical indication to assess either the urethra or bladder (such as suspicion of urethral strictures or false passages, bladder stones, or bladder cancer)


=== Timing ===
=== Timing ===
*'''The timing of this initial evaluation is variable and dependent on the severity of symptoms, underlying risk of serious urological complications, and the etiology of the neurogenic bladder.'''
*'''Depends on the severity of symptoms, underlying risk of serious urological complications, and the etiology of the neurogenic bladder.'''
** '''SB and SCI have a significant risk of renal dysfunction and are acquired at birth (SB) or often as young adults (SCI); this makes patients particularly susceptible to renal dysfunction in their lifetime. This contrasts with slowly progressive diseases, such as relapsing-remitting MS, or the predominately elderly population with Parkinson’s disease or dementia.'''
** '''SB and SCI have a significant risk of renal dysfunction and are acquired at birth (SB) or often as young adults (SCI); this makes patients particularly susceptible to renal dysfunction in their lifetime. This contrasts with slowly progressive diseases, such as relapsing-remitting MS, or the predominately elderly population with Parkinson’s disease or dementia.'''
** '''The urological evaluation of a patient with a newly acquired SCI should occur within 3–6 months of the SCI.'''
** '''The urological evaluation of a patient with a newly acquired SCI should occur within 3–6 months of the SCI.'''
*** Significant bladder dysfunction can appear early after SCI. Efforts should made to assess patients with urological complications or concerns as soon as possible after the acute SCI.
*** Significant bladder dysfunction can appear early after SCI. Efforts should made to assess patients with urological complications or concerns as soon as possible after the acute SCI.
* '''Summary: initial investigations and risk stratification for neurogenic lower urinary tract dysfunction (NLUTD) patients'''
** '''See Figure 2 from Original Guideline'''


== Management ==
== Management ==
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=== Assisted bladder drainage ===
=== Assisted bladder drainage ===
*'''CIC or condom-catheter preferred'''
*'''<span style="color:#ff0000">CIC or condom-catheter preferred'''
*# '''Non-catheter mechanisms'''
*# '''<span style="color:#ff0000">Non-catheter mechanisms'''
*#* Rely on involuntary emptying that is either induced or spontaneous
*#* Rely on involuntary emptying that is either induced or spontaneous
*#* '''Some bladder methods (reflex triggering and Valsalva or Credé manoeuvres) should be strongly discouraged due their associated risk of upper tract injury.'''
*#* '''Some bladder methods (reflex triggering and Valsalva or Credé manoeuvres) should be strongly discouraged due their associated risk of upper tract injury.'''
*#** The '''Crede manoeuvre''' (external pressure on the bladder) '''and Valsalva''' voiding induces bladder drainage via an increase in abdominal pressure that can overcome the external urethral sphincter. It can be '''inefficient and risk high pressures and cause hemorrhoids, hernias, and VUR.'''
*#** The '''Crede manoeuvre''' (external pressure on the bladder) '''and Valsalva''' voiding induces bladder drainage via an increase in abdominal pressure that can overcome the external urethral sphincter. It can be '''inefficient and risk high pressures and cause hemorrhoids, hernias, and VUR.'''
*#* '''Condom catheter drainage''' is often used to collect urine in these non-catheter methods
*#* '''Condom catheter drainage''' is often used to collect urine in these non-catheter methods
*# '''Catheter mechanisms'''
*# '''<span style="color:#ff0000">Catheter mechanisms'''
*#* '''Options (3): CIC (preferred), indwelling urethral and suprapubic catheter'''
*#* '''<span style="color:#ff0000">Options (3): CIC (preferred), indwelling urethral and suprapubic catheter'''
*#** '''CIC associated with reduced risk of infection, reduced risk of stones, and preservation of bladder compliance compared with indwelling urethral or SP catheter'''
*#** '''<span style="color:#ff0000">CIC associated with reduced risk of infection, reduced risk of stones, and preservation of bladder compliance compared with indwelling urethral or SP catheter'''
*#* Until evidence can confidently demonstrate that multiple use is as safe as single-use catheters, healthcare providers should advocate a single use of catheters in individuals with SCI.
*#* Until evidence can confidently demonstrate that multiple use is as safe as single-use catheters, healthcare providers should advocate a single use of catheters in individuals with SCI.


=== Oral therapy (2): ===
=== Oral therapy ===
*'''Anticholinergics and beta-3 agonists'''
 
*# '''Anticholinergics''' (with dose-escalation)
==== Options (2): ====
*#* '''First-line pharmacological treatment for patients with NLUTD'''
 
*#* Should be offered to people with urodynamic findings of NDO or those with SCI and symptoms of overactive bladder (OAB)
*'''<span style="color:#ff0000">Anticholinergics'''  
*#** Should be considered whether or not patients are using assisted bladder drainage.
*'''<span style="color:#ff0000">Beta-3 agonists'''
*#** '''Absence of its usage has been shown to be a risk factor for upper tract deterioration'''
 
*#* '''Use improves OAB symptoms and NDO, decreases urgency urinary incontinence, and lowers detrusor pressures'''
==== Anticholinergics ====
*#* '''Do not alter the detrusor or abdominal leak point pressures since they do not act on the external urethral sphincter'''
* '''<span style="color:#ff0000">First-line pharmacological treatment for patients with NLUTD'''
*#* '''Studies that compared one medication to another''' (usually oxybutynin IR) '''did not reveal statistically significant differences.''' The optimal drug dosage was not identified.
* '''<span style="color:#ff0000">Indications'''
*#* '''Supratherapeutic dosages may be considered according to tolerability''' but should be used cautiously.
**'''<span style="color:#ff0000">Should be offered to people with urodynamic findings of NDO or those with SCI and symptoms of overactive bladder (OAB)'''
*#* '''Combining antimuscarinics may be beneficial for patients who are refractory to dose escalation antimuscarinic monotherapy'''
** '''<span style="color:#ff0000">Should be considered whether or not patients are using assisted bladder drainage.'''
*#* '''There is very limited data supporting the use of transdermal oxybutynin in NLUTD'''
*** '''Absence of its usage has been shown to be a risk factor for upper tract deterioration'''
*# '''Beta-3 adrenergic agonist therapy'''
* '''<span style="color:#ff0000">Use improves OAB symptoms and NDO, decreases urgency urinary incontinence, and lowers detrusor pressures'''
*#* '''Mirabegron may be a useful alternative to anticholinergics for patients with symptoms of OAB and NLUTD, but further evidence of urodynamic changes are needed in this population'''
* '''<span style="color:#ff0000">Do not alter the detrusor or abdominal leak point pressures since they do not act on the external urethral sphincter'''
*#** There is very limited data supporting the use of mirabegron in NLUTD
* '''Studies that compared one medication to another''' (usually oxybutynin IR) '''did not reveal statistically significant differences.''' The optimal drug dosage was not identified.
* '''Supratherapeutic dosages may be considered according to tolerability''' but should be used cautiously.
* '''Combining antimuscarinics may be beneficial for patients who are refractory to dose escalation antimuscarinic monotherapy'''
* '''There is very limited data supporting the use of transdermal oxybutynin in NLUTD'''
 
==== Beta-3 adrenergic agonist ====
* '''<span style="color:#ff0000">Mirabegron may be a useful alternative to anticholinergics for patients with symptoms of OAB and NLUTD, but further evidence of urodynamic changes are needed in this population'''
** There is very limited data supporting the use of mirabegron in NLUTD


=== Intravesical therapy (2): ===
=== Intravesical therapy ===
*'''Botox and oxybutynin'''
 
*# '''Botox'''
==== Options (2): ====
*#* '''Ona-botulinum toxin A injection (200 units) in the detrusor is an effective, minimally invasive treatment that can achieve continence, improve bladder function, and diminish NDO in individuals with SCI or MS who have an inadequate response to or are intolerant of an anticholinergic medication'''
 
*#* '''Abo-botulinum toxin A is also effective in NLUTD, with the optimal dose of 750 units'''
*'''<span style="color:#ff0000">Botox'''
*#* Sustained efficacy in terms of reduced incontinence episodes, enhanced bladder function, as well as substantial improvements in key urodynamic parameters and QoL
*'''<span style="color:#ff0000">Oxybutynin'''
*#* UTIs and large urine residual or urinary retention are the most frequent adverse events. Therefore, the likelihood of future need of CIC is increased
 
*# '''Oxybutynin by CIC'''
==== Botox ====
*#* '''A safe alternative approach to managing NDO and NLUTD in patients who are doing CIC;''' safe and effective short-term therapy in patients suffering from NDO who remain incontinent or are intolerant of oral anticholinergic medication
* '''<span style="color:#ff0000">Ona-botulinum toxin A injection (200 units) in the detrusor is an effective, minimally invasive treatment that can achieve continence, improve bladder function, and diminish NDO in individuals with SCI or MS who have an inadequate response to or are intolerant of an anticholinergic medication'''
*#* '''Results in significant increase in bladder capacity'''
* '''Abo-botulinum toxin A is also effective in NLUTD, with the optimal dose of 750 units'''
*#* '''This approach avoids systemic side effects compared to oral oxybutynin'''
* Sustained efficacy in terms of reduced incontinence episodes, enhanced bladder function, as well as substantial improvements in key urodynamic parameters and QoL
* UTIs and large urine residual or urinary retention are the most frequent adverse events. Therefore, the likelihood of future need of CIC is increased
 
==== Oxybutynin by CIC ====
* '''A safe alternative approach to managing NDO and NLUTD in patients who are doing CIC;''' safe and effective short-term therapy in patients suffering from NDO who remain incontinent or are intolerant of oral anticholinergic medication
* '''Results in significant increase in bladder capacity'''
* '''This approach avoids systemic side effects compared to oral oxybutynin'''


=== Neural stimulation and neuromodulation therapy ===
=== Neural stimulation and neuromodulation therapy ===
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=== Surgical management of LUTD ===
=== Surgical management of LUTD ===
* '''Indicated when conservative measures, medical therapy, and minimally invasive interventions alone fail to achieve the objectives of:'''
 
==== Indications ====
 
*'''When conservative measures, medical therapy, and minimally invasive interventions alone fail to achieve the objectives of:'''
*# Protecting kidney function and mitigating autonomic dysreflexia by maintaining bladder storage at safely low pressures
*# Protecting kidney function and mitigating autonomic dysreflexia by maintaining bladder storage at safely low pressures
*# Ensuring adequate and timely bladder emptying to mitigate the risks of overflow incontinence, recurrent UTIs, bladder stones, and kidney damage
*# Ensuring adequate and timely bladder emptying to mitigate the risks of overflow incontinence, recurrent UTIs, bladder stones, and kidney damage
*# Preventing the adverse effects of incontinence (e.g., dermatitis)
*# Preventing the adverse effects of incontinence (e.g., dermatitis)
*# Improving QoL by relieving bothersome symptoms of OAB and incontinence.
*# Improving QoL by relieving bothersome symptoms of OAB and incontinence.
* '''Options (5): bladder augmentation, catherizable channel, external urethral sphincterotomy, bladder neck closure with continent or incontinent channel, incontinent diversion'''
 
*# '''Bladder augmentation'''
==== Options (5): ====
*#* '''Indications (2):'''
 
*#*# '''Reduced compliance or NDO refractory to all other non-surgical treatments'''
#'''<span style="color:#ff0000">Bladder augmentation'''
*#*# '''Reduced bladder capacity necessitating an indwelling catheter or CIC to be done too frequently'''
#'''<span style="color:#ff0000">Catherizable channel'''
*# '''Catheterizable channels and continent cutaneous urinary diversion'''
#'''<span style="color:#ff0000">External urethral sphincterotomy'''
*#* '''In cases where urethral catheterization is precluded, a catheterizable channel may be offered''' after careful consideration and multidisciplinary evaluation.
#'''<span style="color:#ff0000">Bladder neck closure with continent or incontinent channel'''
*#* '''The most commonly used tube is the appendix (Mitrofanoff appendicovesicostomy). Where the appendix is unavailable or unsatisfactory''' (must be 8–10 cm in length for adult patients), '''a segment of terminal ileum can be employed''' (Yang-Monti or Casale technique), albeit with slightly poorer outcomes.
#'''<span style="color:#ff0000">Incontinent diversion'''
*# '''External urethral sphincterotomy'''
 
*#* '''Contraindications (4):'''
===== Bladder augmentation =====
*#*# '''Female'''
* '''<span style="color:#ff0000">Indications (2):'''
*#*# '''Unable to wear condom catheter'''
*# '''<span style="color:#ff0000">Reduced compliance or NDO refractory to all other non-surgical treatments'''
*#*# '''Detrusor underactivity'''
*# '''<span style="color:#ff0000">Reduced bladder capacity necessitating an indwelling catheter or CIC to be done too frequently'''
*#*# '''Patient wants to maintain fertility'''
 
*# '''Bladder neck closure combined with a continent or incontinent channel'''
===== Catheterizable channels and continent cutaneous urinary diversion =====
*#* '''Indicated in cases of severe outlet damage'''
* '''<span style="color:#ff0000">In cases where urethral catheterization is precluded, a catheterizable channel may be offered</span>''' after careful consideration and multidisciplinary evaluation.
*# '''Incontinent urinary diversion (ileovesicostomy and ileal conduit)'''
* '''The most commonly used tube is the appendix (Mitrofanoff appendicovesicostomy). Where the appendix is unavailable or unsatisfactory''' (must be 8–10 cm in length for adult patients), '''a segment of terminal ileum can be employed''' (Yang-Monti or Casale technique), albeit with slightly poorer outcomes.
*#* '''Last resort in managing the complications of NLUTD'''
 
*#* The bladder should be removed at the time of surgery to reduce the risks of pyocystis, chronic symptomatic cystitis, and malignancy
===== External urethral sphincterotomy =====
* '''Contraindications (4):'''
*# '''Female'''
*# '''Unable to wear condom catheter'''
*# '''Detrusor underactivity'''
*# '''Patient wants to maintain fertility'''
 
===== Bladder neck closure combined with a continent or incontinent channel =====
* '''Indicated in cases of severe outlet damage'''
 
===== Incontinent urinary diversion (ileovesicostomy and ileal conduit) =====
* '''Last resort in managing the complications of NLUTD'''
* The bladder should be removed at the time of surgery to reduce the risks of pyocystis, chronic symptomatic cystitis, and malignancy


== Surveillance studies for NLUTD patients in the community setting ==
== Surveillance studies for NLUTD patients in the community setting ==
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