Long-term Management Program

1. General Long-term Surveillance Strategies

  • To date, there is no consensus on the standard practice on the following issues:
    • Followup interval
    • Timing of the commencement of screening
    • Screening tools
  • The reason for non standardized approaches
    • The epidemiology and natural history of the condition are not fully understood.
    • No high quality, randomized, controlled trials exist to indicate decreased mortality and morbidity.
  • The surveillance guideline generally varies by institution and urologist. The following program may be generally accepted: periodic followup is safe, at more than two years after injury, if a careful check-up including urodynamics, renal function studies, and upper and lower tract imaging are performed yearly.
  • In those patients managed by indwelling catheters, in addition to the studies above an annual cystoscopy and biopsy may be necessary for those with 10 or more years of catheterization and for those with an episode of gross hematuria, chronic symptomatic UTI refractory to therapy [Wyndaele JJ, Incontinence 2005].
  • Acceptable followup interval
    • 6 months basis: In high-risk patients, follow-up examination is carried out at 6 months. If the upper tracts are stable, subsequent imaging studies are obtained at yearly intervals.
    • A yearly basis: Most urological clinics advocate followup a yearly basis Close urological follow up is particularly necessary in patients with risk factors to the upper urinary tract .In this regard periodic radiographic evaluation is not enough. Periodic urodynamic evaluation is especially important in the first few years after injury as urodynamic changes always antedate radiographic ones.
  • Lifetime follow-up:
    • The condition of a person with a chronic SCI can change over time. Neurologic improvement routinely occurs in the initial period after discharge, and new medical problems may appear at any time.
    • Routine lifetime follow-up by a urology team, in conjunction with primary medical care in the community, is necessary.
    • Proper and diligent followup is needed to avoid major morbidity and mortality in the high risk patients

2. Specific Long-term Surveillance Strategies

1) Kidney:

  • Purpose:
    • detection of morphological deterioration as well as any change in of renal function as measured by chemical blood tests and creatinine clearance
    • Surveillance for renal or ureteral stones
  • Tool:
    • Kidney ultrasound and/or renal scan: Noninvasive ultrasound is preferred.
    • CT scan or intravenous pyelography: Not routine
  • Interval and Indication:
    • Kidney ultrasound: yearly routine
    • CT scan or intravenous pyelography: When evidences for urosepsis, stone, new onset of hematuria, recurrent UTI are demonstrated

2) Bladder:

  • Purpose:
    • detection for altered bladder function(link to the Tx-6-1) Problems Encountered During Long-term Follow-up/ 1. Micturition and Urinary Incontinence)risk factors
    • detection for bladder cancer
    • detection for bladder stone
  • Tool: [VIDEO]
    • Cystoscopy: to detect bladder cancer, bladder stone, identify altered bladder or urethral morphology [VIDEO]
    • Cytology: to detect bladder cancer
    • Urodynamic study: to detect risk factors for renal damage
  • Interval and Indication:
    • Cystoscopy
      • Interval: Yearly basis
      • Indications:
        • Especially in patients with chronic urethral or suprapubic catheter indwelling.
        • Recurrent unexplained UTI, new onset of hematuria
    • Cytology
      • Interval: yearly basis [Stonehill 1997; Locke 1985], but its role remains debatable [Locke 1985].
      • Indications: same as in cystoscopy
    • Urodynamic study
      • Interval: debatable but is subject to individualized
      • Indications:
        • In the patients with high risk factors such as hydronephrosis, VUR, and UTI, more close followup is desirable.
        • Patients who shows recent change in voiding pattern or symptoms which indicate the change in the micturition dynamics.

3. Surveillance Protocol in Dr McGuire’s Clinic

Name of studyFollowup intervalIndicationComments
 
 

 

Key Points of This Section
  • Urodynamic study is the cornerstone of care in these patients.
  • Upper tract studies and renal studies will stay normal if pressures are controlled.
  • Catheters introduce another complication, which is compounded by smoking. Be alert for cancer after 10 years.

References

  • Wyndaele JJ, Castro D, Maderbacher H, Chartier-Kastler E, Igawa Y, Kovindha A, Radziszewski P, Stone A, Wiesel P. Neurologic urinary and faecal incontinence. In: Abrams P, Cardozo L, Khoury S, Wein AJ, editors. Incontinence. Health Publication Ltd, Paris. 2005;1059-162.
  • Stonehill WH, Goldman HB, Dmochowski RR. The use of urine cytology for diagnosing bladder cancer in spinal cord injured patients. J Urol. 1997 Jun;157(6):2112-4.
  • Locke JR, Hill DE, Walzer Y. Incidence of squamous cell carcinoma in patients with long-term catheter drainage. J Urol. 1985 Jun;133(6):1034-5.

©2007 University of Michigan - Tx

Home Link to UMHS