Long-term urological management in spinal injury units in the UK and Eire: a follow-up study

Spinal Cord (2014) 52, 640–645 & 2014 International Spinal Cord Society All rights reserved 1362-4393/14 www.nature.com/sc ORIGINAL ARTICLE Long-term urological management in spinal injury units in the UK and Eire: a follow-up study JR Burki, I Omar, PJR Shah and R Hamid Aims: The majority of patients with spinal cord injury (SCI) will develop neurogenic lower urinary tract dysfunction (NLUTD). These patients require a long-term urological follow-up. The follow-up protocol has varied across SCI units in the United Kingdom and Eire. We reviewed the long-term management in the SCI units to identify changes in practice over a decade and compared them to current guidelines. Methods: We present results of a review of all SCI centres in the United Kingdom and Eire on their long-term urological management before and after the current guidelines and compared the results with European Association of Urology (EAU) Guidelines on NLUTD and the proposed British guidelines for the urological management of patients with SCI. Data were collected through questionnaires posted to SCI units. Results: SCI patients are followed up in outpatients annually in the SCI centres and the frequency of follow-up remains largely unchanged. More SCI units perform renal tract imaging annually as a part of SCI follow-up. Most units follow the proposed British guideline indications for urodynamics and do not perform ‘routine urodynamics’. Conclusions: We conclude that the long-term management of SCI patients in SCI units in the United Kingdom and Eire has changed overtime to follow the proposed British guidelines. EAU guidelines offer a more extensive follow-up regime. Last, there is a continued lack of high-quality evidence to support an optimal long-term follow-up protocol. Importantly, there is a lack of evidence on clinical outcomes when these guidelines have been followed. Spinal Cord (2014) 52, 640–645; doi:10.1038/sc.2014.90; published online 10 June 2014 INTRODUCTION The annual incidence of spinal cord injury (SCI) is up to 40 cases per million.1 Most of these patients develop neurogenic lower urinary tract dysfunction (NLUTD).2 Mortality due to urological complications has decreased over recent years;3 due to meticulous attention to the kidneys and bladder. Long-term urological follow-up is needed to optimise the bladder by low-pressure filling and complete bladder emptying. Restoration of continence is a goal for improved quality of life.4 SCI patients are best managed in a SCI centre with integrated facilities for rehabilitation and a multidisciplinary approach: involving urologists, rehabilitation specialists, specialist nurses and physiotherapists etc.5 Although it is agreed that patients with NLUTD should have regular follow-up, there is little concusses how this should be monitored over the long-term to detect urological complications.6 We conducted a survey of SCI units in 2004 to evaluate the longterm urological management of SCI patients in the United Kingdom and Eire, which showed a considerable variation in urological practice among SCI centres in the United Kingdom and Eire.7 Since then guidelines have been published on the management of NLUTD, and NLUTD in association with SCI. These include the European Association of Urology (EAU) guidelines for management of NLUTD,4 proposed British guidelines for the urological management of patients with SCI5 and the consortium for spinal cord medicine in the United States.8 There seems to be a consensus among all the guidelines on the immediate and short-term management of SCI patients as is the agreement for the need for lifelong follow-up to preserve renal function, prevent complications, promote continence and improve quality of life.4,5 However, the frequency of follow-up and investigations undertaken reveal considerable variation among these guidelines. We conducted a repeat survey of 12 SCI units in the United Kingdom and Eire on their current neuro-urological practice on the long-term follow-up of SCI patients and evaluated the change in management over the years in the light of EAU guidelines on NLUTD and proposed British guidelines. MATERIALS AND METHODS We sent the same questionnaire as in the earlier study7 to the consultant urologists at the 12 SCI centres in the United Kingdom and Ireland (Appendix). If the filled questionnaire was not received after 1 month, a second questionnaire was sent. Not receiving the questionnaire the second time a telephone contact was made and a third questionnaire was sent. A further telephonic contact was made for information on general setup. The questionnaire addressed the general setup, management of urinary tract infections, outpatient follow-up, upper tract surveillance and urodynamics. RESULTS There was a 100% reply rate (12/12). Eight SCI centres replied on the receipt of the first questionnaire. The SCI centres contacted are listed in Table 1. London Spinal Cord Injury Centre, Royal National Orthopaedic Hospital Stanmore, London, UK Correspondence: JR Burki, Department of Neuro-urology, London Spinal Cord injury Centre, Royal National Orthopaedic Hospital, Stanmore, London HA7 4LP, UK. E-mail: Received 25 February 2014; accepted 3 May 2014; published online 10 June 2014 Long-term urological follow-up in spinal injury units JR Burki et al 641 General setup Overall, 12 urology consultants cover the spinal injury units. Three consultants work full time and nine work part time. Six units do not have a urology registrar, five have one registrar and one has two registrars. Six units employ urology nurse specialists, with a total of 13 nurse specialists in all units. The maximum number of nurse specialists in a unit was four. The number of acute and rehabilitation beds in the SCI centres range from 28 to 113 (mean 50.5). National SCI centre, Stoke Mandeville has the largest number of beds. All SCI centres offer regular outpatients follow-up and urological surgery as appropriate at either the SCI centre or the affiliated hospital. Urodynamic studies Ten units perform videourodynamics (VCMG), one does standard urodynamics and one unit did not comment on the type of urodynamics undertaken. These are performed by urologist in six units, specialist nurses in three units, rehabilitation team in two and General Practitioner (GP) with special interest in urodynamics in one unit. In patients with suprasacral lesions, 10 units do not perform routine urodynamics, 1 unit performs annually, whereas 1 does so every 2–3 years. Only one unit undertakes VCMG yearly in patients with infrasacral lesions. These are summarised in Table 4 along with comparisons. Urology outpatient review In eight SCI units, the follow-up is performed by urologists. In three units, follow-up for SCI patients is performed by the rehabilitation team and referred to urology for intervention. One unit shares the follow-up with rehabilitation team. Seven units offer annual urological review to patients with suprasacral lesions. Th (...truncated)