Bladder Function

8/8/2019 Bladder Function

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Supported by National Institute for Disability and Rehabilitation Research, Grant # H133B031114

Bladder Function and Dysfunction

after Neurologic Insult: Preventing

Secondary Conditions andImproving Function

Suzanne L. Groah, MD, MSPHSuzanne L. Groah, MD, MSPHNational Rehabilitation HospitalNational Rehabilitation Hospital

RRTC on Secondary Conditions after SCIRRTC on Secondary Conditions after SCI


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Anatomy and Physiology


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Bladder - Anatomy


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Neuroanatomy of Voiding


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Neuroanatomy of Voiding

Frontal lobeFrontal lobe

Micturition centerMicturition center

SendsSends inhibitoryinhibitory signalssignals

Pons (Pontine Micturition Center)Pons (Pontine Micturition Center)

Major relay/excitatory centerMajor relay/excitatory center

Coordinates urinary sphincters and the bladderCoordinates urinary sphincters and the bladder

Affected by emotionsAffected by emotions

Spinal cordSpinal cord

Intermediary between upper and lower control


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Normal Voiding

SNS primarily controls bladder and the IUS Bladder increases capacity but not pressure

Internal urinary sphincter to remain tightly closed

Parasympathetic stimulation inhibited

Somatics (pudendal N) regulate

External urinary sphincter

Pelvic diaphragm

PNS

Immediately prior to PNS stimulation, SNS is suppressed Stimulates detrusor to contract

Pudendal nerve is inhibitedp external sphincter openspfacilitation of voluntary urination


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Innervation of the Lower

Urinary TractFunction

Balance between suprasacral

modulating pathways, sacral cord

and the pelvic floor

Emptying phase: Voiding Reflex

Series of coordinated eventsSeries of coordinated events

involving outlet relaxation,involving outlet relaxation,

detrusor contractiondetrusor contractionStorage phase: Guarding

reflexes constant afferent input

to maintain continence


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Bladder Dysfunction


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Functional Classification

Failure to storeFailure to store

Because of bladderBecause of bladder

Because of outletBecause of outlet Failure to emptyFailure to empty

Because of bladderBecause of bladder

Because of outletBecause of outlet CombinationCombination


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Pathophysiology of

Voiding Brain lesion above pons destroys masterBrain lesion above pons destroys master

control centercontrol center

ExEx stroke, brain tumor, hydrocephalus, CP,stroke, brain tumor, hydrocephalus, CP,ShyShy--DragerDrager

ResultResult urge incontinence, night incontinence,urge incontinence, night incontinence,coordinated sphinctercoordinated sphincter

Spinal cord lesion, myelomeningocele, MSSpinal cord lesion, myelomeningocele, MSDetrusor hyperreflexiaDetrusor hyperreflexia

Spastic bladderSpastic bladder

Areflexic bladderAreflexic bladder


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Pathophysiology of

Voiding

Lumbosacral spinal lesionLumbosacral spinal lesion

ExEx spinal tumor, sacral SCI, herniated disc,spinal tumor, sacral SCI, herniated disc,

lumbar laminectomy, radical hysterectomy,lumbar laminectomy, radical hysterectomy,pelvic traumapelvic trauma

ResultResult areflexic bladderareflexic bladder

Peripheral nerve injuryPeripheral nerve injury

ExEx AIDS, diabetes, polio, GBSAIDS, diabetes, polio, GBS

ResultResult urinary retentionurinary retention


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Medication Options


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Medications

Failure to store due to outlet

Alpha-adrenergic drugs

Location - Bladder neck receptors Function - Increase bladder outlet resistance by

contracting the bladder neck

Example - pseudoephedrine


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Medications

Failure to store due to outlet

Estrogen derivatives Mechanism - Increases the tone of urethral

muscle by up-regulating the alpha-adrenergicreceptors in the surrounding area

Mechanism - Enhances alpha-adrenergiccontractile response to strengthen pelvicmuscles

Use inStress incontinence


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Medications

Failure to store due to bladder

Anticholinergic drugs

Function - Inhibit involuntary bladder contractions

Adverse effects Blurred vision

Dry mouth

Heart palpitations

Drowsiness

Facial flushing

Ex. Pro-banthine, Levsin


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Medications


Antispasmodic drugs

Function - Relax the smooth muscles of the

urinary bladder

Function Directly relaxes the smooth muscle of

the bladder

Adverse effects similar to anticholinergic agent

Impaired mental alertness and physical coordination

Ex. Ditropan, Detrol


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Medications


Tricyclic antidepressant drugs

Mechanism - Increase norepinephrine andserotonin levels

Mechanism - Anticholinergic and direct

muscle relaxant effects on the urinary

bladder and bladder neck

Ex. imipramine


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Medications

Failure to empty due to outlet/DSDFailure to empty due to outlet/DSD

BotoxBotox

MOAMOA

Inhibition of Ach release at neuromuscular junctionInhibition of Ach release at neuromuscular junction

Relax spastic/overactive musclesRelax spastic/overactive muscles

Relaxes sphincter when DSD presentRelaxes sphincter when DSD present

Effect not permanentEffect not permanent

DSD is often present with reflex voidingDSD is often present with reflex voiding Injection transurethrally or transperineally into theInjection transurethrally or transperineally into the

urinary sphincter mechanismurinary sphincter mechanism

ReRe--injection necessary as effect is lost after 3injection necessary as effect is lost after 3--6 months6 months


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Effect of Foods

Heightened urge incontinenceHeightened urge incontinence

Spicy foodsSpicy foods

Caffeine/chocolateCaffeine/chocolateCitrus fruitsCitrus fruits

Carbonated beveragesCarbonated beverages


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Bladder Management Options


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Management Options

Type ofType of

ManagementManagement

AdvantageAdvantage DisadvantageDisadvantage

Indwelling catheterIndwelling catheter ConvenienceConvenience

Less caregiverLess caregiverassistanceassistance

InfectionInfection

Urethral damageUrethral damage

Bladder cancerBladder cancer

Intermittent catheterIntermittent catheter Reduced infectionReduced infection Need anticholinergicNeed anticholinergic

Urethral damageUrethral damage

AssistanceAssistanceCostCost

LaborLabor


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Management Options

Type ofType of



Reflex voidingReflex voiding NonNon--invasiveinvasive High pressureHigh pressure

ContinenceContinence

High residualsHigh residuals

Need forNeed for

sphincterotomysphincterotomy

Electrical stimulation +Electrical stimulation +

rhizotomyrhizotomy

Improved bowel fxnImproved bowel fxn

Reduced labor/costReduced labor/cost

Cosmetically appealingCosmetically appealing

Significant surgerySignificant surgery

Side effectsSide effects-- rhizotomyrhizotomy

Reflex erectionReflex erection

Reflex ejaculationReflex ejaculation


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Management Options

Type ofType of



Surgical diversionSurgical diversion May produceMay produce

continencecontinenceContinent pouch easierContinent pouch easier

for female to cathfor female to cath

Significant surgerySignificant surgery

Committed toCommitted tocollection device/cathcollection device/cath

Risk of cancerRisk of cancer


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Electrical Stimulation

Electrical Stimulation and Posterior Sacral RhizotomyElectrical Stimulation and Posterior Sacral Rhizotomy To produce effective voiding and reduce urinary tract infectionTo produce effective voiding and reduce urinary tract infection

Electrodes surgically implanted on the sacral nervesElectrodes surgically implanted on the sacral nerves

Stimulator placed under the skin of the abdomen or chestStimulator placed under the skin of the abdomen or chest

BatteryBattery--powered remote controlpowered remote control Posterior sacral rhizotomyPosterior sacral rhizotomy

Abolishes hyperAbolishes hyper--reflexia of the detrusor and sphincterreflexia of the detrusor and sphincter

Increases bladder capacity and complianceIncreases bladder capacity and compliance

Reduces reflex incontinenceReduces reflex incontinence

Reduces autonomic dysreflexiaReduces autonomic dysreflexia

Abolishes reflex erection, reflex ejaculation, sacral sensation, andAbolishes reflex erection, reflex ejaculation, sacral sensation, andreflex defecationreflex defecation

1% risk of infection of the implant1% risk of infection of the implant

1 fault per 20 implant1 fault per 20 implant--yearsyears


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Electrical Stimulation

Consider inConsider in

PVR PVR

Chronic/recurrent UTIChronic/recurrent UTI

Problems with cathetersProblems with catheters

Reflex incontinenceReflex incontinence

bladder capacity andbladder capacity andcompliancecompliance

Intolerance ofIntolerance ofanticholinergic medicationanticholinergic medication

DSDDSD ADAD

EvidenceEvidence

Reflex incontinenceReflex incontinence(post rhiz)(post rhiz)

Bladder capacity andBladder capacity and

compliancecompliance need for a need for anticholinergicsnticholinergics

DSDDSD

AD if posteriorAD if posteriorrhizotomyrhizotomy

ADAD if no posteriorif no posteriorrhizotomyrhizotomy


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Bladder Augmentation

Procedure that increases bladder capacity using intestinalProcedure that increases bladder capacity using intestinalsegmentssegments Ileum, colon, or stomach are usedIleum, colon, or stomach are used

GoalsGoals

Decreasing intravesicle pressureDecreasing intravesicle pressure Restore urinary continenceRestore urinary continence

Preserve upper urinary tracts by alleviating reflux andPreserve upper urinary tracts by alleviating reflux andhydronephrosishydronephrosis

Can combine with a continent abdominal stomaCan combine with a continent abdominal stoma

Consider in patients withConsider in patients with Intractable involuntary bladder contractions causing incontinenceIntractable involuntary bladder contractions causing incontinence Patients who are able and motivated to perform CICPatients who are able and motivated to perform CIC

Reflex voiders wishing to convert to CICReflex voiders wishing to convert to CIC

Females with paraplegiaFemales with paraplegia


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Urinary Diversion

Diverts the urine flow from the bladderDiverts the urine flow from the bladder

Secondary form of bladder management when primary methods haveSecondary form of bladder management when primary methods havefailedfailed

Ureters transected just above the bladder and connected to a segmentUreters transected just above the bladder and connected to a segmentof intestine (terminal ileum) which is in turn brought to the skin of theof intestine (terminal ileum) which is in turn brought to the skin of the

lower abdominal walllower abdominal wall External appliance used as collection deviceExternal appliance used as collection device

Considered if:Considered if: Lower urinary complications secondary to indwelling cathetersLower urinary complications secondary to indwelling catheters

Urethrocutaneous fistulas, perineal decubitus ulcersUrethrocutaneous fistulas, perineal decubitus ulcers

Urethral destruction in femalesUrethral destruction in females

Hydronephrosis secondary to a thickened bladder wall and forHydronephrosis secondary to a thickened bladder wall and forhydronephrosis secondary to vesicoureteral reflux or failed reimplant.hydronephrosis secondary to vesicoureteral reflux or failed reimplant.

Bladder malignancy requiring cystectomyBladder malignancy requiring cystectomy


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Yet To Be Released PVA Guideline

Recommendations


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Recommendations from

the PVA Guidelines

Recommendation 1Recommendation 1: Intermittent: Intermittentcatheterization is the preferable method forcatheterization is the preferable method forbladder emptying for men and women whobladder emptying for men and women who

have adequate hand function or a willinghave adequate hand function or a willingcaregiver to perform the catheterization andcaregiver to perform the catheterization andhave bladders that do not empty adequately.have bladders that do not empty adequately.

Recommendation 2Recommendation 2: Intermittent: Intermittentcatheterization should be ideally performedcatheterization should be ideally performedevery 4 to 6 hours to keep bladder volumesevery 4 to 6 hours to keep bladder volumesbelow 400ccs.below 400ccs.


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the PVA Guidelines

Recommendation 5:Recommendation 5: Consider sterileConsider sterile

catheterization for those individuals withcatheterization for those individuals with

recurrent symptomatic infections occurringrecurrent symptomatic infections occurringwith clean intermittent catheterization.with clean intermittent catheterization.

Rationale:Rationale: Lower infection rates can beLower infection rates can be

achieved with sterile techniques and withachieved with sterile techniques and with

prepre--lubricated self contained catheter setslubricated self contained catheter sets


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the PVA Guidelines

Recommendation 5:Recommendation 5: Risk of symptomaticRisk of symptomatic

infection is at least comparable and may beinfection is at least comparable and may be

less in individuals with indwelling cathetersless in individuals with indwelling cathetersthan those managing their bladders withthan those managing their bladders with

clean intermittent catheterization.clean intermittent catheterization.


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the PVA Guidelines

Recommendation 6: Patient should beRecommendation 6: Patient should beadvised of longadvised of long--term complications ofterm complications ofindwelling catheterization, including:indwelling catheterization, including:

Bladder stonesBladder stones

Kidney stonesKidney stones

Urethral erosionsUrethral erosions

Bladder cancerBladder cancerEpididymitisEpididymitis

Recurrent symptomatic urinary tractRecurrent symptomatic urinary tractinfectionsinfections


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Genitourinary Assessment of

Function


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Assessment of Function

U/a and c & s

BUN & Cr

if compromised renal function is suspected Postvoid residual urine

If high, the bladder may be contractile or

the bladder outlet may be obstructed


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Renal/Bladder US

AdvantagesAdvantages SimpleSimple

Eval kidney,Eval kidney,

parenchymal loss, abnlparenchymal loss, abnl

echogenicityechogenicity

Eval forEval for

hydronephrosis, stoneshydronephrosis, stones

DisadvantagesDisadvantages Low sensitivity forLow sensitivity for

small stonessmall stones

Ureters not evaluatedUreters not evaluated

wellwell

Mainstay of screening in many institutionsMainstay of screening in many institutions


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Nuclear Renal Scan

AdvantagesAdvantages

Functional infoFunctional info

No nephrotoxicNo nephrotoxic

reactionsreactions

Low radiationLow radiation

DisadvantageDisadvantage

Less anatomic infoLess anatomic info

Cannot detect stonesCannot detect stones


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KUB

Historically, routinely used to detect renalHistorically, routinely used to detect renal

and bladder stonesand bladder stones

DisadvantagesDisadvantagesPoorly sensitive to stonesPoorly sensitive to stones

KUB not justified in routine f/u of urinaryKUB not justified in routine f/u of urinary

tract in SCItract in SCI

Tins et al. Spinal Cord 2005Tins et al. Spinal Cord 2005


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Filling Cystogram

Bladder capacity

Bladder compliance

Presence of phasic

contractions

(detrusor instability)


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Cystogram

Static Cystogram

Confirm the presence of

stress incontinence

Degree of urethral motion

Presence of a cystocele

Intrinsic sphincter

deficiency

Vesicovaginal fistula

Bladder diverticulum

Voiding cystogram

Bladder neck and

urethral function (internal

and external sphincter)

during filling and voidingphases

Urethral diverticulum

Urethral obstruction

Vesicoureteral reflux


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Cystometrogram

Volume vs pressure graphVolume vs pressure graph

EvaluatesEvaluatesDetrusor complianceDetrusor compliance

Stability of detrusorStability of detrusor


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Urodynamics

Filling cystometryFilling cystometry

Flow/pressure studyFlow/pressure study

Detrusor pressure at maximum flowDetrusor pressure at maximum flow

Obstruction to passage of urine can be distinguished from a lack ofObstruction to passage of urine can be distinguished from a lack oftone in the detrusor muscletone in the detrusor muscle

Electromyography Coordinated or uncoordinated voiding

Detrusor sphincter dyssynergia

Videocystourethography Combined x-ray or ultrasound


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UD - Stable Bladder


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Detrusor Hyperactivity

and Low Bladder Capacity


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Cystoscopy

Bladder cancer

Bladder stone

Indicated in persistent irritative voidingsymptoms or hematuria


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Selected Genitourinary Secondary

Conditions After BladderDysfunction due to

Neurologic Disease


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Secondary Conditions

Increased risk ofIncreased risk of

Bladder infectionBladder infection

Kidney infection

Kidney infection

HydronephrosisHydronephrosis

Urethral trauma/laxityUrethral trauma/laxity


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Urinary Stones and SCI

Higher incidence, especially in first 6 mosHigher incidence, especially in first 6 mos

33--6% upper tract6% upper tract

1111--15% bladder15% bladder

EtiologyEtiology

StasisStasis

Calcium metabolismCalcium metabolism

InfectionInfection DiagnosisDiagnosis

CT is gold standardCT is gold standard


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Bladder Cancer

Epidemiology

55thth most common cancermost common cancer

1212thth leading cause cancer mortalityleading cause cancer mortality

Adjusted yearly incidence 17/100,000 pyAdjusted yearly incidence 17/100,000 py 54,400 new cases per year54,400 new cases per year

Males at greater riskMales at greater risk

Majority are transitional cell carcinomaMajority are transitional cell carcinoma


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Risk Factors for Bladder

Cancer

SmokingSmoking

Male genderMale gender

Exposure to aromatic aminesExposure to aromatic amines Schistosomiasis infectionSchistosomiasis infection

UTIUTI


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Is there a heightened risk of bladder

cancer after SCI?

If so, why?


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The Evidence in SCI

SourceSource IncidenceIncidence

ReportedReported

InterpretationInterpretation

Paraplegia, 1966Paraplegia, 1966 290/100,000 (.0029)290/100,000 (.0029)

Unspecified timeUnspecified time

Period prevalencePeriod prevalence

Paraplegia, 1981Paraplegia, 1981 25/6744 (.0037)25/6744 (.0037)


Prevalence/case seriesPrevalence/case series

J Urology, 1991J Urology, 1991 8 cases, 1 year 8 cases, 1 year

No populationNo population

denominatordenominator

Case seriesCase series

Urology, 1999Urology, 1999 130/33,565; (.0039)130/33,565; (.0039)

5 yr reporting period5 yr reporting period

Appropriately reportedAppropriately reported

as prevalenceas prevalence


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The Evidence in SCI

SourceSource IncidenceIncidence

ReportedReported

InterpretationInterpretation

J Urology, 1981J Urology, 1981 10 cases/10,05210 cases/10,052

(.0009)(.0009)Unspecified timeUnspecified time

Case seriesCase series

J Urology, 1977J Urology, 1977 6 cases/62 (.097)6 cases/62 (.097)


PrevalencePrevalence

Urology, 2002Urology, 2002 48 cases/43,56148 cases/43,561

(.0011)(.0011)

Questionnaire dataQuestionnaire data

PrevalencePrevalence

J Urology, 1985J Urology, 1985 2/25 (.08)2/25 (.08)


Case series/prevalenceCase series/prevalence


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Recent Evidence

Groah SL. Arch Phys Med Rehabil 2002Groah SL. Arch Phys Med Rehabil 2002

3,670 subjects contributed 39,729 p3,670 subjects contributed 39,729 p--yy

Stratified by bladder management methodStratified by bladder management methodAgeAge--adjusted incidenceadjusted incidence

Indwelling catheterIndwelling catheter 77/100,000 py77/100,000 py

Mixed methodsMixed methods 56.1/100,000 py56.1/100,000 py

NonNon--indwelling catheterindwelling catheter 18.6/100,000 py18.6/100,000 py


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Recent Evidence

Groah SL. Arch Phys Med Rehabil 2002Groah SL. Arch Phys Med Rehabil 2002

Using cox regression, only bladderUsing cox regression, only bladder

management method and age predicted diseasemanagement method and age predicted disease


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Cumulative Incidence of

Bladder Cancer

0.000%

0.001%

0.002%

0.003%

0.004%

0.005%

0.006%

0.007%

0.008%

0.009%

0.010%

0 5 10 15 20 25 30 35 40 45 50 55 60

Years Post-S I

umulativeIncidence

ID

NID

Wilcoxan < 0.05

l i id f


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Cumulative Incidence of

Bladder Cancer

0.000%

0.001%0.002%

0.003%

0.004%

0.005%

0.006%

0.007%

0.008%

0.009%

0.010%

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

Age

umulativeIncidence

ID

NID

Wilcoxan < 0.05

l dd C li


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Bladder Cancer Mortality

by Age

020

40

60

80

100

120

140

160

180

0- 10-19 20-29 0- 9 40-49 0- 9 60+

A e (ye rs)

M

rt

ty

100,

000

-Y ID

R

P i l M li


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Proportional Mortality

Due to Bladder Cancer

0%10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Years post-SCI

Prop

ortionSurvivingwi

thBC

IDC


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Recent Evidence

Subramonian et al. BJU Int, 2004.Subramonian et al. BJU Int, 2004.

4 cases/1334 people followed4 cases/1334 people followed

30.7/100,000 person30.7/100,000 person--yearsyearsReported as not statistically different fromReported as not statistically different from

general population and lower than reported ingeneral population and lower than reported in

other studiesother studies

Ri k F f Bl dd


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Risk Factors for Bladder

Cancer

SourceSource ResultsResults

Groah SL. JSCM 2003;26:339Groah SL. JSCM 2003;26:339--4444

(mortality study)(mortality study)

Multiple risk factors (2 or more)Multiple risk factors (2 or more)

Catheter, tobaccoCatheter, tobacco

Hess MK. JSCM 2003;26:335Hess MK. JSCM 2003;26:335--88 Gross hematuria present in 14/16Gross hematuria present in 14/16

Vereczkey ZA. JSCM 1998;21:230Vereczkey ZA. JSCM 1998;21:230--99

19 RF and 12 interactions analyzed19 RF and 12 interactions analyzedDuration of indwelling catheter useDuration of indwelling catheter use

>10 years>10 years

P 3 D i C


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Part 3 Design: Case-

control

Bladder

cancer

survivors

Controls

deceased

due to

bladder

cancer

Age at SCI

Duration of SCI

Age at BC

Level of SCIASIA

Method of bladder

management

Histology

Presentation

DiagnosisSurveillance

Biopsy results

Risk Factors

Medical record

review


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Presentation

0%

10%

20%

30%

40%

50%

60%

70%

S/Sx H/O r ss

hem t r

Gr ss hem t r Re f re

Sur r tr

P t ti l A i t d Ri k


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Potential Associated Risk

Factors

*

*

0

25

50

75

100

ID use T b cc use culi Pyelonephritis Prophylactic

antibiotic

Sur ivor ontrol


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Risk Factors

*

*

*

0%

25%

50%

0 RF 1 RF 2 RF 3 RF 4 RF

Survivor

Control

RF: IDC use, tobacco use, calculi, or pyelonephritis

Bl dd C


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Bladder Cancer

Surveillance

SurvivorSurvivor ControlControl p valuep value

MeanMean

numbernumber

cystoscopiescystoscopies

7.87.8 16.816.8 .06.06

MeanMean

numbernumberbiopsiesbiopsies 1.61.6 3.63.6 > .1> .1


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Genitourinary Surveillance

S ill P ti f


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Surveillance Practices of

the MSCIS Centers

16 centers surveyed16 centers surveyed

13 responded13 responded

12/13 have a GU surveillance protocol12/13 have a GU surveillance protocol 6/13 have a bladder cancer surveillance6/13 have a bladder cancer surveillance

protocolprotocol

I iti l GU S ill


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Initial GU Surveillance

from the MSCIS Centers

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313U/AU/A

C/SC/S

Bun/CrBun/Cr

CreatCreat

ClearClear

USUS

VCUGVCUG

RenalRenal

ScanScan

I iti l GU S ill


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Initial GU Surveillance

from the MSCIS Centers

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313CytolCytol

IVPIVP

CMGCMG

UDUD

Bl USBl US

KUBKUB

CScopeCScope

Bladder Cancer


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Bladder Cancer

Surveillance from MSCIC

ProtocolsProtocols

If IDC, cysto at 5 yrs and yearly thereafterIf IDC, cysto at 5 yrs and yearly thereafter

Cysto every 5Cysto every 5--10 years10 years

Cysto if hematuriaCysto if hematuria

Cysto for longCysto for long--term IDCterm IDC

Cysto if IDC + hematuriaCysto if IDC + hematuria

Cysto at 10 years then yearly if IDCCysto at 10 years then yearly if IDC

Cysto yearly if IDC (2 centers)Cysto yearly if IDC (2 centers)

Bladder Cancer


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Bladder Cancer

Surveillance

Yang CC. Spinal Cord 1999;37:204Yang CC. Spinal Cord 1999;37:204--77

Cysto if >10yrs catheter, smoker + cath (5yrs)Cysto if >10yrs catheter, smoker + cath (5yrs)

59 subjects had 156 cystos59 subjects had 156 cystos

No cancer diagnosedNo cancer diagnosed

4 other cases diagnosed during same period (24 other cases diagnosed during same period (2

did not meet criteria;1 not unit patient;1 haddid not meet criteria;1 not unit patient;1 had

screen 4 months prior)screen 4 months prior)

Bladder Cancer


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Bladder Cancer

Surveillance

Groah SL. JSCIM 2003;26:339Groah SL. JSCIM 2003;26:339--4444

8 survivors with bladder cancer compared with8 survivors with bladder cancer compared with

13 deceased13 deceased

Surveillance cystoscopy identified cancer inSurveillance cystoscopy identified cancer in

14% survivors14% survivors

11% deceased11% deceased

Survivors had fewer surveillance cystoscopiesSurvivors had fewer surveillance cystoscopiesand biopsies than deceased groupand biopsies than deceased group

Bladder Function

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