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Clinical Policy Bulletin:
Neurogenic Bladder: Selected Treatments
Number: 0852


Policy

Aetna considers enterocystoplasty (augmentation cystoplasty) medically necessary for neurogenic bladder refractory to medication. 

Aetna considers intravesical transurethral bladder stimulation experimental and investigational in the treatment of neurogenic bladder.



Background

A neurogenic bladder is the loss of normal bladder function caused by damage to part of the nervous system. It may result from a disease, an injury, or a birth defect affecting the brain, spinal cord, or nerves leading to the bladder, its outlet (the opening into the urethra from the bladder), or both. 

Intravesical transurethral bladder stimulation is a diagnostic and rehabilitative technique for the neurogenic bladder. The ultimate goal of the treatment is to create conscious micturition control. The technique combines direct electrical stimulation of bladder receptors with visual biofeedback using patient observance of a water manometric representation of the detrusor response. The bladder is catheterized, and a slow-fill cystometrogram is performed. At the end of the cystometrogram, the bladder is emptied. This emptied volume is defined as the bladder capacity. The measured pressure at the end of the cystometrogram when bladder capacity is reached is defined as the bladder capacity pressure. Following the initial cystometrogram, the bladder is filled to half capacity. An initial 15-minute bladder observation period is followed by a 90-minute therapy session. Observations during the first treatment are used in setting initial parameters for future stimulation. Patients are usually treated with 20 outpatient sessions (a series) during which periodic adjustments are made depending on the response of the bladder to stimulation. Following the first series, a cystometrogram is performed, and the bladder is allowed to rest for approximately 3 to 6 months. At the next visit, a cystometrogram is repeated, and a subsequent course of stimulation sessions (5 to 15) is administrated for 1 to 2 weeks. Medications that may affect bladder dynamics are routinely discontinued a few days before urodynamic studies and during bladder stimulation therapy. The program is multistaged, and not all patients require full therapy. Once the training process is completed, no additional therapy is usually necessary, and the results are permanent. 

In 1992, Boone, Roehrborn, and Hurt conducted a prospective, randomized, sham controlled and blinded study on the efficacy of intravesical transurethral electrotherapy in treating urinary incontinence in the myelodysplastic child. A total of 31 children completed the protocol. Of the patients completing the study, 13 were randomly selected to serve as an internal sham control having the electrocatheter placed without activating the stimulator. These patients were subsequently treated with a 3-week course of electrotherapy.  The remaining 18 patients completing the study were randomly selected to undergo 2, 3 week courses of intravesical bladder stimulation. Urodynamic studies were performed before and after each treatment series.  Detailed daily questionnaires were submitted to each participant covering subjective improvement in urinary continence and any development of bladder sensory awareness. Analysis of urodynamic data and questionnaires failed to reveal any statistically significant increase in bladder capacity, development of detrusor contractions, improvement in detrusor compliance, or the acquisition of bladder sensation allowing timely intermittent catheterization and preventing urinary incontinence. 

Lyne and Bellinger reported, in 1993, on a study of patients with neurovesical dysfunction that were treated with transurethral electrical bladder stimulation. Seventeen patients (2.5 years to 20 years) completed the series. All patients demonstrated detrusor contraction during therapy, and 88% had sensation of contractions, usually developing later in therapy. 

In 1994, Decter, Snyder, and Laudermilsch published a follow-up report on the use of transurethral electrical stimulation in patients with neurogenic bladder. Since 1989, they performed 64 series in 25 patients with neurogenic bladders. A cystometrogram was performed before each series of stimulation to monitor progress, and impressions of the stimulation were obtained by a questionnaire. The initial evaluation cystometrogram before stimulation revealed that 18 patients (72%) had bladder contractions.  After electrical bladder stimulation, 24 patients (96%) manifested contractions. Before stimulation, only 3 children sensed the contractions, while during stimulation half of the patients perceived the contractions. A cystometogram performed before each series demonstrated a greater than 20% increase in the age adjusted bladder capacity in 6 of the 18 patients (33%) with serial studies. Improvements in the end filling pressure defined by clinically significant decrease were observed in 5 of these patients (28%). The authors concluded, “transurethral electrical bladder stimulation is a time-consuming, labor intensive technique, and the limited urodynamic benefits the patients achieved did not materially alter the daily voiding regimen. As a result, the authors were not enrolling any new patients into the program.”

In 1996, Cheng, Richards, and Kaplan, et al published the results of their continuing study (since 1984) on the use of intravesical transurethral bladder stimulation in children with neurogenic bladder. The authors examined data from multiple institutions and compared it to their own experience. Three hundred and thirty-five patients had adequate and accurate pretreatment and posttreatment urodynamic studies, and were reviewed in the study. Bladder capacity and bladder capacity pressure were determined for each patient before and after therapy. Overall, 53% of patients had increased bladder capacity of 20% or greater after treatment, which represented a 63% increase from pretreatment values. The increase occurred in an average of 1.9 years. Further analysis of the patients revealed that in 90% intravesical storage pressures were decreased or maintained within a safe range (less than 40 cm. water). Evaluation of patients who did not respond to bladder stimulation with a 20% or greater increase in bladder capacity revealed that they had nearly normal bladder capacity before therapy. According to the authors, bladder stimulation is effective in increasing bladder capacity without significantly elevating storage pressure in a majority of patients. The technique is safe and effective in improving bladder compliance, and the program can be reproduced elsewhere. However many other institutions have conducted similar trials with mixed regard to the efficacy of the treatment modality, and that, to date, clinical experience with bladder stimulation has been too limited to permit identification of the cases that will succeed or fail with the therapy.    

 

In a 2007 article, Hagerty, Richards and Kaplan evaluated their 22-year experience with intravesical electrotherapy in patients with neurogenic bladder. The charts of 405 patients who received intravesical electrotherapy were reviewed. Cystometrograms were performed at the start of each treatment series. Bladder capacity and pressure were determined for each patient before and after therapy. Patients were also questioned regarding the sensation of bladder filling. From 1985 to 2006, 372 patients with an average age of 5.5 years (range 0 to 43) had followup information available and were included for evaluation. Patients received a median of 29 treatment sessions (range 2 to 197). Mean patient followup was 6.6 years (range 0 to 19.7). Of the 372 patients 286 (76.9%) had a 20% or greater increase in bladder capacity after treatment. In this subset of patients bladder storage pressure at capacity was normal (less than 40 cm water) in 74.4% (213 of 286). Of the 17.2% of patients (64 of 372) who had no change in bladder capacity 81.21% (52 of 64) had normal bladder storage pressures after treatment. Bladder sensation was developed and sustained in 61.6% of patients (229 of 372), including 33.6% in the first series. 

It is written in the 2011 textbook Wein: Campbell-Walsh Urology, intravesical electrotherapy, an old technique which has been has been resurrected with some interesting and promising results is “certainly controversial”. 

Enterocystoplasty, also called augmentation cystoplasty, is an enlargement of the bladder with a patch of small or large intestine or stomach. Clean intermittent catheterization is necessary after the procedure.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
51960 Enterocystoplasty, including intestinal anastomosis
ICD-9 codes covered if selection criteria are met:
344.61 Cauda equina syndrome with neurogenic bladder
596.53 Paralysis of bladder
596.54 Neurogenic bladder nos


The above policy is based on the following references:

Enterocystoplasty 

  1. Behrman: Nelson Textbook of Pediatrics. Seventeenth Edition. 2004.
  2. Blaivas JG et al. Long-term followup of augmentation enterocystoplasty and continent diversion in patients with benign disease. J Urol, 713(5): 1631-4  2005.
  3. Kass EJ; Koff SA. Bladder augmentation in the pediatric neuropathic bladder. J Urol, 129(3): 552-5  1983.
  4. King LR; Webster GD; Bertram RA.  Experiences with bladder reconstruction in children. J Urol, 138(4 Pt 2): 1002-6  1987.
  5. Quek ML; Ginsberg DA. Long-term urodynamics followup of bladder augmentation for neurogenic bladder. J Urol, 169(1): 195-8  2003.
  6. Scales CD Jr; Wiener JS. Evaluating outcomes of enterocystoplasty in patients with spina bifida: a review of the literature. J Urol, 01-Dec-2008; 180(6): 2323-9.
  7. Sidi AA; Becher EF; Reddy PK; Dykstra DD. Augmentation enterocystoplasty for the management of voiding dysfunction in spinal cord injury patients. J Urol, 143(1): 83 1990.
  8. Smith RB et al. Augmentation enterocystoplasty: a critical review. J Urol, 118(1 Pt 1): 35-9  1977.
  9. Walsh: Campbell’s Urology. Eighth Edition. 2002.
  10. Wein: Campbell-Walsh Urology. Ninth Edition. 2007.

 Transurethral electrical bladder stimulation:

  1.  Bani-Hani AH et al. Neuromodulation in pediatrics. Urol Clin of North Am, 32(1)  2005.
  2. Boone TB et al. Transurethral intravesical electrotherapy for neurogenic bladder dysfunction in children with myelodysplasia: a prospective, randomized clinical trial. J Urol, 148(2 Pt 2):550-4 1992.
  3. Cheng EY et al. Bladder stimulation therapy improves bladder compliance: results from a multi-institutional trial. J Urol, 156:761-764 1996.
  4. Decter RM et al. Transurethral electrical bladder stimulation: a follow-up report. J Urol, 152(2 Pt 2):812-4  1994.
  5. De Gennaro M et al. Current state of nerve stimulation technique for lower urinary tract dysfunction in children. J Urol, 185(5): 1571-7  2011.
  6. Hagerty JA et al. Intravesical electrotherapy for neurogenic bladder dysfunction: a 22-year experience. J Urol, 178(4 Pt 2): 1680-3; discussion 1683  2007.
  7. Kaplan WE; Richards I. Intravesical transurethral electrotherapy for the neurogenic bladder. J Urol, 136:243-246  1986.
  8. Kaplan WE et al. Intravesical transurethral bladder stimulation to increase bladder capacity. J. Urol, part 2, 142:600-602  1989.
  9. Lyne CJ; Bellinger MF. Early experience with transurethral electrical bladder stimulation. J Urol, 150(2 Pt 2):697-9  1993.
  10. Wein: Campbell-Walsh Urology. Ninth Edition. 2007.  Tenth Edition. 2011.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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