The urological consequences of SCI can be devastating, leading to incontinence and renal failure. The management of patients with tetraplegia is even more challenging, especially those who cannot perform intermittent self catheterization (ISC). Indwelling catheters (either urethral or suprapubic) and spontaneous voiding are often proposed, but present high rates of urologic complications. This workshop will focus on alternatives managements for those with high dependency.

(i) Non-continent cutaneous urinary diversion (Emmanuel Chartier-Kastler, chair, 15 minutes + 5 minutes Introduction)
Non continent cutaneous urinary diversion (NCCUD) is a last resort surgical procedure that can be considered when conservative therapies have failed, especially in patients with intractable incontinence, and when the upper urinary tract is severely compromised. The ileal conduit is most commonly used. It allows continence with correct fitting of the stoma in the majority of patients. A regular follow-up by a multidisciplinary team is needed, NCCUD is accompanied by a high rate of early complications, that sometimes require late reoperations.

(ii) Continent cutaneous urinary diversion (Marie-Aimée Perrouin-Verbe, 15 minutes)
Continent cutaneous urinary diversion (CCUD) may be proposed in patients with tetraplegia who are unable to perform ISC. The key point is the selection of patients and assessment of their ability to reach a fake abdominal stoma to perform ISC. Urodynamics must also be performed to know if a concomitant procedure (augmentation cystoplasty or surgery for continence) is required. The main complication is stenosis (tube or skin), that can often be managed by dilation. CCUD is associated with a high rate of patients able to self-catheterize and a high rate of continence.

(iii) Surgical rehabilitation of the upper limb in tetraplegia to allow self-catheterization (Benjamin Bernuz, 15 minutes)
The ability to perform ISC depends mainly on hand ability and on access to the urethral meatus.
When necessary (especially in patients with a C6 level of lesion) hand function can be improved by upper limb reanimation protocols consisting in reconstructive surgery (tendon transfert, tenodeses, arthrodeses) combined with specific rehabilitation procedures. The key-grip strength is the key point to allow ISC, and motivational parameters have to be well assessed before this long therapeutic program. This procedure can be combined with CCUD when necessary.

(iv) Sacral anterior root stimulation (Brindley procedure) (Brigitte Perrouin-Verbe, 15 minutes)
Sacral anterior root stimulation associated with sacral deafferentation is an effective procedure, allowing complete voiding in most patients, a high continence rate and a significant decrease of urologic complications. Best indications are patients with complete SCI and uncontrolled neurogenic detrusor overactivity.
In men, the Brindley procedure imposes the wear of a condom. They must be informed that reflex erection and ejaculation will be lost due to the sacral deafferentation. In women, the social environment must be assessed, as they remain dependent on caregivers for the transfer on toilet or bed.

Interactive Discussion (All speakers & workshop participants, 30 minutes)
Professor Chartier-Kastler (chair) and the panel of speakers will engage discussion with the audience, identifying the different approaches that are proposed, their respective characteristics and potential advantages.