Medical Minute In Depth Interview: Surgery For Paralyzed
Gerald Tuite, M.D., a pediatric neurosurgeon at All Children's Hospital in St. Petersburg, Fla., explains how an experimental procedure is giving some kids with paralysis control of their bladder and opening the door to organ transplants
Font Size:

What is the Xiao procedure?

Dr. Tuite: The Xiao procedure is an operation that was conceived and studied by Professor Xiao. He’s a urologist who now works in China, but when he was in the United States, he did some training and he did a lot of research to come up with a way to allow people to regain bowel and bladder control after a spinal cord injury, or in patients who have congenital spinal cord problems.

Is this mainly a procedure for children or has it been done on adults?

Dr. Tuite: The study that we’re conducting focuses on children, but if it is found to be effective, it will be applicable to adults as well.

How does the procedure work?

Dr. Tuite: During this operation, we’re trying to restore bowel and bladder function to patients who don’t have that control because of spinal cord injury or spinal cord dysfunction.

What are you doing to the body during this procedure?

Dr. Tuite: We take a small portion of a nerve that usually controls motor function or movement in the leg, and we cut it and splice it to a nerve that usually controls bowel and bladder function, thereby trying to create a new reflex arc that can allow these patients to regain control of their bowel and bladder function.

Are you essentially rewiring the body?

Dr. Tuite: We’re re-wiring the nerves within the spinal canal, right near the spinal cord, so that the body can then control the bowel and bladder.

How do you activate it?

Dr. Tuite: You know how you usually can create a reflex in your leg if you tap on your knee or your ankle? What we’re doing is creating a similar type of reflex, by connecting different nerves to the bladder nerves, so that if you say, scratch, in the same distribution of the nerve that you’re sectioning, the idea is that you will then be able to trigger your own voiding through a reflex.

How successful has this procedure been so far?

Dr. Tuite: I want to emphasize that this is a study and that we are trying to analyze the effectiveness of the procedure. Professor Xiao has performed the procedure in close to two thousand patients in China, and he’s reported very good results -- something in the order of 60 to 80 percent control of bowel and bladder function. In our study, we are trying to replicate that study, to confirm that it actually does work.

How many Xiao procedures have you yourself done?

Dr. Tuite: Our group, our team of surgeons has enrolled eight patients into our study so far.

If this surgery is successful, what would it mean for those patients to regain that control?

Dr. Tuite: If Professor Xiao’s procedure is validated, if we can confirm that this is in fact effective, then it will have profound effects on the quality of life of many people who have a spinal cord problem, and as a result, do not have control of their bowel and bladder.

Having taken care of many children for many years with these sorts of problems, as they grow up, this is a major concern for them, and so I think that if it is proven to be effective, it will have a significant effect on their life.

Because this is a double-blind study, Adam is the only child that you know that actually had this procedure?

Dr. Tuite: Yes. We actually have two studies going on. One is studying patients with spinal cord injury like Adam, and all of those patients will have the procedure performed. In the other study, we are looking at patients who have spina bifida, and they have bowel and bladder dysfunction as a result of the spina bifida. The way we’re able to double-blind and study these patients in a more scientific way is because these patients that are enrolled in this study need spinal cord surgery for other reasons. So, at the time of that spinal cord surgery, half of them will receive the Xiao procedure in addition, and the others will just have the standard spinal cord operation. We thought that was the safest way to study this procedure, is in patients who otherwise need surgery for other reasons.

How long does it take typically to see results?

Dr. Tuite: Professor Xiao says that it takes at least six months, and it can be as long as 18 months until you see any real improvement in their bowel and bladder function.

How would test whether the procedure is effective?

Dr. Tuite: In patients who have spina bifida, Professor Xiao has told us that it’s not necessary for them to scratch in a certain distribution, that they will just regain control of their bowel and bladder spontaneously. He tells us that in spinal cord injured patients that they do scratch at a certain distribution of a nerve, and then they’re able to void.

Because he’s in a wheelchair, is that the case for Adam?

Dr. Tuite: Yes, with Adam, hopefully in the next year or year and a half, we’ll be able to tell if this reflex has really taken place, if he’s able to scratch in a certain distribution and empty his bladder.

Why did Adam need this procedure?

Dr. Tuite: I believe I met Adam in the middle of the night, many years ago, when he came to the emergency room at this hospital unable to move his legs, and he was found to have a tumor pressing on his spinal cord. The tumor was removed, and he has been successfully treated, but he never did regain any of this leg function that was disserved by this tumor.

Does he have a spastic bladder?

Dr. Tuite: Yes. When you lose spinal cord function, obviously you lose leg function, but you also lose the control of your bladder, and his bladder did not empty well. As a result, the urine backed up and damaged his kidneys significantly, to the point that he’s now on dialysis.

What is the ideal outcome for Adam?

Dr. Tuite: We are hoping that if this operation is successful, that Adam’s bladder will not be as hostile. It will contract and fill in a more normal way, and hopefully he will be able to regain some of the control of his bladder, if the operation is successful.

Does his bladder have to be in control in order to get the kidney transplant he needs?

Dr. Tuite: Certainly, if his bladder is better controlled, if he does eventually have the kidney transplant, then the transplant will be less likely to fail in the long run, and so this hospital was kind enough to donate their services for him to have this experimental procedure, but future funding is necessary for us to treat other patients with spinal cord injury.

Because the Xiao procedure is experimental, is it not covered by insurance?

Dr. Tuite: For patients with spinal cord injury, it is not covered by insurance, and research grants are pending all around the country, and we’re hoping that some funding will become available for those patients. For the patients with spina bifida, if they otherwise need an operation, then they can be enrolled in the study. The hospital has offered to not charge them any additional fees for the extra Xiao procedure, and of course, none of the surgeons or physicians are charging anything extra. The short answer then is yes, patients that otherwise need spinal cord surgery can be enrolled.

Are there any risks to this procedure?

Dr. Tuite: That’s something that people have glossed over in the general public, because there’s so much enthusiasm about this procedure among people who have spinal cord problems and abdominal bladder issues. Yes, there are risks, because you are taking a part of the nerve that usually controls some motor function -- some muscle in your leg -- you’re taking a portion of that and sewing it to a nerve that controls the bladder. A very important part of our study is to assess the safety of doing that. Dr. Xiao claims that there is very little risk in the long-term for these patients, but we want to be sure.

What kind of risks does that entail?

Dr. Tuite: For patients who have no leg function at all, of course they’re not going to lose any more strength in their legs, but for say, kids with spina bifida who have some leg function, there is some extra risk, we believe, to taking part of that nerve. Whether or not that risk will be long-term, the study will tell us.

What are the possible effects of that?

Dr. Tuite: There is a risk that say, you were able to move your foot up like this before the operation, if we took part of the nerve that controlled that, then you might not be able to move your foot up as well. Dr. Xiao has told us that while initially they have weakness, over time, the nervous system is able to compensate for that, and usually their say, foot function returns to where it was, but we, as part of the study, want to be absolutely sure we know what the risks are.

Is it too early to say whether there are any risks because this is still experimental?

Dr. Tuite: It’s much too early to say. Our patients are being studied over time and I don’t expect us to have any real data about their bowel and bladder function for close to a year. Most of the patients tolerate the procedure well. Adam had a superficial infection of his back that resolved with antibiotics, but by and large, the patients did very well with this surgery.

Is there currently an alternative treatment for these patients?

Dr. Tuite: There has been very little progress over the past several decades in the treatment of bladder dysfunction, other than small incremental changes. The use of catheters was a huge breakthrough many years ago, but since then, there have been medicines and other experimental things tried, but nothing has given people control of their bladder. If this procedure actually is successful, it will be a revolutionary change for these patients.

With the catheter, you would still be sort of restricted in life a little bit, right?

Dr. Tuite: Right. It’s not just that, but it’s also to be able to control your urine, to be able to control your bowels -- all of those are very big issues, particularly as kids become teenagers and adults. When they’re little kids, maybe it’s not as big an issue, but as they grow up, it can really be a significant issue, so we’re hopeful that this procedure will prove to be effective, but we will not know until the study is completed.

What is your hope as a doctor who has treated these children that have had this condition where there hasn’t been a treatment?

Dr. Tuite: My hope is that we can help give them continence, that we can give them a better quality of life. It’s possible that not every patient would have complete success. I would be happy with even some success, because there are so few options for kids and adults that have problem controlling their bowel and bladder as the result of a spinal cord problem.

Is it possible that if they don’t regain control fully, they might have some sort of partial control?

Dr. Tuite: We will see. That’s one of the reasons we’re performing this study in a systematic way, because even if it doesn’t give them a completely normal bladder, I think if you asked any of these patients if we could improve their bladder and bowel function even 50 percent, that would make a huge difference in their quality of life.