Detrusor Compliance Research Articles

Inflammatory Expression Profiles in Bladder Exstrophy Smooth Muscle: Normalization Over Time

ObjectiveTo test the hypothesis that phenotypes in bladder exstrophy result from alterations in detrusor smooth muscle cell (SMC) gene expression. MethodsWe generated primary human bladder smooth muscle cell lines from patients with classic bladder exstrophy (CBE) undergoing newborn closure (n = 6), delayed primary closure (n = 5), augmentation cystoplasty (n = 6), and non-CBE controls (n = 3). Gene expression profiles were then created using RNA sequencing and characterized using gene set enrichment analysis (GSEA). ResultsWe identified 308 differentially expressed genes in bladder exstrophy SMC when compared to controls, including 223 upregulated and 85 downregulated genes. Bladder exstrophy muscle cell lines from newborn closure and primary delayed closures shared expression changes in 159 genes. GSEA analysis revealed increased expression in the inflammatory response and alteration of genes for genitourinary development in newborn and delayed closure SMC. However, these changes were absent in SMC from older exstrophy patients after closure. ConclusionBladder exstrophy SMC demonstrate gene expression changes in the inflammatory response and genitourinary development. However, gene expression profiles normalized in exstrophy SMC from older patients after closure, suggesting a normalization of exstrophy SMC over time. Our in vitro findings regarding the normalization of exstrophy SMC gene expression following bladder closure suggest that the development of poor detrusor compliance in bladder exstrophy has a complex multifactorial etiology. Taken together, our findings suggest that alterations in SMC gene expression may explain abnormalities in the exstrophy bladder seen prior to and immediately after closure and suggest that surgical closure may allow exstrophy SMC to normalize over time.

Reduction of transverse rectal diameter and its effect on bladder dynamics in children with spinal dysraphism

IntroductionTo examine the reduction of transverse rectal diameter and its effect on bladder dynamics in children with spinal dysraphism.MethodsWe prospectively evaluated 61 consecutive children with spinal dysraphism, 25 (41%) boys and 36 (59%) girls, aged 4 to 16 years; mean age 9.3 ± 3.8 years, who received bowel management. All children underwent echosonographic measurement of transverse rectal diameter before and after starting bowel management. Also, all the patients had undergone urodynamic studies before and after starting bowel management, with no changes in their urological treatment.ResultsBowel management caused an decrease in transverse rectal diameter by 56 ± 7.2% (p < 0.001). In addition, a decrease was observed for maximal detrusor pressure by 27.8 ± 7.8% (p < 0.001), leak point pressure by 37.2 ± 4.4% (p < 0.001), and PVR by 36.7 ± 8.0 (p < 0.001). Maximum bladder capacity was significantly increased after bowel management in both non-adjusted (36.4 ± 14.8%; p < 0.001) and adjusted analysis for age (39.4 ± 14.3%, p < 0.001). Detrusor compliance was also increased by 89.2 ± 24.8% (p < 0.001). Female gender and % change of maximal detrusor pressure were significant predictors of transversal rectal diameter change in univariate as well as in multivariate analysis (OR = 10.548, 95% CI 2.309–48.180; p = 0.002 and OR = 1.121, 95% CI 1.009–1.245; p = 0.034).ConclusionsDecrease in transverse rectal diameter may be useful for bladder function and urodynamic findings in children with spinal dysraphism. Therefore, decrease in transverse rectal diameter should be a supplement to standard urotherapy.

The neurogenic bladder characteristics and treatment approaches in the patients with multiple sclerosis

ObjectivesTo analyze the neurogenic bladder characteristics and the treatment approaches in patients with multiple sclerosis (MS) to facilitate proper and reasonable decisions in relevant patients. DesignRetrospective study. SettingDepartment of Physical Medicine and Rehabilitation, Ankara Training and Research Hospital, Ankara, Turkey. ParticipantsSeventy-five patients diagnosed with MS between 2002 and 2015 were included in the study. InterventionUrodynamic examination. Outcome MeasureThe detrusor type, detrusor compliance, sense of bladder fullness, storage disorder, emptying disorder, voided volume, post-void residual volume, urine culture, emptying method, and medical treatments were recorded. ResultsThe study included 53 females and 22 males with a mean age of 36 ± 10.1 years. Urodynamic examinations indicated that 74.7% of the patients had detrusor overactivity, 74.7% had detrusor hypocompliance, 77.3% had storage dysfunction, and 81.3% had emptying dysfunction. An anticholinergic medication was recommended to 74.7% of the patients, while alpha-adrenergic receptor blockers were recommended to 69.3%. The detrusor hypocompliance was more common in the group with a disease duration of ≥10 years (p = 0.045). The use of external collector systems was more common, and urine culture was more frequently positive for infections in the female patients (p = 0.001 and p = 0.049, respectively). The frequency of normal bladder-filling sensation was higher in women (p = 0.01). The frequencies of detrusor overactivity and storage and emptying disorders, voided and postvoid volumes (mL), and bladder emptying methods were not significantly different among the subgroups (p > 0.05). ConclusionThe study revealed a significant neurogenic bladder dysfunction and an inadequate management of this dysfunction in MS patients. Considering that the symptoms may progress over time, the urinary systems of MS patients should be evaluated periodically, and necessary modifications should be made in their treatments.

Non-invasive assessment of urinary bladder compliance using ultrasound: first validation study based on clinical urodynamic study.

This study aims to validate a recently introduced non-invasive method, ultrasound bladder vibrometry (UBV), for the assessment of detrusor compliance in patients with neurogenic bladders. The study was carried out on 79 adult patients with neurogenic bladders (60 male and 19 female). The UBV test was performed on each patient to measure the Lamb wave group velocity (cg ) in the anterior bladder wall at every 50mL volume increment throughout the filling phase. Bladder compliance was assessed based on the trend of Lamb wave group velocity squared (cg 2 ) versus volume. A compliance index was defined to differentiate between the compliant and non-compliant bladders. Results of the UBV compliance assessment were validated using the readings of the corresponding urodynamic studies as the clinical gold standard. The Patients' bladders were divided into non-compliant and compliant groups by an experienced urologist using the information in the urodynamic study (UDS) recordings. The compliance index defined on the basis of cg 2 showed a significant difference (P<0.008) between the compliant and non-compliant groups. The areas under the receiver operating characteristic curve were 0.813, with 95% CI ranging from 0.709 to 0.892. Under the optimal criterion, the bladder was considered as non-compliant if the compliance index was less than 100 mL∙s2/m2, resulting in a sensitivity and specificity of 86.4% and 71.9%, respectively. The results of this study demonstrate that UBV can be used as a non-invasive method for the determination of bladder compliance; thus, it can potentially serve as an alternative method to UDS for the appropriate patient groups.

The relationship between lower urinary tract dysfunctions and urinary leakage from ureterocystoneoanastomosis in male patients after kidney transplantation.

The aim of this study was to investigate the association of lower urinary tract dysfunctions with urinary leakage from ureterocystoneoanastomosis (UCNA) after kidney transplantation. The UCNA leakage after kidney transplantation can be associated with various conditions while severe lower urinary tract dysfunctions could be one of them. The analysis included all men who underwent kidney transplantation between January 2009 and December 2014. The parameters of storage and voiding functions were evaluated. All patients were monitored during their post-transplantation period for the incidence of urinary leakage from UCNA. Urodynamic parameters were compared between men with and without a documented leakage. The study cohort included 127 male patients, while UCNA leakage was observed in 11 (8.7 %) patients. Significant differences between both groups of patients were found for storage parameters (patients with leakage had smaller volume at first and a normal desire to void, smaller maximal cystometric capacity, and lower detrusor compliance) and voiding parameters (patients with leakage had a lower maximal flow rate, higher detrusor pressure at maximal flow rate and higher bladder outlet obstruction index). This study shows an association between lower urinary tract dysfunction and UCNA leakage in men without previous urological history (Tab. 2, Fig. 2, Ref. 24). Text in PDF www.elis.sk Keywords: urinary leakage, ureterocystoneoanastomosis, lower urinary tract dysfunctions, kidney transplantation.

Real-World Effects of Mirabegron in Patients with Chronic Neurogenic Detrusor Overactivity - A Retrospective Cohort Study.

PurposeTo investigate the tolerability and the effects of the β-3-adrenoceptor-agonist mirabegron on urinary incontinence and urodynamic parameters in patients with chronic neurogenic detrusor overactivity (NDO).Patients and MethodsThe patient database of a spinal cord injury rehabilitation center in Switzerland was screened for patients with chronic (>12 months) NDO, who had been prescribed mirabegron. Patient characteristics, data regarding bladder management, urinary incontinence and concurrent medication for NDO as well as urodynamic parameters were collected retrospectively. The changes in the urodynamic parameters and the occurrence of urinary incontinence over time were investigated.ResultsThe data of 63 patients with a median age of 48 years and a median NDO duration of 8.9 years at the initiation of the mirabegron treatment were analyzed. A median 3.0 and 12.7 months had elapsed from the initiation of the mirabegron therapy to the first and second follow-up evaluation, respectively. The majority of patients (73%) received mirabegron in combination with an established antimuscarinic or onabotulinum toxin therapy. The number of patients suffering from urinary incontinence decreased significantly (p≤0.005) from 60.3% (95% CI 47.2/72.4%) to 38.1% (95% CI 23.6/54.4%). Furthermore, the maximum detrusor pressure during the storage phase was significantly (p≤0.04) lower at the second follow-up evaluation (29.5cmH2O, 95% CI 22/40cmH2O) compared to before the mirabegron treatment (35cmH2O, 95% CI 29/41cmH2O). The bladder capacity and detrusor compliance were significantly (p≤0.005) increased during the mirabegron treatment. No patient had discontinued the mirabegron treatment as a result of side effects.ConclusionMirabegron demonstrated a clinically relevant effect and a good safety profile. Concomitant treatment of NDO with mirabegron may allow reduction in the dose of antimuscarinic medication and thus, improve the long-term persistence of NDO treatment.

An investigation into the sensitivity of shear wave ultrasound elastography to measure the anterior bladder wall pressure in patients with neurogenic bladder.

Introduction and Objective:Urodynamic testing (urodynamics) is widely used for evaluating bladder function as a result of high detrusor compliance. This aggressive and uncomfortable test is especially difficult for children. This study aimed to determine the sensitivity of shear wave ultrasound elastography (SWE) as a new method for evaluating the biomechanical characteristics of bladder to measure the anterior bladder wall pressure in children with neurogenic bladder (NB).Materials and Methods:The present prospective clinical study was carried out on 30 children with allegedly NB and 20 healthy children as control group. These children referred to Ahwaz Golestan Hospital in 2018. After clinical evaluations, urodynamics was performed for children with NB and detrusor compliance was measured in cm/H2O. The ultrasonography of the SWE was performed on the anterior wall of the bladder (Estimated bladder capacity (EBC) 50%) for the two groups. The relationship between shear wave speed (SWS) and detrusor compliance was estimated using Pearson's correlation coefficient. Independent t-test was used to compare SWS between two groups.Results:In patients with NB, there was a significant relationship between the mean SWS of the anterior bladder wall and detrusor compliance (R = 0.89, P = 0.0001). The comparison between normal and NB groups showed that the mean SWS of the anterior bladder wall in the patients was significantly higher than the healthy group (1.88 ± 0.88 m/s vs. 0.94 ± 0.15; P = 0.0001). There was also no significant relationship between SWS, gender, age, weight, and body mass index of patients (P > 0.05).Conclusion:The results showed that SWE can be used as a useful alternative for urorodynamic testing in the evaluation of NB (bladder dysfunction) in children.

Change in urodynamic pattern and incidence of urinary tract infection in patients with traumatic spinal cord injury practicing clean self-intermittent catheterization

Objective: To observe changes in cystometric parameters in individuals with spinal cord injury (SCI) with neurogenic bladder practicing clean intermittent self-catheterization (CIC) and incidence of urinary tract infection (UTI) in such patients.Design: Prospective, observational study.Setting: Tertiary Urban Rehabilitation Hospital.Participants: Persons with neurogenic bladder caused by traumatic SCI and practicing CIC.Interventions: Clinical evaluation, complete urine analysis, urine culture and sensitivity, ultrasonography of the abdomen and urodynamic study were evaluated at baseline and at follow-up (6 months to 1 year).Outcome Measures: Detrusor pattern, cystometric capacity, detrusor compliance, detrusor leak point pressure, residual urine, incidence of UTI.Results: Thirty-one participants were included in the study. The baseline cystometric study showed that 15 had overactive detrusor and 16 had detrusor areflexia. The mean cystometric capacity decreased significantly between baseline and follow-up in both the groups but remained within the normal threshold limit, decline being more marked in the overactive detrusor group, who also had more marked decrease in compliance. Mean detrusor leak point pressure was below 40 cm H2O in all participants in both groups at baseline and follow-up. Mean residual urine improved at follow-up in both groups. Incidence of UTI was 2.29 episodes per patient per year, and more frequent in the overactive detrusor group. Escherichia coli was the causative agent in 45%.Conclusion: The cystometric capacity and compliance decreased significantly though patients were doing regular CIC and managed on antimuscarinics for detrusor overactivity (DO). UTI is more common in individuals with SCI with DO and E. coli is the most common cause of UTI.

Protocol for a randomized clinical trial investigating early sacral nerve stimulation as an adjunct to standard neurogenic bladder management following acute spinal cord injury

BackgroundNeurogenic bladder (NGB) dysfunction after spinal cord injury (SCI) is generally irreversible. Preliminary animal and human studies have suggested that initiation of sacral neuromodulation (SNM) immediately following SCI can prevent neurogenic detrusor overactivity and preserve bladder capacity and compliance. We designed a multicenter randomized clinical trial to evaluate the effectiveness of early SNM after acute SCI.Methods/DesignThe scientific protocol comprises a multi-site, randomized, non-blinded clinical trial. Sixty acute, acquired SCI patients (30 per arm) will be randomized within 12 weeks of injury. All participants will receive standard care for NGB including anticholinergic medications and usual bladder management strategies. Those randomized to intervention will undergo surgical implantation of the Medtronic PrimeAdvanced Surescan 97,702 Neurostimulator with bilateral tined leads along the S3 nerve root in a single-stage procedure. All patients will undergo fluoroscopic urodynamic testing at study enrollment, 3 months, and 1-year post randomization. The primary outcome will be changes in urodynamic maximum cystometric capacity at 1-year. After accounting for a 15% loss to follow-up, we expect 25 evaluable patients per arm (50 total), which will allow detection of a 38% treatment effect. This corresponds to an 84 mL difference in bladder capacity (80% power at a 5% significance level). Additional parameters will be assessed every 3 months with validated SCI-Quality of Life questionnaires and 3-day voiding diaries with pad-weight testing. Quantified secondary outcomes include: patient reported QoL, number of daily catheterizations, incontinence episodes, average catheterization volume, detrusor compliance, presence of urodynamic detrusor overactivity and important clinical outcomes including: hospitalizations, number of symptomatic urinary tract infections, need for further interventions, and bowel and erectile function.DiscussionThis research protocol is multi-centered, drawing participants from large referral centers for SCI and has the potential to increase options for bladder management after SCI and add to our knowledge about neuroplasticity in the acute SCI patient.Trial registrationClinicalTrials.gov #NCT03083366 1/27/2017.

Clinical and Urodynamic Results of Repeated Intradetrusor Onabotulinum Toxin A Injections in Refractory Neurogenic Detrusor Overactivity: Up to 5 Injections in a Cohort of Children With Myelodysplasia

To determine the efficacy and safety of repeated intradetrusor onabotulinum toxin A (onaBoNT-A) injections in children with neurogenic detrusor overactivity due to myelodysplasia. The study group consisted of 19 children (4 boys and 15 girls) with a mean age of 10.3 ± 3.1 years old, who had received at least 2 injections of 10 U/kg onaBoNT-A for the treatment of urinary incontinence resistant to anticholinergic treatment and clean intermittent catheterization in our clinic, between 2010 and 2015. Controlled urodynamic studies were performed at the baseline and 3 months after each injection. Eight of the children received 3 injections, 5 children had 4 injections, and 2 children had 5 injections. From the baseline to the fifth injection, the detrusor compliance (1.3, 4.5, 10, 20.7, 18.8, and 16.6 mL/cm H2O), the maximum bladder capacity (82.0, 157.0, 191.0, 272.0, 299.0, and 210.5 mL), and the maximum detrusor pressure (55.0, 33.0, 22.0, 12.5, 16.0, and 12.5 cm H2O) were assessed. The findings significantly improved following the first, second, and third injections, when compared with the previous bladder dynamics (P <.05), but the differences with the fourth were not statistically significant (P >.05). The continence periods were similar under clean intermittent catheterization after all of the injections (P <.05), and no severe side effects were observed. Repeated onaBoNT-A injections are a safe treatment modality and can be offered as an effective alternative choice, instead of more invasive surgery, in children with neurogenic detrusor overactivity due to myelodysplasia.

Effects of vesical and perfusion pressure on perfusate flow, and flow on vesical pressure, in the isolated perfused working pig bladder reveal a potential mechanism for the regulation of detrusor compliance.

Although there is evidence that deficits in bladder blood flow negatively impact bladder function, the effects of vesical, and perfusion pressures on bladder perfusion (perfusate flow), and of perfusate flow on vesical pressure, remain poorly understood. The present study used the isolated perfused working pig bladder model to examine the relationships between blood flow, and vesical and perfusion pressures. Vesical arteries of pig bladders obtained from a local slaughterhouse were cannulated and perfused with Krebs-Henseleit solution at different pressures, and with carbachol to cause bladder contraction. The urethra of each bladder was cannulated to permit filling (10 mL/min), isovolumetric contraction and emptying. A ureter was cannulated with a pressure sensor to monitor vesical pressure. When at rest (50 mL vesical volume), bladder vesical pressure was 8.06 ± 1.5 mmHg and perfusate flow driven by a pressure gradient of 105 mmHg was 22.5 ± 2 mL/min (58.9 ± 7.8 mL/min-100 g). During filling, vesical pressure increased and flow decreased, but not necessarily in-parallel. Perfusate flow decreased transiently during isovolumetric contraction, and flow increased during emptying. A reduction in perfusion pressure from ∼105 to ∼40 mmHg reduced flow from ∼70 to ∼20 mL/min-100g, and reduced flow correlated with reduced vesical pressure. Perfusate flow is dependent on bladder perfusion pressure, and not necessarily reciprocally dependent on vesical pressure. Vesical pressure is highly sensitive to the level of perfusate flow, which supports the hypothesis that vesical pressure is dependent on the level of detrusor smooth muscle contractile activity (tone), and that compliance is dependent on bladder perfusion.

Effect of imidafenacin on the urodynamic parameters of patients with indwelling bladder catheters due to spinal cord injury

Study design:A retrospective study.Objectives:To investigate the effect of imidafenacin on the urodynamic parameters of patients with indwelling bladder catheters due to spinal cord injury (SCI).Setting:Spinal center (Tokyo, Japan).Methods:Imidafenacin was prescribed to 34 patients with SCI who had a low cystometric volume and/or detrusor compliance according to a urodynamic study. A low cystometric volume and detrusor compliance were defined as <200 ml and <20 ml cm−1 H2O, respectively. The urodynamic study was repeated 4 weeks after imidafenacin was prescribed. When the urodynamic parameters did not improve in the follow-up study, the dose of imidafenacin was increased twofold. Then the urodynamic study was repeated 4 weeks thereafter. We compared the urodynamic parameters before and after imidafenacin treatment. Complications such as vesico-urethral reflux (VUR) and autonomic dysreflexia (AD) were documented.Results:Fifteen patients took 0.2 mg of imidafenacin daily, and 19 received 0.4 mg of imidafenacin daily. Imidafenacin increased the cystometric volume from 246.0 to 321.5 ml (median, P=0.002), detrusor compliance from 6.67 ml cm−1 H2O to 8.98 ml cm−1 H2O (median, P=0.012), and decreased the detrusor pressure from 37.0 cm H2O to 30.5 cm H2O (median, P=0.056). All three patients who had VUR fully recovered. Although 3 of 12 patients recovered from AD, 3 patients newly developed symptoms of AD. No patient withdrew from treatment due to adverse effects.Conclusion:Imidafenacin is a safe drug that may improve the urodynamic parameters of patients with SCI, and it possibly alleviates bladder complications.

Urogynecology and Reconstructive Pelvic Surgery. 4th ed.

This is a truly comprehensive textbook that covers the whole spectrum of female pelvic medicine and reconstructive surgery (FPMRS). It starts with reviewing the history of female pelvic surgery, gynecology, and female urology. This is a nice setup for covering the latest evolutions in FPMRS such as female sexual dysfunction, robotic surgery for pelvic organ prolapse, and surgical management of detrusor compliance abnormalities. The basic science part includes chapters that are dedicated to the physiology of the pelvic muscles, vagina, and anorectum. In addition, the chapter on the psychosocial impact of pelvic floor disorders provide the reasons for trying to master this difficult to learn field. A welcome addition to this edition is the step-by-step instructions on regular and video urodynamics. But perhaps more important may be the two dedicated two chapters and interspersed review of possible surgical complications and their method of management. Four chapters are dedicated to fecal incontinence and defecation disorders, and the book ends with explaining on what to use in measuring outcomes and quality of life in pelvic floor research. This book should be seriously considered by anyone involved in FPMRS.

Functional outcome of supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction.

To investigate the functional outcome after supratrigonal cystectomy and augmentation ileocystoplasty in adult patients with refractory neurogenic lower urinary tract dysfunction (NLUTD). Retrospective follow-up investigation in a single spinal cord injury rehabilitation center. In 29 patients, urodynamic data before and after supratrigonal cystectomy and augmentation ileocystoplasty, clinical outcome and post-operative complications were evaluated. The median age of the 29 patients at the time of surgery was 31 years, a median 14 years after NLUTD had occurred. At the last follow-up visit (median 2.4, range 0.4-9.0 years post-operatively), 20/29 patients (69%) were continent compared to 2/29 pre-operatively (P = 0.001). Furthermore, 16 patients required no or less detrusor relaxation therapy after augmentation ileocystoplasty. Augmentation cystoplasty resulted in a significant (P = 0.001) increase in the median bladder capacity (from 240 ml to 500 ml) and compliance (from 13 ml/cm H2 O to 50 ml/cm H2 O). The median maximum detrusor pressure had decreased significantly (P = 0.001) from 38 cm H2 O to 15 cm H2 O. Significantly (P = 0.001) fewer patients presented with a risk for renal damage (1 vs. 15 with maximum detrusor pressure >40 cm H2 O and 1 vs. 12 with detrusor compliance <20 ml/cm H2 O) at the last follow-up. The following complications were observed in 11/29 (38%) patients: paralytic and obstructive ileus, impaired bowel function, bladder stones, dehiscence, metabolic acidosis and autonomic dysreflexia. Protection of renal function, adequate bladder capacity and low detrusor pressure can be achieved using supratrigonal cystectomy and augmentation ileocystoplasty in patients suffering from refractory NLUTD.

Long-Term Enterocystoplasty Follow-Up: Metabolic and Neoplastic Concerns

Augmentation enterocystoplasty is indicated for the management of refractory neurogenic or non-neurogenic detrusor overactivity, impaired detrusor compliance, and bladder pain. Enlarging the bladder, utilizing segments of the stomach, small bowel, or colon, has been reliably proven to successfully create a low-pressure reservoir with preserved renal function. Incorporating stomach or bowel into the urinary tract may result in genitourinary stone formation, bladder cancer, long-term metabolic disturbances, or other complications. This review focuses on the incidence and management of augmentation enterocystoplasty complications based on the most recent published literature.

Comparative Effectiveness of Combined Low- and Standard-Dose Trospium and Solifenacin for Moderate Overactive Bladder Symptoms in Elderly Men and Women

Objective: To increase the safety and effectiveness of treatments for overactive bladder (OAB) with moderate symptoms in elderly patients. Patients and Methods: Patients were examined at the Urodynamic Department of the Regional Diagnostic Center (Vladivostok, Russian Federation) from September 1, 2012 to December 31, 2012. The assignment of patients [n = 177, average age 69. 4 years, 98 women (55.4%) and 79 men (44.6%)] was random and blind in this placebo-controlled study. Patients were distributed into subgroups according to the method of treatment as follows: group А1: n = 57, trospium 30 mg/day + solifenacin 10 mg/day; group А2: n = 61, trospium 15 mg/day + solifenacin 5 mg/day; group А3: n = 59, placebo. All patients underwent a urodynamic examination in accordance with international standards before and 2 months after treatment. ICIQ-SF questionnaires recommended by the International Continence Society (ICS) and bladder diaries were used to evaluate the clinical results. The clinical severity of the OAB symptoms and the effectiveness of the treatment were evaluated based on the frequency of episodes of incontinence (EI) per day. Three or fewer EI per day were considered moderate dysfunction of the lower urinary tract. Results: Groups of elderly patients with moderate symptoms of OAB who were treated with standard- and low-dose trospium and solifenacin demonstrated a significant increase in the median values of reflex volume, bladder capacity, and detrusor compliance and a decrease in the frequency of urination and urinary urgencies. The frequency of EI in both of the main groups decreased by almost 2-fold in comparison to the initial data and reached the following values: group А1: 1.27 (-1.08), p ≤ 0.05; group A2: 1.49 (-1.18), p ≤ 0.05. The correlation with the decrease in the frequency of EI in these groups was r = 0.85 (p ≤ 0.01). The percentage of patients with a significant decrease (EI ≥1.0) among those treated with standard- and low-dose trospium and solifenacin increased synchronously, prompting us to suppose the absence of a direct correlation between medicine dose and therapeutic effect for moderate OAB symptoms. Conclusion: The combination of low-dose trospium and solifenacin provides good clinical and urodynamic effects in elderly patients with moderate symptoms of OAB. Combination of these drugs in standard doses for such patients is excessive.

Factors Associated With Renal and Urological Complications in Patients Suffering From Spinal Cord Injuries During Subsequent Years of Post-Injury

Virtually all patients with a spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD). The major goal of any treatment of these patients is the preservation of renal function. Especially suprasacral SCI frequently leads to elevated bladder storage pressures which are the major risk factor for renal deterioration. Therefore, the primary objective of bladder management is to achieve low pressure urine storage and emptying. To classify NLUTD of an individual patient and to monitor treatment, regular controls of bladder function are mandatory. The authors assessed the patients with SCI by questionnaires, laboratory tests and imaging. The number of patients included (5901) is impressive. The number of urologic complications observed is rather high. It was not surprising that presence of urologic complications was associated with level of injury and time since injury. It is noteworthy, however, that these complications are depending on the living place (1). Unfortunately, but understandably, no urodynamic data were included in the analysis. It is very demanding to collect urodynamic data from such a large patient cohort. Furthermore, urodynamic examinations are merely possible in specialized centers, and I suspect that this examination was not available for all patients at every control visit. Urodynamics, however, are considered the gold standard for the assessment of the main risk factors for renal damage, namely a detrusor leak point pressure/storage pressure > 40 cm H2O and/or a low detrusor compliance (< 20 mL/cm H2O). Until today, these factors can exclusively be assessed by urodynamics. Thus, it is crucial for the evaluation of NLUTD, since significant changes in NLUTD may occur without symptoms in about 70% of patients with SCI (2). The lack of urodynamic examinations may at least be one explanation for the higher risk for renal complications in SCI patients living in rural areas. As a consequence, the more frequent use of urodynamic testing in this group of patients may in the future even improve the outcome of patients with SCI. As urodynamics are expensive, time consuming, and carry the risk of urinary tract infections, a new diagnostic parameter would be clinically helpful if it either could replace urodynamics or could be used as an additional diagnostic tool to detect SCI patients with NLUTD without risks for consecutive renal damage. Sonographic measurement of the bladder wall thickness may be a future option, but until today, this technique is not well standardized and cannot replace urodynamics yet (3). Not unexpectedly, urinary tract infections are the most common urologic complication in these patients. The frequency of urinary tract infections depends on the method used for bladder evacuation, with indwelling catheters having the highest infection rates. The study does not distinguish between the different methods of bladder management. In general, indwelling catheters should be avoided if ever possible to reduce the number of urinary tract infections (4). In summary, the authors are congratulated for their extensive study, providing the readers with important information about the impact of demographic and environmental factors on urologic complications in SCI patients. As these factors also include the coverage of medical supplies, which is world-wide dependent on living place and social status, the results also mirror the need of optimized diagnostics and treatment of SCI patients as demanded by the world health organization (5). As meticulous urodynamic diagnostics and adequate urologic treatment have been proven to dramatically decrease the rate of urologic complications after SCI (6), the nationwide access to urologic care for patients with SCI should be targeted in the future. Footnotes Financial Disclosure: I have no conflict of interest.

Botox for the Neurogenic Bladder

OnabotulinumtoxinA has been shown to be a safe, successful and cost effective treatment option for neurogenic detrusor overactivity improving clinical parameters and quality of life in patients with neurogenic detrusor overactivity. The most common side effects are urinary tract infections and elevated post-void residual requiring clean intermittent catheterization. The median time to retreatment is approximately 8-9 months. There appears to be little difference in efficacy or duration of treatment at 200 Units compared to 300 U and the lower dose has shown a moderately improved safety profile. Patients with multiple sclerosis and Parkinson’s disease have shown benefit starting a 100 U. OnabotulinumtoxinA has also been shown to benefit patients with low detrusor compliance and those with recurrent UTIs. Treatment benefits have been shown to be durable without increased fibrosis to the detrusor.

Urodynamic results, clinical efficacy, and complication rates of sacral intradural deafferentation and sacral anterior root stimulation in patients with neurogenic lower urinary tract dysfunction resulting from complete spinal cord injury

To investigate the outcome and complications of sacral deafferentation (SDAF) and sacral anterior root stimulation (SARS) in patients with neurogenic lower urinary tract dysfunction (NLUTD) resulting from complete spinal cord injury (SCI). Retrospective chart analysis of 137 patients who underwent SDAF/SARS at a single institution. Patients were categorized as being at risk of renal damage when the maximum detrusor pressure was >40 cmH2 O or detrusor compliance was <20 ml/cmH2 O. After a mean follow-up time of 14.8 ± 5.3 years, SDAF/SARS treatment significantly (P < 0.001) reduced the number of patients suffering from elevated detrusor pressure from 65 to 2, and from low detrusor compliance from 62 to 13, respectively. Mean bladder capacity significantly (P < 0.001) improved from 272.4 ± 143.0 to 475.0 ± 82.7 ml. The mean number of symptomatic UTI also decreased significantly (P < 0.001) from 6.2 ± 4.5 to 2.5 ± 2.6 per year. The number of patients suffering from incontinence had significantly (P < 0.001) decreased from 70 to 44. At the last follow-up visit, 107 (78.1%) patients were still using the stimulator. A total of 84 complications requiring surgical revision were observed. Defects of the stimulator cables or the receiver plate were the most common events (n = 38). The retrospective design pertains to the limitations of the study. Sacral deafferentation and SARS are an effective treatment option for refractory NLUTD in patients with complete SCI, despite a substantial long-term complication rate.

OnabotulinumtoxinA improves urodynamic outcomes in patients with neurogenic detrusor overactivity

To evaluate the effect of onabotulinumtoxinA on urodynamic outcomes in patients with urinary incontinence (UI) due to neurogenic detrusor overactivity (NDO). Results from two pivotal Phase III trials (n = 691) were pooled. MS or SCI patients with NDO, received intradetrusor onabotulinumtoxinA 200 U (n = 227), 300 U (n = 223), or placebo (n = 241). Change from baseline in UI episodes/week (Week 6), maximum cystometric capacity (MCC), maximum detrusor pressure at first involuntary detrusor contraction (IDC) (PdetmaxIDC), volume at first IDC (VpmaxIDC), and detrusor compliance (DC) were measured. OnabotulinumtoxinA significantly increased MCC overall (+153.6 ml with 200 U vs. +11.9 ml with placebo). Over 60% of onabotulinumtoxinA-treated patients had no IDC at Week 6; in patients with an IDC at Week 6, VpmaxIDC improved (+183.4 ml with 200 U vs. +17.5 ml with placebo), and PdetmaxIDC decreased (-32.4 cmH2O with 200 U vs. +1.1 cmH2O with placebo). OnabotulinumtoxinA-treated patients had a significant increase in DC (+59.8 ml/cmH2O with 200 U vs. -5.2 with placebo). Urodynamic improvements were comparable in patients regardless of baseline DC and corresponded with significant reductions in UI episodes/week for both onabotulinumtoxinA doses versus placebo, with no clinically relevant differences between 200 and 300 U groups. Most common adverse event was urinary tract infection (UTI); complicated UTIs were low across all treatment groups. In patients not catheterizing at baseline, a dose-dependent increase in post-void residual urine was observed at Week 2 following onabotulinumtoxinA treatment. OnabotulinumtoxinA significantly improved urodynamic outcomes in NDO patients, even in those with low baseline DC, and corresponded with improvements in UI episodes. Both doses of onabotulinumtoxinA were well tolerated.