Detrusor Instability Research Articles

Intravesical Botulinum Toxin for Persistent Autonomic Dysreflexia in a Pediatric Patient.

Introduction. We present a novel case of persistent autonomic dysreflexia in a pediatric spinal cord injury patient treated successfully with intravesical botulinum toxin. Study Design. A retrospective chart review of one patient seen at the Children's Hospital of Wisconsin from 2006 to 2012 was performed. Results. A pediatric spinal cord injury patient with known neurogenic bladder presented with severe hypertension consistent with autonomic dysreflexia. His symptoms and hypertension did not improve with conservative measures, and he necessitated ICU admission and antihypertensive drips. He was taken to the operating room for intravesical botulinum toxin for refractory bladder spasms. Following this, his symptoms abated, and he was weaned off IV antihypertensives and returned to his baseline state. His symptoms were improved for greater than six months. Conclusions. There are few treatment options for the management of refractory autonomic dysreflexia. Intravesical botulinum toxin has never been reported for this use. Dedicated research is warranted to assess its efficacy, as it was used successfully to abort autonomic dysreflexia in this patient.

Effect of the Chinese traditional prescription Suo Quan Wan on TRPV1 expression in the bladder of rats with bladder outlet obstruction.

BackgroundSuo Quan Wan (SQW) is a Chinese traditional prescription that has been used in clinical treatment of lower urinary tract symptoms for centuries. However, scientific basis of SQW efficacy and mechanism is still needed. This study investigated the effect of SQW on bladder function and transient receptor potential vanilloid 1 (TRPV1) expression in the bladder of rats with bladder outlet obstruction (BOO). The induced changes in bladder function in overactive bladder (OAB) rat model were observed following different periods of outlet obstruction to obtain an appropriate rat model.MethodsThis study was carried out in two parts. In the first part, female Sprague–Dawley rats received sham operations or partial BOO operations. Two, four, and six weeks later, the OAB model groups and control were subjected to urodynamic tests to measure differences in bladder functions. Once the appropriate rat model was obtained, the second part of the experiment was performed. The rat model was recreated and treated with SQW. Urodynamic assessment was conducted, and the bladders of the rats were then removed. Immunofluorescence staining, real-time PCR, and Western blot were performed to localize and quantify the expression of TRPV1 in the bladder.ResultsResults of the first part indicated that at 2 and 4 weeks, the OAB model group exhibited significant differences in urodynamic parameters, including bladder pressure, maximum voiding pressure, and maximum bladder capacity, compared with the sham group. At 4 and 6 weeks, the OAB model group exhibited significant differences in residual volume (RV) and non-voiding contraction frequency. Six-week OAB model group showed much more RV but less voiding efficiency when compared with 6-week sham group or 2—and 4-week OAB model group. Rats that underwent BOO exhibited similarities with the compensated state before four weeks and may have entered decompensated state at six weeks. Studies conducted with 4-week OAB model were appropriate.In part two of the experiment, unstable bladder in the OAB model group recovered bladder stability after SQW treatment, accompanied by improved bladder hypertrophy, as well as corrected urodynamic parameters. Expression of TRPV1 mRNA and proteins in the bladder was significantly greater in the OAB model group than that in the control group, which subsequently decreased significantly with SQW treatment in BOO-induced rats.ConclusionsSQW can modulate the expression of TRPV1 in accordance with the recovery of bladder function.Electronic supplementary materialThe online version of this article (doi:10.1186/s12906-015-0898-7) contains supplementary material, which is available to authorized users.

Origin of Urgency Symptom in Underactive Bladder: Commentary on "Underactive Bladder: Clinical Features, Urodynamic Parameters, and Treatment" (Int Neurourol J 2015;19:185-9).

To the editor: In the previous issue of International Neurourology Journal, Nathan Hoag and Johan Gani reported clinical features of underactive bladder (UAB) in their cohort [1]. The most common urinary symptom among identified UAB patients was urgency (63.3%), followed by weak stream (61.0%). Discussing this unexpected finding, the authors only commented that “an appropriate symptom-based definition will prove challenging to describe” for defining UAB. Urinary urgency is definitely the predominant symptom of overactive bladder. Of course, a patient with urgency does not always have overactive bladder. As the authors reported, it is quite possible that a patient with urgency will prove to have UAB in actual practice. The origin of urgency symptoms in UAB patients may be attributed to three possible explanations. The first candidate is definitely concomitant detrusor overactivity. This condition is traditionally termed detrusor hyperreflexia with impaired contractility (DHIC). DHIC seems to be the most probable and attractive explanation for urgency in UAB. However, only 24.1% of patients in the cohort proved to have DHIC, which could not explain all cases. As the next candidate, urinary tract infection (UTI) could be associated with urgency in UAB patients. Recurrent UTI was reported in 25.3% of patients in the cohort, which possibly affected reports of subjective urinary symptoms. Bacteriuria proved to be associated with urinary urgency, especially in elderly women [2]. The last candidate may be deranged bladder sensation, which is often combined with UAB [3]. In patients with diabetes, a sensory deficit precedes bladder motor problems in the development of UAB [4]. These patients often recognize bladder fullness as a vague pressure in the lower abdomen rather than a true initial voiding sensation. With the resulting increased bladder volume, this recognition tends to come too late to allow enough time for actual voiding. The short time interval between first recognition and actual voiding may cause patients to report urgency symptoms. Urgency symptoms in UAB may well occur, and originate from diverse causes including DHIC, UTI, or a sensory deficit. The old axiom that “the bladder is an unreliable witness” seems to be also true in the case of UAB [5]. Differential diagnosis may give us a clue to management. In cases of urgency associated with UTI, antibiotics should be considered first. Anticholinergics may be helpful to decrease urgency with DHIC, but not with a sensory deficit. The clinical implication of UAB subclassification by sensory component warrants further research.

Pearls, tricks, and quirks of the reconstruction for hypospadias and chordee

s / Urological Science 26 (2015) 294e300 297 Can that save the cost with avoidance of repeated semen analysis if the first semen analysis had nonmotile sperm density <100,00/ml. Materials and Methods: From Jan 2010 to Dec. 2014 a total of 419 men underwent vasectomy for birth control in our hospital. Patients demographics and postvasectomy semen analysis results were collected retrospectively. Results: During the period of recent 5 years, 419 patients underwent vasectomy in our hospital. Most of the patients has 2 or more children after marriage. Postvasectomy semen analysis was completed within the 3-6 months after surgery. No patient has motile sperm in their PVSA. Few patients had nonmotile sperm with the concentration <100,000/ml (AUA clearance parameter). Repeated semen analysis confirm the azospermia later. The cost saving is not high. Conclusion: The AUA special clearance parameter is not applied in our hospital. The cost saving is not efficacy than the compensation of legal problem. So repeated semen analysis is still warranted in our hospital until azospermia confirmed. MP2-6: PEARLS, TRICKS, AND QUIRKS OF THE RECONSTRUCTION FOR HYPOSPADIAS AND CHORDEE Jesun Lin , Herng-Jye Jiang , Jian Ting Chen , Bai-Fu Wang , Chin-pao Chang , Mon-I. Yen , Sheng-Hsien Huang , Hon-Jen Shi , Ming-Chih Chou . Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan; 2 Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan Purpose: We reviewed our 33 years experience in the management of hypospadias, chordee and their complications after reconstruction in order to understand their presenting Problems. We would recommend the factors of successful techniques for this congenital disease of penis. Materials and Methods:We reviewed the records of 998 hypospadias and chordee patients between January 1981 and December 2014. The complications after reconstruction might be single or combined with several presenting problems in the same patient. This article represents a collection of recommendations, technical nuances, and innovative management techniques that have been found to contribute to the success of hypospadias and chordee surgery. We would classify the main problems of complications to be (1) 89 urethrocutaneous fistulae, (2) 36 urethral strictures, (3) 15 meatal stenosis (4) 38 remaining chordee, (5) 14 diverticula and (6) 6 hairy urethra. The penile shaft and perineum fistulae were repaired with the “pants-over-vest urethroplasty modified to the procedure of Turner-Warwick. The coronal fistulas were converted into repair for coronal hypospadias. The remaining urethral plate was tubularized with or without a relaxing midline incision (Reddy-Snodgrass). We wrapped dorsal dartos or subcutaneous flap to cover the neourethra for preventing urethrocutaneous fistula. The meatal stenosis was performed with dorsal meatotomy, Y-V glans flap, meatal skin graft and transverse meatotomy. Residual chordee were performed with dorsal plication, excision the chordee, the urethral diverticula were excised and tailored for redo-urethroplasty. Hairy urethra were resected and then urethroplasty. We performed double-tube stent and vacuum drain in subcutaneous layer for prevention of bladder spasm, hematoma and infection. Results: The over all successful rate is 85% in one stage surgery for the fresh cases. The number of redo-operations for their presenting problems of complications ranged from 1 to 8 attempts. The successful rate for urethrocutaneous fistula is 76%, for urethral strictures is 82%, for meatal stenosis is 70%, for chordee is about 70%, for diverticula is about 85%, for the hairy urethra is about 70%. We followed up the outcome of consequent surgery from 6 months to more than ten years. Conclusions: The successful surgery of the hypospadias, chordee redo operation for them requires radical correction of all deformities. It is true that“Experience is by far the best teacher. It might be said that unless the technique and subsequent good results of an individual method are transferable to others, the technique as taught is suspect”said by Dr. John W. Duckett. Moderated Poster-3

Three Types of Intravesical Hem-o-Lok Clip Migration After Laparoscopic Radical Prostatectomy.

Hem-o-Lok® clips (HOLCs) (Weck® Surgical Instruments, Teleflex Medical, Durham, NC) are widely used for controlling the lateral pedicles in laparoscopic radical prostatectomy, but intravesical HOLC migrations have been reported in more and more studies. This study aimed to summarize clinical presentations, management, and outcomes of these patients. Six patients with intravesical HOLC migration were retrospectively identified from 750 consecutive patients who underwent robot-assisted laparoscopic prostatectomy between 2005 and 2014 performed by a single surgeon. The PubMed database was also searched for Hem-o-Lok clip migration after laparoscopic prostatectomy. The incidence of intravesical HOLC migration in this study was 0.8% (6/750). In total, 22 patients were reported, including six from the current series. Three types of migrations were classified: Type I migration resulted in obstructive lower urinary tract symptoms 2-8 months after prostatectomy, whereas Type II migration led to stone formation, gross hematuria, or bladder spasm; in Type III migration, patients had spontaneous expulsion of the HOLC weeks after surgery. Although the incidence of intravesical HOLC migration is relatively low, Type I migration with long-term sequelae remains a concern. The use of HOLCs adjacent to anastomosis should be minimized, and any loose clip must be retrieved to reduce complications.

Quantitative Proteomic Analysis of Differentially Expressed Proteins and Downstream Signaling Pathways in Chronic Bladder Ischemia

Growing evidence suggests that ischemia may contribute to aging associated bladder dysfunction and lower urinary tract symptoms. Our goal was to determine the effects of chronic ischemia on bladder proteomic profiles and characterize downstream signaling pathways. Bilateral iliac artery atherosclerosis and chronic bladder ischemia were created in male Sprague Dawley® rats. At 8 weeks cystometrograms were obtained. Ischemic and control bladder tissues were then processed for label-free quantitative proteomic analysis. GO (Gene Ontology) andIPA (Ingenuity® Pathway Analysis) software were used to classify altered proteins in bladder ischemia. Western blot was done to confirm differentially expressed proteins. Tissue structure was examined by transmission electron microscopy. Chronic ischemia resulted in detrusor instability and noncompliance. Proteomic analysis revealed a total of 4,277 proteins in ischemic and 4,602 in control bladder tissues. In ischemic bladders 359 and 66 proteins were differentially expressed with a greater than twofold and fivefold change, respectively. On GO analysis differentially expressed proteins were associated with molecular signaling mechanisms underlying proteolysis and degenerative processes. Pathway and network analysis of ischemic tissues suggested that altered proteins are involved in ubiquitination, Nrf2 mediated oxidative stress response, cell death, glucose metabolism and cytoskeleton remodeling. Western blot verified changes in 4 representative proteins, including Nedd4l, Mpo, Ca3 and Fkbp5. Altered proteomic profile of the bladder was associated with widespread ultrastructural damage. Alterations of bladder proteomic profiles in ischemia may provide new insight into molecular pathways underlying bladder dysfunction and lower urinary tract symptoms in pelvic atherosclerosis.

Twin pregnancy in a woman with spinal cord injury (SCI): a case report

Pregnancy in women with spinal cord injury (SCI) is associated with various complications. Pregnant women with spinal cord lesions are at a greater risk of many medical complications, compared to healthy women. These complications include urinary tract infections, venous thrombosis, anemia, autonomic hyperreflexia, increased spasticity, bladder spasm, dysautonomia, and pressure sores; some of these complications may beeven life-threatening. Herein, we report a case of a 41-year-old woman with SCI and twin pregnancy.

The significance of urodynamic analysis in evaluating neurogenic vesicoureteral reflux in patients with thoracolumbar spinal cord injury

Objective To investigate the utility of urodynamic testing in the evaluation of neurogenic vesicoureteral reflux in patients with thoracolumbar spinal cord injury at the T10 to L2 level. Methods Twenty-six patients with thoracolumbar spinal cord injury at the T10 to L2 level and who displayed vesicoureteral reflux were enrolled and divided into a detrusor hyper-reflexia group (n=21) and a detrusor a-reflexia group (n=5) according to their cystourethrograms and urodynamic test results. Their bladder volume, detrusor pressure (Pdet) and compliance were observed and analyzed at the vesicoureteral reflux point and the leak point. Results The bladder volume and compliance of the detrusor hyper-reflexia group at the vesicoureteral reflux point were (122.46±87.89) ml and (5.94±4.96) ml/H2O respectively, significantly different from the detrusor a-reflexia group (P<0.01). At the leak point, the average bladder volume of the detrusor hyper-reflexia group was (210.81±69.72)ml, while the average bladder compliance was (9.53±5.43)ml/H2O and the average detrusor pressure was (42.29±9.57)cm H2O. All were significantly different from the detrusor a-reflexia group's averages. Moreover, there was a significant difference in the Pdet between the leak point and the vesicoureteral reflux points in the detrusor hyper-reflexia group. Conclusions Patients with thoracolumbar spinal cord injuries at the T10 to L2 level with neurogenic bladder and detrusor hyper-reflexia have low bladder volumes and compliance, and vesicoureteral reflux tends to occur at an early stage after injury with a destrusor pressure lower than 40 cm H2O. For patients with detrusor a-reflexia, vesicoureteral reflux and bladder leakage may occur when detrusor pressure is low. Key words: Spinal cord injury; Neurogenic bladder dysfunction; Vesicoureteral reflux; Urodynamics

The research progress of bladder spasm after the transurethral electrovaporization of prostate

Transurethral electrovaporization of prostate(TUVP) is generally carried out in recent years, which is a method for the treatment of benign prostatic hyperplasia, with less bleeding, short operation time, rapid recovery. The results of clinical treatment show it is more safe and effective. But the problem on the occurrence of bladder spasm after the operation has been plagued by the medical staff. In order to offer references for clinical nursing work, the paper reviewed the influencing factors of bladder spasm and nursing progress of this field after the TUVP. Key words: TUVP; Benign prostatic hyperplasia; Bladder spasm

Is peri-operative urethral catheter drainage enough? The case for stentless pediatric robotic pyeloplasty

The necessity for urinary diversion with trans-anastomotic ureteral stenting during pyeloplasty is currently under debate. Performing a stentless repair could eliminate stent-related morbidity, including: stent migration, urinary tract infection, flank pain, and bladder spasms. In addition, there would be no need for a second procedure and associated anesthesia required for stent removal. This study describes the outcomes of robotic-assisted laparoscopic pyeloplasty without use of a ureteral stent. An IRB-approved prospective database of all pediatric patients undergoing robotic pyeloplasty from July 2012 to July 2014 at a single institution was reviewed. The 'bypass pyeloplasty' or Anderson-Hynes dismembered pyeloplasty (DP) technique was performed. In both groups, neither a ureteral stent nor an abdominal drainage catheter was utilized. Complications were recorded, including: postoperative pain, bladder spasms, fever, and urinary tract infections. Follow-up renal ultrasound was reviewed for hydronephrosis. Twenty-seven children (17 male, 10 female) with a mean age of 25 months (range 6-157 months) underwent robotic ureteral stentless pyeloplasty during the study time period. The bypass pyeloplasty technique was performed on 19 children (70%). Mean length of stay was 20.2 hours (range 11-46). No fever, urinary tract infections, or hematuria requiring intervention were experienced. Additionally, there were no reports of bladder spasms or pain requiring pharmacotherapy. The mean follow-up was 8 months (range 4-21). Pre-operative Society of Fetal Urology grading was 3.5 and 3.4 for the dismembered and bypass cohort, respectively, with improvements to 1.1 for both groups at 3 months. Postoperative renal ultrasound hydronephrosis resolved in eight children (29.6%), improved in 14 (51.9%), and was stable in five (18.5%). The overall success rate was 100%. This study was limited by its small cohort and short follow-up, which may not thoroughly describe the efficacy of the stentless repair as it has been shown that stricture and re-obstruction can occur several years after surgery. Robotic stentless pyeloplasty is a feasible alternative to conventional methods, with excellent success rates and minimal complications. Importantly, this technique circumvents the need for a second procedure and the associated risks of anesthesia.

Clinical value of multidisciplinary team assessment for chronic constipation

Objective To investigate the clinical value of multidisciplinary team (MDT) assessment for chronic constipation. Methods The clinical characteristics of 346 patients with chronic constipation who were admitted to the Third Peolep's Hospital of Hangzhou from January 2010 to December 2013 were multidisciplinarily assessed. The multidisciplinary team was involved surgeons from the department of colorectal surgery, urology, gynecology, psychiatry and psychology, and tools including questionnaires, defecography, anorectal manometry, colon transit study, urodynamic tests, gynecological examination were applied in the study. The measurement data with normal distribution were presented as±s, the comparison between groups was analyzed using the ANOVA, and the count data were analyzed using the chi-square test. Results Three hundred and forty-six patients who met criteria of this research were selected, including 86 males and 260 females with the ratio of 1∶3; the mean age was (55±11) years. Of the 346 patients, slow transit constipation accounted for 7. 52% (26/346) , defecatory disorder for 60.98% (211/346) , and mixed constipation for 31.50% (109/346) . A total of 93.85% female patients (244/260) had anterior rectocele, 75.43% (261/346) patients had internal rectal mucosal prolapse, 66.76% (231/346) patients had perineum descending, 23. 99% (83/346) had achalasia or inappropriate contraction of internal anal sphincter, 18.79% (65/346) had puborectalis rectocele muscle thickening, 5. 49% (19/346) had rectal prolapse. A total of 82. 37% (285/346) patients were involved in other subjects than colorectal surgery. A total of 28.61% (99/346 ) patients presented with urinary symptoms, including 65 cases with stress urinary incontinence, 23 cases with unstable bladder and 19 cases with bladder neck obstruction (some patients had multiple urological systoms) . The incidence of reproductive organ prolapse in female patients was 31.92% (83/260) , the incidence of uterine prolapse and anterior vaginal prolapse were 26.15% (68/260) and 29. 23% (76/260) , respectively. Patients with anxiety and/or depression accounted for 36.13% (125/346) . The male and female patients of slow transit constipation, defecatory constipation and mixed constipation were 10 vs 16, 30 vs 79, 46 vs 165, respectively, the age was 60 ± 12, 56 ± 11, 52 ± 10 , showing no significant differences (χ2= 4. 046 , F =2. 877 , P >0.05) . In the three kinds of constipation, patients with urinary diseases accounted for 26. 92% (7/26) , 26. 61% (29/109) and 29.86% (63/211) , patients with gynecological diseases accounted for 11. 54% (3/26) , 20.18% (22/109) , 27.49% (58/211) , patients with psychological diseases accounted for 38. 46% (10/26) , 39.45% (43/109) , 34.12% (72/211) , respectively, showing no significant difference (χ2= 4. 090, P >0.05 ) . Conclusion MDT assessment for patients with chronic constipation can reflect comprehensively clinical characteristics of chronic constipation, therefore multidisciplinary team should be emphasized in clinical diagnosis and treatment of chronic constipation. Key words: Chronic constipation; Multidisciplinary team; Clinical assessment

Multi-factor analysis of factors influencing the outcomes in patients with benign prostatic hyperplasia and overactive bladder after transurethral resection of the prostate

Objective To study the factors influencing the factors influencing the prognosis in patients with benign prostatic hyperplasia(BPH)and overactive bladder(OAB)subject to the transurethral resection of the prostate(TURP). Methods A total of 216 patients diagnosed with BPH and OAB in our hospital were treated with TURP.Clinical data including age, blood pressure, blood glucose, prostate volume, residual urine volume, average urinary flow rate, maximum urinary flow rate, detrusor instability, international prostate symptom score(I-PSS), urinary infection, urinary retention and other aspects were collected in our study.The related data were used for univariate analysis first.Multivariate analysis was done by the Logistic regression. Results Univariate analysis showed that the following features were associated with the prognosis of patients with TURP: residual urine volume(χ2= 4. 761,P< 0. 05), I-PSS(χ2= 9. 313,P< 0. 05), maximum urinary flow rate(χ2= 4. 539,P< 0. 05) and detrusor instability(χ2= 5. 252,P< 0. 05). Multivariate analysis showed that the following features were independently associated with prognosis of patients subject to TURP:I-PSS and detrusor instability. Conclusion I-PSS[odds ratio(OR)= 1. 952,P< 0. 05] and detrusor instability(OR= 2. 791,P< 0. 05)could be independent predictive factors in the clinical efficacy of TURP in the patients with BPH and OAB. Key words: Benign prostatic hyperplasia; Overactive bladder; International prostate symptom score; Risk factors

ATP as a cotransmitter in the autonomic nervous system.

The role of adenosine 5'-triphosphate (ATP) as a major intracellular energy source is well-established. In addition, ATP and related nucleotides have widespread extracellular actions via the ionotropic P2X (ligand-gated cation channels) and metabotropic P2Y (G protein-coupled) receptors. Numerous experimental techniques, including myography, electrophysiology and biochemical measurement of neurotransmitter release, have been used to show that ATP has several major roles as a neurotransmitter in peripheral nerves. When released from enteric nerves of the gastrointestinal tract it acts as an inhibitory neurotransmitter, mediating descending muscle relaxation during peristalsis. ATP is also an excitatory cotransmitter in autonomic nerves; 1) It is costored with noradrenaline in synaptic vesicles in postganglionic sympathetic nerves innervating smooth muscle preparations, such as the vas deferens and most arteries. When coreleased with noradrenaline, ATP acts at postjunctional P2X1 receptors to evoke depolarisation, Ca(2+) influx, Ca(2+) sensitisation and contraction. 2) ATP is also coreleased with acetylcholine from postganglionic parasympathetic nerves innervating the urinary bladder and again acts at postjunctional P2X1 receptors, and possibly also a P2X1+4 heteromer, to elicit smooth muscle contraction. In both cases the neurotransmitter actions of ATP are terminated by dephosphorylation by extracellular, membrane-bound enzymes and soluble nucleotidases released from postganglionic nerves. There are indications of an increased contribution of ATP to control of blood pressure in hypertension, but further research is needed to clarify this possibility. More promising is the upregulation of P2X receptors in dysfunctional bladder, including interstitial cystitis, idiopathic detrusor instability and overactive bladder syndrome. Consequently, these roles of ATP are of great therapeutic interest and are increasingly being targeted by pharmaceutical companies.

Obturator nerve block transurethral surgery for bladder cancer: comparison of inguinal and intravesical approaches: prospective randomized trial.

Transurethral resection of bladder tumors close to these areas may stimulate the obturator nerve, causing violent adductor contraction and possible inadvertent bladder perforation. To avoid this reaction, local anesthetic blockade of the obturator nerve as it passes through the obturator canal is effective in stopping adductor spasm during spinal anesthesia. Forty-one patients undergoing (transurethral resection of bladder tumor) TUR-BT with spinal anesthesia who required (obturator nerve block) ONB were included in the study. After spinal anesthesia, ONB was performed with an inguinal approach (group 1) (n=21) or an intravesical approach (group 2) (n=20). In this study, we used 10ml of 2% lidocaine to perform the ONB. The mean age of patients was 60.8±7.5years. The groups were not different with regards to age, tumor localization and tumor size. There were two bladder perforations in group 1 and six perforations in group 2 (p=0.130). However, the efficacy of ONB was significantly higher in inguinal approach group compared to intravesical approach group (p=0.032). Obturator nerve block plays an additive role on the quality of analgesia for bladder surgery. Our data suggests that identification of the obturator nerve with ultrasound is easy and the block can be assessed by observing avoidance of bladder spasm.

MP75-10 PATIENT EDUCATION AND THE IMPACT ON URETEROSCOPY EXPERIENCE

You have accessJournal of UrologyStone Disease: Evaluation I1 Apr 2015MP75-10 PATIENT EDUCATION AND THE IMPACT ON URETEROSCOPY EXPERIENCE Nathan Grunewald, Carley Davis, and Jonathan Amos Nathan GrunewaldNathan Grunewald More articles by this author , Carley DavisCarley Davis More articles by this author , and Jonathan AmosJonathan Amos More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2707AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary lithiasis is a common problem where treatment is influenced by patient comorbidities, anatomy, as well as the patient's tolerance for medical expulsive therapy. Endoscopy is a common method to treat upper tract urinary lithiasis. To manage procedural related ureteral edema and prevent urinary obstruction a ureteral stent is often placed post operatively. Ureteral stents are well known to negatively impact patient quality of life and cause significant morbidity. We set out to improve patient understanding of ureteroscopy and the expected post-operative course, including symptom identification, by providing additional patient counseling with an accompanying handout. METHODS A patient handout on ureteroscopy was created focusing on the procedure and expectations. Patients and family were provided advanced patient counseling on ureteroscopy including a thorough review of the handout. We performed a retrospective chart review of all patients from a single surgeon who performed ureteroscopy with laser lithotripsy and ureteral stent placement for renal or ureteral lithiasis. The primary outcome was to identify whether the patient in the 6 weeks after their procedure had a “post-operative qualified morbidity” event. These events included complaints of hematuria, flank pain on urination, general flank pain, post stent removal pain, bladder spasms, nausea and/or vomiting, general stent removal questions, and other. RESULTS 142 patients underwent ureteroscopy with laser lithotripsy treatment and 56 of the 142 patients received advanced counseling with handout. Overall, 46 patients in the pre-handout group had a postoperative qualified morbidity encounter as compared to 18 in the post handout group. This resented a significant difference between the two groups (p=0.01). Qualified encounter complaints in the pre- vs. post-handout group included hematuria (12/6) (first number is the pre-handout group), flank pain with urination (7/3), general flank pain (10/7), post stent removal pain (13/5), bladder spasms (4/4), nausea and/or vomiting (6/5), stent removal questions (8/2), and emergency department visits (12/5). CONCLUSIONS We believe this demonstrates patient education pre-operatively regarding the details of their upcoming procedure and the expected post-operative course significantly decreases patient post-operative concerns and their utilization of resources for normal sequela of ureteroscopy. This can be done without adding significant amount of time to office visits or day of surgery pre-operative conference with patient, family and friends. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e951 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Grunewald More articles by this author Carley Davis More articles by this author Jonathan Amos More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V12-13 URETHROLYSIS FOR SYNTHETIC PERI-URETHRAL BULKING AGENT COLLECTION

You have accessJournal of UrologyReconstruction1 Apr 2015V12-13 URETHROLYSIS FOR SYNTHETIC PERI-URETHRAL BULKING AGENT COLLECTION Tony Nimeh, William Kobak, Whitney Halgrimson, and Ervin Kocjancic Tony NimehTony Nimeh More articles by this author , William KobakWilliam Kobak More articles by this author , Whitney HalgrimsonWhitney Halgrimson More articles by this author , and Ervin KocjancicErvin Kocjancic More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2783AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Although urethral bulking therapy (UBT) is a minimally invasive procedure for stress incontinence, it nevertheless carries risks and potential for complications. We present the case of a 63 year old female with a history of hysterectomy and stress incontinence who failed sling placement and a subsequent peri-urethral Durasphere ® injection and presented with incontinence, bladder spasms and sharp, throbbing pain. An MRI 6 months after her UBT revealed a periurethral submucosal soft tissue mass. transvaginal ultrasonography revealed a 1 cm spherical periurethral collection at the bladder neck. Cystoscopy revealed a spherical bulge in the proximal urethral wall and retroflexion revealed a spherical bulge at the bladder neck. We present a video demonstrating the surgical technique utilized to perform a transvaginal urethrolysis and removal of peri-urethral Durasphere ® collection. METHODS A circumferencial incision was made around the urethral meatus. Sharp and blunt dissection was then carried out to mobilize the urethra from the meatus to the bladder neck. The pubo-urethralis muscle was then divided, and circumferential urethrolysis was carried out proximally. The urethro-pelvic ligament was also incised. Urethrolysis was carried out to the bladder neck with care taken not to injure the urethral wall. The peri-urethral collection was dissected and the collection of Durasphere (R) with exudate was identified. The collection sac was then thoroughly examined using the flexible cystoscope and no communications was found with the urethral lumen. Intra-operative flexible cystoscopy was repeated and revelead a resolution of the previously noted spherical bulge at the bladder neck. The urethra was then plicated bilaterally on the lateral walls using 4.0 vicryl interrupted sutures and the the urethra was wrapped with a strip of Interseed mesh to guide the healing process. 4.0 vicryl sutures were used to stabilize the Interseed mesh and to prevent its migration and the peri-meatal incision was closed. RESULTS There were no complications and the patient was discharged home the following day with an indwelling foley catheter which was removed 10 days following the procedure. Two weeks postoperatively the patient had complete resolution of her pain as well as incontinence. CONCLUSIONS Transvaginal urethrolysis can correct complications associated with paraurethral Durasphere ® injections. When combined with a urethral and bladder neck plication, this technique can also lead to resolution of the original incontinence symptoms. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e980-e981 Peer Review Report Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tony Nimeh More articles by this author William Kobak More articles by this author Whitney Halgrimson More articles by this author Ervin Kocjancic More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD10-06 THE TENSION FREE VAGINAL TAPE VERSUS THE PUBOVAGINAL SLINGS FOR WOMEN WITH NEUROGENIC STRESS URINARY INCONTINENCE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Neurogenic Voiding Dysfunction II1 Apr 2015PD10-06 THE TENSION FREE VAGINAL TAPE VERSUS THE PUBOVAGINAL SLINGS FOR WOMEN WITH NEUROGENIC STRESS URINARY INCONTINENCE Ahmed El-Azab and Sherif El-Nashar Ahmed El-AzabAhmed El-Azab More articles by this author and Sherif El-NasharSherif El-Nashar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.946AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES There are little data in the literature about the use of the minimally invasive midurethral slings (MUS) in women with neurogenic stress incontinence (nSUI) due to spinal pathologies at or below sacral micturition center. We designed this clinical trial to compare the efficacy and safety of TVT and rectus fascia Pubovaginal sling (PVS) in treating SUI in women with LMNL presenting with SUI. METHODS This is a pilot nonrandomized clinical trial including women with SUI associated with pathology at below S2 spinal segment. Women were non randomly assigned into TVT or PVS groups. Failure was defined as leakage of urine during cough test at 250 mL bladder volume. Primary outcome was time to treatment failure based on positive cough stress test. Other outcomes included UDI6 IIQ7 and Urodynamics. Regression models were utilized to adjust for confounders. Time to failure was the endpoint for that outcome and Kaplan Meier curves were used to calculate the cumulative failure rate in each group. RESULTS 40 women were included; 20 TVT and 20 PVS. For primary outcome, 7 out of 40 (17.5%) women had positive cough stress test and were considered treatment failures. 4 (20%) in the TVT group and 3 (15%) in PVS group. The time to treatment failure in TVT group was comparable to the PVS group with an unadjusted hazard ratio of 2.90 (95%CI, 0.61, 15.42, long-rank test P value=0.154). At 2 year, the cumulative objective failure rate was 5.9% in TVT group compared to 0% at the PVS group. At 4 years, cumulative failure rate was 41.8% in TVT group compared to 25.4% in the PVS group. In both groups, there were significant reductions in UDI-6 and the IIQ-7 total scores. IWhile all patients in PVS group had PVR >150 mL after surgery and required CIC, 8 patients (53%) in TVT group had PVR <150 mL and did not require CIC after surgery. Out of the remaining 12 patients in the TVT group, 5 patients were utilizing CIC before surgery. The remaining 7 had De novo increased PVR (PVR>150) and required CIC after surgery. The prevalence of De novo urge urinary incontinence was significantly higher after TVT (30% n=6 women) than after PVS (10%, n=2). Urodynamics 1 year after operation in those patients with De novo urge symptoms reveal low compliance in 2 patients and unstable bladder contractions in 6 patients (4 in TVT and 2 in PVS group). CONCLUSIONS Both PVS and TVT can be used effectively and safely to treat women with nSUI associated with spinal pathology. While postoperative CIC is needed in all patients after PVS, de novo postoperative CIC after TVT can be avoided in 50% of patients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e202 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed El-Azab More articles by this author Sherif El-Nashar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Diabetic cystopathy: A review.

Herein we review and discuss epidemiological, clinical, and experimental studies on diabetic cystopathy, a common chronic complication of diabetes mellitus with a variety of lower urinary tract symptoms, providing directions for future research. A search of published epidemiological, clinical, or preclinical trial literature was performed using the key words "diabetes", "diabetic cystopathy", "diabetic bladder dysfunction", "diabetic lower urinary tract dysfunction", "diabetic detrusor instability". The classic symptoms of diabetic cystopathy are decreased bladder sensation, increased bladder capacity, and impaired bladder emptying with resultant increased post-void residual volume. However, recent clinical evidence indicates a presence of storage symptoms, such as overactive bladder symptoms. The pathophysiology of diabetic cystopathy is multifactorial, including disturbances of the detrusor, neuron, urothelium, and urethra. Hyperglycemia, oxidative stress, and polyuria play important roles in inducing voiding dysfunction in diabetic individuals. Treatment choice depends on clinical symptoms and urodynamic abnormalities. Urodynamic evaluation is the cornerstone of diagnosis and determines management strategies. Diabetes mellitus could cause a variety of lower urinary tract symptoms, leading to diabetic cystopathy with broadly varied estimates of the prevalence rates. The exact prevalence and pathogenesis of diabetic cystopathy remains to be further investigated and studied in multicenter, large-scaled, or randomized basic and clinical trials, and a validated and standardized workup needs to be made, improving diabetic cystopathy management in clinical practice. Further studies involving only female diabetics are recommended.

Laparoscopic extravesical detrusorraphy, a minimally invasive treatment option for vesicoureteral reflux: A single centre experience

Laparoscopy in pediatric patients offers more benefits than was earlier presumed and these widely reported benefits significantly outweigh any concerns regarding the technical difficulties. Laparoscopic correction of vesicoureteral reflux aims to duplicate the excellent results of open surgery while at the same time reducing perioperative morbidity and analgesic requirements, improving cosmesis and shortening hospital stay. To share our experience of laparoscopic extravesical detrusorraphy, highlight our technical modification of intraoperative minimal "atraumatic" ureteric handling of the ureter, which we hypothesize may decrease ureteral complications, and report our results. This was a retrospective chart review of 76 toilet-trained children (98 refluxing units), in the age group of 3-16 years, with Grade I-IV reflux, who underwent laparoscopic detrusorraphy from June 2006 to January 2014. A ureteric catheter is inserted into the refluxing ureter and is tied to the Foleys to drain into a common bag. A three port technique is used. During ureteral dissection, a vascular sling in the form of a Rumel loop is used for atraumatic handling of the ureter. A detrusor tunnel is created with hook electrocautery. A stay suture is later passed through the abdominal wall and slings around the dissected ureter, which helps in holding the ureter approximated against the mucosal trough during detrusorraphy. Detrusor fibers are approximated with 5-0 Vicryl. No drain is placed and the Foley and ureteric catheter(s) are removed after 24 h. Intravenous ketorolac is given every 6 h for the first 24 h. Oral paracetamol is used for analgesia after the first 24 h. Adequate bladder emptying is ensured by assessment of post void residual urine before discharge. Renal USG alone is performed 2 weeks post operatively and repeated after 3 months along with a VCUG (voiding cystourethrography). Success was defined as absence of reflux in the follow-up VCUG done at 3 months. Mean operative time was 102 ± 26.5 min for unilateral detrusorraphy and 165 ± 18 min for bilateral extravesical detrusorraphy. The mean duration of hospital stay was 1.5 ± 1.7 days. There was one case of urinary retention that was managed with temporary recatheterization. There were no cases of ureteral ischemia, obstruction, hematuria or bladder spasms. Surgery was successful in 97.9% of the refluxing units (96/98). In two patients with grade IV reflux, there was downgrading to grade II on VCUG done at 3 months' follow-up. The reflux resolved at 8 and 14 months' follow-up, respectively. Our technique of atraumatic handling of the ureter, initially with the help of a vascular sling and later with the help of a stay suture passed percutaneously through the abdominal wall, resulted in no ureteric injuries. The postoperative morbidity of this procedure is low because the bladder is not opened, the ureter is not transected, no new UVJ is created and there is no need for placement of a drain. The risk of postoperative bowel adhesions is low as the ureter is dissected out through a narrow peritoneal window, which is again extraperitonealized at the end of the procedure (see figure). The postoperative complications of gross hematuria and bladder spasms, which may be especially encountered in patients undergoing laparoscopic Cohen's, were not seen in our case series. Laparoscopic extravesical detrusorraphy provides a minimally invasive treatment option for treatment of unilateral/bilateral grade I-IV vesicoureteral reflux. The postoperative morbidity is low and the success rate is favorable. Our technical modification of a "vascular sling" around the ureter facilitates atraumatic ureteric handling, which may reduce distal ureteral complications like ureteral ischemia and obstruction.

Management of chronic spinal cord dysfunction.

Both acute and chronic spinal cord disorders present multisystem management problems to the clinician. This article highlights key issues associated with chronic spinal cord dysfunction. Advances in symptomatic management for chronic spinal cord dysfunction include use of botulinum toxin to manage detrusor hyperreflexia, pregabalin for management of neuropathic pain, and intensive locomotor training for improved walking ability in incomplete spinal cord injuries. The care of spinal cord dysfunction has advanced significantly over the past 2 decades. Management and treatment of neurologic and non-neurologic complications of chronic myelopathies ensure that each patient will be able to maximize their functional independence and quality of life.