Detrusor-sphincter Dyssynergia Research Articles

Facteurs pronostiques cliniques et urodynamiques de complications urinaires chez le blessé médullaire

AimLiterature review on the prognostic clinical and urodynamic factors of urinary complications in spinal cord injury (SCI) patients. MethodArticles dealing with SCI urinary complications and their prognostic clinical and urodynamic factors have been searched in the Pubmed database until march 2024, articles in english or in french were included and analysed. ResultsThirty-eight articles published between 1965 and 2024 were included in this review, the incidence of urinary complications has decreased considerably since the 60s. Clinical prognostic factors are a cervical or complete SCI, age, voiding mode, the indwelling catheter most at risk. Urodynamics factors are compliance disorder (<20), high detrusor pressure (>40 cm of water), detrusor sphincter dyssynergia and a postvoid residual volume. ConclusionUrinary complications in SCI patients are frequents, it is necessary to know the prognostic factors in order to have an early detection and management to limit them.

Duration of detrusor overactivity as an independent predictive factor of upper urinary tract deterioration in patients with traumatic spinal cord injury: results of a retrospective cohort study.

To determine whether duration of detrusor overactivity (DO) during a cystometric study is an independent predictive factor of upper urinary tract deterioration (UUTD) in patients with traumatic spinal cord injury (TSCI). Retrospective cohort study. A rehabilitation facility in Chiang Mai, Thailand. Data were obtained from medical records of patients who underwent cystometric evaluation at 6-12 months after TSCI. The independent predictor of interest is the duration of DO, which was evaluated by the DO/cystometry ratio (DOratio). Other conventional urodynamic parameters (maximum detrusor pressure, cystometric capacity, bladder compliance, and detrusor-sphincter dyssynergia) and clinical parameters (age, sex, level and severity of injury, comorbidities, bladder emptying method, and history of urinary tract infection) were determined. The outcome was UUTD, which is indicated by chronic kidney disease (GFR < 60 ml/min/1.73 m2), hydronephrosis, and/or vesicoureteral reflux. Multivariable Cox regression analysis was used to determine the independent associations between DOratio and UUTD by adjusting with all other parameters. Medical records of 194 patients with TSCI were included in the study. During a combined total of 1260 follow-up years of those patients, 34 UUTD events were identified, indicating an incidence rate of 27.0 cases per 1000 person-years. After adjusting for all other parameters, a high DOratio (≥0.33) was significantly associated with UUTD (hazard ratio = 3.00 [95% CI: 1.12-7.99], p = 0.025). DOratio may be an independent cystometric predictor of UUTD in patients with TSCI. However, further prospective study is needed prior to applying DOratio as a predictor of UUTD in clinical settings. There was no clinical trial registration since this study is not a clinical trial.

Chronic chemogenetic inhibition of TRPV1 bladder afferent promotes micturition recovery post SCI

Spinal cord injury often results in chronic loss of micturition control, which is featured by bladder hyperreflexia and detrusor sphincter dyssynergia. Previous studies showed that treatment of capsaicin reduces non-voiding bladder contractions in multiple animal injury models and human patients. However, its underlying neural mechanisms remain largely unknown. Here, by injecting a RetroAAV into the bladder wall, we specifically targeted TRPV1+, a capsaicin receptor, bladder afferent neurons. Morphometric analysis revealed borderline increase of the soma size and significant spinal axon sprouting of TRPV1+ bladder afferent neurons post a complete T8 spinal cord crush. We further demonstrated that chronic chemogenetic inhibition of these DRG neurons improved micturition recovery after SCI by increasing voiding efficiency and alleviating bladder hyperreflexia, along with reduced morphological changes caused by injury. Our study provided novel insights into the structural and functional changes of TRPV1+ bladder afferent post SCI and further supports the clinical use of capsaicin as an effective treatment to improve bladder functions in patients with SCI.

Developing new ways to assess neural control of pelvic organ function in spinal conditions: ICI-RS 2023.

Several central nervous system (CNS) centers affect muscle groups of the lower urinary tract (LUT) and anorectal tract (ART) via autonomic and somatic pathways, working in different modes (storage or expulsion). Hence spinal cord dysfunction can affect the LUT and ART by several possible mechanisms. This review reports the discussions of a workshop at the 2023 meeting of the International Consultation on Incontinence Research Society, which reviewed uncertainties and research priorities of spinal dysfunction. Discussion focussed on the levator ani nerve, mechanisms underpinning sensory function and sensation, functional imaging, dyssynergia, and experimental models. The following key research questions were identified. (1) Clinically, how can we evaluate the levator ani muscle to support assessment and identify prognosis for effective treatment selection? (2) How can we reliably measure levator ani tone? (3) How can we evaluate sensory information and sensation for the LUT and the ART? (4) What is the role of functional CNS imaging in development of scientific insights and clinical evaluation? (5) What is the relationship of detrusor sphincter dyssynergia to renal failure? Spinal cord dysfunction can fundamentally disrupt LUT and ART function, with considerable clinical impact. The evaluation needs to reflect the full scope of potential problems, and new clinical and diagnostic approaches are needed, for prognosis and treatment. The preclinical science evaluating spinal cord function in both LUT and ART storage and elimination remains a major priority, even though it is a challenging experimental context. Without this underpinning evidence, development of new clinical evidence may be held back.

The Efficacy and Safety of Intrasphincteric Botulinum Toxin-A Injections in Patients with Non-Spinal Cord Injury-Related Detrusor Sphincter Dyssynergia: A Retrospective Study.

Botulinum toxin-A (BoNT-A) injections into the external urethral sphincter are an established therapeutic procedure for reducing bladder outlet obstruction in patients with detrusor sphincter dyssynergia (DSD) due to spinal cord injury (SCI). Given the paucity of data on patients with DSD but without SCI, we aimed to assess the efficacy of intrasphincteric BoNT-A injections in this cohort. For this retrospective study, we screened all patients who underwent their first intrasphincteric BoNT-A injection at our institution between 2015 and 2021. The inclusion criteria were patients aged 18 years or older with neurogenic detrusor overactivity (NDO) and DSD with a maximum detrusor pressure (Pdetmax) of >40 cmH2O, confirmed via video-urodynamic studies (VUDS). The primary outcome was a reduction in Pdetmax and detrusor overactivity leak point pressure (DOLPP) during NDO-associated urinary incontinence posttreatment. The secondary outcome was a reduction in patients relying on indwelling urinary catheters posttreatment. We included 13 eligible patients (all male, median age 31 years, with different underlying neurological disorders, except SCI). All underwent intrasphincteric BoNT-A injections with either 100 (n = 7) or 150 (n = 6) units, respectively. Pdetmax during voiding was significantly reduced posttreatment (median 105 vs. 54 cmH2O, p = 0.006), whereas DOLPP remained unchanged (i.e., median 50 cmH2O). While seven patients relied on indwelling urinary catheters pre-treatment, all were catheter-free posttreatment. Intrasphincteric BoNT-A injections in patients with non-SCI related DSD appear feasible for reducing bladder outlet obstruction to a certain degree in this cohort and subsequently for reducing the rate of indwelling catheters.

Prevalence of Unfavorable Video-Urodynamic Findings and Clinical Implications in Patients with Minimally Conscious State/Unresponsive Wakefulness Syndrome: A Retrospective Descriptive Analysis.

The aim of this retrospective exploratory study was to investigate the prevalence of unfavorable findings during video-urodynamic studies (VUDS) in patients with minimally conscious state (MCS)/unresponsive wakefulness syndrome (UWS) and whether management of the lower urinary tract (LUT) was adjusted accordingly. A retrospective chart review was conducted to screen for patients diagnosed with MCS/UWS at our rehabilitation center between 2011 and 2020. Patients 18 years or older were included and underwent baseline VUDS after being diagnosed with MCS/UWS. We analyzed urodynamic parameters and subsequent changes in LUT management in this cohort. In total, 32 patients (7 females, 25 males, median age 37 years) with MCS/UWS were included for analysis. While at least one unfavorable VUDS finding (i.e., neurogenic detrusor overactivity [NDO], detrusor sphincter dyssynergia {DSD, high maximum detrusor pressure during storage phase [>40 cmH2O], low-compliance bladder [<20 mL/cmH2O], and vesico-uretero-renal reflux [VUR]) was found in each patient, NDO (78.1%, 25/32) and DSD (68.8%, 22/32) were the two most frequent unfavorable VUDS findings. Following baseline VUDS, new LUT treatment options were established in 56.3% (18/32) of all patients. In addition, bladder-emptying methods were changed in 46.9% (15/32) of all patients, resulting in fewer patients relying on indwelling catheters. Our retrospective exploratory study revealed a high prevalence of NDO and DSD in patients with MCS/UWS, illustrating the importance of VUDS to adapt LUT management in this cohort accordingly.

Urologic manifestations of hypotonia, ataxia, and delayed development syndrome (HADDS), a rare neurodevelopmental disorder

Early B-cell factor 3 (EBF3) is a transcription factor involved in neuronal differentiation and maturation. Pathogenic variants are associated with hypotonia, ataxia, and delayed development syndrome (HADDS) (MIM#617330). Urologic manifestations are common and may have implications regarding long term renal function. To review all known patients with pathogenic variants of the EBF3 gene resulting in HADDS with urologic manifestations. We hypothesize a high rate of bladder dysfunction secondary to the EBF3 variant's impact on relaxation of the urinary sphincter leading to detrusor sphincter dyssynergia (DSD). The PubMed database was queried for publications of the EBF3 mutation between January 2017 and January 2023. Search terms were "EBF3 mutation OR HADDS AND urology OR phenotype". Retrospective analysis of HADDS patients cared for in our institution was performed. Demographic and clinical information was collected. We identified 52 patients (33F:19M) through literature (28F:18M) and retrospective review (5F:1M). There was a high prevalence of genitourinary physical exam abnormalities, history of urinary tract infection, vesicoureteral reflux (VUR), and diagnosis of neurogenic bladder. Within the literature review cohort, 67% had a urologic diagnosis. Females were disproportionately affected with urologic manifestations. In our cohort, four of six children were diagnosed with VUR and severe voiding dysfunction consistent with neurogenic bladder (67%). These children were managed with a vesicostomy. Five children had bowel dysfunction requiring therapy. Urodynamics suggested a high prevalence of external sphincter dyssynergia. Less severe forms of DSD were felt to be implicated in the abnormal voiding parameters in children who presented later in life based on non-invasive flow studies. There is significant variability in the phenotypic presentation of patients with HADDS. While EBF3 plays a clear role in neurodevelopment, it also impacts muscle development and may impact muscle relaxation. The location of the genetic variant may impact the degree of DSD, with more severe forms leading to earlier presentations. Initial work-up should include a renal ultrasound (RUS) and post void residual (PVR). Consideration can be given to obtaining a VCUG, DMSA scan or urodynamic studies. Yearly screening should be pursued with an RUS and PVR in those with an initial unremarkable work-up given the variable timing and severity of presentation. Urologic manifestations of HADDS include high rates of bladder dysfunction secondary to DSD, vesicoureteral reflux, urinary tract infection, and cryptorchidism. These patients are at risk of renal deterioration if urinary abnormalities are not properly diagnosed and managed.

Urodynamics Are Essential to Predict the Risk for Upper Urinary Tract Damage after Acute Spinal Cord Injury.

We used clinical parameters to develop a prediction model for the occurrence of urodynamic risk factors for upper urinary tract (UUT) damage during the first year after acute spinal cord injury (SCI). A total of 97 patients underwent urodynamic investigation at 1, 3, 6, and 12 months after acute SCI, within the framework of a population-based longitudinal study at a single university SCI center. Candidate predictors included demographic characteristics and neurological and functional statuses 1 month after SCI. Outcomes included urodynamic risk factors for UUT damage: detrusor overactivity combined with detrusor sphincter dyssynergia, maximum storage detrusor pressure (pDetmax) ≥ 40 cmH2O, bladder compliance < 20 mL/cmH2O, and vesicoureteral reflux. Multivariable logistic regression was used for the prediction model development and internal validation, using the area under the receiver operating curve (aROC) to assess model discrimination. Two models showed fair discrimination for pDetmax ≥ 40 cmH2O: (i) upper extremity motor score and sex, aROC 0.79 (95% CI: 0.69-0.89), C-statistic 0.78 (95% CI: 0.69-0.87), and (ii) neurological level, American Spinal Injury Association Impairment Scale grade, and sex, aROC 0.78 (95% CI: 0.68-0.89), C-statistic 0.76 (95% CI: 0.68-0.85). We identified two models that provided fair predictive values for urodynamic risk factors of UUT damage during the first year after SCI. Pending external validation, these models may be useful for clinical trial planning, although less so for individual-level patient management. Therefore, urodynamics remains essential for reliably identifying patients at risk of UUT damage.

Understanding factors influencing primary treatment with intradetrusor onabotulinumtoxinA versus augmentation cystoplasty in patients with spina bifida.

Surgical interventions in the urologic management of children with neurogenic bladder secondary to spina bifida aim to preserve upper tract function, prevent urinary tract infections, and optimize quality of life. However, since the introduction of intravesical onabotulinumtoxinA (Botox) in the management of these patients, the indications for choosing Botox over augmentation cystoplasty (AC) remain undefined. The objective of this study was to determine which factors lead patients to undergo Botox versus AC as a primary surgical treatment after failing medical management. We retrospectively reviewed the records of pediatric patients with myelomeningocele undergoing either primary Botox or primary AC at our institution between 2013 and 2018. We recorded demographic and clinical information. We identified 10 important clinical decision-making factors: bladder trabeculation, vesicoureteral reflux, or hydronephrosis on imaging; end-filling pressure (EFP) ≥40 cm H2O, detrusor overactivity, detrusor-sphincter dyssynergia, or reduced capacity on urodynamic studies; physician-perceived bladder hostility; and patient/family desire for continence and independence. The presence of these factors was compared between patients undergoing either primary Botox or primary AC. We identified 14 and 50 myelomeningocele patients who underwent primary AC and primary Botox, respectively. We found no significant differences in age, sex, race, or history of reconstructive surgery (antegrade continence enema or catheterizable channel). For the 10 decision-making factors, desire for independence/continence (p = <0.001) and reduced capacity (p = 0.002) were significantly associated with AC, while trabeculation (p = 0.006), EFP ≥40 cm H2O (p = 0.029), rising slope (p = 0.019), and physician-perceived hostility (p = 0.012) were significantly more common with Botox. At our institution, quality of life measures prompted AC over objective urodynamic or imaging findings before attempting Botox. These findings support a shared decision-making approach when considering surgical intervention for neurogenic bladder secondary to myelomeningocele.

Assessing Neurogenic Lower Urinary Tract Dysfunction after Spinal Cord Injury: Animal Models in Preclinical Neuro-Urology Research.

Neurogenic bladder dysfunction is a condition that affects both bladder storage and voiding function and remains one of the leading causes of morbidity after spinal cord injury (SCI). The vast majority of individuals with severe SCI develop neurogenic lower urinary tract dysfunction (NLUTD), with symptoms ranging from neurogenic detrusor overactivity, detrusor sphincter dyssynergia, or sphincter underactivity depending on the location and extent of the spinal lesion. Animal models are critical to our fundamental understanding of lower urinary tract function and its dysfunction after SCI, in addition to providing a platform for the assessment of potential therapies. Given the need to develop and evaluate novel assessment tools, as well as therapeutic approaches in animal models of SCI prior to human translation, urodynamics assessment techniques have been implemented to measure NLUTD function in a variety of animals, including rats, mice, cats, dogs and pigs. In this narrative review, we summarize the literature on the use of animal models for cystometry testing in the assessment of SCI-related NLUTD. We also discuss the advantages and disadvantages of various animal models, and opportunities for future research.

Protocolo de tratamiento de la disfunción del tracto urinario inferior en la esclerosis múltiple y trastornos relacionados

Lower urinary tract dysfunction (LUTD) affects between a third and the majority of patients with multiple sclerosis, its prevalence increasing with the duration of the disease and causing a great impact on quality of life. LUTD is classified into filling symptoms, voiding symptoms, or mixed symptoms. The scenario of simultaneous contraction of the detrusor and bladder sphincter is called bladder detrusor sphincter dyssynergia and requires periodic ultrasound and renal function monitoring, due to the risk of kidney impairment caused by a retrograde increase in pressure. Filling symptoms are treated with hygienic-dietary measures, antimuscarinics, mirabegron, desmopressin, botulinum toxin or neuromodulation. Symptoms of voiding (postvoid residue greater than 100mL) are treated with intermittent self-catheterization or, less commonly, indwelling bladder or suprapubic catheterization.

A Case of Hutch Diverticulum Leading To Non-Functioning Kidney Due To Vesico-Ureteric Reflux

Bladder diverticulum is caused by herniation of the urothelium through the muscular layer of the bladder wall, being formed by mucosa, lamina propria, few muscular fibres and adventitia. Bladder diverticula are classified as congenital or acquired. Congenital ones usually appear in young ages with a maximum incidence before 10 years and are usually unique, almost exclusively in males, located posteromedially to the ureteral ostium and resulting from the weakness of the bladder wall in this portion. Acquired ones generally are due to high intra-vesical pressure caused by infra-vesical obstruction or detrusor-sphincter dyssynergia. More rarely are due to wall debility after bladder surgery. Often develop in males after sixth decade, in about 12% of patients with infra-vesical obstruction. Usually multiple and associated with important trabeculation of the bladder wall. If the ureteral ostium is included in the bladder diverticulum, it is called Hutch diverticulum, which is a rare entity, typically in young ages, with few cases identified in the adult. We hereby present a case of a patient with acquired hutch diverticulum leading to non-functioning kidney due to vesico-ureteric reflux.

Determination of tibial somatosensory evoked potentials predicts detrusor sphincter dyssynergia in children with neurogenic bladder dysfunction.

Tibial somatosensory evoked potentials (SEP) are used to identify the neurological status and tethered cord (TC) in patients with spina bifida (SB). Its significance in contributing to the interpretation of urodynamics to determine bladder status is unknown. This study aimed to determine the correlation between SEP and urodynamics in children with SB. SEP and urodynamic results, for differential diagnosis of TC, were evaluated. SEP scores were correlated with urodynamic findings. SEP results were scored from 1 to 6, with 1, denoting a favorable score and 6, an unfavorable score. Age, gender, detrusor, and sphincter activities in urodynamics were noted. Results were analyzed using the χ2 test and logistic regression analysis. Receiver operating characteristic (ROC) curve was formed to get a valid threshold for the SEP score to predict the urodynamic condition. There were 44 SB patients for whom SEP was done for differential diagnosis of TC. Fifteen patients who did not meet the inclusion criteria were excluded from the study. SB aperta was present in 17 patients and occulta in 12, respectively. The patients had a mean age of 6.6 ± 3.2 years. There were 13 boys and 16 girls. A strong correlation was found between high SEP scores and detrusor sphincter dyssynergia (p < 0.001). A SEP score over 3.5 was found to be 93% sensitive and 73% specific to predict this correlation. There was no relationship between detrusor activity and SEP scores (p = 0.18). Tibial SEP is an important noninvasive adjunct tool for the diagnosis of TC in patients with SB. Urodynamic studies are the gold standard in the evaluation of bladder status in neurogenic bladder dysfunction due to SB. Detrusor sphincter dyssynergia may be regarded as a sign of severe spinal cord injury in these patients. Our findings suggest that in children with neurogenic bladder, high SEP scores may predict the presence of detrusor sphincter dyssynergia but not the status of detrusor function while providing pathophysiological evidence for neural injury.

Molecular Mechanisms of Neurogenic Lower Urinary Tract Dysfunction after Spinal Cord Injury.

This article provides a synopsis of current progress made in fundamental studies of lower urinary tract dysfunction (LUTD) after spinal cord injury (SCI) above the sacral level. Animal models of SCI allowed us to examine the effects of SCI on the micturition control and the underlying neurophysiological processes of SCI-induced LUTD. Urine storage and elimination are the two primary functions of the LUT, which are governed by complicated regulatory mechanisms in the central and peripheral nervous systems. These neural systems control the action of two functional units in the LUT: the urinary bladder and an outlet consisting of the bladder neck, urethral sphincters, and pelvic-floor striated muscles. During the storage phase, the outlet is closed, and the bladder is inactive to maintain a low intravenous pressure and continence. In contrast, during the voiding phase, the outlet relaxes, and the bladder contracts to facilitate adequate urine flow and bladder emptying. SCI disrupts the normal reflex circuits that regulate co-ordinated bladder and urethral sphincter function, leading to involuntary and inefficient voiding. Following SCI, a spinal micturition reflex pathway develops to induce an overactive bladder condition following the initial areflexic phase. In addition, without proper bladder-urethral-sphincter coordination after SCI, the bladder is not emptied as effectively as in the normal condition. Previous studies using animal models of SCI have shown that hyperexcitability of C-fiber bladder afferent pathways is a fundamental pathophysiological mechanism, inducing neurogenic LUTD, especially detrusor overactivity during the storage phase. SCI also induces neurogenic LUTD during the voiding phase, known as detrusor sphincter dyssynergia, likely due to hyperexcitability of Aδ-fiber bladder afferent pathways rather than C-fiber afferents. The molecular mechanisms underlying SCI-induced LUTD are multifactorial; previous studies have identified significant changes in the expression of various molecules in the peripheral organs and afferent nerves projecting to the spinal cord, including growth factors, ion channels, receptors and neurotransmitters. These findings in animal models of SCI and neurogenic LUTD should increase our understanding of pathophysiological mechanisms of LUTD after SCI for the future development of novel therapies for SCI patients with LUTD.

The Utility of Urodynamic Studies in Neuro-Urological Patients

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review. For this narrative review, a PubMed® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used. Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities. Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

MP60-08 COMPARISON OF LOWER URINARY TRACT DYSFUNCTION AFTER SPINAL CORD INJURY (SCI) BETWEEN FEMALE AND MALE MICE

You have accessJournal of UrologyCME1 Apr 2023MP60-08 COMPARISON OF LOWER URINARY TRACT DYSFUNCTION AFTER SPINAL CORD INJURY (SCI) BETWEEN FEMALE AND MALE MICE Mamoru Hashimoto, Kang Jun Cho, Stephanie L Daugherty, PA Pittsburgh, Nobutaka Shimizu, Pradeep Tyagi, Akihide Hirayama, Hirotsugu Uemura, Jonathan M Beckel, Sergei Karnup, and Naoki Yoshimura Mamoru HashimotoMamoru Hashimoto More articles by this author , Kang Jun ChoKang Jun Cho More articles by this author , Stephanie L DaughertyStephanie L Daugherty More articles by this author , PA PittsburghPA Pittsburgh More articles by this author , Nobutaka ShimizuNobutaka Shimizu More articles by this author , Pradeep TyagiPradeep Tyagi More articles by this author , Akihide HirayamaAkihide Hirayama More articles by this author , Hirotsugu UemuraHirotsugu Uemura More articles by this author , Jonathan M BeckelJonathan M Beckel More articles by this author , Sergei KarnupSergei Karnup More articles by this author , and Naoki YoshimuraNaoki Yoshimura More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003318.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In humans, voiding occurs during synergic relaxation of the external urethral sphincter (EUS), and SCI induces detrusor-sphincter dyssynergia (DSD) shown by tonic EUS contraction during voiding. However, EUS bursting activity is known to be an important mechanism for efficient voiding in spinal intact (SI) and SCI rats while such data are less available in mice. Thus, we evaluated gender-specific EUS function during voiding in male and female mice with or without SCI. METHODS: C57BL/6N mice at 9-10-weeks old were used. SCI mice underwent complete transection of the Th8-9 spinal cord. Six weeks after SCI, cystometrograms (CMGs) and EUS- electromyography (EMG) were performed under an awake condition. Thereafter, L6-S1 dorsal root ganglia (DRG) were harvested to evaluate the transcripts of TRPV1 and Piezo2 using qPCR. RESULTS: In female SI mice, voiding occurred during an EUS relaxation period. Female SCI mice voided urine during notch like reductions in bladder pressure, which corresponded to EMG signal reduction periods during tonic EMG activity (DSD). On the other hand, male SI and SCI mice voided during EUS bursting activity characterized by alternating active and silent phases of EMG activity, with the longer active phase and low voiding efficiency in SCI vs. SI mice (Table and Figure). The mRNA levels of TRPV1 and Piezo2 in L6-S1 DRG were significantly higher in SCI male mice (n=4) and female mice (n=4) vs. SI mice (n=4). CONCLUSIONS: Lower urinary tract function during the voiding phase was different between male and female mice. Female SI mice, in which voiding occurs during EUS relaxation, and female SCI mice, which exhibit DSD with periodic EUS relaxations, seem to be more suitable for the study of SCI-induced EUS dysfunction in humans, compared to SI and SCI male mice that exhibit EUS bursting activity during voiding. Source of Funding: NIH R01DK129194 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e846 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mamoru Hashimoto More articles by this author Kang Jun Cho More articles by this author Stephanie L Daugherty More articles by this author PA Pittsburgh More articles by this author Nobutaka Shimizu More articles by this author Pradeep Tyagi More articles by this author Akihide Hirayama More articles by this author Hirotsugu Uemura More articles by this author Jonathan M Beckel More articles by this author Sergei Karnup More articles by this author Naoki Yoshimura More articles by this author Expand All Advertisement PDF downloadLoading ...

PD06-12 INTER- AND INTRA-RATER VARIABILITY OF VIDEOURODYNAMIC STUDY INTERPRETATION AMONG UROLOGIC SURGEONS FOR PATIENTS WITH SPINA BIFIDA

You have accessJournal of UrologyCME1 Apr 2023PD06-12 INTER- AND INTRA-RATER VARIABILITY OF VIDEOURODYNAMIC STUDY INTERPRETATION AMONG UROLOGIC SURGEONS FOR PATIENTS WITH SPINA BIFIDA Maria Antony, John K. Weaver, Madalyne Martin-Olenski, Joseph Logan, Reiley Broms, David Ostrowski, Jason Van Batavia, Dana A. Weiss, Christopher J. Long, Ariana L. Smith, Jing Huang, Stephen A. Zderic, Yong Fan, and Gregory E. Tasian Maria AntonyMaria Antony More articles by this author , John K. WeaverJohn K. Weaver More articles by this author , Madalyne Martin-OlenskiMadalyne Martin-Olenski More articles by this author , Joseph LoganJoseph Logan More articles by this author , Reiley BromsReiley Broms More articles by this author , David OstrowskiDavid Ostrowski More articles by this author , Jason Van BataviaJason Van Batavia More articles by this author , Dana A. WeissDana A. Weiss More articles by this author , Christopher J. LongChristopher J. Long More articles by this author , Ariana L. SmithAriana L. Smith More articles by this author , Jing HuangJing Huang More articles by this author , Stephen A. ZdericStephen A. Zderic More articles by this author , Yong FanYong Fan More articles by this author , and Gregory E. TasianGregory E. Tasian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Videourodynamics (VUDS) provides functional insight into bladder storage and micturition, particularly in children with neurogenic bladder who are at risk of upper tract injury. These studies can serve as drivers for both medical and surgical decision-making, as well as intervention escalation. However, VUDS interpretation is at threat of both intra- and inter-observer variability. Efforts exist to improve standardization, but it is unclear the extent to which surgeons’ interpretations vary. In this study, we evaluated variability in interpretation of upper tract deterioration secondary to bladder dysfunction in a sample of children with spina bifida. METHODS: A total of 303 VUDS studies were evaluated from 256 unique patients between 2 months to 28 years of age. An initial pilot study of 10 VUDS studies were assessed by 5 fellowship trained urologists to align on risk stratification criteria of 3 graded categories (mild, moderate, or severe). Criteria considered to assess upper tract deterioration included bladder compliance, elevated detrusor leak point pressure, and detrusor sphincter dyssynergia from pressure volume tracings and fluoroscopy images. Subsequently, 303 VUDS studies were randomized to 5 reviewers such that each study received a minimum of 3 reviews. Intraclass correlation coefficients were used to reliability of average and single raters. Reviewers also reassessed a portion (range: 5-16%) of same studies within 6 months of their first review. Percent agreement was determined for each surgeon between initial and repeat reviews, as well as initial review and group consensus. RESULTS: Among the 303 VUDS studies, single and average raters’ intraclass correlation (ICC) was 0.67(95% CI: 0.62-0.71) and 0.91(95% CI: 0.89-0.92), respectively. At least one reviewer showed disagreement with other reviewers in 37.3% (113/303) of cases. There was a sole case (0.3%, 1/303) in which 3 different risk scores were assigned to the same patient. Among the sample of studies that were reassessed for intrarater reliability, median agreement of a single urologist with their previous risk score was 76.25% (IQR: 68.75-78.525). Median agreement of a single urologist with group consensus was 80.4% (IQR: 75-81.6). CONCLUSIONS: Class reliability trended upwards with raters average compared to a single rater, showing moderate and good reliability respectively. Single rater inter- and intra-rater variation may compound across serial urodynamic evaluation in clinical and research uses of VUDS to evaluate upper tract deterioration. Source of Funding: NA © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e160 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Maria Antony More articles by this author John K. Weaver More articles by this author Madalyne Martin-Olenski More articles by this author Joseph Logan More articles by this author Reiley Broms More articles by this author David Ostrowski More articles by this author Jason Van Batavia More articles by this author Dana A. Weiss More articles by this author Christopher J. Long More articles by this author Ariana L. Smith More articles by this author Jing Huang More articles by this author Stephen A. Zderic More articles by this author Yong Fan More articles by this author Gregory E. Tasian More articles by this author Expand All Advertisement PDF downloadLoading ...

HF02-10 AT THE EPICENTER OF INNOVATION IN THE 1970S: DR. JACK LAPIDES' RIGHT-HAND MAN, DR. ANANIAS DIOKNO

You have accessJournal of UrologyCME1 Apr 2023HF02-10 AT THE EPICENTER OF INNOVATION IN THE 1970S: DR. JACK LAPIDES' RIGHT-HAND MAN, DR. ANANIAS DIOKNO Justin Refugia and Gopal Badlani Justin RefugiaJustin Refugia More articles by this author and Gopal BadlaniGopal Badlani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003242.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Dr. Jack Lapides’ research in urology is widely recognized. His mentee, Dr. Ananias Diokno, was paramount to this work. We present Dr. Diokno’s contributions to highlight his role in pioneering treatments in neuro-urology and review a portion of his innumerable accomplishments. METHODS: We reviewed literature published by Drs. Lapides and Diokno to define their collaborative efforts. Web searches were performed with Google Scholar and PubMed and internal searches of our institution’s libraries. RESULTS: Dr. Lapides’ fruitful career largely occurred at the University of Michigan (UM). During his residency under the direction of Dr. Nesbit, his academic prowess was honed. In the 1960s, he became known for sentinel works on bladder physiology and voiding dysfunction. An important young person looking up to him was Dr. Diokno, a recent graduate of the University of Santo Tomas in the Philippines. In the late 1960s, Dr. Lapides went on to mentor him, later recruiting him to the UM urology residency and then Babcock Fellowship. One influential contribution that Dr. Diokno assisted with was the controversial study of non-sterile, clean intermittent catheterization (CIC) that challenged Dr. Guttman’s sterile approach. The team successfully taught CIC to patients with voiding dysfunction to prevent increased intravesical pressures. This lead to better control of their urinary difficulties and minimized UTIs, with no additional risks. Co-residents Drs. Diokno and Silber were astonished by the results. Initially, their enthusiasm was not met with a warm reception, yet the team persisted and saw their work revolutionize medicine worldwide. With his academic vigor, Dr. Diokno continued to move the needle during fellowship by discovering new categories of detrusor sphincter dyssynergia (DSD) and went on to establish use of CIC in clinical practice. CONCLUSIONS: Beyond the 1970s, Dr. Diokno maintained a remarkable career. He pioneered the initial efforts of geriatric incontinence by leading the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) efforts on community dwelling elderly as a separate category than institutionalized elderly. He also led the Beaumont Health System to becoming a recognized center for voiding dysfunction, first as the chair of urology and later as the chief medical officer (CMO). Many American and Asian urologists have benefitted from Dr. Diokno’s contributions and for this he deserves continued recognition. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e253 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Refugia More articles by this author Gopal Badlani More articles by this author Expand All Advertisement PDF downloadLoading ...

MP52-20 OPTIMISATION OF TRANSCUTANEOUS SPINAL CORD STIMULATION IN MODULATION OF MICTURITION REFLEXES FOLLOWING SPINAL CORD INJURY

You have accessJournal of UrologyCME1 Apr 2023MP52-20 OPTIMISATION OF TRANSCUTANEOUS SPINAL CORD STIMULATION IN MODULATION OF MICTURITION REFLEXES FOLLOWING SPINAL CORD INJURY Hannah Houliston, Richard Nobrega, Natalia Vasquez, Frank Lee, and Sarah Knight Hannah HoulistonHannah Houliston More articles by this author , Richard NobregaRichard Nobrega More articles by this author , Natalia VasquezNatalia Vasquez More articles by this author , Frank LeeFrank Lee More articles by this author , and Sarah KnightSarah Knight More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Spinal cord injury (SCI) can result in neurogenic lower urinary tract dysfunction including neurogenic detrusor over-activity (NDO) and detrusor-sphincter dyssynergia (DSD). Exciting developments in spinal cord stimulation (SCS) have demonstrated potential to improve motor function. Transcutaneous SCS (tSCS) provides a non-invasive alternative to epidural SCS, and there is preliminary evidence to suggest it can modulate spinal networks involved in micturition. However, there is ambiguity regarding optimal electrode sites and stimulation parameters. The aim of this study was to investigate optimisation of electrode site and tSCS parameters during the filling and voiding phase of the micturition cycle in people with SCI. METHODS: Ethical approval was obtained from the Research Ethics Committee. Participants were recruited if they had a supra-sacral SCI and proven NDO on most recent urodynamics. During visit 1, 1 ms tSCS pulses of increasing amplitude where administered at three randomised electrode sites; cathode between spinous process of T11-12, or L1-2, anodes at iliac crests or abdomen. External anal sphincter (EAS) and bilateral tibialis anterior EMG were recorded throughout. Optimal electrode site was selected based on motor-evoked potential response, and tolerance to stimulation. With electrodes placed at the optimal site, tSCS was applied in 5 s bursts at either 1, 15 or 30 Hz during voluntary pelvic floor contraction, relaxation and control. During visit 2, participants completed 6 cycles of urodynamics, one control cycle at the start and end, two cycles applying either 30 or 15 Hz tSCS during bladder filling, and two cycles applying either 1 or 15 Hz tSCS during voiding. RESULTS: Six participants were recruited (4 male, 2 female), with mean age 50±20 years old. 4 had an incomplete cervical and 2 an incomplete thoracic SCI. All participants tolerated the stimulation, and there were no adverse events. Optimal electrode sites were cathode L1-2, anode abdomen (n=2), cathode T11-12, anode iliac crest (n=2), cathode L1-2, anode iliac crest (n=1) and cathode T11-12, anode abdomen (n=1). Preliminary analysis of EMG data indicates that tSCS may enhance voluntary contraction of EAS. In addition, tSCS during the filling phase may increase bladder capacity. Further analysis is on-going. CONCLUSIONS: tSCS is an exciting new development which may improve bladder and bowel function following SCI. Our initial studies optimising electrode positioning and parameters will be used to investigate the use of tSCS in a further study combining it with pelvic floor muscle training. Source of Funding: International Spinal Research Trust Grant © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e710 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hannah Houliston More articles by this author Richard Nobrega More articles by this author Natalia Vasquez More articles by this author Frank Lee More articles by this author Sarah Knight More articles by this author Expand All Advertisement PDF downloadLoading ...

Dysfunctional elimination syndrome: a short review of the literature.

The combination of the functional disorders of urination and defecation constitutes the Dysfunctional Elimination Syndrome (DES). DES refers to an abnormal pattern of elimination of unknown etiology characterized by bowel and bladder incontinence and withholding, with no underlying anatomic or neurologic abnormalities. Essential precondition for a child to be subsumed under this entity is the exclusion of either anatomical or neurological causative factors. In the present review study the individual entities of dysfunctional filling, such as the unstable or lazy bladder, or dysfunctional urination, such as the detrusor sphincter dyssynergia and the functional constipation are being described comprehensively. Subsequently, the analysis of the pathophysiological effects of the dysfunctional elimination syndrome such as incontinence, urinary tract infections and the conservation or the deterioration of vesicoureteric reflux, is being accentuated. With the documentation of DES, the therapeutic strategy should aim at treating both the functional disorder of the vesicourethral unit and the functional constipation. The first part does not specify depending on the type of this disorder. Rarely, surgical treatment of functional urinary disorders may be required.