Empty Bladder Research Articles

Comparison of two retropubic tension-free vaginal tape procedures in women with stress urinary incontinence: a randomized controlled multicenter trial.

Midurethral slings are a well-established treatment option in women suffering stress urinary incontinence. Various different products and methods are used, therefore, the aim of our study was to compare two inside-out retropubic slings (TVT exact® vs. RetroArc®) inserted in two different ways regarding perioperative and mid-term outcomes. In this prospective randomized controlled non-inferiority multicentre trial, primary endpoint was postoperative cure rate, both objective (negative cough test) and subjective (absence of leakage during physical activity using the UDI-6 questionnaire). Secondary endpoints were patients' satisfaction (Likert scale; ICIQ-UI-SF questionnaires). In addition, intra-and postoperative complications were evaluated. The TVT®-group was operated with an empty bladder, a 18 CH catheter was used with a straight inserter as instructed. Patients randomized into the RetroArc®-group were operated without inserter leading to a reduced catheter size (14 CH), bladder was filled (200ml) during the procedure. Of the 303 women, 152 were randomized to the TVT® and 151 to the RetroArc® operation. At 3 months, n = 288 (95.0%) and at 12months n = 229 (75.6%) were assessed. In postoperative objective cure the RetroArc®-procedure was not inferior to TVT® (p = 0.144). In subjective cure, however, the TVT exact® procedure achieved significant better results (TVT® 76.1%, RetroArc® 54.3%, p = 0.002). Perioperative complications were in majority voiding difficulties and lower after the TVT exact®-procedure. Retropubic sling procedures are safe and successful to treat female stress urinary incontinence. However, different materials and techniques result in differences between outcomes also experienced surgeons should be aware of.

Bladder Neuromodulation in Acute Spinal Cord Injury via Transcutaneous Tibial Nerve Stimulation: Cystometrogram and Autonomic Nervous System Evidence From a Randomized Control Pilot Trial.

Aim: Percutaneous tibial nerve stimulation is used to decrease incontinence in chronic neurogenic bladder. We report the findings from a subset of patients in a randomized control trial of transcutaneous tibial nerve stimulation (TTNS) for bladder neuromodulation in acute spinal cord injury (SCI) in whom heart rate variability (HRV) was recorded before and after cystometrogram (CMG). The aim was to correlate autonomic nervous system (ANS) changes associated with the CMG changes after the trial using HRV analyses.Methods: The study was a double-blinded sham-controlled 2-week trial with consecutive acute SCI patients admitted for inpatient rehabilitation, randomized to TTNS vs. control sham stimulation. Pre- and Post- trial CMG were performed with concurrent 5-min HRV recordings with empty bladder and during filling. Primary outcomes were changes with CMG between/within groups and associations to the HRV findings.Results: There were 10 subjects in the TTNS group and 6 in the control group. Pre-trial baseline subject characteristics, blood pressures (BPs), and CMG were similar between groups. In both groups, the pre-trial systolic BP increased during filling CMG. After the trial, the control group had significantly increased detrusor pressure and counts of detrusor-sphincter dyssynergia on CMG, not seen in the TTNS group. Also, the control group did not maintain rising BP post-trial, which was observed pre-trial and remained in the TTNS group post-trial. HRV was able to detect a difference in the ANS response to bladder filling between groups. Post-trial HRV was significant for markers of overall increased parasympathetic nervous system activity during filling in the controls, not seen in the TTNS group.Conclusion: Preliminary evidence suggests that TTNS in acute SCI is able to achieve bladder neuromodulation via modulation of ANS functions.Clinical Trial Registration: clinicaltrials.gov, NCT02573402.

Less to Hold – a Comparison of Bowel and Bladder Toxicities in Patients Undergoing Prostate Radiotherapy between those Treated with an Empty Bladder and those Following a Bladder Filling Protocol

Purpose: Radical radiotherapy to the prostate is conventionally treated with a full bladder to minimise dose to bladder and bowel. Patients’ tolerance of the bladder filling protocol varies and ‘accidents’ during treatment can cause undue distress to patients and increased pressure on the radiotherapy department. Several UK centres report treating with an empty bladder. We carried out a feasibility study of full bladder versus empty bladder to ascertain if we can safely change our practice.

Follow-Up Ultrasound after Pyeloplasty should be Performed with An Empty Bladder: A Lesson from Monsieur Laplace

Reason to report: Hydronephrosis caused by congenital ureteropelvic obstruction is quite common affecting up to 0.2% of infants and a pyeloplasty is the way to correct. Ultrasound is the technique of choice to follow up this kind of patient, but no other recommendations are present in literature.

Implications of bladder volume on target coverage and dose to critical structures during high dose rate intracavitary brachytherapy for cervical cancer: A dosimetric study.

The distension of the bladder during intracavitary brachytherapy (ICBT) affects the applicator position and in turn the dose to tumour and normal structures. To quantify the changes in the dose to high risk clinical target volume (HRCTV) and organs at risk (OARs) due to bladder filling. In this prospective study, dosimetric parameters of 40 cervical cancer patients treated with (ICBT) were studied. Two sets of CT images with empty and bladder filled with 100 ml of contrast were used for analysis of doses to HRCTV and organs at risk OARs. The distance between posterior wall of the bladder and reference point on the flange was recorded in X,Y and Z. Target coverage between bladder distension and empty bladder was 84.15 vs 84.85 % (P=0.003) respectively. Mean dose to bladder was 1.57vs 2Gy (P=0.000), median dose was 6 vs7.25Gy (P=0.000), D5cc was 3.94 vs 4.17 Gy (P=0.103) and D2cc was 4.5 vs 5 Gy (P=0.01) respectively. The doses to rectum was D2cc - 3.76 vs 4.07Gy (P=0.000), Sigmoid was D2cc - 2.18 vs 2.43Gy (P=0.005), bowel D2cc was 2.81 vs 3.43Gy (P=0.000). The mean distance of the posterior wall of the bladder from reference point was 0.042 vs -0.079cm (P=0.391) in the X-axis, -0.618 vs -0.630cm (P=0.603) in Z-axis and 0.19 vs 0.26cm (P=0.009) in the Y-axis between two status of the bladder. Smaller volume of bladder receive higher dose and larger volumes a lower dose with bladder distension, while dose is same for rectum, sigmoid and bowel. The applicators shift posteriorly when the bladder is distended.

Pitfalls in the use of shear wave elastography on the cervix

Introduction Ultrasound shear wave elastography has the potential to assess the strength of the maternal cervix for signs of insufficiency.1, 2 The reliability of shear wave elastography in biological tissues can be affected by numerous ultrasound artifacts and prestress of tissues in the region of interest can also affect the shear wave speed. This study investigates the use of the transvaginal ultrasound approach to obtain shear wave speeds in the uterine cervix with the aim of identifying factors that affect shear wave speed and transmission. Objectives The primary aim of this study is to identify biological and technical confounders for the use of two dimensional shear wave elasography applied to the uterine cervix. The goal was to identify confounders, and develop shear wave technique in the low risk non-gravid population. Methods Sixty nine non-gravid participants with varying medical history and ethnicity consented to be part of this research. Inter-operator testing was performed on fifteen participants.Imaging methodology As an adjunct to the normal imaging examination extra imaging of cervical speed measurements using two dimensional shear wave elastography was performed.The transvaginal approach utilises an endocavity transducer with an empty maternal bladder. Shear wave elastography speed measurements are acquired at the external and internal os anterior and posterior portions. Results Reliable measurements were obtained at the external os and internal os, anteriorly and posteriorly, in 63, 55, 55 and 26 patients respectively. The mean speed obtained at the external os, anteriorly and posteriorly, was 2.52 ± 0.49 m/s and 2.87 ± 0.63 m/s respectively, and at the internal os anteriorly and posteriorly, 3.29 ± 0.79 m/s and 4.10 ± 1.11 m/s respectively. The difference in speed between all regions was statistically significant] (p Interoperator testing The intraclass correlation coefficient obtained at the regions of the cervix was as follows - external os anterior 0.83 (CI 0.45 – 0.95), external os posterior 0.69 (CI 0.07-0.90), internal os anterior 0.92 (CI 0.76 – 0.97), internal os posterior 0.90 (CI 0.37-0.98) Conclusion Biological factors and ultrasound induced artifacts appear to affect the transmission of the elastographic main pulse, with cervical position appearing to affect shear wave production. Reliable shear wave propagation can be achieved in the anterior cervix in most patients.

Can shear wave elastography of the cervix be of use in predicting imminent cervical insufficiency and preterm birth? - preliminary results

Introduction Ultrasound strain elastography may be able to identify women presenting with a normal cervical length, who are at an increased risk of preterm birth due to softening of the cervix.1,2 Shear wave elastography (SWE) uses acoustic radiation force impluse to produce shear waves.3 It is expected that SWE will produce a more objective and reproducible mechanical evaluation of the cervix than strain elastography.4,5 There is promise for the use of SWE on the maternal cervix to assess cervical strength.6,7 Objectives The primary aim of this study is to assess if reduced cervical strength and imminent cervical insufficiency can be identified by shear wave elastography. Methods This is a cross-sectional study of patients presenting for their mid-trimester ultrasound examination. Ethics approval was from the Curtin University Human Research Ethics Committee and SKG Radiology Clinical Standards Committee. All data has been collected at sites of SKG Radiology in Perth, Western Australia. Informed consent was required to participate. Imaging Methodology The transabdominal approach utilizes a 6C1 curvilinear transducer and a partially full maternal bladder.8 The transvaginal approach utilises an endocavity transducer with an empty maternal bladder. Shear wave elastography speed measurements are acquired at the external and internal os anterior and posterior portions.8,9 Results Data assessment currently includes 156 of the 473 participants enrolled to date. Participants were from varying ethnicity with a mean age of 29 years (18-33 years), mean gestation of 2(0-5), mean number of births 1(0-5), 102 cases of spontaneous labour, 38 of induced labour and 16 planned c-section. Mean shear wave speeds and number of cases at varying gestation for patients going into spontaneous labour are as follows: Conclusion Early results indicate the shear wave speeds may be reduced in patients with a subsequent preterm birth. Larger numbers will need to be assessed to substantiate these findings.

A Rare Cause of Anuria: A Case of Inflammatory Iliac Aneurysm

The patient was a 68-year-old male. The patient of complaint was anuria. There was no sense of urination. Abdominopelvic ultrasonography USG and abdominopelvic computed tomography CT without contrast revealed an empty bladder and the presence of bilateral hydroureteronephrosis. Aneurysms in the aorta and bilateral iliac arteries were detected. It caused bilateral hydroureteronephrosis via compressing “aneurysmal bilateral ureter”. Creatinine was 4.97 mg/dL, BUN 37 mg/dL, C reactive protein CRP 193 mg/L and erythrocyte sedimentation rate ESR 99 mm/h. A double J stent was inserted on the right and a nephrostomy tube was placed on the left. The urea and creatinine levels returned to normal postoperatively. Urinary obstruction or anuria can develop due to a lot of reasons such as stricture, urolithiasis, clot, and malignancy or inflammation of peripheral organs and etc. Abdominal aortic aneurysm AAA or iliac artery aneurysm IAA is a very rare cause of urinary obstruction or anuria. Abdominal aortic aneurysm AAA and iliac artery aneurysm IAA are rare factors that can cause urological symptoms with an inflammatory or direct compressive effect. There have been very rarely reported as a cause of acute anuria. We present a case of acute anuria due to bilateral inflammatory iliac artery aneurysm

1034: Abdominal vs. vaginal approach for the mid-trimester cervical length screening

Cervical length (CL) of less than 25mm is a risk factor for preterm birth. Recent studies have suggested the use of a routine cervical length (CL) measurement, to identify women at risk for preterm birth. In this study, we compared between transabdominal and transvaginal CL measurement in order to establish practical recommendations for CL screening following routine mid-trimester anatomy scan. CL measurements were performed at 20-24 weeks' gestation, from January 2017 until April 2018, immediately after fetal anatomy scan. CL measurements were obtained transabdominally before (full bladder), and transvaginally after (empty bladder) voiding. The differences in CL and duration of transabdominal and transvaginal measurements were compared between the groups and adjustment was made for maternal age (MA), and body mass index (BMI). 468 women carrying a singleton pregnancy gave their informed consent to participate in the study. The overall duration for the fetal anatomy scan was 27±5.3minutes. The duration of CL measured transabdominally was significantly shorter than the duration of CL measured transvaginally (6.9±1.38min vs. 0.46±0.3min, P<0.001). Difficulty in demonstrating the cervix transabdominally has been noted in 39 women (8.3%). The CL measured transvaginally was significantly longer than the CL measured transabdominally (42±7.5mm vs 37.34±6.8mm, p<0.001). The differences between the groups were unrelated to maternal age or BMI. All women whom transabdominal measurements of CL were above 35mm (66% of patients) had transvaginal CL above 25mm (98.2% of patient) (Fig 1). Transvaginal measurement of CL is associated with discomfort and embarrassment. Additionally, the transvaginal measurement is a time-consuming procedure with a significant prolongation of fetal anatomy scan compared with the transabdominal approach. Therefore, transabdominal measurement of CL should be offered as an initial tool for cervical length screening. Transvaginal measurements of CL should be reserved for high-risk women (who had preterm delivery in the past), when there are difficulties in demonstrating the cervix abdominally, and for women with transabdominal measurements of less than 35mm.

Cone beam computed tomography-based monitoring and management of target and organ motion during external beam radiotherapy in cervical cancer.

Background and purposeOrgan motion is a challenge during high-precision external beam radiotherapy in cervical cancer, and improved strategies for treatment adaptation and monitoring of target dose coverage are needed. This study evaluates a cone beam computed tomography (CBCT)-based approach.Materials and methodsIn twenty-three patients, individualized internal target volumes (ITVs) were generated from pre-treatment MRI and CT scans with full and empty bladders. The target volumes encompassed high-risk clinical target volume (CTV-T HR) (gross tumor volume + remaining cervix) and low risk (LR) CTV-T (CTV-T HR + uterus + parametriae + upper vagina). Volumetric Modulated Arc Therapy (VMAT) was used to deliver a dose of 45 Gy in 25 fractions. CBCTs were used for setup and for radiation therapists (RTTs) to evaluate the target coverage (inside/outside the planning target volume). CBCTs were reviewed offline. Estimates of the dose delivered with minimum (point) doses across all fractions to CTV-T HR (aim 42.75 Gy) and CTV-T LR (aim 40 Gy) were assessed. In patients with insufficient dose coverage, re-plans were generated based on previous imaging.ResultsMedian (range) of the ITV-margins (mean of anterior-posterior margins) related to uterus and cervix was 1.2 (0.5–2.2 and 1.0–2.1) cm. RTTs were able to assess the target coverage in 90% of all CBCTs (505/563). With re-planning, one patient had considerable benefit (12.7 Gy increase of minimum dose) to CTV-T LR_vagina, four patients had improved dose to the CTV-T LR_uterus (1.2–1.8 Gy), and 3 patients did not benefit from re-planning.ConclusionsDaily CBCT-based monitoring of target coverage by the RTTs has proven safe with limited workload. It allows for reduction in the treated volumes without compromising the target dose coverage.

3 Single shot stereotactic body radiotherapy for localized prostate cancer: Case report

Introduction We report on the quality assurance (QA) and treatment management of the first patient included in the ONE SHOT trial. ONE SHOT, single shot stereotactic body radiotherapy (SBRT) for localized prostate cancer, is a multicenter single arm phase I/II trial which will enrolled 45 patients in total. Its main objective is to determine the safety and efficacy of a single SBRT fraction at a dose of 19 Gy in patients with localized prostate cancer. Indeed, recent data showed good tolerance and biochemical control after single interstitial application of 19/20 Gy to the prostate or after SBRT in five fractions, so that ultra-hypofractionated single-dose SBRT employing imaged-guided radiotherapy and real-time tumour tracking with implanted electromagnetic transponders (Calypso® with DynamicEdge™ gating) may be feasible with a safe toxicity profile and an optimal long-term tumor control. Methods Three Calypso beacons were implanted in the patient prostate 4 days before the planning CT scan. The patient was imaged with empty rectum and full bladder with 1 mm slices thickness. For urethra contouring and visualization during treatment, a non-radiopaque catheter was inserted during CT simulation and before the treatment delivery. The prescription dose was 19 Gy in a single fraction to the whole prostate gland ±proximal seminal vesicles and 17 Gy to the urethra planning-risk volume (PRV). The plan consisted into 2 full VMAT arcs using 10MV FFF beam from the TrueBeam linac with 6 degrees of freedom couch. It was optimized on Eclipse TPS (Varian) with Rapidplan™, a knowledge-based planning software, and the dose was calculated with AAA v13026 algorithm. QA controls included portal dosimetry (PD) (Varian, PDIP v13026), absolute dose measurements with Diamond detector (PTW) inserted in Lucy 3D QA phantom (Standard Imaging) and Gafchromic film measurements (EBT-XD films). Results The treatment plan of the first ONE SHOT patient satisfied the dose-volume constraints for all OARs and the coverage requirement for the PTV and PRV. The total number of monitor units for the two arcs was 7125. The results of the PD QA were within the tolerance, with Gamma index 1%/1 mm = 98.7%. For absolute dose measurement, the difference between expected and measured dose was 1.7% inside PRV and 3% in the PTV region. Film gamma index with 4%/1 mm criteria was 97.4%. Patient positioning before treatment required two cone-beam CT (CBCT) before the first arc, because Calypso detected a 2 mm shift in the longitudinal direction after the couch adjustment made after the 1st CBCT. The first arc was treated without interruption and a third CBCT was acquired between the arcs. However, no shift was observed and the second arc was treated without patient realignment. Conclusions QA results were all within the tolerance for SBRT treatment and the first ONE SHOT patient was treated successfully as planned.

Bladder-Sparing Hypofractionated Intensity Modulated Radiation Therapy plus Weekly Gemcitabine in Patients with Invasive Bladder Cancer

Trimodality therapy (TMT) is an effective and appealing alternative for bladder preservation in selected patients with muscle invasive bladder cancer (MIBC). Cisplatin has been frequently used as a radiosensitizer. However, in this usually elderly population with compromised renal function, the use of cisplatin may not be always feasible. We report results of hypofractionated IMRT (HypoIMRT) and weekly gemcitabine as components of a TMT regimen for patients with MIBC. From June 2008 to June 2017, 49 patients with T2-3N0M0 bladder cancer underwent treatment with HypoIMRT with concomitant weekly gemcitabine following maximal transurethral resection of bladder tumor (TURBT). HypoIMRT delivered a dose of 50 Gy in 20 fractions to the completely empty bladder and 40 Gy to pelvic nodes in the same 20 fractions. Weekly gemcitabine at a dose of 100 mg/m2 was given concomitantly. Patients treated with neoadjuvant chemotherapy or those treated with another chemotherapy agent were not included. Response rate was assessed by cystoscopy evaluation and bladder biopsy. The median age was 76 years (range: 58-91). A complete TURBT was achieved in 90% of patients. A complete response post-therapy was confirmed in 88% of the patients. At a median follow-up of 20 months, 20 patients had died, 10 of them from bladder cancer. Of those patients achieving a complete response, 29 patients (67.5%) have remained disease-free at a median follow-up of 21 months. The median time for either local or distant failure was 12 months. 8 patients (16%) failed in the bladder only (5 with superficial and 3 with invasive disease) with an actuarial local control projection of 75% at 3 years. Of the 8 patients failing locally, 3 of them presented with hydronephrosis and 2 had an incomplete TURBT; 13 patients (26.5%) failed distantly. The 3- and 5-year cancer-specific survival rate was 77%. Treatments were well tolerated with all patients completing HypoIMRT and 78% completing 4 cycles of gemcitabine. Grade 3 acute GU or GI toxicity was seen in 2% of patients (no grade 4 or 5). Late grade 2 or higher GI or GU toxicity was seen in 2% and 6%, respectively (no grade 4 or 5). HypoIMRT plus concurrent weekly gemcitabine post-TURBT is an effective, feasible and well-tolerated curative treatment strategy in selected patients with MIBC.

Abstract P402: A New Oral Salt Tolerance Test has Acceptable Consistency for its First Volunteer

Objectives: One of the cores of salt restriction is to keep balance of salt intake and excretion. There is still no method to identify salt tolerance based on salt intake and excretion. In order to evaluate the ability to absorb and excrete salt, we established a new method Oral Salt Tolerance Test (OSTT). We firstly evaluated its consistency for one person among repeated tests. Methods: After signing informed consent, the 40-year-old healthy woman volunteer was asked to keep fasting after 9PM and empty bladder before sleep on the day before test. On the morning for test, she emptied bladder firstly and then drank 500ml 0.9% saline in 15 minutes. Urine volume and urine samples for sodium test were collected at 30min, 60min, 120min and 180min time points. This test was repeated twice on the other two days. Results: 1. According to sodium concentration and urine volume at each timepoints, we calculated equal sodium chloride amount. The baseline urine sodium concentration before test 1 is higher than those before test 2 and test 3. Accordingly, the 30min sodium concentration and urine volume are lower and higher respectively than those of the other two tests, while the 30min equal sodium chloride amounts are similar among the three tests. 2. The Intraclass Correlation Coefficient for equal sodium chloride amount among the three tests is 0.94 (95% Confidence Interval 0.6810 to 0.9958) and this indicates that the consistency among the three tests is acceptable. Conclusion: The acceptable consistency makes this new OSTT possible to screen more subjects with various clinical conditions. In the future, we hope this new method would give us a novel insight for hypertension or renal diseases patients.

Efficacy of urinary glucose for diabetes screening: a reconsideration

Previous studies indicated that urinary glucose (UG) had a limited efficacy in diabetes screening. This study was designed to have a re-evaluation of its efficacy, taking into consideration the collection method of urine and the measurement approach for UG among Chinese adults. This cross-sectional study enrolled a total of 7689 participants without known diabetes, who were fasted and asked to empty bladders before a 75g glucose loading. Urine was collected 2 h post glucose loading, and UG was measured using quantitative and qualitative approaches. The efficacy of UG in detecting diabetes was assessed by the receiver operating characteristic (ROC) curve. The area under the ROC curve was 0.89 for quantitative UG and 0.87 for qualitative UG. Quantitative UG was positively correlated with fasting plasma glucose (FPG) and 2h plasma glucose (2h PG) (r = 0.55 and 0.56, respectively, both P < 0.001). Quantitative UG displayed a sensitivity of 82.9% and a specificity of 84.7% in detecting diabetes at the corresponding optimal cutoff of 130mg. Qualitative UG exhibited a sensitivity of 80.2% and a specificity of 85.6% at the optimal cutoff of glycosuria + 1. In addition, the sensitivity of both quantitative and qualitative UG was significantly higher than that of HbA1c (≥ 6.5%) (P < 0.001) and had a comparable sensitivity to 2h PG (≥ 11.1mmol/L) (P = 0.493). UG, either quantitatively or qualitatively measured at 2 h post glucose loading, was effective in diabetes screening. This indicates that UG is a feasible approach for diabetes screening.

A comparison of a step-initiation task in women with and without urinary incontinence. A case-control study.

The aim of the study was to objectively determine differences in postural response by women with and without urinary incontinence during a step-initiation task depending on the degree of bladder filling. The study comprised 22 women with stress urinary incontinence and 20 women without urinary incontinence. All women participated in four trials: unperturbed and perturbed (obstacle crossing) transition between platforms, step-up and step-down trials. Velocities of center of pressure displacement, double-support period, time from exit from steady standing until the lead foot resting on the other platform and time from raising the foot from the first platform until gaining quiet standing on the other platform were measured and compared. No significant differences were noted between the performance of a step-initiation task by incontinent women with full/empty bladder whereas continent women performed differently during unperturbed transition with full/empty bladder. The step-up trial revealed significant intergroup differences. The antero-posterior mean velocity of center of pressure during the empty bladder test was significantly higher in women with stress urinary incontinence (effect size = 1.02). During the same bladder condition the women with stress urinary incontinence performed significantly more slowly in unperturbed (effect size = 1.09) and perturbed (effect size = 0.84) transition compared to control group. Our results indicate that women with incontinence performed the step initiation task slowly on the empty bladder tests compare to continent women.

Anisotropic Bladder Planning Target Volume in Bladder Radiation Therapy

PurposeThis study aimed to investigate 3 planning target volume (PTV) margin expansions and determine the most appropriate volume to be used in bladder preservation therapy when using daily cone beam computed tomography (CBCT). We aimed to establish whether a smaller PTV expansion is feasible without risking geographical miss. Methods and materialsThe study included patients with bladder cancer who were treated with a hypofractionated course of radiation therapy delivered with intensity modulated radiation therapy. The clinical target volume (CTV) was the whole empty bladder, and the PTV consisted of a 1.5-cm margin around the bladder (PTV1.5 cm). Patients underwent daily CBCT imaging before treatment to assess the bladder volume and ensure accurate positioning. We investigated 2 additional smaller PTV margin expansions to determine the most appropriate volume to be used with CBCT as a daily image guided radiation therapy modality. These margins were created retrospectively on every CBCT. The first additional volume was a uniform PTV margin of the surrounding 1 cm (PTV1 cm). When considering that the majority of the internal bladder movement was due to the variation in filling that occurs in the superior and anterior directions, a second volume of an anisotropic PTV margin with a 1.5-cm superior/anterior and 1 cm in other directions (PTV1/1.5 cm) was created. We recorded the frequency and measured the volume of bladder falling out of each PTV based on the daily CBCT. ResultsFor the purpose of this study, we considered an arbitrary 5 cm3 of CTV falling out of the designated PTV as a clinically significant volumetric miss. The frequency of such a miss when applying the uniform PTV1 cm was 1%. However, when applying the uniform PTV1.5 cm and anisotropic PTV1/1.5 cm margins, the frequency was 0.5% and 0.5%, respectively. ConclusionsThe anisotropic PTV expansion of 1.5 cm superiorly and anteriorly and 1 cm in all other directions around the bladder (CTV) provides a safe PTV approach when daily CBCT imaging is used to localize an empty bladder.

OA130] Adaptation of external beam radiotherapy through daily cone beam CT monitoring for cervical cancer patients

Purpose To evaluate an image-guided and adaptive EBRT workflow in locally advanced cervical cancer (LACC) patients treated according to EMBRACE II guidelines in terms of individualized ITV margins and new criteria for dose coverage. Interfractional target-(cervix/uterus) and organ filling was monitored on a daily basis and investigated along with the impact of patient feedback on organ fillings. Methods Patients treated with definitive radiochemotherapy were included. Pretreatment MRI- and (PET)-CT scans with full and empty bladders were performed and a bladder-filling protocol applied. Contouring was according to EMBRACE II guidelines with individualized ITV margin and 5 mm PTV margin. VMAT plans were used to deliver 45Gy/25 fractions with daily onboard cone beam CT (CBCT) scans. Trained RTTs monitored the interfractional target motion and organ fillings, and provided patients with daily feedback on organ-filling. A clinical workflow including thresholds for re-planning if target was not inside PTV was designed and followed. CBCTs were retrospectively reviewed, and the accuracy of the RTT scorings analyzed. Minimum doses to CTV-T HR(aim 42,75 Gy) and CTV-T LR(aim 40 Gy) were retrospectively estimated for replanned patients. Results Twenty-three patients were evaluated. RTT scoring of target coverage was correct in 90% of the CBCTs (505/563), incorrect in Conclusions The study proposes a practical adaptive approach for EBRT in LACC patients with daily IGRT monitoring supporting the EMBRACE II guidelines. The strategy allowed safe treatment with relatively tight ITV margins. In patients with unpredictable interfractional target- and organ motion, the compromised coverage benefitted from re-planning. The approach has limited workload and can be performed with high accuracy by RTTs.

Restoring the sense of bladder fullness for spinal cord injury patients

Abstract Spinal cord injuries (SCI) have vast effects on day-to-day life, including the loss of sensation and control of the bladder. Since elevated bladder pressures from urine production and storage can be detrimental to renal functionality, urologists recommend performing clean-intermittent catheterization (CIC) every two to four hours throughout the day. However, limitations in mobility make the high frequency of these trips to the bathroom prohibitive. Sometimes a patient׳s bladder fills to capacity before performing CIC and eventually leaks urine, causing unnecessary embarrassment. As such, continence is the primary concern of most SCI patients. The issue in performing CIC is that it is a time-based approach, whereas urine production does not occur at a constant rate. A demand-based ’bladder almost-full’ warning system would provide more useful notifications and help SCI patients plan their bathroom trips accordingly. In this work, we explore using near-infrared light to create a discrete, wearable, non-invasive bladder state estimation system using machine learning to determine urine volume in the bladder to provide continuous monitoring for a patient throughout the day. We do this through proof-of-concept evaluation studies using Monte Carlo simulations and describe our bladder state estimation system. We also highlight some preliminary results using the system and distinguish differences in light intensity between a full and empty bladder on a volunteer.

Aquaporin-2 plays an important role in water transportation through the bladder wall in rats.

We investigated the role of the bladder wall in permeating water, focusing on aquaporins. Female Sprague-Dawley rats weighing 300 g were used to investigate the role of the bladder wall in saline permeation. Changes in intravesical fluid volume and sodium concentration were measured in the desmopressin acetate hydrate-loaded and control groups 3 h after administration. Bladders were resected to measure aquaporin-1, 2, and 3 gene expression using qRT-PCR. Additionally, the change of aquaporin-2 expression was measured using Western blotting and immunohistochemistry in intravesical aquaporin-2 siRNA-treated and control groups. Although the intravesical fluid volume and sodium concentration significantly decreased from 0 to 3 h (1.00 ± 0.00 vs 0.83 ± 0.08 mL, 157.80 ± 1.30 vs 146.8 ± 1.92 mEq/mL, P < 0.01, respectively in the control group), administration of desmopressin did not affect the extent of volume change. Aquaporin-2 expression was significantly higher in the 3-h distended bladders than in the empty bladder. Aquaporin-2 siRNA treatment suppressed aquaporin-2 expression and the change of intravesical fluid volume from 0 to 3 h (1.00 ± 0.00 and 0.99 ± 0.02 mL), which was related to the suppression of sodium concentration change in comparison with control siRNA treatment (149.6 ± 2.4 vs 143.6 ± 3.67 mEq/mL, P < 0.05). The rat urinary bladder absorbs water and salts under the full-filled condition. Aquaporin-2 plays an important role in the transport of water, accompanied by sodium concentration change. We demonstrated a part of the bladder absorption mechanism, which may lead to development of a new method for regulating bladder storage function.

PD19-07 CRH NEURONS OF BARRINGTON’S NUCLEUS ARE NECESSARY BUT NOT SUFFICIENT FOR CO-ORDINATED VOIDING IN MICE

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Basic Research & Pathophysiology I1 Apr 2018PD19-07 CRH NEURONS OF BARRINGTON’S NUCLEUS ARE NECESSARY BUT NOT SUFFICIENT FOR CO-ORDINATED VOIDING IN MICE Hiroki Ito, Marcus Drake, Christopher Fry, Anthony Kanai, and Anthony Pickering Hiroki ItoHiroki Ito More articles by this author , Marcus DrakeMarcus Drake More articles by this author , Christopher FryChristopher Fry More articles by this author , Anthony KanaiAnthony Kanai More articles by this author , and Anthony PickeringAnthony Pickering More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.997AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The pontine micturition centre (PMC) is thought to activate the sacral parasympathetic neurons controlling the detrusor and inhibit the somatic motoneurons of the external urethral sphincter (EUS). Many PMC neurons express corticotropin-releasing hormone (CRH) and a recent study using CRH-ires-CRE knock-in mice enabled opto- and chemo-genetic manipulation of their activity (Hou et al. Cell 2016). This indicated that the CRH neurons were glutamatergic, caused bladder contraction and an increase in the probability of micturition. We asked whether these CRH neurons alone could produce co-ordinated micturition. METHODS To target PMC in CRH-ires-CRE mice, stereotaxic injections of Cre-inducible vectors (AAV-EF1a-DIO-hChR2-mCherry or AAV-hSyn-DIO-hm4D-mcherry) to enabled light-activation or clozapine N-oxide (CNO)-induced neuronal silencing. Subsequently under urethane anaesthesia an optic fibre was placed above PMC for optogenetic stimulation. Bladder pressure was monitored with a PE-50 catheter and EUS-EMG was recorded with implanted electrodes. RESULTS The vectors allowed selective expression of ChR2/DREADD within CRH+ PMC neurons (Fig. 1a). Optogenetic activation of PMC-CRH neurons (473 nm, 5-30ms x 2.5-20Hz for 5s) reliably evoked transient non-voiding bladder contractions (“opto-NVCs”, 1.6 ? 0.4 mmHg, 20ms-pulse x 20Hz, n=9) of an empty bladder (Fig. 1b). Surprisingly there was little relationship between opto-stimulus parameters and opto-NVC amplitude unlike response probability. A comparison of opto-NVCs and spontaneous NVCs showed that the optogenetic activation did not activate the EUS. Opto-stimulation when the bladder was full could trigger voids. Chemogenetic inhibition of the PMC-CRH neurons with CNO (5ug/kg) reversibly inhibited voiding. CONCLUSIONS These data support the role of the PMC CRH neurons as being pre-parasympathetic neurons that are required for voiding but they are not part of EUS motor control. The PMC-CRH neurons are not high-fidelity controllers of micturition but they do influence timing of events. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e397-e398 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Hiroki Ito More articles by this author Marcus Drake More articles by this author Christopher Fry More articles by this author Anthony Kanai More articles by this author Anthony Pickering More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...