High Intravesical Pressure Research Articles

Pediatric Lower Urinary Tract Dysfunction: A Comprehensive Exploration of Clinical Implications and Diagnostic Strategies.

Lower urinary tract dysfunction is clinically important because it may cause urinary tract infections, mainly due to accumulation of residual urine, and adversely affect renal function. In addition, it may cause urinary incontinence, strongly affecting the child's quality of life. The function of the lower urinary tract is closely associated with function of the bowel because constipation is commonly present with bladder dysfunction. The interplay between the lower urinary tract and bowel function, coupled with common conditions such as detrusor overactivity and voiding dysfunction, requires a nuanced diagnostic approach. Detrusor overactivity, a benign but socially harmful condition, is the principal cause of daytime urinary incontinence in childhood. It needs to be differentiated from more serious conditions such as neurogenic bladder dysfunction or urethral obstruction. Voiding dysfunction, a habitual sphincter contraction during voiding, is common in children with detrusor overactivity and may be self limiting but may also result in residual urine and urinary tract infections. It may resemble, in severe cases, neurogenic bladder dysfunction, most often caused by spinal dysraphism, which very often leads to recurrent urinary tract infections and high intravesical pressures, jeopardizing renal function. A voiding diary is crucial in the initial evaluation of lower urinary tract function in children.

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.

Urinary ascites in a neonate with posterior urethral valve

Urinary ascites in a newborn is an extremely rare condition, most commonly due to posterior urethral valves, due to transmission of high intravesical pressure to calyceal fornices, and subsequent urinary ascites either by calyceal perforation or filtration through walls of urinary tract and their rupture. We describe a newborn male baby, who presented with huge abdominal distension at birth, and diagnosed as urinary ascites on paracentesis. Baby was asphyxiated and required resuscitation at birth, and ventilatory support for 4 days in v/o significant abdominal distension. Micturating cystourethrogram (MCUG) and magnetic resonance imaging (MRI) showed posterior urethral valves. Baby also had a left sided urinoma and grade 4 vesicoureteral reflux (VUR) on MCUG. Post paracentesis and drainage of 400ml of ascetic fluid, and urinary catheterization, baby had significant improvement of deranged renal parameters, and diuresis, and could be weaned from ventilation. In v/o inability to negotiate a urethroscope, a vesicostomy was done for urinary drainage and fulguration of valves planned on follow-up.

SPARC: Spinal cord epidural stimulation and microstimulation of dorsal root ganglion with penetrating microelectrode arrays enables selective activation of micturition and continence reflexes.

Lower urinary tract (LUT) dysfunction arising from injury and disease remain a clinical challenge due to unavailability of pharmacological treatments. Neuromodulation devices developed to tackle these disorders, such as sacral stimulators, are non‐selective for a single nerve with numerous off‐target effects while also stimulating the afferent and efferent population in a nerve. Here, we investigate whether epidural spinal cord stimulation (SCS) and microstimulation of dorsal root ganglion (DRG) through penetrating microarrays, can selectively activate and control reflexes relevant to LUT function. We demonstrate that custom high‐density epidural arrays and Utah arrays in the DRG can selectively access pelvic and pudendal innervation, and can modulate LUT function.To determine the effects of stimulation on peripheral nerve recruitment, α‐chloralose anesthetized male cats (SCS: n=6, DRG: n=4) were instrumented with nerve cuffs on the pelvic nerve as well as the pudendal nerve and its branches. High‐density epidural electrodes were placed corresponding to the lumbosacral (L6 and L7 laminae) and sacral (S1 laminae) spinous processes. In separate DRG experiments, 32‐channel high‐density penetrating Utah arrays were implanted in the S1, S2 and S3 DRG. We stimulated epidurally and within the DRG while recording compound action potentials in nerve cuffs. Functional effects of stimulation were measured using intravesical and transurethral catheters to measure bladder and urethral pressures respectively across various stimulus amplitudes and frequencies.All the instrumented nerves could be selectively recruited with both DRG and SCS stimulation, although not every nerve was selectivity recruited in every animal. The stimulation amplitude to evoke functional responses was higher (SCS: 600–1000 μA, DRG: 20–45 μA) than the minimum threshold to evoke antidromic activity in nerve cuffs. SCS and DRG stimulation both evoked bladder parasympathetic contractions similar to direct stimulation of the pelvic nerve. In several trials, stimulation through the same epidural electrode during cystometry, low frequency (3 Hz) stimulation evoked a continence reflex resulting in a suppression of detrusor activity, while high frequency (33 Hz) stimulation evoked a micturition reflex resulting in high intravesical pressures. Isovolumetric and filling cystometry was performed to confirm the action of these reflexes.SCS and DRG stimulation can selectively activate pelvic and pudendal innervation, and elicit micturition and continence reflexes.Support or Funding InformationR01 NS088184 and OT2OD024908. Craig H. Neilsen Foundation Award 476681

Botulinum toxin a external urethral sphincter quadrant injection guided by transrectal ultrasound for treatment of detrusor sphincter dyssynergia

Detrusor sphincter dyssynergia (DSD) causes impaired micturition and high intra-vesical pressure that leads to potentially life-threatening urological complications. Botulinum toxin A (BTX-A) is an inhibitor of acetylcholine release at the neuromuscular junction, which can decrease muscle contractility. It has been used successfully in the treatment of focal dystonia and spasticity of skeletal muscles. This study investigates the effectiveness of BTX-A injection to the external urethral sphincter guided by transrectal ultrasound in the treatment of spinal cord injury (SCI) patients with DSD. A total of 18 patients with DSD (15 men and 3 women) were caused by SCI. BTX-A (100μ) was injected into external urethral sphincter(EUS) respectively in four sites at 12.3,6.9 o’clock guided by transrectal ultrasound. Clinical effects and urodynamic parameters were compared at baseline and after treatment one month. The EUS was clearly identified as a neatly hypoechoic area extending from the prostatic apex to the levator ani muscle in men patients, but not in women patients. After treatment, the urinary function and urodynamic parameters is improved significantly compared with the baseline ( P < 0.05), and at 4 week up to a maximum efficacy. In total, 6 (33.3%) patients had an excellent result and had 5 (27.7%) significant improvement. Relatively poor bladder contractility tended to be more frequent in the unimproved patients. However, the catheter insertion becomes easier in patients with failed treatment. Stress urinary incontinence was reported in 4 patient. There was no other obvious side effects occurred in patients. Transrectal ultrasound is an effective method to visualize the lower urinary tract and allows for the accurate targeting of the EUS. It is a simple and repeatability method for the treatment of DSD. BTX-A injection to the EUS guided by transrectal ultrasound is an effective method in the treatment of SCI patients with DSD.

Intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity incontinence: do we need urodynamic investigation for outcome assessment?

To evaluate if urinary continence in patients with refractory neurogenic detrusor overactivity (NDO) incontinence after intradetrusor onabotulinumtoxinA injections is sufficient for appropriate outcome assessment or if urodynamic investigation (UDI) is needed. A consecutive series of 148 patients undergoing intradetrusor onabotulinumtoxinA injections for refractory NDO incontinence were prospectively evaluated. Patients underwent UDI before and at 6 weeks after onabotulinumtoxinA injections. The primary outcome was the prevalence of maximum storage detrusor pressure (Pdetmax storage) of >40 cmH2 O in continent patients at 6 weeks after treatment. The secondary outcomes were treatment effects on other clinical and video-urodynamic variables. At 6 weeks after intradetrusor onabotulinumtoxinA injections, 98 of the 148 patients (66%) with NDO incontinence were continent. Of these patients, 18 (18%, confidence interval 12-27%) had a Pdetmax storage of >40 cmH2 O. Gender, underlying neurological disorder, and high Pdetmax storage before treatment appear to increase the risk of poor urodynamic outcomes. Urinary continence is not sufficient for outcome assessment after intradetrusor onabotulinumtoxinA injections, as high intravesical pressures threatening the upper urinary tract may be missed in a relevant proportion of continent patients. Therefore, we strongly recommend UDI as a routine part of the follow-up.

Pharmacotherapy for Pediatric Neurogenic Bladder.

Neurogenic bladder (NB) is a nonspecific term that may describe conditions ranging from areflectic noncontractile bladder to detrusor overactivity. The most common cause of NB in children is the presence of dysraphic malformations. Urodynamic evaluations make it possible to describe bladder dysfunctions and to plan a therapeutic strategy for each patient. In a child with NB there are two major dangerous functional problems seen in urodynamic investigations: high intravesical pressure in the storage phase and high pressure during urination. The basic goals of urologic treatment for a child with NB are the protection of the urinary tract from complications and improvement of continence. Treatment for a child with NB is usually conservative, and focuses on achieving safe bladder pressures during storage with reliable emptying, via voiding or catheterization. The two most important forms of conservative treatment are clean intermittent catheterization and pharmacological treatment of functional disorders. Some drugs are used in the treatment of functional disorders in children with NB, but none of the drugs are officially approved for small children and babies.

Cystometrogram appearance in PUV is reliably quantified by the shape,wall, reflux and diverticuli (SWRD) score, and presages the need for intervention

Radiological bladder abnormalities in boys with posterior urethral valves (PUV) are well recognised; however, the assessment is subjective. The shape, wall, reflux and diverticuli (SWRD) score objectively assesses shape, wall, reflux and diverticuli in a simple way. This study was undertaken to demonstrate that the SWRD score is reliable, reproducible and correlates with bladder outcome and videourodynamic (VUD) assessment in boys with PUV. Three blinded assessors determined the SWRD scores of PUV bladders from cystometrograms taken during VUD from September 2012 to October 2013. The scores were correlated with clinical outcome and VUD pressure measurements. Data were given as median (interquartile range), non-parametric tests used as appropriate (Mann-Whitney U test, or Kruskall-Wallis) and P<0.05 was taken as significant. A total of 55 boys with PUV underwent VUD assessment, for which 52 cystometrograms were available. The SWRD score for non-operative management was 1.0 (0.1-1.9) vs 2.0 (1.0-3.3) for operative intervention, P=0.018 (Summary Figure). The SWRD score for compliant bladderswas 1.1 (0.6-2.0) vs hypercompliant 1.7 (0.5-2.8) vs non-compliant 3.3 (2.8-5.0), Kruskall-Wallis P=0.011. The hostile detrusor overactivity (DO) bladders (Pdet >40 cmH2O) had a SWRD score of 2.0 (1.3-3.7) vs 1.0 (0.5-2.5) for low-pressure DO bladders, P<0.05. In this series of patients, increasingly distorted bladder shape was seen to be associated with poor bladder dynamics on VUD. Patients with poorly compliant bladders had a significantly higher SWRD score than normal or megacystis patients. Severe DO was also significantly associated with a high SWRD score. Therefore, the radiological appearance of a hostile bladder represented a marker for high intravesical pressure. VUR and bladder diverticuli may lead to spurious pressure measurements during VUD; however, the SWRD score provided an independent mechanism with which to objectively assess these patients, even in the presence of gross VUR. The SWRD score is a simple and objective scoring system for the radiological abnormalities of PUV bladders. It correlates with clinical outcome and VUD assessment of compliance and DO, but is independent of pressure measurements and so not confounded by VUR acting as a 'pop-off' mechanism.

Intravital imaging of mouse urothelium reveals activation of extracellular signal-regulated kinase by stretch-induced intravesical release of ATP.

To better understand the roles played by signaling molecules in the bladder, we established a protocol of intravital imaging of the bladder of mice expressing a Förster/fluorescence resonance energy transfer (FRET) biosensor for extracellular signal‐regulated kinase (ERK), which plays critical roles not only in cell growth but also stress responses. With an upright two‐photon excitation microscope and a vacuum‐stabilized imaging window, cellular ERK activity was visualized in the whole bladder wall, from adventitia to urothelium. We found that bladder distention caused by elevated intravesical pressure (IVP) activated ERK in the urothelium, but not in the detrusor smooth muscle. When bladder distension was prevented, high IVP failed to activate ERK, suggesting that mechanical stretch, but not the high IVP, caused ERK activation. To delineate its molecular mechanism, the stretch‐induced ERK activation was reproduced in an hTERT‐immortalized human urothelial cell line (TRT‐HU1) in vitro. We found that uniaxial stretch raised the ATP concentration in the culture medium and that inhibition of ATP signaling by apyrase or suramin suppressed the stretch‐induced ERK activation in TRT‐HU1 cells. In agreement with this in vitro observation, pretreatment with apyrase or suramin suppressed the high IVP‐induced urothelial ERK activation in vivo. Thus, we propose that mechanical stretch induces intravesical secretion of ATP and thereby activates ERK in the urothelium. Our method of intravital imaging of the bladder of FRET biosensor‐expressing mice should open a pathway for the future association of physiological stimuli with the activities of intracellular signaling networks.

التهاب المثانة الهوائي لفترة طويلة قد ينتهي بفشل كلوي مزمن مع ارتفاع في ضغط المثانة

A 61-year old male patient with end stage renal failure and severe bilateral hydronephrosis was admitted to our hospital. The patient had pneumaturia since many years with history of several surgeries due to urethral strictures. Computed tomography showed air fluid level in the bladder and bilateral hydronephrosis with air bubbles in the kidneys. Urodynamic study revealed normal bladder volume with increased intravesical pressure during the filling phase. Urine culture was positive for klebsiella pneumonia. Prompt reduction in the serum creatinine level was observed after appropriate medical therapy and catheterization of the bladder. Emphysematous cystitis although it can be managed easily, it may lead to impairment of renal function if no appropriate management was given. مريض ذكر بعمر 61 سنة حضر الى مستشفانا بفشل كلوي مع وجود انتفاخ حاد في حوض الكليتين. يعاني المريض من وجود هواء في البول منذ عدة سنوات واجري له العديد من العمليات بسبب تضيق في مجرى البول (الاحليل). اتضح بالصورة الطبقية وجود مستوى هواء و سائل في المثانة مع وجود انتفاخ وفقاعات هواء في كلا الكليتين. اجري له تخطيط مثانة وتبين أن حجم المثانة طبيعي مع زيادة في ضغط المثانة خلال فترة التعبئة. بعد زراعة البول تبين ان البول يحتوي على klebsiella pneumonia. كان هناك تحسن ملحوظ بوظائف الكلية بعد اعطاء العلاج المناسب ووضع قسطرة للمثانة. بالرغم من أن التهاب المثانة الهوائي يعالج بسهولة إلا أنه قد يؤدي الى خلل حاد في وظائف الكلية اذا لم يتم اعطاء العلاج المناسب له.

Morphological changes in the bladder of spinal cord injured patients affected by detrusor overactivity

It is well known that the neurogenic detrusor over activity (NDO) represents one of the most disabling condition in patients with suprasacral spinal cord injury (SCI). The treatments with anti-muscarinic drugs and botulinum toxin local injection show a temporary efficacy in controlling the bladder impairment; after that, the typical NDO urodynamical signs, such as reduced bladder capacity, high intravesical pressure with potentially upper urinary tract damage, reoccurs (1). At this stage, these patients can choice to perform a cystectomy with or without bladder augmentation. In order to investigate the pathological remodelling of bladder wall, we collected bladder specimens from SCI patients underwent to cystectomy. Control specimens were obtained from patients underwent to surgery for bladder cancer. Data obtained from clinical records, histology and immunohistochemistry were paralleled. The group of SCI patients were uniform on the basis of age, legion level, previous therapies and urodinamic parameters. These latter indicated a strong reduction of bladder capacity and reflex volume. Histologically, SCI bladder showed an important inflammatory state with oedema and congestive blood vessels in the submucosa and lamina propria; in the most serious cases, phlogosis was present also in the detrusor and characterized by eosinophilic infiltrate. Moreover, an important alteration of smooth muscle cell organization was appreciable. The immunohistochemical experiments demonstrated a redistribution of alpha-smooth muscle actin filaments (αSMA) in the smooth muscle cells associated with an altered distribution of caveolin 1 (cav1). Present findings show consistent alteration of the contractile structures and molecules that might explain the recurrence of NDO sign and symptoms in SCI patients. It remains to understand whether these changes are side effects of pharmacological therapies or instead the typical evolution of the disease that the therapies, eventually, postponed.

Bladder exstrophy: Quality of primary care and long-term prognosis

It is universally agreed that successful and gentle initial bladder closure is decisive for favorable long-term outcome. Due to a number of reasons, including a lack of comparable multicenter studies, there are numerous concepts for initial exstrophy closure. Therefore, we describe our concept of delayed, staged reconstruction without osteotomy in classical bladder exstrophy, while taking into considerion the available literature on long-term follow-up as well as on own clinical and research data. Most notably there are multiple medical but also psychological advantages of a delayed procedure. Primary closure without osteotomy is feasible and has no disadvantages in the long-term follow-up when compared to the invasive procedure of osteotomy. Due to high intravesical pressure, initial bladder neck surgery might have negative effects on bladder development and on the upper urinary tract.

Botulinum toxin injections for treating neurogenic detrusor overactivity.

Neurogenic detrusor overactivity (NDO) is a disorder that can cause high intravesical pressure, decreased capacity, decreased bladder compliance, and upper urinary system damage. The current treatment options for NDO are established on the basis of agents that block parasympathetic innervation of the detrusor and inhibit involuntary bladder contractions. Several side effects, such as dryness of mouth, constipation, dyspepsia, changes in visual accommodation, somnolence, and being unable to obtain consistently favorable results, caused by anticholinergic agents, which are frequently used for this purpose, decrease the patient's compliance to treatment. Procedures such as neuromodulation, auto-augmentation, and enterocystoplasty are surgical options, and they could be used as the last alternative. Thus, botulinum toxin (BTX) injections to the detrusor have been commonly performed in recent years and lead to satisfactory results. The mechanism of action of BTX in NDO is based on the principal of smooth muscle relaxation in the bladder by the transient inhibition of neuromuscular nerve signals. The aim is to decrease acetylcholine secretion by blocking presynaptic vesicles in the neuromuscular junction. When studies were evaluated, it was observed that BTX injections to the detrusor muscle are a necessary and effective option in patients with incontinence caused by NDO. This treatment option could be indicated in situations where anticholinergic agents are not effective or could not be tolerated, and it could be a valuable alternative to major surgical treatments. In this review, we evaluated the effectiveness and reliability of BTX in patients with NDO.

Long-term follow up and predictive factors for successful outcome of transurethral incision of the bladder neck in women with detrusor underactivity.

Detrusor underactivity (DU) is a common urologic problem. Our previous study revealed the transurethral incision of the bladder neck (TUI-BN) improves short-term voiding efficiency (VE) in female patients with DU. This study focused on the long-term outcomes of TUI-BN and identified the predictive factors of satisfactory outcomes. A total 50 women with DU for whom medical treatment failed underwent TUI-BN. The urodynamic parameters at baseline and follow-up visits were analyzed. Patients with VEs >50% were considered to have satisfactory outcomes. Baseline urodynamic parameters were analyzed as factors predictive of outcomes. After a mean follow up of 61.8 months, 26 of 50 patients had satisfactory outcomes. The mean VE, maximum flow rate, voided volume, detrusor pressure, and postvoid residual volume significantly improved after TUI-BN. A higher intravesical pressure [Pves, odds ratio (OR)=1.023, p=0.013] and smaller first sensation of bladder filling (OR=0.990, p=0.020) at baseline were predictive factors for satisfactory outcomes. The multivariate analysis revealed that only baseline Pves was a significant predictor of satisfactory outcomes (OR=1.024, p=0.038). The receiver operating characteristic curve analysis of baseline Pves showed that the area under the curve was 0.767 (95% confidence interval=0.624-0.876). The optimal cutoff value of Pves for a satisfactory outcome was 45 cmH2O, which had a specificity of 78.26% and acceptable sensitivity of 73.08%. TUI-BN improved VE in women with DU over the long term. A higher Pves compared to a lower Pves was predictive of satisfactory surgical outcomes.

Urodynamic changes in mice with experimental autoimmune encephalomyelitis correlate with neurological impairment.

Neurogenic bladder dysfunction is a major issue in Multiple Sclerosis (MS). High intravesical pressure should be treated early. Available therapies are insufficient and there is need for drug development and investigation of pathogenesis. Experimental Autoimmune Encephalomyelitis (EAE) in rodents is a well validated model to study MS. Previous research has shown that these animals develop urinary symptoms. However, from clinical studies, we know that symptoms do not necessarily reflect changes in bladder pressure. This paper aims to provide a complete overview of urodynamic changes in a model for detrusor overactivity in MS. Female C57Bl/6J mice, injected with MOG35-55 and control mice, injected with vehicle (Complete Freund's adjuvant), were monitored daily for neurologic symptoms. Within 1 month after symptom development, mice were used for cystometry or histology of the bladder. Increasing disease score correlated with increased micturition frequency, basal pressure, and average pressure, and with a decrease in functional bladder capacity, voiding amplitude, and maximum pressure. This paper provides a detailed description of bladder function in C57Bl/6J mice with Myelin Oligodendrocyte Glycoprotein peptide (MOG35-55 ) induced EAE. This EAE model induces detrusor overactivity in close relationship to neurological impairment. EAE in mice is a suitable model to study detrusor overactivity in MS. Neurourol. Urodynam. 35:450-456, 2016. © 2015 Wiley Periodicals, Inc.

Chapter 9 - Approach to the male patient with lower urinary tract dysfunction

History and physical examination are the cornerstones of evaluation of the male patient with lower urinary tract (LUT) symptoms and (suspected) neurologic disorder, both to diagnose the nervous system lesion, and to get insight into the type of LUT dysfunction (LUTD). Non-neurologic LUTD needs to be ruled out. Laboratory testing is necessary to diagnose urinary infection. In those in whom neurogenic LUTD is probable, postvoid residual urine and urinary flow measurement generally rule out significant outflow obstruction and allow for basic symptomatic management. If symptomatology is complex or severe, or the pathophysiology uncertain, or invasive treatment planned, urodynamic or videourodynamic measurements should be performed to inform on bladder sensation, detrusor contractility, pressures generated in the bladder, as well as the behavior of bladder neck, the striated urethral sphincter, and urinary flow. This information is paramount to the clinician to plan management and consider prognosis. Assessment needs to be repeated, as chronic neurogenic LUTD is not a stable condition; in progressive neurologic diseases the nature of LUTD itself may change. The upper urinary tract needs to be checked and followed up regularly, particularly in patient groups in which high intravesical pressures may be generated.

OP2-06 FUNCTIONAL RECOVERY OF HYPOCOMPLIANT DEFUNCTIONALIZED BLADDER DUE TO LONG-TERM DIALYSIS AFTER KIDNEY TRANSPLANTATION

You have accessJournal of UrologyOutstanding Posters: Benign Disease1 Apr 2014OP2-06 FUNCTIONAL RECOVERY OF HYPOCOMPLIANT DEFUNCTIONALIZED BLADDER DUE TO LONG-TERM DIALYSIS AFTER KIDNEY TRANSPLANTATION Takamitsu Inoue, Shigeru Satoh, Takashi Obara, Mingguo Huang, Mitsuru Saito, Kazuyuki Numakura, Shintaro Narita, Norihiko Tsuchiya, and Tomonori Habuchi Takamitsu InoueTakamitsu Inoue More articles by this author , Shigeru SatohShigeru Satoh More articles by this author , Takashi ObaraTakashi Obara More articles by this author , Mingguo HuangMingguo Huang More articles by this author , Mitsuru SaitoMitsuru Saito More articles by this author , Kazuyuki NumakuraKazuyuki Numakura More articles by this author , Shintaro NaritaShintaro Narita More articles by this author , Norihiko TsuchiyaNorihiko Tsuchiya More articles by this author , and Tomonori HabuchiTomonori Habuchi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2556AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES It has been reported that oliguria due to long-term dialysis decreases bladder capacity, and the small bladder recovers its capacity after kidney transplantation. However, incidences of functional bladder recovery including bladder compliance and high intravesical pressure have not yet been well documented. Following kidney transplantation, we evaluated the functional recovery of hypocompliant defunctionalized bladders due to long-term dialysis. METHODS A total of 80 living kidney transplantations were performed at our institute between 2009 and 2012. Fifty recipients who underwent cystometry both before and 1 year after transplantation were enrolled in this study. Bladder compliance, which was calculated by the cystometric bladder capacity and maximum intravesical pressure, was evaluated by cystometry. A hypocompliant bladder was defined that with compliance of <10 mL/cm H2O. Urinary complications including urinary tract infection (UTI) and vesicoureteral reflux (VUR) were retrospectively evaluated. RESULTS Pretransplant bladder compliance significantly correlated with the dialysis duration (R2 = 0.486, p < 0.001). In 14 patients with a pretransplant hypocompliant bladder, the bladder compliance, cystometric bladder capacity, and maximum intravesical pressure significantly improved 1 year after transplantation (p = 0.001, p < 0.0001, p = 0.005, respectively). Prevalence of VUR or UTI, including pyelonephritis, was not increased in patients with a pretransplant hypocompliant bladder. CONCLUSIONS Pretransplant bladder compliance significantly decreased in patients on long-term dialysis. The pretransplant hypocompliant bladder significantly recovered 1 year after transplantation without an increase in the prevalence of VUR or UTI. The pretransplant hypocompliant bladder, caused by long-term dialysis, can safely recover functionality following kidney transplantation. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e389 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Takamitsu Inoue More articles by this author Shigeru Satoh More articles by this author Takashi Obara More articles by this author Mingguo Huang More articles by this author Mitsuru Saito More articles by this author Kazuyuki Numakura More articles by this author Shintaro Narita More articles by this author Norihiko Tsuchiya More articles by this author Tomonori Habuchi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of the Detrusor Sphincter Dyssynergia

Detrusor sphincter dyssynergia (DSD) is a disturbance of the normal synergistic coordination between bladder contraction and external urethral sphincter muscles relaxation during voiding. In patients with neurogenic bladder, the urethral sphincter muscle contracts during voiding instead of completely relaxing. This results in alteration of the normal flow and rising of the bladder pressure. The voiding dysfunction and the subsequent dysfunction of the emptying phase of micturition represent a high risk of complications for patients with neurogenic bladder, in relation with high intra-vesical pressure and lack of complete bladder emptying such as: lithiasis, urinary tract infection (UTI), vesico-ureteral reflux, hydronephrosis, and renal failure. Therefore, management of DSD requires a multidisciplinary and careful follow-up to prevent complications. Various physicians should be involved including surgeon, rehabilitation physician, neurologist. Treatment of DSD is a moving field with new emerging approaches and therapies such as botulinum toxin, urethral stent, and promising pharmacological treatment. Therapeutics are often highly specific and should be individually tailored, but with always the same aim: to prevent complications which can impact quality of life, and life expectancy of patients. Here we propose a therapeutic approach to DSD, based on a review of the recent literature and our personal experience. At the end, we try to summarize recommendations for managing DSD in neurogenic bladder.

Vesicoureteral Reflux and Urodynamic Dysfunction

Introduction: The concept of vesicoureteral reflux (VUR) as a consequence of congenital anomaly of vesicoureteral junction has undergone changes owing to the finding that such children may have lower urinary tract dysfunction, which produces high intravesical pressure and consequently a predisposition for VUR. Patients and Methods: The urodynamics was investigated by pressure-flow-EMG study in 132 children with VUR and 162 refluxing units. Results: Only 33 (25.0%) patients had normal urodynamic finding. The most frequent pathological finding was overactive bladder (OAB), found in 59 (44.7%) children, followed by dysfunctional voiding (DV) in 25 (18.9%) children. Children with VUR grades I and II had a higher percentage of pathological urodynamic findings than children with VUR grades III and IV. OAB was more frequent in children under 5 years of age with unilateral and lower grade VUR. It was found equally in children with and without uroinfections. DV was more frequent in children older than 5 years, with bilateral VUR, higher grade VUR and uroinfections. Conclusions: Children with VUR have a high incidence of urodynamic disorders. The results of the study indicate the possible role of urodynamic dysfunction in the pathogenesis of VUR, especially mild one.

Serial Intravesical Pressure Measurements Can Predict the Presence and the Severity of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) which is accompanied with gastrointestinal ulceration and necrosis is one of the most important problems of preterm infants in neonatal intensive care unit (NICU). Increased intra-abdominal pressure (IAP) is detected among most of the pediatric patients hospitalized in intensive care unit and undergoing surgery or trauma. This pathology, namely, abdominal compartment syndrome, causes ischemia and hypoperfusion of abdominal organs. Recently, the effect of increased IAP on NEC is under focus and this increase is thought to be related with the onset of NEC by leading to intestinal ischemia and necrosis. In this study, we aimed to investigate if serial intravesical pressure (IVP) measurements as an indirect indicator of IAP may help to early diagnosis in NEC and to decision for surgery besides to predict the mortality of NEC. A total number of 61 preterm infants with a birth weight of ≤ 1,500 g hospitalized in NICU were included to the study. IVP values were measured by the same nurse twice daily during their hospitalization through urinary catheter. The IVP values of the preterm infants with and without NEC were compared. Totally 61 premature infants included in the study were grouped as follows: group 0, the control group without NEC (n = 38); group 1, medically treated NEC patients (n = 14); and group 2, NEC patients undergoing surgery (n = 9). The median IVP measurements of group 0 were lower than the other groups (p = 0.001). No statistically significant difference in IVP measurements was detected between group 1 and group 2 (p = 0.155). A 10% of increase in IVP measurement was significant in predicting the development of NEC with consecutive serial measurements. The mean IVP measurements were higher in infants with NEC who died during their follow-up at NICU compared with NEC patients who survived (p = 0.043). Serial IVP measurements may help for early diagnosis and surgery decision of NEC and high IVP levels also may predict mortality in cases with NEC.