Increase In PVR Research Articles

Pulmonary vasoconstriction plays a major role in the acute phase of pulmonary embolism in pigs

Abstract Background Pulmonary vascular resistance (PVR) increases in acute pulmonary embolism (PE) due to both mechanical obstruction and pulmonary vasoconstriction. Attenuation of adverse pulmonary vasoconstriction has shown promise as a treatment of acute PE in experimental studies. However, clinical trials have failed to replicate these beneficial effects in PE patients. Time may be a factor in this discrepancy between experimental and clinical studies. In experimental PE studies, PVR acutely increases and decreases within hours. Meanwhile in clinical trials, the time from symptom onset to study inclusion is often days, at which time PVR may already be decreased. Whether this decrease in PVR is due to reduced mechanical obstruction by endogenous fibrinolysis or attenuation of adverse pulmonary vasoconstriction is unknown. Purpose To investigate the contribution of the mechanical obstruction and pulmonary vasoconstriction to PVR in two days following PE in pigs. Methods In a controlled animal study, using an estabilished model of autologous PE in pigs (PE, n=12 ∼60 kg), changes in pulmonary hemodynamics and clot burden were evaluated. CT pulmonary angiograms were performed at baseline (BL), after acute PE and the following two days, quantifying clot burden using the Qanadli Obstruction Score. Hemodynamics were evaluated with real-time biventricular catheterization and systemic invasive pressures. To evaluate the vasoactive component, pulmonary vasodilators sildenafil (bolus 0.1 mg/kg) and oxygen (inspired fraction of oxygen 40%) were administered. Results Following PE, both mean PVR (Figure 1A) and pulmonary obstruction scores (Figure 1B) increased. PVR decreased at day one and remained unchanged at day two (Figure 1A). Meanwhile, mean obstruction score decreased slightly at day one but remained elevated throughout the study (Figure 1B). Vasodilatation induced by sildenafil and oxygen (SIL+OXY) decreased PVR at day zero but displayed no effect on the subsequent days (Figure 1A). Conclusion Pulmonary vasoconstriction and mechanical obstruction both contributed to the increase in PVR during the acute phase of PE. PVR decreased towards levels of baseline already day one and remained unchanged at day two. The contribution of pulmonary vasoconstriction decreased at day one and two, while the mechanical obstruction remained significantly increased. Accordingly, the effects of pulmonary vasodilators were only present in the acute phase of PE.Figure 1

337.3: Effects of Tacrolimus on Mechanical and Humoral Determinants of Brain Death-Induced Lung Injury

Background: Donor brain death-induced lung injury may compromise graft function after transplantation. The mechanisms of this particular form of neurogenic lung edema and its possible prevention by immunomodulator Tacrolimus remain incompletely understood. Methods and Results: Brain death was induced, by slow intracranial infusion of blood, in anesthetized pigs after randomisation to placebo (n=9) or to Tacrolimus (n=8). One, three, five and seven hours after brain death, pulmonary artery pressure (Pap), wedged Pap (Papo), right atrial pressure (Pra), effective pulmonary capillary pressure (Pcap), systemic artery pressure (Psa) and thermodilution cardiac output (Q) were measured. Blood and lung tissue were sampled and lung injury scored on pathological examination. Brain death was associated with marked increases in Pap, PVR and Pcap, decreases in Psa and Q with growing need for Noradrenaline while Ppao and Pra remained in a physiological range. Arterial O2 pressure to fraction of inspired O2(PaO2/FiO2) decreased. Brain death was associated with increased lung injury score together with increased gene expressions of interleukin (IL)-6 and IL-1b, heme-oxygenase-1, signal transducer and activator of transcription-3. Lung tissue pro-inflammatory IL-6/IL-10 ratio was decreased and pro-apoptotic Bax/Bcl2 ratio was increased. Tacrolimus partially corrected pulmonary hypertension and lung tissue biological perturbations. PaO2/FiO2 was inversely correlated to PCP and lung injury score. Serum IL-6 and IL-1b were correlated to PCP. Conclusion: Brain death induced lung injury is related to effective pulmonary capillary hypertension with normal PAWP and pro-inflammatory and pro-apoptotic biological changes all partially reversed by preventive Tacrolimus treatment.

Effects of Tacrolimus on Mechanical and Humoral Determinants of Brain Death-Induced Lung Injury

<h3>Purpose</h3> Donor brain death-induced lung injury may compromise graft function after transplantation. The mechanisms of this particular form of neurogenic lung edema and its possible prevention by immunomodulator Tacrolimus remain incompletely understood. <h3>Methods</h3> Brain death was induced, by slow intracranial infusion of blood, in anesthetized pigs after randomisation to placebo (n=9) or to Tacrolimus (n=8). One, three, five and seven hours after brain death, pulmonary artery pressure (Pap), wedged Pap (Papo), right atrial pressure (Pra), effective pulmonary capillary pressure (Pcap), systemic artery pressure (Psa) and thermodilution cardiac output (Q) were measured. Blood and lung tissue were sampled and lung injury scored on pathological examination. <h3>Results</h3> Brain death was associated with marked increases in Pap, PVR and Pcap, decreases in Psa and Q with growing need for Noradrenaline while Ppao and Pra remained in a physiological range. Arterial O₂ pressure to fraction of inspired O₂(PaO₂/FiO₂) decreased. Brain death was associated with increased lung injury score together with increased gene expressions of interleukin (IL)-6 and IL-1βετα, heme-oxygenase-1, signal transducer and activator of transcription-3. Lung tissue pro-inflammatory IL-6/IL-10 ratio was decreased and pro-apoptotic Bax/Bcl2 ratio was increased. Tacrolimus partially corrected pulmonary hypertension and lung tissue biological perturbations. PaO₂/FiO₂ was inversely correlated to PCP and lung injury score. Serum IL-6 and IL-1βετα were correlated to PCP. <h3>Conclusion</h3> Brain death induced lung injury is related to effective pulmonary capillary hypertension with normal PAWP and pro-inflammatory and pro-apoptotic biological changes all partially reversed by preventive Tacrolimus treatment.

Perioperative Management for Surgical Repair of Ebstein's Anomaly.

Background: Ebstein's anomaly is a rare and complex heart defect that affects the tricuspid valve and is accountable for around 1% of congenital cardiac abnormalities. It is one of the most common congenital causes of tricuspid valve regurgitation. Ebstein's anomaly often is diagnosed prenatally, due to its severe cardiomegaly. Some individuals with this anomaly do not experience complications until adulthood and even then, they have mostly minor complaints like exercise intolerance. An atrial septal defect is most commonly (70-90%) associated with Ebstein's anomaly. However, ventricular septal defect (VSD) can be associated with 2-6% of the cases.&#x0D; Case presentation: This report presents a case of surgical intervention for a 38-year-old female with Ebstein's anomaly symptomatic with moderate-severe pulmonary regurgitation and foramen ovale apertum.&#x0D; Conclusions: Ebstein anomaly is a complicated form of congenital heart disease with variable clinical presentations. The anesthetic plan must also focus on maintenance of RV function and avoidance of increase in PVR. Reversible causes of increased PVR, such as acidemia, hypoxemia, and hypercarbia must be avoided. Agents that lower PVR, such as nitrates, and nitric oxide may be beneficial in patients with severe pulmonary hypertension.&#x0D; With a sound knowledge of the cardiac anatomy, accurate scheming of surgical outcomes, routine follow-ups, multidisciplinary team approach, and better management, an experienced center can ultimately improve the prognosis of such patients.

Changes in the Pulmonary Artery Wave Reflection in Dogs with Experimentally-Induced Acute Pulmonary Embolism and the Effect of Vasodilator

Simple SummaryPulmonary hypertension (PH) remains a fatal disease, despite the advances in disease-specific therapies. This may be because the assessment of pulmonary hemodynamics in PH has not been established. Recently, several studies have reported that the pulmonary arterial wave reflection (PAWR) might influence the right ventricular afterload and could provide additional information regarding the severity and progression of PH. However, the pathophysiology of PAWR has some unclear points particularly in the case of acute pulmonary embolism (APE). The objective of this study was to investigate, for the first time, the characteristics of PAWR in a dog model of APE using dual-tipped sensor wire. From the result of the present study, after dogs developed PH by injections of dextran microsphere, PAWR was increased significantly along with the pulmonary vascular resistance (PVR) and reduced after vasodilator administration. In addition, PAWR was significantly correlated with PVR and right ventricular fractional area of change (FAC). These results indicating that PAWR may be useful as a new evaluation method in PH and may detect changes related to right ventricular afterload earlier than pulmonary artery pressure (PAP).Pulmonary hypertension (PH) is a complex syndrome that has been frequently diagnosed in dogs and humans and can be detected by Doppler echocardiography and invasive catheterization. Recently, PAWR attracts much attention as a noninvasive approach for the early detection of PH. The present study aims to investigate the PAWR changes in acute pulmonary embolism (APE) and highlight the response of PAWR variables to vasodilator therapy in dogs. For this purpose, anesthesia and catheterization were performed in 6 Beagle dogs. After that, APE was experimentally conducted by Dextran microsphere administration, followed by vasodilator (Nitroprusside; 1μg/kg/min/IV) administration. The hemodynamics, echocardiography, PVR and PAWR variables were evaluated at the baseline, after APE and after administration of nitroprusside. The result showed a significant increase in PVR, PAP, tricuspid regurgitation (TR) as well as PAWR variables following APE induction compared with the baseline (p < 0.05). Vasodilation caused by administration of nitroprusside reduced the mean atrial pressure, PVR and PAWR parameters. There were a significant correlation and linear regression between PAWR indices and PVR as well as right ventricular function parameters. In conclusion, PAWR is not only correlated with PVR but also the right ventricular function parameter, which indicates that PAWR may be useful as a new evaluation method in PH, considering that PAWR can assess both right ventricular afterload and right ventricular function.

Perioperative Management of Patients with Ventricular Septal Defect, Severe Tricuspid Regurgitation and Gerbode Defects

&lt;p&gt;Ventricular Septal Defect (VSD) is a congenital heart disease that causes the connection between left and right ventricles called a Gerbode defect. Manifestation of a Gerbode defect is damage to the opening tricuspid valve caused regurgitation of the tricuspid valve. Delay in diagnosis and intervention will affect pre-operative nutritional status and malnutrition.&lt;/p&gt;&lt;p&gt;We reported a boy aged 2 months, weighing 3100 grams with biliary atresia followed by VSD, severe TR, and Gerbode defect who will undergo the Kasai procedure. Preoperative physical examination showed GCS E4V5M6, SpO2 100%. The skin gets icteric all over the body and conjunctiva. The cardiovascular system has a regular I-II heart sound, 2/3 mid clavicular S noise as high as 2 ICS and a pansystolic murmur. The examination of the abdomen is slight distended. Child pug score 8. Hemoglobin value 6.7gr%, hematocrite 37%, APTT 44.8 seconds, SGOT 443 U / L, SGPT 560 U / L, total bilirubin 23.89 mg / dl, direct bilirubin 13.92 mg / dl, and indirect bilirubin 9.97 mg / dl.&lt;/p&gt;&lt;p&gt;The goal of anesthesia in VSD, Severe Tricuspid Regurgitation (TR) with Gerbode Defect is preventing excessive ventilation to avoid severe pulmonary hypertension. The choice of anesthetic agent is based on the patient's physiology and balancing pulmonary and systemic blood flow. Perioperative management of cases of VSD, TR Severe with Gerbode defect in the following report describes the importance of understanding the pathophysiology of VSD and Gerbode defects to obtain a good outcome.&lt;/p&gt;&lt;p&gt;Perioperative management of VSD patients, severe tricuspid regurgitation with Gerbode defect requires more supervision, especially to minimize the increase in PVR, maintain systemic vascular resistance (SVR) and avoid excessive ventilation to prevent severe pulmonary hypertension.&lt;/p&gt;

Efficacy and safety of tamsulosin vs its combination with mirabegron in the management of lower urinary tract non-neurogenic overactive bladder symptoms (OABS) because of Benign Prostatic Enlargement (BPE)-An open label randomised controlled clinical study.

The efficacy and safety of βeta-3 agonists (Mirabegron 50mg) have been sparingly assessed in the published English literature. We aim to do an efficacy-safety analysis of Mirabegron-Tamsulosin combination therapy vs tamsulosin-placebo monotherapy in a select subset of medication virgin Benign Prostatic Enlargement (BPE) patients with coexisting predominant non-neurogenic overactive bladder symptoms (OABS). After prior written informed consent and IEC, 80 patients of uncomplicated BPE with coexisting non-neurogenic OABS and IPSS of >7 without contraindications to drug therapy were computer randomised/allocated to receive either[50mg Mirabegron plus Tamsulosin 0.4mg (Intervention arm-I)]or [Tamsulosin 0.4mg plus capsule lactobacillus (Comparator arm-II)] once daily for 8weeks. Efficacy was evaluated using the OABS Score (OABSS), mean change in nocturnal frequency (NF), PVR and IPSS, while safety was assessed by recording treatment emergent adverse events (TEAE). Follow-up visits were performed at second, fourth and eighth week. Patient data in both groups were generally comparable with the exception of NF and IPSS storage sub score (IPSS-ss). Significant improvements were visualised in the eighth week primary endpoint total OABS sub score (OABSS-ss) in the combination group (P<.001).Similar significant improvements were seen with most secondary parameters such as the mean change in NF, IPSS, IPSS-ss, OABS-ss, voided volume, Qmax, and Quality of life index (QOL) (P<.001). No significant increase in PVR was observed in the Mirabegron arm and no patient developed urinary retention. The TEAE were minor, self-limiting and managed symptomatically without drug discontinuity. Mirabegron can be significantly efficacious and safe in ameliorating non-neurogenic OABS induced by BPE vs placebo by initiating combination therapy from the start as opposed to the usual 'add on therapy' protocol. This combination appeared to be superior in terms of overall safety, minimal side effects, better compliance and tolerability vs Tamsulosin monotherapy in select BPE patients with predominant non-neurogenic OABS.

Pengelolaan Neuroanestesi pada Pasien dengan Pentalogy of Fallot

Pentalogy of Fallot (POF) is a rare type of cyanotic congenital heart defect with high risk of having cerebral abscesses as one of its complications. Cerebral abscesses are often found in cyanotic heart disease due to chronic hypoxia and hyperviscosity reduced microcirculatory flow to the brain. We report a 6-year-old boy, 14 kg body weight with multiple brain abscesses accompanied by Pentalogy of Fallot (POF) who undergone a craniotomy to evacuate the abscess. Preoperative physical examination found GCS E4V5M6, other vital signs within normal limits, preductal oxygen saturation 88%, post ductal oxygen saturation in supine position 84%. The I-II heart sounds are regular with grade 3 systolic murmur in the left parasternal third intercostal space and clubbing finger was found. The laboratory shows a hemoglobin value of 14.4gr%, hematocrit of 43%, leukocytosis 13,200/mm³. The goal of anesthesia in cyanotic heart disease is to maintain cardiac output by stabilize heart rate, contractility as well as preload, prevent the increase of PVR:SVR ratio and avoid hypercyanotic due to sudden increase in systemic oxygen demand. The choice of anesthetic agent must be based on the patient's physiology. Adequate rehydration before induction and use of mannitol diuretics can be considered to reduce hyperviscosity that decrease oxygen delivery to the brain. Increased intracranial pressure from ketamine can be reduced by hyperventilation, in conjunction to benzodiazepines and prevention of hypercapnia. Therefore, monitoring end tidal CO2 (ETCO2) needs to be done. This case report delineating the perioperative management of a 6 years old boy with POF underwent evacuation of cerebral abscesses, will highlight the importance of understanding the pathophysiology of POF and neuroanesthesia techniques in order to receive a good outcome.

Outcome of Anastomotic Urethroplasty in Posterior Urethral Distraction Defect With or Without Mucosal Fixation- a Randomized Clinical Trial

Introduction: Anastomotic urethroplasty is the treatment of choice for posterior urethral distraction defect. To notice the high failure rate of anastomotic urethroplasty, several peri-operative factors are identified. Among the per-operative factors, mucosal fixation of the both urethral ends is one of the outcome influencing factor that is recently identified. So, this randomized clinical trial has been designed to compare the outcome of anastomotic urethroplasty in posterior urethral distraction defects with or without mucosal fixation. Objective: To compare the outcome of anastomotic urethroplasty of PUDD patient groups with or without mucosal fixation in terms of post-operative IPSS, maximum urine flow rate and post void residual urine. Patients and Methods: The present study was conducted in the department of Urology, BSMMU between January’16 - November’17. Posterior urethral distraction defects with length of gap between two urethral segments upto 3 cm. were included in the study. The patients in whom anastomotic urethroplasty were done with mucosal fixation were enrolled as study group(n=21) and patients in whom anastomotic urethroplasty were done without mucosal fixation were included as control group(n=21). All the patients were followed upto 6 months of anstomotic urethroplasty and failure of anastomotic urethroplasty (by RGU and MCU), PVR and maximum urine flow rate (Qmax) in between two groups were compared. Result: The failure rate was found significantly higher in control group than in the study group (p=0.043). The control group showed highly significant (0.001) increase in postoperative PVR than the study group and the study group showed significant (0.007) increase in post operative maximum urine flow rate than the control group as was assumed in the hypothesis. Conclusion: In conclusion, it can be said that anastomotic urethroplasty with mucosal fixation is a better option than anstomotic urethroplasty without mucosal fixation. But multicentric trial is needed to further comment. Bangladesh Journal of Urology, Vol. 21, No. 1, January 2018 p.31-34

Increased Vasoconstriction of the Pulmonary Vasculature in Response to a Hypoxic Challenge in Swine Exposed to Hypoxia in the Neonatal Period

IntroductionAdvances in neonatal care improved the survival of very prematurely born infants. Exposure to high oxygen is often necessary to ensure adequate oxygen uptake in these infants, leading to halted development and oxidative injury of the pulmonary vasculature which is often accompanied by increased pulmonary arterial pressure (PAP). Although pressures normalize in school age childhood, various stressors as hypoxia and exercise may unmask increased pulmonary vasoreactivity. Furthermore, now that these infants reach adulthood, it is increasingly recognized that this large, preterm born adult cohort has a less favorable cardiopulmonary risk profile. Particularly male subjects were shown to respond with a higher increase in PAP upon re‐exposure to hypoxia, which might be a predisposition to pulmonary vascular disease later in life. Pathophysiological risk factors causing this predisposition are unidentified and challenging to investigate in the human population.ObjectiveTo assess if swine with perinatal oxidative injury of the pulmonary vasculature respond differently to re‐exposure to a hypoxic stimulus compared to healthy swine.Methods6 male swine were exposed to 10–12% hypoxia in the neonatal period (NH‐swine) for a maximum of 4 weeks to interfere with normal lung development, while 5 male control pigs (healthy swine) were raised in normoxic conditions. In the NH‐swine, a symptom‐guided method (echocardiographic changes and clinical symptoms) orchestrated timing of the return to normoxic conditions. At the age of 8 weeks, NH and healthy swine were chronically instrumented. In week 10, hemodynamics were evaluated at rest and during exposure to 14–15% oxygen for 20 minutes.ResultsNH‐swine were exposed to a 23±5 days of hypoxia. 2 NH‐swine passed away as a consequence of heart failure before chronic instrumentation. At the age of 10 weeks, baseline PAP (14.6±2 vs 13.8±1 mmHg) and pulmonary vascular resistance (PVR, 4.1±0.7 vs 2.8±0.4 WU) at rest was not different in NH‐swine compared to healthy swine. During the hypoxic challenge, oxygen saturation decreased similarly in both groups compared to baseline measurements. PAP increased upon exposure to hypoxia due to an increase in PVR. The increases in PAP and PVR showed a transient peak after two minutes, which were larger in in NH‐swine compared to healthy swine. PAP and ΔPVR stabilized between 10 and 20 minutes of hypoxia exposure at levels that were not different between groups.ConclusionsInterfering with normal lung development in the first weeks of life induces a transiently exaggerated increase in PAP and PVR during a hypoxic challenge at the age of ten weeks. Normalization of PAP and PVR suggests effective counter mechanisms to reduce cardiac work and increase arterial oxygen saturation. The increased response to hypoxia of the pulmonary circulation suggest long‐term structural and/or functional changes that possibly predisposes the pulmonary circulation to adult pulmonary vascular disease.Support or Funding InformationErasmusMC M‐RACEHypoxic challenge data in 10 week old swine exposed to neonatal hypoxia (NH‐swine) compared to healthy swine. A: Arterial oxygen saturation (sO2), B: Pulmonary arterial pressure (PAP), C: Difference in pulmonary vascular resistance compared to baseline values (ΔPVR). BL ‐ baseline, WU ‐ Wood units. *=p&lt;0.05 between groups, †=p&lt;0.05 compared to baseline valuesFigure 1

MP31-07 POST VOID RESIDUAL VOLUME AND RATES OF CLEAN INTERMITTENT CATHETERIZATION WITH SPONTANEOUS AND NON-SPONTANEOUS VOIDING AFTER ONABOTULINUMTOXINA TREATMENT

INTRODUCTION AND OBJECTIVE: OnabotulinumtoxinA (onabotA) is a well-tolerated, effective treatment for overactive bladder (OAB); transient increases in post void residual volume (PVR) have been reported following treatment with some cases requiring clean intermittent catheterization (CIC). Increases in PVR may be a driver for follow-up and CIC initiation in real-world practice. The rate of the complete inability to void has not previously been reported. This analysis evaluated maximum PVR (maxPVR) after onabotA 100U treatment, CIC use, and rates of spontaneous/non-spontaneous voiding. METHODS: This was a pooled post hoc analysis of two phase 3 studies. Patients were stratified based on maxPVR measured during the 12 weeks after initial onabotA 100U treatment into groups of 100 mL increments (0-100 mL, 101-200 mL, 201-300 mL, 301-400 mL, 401-500 mL, 501-600 mL, and ≥601 mL). Rates of clean intermittent catheterization (CIC) were assessed at each maxPVR category and rates of spontaneous and non-spontaneous voiding were calculated in patients who initiated CIC. Per phase 3 protocols, CIC was initiated if PVR was ≥200 to <350 mL with relevant associated symptoms assessed by the investigator, or if PVR was ≥350 mL regardless of symptoms. RESULTS: This analysis included 551 onabotA-treated patients. Most patients had a maxPVR ≤200 mL (494/551, 89.7%) and few patients had a maxPVR ≥201 mL (57/551, 10.3%). Most episodes of significantly raised PVR occurred within the first 6 weeks. In total, 36/551 (6.5%) patients receiving onabotA required CIC throughout the study and was highest in patients with maxPVR >300 mL (25/30, 83.3%) versus ≤300 mL (11/521, 2.1%). No consistent trend in mean CIC duration was observed across the maxPVR subgroups (39-106 days). Only one patient (0.2%) with a maxPVR in the ≥601 mL category was unable to spontaneously void (Figure). CONCLUSIONS: This analysis suggests the vast majority of onabotA-treated patients (99.8%) do not develop a complete inability to void; seen here in only one patient. All other patients that initiated CIC were able to spontaneously void and so did not meet the International Continence Society’s definition of urinary retention (inability to pass urine despite persistent effort).Source of Funding: Allergan plc.

Delivery of intravesical botulinum toxin A using low-energy shockwaves in the treatment of overactive bladder: A preliminary clinical study

ABSTRACTObjective: To evaluate the efficacy and safety of botulinum toxin A (BoNT-A) instillation in the bladder under the effect of low-energy shockwaves (LESWs) for the treatment of refractory idiopathic overactive bladder (OAB).Patients and methods: A preliminary clinical study was conducted, including 15 patients with refractory OAB, between September 2016 and July 2017. Intravesical instillation of 100 IU of BoNT-A was done followed by LESWs (3000 shocks over 10 min) exposure to the supra-pubic area. Patients were followed-up by urine analysis, urine culture, post-void residual urine volume (PVR), and Overactive Bladder Symptom Score (OABSS) at 1, 2 and 3 months.Results: There were statistically significant improvements in all OABSS domains and the total score after 1 and 2 months of treatment (P < 0.05). Whereas, only the nocturia domain remained significantly improved after 3 months (P = 0.02). There was no significant increase in PVR throughout the study period (P > 0.05) and none of the patients required clean intermittent catheterisation. Two, two and three patients developed urinary tract infections after 1, 2 and 3 months, respectively.Conclusion: Intravesical instillation of BoNT-A and LESWs is safe and effective method for the treatment of refractory OAB with a durable response for 2 months.Abbreviations: BoNT-A: botulinum toxin A; CIC: clean intermittent catheterisation; DO: detrusor overactivity; LESWs: low-energy shockwaves; OAB: overactive bladder; OABSS: Overactive Bladder Symptom Score; Qmax: maximum urinary flow rate; QoL: quality of life; UUI: urgency urinary incontinence

Adjustable transobturator sling for the treatment of primary stress urinary incontinence.

The purpose of the study was to evaluate the rate of postoperative voiding dysfunction after the insertion of an adjustable transobturator sling for the treatment of primary stress urinary incontinence (SUI). The secondary aim was to assess the objective and subjective cure rates and the impact of the surgery on quality of life. This prospective study included 171 patients with primary SUI who underwent insertion of an adjustable transobturator tape. A postoperative tension adjustment algorithm that included a cough stress test (CST), uroflowmetry and postvoid residual volume (PVR) measurement was applied in all patients the day after surgery. The baseline and control postoperative evaluations included vaginal examination, CST, Q-tip test, uroflowmetry and PVR measurement, 1-h pad test and administration questionnaires (UDI-6, IIQ-7, PISQ-12, ICIQ-SF). The day after surgery 65 patients (38.0%) required tape tension adjustment: an increase in tension in 53 patients (31.0%) and a decrease in 12 (7.0%). Continence was achieved in all patients. No patients showed voiding dysfunction after adjustment. Follow-up data for 12months were available in 157 patients (91.8%). The objective and subjective cure rates were 96.2% and 97.5%, respectively. There was no statistically significant decrease in Qmax (p = 0.899) or increase in PVR (p = 0.187). According to the questionnaires scores, quality of life was improved in all patients. The adjustable transobturator sling minimizes the risk of postoperative voiding dysfunction and allows high objective and subjective cure rates to be achieved in patients with primary SUI. The technique also improves the patient's quality of life.

The Relationship of Anterior Vaginal and Apical Position to Postvoid Residual Urine.

The aim of the study was to investigate the association between severity of anterior vaginal or apical prolapse and postvoid residual volume (PVR). The charts of all women who presented to Urogynecology Clinic at Olive View-UCLA Medical Center for a 2-year period were reviewed. Demographic data, the degree of prolapse pelvic organ prolapse quantification points Aa, Ba, and C, and PVR were recorded. Patients with incomplete pelvic organ prolapse quantification assessment or improperly measured PVR were excluded. Three hundred fifty-two patients were included. Median age was 54 years (range, 26-80). Mean gravidity and parity were 4.4 and 3.7, respectively. Mean body mass index was 29.9 kg/m. One hundred forty-nine women had previous pelvic surgery. Median PVR was 25 mL, and 40 patients (11.4%) had a PVR of 100 mL or greater.Considering 15 potential PVR predictors, we found that the position of apex/cervix (point C) significantly correlated with an increase in PVR and also after controlling for the other significant covariates (rate of change b = 4.7% increase in PVR/cm, P = 0.0007). The other significant (P < 0.05) covariates were gravidity (5.7% per pregnancy), postmenopausal status (32.4%), and vaginal surgical history (61.4%). This was not true, however, for the anterior vaginal position (points Aa, Ba; P > 0.15). There was no difference in mean PVR in patients with versus without a hysterectomy (P = 0.236). Elevated PVR values have long been linked with prolapse of the anterior vaginal wall. We found that there is a linear association between PVR and the anatomic position of the apex. There was no association of PVR with the position of the anterior vaginal wall.

The Aging Bladder in Females Evaluated by Urodynamics

Aim: To determine whether bladder functions deteriorate with age. Methods: Data contained in electronic medical record (INFOMED?) were used in this institutional retrospective review. Analysis was done on the urodynamic studies in women over 18 years old conducted between May 2011 and November 2015. Patients with previous history of pelvic surgery or radiotherapy, neurological disease, vaginal prolapse greater than grade I, congenital urogenital malformations, urinary obstructive disease, diabetes, or the use of any medication that could interfere with bladder function were excluded from the analysis. The urodynamic parameters analyzed were the Maximum Cystometric Capacity (MCC), Voiding Volume (VV), Maximum Flow (Qmax), Bladder Compliance (BC), Detrusor Pressure at Maximum Flow (PdetQmax), Bladder Contractility Index (BCI), Bladder Voiding Efficiency (BVE) and Post-Void Residual Urine Volume (PVR). Patients were further stratified in five groups according to age (A—18 to 40; B—41 to 50; C—51 to 60; D—61 to 70; E—over 70 years old). Results: Out of 3103 urodynamic studies analyzed, 719 were eligible for the study. The average age of patients was 49.3 (+13.2) years old and in all evaluated parameters, statistically significant correlation between age and decline of bladder function was obtained (p < 0.05). Moreover, mathematical equations were presented to estimate the parameters values in relation to age. Conclusions: This study showed a decline in bladder storage function (reduction in MCC and BC) and in bladder emptying function (reduction in Qmax, PdetQmax, VV, BCI and BVE with an increase in PVR) with age.

Efficacy and Safety of Medium-to-long-term Use of Tolterodine Extended Release with or without Tamsulosin in Patients with Benign Prostate Hyperplasia and Larger Prostate Size: A Double-blind, Placebo-controlled, Randomized Clinical Trial.

Background:The medium-to-long-term use of antimuscarinics alone or in combination with an α-blocker in men with an enlarged prostate is still controversial. This double-blind, placebo-controlled, randomized clinical trial aimed to investigate the efficacy and safety of medium-to-long-term use of tolterodine extended release (ER) with or without tamsulosin in patients with benign prostate hyperplasia (BPH) and larger prostate size.Methods:Totally, 152 patients (age ≥50 years) with BPH, International Prostate Symptom Score (IPSS) ≥12, quality-of-life (QoL) score ≥3, and total prostate volume ≥25 ml were enrolled in this study. The patients were randomized into four groups (n = 38 in each) to receive tolterodine ER placebo plus tamsulosin placebo, 0.2 mg tamsulosin plus tolterodine ER placebo, 4 mg tolterodine ER plus tamsulosin placebo, or tolterodine ER plus tamsulosin once daily for 24 weeks. IPSS (total, storage, and voiding subscales), QoL, maximum urinary flow rate (Qmax), and postvoid residual volume (PVR) were collected at baseline, and at weeks 4, 12, and 24.Results:Compared with placebo, tolterodine ER plus tamsulosin significantly improved total IPSS (−7.15, −12.20, and −14.66 vs. −3.51, −5.78, and −7.23), storage IPSS (−3.56, −5.63, and −6.66 vs. −1.52, −1.21, and −2.43), voiding IPSS (−2.88, −5.10, and −6.48 vs. −1.52, −3.03, and −2.97), QoL (−1.21, −2.40, and −3.21 vs. −0.39, −1.41, and −1.60), Qmax (2.21, 7.97, and 9.72 ml/s vs. 2.15, 2.44, and 2.73 ml/s), and PVR (−17.88, −26.97, and −27.89 ml vs. −12.03, −11.16, and −16.73 ml) at weeks 4, 12, and 24, respectively; the differences were all statistically significant (P < 0.05). Adverse events (AEs) were not increased with treatment progression. Tolterodine ER alone did not improve total IPSS (−4.61, −6.79, and −5.70), voiding IPSS (−0.64, −1.83, and −1.45), QoL (−0.69, −1.21, and −1.41), or Qmax (−0.79, 2.83, and 1.11 ml/s), compared with placebo (all P > 0.05). However, a gradual increase in PVR (10.03, 10.41, and 12.89 ml) and more urinary AEs suggestive of urinary retention (11/38 vs. 4/38) were observed.Conclusion:Medium-to-long-term use of tolterodine ER plus tamsulosin should be recommended in patients with BPH and an enlarged prostate volume.Trial Registration:www.chictr.org.cn, ChiCTR-TRC-09000596; http://www.chictr.org.cn/showproj.aspx?proj=8939.

MP77-07 SAFETY AND EFFICACY OF BOTULINUM TOXIN A TREATMENT FOR PATIENTS WITH DETRUSOR OVERACTIVITY AND INADEQUATE CONTRACTILITY

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction II1 Apr 2016MP77-07 SAFETY AND EFFICACY OF BOTULINUM TOXIN A TREATMENT FOR PATIENTS WITH DETRUSOR OVERACTIVITY AND INADEQUATE CONTRACTILITY Shu-Yu Wu, Chung-Cheng Wang, and Hann-Chorng Kuo Shu-Yu WuShu-Yu Wu More articles by this author , Chung-Cheng WangChung-Cheng Wang More articles by this author , and Hann-Chorng KuoHann-Chorng Kuo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1921AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Botulinum toxin A (BoNT-A) significantly improves OAB symptoms and urodynamic parameters. However, increased PVR volume and risk of urinary tract infection (UTI) after treatment remain concerns among frail elderly patients. This study retrospectively analyzed the therapeutic efficacy and safety in OAB patients who had a baseline PVR >100 mL or VE <67% and received intravesical BoNT-A 100 U injections. METHODS A total of 21 patients with urodynamically proven DHIC and 21 age-matched controlled patients with urodynamic DO were selected from our previous clinical trials. Patients with DHIC should have a PVR of >100 mL but <250 mL, or a VE of less than 67% (voided volume <67% of maximal bladder capacity) at baseline. Patients with DO should have a PVR<50 mL and VE >67% at baseline. Patients were treated with suburothelial injections of 100 U BoNT-A (Allergan, Irvine, CA, USA) in 10 mL, 0.5 mL in each injection, total 20 injections in the bladder body, sparing the trigone. All patients were evaluated at baseline, 2 weeks, and 1, 3, and 6 months after treatment. Treatment results were assessed with global response assessment (GRA), OAB symptom score (OABSS), USS, patient perception of bladder condition (PPBC), and voiding diary parameters. Procedure-related AEs were recorded during the follow-up period after BoNT-A treatment. RESULTS The mean age of DHIC and OAB patients were 71.2±8.2 and 70.9±14.1 years, respectively. The changes of measured parameters from baseline to 6 months in the two groups. The subjective symptom scores after BoNT-A all showed significantly improved in both groups and no difference between groups. However, the changes of urgency episodes per 3 days were only noted in OAB patients after BoNT-A injection. UUI was significantly improved at 3 months and frequency episode was significantly improved at 6 months in OAB patients, but not in DHIC patients. Interestingly, there was no increase of bladder capacity or voided volume in either group. Qmax showed no significant change after BoNT-A injection in either group. PVR increased in DHIC patients at 2 and 4 weeks, but not at 3 and 6 months after BoNT-A injection. However, in OAB patients, the significant increase of PVR was noted at 2 months and lasted to 6 months. Adverse events in the DHIC and OAB patients showed no significant difference between DHIC and OAB. Among these patients, the therapeutic efficacy lasted for a mean of 2.3 months and 4.5 months in DHIC and OAB patients, respectively. CONCLUSIONS Patients with DHIC do not increase the risk of large PVR or decrease of VE after 100 U BoNT-A injection. However, the therapeutic efficacy was significantly diminished in DHIC patients. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1018 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Shu-Yu Wu More articles by this author Chung-Cheng Wang More articles by this author Hann-Chorng Kuo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Pulmonary Hypertension: A Clinical Case Study

The pathophysiology of pulmonary hypertension can vary, depending on the cause. It can be classified as idiopathic/ primary, or it can be secondary to a variety of conditions, such as congenital heart defects, collagen vascular diseases, liver cirrhosis, infections, drugs and radiation therapy, and it can occur postoperatively for several reasons. It can be a result of increased pulmonary vascular resistance due to lung conditions such as COPD, or after lung resection surgeries [1]. Secondary pulmonary arterial hypertension due to cardiac or respiratory diseases can be caused by volume or pressure overload leading to proliferation of pulmonary vasculature and therefore obstruction. Lung parenchymal diseases lead to vascular changes causing vasoconstriction. This increased vascular resistance causes increased right ventricular after load, and eventually hypertrophy and failure [4]. When lung parenchyma is destroyed (as in COPD), there is a destruction of vasculature as well. Hyperinflation of the lungs compresses vascular beds, thus resulting in an increase in PVR. Polycythemia, which can result from chronic hypoxemia, increases the viscosity of the blood and contributes to hypertension as well, and alveolar hypoxia also causes pulmonary vasoconstriction. Over time, this leads to hypertrophy of the tunica media of the pulmonary vessels, fibrosis of the tunica intima, and an overall narrower lumen. This increase in vascular resistance and pressures leads to an increased right ventricular afterload, leading to dilation and hypertrophy of cardiac muscle mass in order to maintain cardiac output [1].

Tamsulosin combined with solifenacin versus tamsulosin monotherapy for male lower urinary tract symptoms: a meta-analysis

Objective:To evaluate the efficacy and safety of tamsulosin and solifenacin combination therapy compared with tamsulosin monotherapy for male lower urinary tract symptoms (LUTS).Methods:We identified all eligible studies that compared tamsulosin and solifenacin combination therapy with tamsulosin monotherapy for male LUTS (up to January 2015). The fixed- or random-effects model was selected depending on the proportion of heterogeneity.Results:Seven articles were identified as eligible for this meta-analysis, with a total of 3063 participants. Synthetic data showed combination therapy had significant improvements in Storage International Prostate Symptom Score (WMD = −0.60; 95% CI: −0.81 to −0.38, P < 0.0001), quality of life (WMD = −0.23; 95% CI: −0.34 to −0.11, P < 0.0001), micturitions per 24 hours (WMD = −0.70; 95% CI: −0.86 to −0.55, P < 0.0001) and urgency episodes per 24 hours (WMD = −0.26; 95% CI: −0.48 to −0.05, P = 0.018). The incidence of adverse effects in the tamsulosin and solifenacin combined therapy group (30.82%) was similar to the tamsulosin monotherapy group (25.75%). Acute urinary retention was seldom reported in the studies and no clinically significant changes regarding Qmax were showed in our meta-analysis.Conclusions:Tamsulosin and solifenacin combination therapy may be a reasonable option for male LUTS patients, especially for those who have significant storage symptoms. However, PVR should be measured during treatment to assess the increase in PVR or the incidence of AUR.

Development of Capabilities for Simultaneous Assessment of Pulmonary and Systemic Hemodynamics in Conscious Rat to Identify Therapies with Pulmonary Selectivity

Novel therapies for pulmonary arterial hypertension (PAH) that specifically dilate the pulmonary vasculature are desired. Our aim was to establish capabilities to monitor pulmonary and systemic pressures and cardiac output simultaneously in a conscious rat model of PAH to identify those therapies that show pulmonary selectivity. To achieve this capability, HD‐S21 dual pressure transmitters from Data Science International were surgically implanted to male Sprague‐Dawley rats with one catheter placed in the pulmonary artery and other in the abdominal aorta to measure pulmonary and systemic arterial pressure (PAP, SBP) simultaneously. Rats were also instrumented with flow probes (Transonic Systems Inc) around the ascending aorta to monitor cardiac output (CO) and to calculate intra‐rat pulmonary and systemic vascular resistance (PVR, SVR). Rats were exposed to hypoxia (10% O2) for two weeks to create a clinically relevant PAH disease model. The increase in mean PAP was 18 ± 1 to 50 ± 2 mmHg which was mainly due to the increase in PVR (0.14 ± 0.01 to 0.57 ± 0.06) mmHg/ml/min. The methods were validated using Tadalafil, a standard PAH therapy inhibiting PDE 5 at 1, 3 and 10 mg/kg which showed dose dependent decreases in PAP and PVR to a greater extent than the SBP and SVR. In conclusion, innovative capabilities to determine PVR and SVR simultaneously have been established in conscious rodent which allows us to directly compare pulmonary and systemic hemodynamic activities in the same animal minimizing cross‐study variability with different cohort of animals. These methods have provided us with a powerful approach to identify therapies for PAHs with pulmonary selectivity.