Infravesical Obstruction Research Articles

Surgical treatment of a true diverticulum of the bladder in a patient with aplasia of the left kidney. Case report

A bladder diverticulum (BD) is a blindly terminating sac-like protrusion of the bladder wall with or without involvement of the muscular layer. BDs are categorized into true (congenital) and false (acquired), single and multiple. False diverticula are more common and develop in infravesical obstruction due to urethral stricture, prostate neoplasms, neurogenic disorders and other lower urinary tract diseases. Currently, there are no clear recommendations regarding the tactics of treatment of BD, so the choice of treatment method is based on the determination of the cause of BD, assessment of clinical manifestations and diagnostic results (localization, size, number, etc.), as well as the identification of concomitant anomalies and diseases of the upper urinary tract. The priority in the treatment of BD is surgical treatment. The article presents the observation of a patient with a developmental anomaly in the form of aplasia of the left kidney combined with a large congenital BD in the area of the missing mouth of the aplasic left ureter. The results of examination and treatment in the form of laparoscopic diverticulectomy are presented. A brief review of the literature on the problem of diverticulosis has been carried out.

Commentary on JPUROL-D-23-00699R2: “Seeking clinical consensus on risk assessment in anatomical infravesical obstruction of boys – A Delphi study”

Commentary on JPUROL-D-23-00699R2: “Seeking clinical consensus on risk assessment in anatomical infravesical obstruction of boys – A Delphi study”

Seeking clinical consensus on risk assessment in anatomical infravesical obstruction of boys – A Delphi study

Infravesical obstruction (IO) is a common urological condition in young boys. Patients may present with various signs and symptoms at different ages, with severity depending to a large extent on the degree of obstruction. Consensus concerning accurate and objective modalities to diagnose IO and to differentiate between an anatomical or functional cause is still lacking. This study aimed to reach consensus on the diagnostic determinants that are important to assess the likelihood of anatomical IO in boys and differentiate between an anatomical or functional cause. A Delphi method was used to establish a list of diagnostic determinants that can be utilized in order to diagnose anatomical IO in boys. An international and interdisciplinary panel of experts was recruited to reach consensus using three sequential rounds of electronic questionnaires. Data were collected using the online survey platform Qualtrics. Rounds one and two were used to define diagnostic determinants. Round three was used to stratify key determinants according to age. All rounds received a response rate of 100%. In round one, consensus was achieved on 44 of a total 79 items. In round two, consensus was achieved on 19 of a total 51 items. Round three identified a variation in key determinants per age group. To create an effective tool for assessing IO in boys, key determinants identified in this study will need to be validated in a prospective clinical trial. Due to a large number of determinants and sections, this will not be a trivial task. In addition, since a Delphi study is based on expert opinion, any consensus achieved remains subjective. Diagnostic determinants identified in this study will need to be validated using prospective clinical data. Artificial Intelligence provides techniques for uncovering complex associations that cannot easily be reduced to equations. It may therefore play a pivotal role in the future development of robust IO risk assessment tools. An international group of experts agreed that a risk assessment tool for IO in boys would be beneficial for both clinical practice and research purposes. Using a Delphi study methodology, consensus was reached on a set of diagnostic determinants that were considered important to assess the likelihood of IO and differentiate between an anatomical or functional cause. This study paves the way for further research on IO in boys. Eventually this could lead to an accurate and standardized assessment tool for IO.

THE ROLE OF LATE-ONSET HYPOGONADISM IN THE PATHOGENESIS OF MORPHO-FUNCTIONAL CHANGES IN THE URINARY BLADDER DUE TO BENIGN PROSTATIC HYPERPLASIA

Introduction. One of the key characteristics of the lower urinary tract is its hormone dependence. Pathophysiological mechanisms of lower urinary tract symptoms in patients with benign prostatic hyperplasia include infravesical obstruction, formation of a fibrous framework in the urinary bladder, disruption of the urothelial barrier, and changes in the nervous and vascular networks of the pelvis. However, to date, there is a lack of data on the pathophysiological relationship between testosterone deficiency and morpho-functional changes of the bladder. The purpose of this study is to investigate the role of age-related hypogonadism in the pathogenesis of morpho-functional changes in the urinary bladder among patients with benign prostatic hyperplasia. The results of the examination of 70 patients with benign prostatic hyperplasia, aged from 47 to 83 years (mean age 67.94 ± 7.42 years), were analyzed. The first group consisted of 20 patients, whose disease duration was 4 ± 1.8 years. They had an International Prostate Symptom Score (IPSS) of 16 ± 4.5 points, a maximum flow rate (Qmax ) of 15.8 ± 2.4 ml/s, an average flow rate (Qave) of 12.8 ± 2.8 ml/s, and no post-void residual. The second group included 20 patients with incomplete bladder emptying, with a disease duration of 5.8 ± 3.5 years. Their IPSS was 26 ± 3.9 points, Qmax was 10.8 ± 2.5 ml/s, Qave was 4.4 ± 1.4 ml/s, and post-void residual was 150.1 ± 80.8 ml. The third group comprised 30 patients who had undergone cystostomy, with a disease duration of 10.6 ± 3.3 years. Before cystostomy, their IPSS was 33.1 ± 1.88 points, and post-void residual was 1093.3 ± 458.8 ml. During surgery, all patients with benign prostatic hyperplasia were taken a biopsy from the anterior wall of the bladder. In benign prostatic hyperplasia patients in the stage of bladder compensation, the level of testosterone was 15.39±1.44 nmol/l, the Aging Males Symptoms indicator was 24.80±5.78 points. Morphometric analysis of bladder tissue demonstrated the following: the diameter of the lumen of arterioles was 27.96±2.14 μm, the thickness of the arteriole wall was 16.03±1.83 μm, the Kernoghan index for arterioles was 1.22±0.17, the specific gravity of connective tissue made 4.48±0.82%, the diameter of SMCs was 7.46±1.66 μm. In benign prostatic hyperplasia patients in the stage of bladder subcompensation, the level of testosterone was 10.92±2.24 nmol/l, the Aging Males Symptoms index was 37.9±8.0 points. Morphometric analysis of bladder tissue revealed the following: the diameter of the arteriole lumen was 23.78±1.62 μm, the thickness of the arteriole wall was 18.30±1.32 μm, the Kernoghan index for arterioles was q1.65±0.18, the specific gravity of the connective tissue made up 11.80±1.22%, the diameter of SMCs was 7.07±1.93 μm. In benign prostatic hyperplasia patients in the stage of bladder decompensation, the level of testosterone is 9.66±2.13 nmol/l, the Aging Males Symptoms index is 55.80±6.69 points. Morphometric analysis of bladder tissue showed the following: the diameter of the arteriole lumen was 19.0±2.08 μm, the thickness of the arteriole wall – 21.01±1.57 μm, the Kernoghan index for arterioles was 2.41±0.32, the specific gravity of the connective tissue made up 29. 46±1.35%, the diameter of SMCs was 4.75±1.87 μm. The obstructive component is not the only causal factor of bladder decompensation in patients with benign prostatic hyperplasia. A decrease in the level of testosterone triggers a cascade of pathological processes that negatively affect the morpho-functional state of the prostate gland and worsen the results of surgical treatment of patients with benign prostatic obstruction.

Familial congenital lower urinary tract obstruction (LUTO) suggested by screening for lower urinary tract dysfunction in parents of patients: A descriptive study.

Congenital lower urinary tract obstruction (LUTO) describes a heterogeneous group of congenital malformations. Posterior urethral valves (PUV) represent the most common entity. Familial occurrence has been described, suggestive of underlying genetic factors. LUTO can occur in various degrees of severity. In severe forms, oligohydramnios, pulmonary hypoplasia, and renal damage can occur resulting in high pre- and postnatal mortality. On the contrary, mild forms may become apparent through recurrent urinary tract infections. Such high phenotypic variability has been described even within the same family. Here, we systematically screened parents of affected children for symptoms of LUTO. The study population consisted of parents of LUTO patients. Fathers over 50 years of age were excluded, to avoid inclusion of male phenocopies due to early prostatic hypertrophy. Uroflowmetry, ultrasonography for residual urine and hydronephrosis, and laboratory examination of standard renal retention parameters were assessed, and a detailed patient history was taken, including the assessment of the International Prostate Symptom Score. Twenty-nine of 42 LUTO families enrolled were found eligible for the present study. Of these, we identified five families in which the father had already been diagnosed with infravesical obstruction (17%). Of the remaining families, nine agreed to participate in our study. Of these nine families, eight families had a child affected with PUV and one family had a child with urethral stenosis. Here, we found two fathers and one mother with symptoms ofLUTO suggestive of mild LUTO and one family, in which the unborn male fetal brother of the affected index patient was also diagnosed prenatally with LUTO. Our observations suggest that LUTOs have a higher heritability than previously thought and that first-degree relatives of the affected should be clinically assessed for symptoms of LUTO.

Robot-assisted radical prostatectomy in patients after endoscopic surgeries on the prostate

Background. In literature, data on the results of robot-assisted radical prostatectomy (RARP) in patients after transurethral resection of the prostate (TURP) are contradictory.Aim. To evaluate surgical, functional, and oncological outcomes of RARP after TURP.Materials and methods. At the Urology Center of the Mariinsky Hospital (Saint Petersburg), RARP was performed on 410 patients. Among them, 28 (6.8 %) patients (1st group) previously underwent TURP due to infravesical obstruction. Among them, 18 (64.3 %) patients were diagnosed with prostate cancer after pathomorphological examination of the tissue resected during TURP, and on them RARP was performed on average 3.2 months later. In 10 (35.7 %) patients, prostate cancer was diagnosed during transrectal biopsy due to increased prostate-specific antigen level; on them RARP was performed on average 42.0 months after TURP. The following parameters were evaluated: operative time, time of bladder neck reconstruction and urethrovesical anastomosis formation, blood loss volume, tumor pathological stage, Gleason score, surgical margin status, rates of urine continence and preservation of erectile function.Results. Mean operative time was higher in the 1st group compared to the 2nd: 210 ± 36 min versus 180 ± 25 min (р <0.0001). In the 1st group compared to the 2nd, reconstruction of bladder neck was necessary more frequently (82.1 % versus 10.7 %; р <0.0001), urethrovesical anastomosis took longer time (32 ± 2.3 min versus 24.5 ± 3.1 min; р <0.0001), mean blood loss volume was higher (240 ± 39 mL versus 170 ± 32 mL; р <0.0001). Frequencies of positive surgical margin were 14.3 and 10.7 % respectively in the 1st and 2nd groups (р = 0.840). Frequencies of all complications were 28.6 and 21.4 %, respectively. Severe complications (≥IIIb grade per the Clavien classification) were observed in 2 (7.1 %) patients in both groups. Frequency of anastomosis stricture after surgery was significantly higher in the 1st group: in 2 (7.1 %) and 1 (3.6 %) case, respectively (р <0.05). In the 1st group, total urinary continence was achieved in 14 (50.0 %), 20 (71.5 %), 22 (78.5 %) and 25 (89.3 %) patients at early and 3-, 6and 12-month follow-up after RARP; in the 2nd group, it was achieved in 18 (64.3 %), 22 (78.6 %), 24 (85.7 %) and 26 (92.9 %) patients in the same follow-up periods. After 6 and 12 months, in the 1st group among 15 (53.6 %) patients with normal initial erectile function, satisfactory erectile function was preserved in 46.7 and 93.3 % of patients; in the 2nd group among 19 (67.8 %) patients, in 57.8 and 94.7 % patients, respectively.Conclusion. RARP after TURP is a relatively complicated surgical intervention with long operative time and high blood loss volume. However, functional and short-term oncological outcomes of RARP in these patients do not differ at 12 months.

A review of pediatric infravesical obstructions

A review of pediatric infravesical obstructions

Современные возможности лечения доброкачественной гиперплазии предстательной железы и симптомов нижних мочевыводящих путей: новые данные и опыт клинического применения гексанового экстракта плодов Serenoa repens

The article discusses the pharmacological properties and results concerning the clinical use of a medicinal herbal preparation — hexane extract of Serenoa repens (HESr) (creeping palm fruit). In recent years, quite a lot of research data has been accumulated indicating a multicomponent mechanism of drug action. It has been found to have antiandrogenic, antiproliferative and anti-inflammatory effects in the tissues of the prostate gland (pancreas). Studies have been published describing a new mechanism of action of HESr — antineurogenic, the implementation of which helps to reduce infravesical obstruction, leads to inhibition of α1-adrenergic, thromboxane-induced and cholinergic contraction of the pancreatic and detrusor smooth muscles, and also inhibits the growth of pancreatic stromal cells. At present, there is evidence proving the highest clinical efficacy level of the HESr (data from several meta-analyses). The listed effects and patterns of HESr are illustrated by clinical examples of prescribing this drug to patients with lower urinary tract symptoms and benign pancreatic hyperplasia. The safety of use in conditions of polypragmasy in a comorbid patient, the possibility of long-term use without the adverse events occurrence and ensuring a higher life quality while maintaining full sexual function are also particularly noted. KEYWORDS: lower urinary tract symptoms, benign prostatic hyperplasia, chronic bacterial prostatitis, hexane extract of Serenoa repens fruit, ejaculation, life quality. FOR CITATION: Amdiy R.E., Simanov R.N. Modern treatment options for benign prostatic hyperplasia and lower urinary tract symptoms: new data and clinical picture of the hexane extract of Serenoa repens fruit. Russian Medical Inquiry. 2024;8(4):228–234 (in Russ.). DOI: 10.32364/2587-6821-2024-8-4-7.

Late Arteriovenous Fistula after transurethral resection of the prostate: case report

This study describes a case of symptomatic arteriovenous fistula after Transurethral Resection of the Prostate diagnosed by urethrocystoscopy and confirmed by imaging tests. The patient presented lower urinary tract symptoms associated with hematuria twenty years after being submitted to a TURP. Arterial and venous tomography angiography of the pelvis visualized a hypervascularized lesion involving the membranous urethra and aneurysm of the right external iliac artery. The patient underwent embolization of bilateral prostatic arteries with good post-embolization recovery and complete remission of urinary symptoms. Arteriovenous fistula after transurethral resection of the prostate is a rare pathology that must be considered in the differential diagnosis of persistent hematuria and infravesical obstruction without significant prostatic enlargement. In cases like this, embolization has become a new therapeutic option with excellent obliteration rates and minimal morbidity.

Neglected ureteral stent in a patient with chronic kidney disease and solitary functioning kidney: case report and review of literature

Introduction: A ureteral stent is crucial for managing urinary flow obstruction, ureteral reconstructive surgeries, and iatrogenic ureteral injuries. The authors aim to report a case of forgotten double-J stent for 17 years, the longest time reported in literature in a patient with solitary kidney and no typical long-term complications as stones formation and encrustation. Case presentation: A 58-year-old male with chronic kidney disease and solitary left kidney presented with left loin pain. With creatinine higher than baseline (6.2 mg/dl), he reported a neglected double-J stent placed 17 years ago in a different hospital. In addition, non-contrast computed tomography and cystoscopy revealed hydronephrosis, cystitis, and an element of infra-vesical obstruction, evident by high bladder neck. Treatment included left percutaneous nephrostomy, but he was readmitted few weeks later for cystoscopy, ureteroscopy, and a new double-J insertion. Due to worsening renal function, he was readmitted four weeks later for cystoscopic removal of the new double-J stent and Transurethral Resection of the Prostate, after which creatinine returned to baseline. Discussion: Double-J stents are vital in urological procedures, but neglecting their presence can lead to severe complications like encrustations, stone formation, stent fractures, hydronephrosis, infections, and renal function loss. Treatment of long-term complications is difficult and should consider many factors, including the type and severity of associated complications and the patient’s preoperative status. Conclusion: Preventing complications from neglected or forgotten double-J stents through patient education and follow-up is crucial, especially in those with solitary functioning kidneys due to the imminent loss of renal function.

Clinical use of high dose-rate brachytherapy in treatment of patients with localized prostate cancer and infravesical obstruction

Background. High dose-rate brachytherapy is a new method of interstitial radiation therapy for treatment of localized prostate cancer. The difference from low dose therapy is temporary implantation of radiation sources with targeted high dose-rate irradiation of the affected organ.Aim. To evaluate 3-year effectiveness and safety of high dose-rate brachytherapy in patients with infravesical obstruction. Materials and methods. Between January of 2017 and December of 2019 at the Central Clinical Hospital “RZD-medicine”, 49 patients (mean age 67.8 ± 7.5 years) with verified prostate cancer diagnosis underwent high dose-rate brachytherapy in the regimen of 2 sessions of 15 Gy with 192Ir source. The inclusion criteria were disease stage ≤сТ2с, Gleason score ≤7. Patients were divided into 2 groups: 1st – patients with incidental prostate cancer (n = 21) who previously (more than 6 months ago, mean time 9.4 ± 2.4 months) underwent transurethral prostatectomy; 2nd – patients with verified prostate cancer (mean prostate volume 56 cm3) and obstructive symptoms without previous transurethral prostatectomy (n = 28).Results. In both groups, no intraoperative complications were observed. In 6 (28 %) patients of the 1st group and 2 patients of the 2nd group, grade II genitourinary toxicity in the form of moderate dysuria and nocturia was observed. Acute gastrointestinal toxicity was observed in 3 (14 %) patients of the 1st group, in the 2nd group such complications were absent. In the 2nd group during the postoperative period after the 2nd session, 4 patients (14 %) experienced acute urinary retention requiring cystostomy.Conclusion. High dose-rate brachytherapy is a safe and effective radical treatment method for patients with localized prostate cancer with obstructive symptoms who have contraindications for surgical treatment.

Indirect signs of infravesical obstruction on voiding cystourethrography improve post-neonatal posterior urethral valves detection rate

ObjectivesTo identify the diagnostic performance of clinical and radiological signs (on voiding cystourethrography [VCUG]) to detect posterior urethral valves (PUV) in the post-neonatal period.Materials and methodsOne hundred eighteen males (median age = 0.8 years, range = 1 month–14 years, 48 toilet-trained) undergoing VCUG in a 2-year period were prospectively enrolled. Direct (dilated posterior urethra) and indirect (hypertrophied bladder neck, musculus interuretericus hypertrophy, and trabeculated appearance of the bladder wall) PUV signs on VCUG were assessed. Uroflowmetry was defined pathological by patterns suggesting infravesical obstruction.ResultsTwenty-two patients with direct, 28 with indirect PUV signs on VCUG, and one with normal VCUG but persisting micturition symptoms with pathological uroflowmetry underwent urethrocystoscopy and in 43/51 a PUV diagnosis was made (n = 22, 51.2%, with direct PUV signs). In 8/28 patients with indirect signs, PUV were not confirmed. Among non-toilet-trained patients, none of the clinical signs/symptoms was associated with PUV while among toilet-trained patients only pathological uroflowmetry (odds ratio, OR = 4.0 [95% confidence interval:1.2–13.2; p = 0.02]) and pathological uroflowmetry with history of urinary tract infection (OR = infinity) were significantly associated with PUV. Significant associations with PUV of direct and indirect signs on VCUG were found both in toilet-trained and non-toilet trained patients. Direct PUV sign had 100% specificity and sensitivity while indirect PUV signs showed sensitivity = 58.1% and specificity = 89.3%. The absence of any radiological sign had a negative predictive value = 98.5%.ConclusionOnly half of patients with endoscopy-confirmed PUV presents with direct sign of PUV on VCUG. Accounting for indirect PUV signs on VCUG and pathological uroflowmetry (in toilet-trained children) could improve the PUV detection rate.Clinical relevance statementIndirect radiological PUV signs should be valorized when interpreting VCUG to improve the PUV detection rate. The absence of any radiological PUV (direct and indirect) sign on VCUG excludes PUV with a very high negative predictive value.Key Points• Worldwide agreement is that a non-dilated urethra on voiding cystourethrography excludes obstruction.• Half of patients with posterior urethral valves have non-dilated urethra on voiding cystourethrography.• Accounting for indirect signs of posterior urethral valves on voiding cystourethrography improves the diagnostic performance.

Гипотеза о возможных механизмах терапевтического действия гексанового экстракта Serenoa repens на состояние гипертрофированного мочевого пузыря в соответствии с патогенезом его дисфункции при инфравезикальной обструкции.

Introduction. Traditionally it is believed that the therapeutic effect of the hexane extract of Serenoa repens (HSRE) in patients with benign prostatic hyperplasia is realized due to its effect on prostate cells. However, in the literature there is data about the possible HSRE effect not only on the prostate, but also directly on the bladder. This paper summarizes data and analyzes the possible cellular mechanisms of HSRE action on the bladder under the development of infravesical obstruction (bladder outlet obstruction – BOO). Materials and methods. Literature data from the PubMed and eLibrary.ru databases for a 25-years period related to the study of the pathogenesis of bladder dysfunction in the development of BOO, cellular and molecular mechanisms by which pathological and adaptive processes in bladder cells are realized, as well as the influence of HSRE on these processes are analyzed. Results. The concept of the pleiotropic effect of HSRE on various links in the pathogenesis of bladder dysfunction caused by BOO has been formed. The main of which are: the antioxidant and anti-inflammatory effects of HSRE components, as well as the regulatory effect on cell growth and proliferation factors and transcription factors. All this reduces the cytotoxic effect of oxidative stress on the cells of the bladder developing in IVO, contributing to a more active proliferation of detrusor smooth muscle cells. The consequence of the complex action is to maintain the contractile function of the bladder in a state of adaptation to increased stress, due to BOO. Conclusions. The present hypothesis about the direct effect of HSRE on the hypertrophied bladder and possible mechanisms of its therapeutic action is based on an understanding of the general biological mechanisms and allows us to explain better the results of previous clinical studies and to assess the prospects for expanding the scope of further drug application.

Отдаленные результаты применения субуретральной петлевой пластики с контролем натяжения в лечении недержания мочи.

Introduction. Urinary incontinence is a disease that significantly reduces the quality of life in patients. Suburethral loop plasty is still the gold standard for the treatment of stress urinary incontinence, which is highly effective, but also has a number of possible postoperative complications. The purpose of this article is to evaluate the long-term results (after 4 years), the effectiveness and safety of the use of suburethral loop plasty with tension control. Materials and methods. Currently, there is no single way to adjust the tension of the hinge during its installation. At the Department of Urology of A.I. Yevdokimov Moscow State University of Medicine and Dentistry developed a device to control the tension of the loop, presented in the form of a self-absorbable pad (damper layer) located in the middle of a synthetic prosthesis. A prospective, comparative, randomized study that began in 2018 showed a high efficacy and safety profile for this device. When analyzing the results 1 year after the operation, the effectiveness of surgical treatment was 96%, the rate of postoperative complications in the form of infravesical obstruction was 2%, de novo urgency in the study group was 6%. In this study, we assessed long-term mid-term outcomes (over 4 years) through a telephone survey and filling in validated questionnaires (Urogenital distress inventory – UDI-6, Incontinence Impact Questionnaire – IIQ-7) among patients who underwent suburethral loop plasty with a loop tension control device. Results. The average score on the UDI-6 survey was 1.22 ±0.81, and 1.2±0.77 on the IIQ-7 survey. After a telephone survey after 48 months, there was a slight increase in scores, when compared with the results of the survey 12 months after surgical treatment, but not statistically significant (p>0.05). In the analysis of individual clinical cases after 48 months, 10 patients noted worsening of symptoms. Of these, 6 patients noted a recurrence of urinary incontinence when coughing, physical activity. Accordingly, the subjective effectiveness of surgical treatment over a 4-year follow-up period was 88%. Conclusions. Efficacy and safety data, in the medium-term follow-up of patients after suburethral loop plasty with tension control, are comparable to world data. However, further monitoring of patients in the long term is required.

Infravesical Obstruction in a Boy with Orthotopic Ureterocele: Clinical Case

Background. Ureterocele is a cystic dilatation of the distal ureter. Orthotopic ureterocele is relatively rare form of this disease, and it is commonly diagnosed in female children. The clinical picture of orthotopic ureterocele is usually not significant, and the management variants are unclear. Clinical case description. Ultrasound has revealed dilatation in the distal part of the left ureter (up to 6.5 mm) and cyst formation (diameter of 8 mm, thick walls) in the bladder in 8-months-old boy. The retrograde voiding cystourethrogram has shown no signs of vesicoureteral reflux. The evaluation of the voiding rhythm was performed: the volume of residual urine was > 30%, it indicates the infravesical obstruction. The child underwent diagnostic cystourethroscopy, transurethral resection of the ureterocele, intubation ureteral catheter in the left ureter (all procedures was performed under general anesthesia). There were no enlargements of calices-pelvis system and ureters 12 months after surgery according to urinary system ultrasound. Clinical urine test with no inflammatory changes. Voiding rhythm was without pathology.Conclusion. The widespread implementation of high-tech and minimally invasive methods of diagnosis and management allow us to achieve timely detection and provide effective treatment for children with ureterocele.

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.

Hyperactive Bladder in Men: Modern Recommendations and Practical Approaches to Diagnosis and Treatment

An analysis of modern recommendations of the European Association of Urologists (EAU) regarding diagnosis and treatment options for overactive bladder (OAB) in men was carried out, taking into account real practice. The article discusses the general principles of diagnosis and treatment of non-neurogenic male lower urinary tract symptoms (LUTS) in the case where the predominant clinical features are urgency, pollakiuria, nocturia, which can be combined with urinary incontinence – complaints typical of GSM. Approaches to the treatment of such patients are still not clearly defined, and the effectiveness of treatment does not always satisfy both doctors and patients. It is indicated that in recent years, doctors have received completely new treatment options for this disease in men. In addition to adrenoblockers (AB) and cholinolytics (HL), phosphodiesterase-5 inhibitors (IPDE) and beta-3 adrenomimetics (BAM) were added, which showed their effectiveness and safety not only in women, but also in men. In addition, new options for combined treatment appeared in the recommendations – in addition to AB+HL, a combination of AB+IPDE and HL+BAM is possible. The article discusses various groups of drugs and their combinations recommended for the treatment of LUTS, the specifics of their use and possible side effects, especially the risks of urinary retention in men with infravesical obstruction. It is emphasized that the EAU currently recommends the use of HL in men with moderate and severe LUTS, who mainly have symptoms of accumulation with a residual urine of no more than 150 ml. It is recommended to determine the patient’s residual urine after a week of taking HL. The practical aspects of choosing the category of patients to be treated with certain drugs (or their combinations) are discussed, taking into account the possible side effects of each of the treatment options.

Congenital diverticulum of the anterior urethra of non-obstructive genesisS

Congenital diverticulum of the distal urethra is extremely rare in urological practice, there are isolated descriptions of it in the literature, as a result every clinical observation is of interest. The aim of this study is demonstration of a rare clinical observation congenital diverticula of the distal urethra without infravesical obstruction (meatostenosis) in a teenager.
 The article describes a clinical case of treatment of congenital diverticula of the anterior urethra without signs of infravesical obstruction in a 13-year-old teenager.
 A case of surgical treatment of congenital urethral diverticulum without infravesical obstruction in a 13-year-old teenager is presented. Diverticulectomy with suture of the urethra was performed with good anatomical and functional results.
 A distal urethral diverticulum of a congenital nature is extremely rarely noted as an isolated condition without an anterior urethral valve or another variant of infravesical obstruction. The method of choice is to perform diverticulectomy with suturing of the urethra.

INFLUENCE OF TRANSURETRAL PROSTATE RESECTION ON THE REFLECTOR MECHANISM OF PELVIC FLOOR MUSCLE REGULATION

A group of 9 patients, average age 62, with symptoms of urination disorders, who underwent surgical intervention for infravesical obstruction (IVO), were under observation. Patients underwent urodynamic examination in the volume of liquid static profilometry using a specialized standard 10F catheter before and after surgery. The urodynamic system of domestic production LEVELEST SURD-02 was used. Based on the data obtained, the reflex mechanism of pelvic floor tone was analyzed in patients with prostate adenoma operated by transurethral enucleation.

DISRUPTION OF THE UROTHELIAL BARRIER UNDER BENIGN PROSTATIC HYPERPLASIA AS A COMPONENT OF BLADDER DECOMPENSATION

Introduction. The urothelial barrier resists the aggressive effect of urine on the bladder tissues. Chronic retention of urine causes the development of an infectious and non-infectious inflammatory process with metaplasia and desquamation of the urothelial layer of the bladder. With long-term infravesical obstruction, the contact density between urothelial cells is disturbed, which leads to the loss of the barrier function of the mucous membrane of the urinary bladder.
 The purpose of the study is to investigate the role of urothelial barrier disruption in the development of urinary bladder decompensation in patients with BPH.
 Materials and methods. 70 patients with BPH were selected, their average age was 67.94±7.42 years. They underwent a bladder biopsy during the operation, followed by a pathomorphological examination.
 According to clinical manifestations, patients were divided into three groups: group I included 20 patients with bladder compensation (I-PSS – 16±4.5, Qmax – 15.8±2.4 ml/s, Qave – 12.8±2.8 ml/s, without post void residual); group II involved 20 patients with bladder subcompensation (I-PSS – 26±3.9, Qmax – 10.8±2.5 ml/s, Qave – 4.4±1.4 ml/s, post void residual – 150.1 ±80.8 ml.); and III group included 30 patients with bladder decompensation (before the cystostomy I-PSS – 33.1±1.88, post void residual – 1093.3±458.8 ml).
 Results. In the compensation stage of the bladder there is found multilayer transitional cell urothelium that often forms folds, causing pseudoepithelial outgrowths. The detrusor is represented by hypertrophied smooth muscle cells, with the phenomena of moderate hydropic dystrophy in individual myocytes, with isolated small foci of sclerosis. In the stage of bladder subcompensation we observe foci of desquamation of the surface layers of the urothelium and dystrophic changes in epitheliocytes. Areas of atrophy are combined with foci of hyperplasia of epitheliocytes with stratification of the epithelium (up to 14 - 18 layers or more). The lamina propria of the mucous membrane is swollen in most cases, the formation of lacuniform slits is seen. There are often foci of lymphoplasmacytic infiltration. The detrusor is mostly represented by hypertrophied smooth muscle cells, a significant number of which have signs of hydropic dystrophy.
 In the stage of bladder decompensation the foci of total desquamation of all layers of the urothelium can be observed; pronounced dystrophic changes of epitheliocytes also take place. The own plate of the mucous membrane is sharply thickened: due to the formation of numerous lacuniform slits it has a porous appearance. Erosive changes in the mucous membrane of the urinary bladder are accompanied by pronounced sclerosis of the stroma. In places of desquamation of the urothelium, submucosal foci of sclerosis are observed, which penetrate into the detrusor. The latter is represented by hypotrophied smooth muscle cells with signs of hydropic dystrophy. Due to the massive proliferation of connective tissue, muscle fibres are divided into separate bundles. Diffuse lymphoplasmacytic infiltration is observed in all layers of the bladder.
 Conclusion: The results of pathomorphological studies in the context of clinical and functional characteristics enables to distinguish three stages of SM remodelling in BPH: compensation, subcompensation and decompensation. Long-term chronic retention of urine causes a violation of the urothelial barrier, urine impregnation of all layers of the CM with the development of aseptic inflammation. A progressive increase in the specific weight of connective tissue, dystrophic changes in myocytes and nerve fibres become the cause of decompensation of the CM with a violation of the contractile ability of the detrusor.