Need For Self-catheterization Research Articles

MP46-13 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER: LONG-TERM FUNCTIONAL OUTCOMES AND CONTINENCE PREDICTORS ASSESSMENT FROM A HIGH-VOLUME CENTER LARGE CONSECUTIVE SERIES

You have accessJournal of UrologyCME1 Apr 2023MP46-13 ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER: LONG-TERM FUNCTIONAL OUTCOMES AND CONTINENCE PREDICTORS ASSESSMENT FROM A HIGH-VOLUME CENTER LARGE CONSECUTIVE SERIES Gabriele Tuderti, Riccardo Mastroianni, Umberto Anceschi, Alfredo Maria Bove, Aldo Brassetti, Mariaconsiglia Ferriero, Leonardo Misuraca, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Gabriele TudertiGabriele Tuderti More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003292.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Daytime urinary continence recovery following robot assisted radical cystectomy with intracorporeal orthotopic neobladder (RARC-iON) has been poorly investigated. In this study we reported long-term functional outcomes of RARC-iON and assessed the predictors of daytime urinary continence recovery. METHODS: Our single center IRB approved bladder cancer database was queried for “RARC” and “iON”.All patients treated between January 2012 and September 2020, with a minimum 1-yr follow-up were included. Baseline demographic, clinical, perioperative and pathologic data were reported. Functional outcomes included: renal function modification over time, neobladder stone formation, development of uretero-ileal anastomosis strictures, need for self-catheterization and Trifecta achievement (defined as the coexistence of daytime continence, Clavien-Dindo ≥3 complication-free and recurrence-free status, all assessed at 1 year).Day- and night-time continence recovery probabilities were assessed with Kaplan-Meier method; univariable and multivariable analyses were performed to identify predictors of day-time continence. RESULTS: Overall, 192 patients were included, 146 were male (76%).Mean baseline eGFR was 83.5 ml/min (± 23.5). At a median follow- up of 41 months (IQR 21-60), mean last eGFR was 63.8 ml/min (± 22.1).The incidence of significant renal function deterioration (newly onset CKD stage ≥3b) was 16.1%. Neobladder stones were reported in 16 patients (8.3%), all of which successfully treated as outpatient endoscopic procedure. Incidence of ureteroileal anastomosis stricture was 22.4%. Trifecta was achieved in 64.1% of cases. One-yr day- and night-time continence rates were 78.6 % and 48.3 %, respectively. At multivariable analysis age, female gender and severe 30-d complications occurrence were identified as independent predictors of lower day-time continence recovery probabilities. CONCLUSIONS: We reported functional outcomes of a large single center consecutive series of RARC-iON. Male, young and those patients who did not experience severe perioperative complications had significantly higher likelihood of recovering daytime urinary continence. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e636 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriele Tuderti More articles by this author Riccardo Mastroianni More articles by this author Umberto Anceschi More articles by this author Alfredo Maria Bove More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

An analysis of factors that influence patient preference of third-line therapy for overactive bladder.

Patients with overactive bladder (OAB) refractory to first- and second-line therapy may pursue third-line therapies, including intradetrusor onabotulinum toxin-A (BTX), peripheral tibial nerve stimulation (PTNS), and sacral neuromodulation (SNM). The factors that influence patient preference for each treatment modality have not yet been explored. This study sought to investigate the specific parameters that patients consider in choosing a third-line therapy for OAB. Patients refractory to first- and second-line therapies for OAB were identified in our outpatient clinic and asked to watch an educational video providing information on the risks and benefits of each third-line treatment option. They were then given a questionnaire to rank their preference of therapy and select reasons for why they found each therapy favorable and unfavorable. Patients under age 18 years, non-English speakers, those with a developmental disability, and those with a diagnosis of neurogenic bladder were excluded. Of the 98 patients included in the study, 40 participants (40.8%) chose intradetrusor BTX injections, 34 (34.7%) chose PTNS, and 16 (16.3%) chose SNM as their first choice. Seven patients (7.1%) chose none of the offered therapies, and one patient (1.0%) chose all three therapies with equal preference. BTX was found most attractive for its long efficacy (47%); its least attractive feature was the potential need for self-catheterization due to urinary retention (54%). PTNS was found most attractive for being a nonsurgical option (32%) and having no reported significant complications (39%); its least attractive feature was need for frequent office visits (61%). SNM was found most attractive for its potential for long-term relief without frequent office visits (53%); its least attractive feature was need for an implanted device (33%). Patients opting for SNM had higher scores on Urinary Distress Inventory-6and Incontinence Impact Questionnaire-7 questionnaires when compared to patients opting for BTX injections or PTNS (p < 0.05). 47.4% of patients eventually pursued a third-line therapy. Of those, there was a 67.6% concordance rate between the therapy patients ranked first and the therapy they eventually underwent. Patients with more severe OAB symptoms opt for more invasive and less time-consuming therapy with the potential for long-term relief, namely SNM. Despite thorough counseling, many patients do not progress to advanced OAB therapies. Understanding factors that influence patients' affinity towarda specific type of treatment can aid with individualized counseling on third-line OAB therapies.

Parametrial endometriosis: A predictive and prognostic factor for voiding dysfunction and complications

ObjectiveParametrial involvement (PI) in endometriosis is poorly defined resulting in an underestimation of its impact during surgical excision. The aim of our study was to assess the surgical complications associated with parametrectomy during surgery for endometriosis. Our secondary objective was to compare the surgical complications rates of a parametrectomy to the excision of other deep pelvic endometriotic locations. Study designPatients who underwent surgery for deep pelvic endometriosis from 2013 to 2018 in a French referral center were retrospectively included. Surgical complications were assessed according to whether a parametrectomy had been performed. The extent of surgery (colpectomy, torus, utero-sacral (USL) and/or rectal resection) was also assessed. Voiding dysfunction was defined as the need for self-catheterization ≥1 month and intra and postoperative complications were graded using the Clavien-Dindo classification (CDC). ResultsWe included 753 patients: 285 (37.8 %) with PI. Patients with PI had higher ASRM scores and more extensive surgery than those without. These patients also had higher rates of voiding dysfunctions (17.5 % versus 8.98 %, p < 0.01), and postoperative complications (44.6 % versus 24.6 %, p < 0.01), including major complications (CDC 3–4) (14.7 % vs 8.5 %, p = 0.01). The extent of the surgical resection of endometriosis was strongly associated with surgical complications after multivariable analysis, and the addition of a parametrectomy during surgery greatly increased rates of adverse postoperative events. Voiding dysfunction was frequent in women with combined resection of the torus, utero-sacral ligaments, parametrium and vagina (adjusted OR = 37.28, 95 %CI = 6.84–203.11, p < 0.01, reference: resection of the USL). ConclusionParametrectomy significantly impacts postoperative complications in patients undergoing surgery for endometriosis.

Predicting outcomes after intradetrusor onabotulinumtoxina for non-neurogenic urgency incontinence in women.

Develop models to predict outcomes after intradetrusor injection of 100 or 200 units of onabotulinumtoxinA in women with non-neurogenic urgency urinary incontinence (UUI). Models were developed using 307 women from two randomized trials assessing efficacy of onabotulinumtoxinA for non-neurogenic UUI. Cox, linear and logistic regression models were fit using: (1) time to recurrence over 12 months, (2) change from baseline daily UUI episodes (UUIE) at 6 months, and (3) need for self-catheterization over 6 months. Model discrimination of Cox and logistic regression models was calculated using c-index. Mean absolute error determined accuracy of the linear model. Calibration was demonstrated using calibration curves. All models were internally validated using bootstrapping. Median time to recurrence was 6 (interquartile range [IQR]: 2-12) months. Increasing age, 200 units of onabotulinumtoxinA, higher body mass index (BMI) and baseline UUIE were associated with decreased time to recurrence. The c-index was 0.63 (95% confidence interval [CI]: 0.59, 0.67). Median change in daily UUIE from baseline at 6 months was -3.5 (IQR: -5.0, -2.3). Increasing age, lower baseline UUIE, 200 units of onabotulinumtoxinA, higher BMI and IIQ-SF were associated with less improvement in UUIE. The mean absolute error predicting change in UUIE was accurate to 1.6 (95% CI: 1.5, 1.7) UUI episodes. The overall rate of self-catheterization was 17.6% (95% CI: 13.6%-22.4%). Lower BMI, 200 units of onabotulinumtoxinA, increased baseline postvoid residual and maximum capacity were associated with higher risk of self-catheterization. The c-index was 0.66 (95% CI: 0.61, 0.76). The three calculators are available at http://riskcalc.duke.edu. After external validation, these models will assist clinicians in providing more accurate estimates of expected treatment outcomes after onabotulinumtoxinA for non-neurogenic UUI in women.

Predictors of need for catheterisation and urinary retention after radical cystectomy and orthotopic neobladder in male patients.

To investigate the prevalence of catheterisation and urinary retention in male patients with bladder cancer after radical cystectomy (RC) and orthotopic neobladder (ONB) and to identify potential predictors. Using an Institutional Review Board approved, prospectively maintained bladder cancer database, we collected information using a diversion-related questionnaire from 299 consecutive male patients with bladder cancer upon postoperative clinic visit. Urinary retention was defined as ≥3catheterisations/day or a self-reported inability to void without a catheter. Uni- and multivariable Cox regression analysis was performed to identify predictors of catheterisation and urinary retention. Self-catheterisation was reported in 51 patients (17%), of whom, 22 (7.4% of the total patients) were in retention. Freedom from any catheterisation at 3, 5, and 10years after RC was 85%, 77%, and 62%, respectively. Freedom from retention at 3, 5, and 10years after RC was 93%, 88%, and 79%, respectively. Multivariable Cox regression showed that higher body mass index (BMI; ≥27kg/m2 ) significantly increased the need for catheterisation (hazard ratio [HR] 2.34, 95% confidence interval [CI] 1.26-4.32) as well as retention (HR 5.20, 95% CI 1.74-15.51). Greater medical comorbidity (Charlson Comorbidity Index score ≥2) correlated with the need for any catheterisation (HR 1.84, 95% CI 1.02-3.3), but not retention. Pathological stage and type of diversion were not significant predictors of the need to catheterise or urinary retention. In males undergoing RC with ONB, retention requiring catheterisation to void is uncommon. Patients with a BMI of ≥27kg/m2 are at significantly increased risk of retention and need for self-catheterisation.

Predictive Factors for Voiding Dysfunction after Surgery for Deep Infiltrating Endometriosis

To evaluate the prognostic value of pre- and perioperative factors for voiding dysfunction after surgery for deep infiltrating endometriosis (DIE). Single-center retrospective cohort study. University hospital. A total of 198 women with DIE in the posterior compartment who underwent surgery and a postoperative bladder scan. Surgical resection of the DIE nodule from the dorsal compartment. After surgery, 41% of the patients initially experienced voiding dysfunction (defined as >100 mL postvoid residual urine volume at second bladder scan). The number decreased to 11% by the time of hospital discharge. Among those with a need for self-catheterization after discharge (n = 17), voiding dysfunction lasted for a median of 41 days before a return to normal bladder function, with a residual urine volume of <100 mL. The preoperative presence of DIE nodules in the ENZIAN compartment B was associated with postoperative voiding dysfunction (p = .001). The hazard ratio for elevated residual urine volume was highest when the disease stage was B3 (hazard ratio 6.43; CI, 2.3-18.2; p <.001), describing a nodule diameter of >3 cm in lateral distension. Receiver operating characteristic curve analyses showed that a first residual urine volume >220 mL has a good predictive value for the risk of intermittent self-catheterization (area under the receiver operating characteristic curve 0.893; p <.001). Postoperative voiding dysfunction is frequent; of note, in most cases the problem is temporary. When DIE with an ENZIAN classification B is noted intraoperatively and, most of all, when the diameter of the lesion is >3 cm, a higher risk of postoperative voiding dysfunction is to be expected.

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes

Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

Long-term functional results of orthotopic urinary derivation by Studer and VIP after radical cystectomy in women

Introduction. The feasibility of reconstructing an orthotopic urinary reservoir after radical cystectomy (RCE) in women is still debatable. This is due to the peculiarities of the physiology and anatomy of the female lower urinary tract and an increased risk of developing urinary incontinence or urinary retention after surgery.Purpose of the study. Studying long-term functional results of creating an orthotopic urinary reservoir by VIP in comparison with the technique of creating a urinary reservoir by Studer after RCE in women.Materials and methods. The study included 32 women who underwent RCE with the formation of an orthotopic urinary reservoir by to Studer — 13 patients and a «spherical» reservoir in the VIP — 19 modification. At the time of surgery, the age of patients was 61.1±1.9 years (29 ‒ 82). The average follow-up time was 77.5±7.8 months (17 ‒ 157, median 82). The patients who underwent a more complex type of plastic were younger than the patients operated on by the Studer method (p = 0.014). The groups did not differ statistically in other parameters.Results. The overall five-year survival rate in the Studer group was 90.9%, and in the VIP group — 94.7% (p = 0.596). 59.4% of patients were completely continent. Women after plastic surgery by VIP held urine better (68.4% vs 46.2%). The incidence of mild urinary incontinence was higher after Studer surgery. The incidence of severe urinary incontinence was the same in both groups. Nighttime urinary incontinence was the same in both groups. Intermittent catheterization was used more often by patients after VIP plastic surgery than after Studer surgery (21% vs 7.7%). In urodynamic studies, it was shown that the lower physiological capacity of the reservoir according to Studer due to more intense peristalsis of the reservoir wall, which causes involuntary leaking of urine, hyperperistalsis of the reservoir and a higher frequency of urinary incontinence causes more complete emptying in patients less residual urine, less need for self-catheterization. In the group of patients with plastic surgery according to VIP, a high physiological capacity of the reservoir with a lower pressure of the walls of the reservoir during the filling phase was recorded. This is manifested by a lower incidence of urinary incontinence, and, at the same time, a more significant amount of residual urine and a higher need for patients for self-catheterization.Conclusion. The formation of an orthotopic urinary reservoir with favourable long-term results is possible in women after RCE. The most beneficial in terms of the quality of daily held urine is the VIP modification, which is characterized by sufficiently high capacity and low intraluminal pressure. However, with this method of surgery, the risk of hypercontinence increases, which requires periodic catheterization. A complex urodynamic study made it possible to show the direct effect of various characteristics of the reservoir on the nature and degree of impaired urination of patients.

Abstract No. 689 Prostate artery embolization in patients with prior transurethral resection of the prostate: a feasibility study

This study examines the feasibility of prostate artery embolization (PAE) as a treatment for benign prostatic hyperplasia (BPH) with refractory lower urinary tract symptoms (LUTS) after transurethral resection of the prostate (TURP). The feasibility of PAE to treat refractory BPH-associated LUTS in patients with prior TURP has not been established. PAE cases from April 2015 through June 2019 at two hospitals in a tertiary academic health system were queried (n = 159). Patients were included if they underwent elective PAE and had at least one prior TURP (n = 10). Patients undergoing emergent PAE for hematuria were excluded. Demographic, baseline, procedural, and follow-up data were collected where available for consecutive patients meeting the inclusion criteria. Technical success was defined as bilateral stasis. Patients studied had a mean age of 72.5 years (SD = 5.7) and ellipsoid prostate volumes of 131.1 cm3 (range, 54-196 cm3). The median time between most recent TURP and PAE was 7 years (range, 1-15 years). 7 patients had 1 prior TURP, 2 had 2, and 1 had 3. Mean baseline International Prostate Symptom Score (IPSS) was 20.2 (SD = 9.6) and mean Quality of Life score (QOL) was 4.4 (SD = 1.6). Procedures had a mean fluoroscopy time of 37.5 minutes, radiation dose of 647583.2 mGycm2, and contrast volume of 142 mL. Technical success was achieved in 8 of 10 patients. In the other 2 patients, unilateral stasis was achieved. One failure was unilateral due to excessive fluoroscopy time and one was due to inability to visualize the left prostatic artery. After an average of 70.8 days (SD = 88) post-PAE, mean IPSS reduction was 4.9 (n = 7, SD = 5.0, P = 0.03) and mean QOL reduction was 0.5 (n = 6, SD = 0.5, P = 0.04). Post-PAE adverse events included urethral irritation (n = 1), pain (n = 1), and incomplete emptying with a need for self-catheterization (n = 1). While more research is required to fully assess efficacy and safety, preliminary results in a group of 10 patients indicate feasibility of PAE as a promising treatment option in patients with BPH-associated refractory LUTS post-TURP.

Brain activation patterns of female multiple sclerosis patients with voiding dysfunction.

We compared brain activation patterns between female multiple sclerosis (MS) patients with voiding dysfunction (VD) and those without. We aim to expand current knowledge of supraspinal correlates of voiding initiation within a cohort of female MS patients with and without VD. Twenty-eight ambulatory female MS patients with stable disease and lower urinary tract dysfunction were recruited for this study. Subjects were divided into group 1, without VD (n = 14), and group 2, with VD (n = 14), defined as postvoid residual urine of ≥40% of maximum cystometric capacity or need for self-catheterization. We recorded brain activity via functional magnetic resonance imaging (fMRI) with simultaneous urodynamic testing. Average fMRI activation maps (the Student t test) were created for both groups, and areas of significant activation were identified (P < .05). A priori regions of interest (ROIs), identified by prior meta-analysis to be involved in voiding, were selected. Group-averaged blood-oxygen level-dependent (BOLD) activation maps demonstrated significant differences between groups 1 and 2 during initiation of voiding with group 2 showing significantly lower levels of activation in all ROIs except for the left cerebellum and right cingulate gyrus. Interestingly, group 2 displayed negative BOLD signals, while group 1 displayed positive signals in the right and left pontine micturition center, right periaqueductal gray, left thalamus, and left cingulate gyrus. The activation map of group 1 was similar to healthy controls. Our results support the hypothesis that distinct supraspinal activation patterns exist between female MS patients with VD and those without.

Feasibility of early postoperative bladder catheter removal without prior bladder-training exercises after laparoscopic nerve sparing radical hysterectomy

The aim of the study is to evaluate the feasibility of early postoperative bladder catheter removal without prior bladder-training exercises after laparoscopic nerve sparing radical hysterectomy (LNSRH). The post-operative bladder catheterisation period of 30 patients who underwent LNSRH at two institutes in Egypt and Italy were prospectively evaluated with postoperative drainage of the bladder through a Foley catheter for two days without performing bladder-training exercise. The median duration for postoperative bladder catheterisation was 3.5 (3–5) days. Within the fifth postoperative day, 82.7% had a PVR urine volume less than 100 ml. None of the patients had PVR urine more than 100 ml more than 10 days after the operation with no need for self-catheterisation. These results support early postoperative bladder catheter removal without prior bladder-training exercises following LNSRH.IMPACT STATEMENTWhat is already known on this subject? Bladder-training exercise was used routinely following radical hysterectomy (RH) operations before bladder catheter removal. Only two studies reported that these exercises could be omitted, but one study was done on both laparoscopic and open RH patients and the other did not show whether the operation was nerve-sparing and whether it was done by laparoscopy or open technique.What the results of this study add? This study’s results support early postoperative bladder catheter removal without prior bladder-training exercises after laparoscopic nerve sparing RH.What the implications are of these findings for clinical practice and/or further research? Excluding the unnecessary procedure of bladder training, which is time- and effort-consuming, after the operation.

Complications of Botox and their Management.

Adherence to anticholinergic medications is known to be a problem in patients with overactive bladder, with only 13.2% of patients continuing anticholinergic therapy beyond 1year D'Souza et al. (J Manag Care Pharm. 14:291-301, 2008). Prior to the advent of third line therapies such as onabotulinumtoxin A, refractory overactive bladder (OAB) was managed with augmentation cystoplasty, a lengthy surgery with associated side effects including lifetime need for self-catheterization, ileus, and metabolic disturbances. The advent of onabotulinumtoxin A has drastically reduced the rates of augmentation cystoplasties being performed for refractory OAB. However, all procedures are associated with side effects which should be relayed to the patient prior to beginning therapy, as well as their management. In the current review, we summarize the common complications following onabotulinumtoxin A injection as well as their management.

OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial.

Women with refractory urgency urinary incontinence are treated with sacral neuromodulation and onabotulinumtoxinA with limited comparative information. To assess whether onabotulinumtoxinA is superior to sacral neuromodulation in controlling refractory episodes of urgency urinary incontinence. Multicenter open-label randomized trial (February 2012-January 2015) at 9 US medical centers involving 381 women with refractory urgency urinary incontinence. Cystoscopic intradetrusor injection of 200 U of onabotulinumtoxinA (n = 192) or sacral neuromodulation (n = 189). Primary outcome, change from baseline mean number of daily urgency urinary incontinence episodes over 6 months, was measured with monthly 3-day diaries. Secondary outcomes included change from baseline in urinary symptom scores in the Overactive Bladder Questionnaire Short Form (SF); range, 0-100, higher scores indicating worse symptoms; Overactive Bladder Satisfaction questionnaire; range, 0-100; includes 5 subscales, higher scores indicating better satisfaction; and adverse events. Of the 364 women (mean [SD] age, 63.0 [11.6] years) in the intention-to-treat population, 190 women in the onabotulinumtoxinA group had a greater reduction in 6-month mean number of episodes of urgency incontinence per day than did the 174 in the sacral neuromodulation group (-3.9 vs -3.3 episodes per day; mean difference, 0.63; 95% CI, 0.13 to 1.14; P = .01). Participants treated with onabotulinumtoxinA showed greater improvement in the Overactive Bladder Questionnaire SF for symptom bother (-46.7 vs -38.6; mean difference, 8.1; 95% CI, 3.0 to 13.3; P = .002); treatment satisfaction (67.7 vs 59.8; mean difference, 7.8; 95% CI, 1.6 to 14.1; P = .01) and treatment endorsement (78.1 vs 67.6; mean difference; 10.4, 95% CI, 4.3 to 16.5; P < .001) than treatment with sacral neuromodulation. There were no differences in convenience (67.6 vs 70.2; mean difference, -2.5; 95% CI, -8.1 to 3.0; P = .36), adverse effects (88.4 vs 85.1; mean difference, 3.3; 95% CI, -1.9 to 8.5; P = .22), and treatment preference (92.% vs 89%; risk difference, -3%; 95% CI, -16% to 10%; P = .49). Urinary tract infections were more frequent in the onabotulinumtoxinA group (35% vs 11%; risk difference, -23%; 95% CI, -33% to -13%; P < .001). The need for self-catheterization was 8% and 2% at 1 and 6 months in the onabotulinumtoxinA group. Neuromodulation device revisions and removals occurred in 3%. Among women with refractory urgency urinary incontinence, treatment with onabotulinumtoxinA compared with sacral neuromodulation resulted in a small daily improvement in episodes that although statistically significant is of uncertain clinical importance. In addition, it resulted in a higher risk of urinary tract infections and need for transient self-catheterizations.

Risk of urinary retention after nerve-sparing surgery for deep infiltrating endometriosis: A systematic review and meta-analysis.

Recently, nerve-sparing (NS) techniques have been incorporated in surgeries for deep infiltrating endometriosis (DIE) to prevent urinary complications. Our aim was to perform a systematic review and meta-analysis to assess the risk of urinary retention after NS surgery for DIE compared with classical (non-NS) techniques. Following the MOOSE guidelines for systematic reviews of observational studies, data were collected from published research articles that compared NS techniques with non-NS techniques in DIE surgery, with regard to post-operative urinary complications. randomized clinical trials, intervention or observational (cohort and case-control) studies assessing women who underwent surgery for painful DIE. cancer surgery and women submitted to bladder or ureteral resections. The respective relative risks (RR) and 95% confidence intervals (CI) were extracted and a forest plot was generated to show individual and combined estimates. Preliminarily, 1,270 potentially relevant studies were identified from which four studies were selected. A meta-analysis was performed to assess the risk of urinary retention at discharge and 90 days after surgery. We found a common RR of 0.19 [95%CI: 0.03-1.17; (I2 = 50.20%; P = 0.09)] for need of self-catheterization at discharge in the NS group in relation to the conventional technique. Based on two studies, common RR for persistent urinary retention (after 90 days) was 0.16 [95%CI: 0.03-0.84]. Our results suggest significant advantages of the NS technique when considering the RR of persistent urinary retention. Controlled studies evaluating the best approach to manage the urinary tract after complex surgery for DIE are needed. Neurourol. Urodynam. 36:57-61, 2017. © 2015 Wiley Periodicals, Inc.

Ethical and well-constructed research into the surgical management of obstetric fistula: a distant hope or a real possibility?

The number of women presenting with new obstetric fistulae at the Hamlin Fistula Hospital in Addis Ababa, Ethiopia, has fallen from 492 to 329 in the 3 year period from January 2011 to December 2014, representing a drop of 33% (personal audit of Hamlin Fistula Ethiopia operating theatre records, JW 2015). Although this is clearly good news, as it suggests improvements in maternal health are being made, residual urinary incontinence following primary surgery still remains a problem. In a series of 390 women attending for urinary fistula repair, 240 returned for follow-up, of whom 123 (51%) remained incontinent (BJOG 2008;115:1564–9). In the past, urethral buttressing procedures, such as the use of Martius or pubococcygeus grafts, have been tried, but with limited success (BJOG 2004;111:357–61). It is tempting for both resident and visiting surgeons to try more invasive procedures, such as the use of abdomino-urethral slings, bladder augmentation, and urinary diversion; however, we need to remember that treatments now being considered for women with continuing urinary incontinence following fistula repair have largely been abandoned in high-income countries because of their ineffectiveness. For example, bladder augmentation is highly morbid and is rarely performed because of the need for self-catheterization, and urinary diversion is largely only performed for malignancy in aged patients. Whereas these operations may offer hope for women with urinary incontinence following fistula surgery, women need to be informed of the risks and possible, often unknown, benefits, not least of all because the surgery is not easily reversible, and any resulting morbidity will remain for the rest of their lives. Defecation in excess of six times a night is common following a Mainz pouch, and little is known about the long-term effects for these young women. Moreover, a urinary diversion cannot be reversed, but leaves women to cope with many challenges of stoma care within a rural environment where there may be no running water or adequate sanitation. It is therefore imperative that these procedures are trialled in a logical, well-documented, and ethical way, ensuring adequate consent about treatment options and the risks that must be faced. Informed consent, in the true sense, however, is not widely practiced in countries where obstetric fistulae are prevalent, and visiting surgeons need to ensure that they do not compromise their ethical standards simply because they are working out of their familiar context. Unlike clinical trials of medical therapy, new surgical procedures are not subject to ethical scrutiny or rigorous assessment of their efficacy and impact on quality of life. Indeed, many new surgical procedures are introduced without even a rudimentary assessment of patient satisfaction. For our putative patient with a Mainz pouch described above, her continued dribbling urinary incontinence and normal bowels may be a better option than radical surgery that leaves her socially isolated and unable to return to her community. Once surgery is performed, however, there is no turning back. These operations can be done, but should they be done? And if they are to be done, should they not at least be subjected to rigorous assessment of patient-reported outcomes, such as quality of life? None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Multiple Stones in Atypical Heterotopic Reservoir in a Patient with Renal Transplant: Endourologic Resolution

Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity. Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12-52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence. We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones. preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic balloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray, a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted. No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported. In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

Follow-up of dysfunctional bladder and rectum after surgery of a deep infiltrating rectovaginal endometriosis

The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. Major goal of this review article is to compare different surgical techniques of deep infiltrating endometriosis and their follow-up results. The research strategy included the online search of databases [MEDLINE, EMBASE, SCOPUS] for the diagnosis of deep infiltrating endometriosis with the indication of an operative resection. The outcome of the follow-up terms were noticed and compared. All in all, 16 trials could be identified with included follow-up. In all patients at least single-sided resection of the uterosacral ligaments were performed. Follow-up was heterogeneous in all trials ranging from 1 to 92 months. Postoperative symptoms, such as dysmenorrhoea, pelvic pain, and dyspareunia were commonly described in the majority of trials. Nevertheless, a tendency towards lower comorbidity after nerve sparing resection of endometriosis could be observed. Identification of the inferior hypogastric nerve and plexus was feasible in the minority of trials. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients’ outcome

The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. We introduce a case series report of 16 patients with laparoscopic nerve-sparing surgery of deep infiltrating endometriosis. We describe the technique step by step and compare the patients' outcome with patients who had undergone a non-nerve-sparing surgical technique. In 12 patients, a double-sided and in four patients, a single-sided identification of the inferior hypogastric nerve and plexus were performed. In all patients at least single-sided resection of the uterosacral ligaments were performed. Postoperatively dysmenorrhoea, pelvic pain, and dyspareunia disappeared in all patients. The average operating time was 82 min (range 45-185). Postoperatively, the overall time to resume voiding function was 2 days. The residual urine volume was in all patients <50 ml at two ultrasound measurements. Identification of the inferior hypogastric nerve and plexus was feasible. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Bladder exstrophy in adulthood

We report our experience with the treatment of classic exstrophy of the bladder in a small series of seven adult males. There are very few documented cases of adults presenting with exstrophy of bladder in literature. Adult males presenting with classic exstrophy of the bladder and complete epispadias underwent detailed evaluation including psychological assessment and counseling. All were explained regarding the surgical procedure and informed about the need for self-catheterization. Prior to 2002 all patients underwent cystectomy of the existing bladder plate, with creation of catheterizable modified Mainz pouch. Since 2002 patients were assessed for bladder reconstruction with augmentation ileocystoplasty, bladder neck reconstruction, and abdominal wall closure. Seven adult males with classic exstrophy of the bladder and complete epispadias who had not received any previous treatment presented to us during the period 1991-2006. Five of these underwent cystectomy with continent pouch and the remaining two underwent bladder reconstruction. All have been doing well with improved self-esteem and social interaction. Two of these have married and leading a satisfactory sexual relationship. Surgical correction in adults with exstrophy of the bladder greatly improves self-esteem, confidence, and social relationship.

Unilateral or bilateral nerve-sparing radical hysterectomy: a surgical technique to preserve the pelvic autonomic nerves while increasing radicality

We performed unilateral or bilateral nerve-sparing (UNS or BNS) radical hysterectomies combined with a parametrial excision in patients with locally advanced cervical cancer. The parametrial excision technique is characterized by a meticulous sharp dissection of the avascular plane outside the visceral fascia of the uterus and vagina under direct vision, providing an en bloc parametria and ensuring that all regional spread of the disease is contained within negative surgical margins. The aim of this study was to describe this surgical technique and to retrospectively evaluate the feasibility and the impact on early bladder function. From February 2005 to November 2006, 32 patients with FIGO stage IB-IIB cervical cancer, who had the tumor of more than 20 mm in diameter, underwent the UNS surgery or BNS surgery. A parametrial excision was performed in all the patients. The surgical procedure was safely completed in all the patients. Though 14 patients had tumor invasion to the parametria, none of the patients had a positive surgical margin in the parametrium. The bladder function of patients in the UNS group immediately after surgery was more damaged than that in the BNS group. However, all the patients in both groups recovered spontaneous voiding with no need of self-catheterization during the perioperative periods. This preliminary study showed that the surgical technique is feasible and safe. For confirmation of the efficacy of this technique, further large prospective studies are needed.