Non-urological Causes Research Articles

Clean Intermittent Catheterization in Children under 12 Years Does Not Have a Negative Impact on Long-Term Graft Survival following Pediatric Kidney Transplantation.

Congenital anomalies of the kidneys and urinary tract (CAKUTs) are one of the most prevalent primary causes of end-stage renal disease (ESRD) in young children, and approximately one-third of these children present with lower urinary tract dysfunction (LUTD). Many children with LUTD require therapy with clean intermittent catheterization (CIC). CIC commonly leads to bacteriuria, and considerations have arisen regarding whether CIC in immunosuppressed children is safe or whether repeated febrile urinary tract infections (UTIs) may lead to the deterioration of kidney graft function. We retrospectively reviewed all cases of primary kidney transplantation performed in our center between 2001 and 2020 in recipients aged less than twelve years. The number of episodes of febrile UTIs as well as the long-term kidney graft survival of children undergoing CIC were compared to those of children with urological causes of ESRD not undergoing CIC, as well as to those of children with nonurological causes of ESRD. Following successful kidney transplantation in 41 children, CIC was needed in 8 of these patients. These 8 children undergoing CIC had significantly more episodes of febrile UTIs than did the 18 children with a nonurological cause of ESRD (p = 0.04) but not the 15 children with a urological cause of ESRD who did not need to undergo CIC (p = 0.19). Despite being associated with a higher rate of febrile UTIs, CIC was not identified as a risk factor for long-term kidney graft survival, and long-term graft survival did not significantly differ between the three groups at a median follow-up of 124 months. Our study demonstrates that, under regular medical care, CIC following pediatric transplantation is safe and is not associated with a higher rate of long-term graft loss.

Medium and Long-Term Clinical Outcomes of Kidney Transplantation in Patients With Prune Belly Syndrome: A Single-Centre Experience

To present the medium and long-term outcomes of kidney transplantation performed in patients with Prune Belly Syndrome (PBS) which is one of the congenital anomalies of the kidney and urinary tract (CAKUT). Thirteen kidney transplantations were performed in nine patients with PBS from January 1994 to December 2020. Demographics, surgical features, graft and patient survival rates were analyzed. Survival outcomes was compared with 106 age- and donor-type matched controls who underwent transplantation because of nonurological causes. The median ages of PBS patients at the time of first and second transplantation were 19 and 34 years old, respectively. One patient had postoperative Clavien grade 3a complication. Eight of 13 transplants are still functional at the last follow-up. Eight patients underwent pretransplant urological operations in preparation for kidney transplantation, while 4 patients underwent urological operations in the post-transplant period. Graft survival for PBS transplants at 5, 10, and 15 years were 90.9%, 57.7%, and 38.5%, respectively. Graft survival for control cohort at 5, 10, and 15 years were 89.9%, 80%, and 74%, respectively. The patient and graft survival rates were similar between PBS and control groups (P=.449, P=.134, respectively). This single-center study showed that the medium-term graft survival rates in patients with PBS are encouraging and comparable to non-CAKUT transplant patients, however long-term graft survival rates were found to be proportionally inferior. To help determine the reasons for long-term transplant kidney function deterioration and how to improve them we suggest that multicenter international collaboration will be needed.

Factors Associated With Nocturia-Related Quality of Life in Men With Lower Urinary Tract Symptoms and Treated With Tamsulosin Oral Controlled Absorption System in a Non-Interventional Study.

Nocturia impairs quality of life (QoL). We have performed a non-interventional study in which men with lower urinary tract symptoms (LUTS) were treated for at least 3 months with tamsulosin oral controlled absorption system (0.4 mg q.d.). Other than observing efficacy and tolerability of this drug formulation, the study was designed to explore the relative roles of number of nocturia episodes and of non-urological causes of nocturia on nocturia-related QoL at baseline and treatment-associated changes thereof. The study enrolled 5775 men seeking treatment of their LUTS. Tamsulosin improved LUTS, e.g. International Prostate Symptom Score from 19.5 ± 5.9 to 10.1 ± 4.9 (means ± SD). This was associated by clinically meaningful improvements in the Nocturia QoL score (from 45 ± 19 to 73 ± 17 points) and other QoL scores. Number of nocturnal voids was the key driver of all QoL scores at baseline; change of number of nocturia episodes that of improvement of all QoL scores upon treatment. In contrast, non-urological causes of nocturia such as heart failure, diabetes, sleep apnea, fluid or alcohol intake or use of diuretics or hypnotics had only small if any effects on baseline QoL or treatment-associated improvements thereof. The observed effects of non-urological causes on QoL apparently were largely driven by their effect on number of nocturnal voids. These data further support the idea that improvement of nocturia may be an important treatment goal in male LUTS.

PD15-04 EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY HOSPITAL READMISSION CAUSES AND TRENDS

INTRODUCTION AND OBJECTIVE: Extracorporeal shockwave lithotripsy (ESWL) is a noninvasive and generally safe procedure used to treat renal and ureteral stones. Previous retrospective series have estimated 90-day readmission rates around 10%. We aimed to better characterize real-world readmission causes and trends using a large statewide database. METHODS: We performed a population-based cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Using ICD-9 diagnosis and procedure codes, patients who underwent ESWL between 2004-2013 were identified and tracked for 30- and 90-day readmissions. Readmission diagnoses were classified, and rates were tracked over time. Stone characteristics are not available in SPARCS. A multivariable logistic regression was performed using patient age, sex, race, and insurance status to identify factors related to early readmission. RESULTS: 81,425 ESWL cases were obtained for analysis in the 10-year study window. The overall 30-day readmission rate was 6.1% (N=4994) and 90-day readmission rate was 11.3% (N=9226). The number of cases per year remained stable (range 7233 to 9068) as did the readmission rate (range 9.7% to 12.1%). Urological complaints were the most common causes for readmissions accounting for 67.1% (N=3349) of all 30-day readmissions and 56.7% (N=5235) of all 90-day readmissions. The most common urological causes for 30/90-day readmissions were nephrolithiasis (48.2%/40.5%), infection (12.4%/10.9%), stent problems (2.7%/2.2%), and bleeding (1.7%/1.4%). The most common non-urologic causes were cardiac events (6.3%/7.2%) and GI complications (4.4%/5.0%). Logistic regression showed increased odds of 30-day readmission for women (OR 1.13, 95% CI 1.07-1.20, p<0.001), patients with advanced age (61-80 years OR 2.00, 95% CI 1.45-2.78, p<0.001 and 81+ years OR 2.64, 95% CI 1.86-3.75, p<0.001) and those with Medicare (OR 1.32, 95% CI 1.20-1.44, p<0.001) or Medicaid (OR 2.11, 95% CI, 1.88-2.37, p<0.001). CONCLUSIONS: Readmission after ESWL occurred in 6.1% of patients at 30-days and 11.3% at 90-days. The majority of diagnoses driving readmission were urological related to nephrolithiasis. Other commonly cited risks like infection and bleeding remain relatively rare events. These data can help physicians better counsel their patients on the risks of ESWL and evaluate their own outcomes relative to a real-world patient cohort. Source of Funding: None

Outcome of pediatric renal transplantation in urological versus non-urological causes of end stage renal disease: Does it matter?

Causes for end stage renal disease (ESRD) in children can be categorized into urological causes or non-urological causes. We sought to compare the outcomes of urological and non-urological causes of ESRD in children. Patients were divided into two groups: urological causes of ESRD versus non-urological causes of ESRD. All patients and donors had at least 6 months of follow-up. The main outcomes included the effect on complications and renal function. Comparisons were carried out using the chi-square test or the Student t-test. Multivariate logistic regression analysis was used to define the effect of different variables on the outcome of renal transplantation (Table). Our study included 123 patients, 91 males. The mean age was 9 years and mean follow up was 46 months. Two-thirds of the patients had non-urological causes of ESRD. Overall survival was 100%, and only one patient needed a graft nephrectomy 3 months after the transplant. The mean estimated glomerular filtration rate was 117mL/min, and did not differ significantly between the two groups (p=0.13). Multivariable regression showed that female gender (OR 8.7, 95% CI 2.9-26, p=0 0.0001) was associated with better renal function, while having a urological cause of ESRD (OR 0.28, CI 0.08-0.98, p=0 0.05) was associated with worse renal function. Non-urological causes of ESRD were significantly less likely to develop complications following renal transplantation (OR 0.28, CI 0.09-0.89, p=0 0.03). Female patients with non-urological causes of ESRD are more likely to have better long-term renal functions, and less liable to develop complications following renal transplant.

Rate of spontaneous voiding recovery after acute urinary retention due to bed rest in the hospital setting in a nonurological population clinical study of the relationship between lower limbs and bladder function.

ObjectivesTo understand the clinical relationship between lower limbs functions and the recovery of spontaneous voiding after an acute urinary retention (AUR) in older patients admitted to hospitals for non-urological causes using clinical parameters.Materials and Methods56 adult patients (32 men; mean age: 77.9 ± 8.3 and 24 women; mean age 82.1 ± 4.6) with AUR were prospectively followed with validated Physical Performance Mobility Exam (PPME) instrument to evaluate the relationship between the recovery of mobility capacity and spontaneous voiding. After a short period of permanent bladder drainage patients started CIC along evaluation by PPME during hospitalization and at 7, 15, 30 60, 90, and 180 days of discharge. Mann-Whitney U, chi-square test and ANOVA tests were used.ResultsAll patients were hospitalized for at least 15 days (Median 26.3 ± 4.1 days). Progressive improvement on mobility scale measured by PPME was observed after leaving ICU and along the initial 7 days of hospitalization but with a deterioration if hospitalization extends beyond 15 days (p<0.03). Prolonged hospital stay impairs mobility in all domains (p<0.05) except step-up and transfer skills (p<0.02) although a recovery rate on spontaneous voiding persistented. Restoration of spontaneous voiding was accompanied by improvement on mobility scale (p<0.02). Recovery of spontaneous voiding was markedly observed after discharging the hospital. All patients recovered spontaneous voiding until 6 months of follow-up.ConclusionsRecovery to spontaneous voiding after acute urinary retention in the hospital setting may be anticipated by evaluation of lower limbs function measured by validated instruments.

Ureteral Stones: Implementation of a Reduced-Dose CT Protocol in Patients in the Emergency Department with Moderate to High Likelihood of Calculi on the Basis of STONE Score.

Purpose To determine if a reduced-dose computed tomography (CT) protocol could effectively help to identify patients in the emergency department (ED) with moderate to high likelihood of calculi who would require urologic intervention within 90 days. Materials and Methods The study was approved by the institutional review board and written informed consent with HIPAA authorization was obtained. This was a prospective, single-center study of patients in the ED with moderate to high likelihood of ureteral stone undergoing CT imaging. Objective likelihood of ureteral stone was determined by using the previously derived and validated STONE clinical prediction rule, which includes five elements: sex, timing, origin, nausea, and erythrocytes. All patients with high STONE score (STONE score, 10-13) underwent reduced-dose CT, while those with moderate likelihood of ureteral stone (moderate STONE score, 6-9) underwent reduced-dose CT or standard CT based on clinician discretion. Patients were followed to 90 days after initial imaging for clinical course and for the primary outcome of any intervention. Statistics are primarily descriptive and are reported as percentages, sensitivities, and specificities with 95% confidence intervals. Results There were 264 participants enrolled and 165 reduced-dose CTs performed; of these participants, 108 underwent reduced-dose CT alone with complete follow-up. Overall, 46 of 264 (17.4%) of patients underwent urologic intervention, and 25 of 108 (23.1%) patients who underwent reduced-dose CT underwent a urologic intervention; all were correctly diagnosed on the clinical report of the reduced-dose CT (sensitivity, 100%; 95% confidence interval: 86.7%, 100%). The average dose-length product for all standard-dose CTs was 857 mGy · cm ± 395 compared with 101 mGy · cm ± 39 for all reduced-dose CTs (average dose reduction, 88.2%). There were five interventions for nonurologic causes, three of which were urgent and none of which were missed when reduced-dose CT was performed. Conclusion A CT protocol with over 85% dose reduction can be used in patients with moderate to high likelihood of ureteral stone to safely and effectively identify patients in the ED who will require urologic intervention. (©) RSNA, 2016 Online supplemental material is available for this article.

Bladder Function Evaluation Before Renal Transplantation in Nonurologic Disease: Is It Necessary?

To determine whether preoperative cystometry and a pressure flow study (PFS) are necessary in patients with end-stage renal disease from nonurologic causes who will undergo renal transplantation. From April 2009 to June 2010, 30 patients scheduled to undergo renal transplantation were prospectively evaluated with cystometry and PFS. The evaluation was performed immediately before and 6 months after renal transplantation. The inclusion criteria were age >18 years and end-stage renal disease secondary to nonurologic disease. Improvement in the cystometry and PFS parameters was observed after the return of diuresis at 6 months after transplantation. The parameter changes from baseline to the 6-month evaluation were as follows: first sensation of bladder filling, 88.8-168.7 mL (P = .0005); first desire to void, 137.2-251.1 mL (P <.0001); maximal cystometric capacity, 221.2-428.7 mL (P <.0001); bladder compliance, 73.9-138.6 mL/cm H2O (P = .03); and maximal flow rate, 8.1-15.8 mL/s (P <.0001). The Abrams-Griffiths number in the men decreased from 31.8 to 15.2 (P = .002). No significant changes were observed in the detrusor pressure at the maximal flow rate or the postvoid residual urine volume. Patients with a 24-hour urine output <200 mL tended to have had significantly worse parameters before transplantation. Significant improvement in the cystometry and PFS parameters was observed in patients with end-stage renal disease, without urologic disease, 6 months after transplantation, and was associated with recovery of the glomerular filtration rate and urine output by the renal graft.

Longitudinal Study of Lower Urinary Tract Function in Children with Anorectal Malformation

Neurogenic bladder dysfunction (NBD) in children with anorectal malformation (ARM) has been reported in many publications, but with variations in prevalence and connection to type of ARM and spinal cord/sacral malformations. The prevalence of ARM patients with functional nonneurogenic dysfunction, on the contrary, has been addressed only sparsely. Since constipation and soiling have been shown to often accompany functional urinary tract symptoms in children without malformations, and treatment of constipation often improves bladder symptoms, it is interesting to assess such a connection in ARM patients. This study assessed lower urinary tract dysfunction (LUTD) overall in ARM children. Special attention was paid to whether patients with poor bowel function had more LUT symptoms, excluding those with urological reasons for the LUTD (NBD and urogenital malformations). Children with ARM, excluding those with perineal fistula, were included (n = 41). Bladder function was investigated at 5 (n = 25), 10 (n = 28), and 15 (n = 13) years using a structured questionnaire and flow residual. A scoring system was used. In addition, healthy children of comparable age were assessed using the same questionnaire. Data on bowel function were also available, as presented in a recent article. In children with NBD, cystometry was also used at follow-up. NBD was seen in 9 children (22%), whereas nonneurogenic LUTD was diagnosed in 14 cases (34%). A clear difference between the groups was seen, with a permanent dysfunction in neurogenic and often transient and mild in the nonneurogenic LUTD. A significant correlation between LUTD and bowel dysfunction was identified when all LUTD was included (p = 0.045). When children with neurogenic and urological causes of LUTD were excluded, the remaining children with LUTD had lower scores for bowel function than those with normal bladder function, but the difference was not significant (p = 0.1291). Poor bowel function was often seen together with LUTD. In children with NBD, the connection was attributable to a mutual impairment of the nerve supply to both systems. Children with nonneurogenic and nonurological causes of the LUTD also had lower bowel scores than those with normal bladder function; although not significant, it suggests that poor bowel function was responsible for an increase in LUT symptoms.

Strategies to treat children with end‐stage renal dysfunction and severe lower urinary tract anomalies for receiving a kidney transplant

Dealing with children with bladder dysfunction and kidney transplant is certainly not a new issue. Nevertheless, it is still a matter of discussion and dilemma, based on few, not standardized, institutional center experiences. The authors perform a review of the techniques employed to restore the bladder condition in terms of storage and drainage of urine to receive a kidney transplant in a safer condition. Aspects of the etiology and the way of evaluation of such a group of patients are discussed. The strategies and individualized therapeutic options are presented and compared with the author's experience based upon 25 children with urinary anomalies who received 28 kidney transplants. Nevertheless, the number of complications, mainly UTI, graft and patient survival rates are equivalent to the group of children with non-urological causes of ESRD. Patients with severe lower urinary tract abnormalities and ESRD may receive a kidney transplant with comparable success.

Current Trend of the Primary Treatment in Lower Urinary Tract Symptom/Benign Prostatic Hyperplasia

－Abstract－Clinical benign prostatic hyperplasia (BPH) is a multifaceted phenomenon that is due to prostatic and bladder influences as well as nonurological causes. It is also important to differentiate between the more common voiding or obstructive symptoms as well as the more bothersome storage or irritative symptoms. Lower urinary tract symptoms (LUTS) and BPH may be two separate conditions with different underlying pathologies. However, they are often treated incorrectly as one entity. Both conditions are very common and they represent chronic conditions of the aging male. They are often associated with a significant reduction in the patients' quality of life. Although these are not new conditions, there have been enormous changes in the methods of assessing and managing the patients with these conditions.This review describes some of the influential studies in this area and the current trends of the primary treatment for LUTS/BPH.KeyWords:Lower urinary tract symptoms, Benign prostatic hyperplasia, Medical treatment서 론하부요로증상(Lower urinary tract symp- toms: LUTS)과 전립선비대증(benign prostatic hyperplasia: BPH)은 서로 다른 병인에 의한 것인지는 알 수 없지만, 종종 하나의 상태로

Nocturia: when is it not related to overactive bladder?

This article reviews the different nonurologic causes of nocturia. It also discusses the diagnostic algorithms necessary to identify specific factors underlying a patient's symptoms.

Chronic pelvic pain syndrome: diagnosis and management.

Chronic pelvic pain syndrome (National Institutes of Health Category III [abacterial] prostatitis) is quite prevalent in the urologic outpatient setting. Evaluation to exclude serious urologic pathology and nonurologic causes must be undertaken. Treatment options include pharmacologic, behavioral, and surgical interventions. The author of this article advocates a multidisciplinary approach for the management of patients diagnosed with chronic pelvic pain.

Undiagnosed macroscopic haematuria revisited: a follow-up of 146 patients.

To further investigate a group of patients with macroscopic haematuria who had no abnormalities on upper tract imaging and cystoscopy, to determine the appropriate follow up. The hospital notes of patients who presented with frank haematuria between 1990 and 1998 and had no abnormality on cystoscopy and/or upper tract imaging were reviewed, with particular note made of any further bleeding or any other further urological problems. Those with < 2 years of follow-up in the hospital notes were investigated by telephone or via their general practitioner to ensure that all patients had at least 2 years of follow-up after the initial investigation. Of the 146 patients in the study, 98 were alive and had no more bleeding after the initial investigation. None of them were found to have renal or urothelial tumours during the follow-up. Thirty-three patients had recurrent episodes of bleeding after the initial investigation; 26 of these had repeat investigations and one was found to have a renal pelvic transitional cell carcinoma on repeat intravenous urography. One patient in this subgroup had died from a subarachnoid haemorrhage; 15 other patients had died, 13 of non-urological causes and two of unknown causes. Of 146 patients with undiagnosed macroscopic haematuria, only one had a missed tumour and this was detected on further investigation for recurrent bleeding. These results confirm that repeat cystoscopy and upper tract imaging is only warranted in patients who have recurrent bleeding after initial investigation.

Haematuria associated with BPH-Natural history and a new treatment option.

Bleeding of prostatic origin is usually caused by the friable hypervascularity of the prostate, the vessels of which are easily disrupted by physical activity. The condition is often ignored after the patient has been fully investigated and more serious causes for bleeding excluded and treatment is often withheld unless the bleeding becomes excessive. We analysed the clinical effect of finasteride in the treatment of this condition. We retrospectively reviewed 42 patients diagnosed as having haematuria secondary to bleeding from a benign prostate. Eighteen patients were simply reassured and given no treatment. Twenty-four patients with prostatic bleeding were treated using finasteride. All case notes were reviewed and the patients were contacted by telephone. Of 18 patients who had prostatic bleeding but did not receive treatment the mean age was 70 y and the mean follow-up was 10 months; two had died, nine had no further bleeding, two had a single episode of bleeding requiring no treatment, six had several bleeding episodes of whom one started finasteride, one refused treatment, and three required TURP. In the group treated with finasteride the mean follow up was 9 months, the mean age of the patients was 75 y. Twenty patients had no further bleeding, one patient experienced minor intermittent bleed and required no further treatment. Two patients died of non-urological causes, one patient stopped the treatment because of impotence and one patient had mild gynecomastia. Haematuria secondary to prostatic bleeding can be significant if not treated. Finasteride appears to be effective in suppressing haematuria caused by benign prostatic hyperplasia and should be considered in treating this problem.

Photodynamic Therapy for Localised Prostatic Cancer: Light Penetration in the Human Prostate Gland

We are investigating the feasibility of photodynamic therapy in the treatment of localised prostatic cancer. Of major importance in this form of treatment is the extent to which light penetrates the target organ; hence, our interest in the optical properties of the human prostate gland.We obtained three whole prostates from autopsies of patients who died of non-urological causes. Red light was launched interstitially and detector fibres measured light intensity as a function of distance from the delivery fibre end. The optical constants derived from the three prostates were almost identical and indicated that light was predominantly scattered rather than absorbed (mean absorption and scattering coefficients 0.07 ± 0.02mm.−1 and 0.86 ± 0.05mm.−1 respectively). In a comparison of the tissue penetration by four different wavelengths, 633nm red light was found to be transmitted best. Light propagation in the heavily absorbing tissue of the human liver was 4.3 times poorer than in the prostate.Such a combination of low absorption and high scattering characteristics in prostatic tissue would enhance the effectiveness of PDT. The optical constants derived will enable “light treatment planning” in patients with prostatic cancer. (J. Urol., 143: 398–401, 1990)

Evaluation and treatment of urinary incontinence in long term care.

All elderly patients with established urinary incontinence residing in an intermediate care facility during one year were evaluated for medical and urological conditions contributing to the incontinence; treatment was initiated for all diagnosed problems if possible. Unstable detrusor function (65%), sphincter weakness (13%), and overflow incontinence (10%) were all frequent urological causes, although several patients required extensive testing in addition to cystometrics to establish a complete diagnosis. Frequent nonurological causes of incontinence included behavioral problems (53%), immobility (45%), medication problems (24%), diabetes (18%), and local pathology (47%). Thirty-seven percent had three or more conditions identified. Treatment aimed at nonurological causes was more successful in ameliorating incontinence than urological medication; side effects were significant limitations to urological treatment success. Of the 22 patients who completed evaluation, treatment, and follow-up, five patients (23%) were cured, three (14%) showed at least a 65% decrease in incontinence, four (18%) showed at least a 30% decrease in incontinence, and 10 (45%) showed no change or worsened. We conclude that nonurological problems frequently contribute to urinary incontinence in long term care facilities; incontinence in some of these patients can be improved without urological therapy. Nonurological problems need careful definition and treatment; patients whose incontinence persists require comprehensive urological evaluation and therapy. A complete solution to incontinence in this setting may require safer drugs and better understanding of urinary pathophysiology.