Postvoid Residual Research Articles

Functional and safety outcomes after benign prostatic enlargement surgeries in men with detrusor underactivity compared with normal detrusor contractility: Systematic review and meta-analysis.

Men with detrusor underactivity (DUA)and concomitant bladder outlet obstruction (BOO)due to benign prostatic enlargement (BPE)may present poorer functional outcomes after surgical desobstruction. This study aimed to evaluate the safety and efficacy of BPE surgery in men with DUA compared with those with normal detrusor contractility (NC). This review was performed according to the 2020 PRISMA framework. A comprehensive literature search was performed until May 7, 2023, using MEDLINE, EMBASE, and Cochrane Database. No date limits were imposed. Only comparative studies were accepted. The primary endpoint was to assess if there was any difference in short- and long-term functional outcomes after BPE surgery in men with DUA and NC. The secondary endpoint was to evaluate the differences in perioperative outcomes and postoperative complications between the two groups. Meta-analysis was performed using Review Manager (RevMan) software. There were 5 prospective nonrandomized studies and 12 retrospective studies, including 1701 DUA and 1993 NC patients. Regarding surgical procedures, there were eightTURP (transurethral resection of the prostate) studies, fourGreenLight PVP (photoselective vaporization of the prostate) studies, twoHoLEP (Holmium laser enucleation of the prostate) studies, oneGreenLight PVP/HoLEPstudy, oneHolmium laser incision of the prostate study, and onestudy did not report the type of surgery. We did not find a statistically significant difference between the two groups in terms of perioperative outcomes, including postoperative catheterization time, hospitalization time, urinary retention, need to recatheterization, transfusion rate, or urinary tract infections. Also, we found no significant differences in long-term complications, such as bladder neck stenosis or urethral stenosis. Posttreatment bladder recatheterization and retreatment rate for BPE regrowth could not be evaluated properly, because only one study reported these findings. When we analyzed functional outcomes at 3 months, those with NC had lower International Prostatic Symptom Score (IPSS),lower quality-of-life (QoL) score, better maximum flow rate (Qmax), and lower post-voiding residual (PVR)of urine. These results were maintained at 6 months postoperatively, with exception of PVR that showed no difference. However, at 12 and more than 12 months the functional outcomes became similar regarding IPSS and QoL. There were few data about Qmax and PVR at longer follow-up. In this meta-analysis, data suggest that BOO surgical treatment in patients with concomitant BPE and DUA appears to be safe. Despite patients with DUA may present worse functional outcomes in the short postoperative term compared with the NC population, IPSS and QoL scores become comparable again after a longer follow-up period after surgery.

An Innovative Technique for Ejaculation-Sparing Prostatic Enucleation with Thulium:YAG Laser.

Purpose: We report our experience with 100 patients who underwent an innovative prostate enucleation technique that spares the complete urethral-plate from the veru montanum to the bladder neck using a low-energy thulium laser emission. The aim of our study was to evaluate the short-term effects of this procedure on ejaculation preservation and urinary obstruction. Materials and Methods: The International Prostate Symptom Index (IPSS), quality of life (QoL), and Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EJD) Short Form were used as validated instruments to quantify ejaculatory dysfunction before and 6 months after the surgery. Results: The median IPSS score pre- and postoperatively was 20 and 5, respectively (p < 0.0001); QoL dropped from a median of 4-1 (p < 0.0001); and the mean preoperative maximal flow rate improved significantly (8.5 vs 21.2 mL/min) (p < 0.0001). Furthermore, there was significant reduction in postvoid residual postoperatively (p < 0.0001). Postoperative ejaculatory function was preserved in 92/100 patients (92%). According to the MSHQ-EJD score, patients reported a slight nonsignificant decrease in frequency of ejaculation (item 1), force of expulsion (item 2) and reduction in semen volume during ejaculation (item 3), with the exception of ejaculation discomfort (item 4). Conclusion: According to our results, complete removal of the apical tissue, which has been advocated as an integral part of the so called ejaculatory hood, does not interfere with ejaculation if the ventral lissosphincter remains intact.

Clinical outcomes of prostate artery embolization for management of benign prostate hyperplasia (prostate larger than 100 mL) with or without hematuria

Background: In this study, we report 1-year follow-up clinical results of prostate artery embolization (PAE) in patients with glandular hematuria or acute urinary retention caused by a large prostate (over 100 mL).Methods: Twenty-one consecutive patients undergoing PAE from March 2018 to July 2020 were included in this retrospective study. Clinical follow-up was conducted for all patients 1, 3, 6, and 12 months after the procedure. The outcome measures included the International Prostate Symptom Score (IPSS), quality of life (QoL), peak urinary flow rate (Qmax), post-void residual (PVR), prostate volume, prostate-specific antigen, and complications. A p-value &lt;0.05 was considered statistically significant.Results: Twenty-one patients with severe benign prostatic hyperplasia (BPH) with acute urinary retention or prostatic hematuria were enrolled in this study. Technical success rate was 90.5% (19/21), and unilateral PAE was done in 2/21 (9.5%) patients by pelvic vascular obliteration. In all patients, the mean IPSS, QoL score, Qmax, and PVR were significantly improved at 12 months post-PAE. The mean IPSS decreased from 26.1 to 12.1 points (p&lt;0.05), mean QoL score decreased from 4.6 to 2.9 points (p&lt;0.05), mean Qmax increased from 2.1 to 9.4 mL/s (p&lt;0.05), and mean PVR decreased from 300.0 to 70.7 mL (p&lt;0.05). The catheter was successfully removed from 19/21 patients and clinical success rate was 90.5%.Conclusions: PAE was an effective and safe treatment option for patients with BPH and very large prostates (&gt;100 mL) and urinary retention or gross hematuria associated with BPH in men unfit for surgery.

Can we define the optimal postvoid residual volume at which intermittent catheterization should be recommended, and are there other measures that could guide an intermittent catheterization protocol: ICI-RS 2023.

The postvoid residual (PVR) volume of urine in the bladder is widely used in clinical practice as a guide to initiate treatment, including clean-intermittent self-catheterization (CISC). It is often believed that an elevated PVR causes complications such as recurrent urinary tract infections (UTI) and renal failure. However, evidence for this is limited and identifying alternative measures to guide treatment decisions may optimize patient care. At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2023 a Think Tank addressed the question of whether we can define the optimal PVR at which CISC should be recommended, and whether there are other measures that could guide a CISC protocol. The Think Tank conducted a literature review and expert consensus meeting focusing on current limitations in defining and measuring PVR, and highlighting other measures that may optimize selection for, and persistence with, CISC. There is no consensus on the threshold value of PVR that is considered "elevated"or "significant." There is a lack of standardization on terminology, and the normal range of PVR in different populations of different ages remains to be well-studied. The measurement of PVR is influenced by several factors, including intraindividual variation, timing and method of measurement. Furthermore, the evidence linking an elevated PVR with complications such as UTI and renal failure is mixed. Other measures, such as bladder voiding efficiency or urodynamic parameters, may be better at predicting such complications, and therefore may be more relevant at guiding a CISC protocol. There is a lack of high quality evidence to support PVR as a predictor for complications of UTI or renal failure. Threshold values for normal PVR in different populations are unknow, and so threshold values for "elevated"or "significant"PVR cannot be determined. Other factors, such as urodynamic findings, may be better at predicting complications and therefore guiding management decisions, and this remains to be studied. Areas for further research are proposed.

Preoperative Frailty Scores Predict the Early Postoperative Complications of Holmium Laser Enucleation of Prostate.

Background: Frailty is a recent multidimensional concept of a contemporary growing interest for understanding the complex health status of elderly population. We aimed to assess the impact of frailty scores on the outcome and complication rate of holmium laser enucleation of prostate (HoLEP). Methods: A 7-year data of HoLEP patients in a single tertiary referral center were reviewed. The preoperative, operative, early, and late postoperative outcome data were collected and compared according to the preoperative frailty scores. Frailty was assessed preoperatively using the Modified Hopkins frailty score. Results: The study included 837 patients categorized into two groups: group I included 533 nonfrail patients (frailty score = 0), whereas group II included 304 frail patients (frailty score ≥1). The median (interquartile range) age was 70 (11) and 75 (11) years for groups I and II, respectively (<0.001). The 30-day perioperative complication rate (p = 0.005), blood transfusion (p = 0.013), failed voiding trial (p = 0.0015), and 30-day postoperative readmission (p = 0.0363) rates were significantly higher in frail patients of group II. The two groups were statistically comparable regarding postoperative international prostate symptom score (p = 0.6886, 0.6308, 0.9781), incontinence rate (p = 0.475, 0.592, 0.1546), postvoid residual (p = 0.5801, 0.1819, 0.593) at 6 weeks and 3 months, and 1-year follow-up intervals, respectively. Conclusion: In elderly patients undergoing HoLEP, the preoperative frailty scores strongly correlate with the risk of perioperative complications. Frail patients should be counseled regarding their relative higher risk of early perioperative complications although they gain the same functional profit of HoLEP as nonfrail patients.

Efficacy of Biofeedback in Paediatric Urology Patients: A Single Centre Experience

Aim of the Study: Biofeedback assisted pelvic floor muscle training is an underutilised nonpharmacological treatment in paediatric urology. We reviewed all patients who underwent a course of treatment at our centre to evaluate its efficacy. MethodsAll patients who underwent a full cycle of biofeedback in the paediatric urology department from 2016 to 2023 were identified. Demographics and outcomes following treatment were accessed. Results42 patients (28 female) were identified who underwent 8 one-hour sessions on a weekly basis constituted a completed cycle of treatment. Patients were identified for treatment as per local lower urinary tract symptom guidelines and following discussion in a fortnightly urology MDT and including diagnoses of overactive bladder, dysfunctional voiding, and giggle incontinence.Outcomes were measured as successful 29% (continence, normal postvoid residuals, clean intermittent catherization discontinued), partially successful 19% (reduced wetting, abnormal post void residuals, ongoing CIC) and unsuccessful 52% (no change for patient). Age at time of treatment affected likelihood of success: <9 years, 0% success; ≥9 years, 57% [p < 0.05]. There was no significant difference in success for 9–11 years [60%] vs >11 years [56%]. ConclusionsBiofeedback has shown success with improvement in symptoms in 48% of patients (complete or partial), which increases to 57% success in ≥9 years group. We would advocate its use in these difficult to manage patients with LUTS.

Clinical Efficacy and Safety of Transurethral Plasma Enucleation in the Treatment of Benign Prostatic Hyperplasia

Objective: This paper aims to analyze the effectiveness and safety of transurethral plasma enucleation in clinical treatment of benign prostatic hyperplasia. Methods: A total of 100 patients with benign prostatic hyperplasia who received surgical treatment in our hospital from January 2022 to January 2023 were randomly divided into groups by envelope method. 50 patients who received transurethral plasma resection of the prostate were selected as the control group and 50 patients who received transurethral plasma enucleation of the prostate were the study group. The effective rate of treatment, incidence of complications, postvoid residual (PVR) volume, maximum urinary flow rate (Qmax), and international prostate symptom score (I-PSS) were compared between the two groups. Results: By comparison, the effective rate of treatment in the study group was higher (P &lt; 0.05). By comparison, the incidence of complications in the study group was lower (P &lt; 0.05). Before treatment, there was no significant difference in PVR, Qmax, and I-PSS scores between the two groups (P &gt; 0.05). After treatment, the PVR and I-PSS scores of the study group were lower, and Qmax was higher (P &lt; 0.05). Conclusion: In the treatment of benign prostatic hyperplasia, the application of transurethral plasma enucleation can improve the clinical efficacy and clinical symptoms, with high safety and application value.

Tunica Vaginalis Pedicle Flap Substitution Urethroplasty for Reconstruction of Anterior Urethral Stricture

Background: In long-segment urethral stricture, substitutional urethroplasty is the best option to get long-term good results. Though buccal mucosa is the most widely used tissue, it has limitations in some oral pathology. In several publications, there is evidence that Tunica vaginalis can be used as a graft or flap to reconstruct fibrotic urethra as well as to provide a vascularized covering to prevent subsequent urethrocutaneous fistula formation. This study evaluated the efficacy of the tunica vaginalis pedicle flap’s efficacy for managing anterior urethral stricture.Objectives: To evaluate the clinical efficacy of tunica vaginalis pedicle flap for reconstruction of anterior urethral stricture by assessing change in the maximum flow rate (Qmax), International prostatic symptom index (IPSS), postvoid residual urine (PVR) from baseline and the complication of surgery.Materials and Methods: This was a prospective clinical trial conducted in the Department of Urology, Bangabandhu Sheikh Mujib Medical University, Dhaka from July 2017 to June 2018. A total of 15 patients were selected from the study population according to inclusion and exclusion criteria. The standard operation technique of urethroplasty by tunica vaginalis flap was followed. Patients were followed up after 3 months &amp; 6 months to evaluate IPPS score, Qmax, flow time, PVR, and complications.Results: The mean age and stricture length of study participants were 38.93±11.38 years and 3.55±1.05 cm. The maximum flow of urine was 15.844±3.80 ml/sec at the final follow up which showed statistically significant improvement from baseline. There was also a significant improvement in IPSS, and quality of life during follow-up. Flow time and post-void residue reduced significantly from preoperative measurement. A total of 4 patients developed complications after the substitution of urethroplasty with tunica vaginalis.Conclusion: Tunica vaginalis pedicle flap may be an effective choice in the reconstruction of anterior urethral stricture.KYAMC Journal Vol. 14, No. 02, July 2023: 79-82.

Long-Term Effectiveness of a Nonsurgical BPH Treatment System in Prostate Radiation Patients with Medication-Refractory Lower Urinary Tract Symptoms.

To evaluate the long-term outcomes and toxicity of a nonsurgical prostatic urethral lift system in patients with prior prostate cancer radiation therapy (RT). From 2018 to 2020, nineteen patients with a history of prior prostate RT underwent a nonsurgical prostatic urethral lift (PUL) procedure for lower urinary track symptoms (LUTS) refractory to alpha blocker medications. Prostate cancer RT was completed a median of 17.8 months (IQR 13.4-27.4) prior to PUL procedure. All patients were assessed with IPSS/quality of life (QOL) scores and urinary post void residual (PVR) ultrasound before and after PUL. Patients were also assessed for ability to discontinue alpha blockade medications for their LUTS and any post PUL toxicity based on CTCAE v5.0 criteria. All patients underwent successful placement of the PUL implants. Median pre-PUL IPSS score was 20 (IOR 17.5-22.5) and the median prostate volume was 41cc (IQR 33-49). Median follow up was 22 months (IQR 5-30). The average improvement in IPSS score was 8.5 points (IRQ 5.5-11) at 3 months and 7.5 points (IQR 6-10) at last follow-up. Two patients (10%) initially had improvement in IPSS score at 3 months with subsequent significant increase in IPSS (>5 points) at last follow-up. Overall, there was minimal change in reported QOL scores (median 0, IQR 0-1.75). The average reduction in PVR was 90cc. The percentage of patients able to discontinue alpha blockade at last follow-up was 68%. There was no grade 3 or higher GU toxicity in either group. Use of a nonsurgical prostatic urethral lift system in patients with prior prostate RT refractory to alpha blocker medications results in significant long-term improvement of LUTS after radiation therapy for the majority of patients with minimal toxicity.

Urodynamic findings in children with primary refractory nocturnal enuresis: 10 years' experience of a tertiary center.

To identify correlations between urodynamic study (UDS) findings and urinary symptoms in children with refractory monosymptomatic and nonmonosymptomatic primary nocturnal enuresis. A total of 96 neurologically normal children were enrolled, 44 consecutive boys and 51 consecutive girls, aged 5-18 years, of whom 41 (38.8%) had refractory monosymptomatic nocturnal enuresis (MNE) and 55 (61.2%) had refractory non-MNE (NMNE). We assessed the urodynamics of all children to detect any underlying bladder overactivity. A comparative analysis was carried out between the two groups of patients. Detrusor overactivity (DO), low bladder capacity, low compliance, and increased postvoid residual (PVR) were identified in 70 (72.9%), 35 (36.5%), 43, and 76 (79.2%) patients, respectively. The mean bladder compliance was 21.66 ± 14.52 mL/cmH2O (2-75 cmH2O). Of the NMNE patients, 50 (90.9%) had abnormal urodynamic findings, while 40 (97.5%) had abnormal urodynamic findings in the MNE group. There was a statistically significant relationship between NMNE and both increased PVR and abnormal voiding patterns. Both high PVR and DO were significantly associated with obstructive urinary symptoms. Constipation and history of urinary tract infection (UTI) did not significantly correlate with UDS abnormality (p = 1.0 and p = 0.49, respectively). There was a high prevalence of bladder function disorders in both refractory MNE and NMNE patients in our study. This included small functional capacity, low bladder compliance, and marked DO. A nocturnal enuresis may be the only presenting symptom, however, it may be associated with bladder overactivity, UTI, and constipation; the UDS findings may aid in guiding the assessment and treatment of children suffering from primary refractory nocturnal enuresis and its association with bladder and bowel symptoms.

Shifting Trends in Prostate Treatment: A Systematic Review Comparing Transurethral Resection of the Prostate and Holmium Laser Enucleation of the Prostate.

Our systematic review aimed to assess the effectiveness and suitability of holmium laser enucleation of the prostate (HoLEP) as a treatment for benign prostatic hyperplasia (BPH) in comparison to transurethral resection of the prostate (TURP). We analyzed 12 studies involving male participants aged 45-85 years, all of whom had BPH. In our analysis, we compared HoLEP and TURP, with a focus on several primary outcomes, including postoperative International Prostate Symptom Score (IPSS), postvoid residual (PVR) volume, maximum flow rate (Qmax), and changes in sexual function post-treatment. HoLEP demonstrated advantages in certain aspects when compared to TURP. HoLEP generally resulted in an improved postoperative IPSS in some studies, but not all studies showed a significant difference when compared to TURP. HoLEP was associated with improved Qmax in most studies, but one study found no significant difference between HoLEP and TURP.Patients who underwent HoLEP showed improvement in the PVR volume in some studies, while others found no significant change in the PVR volume with either HoLEP or TURP. Some studies reported a reduction in orgasm and ejaculatory scores following TURP, while no significant changes were observed in erectile function, intercourse satisfaction, and overall satisfaction scores. It is worth noting that previous reviews and meta-analyses had limited data on the effects of HoLEP and TURP on sexual dysfunction. TURP is associated with a higher risk of morbidity and mortality, which has led to its replacement with HoLEP as the gold standard for treating BPH, particularly due to its size-independent applicability. HoLEP also demonstrated greater efficacy in the postoperative period.

Current opinion: postpartum urinary disorders.

The aim of this study was to describe the common postpartum urinary sequelae including urinary retention and incontinence, and to summarize the management of these conditions. Despite the high frequency of urinary disorders in obstetrics, screening and management protocols are rarely utilized by providers. Large variation exists in the literature regarding assessment of postpartum urinary retention, values of postvoid residuals and management of indwelling catheters in the immediate postpartum population. Recent expert guidance outlines a strategy for managing this condition.Research also highlights that screening for peripartum urinary incontinence is not a routine practice. The diagnosis is made more challenging by the fact that patients commonly understate and over-normalize their symptoms. Emerging studies have found that pelvic floor muscle training is cost-effective, preventive, and may improve symptoms in the postpartum setting. Increased awareness of urinary disorders in pregnancy and postpartum is imperative for appropriate diagnosis and management. Instituting standardized voiding protocols postpartum will allow providers to avoid undiagnosed postpartum urinary retention and its repercussions. Improved screening and education regarding urinary incontinence in the peripartum is important for early management, such as pelvic floor muscle training, and improved quality of life.

Normal postvoid residual urine in healthy adults.

To establish a normal reference value of postvoid residual (PVR) urine volume in "healthy" adults. Adults were recruited to undergo uroflowmetry and PVR. Those with neurological disorders, malignancy, diabetes, known lower urinary tract dysfunction, and urinary tract infection within the previous 3 months, were excluded from the study. Constipation was defined as Rome IV ≥ 2. Of the 883 adults enrolled in this study, 194 (22.3%) did not complete the questionnaires or perform the uroflowmetry, 103 (11.7%) met ≥1 exclusion criteria and thus were excluded. In addition, 30 and 38 uroflowmetry were excluded due to artifacts and low bladder volume (BV) (<100 mL), respectively. Finally, 515 uroflowmetry and PVR data from adults aged 36-89 (mean: 59.0 ± 9.5) were examined. There was a significant nonlinear relationship between BV and PVR (p < 0.05), with PVR significantly increased when BV was around 528 mL. Women had lower PVR than men (p < 0.05). PVR also increased as the International Prostatic Symptom Score (IPSS) increased. PVR was unaffected by age and functional constipation. A multivariate analysis revealed that BV (p < 0.05) and IPSS (p < 0.05) had significant influence on PVR, but age, gender, and Rome IV score did not. The 90th and 95th percentiles of PVR for men were 73.2 mL (25% of BV) and 102.6 mL (30% of BV), respectively, while for women they were 60.5 mL (21% of BV) and 93.8 mL (27% of BV), respectively. Women had lower PVR than men. The 90th percentile or 95th percentile of normal adults' PVR may serve as the upper limit of normal PVR, and readings above this level may necessitate additional evaluation and treatment. Further studies are required to substantiate these recommendations.

The Diagnostic Accuracy of a Retrograde Voiding Trial for Restoration of Spontaneous Voiding Function after Prolapse and Urinary Incontinence Surgery

To assess the diagnostic accuracy of a retrograde voiding trial for the restoration of spontaneous voiding function after prolapse and urinary incontinence surgery and thereby determine whether the retrograde method can be a reliable alternative to the spontaneous voiding trial. A retrospective cohort study. A single tertiary hospital in South Korea. Women who underwent operations for prolapse, urinary incontinence, or both. Sequential voiding trials on postoperative day 1 or 2-retrograde voiding trial followed by spontaneous voiding trial. Of the 408 women analyzed, 278 (68.1%) passed the spontaneous voiding trial on the first day of assessment and none experienced urinary retention after a successful voiding trial. Receiver operating characteristic analyses of retrograde voiding trials evaluating voided volume (VV), postvoid residual (PVR), and voiding efficiency (VE) all demonstrated high diagnostic accuracy for restoration of spontaneous voiding function, whereas measuring PVR and VE had better discriminative ability than VV (area under the curve [95% confidence interval]=0.93 [0.90-0.95] for PVR, 0.94 [0.91-0.96] for VE, and 0.88 [0.85-0.91] for VV; DeLong's test between PVR/VE and VV p < .01). The optimal cutoffs determined by the Youden index were 200 mL for VV (sensitivity 85.0%, specificity 78.0%), 100 mL for PVR (sensitivity 84.0%, specificity 87.0%), and 66.7% for VE (sensitivity 86.0%, specificity 88.0%). The retrograde voiding trial is an accurate predictor for restoration of spontaneous voiding function after prolapse and incontinence surgery and can be a useful alternative to the spontaneous voiding trial.

Prostatic urethral lift for subjects in urinary retention (PULSAR): 12-Month results of a prospective controlled trial compared with real-world outcomes.

To examine the safety and efficacy of prostatic urethral lift (PUL) in acute urinary retention (AUR) patients within a controlled (PULSAR) and real-world setting (Real-World Retrospective study). PULSAR was a 12-month prospective study of PUL in AUR patients (n = 51) performed at six centres in the United Kingdom; enrolled BPH patients aged ≥50 years, with prostate volume of ≤100 cc. AUR was defined as being catheter dependent with at least one prior failed trial without catheter (TWOC) while on an alpha-blocker. RWR consisted of 3226 consecutive PUL patients across 22 international sites treated between July 2017 and March 2020; 469 of whom were in urinary retention (RWRr), that is, catheter-dependent at the time of their procedure. Symptom response, uroflow and catheter independence rates were compared between PULSAR and RWRr subjects. A logistical regression model was constructed to evaluate patient baseline and dynamic factors predicting success after the procedure. Seventy-three percent of PULSAR subjects were catheter independent and free from surgical reintervention at 12 months post-PUL. Success was associated with higher voiding efficiency during the perioperative period. Slightly higher catheter-independent rates (80%) were seen in RWRr patients; variables that influenced success included age <70 years, lower baseline prostate-specific antigen (PSA), lower baseline post-void residual (PVR) and shorter pre-procedural catheter duration. Logistic regression of the combined PULSAR and RWRr retention groups revealed that procedural age <70 years and higher bladder voiding efficiency (BVE) were associated with success. Lower baseline PSA and PVR, younger age and shorter pre-procedure catheter durations drove successful outcomes in AUR patients undergoing PUL. Post-PUL voiding efficiencies may help ascertain long-term response to treatment.

Four-hour voiding observation: Normative data from term Indian neonates

BackgroundThe four-hour voiding observation is an important non-invasive urodynamic test for infants and young children before toilet training. The study was performed to generate normative data for term Indian neonates. MethodsThe study was a descriptive study performed in the Department of Paediatrics of a secondary care hospital in South India with patients having nationwide representation from August 2018 to August 2020. Term neonates, appropriate for gestational age on days 4–14 of life were included. Neonates at risk of oliguria or abnormal bladder functions were excluded. Four-hour voiding observation was performed by direct observation of voids, pre- and post-void diaper weight and measurement of post-void residue (PVR) by ultrasonography using two formulae within five minutes of voiding. ResultsA total of 102 neonates (166 voids) were studied. Important results were (a) Eight neonates did not void; (b) median (fifth–95th percentile) of important test outcomes as follows: voided volume: 15 (7.5–33.5) ml, maximum voided volume (MVV) 16.5 (8.0–38.7) ml, PVR 3.2 (0.5–10.2) ml, PVR% 17.0 (2.9–46.4) % functional bladder capacity 19.7 (9.6–38.0) ml, and diuresis: 1.7 (0.0–5.1) ml/kg/hour; (c) four (4.3%) neonates had one interrupted void each; (d) linear regression yielded the following formulae: MVV (ml) = 8.1019 + 4.8702 ∗Diuresis (ml/kg/hr) and PVR % (max) = 14.2312 + 3.2682∗ Diuresis (ml/kg/hr). ConclusionNormative data on the four-hour voiding observation study for Indian term exclusively breast-fed neonates are reported.

Urologic manifestations of hypotonia, ataxia, and delayed development syndrome (HADDS), a rare neurodevelopmental disorder

Early B-cell factor 3 (EBF3) is a transcription factor involved in neuronal differentiation and maturation. Pathogenic variants are associated with hypotonia, ataxia, and delayed development syndrome (HADDS) (MIM#617330). Urologic manifestations are common and may have implications regarding long term renal function. To review all known patients with pathogenic variants of the EBF3 gene resulting in HADDS with urologic manifestations. We hypothesize a high rate of bladder dysfunction secondary to the EBF3 variant's impact on relaxation of the urinary sphincter leading to detrusor sphincter dyssynergia (DSD). The PubMed database was queried for publications of the EBF3 mutation between January 2017 and January 2023. Search terms were "EBF3 mutation OR HADDS AND urology OR phenotype". Retrospective analysis of HADDS patients cared for in our institution was performed. Demographic and clinical information was collected. We identified 52 patients (33F:19M) through literature (28F:18M) and retrospective review (5F:1M). There was a high prevalence of genitourinary physical exam abnormalities, history of urinary tract infection, vesicoureteral reflux (VUR), and diagnosis of neurogenic bladder. Within the literature review cohort, 67% had a urologic diagnosis. Females were disproportionately affected with urologic manifestations. In our cohort, four of six children were diagnosed with VUR and severe voiding dysfunction consistent with neurogenic bladder (67%). These children were managed with a vesicostomy. Five children had bowel dysfunction requiring therapy. Urodynamics suggested a high prevalence of external sphincter dyssynergia. Less severe forms of DSD were felt to be implicated in the abnormal voiding parameters in children who presented later in life based on non-invasive flow studies. There is significant variability in the phenotypic presentation of patients with HADDS. While EBF3 plays a clear role in neurodevelopment, it also impacts muscle development and may impact muscle relaxation. The location of the genetic variant may impact the degree of DSD, with more severe forms leading to earlier presentations. Initial work-up should include a renal ultrasound (RUS) and post void residual (PVR). Consideration can be given to obtaining a VCUG, DMSA scan or urodynamic studies. Yearly screening should be pursued with an RUS and PVR in those with an initial unremarkable work-up given the variable timing and severity of presentation. Urologic manifestations of HADDS include high rates of bladder dysfunction secondary to DSD, vesicoureteral reflux, urinary tract infection, and cryptorchidism. These patients are at risk of renal deterioration if urinary abnormalities are not properly diagnosed and managed.

The double-face onlay-tube-onlay transverse preputial flap: An advantageous alternative to the two-stage hypospadias repair?

To compare the surgical outcomes and complications of boys who underwent double-face onlay-tube-onlay transverse preputial island flap (DFOTO) one-stage repair vs. two-stage repair for proximal hypospadias. Males with proximal hypospadias who underwent DFOTO or two-stage repair at a single institution from 2008 to 2021 were identified. Patients who had prior hypospadias surgery were excluded. Outcomes were surgical complications, number of surgical procedures, operative time, and post-operative uroflowmetry results. Fifty-three males who underwent DFOTO and 39 who underwent two-stage repair were included. Median age at surgery was 1.1 years (IQR 0.83-1.6) and median follow-up was 3.0 years (IQR 1.2-6.8). Although not statistically significant, the DFOTO group had higher rates of urethrocutaneous fistula (30% vs. 15%, p=0.10), urethral stricture (15% vs. 3%, p=0.07) and urethral diverticulum (8% vs. 3%, p=0.39). Although the unplanned re-operation rate was higher in DFOTO (58% vs. 33%, p=0.02), the mean number of procedures and median total surgical time were lower in DFOTO (1.8±0.9 vs. 2.4±0.8, p=0.0004; 337min [IQR 278-460] vs. 468 min [IQR 400-563], p=0.008). There were no significant differences between groups for mean peak flow rates and post void residuals. In males who underwent DFOTO, 42% achieved completion of their proximal hypospadias repair with one operation, while the remainder had largely minor complications. Accounting for reoperation rates, the mean number of procedures per patient was lower in the DFOTO group. Comparable results can be achieved with both techniques; the risks of higher unplanned operation rates in the DFOTO group should be considered with the benefit of fewer total procedures.

Uroflowmetry: A follow-up tool for neurogenic bladder patients treated by transcutaneous tibial posterior stimulation?

Neurogenic bladders can suffer from overactivity, underactivity or dyssynergia depending on the level of the initial lesion. These symptoms can lead to severe alterations of the upper urinary tract. One of the first-line treatments is the transcutaneous tibial posterior stimulation (TTNS), which was demonstrated to be efficient on urodynamics. But it is an invasive, expensive and sometimes not patient-accepted examination, contrary to the uroflowmetry. The aim of this study is to assess the feasibility of a follow-up with a uroflowmetry when treated by TTNS and show that the maximum flow rate increased after treatment, displaying a better detrusor contraction. In total, 38 patients with neurogenic bladder undergoing a 12-weeks TTNS treatment and with 2 uroflowmetries interpretable before and after treatment were included. The maximum flow rate (Qmax), the urinated volume and the post-void residual (PVR) were retrieved from the uroflowmetry, and the USP-score and the urinary discomfort were asked at each appointment. Qmax is increased from 17,53ml/s to 18,26ml/s, as well as the PVR (from 76,97ml to 79,16ml). Urinated volume is decreased from 241,4ml to 193,66ml. Patients feel enhanced after TTNS according to the decrease in the USP-score and the urinary discomfort scale. The increase of the cystomanometric capacity and the delay of the detrusor overactivity due to TTNS explains the reduction of the urinated volume and the increase of PVR. Increased Qmax might show a better voluntary bladder contraction, with a restraint due to the lack of abdominal pressure measurement during voiding.

Combination of 180-W GreenLight XPS laser and bipolar transurethral resection of prostate for the treatment of large prostates beyond 100ml: a novel hybrid technique.

The aim of this study was to evaluate the safety and efficacy of the 180-W GreenLight laser (GL) XPS™ plus bipolar transurethral resection of the prostate (TURP) for the treatment of a prostate volume (PV) beyond 100ml. From January 2014 to December 2022, 79 patients with PV > 100ml who underwent GL-XPS plus bipolar TURP were enrolled. The median follow-up time was 13.7months. The International Prostate Symptom Score (IPSS), PV, uroflow study, post-void residual (PVR) volume, and prostate-specific antigen (PSA) before and after the operation were recorded. Subgroup analysis was performed to compare the outcomes between the patients with follow-up times of < 36months and > 36months. Statistically significant improvements in all the postoperative parameters were observed in both < 36months and > 36months groups. There was no blood transfusion or transurethral resection (TUR) syndrome in this series. Most of all, a second TURP was unnecessary during the follow-up. Only one (1.3%) Clavien-Dindo grade 3b complication was noted. The hybrid technique of 180-W XPS™ GreenLight laser plus bipolar TURP can be safely and efficiently performed on patients with a prostate volume of > 100ml.