Small Bladder Capacity Research Articles

Long-term Outcomes of Augmentation Cystoplasty in Genitourinary Tuberculosis in Adults: A 12-year Follow-up Experience at a Tertiary Care Center

ObjectivesTo evaluate the long-term effectiveness and consequences of augmentation cystoplasty in adult patients with small capacity bladder due to genitourinary tuberculosis (GUTB). MethodsAfter approval of the institutional ethical committee, we retrospectively analyzed the database of adult patients with small capacity bladder due to GUTB treated by augmentation cystoplasty from January 2010 to December 2022 at our center. The patients were followed up at six weeks postoperatively, then every three monthly for 1st year and six monthly in second year, and then annually. Patients were assessed for symptoms, renal function, blood biochemistry levels, and ultrasound KUB at each follow-up visit. ResultsA total of 40 patients underwent augmentation cystoplasty were included. All patients underwent augmentation cystoplasty either with ileum (n=35) or sigmoid colon (n=5). On long term follow up, there were statistically significant improvement in bladder capacity, decrease in voiding frequency (p=0.00), decrease in eGFR (p=0.02) and increase in serum creatinine (p=0.02). Significant complications were wound infection 4 (10%), intestinal obstruction 1(2.5%), urinary tract infection 6 (15%), bladder stone 2 (5%), mucus retention 3 (7.5%), hypocalcemia with metabolic acidosis 2 (5%) and need of intermittent catheterisation in 11 (27.5%) patients. ConclusionsMultidrug therapy with judicious reconstructive surgery is the optimal treatment modality for GUTB with cicatrization sequelae. In GUTB, augmentation cystoplasty is a safe procedure and strict long term follow up is needed to prevent complications.

Clinical efficacy of laparoscopic Lich-Gregoir versus transvesicoscopic Cohen reimplantation for ureterobladder junction malformations in children.

To assess the clinical efficacy of laparoscopic Lich-Gregoir (LLG) and transvesicoscopic Cohen reimplantation (TCR) in the treatment of vesicoureteral junction obstruction (VUJO) and vesicoureteral reflux (VUR). This study retrospectively analyzed the clinical data of 66 pediatric patients with VUJO and VUR. They were classified into two groups, undergoing either the laparoscopic Lich-Gregoir operation (LLGO) (n = 35) or transvesicoscopic Cohen reimplantation operation (TCRO) (n = 31). The surgeries were performed between April 2018 and September 2022 at the First Affiliated Hospital of Guangxi Medical University, China. General characteristics, preoperative attributes, postoperative complications, renal function recovery, and improvement of hydronephrosis were compared between the two groups. All surgical procedures were successful with no requirement for reoperation. Both groups were comparable with respect to gender, affected side, weight, and postoperative complications. Nonetheless, the LLGO group contained a greater number of children younger than 12months. The LLGO group demonstrated superiority over the TCRO group regarding the duration of the operation, intraoperative blood loss, and length of postoperative hospital stay. In contrast, postoperative complications, recovery of renal function, and hydronephrosis improvement did not exhibit statistically significant differences between the two groups. Both LLGO and TCRO were demonstrated to be precise, safe, and reliable surgical methods for treating pediatric VUJO and VUR. LLGO ureteral reimplantation offers particular advantages in selecting cases and appears more suitable for children younger than 12months who have a small bladder capacity.

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis.

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

Risk factors associated with recurrent febrile urinary tract infection in children with neurogenic bladder who perform clean intermittent catheterization.

To identify the clinical and urodynamic risk factors associated with the development of recurrent febrile urinary tract infections (FUTIs) in children with neurogenic bladder (NB) who perform clean intermittent catheterization(CIC). Children with NB receiving CIC were prospectively enrolled from January to December 2019 and followed up prospectively for 2 years. All data were compared between occasional (0-1 FUTI) and recurrent FUTIs (≥2 FUTI) groups. In addition, the risk factors for recurrent FUTIs in children were evaluated. Complete data from 321 children were analyzed. Occasional FUTIs occurred in 223 patients, and 98 patients experienced recurrent FUTIs. Univariate and multivariate analyses, showed late-initiation and low-frequency CIC, vesicoureteral reflux (VUR), small bladder capacity and low compliance, and detrusor overactivity were associated with an increased risk of recurrent FUTIs. Children with high-grade VUR (grades IV-V) had a higher risk of recurrent FUTIs than those with low-grade VUR (grades I-III) (odds ratio [OR]: 26.95 vs.OR: 4.78, p < 0.001). Our study suggests that late-initiation and low-frequency CIC, VUR, small bladder capacity and low compliance, and detrusor overactivity were associated with recurrent FUTIs in patients with NB. In addition, high-grade VUR is a crucial risk factor for recurrent FUTIs.

Ketamine uropathy: Clinical experience in a high prevalence center.

Ketamine uropathy causes inflammatory changes to the urothelium, manifesting as significant lower urinary tract symptoms, small bladder capacity, and pelvic pain. Upper tract involvement and hydronephrosis can occur. Data from UK centers are limited, and no formal treatment guidelines exist. All patients with ketamine uropathy presenting to our unit over an 11-year period were identified through operative and clinic lists, emergency presentations, and a prospectively collected local database. Demographic data, biochemical findings, imaging techniques, and both medical and surgical management were recorded. A total of 81 patients with ketamine uropathy were identified from 2011 to 2022; however, a large proportion presented from 2018 onwards. The average age at presentation was 26 years (interquartile range [IQR]: 27-34), 72.8% were male, and average follow-up time was 34 months (IQR: 8-46). Therapeutic interventions included anticholinergic medication, cystodistension, and intravesical sodium hyaluronate. Hydronephrosis was present in 20 (24.7%) patients and nephrostomy insertion was required in six. One patient underwent bladder augmentation surgery. Serum gamma-glutamyl transferase and length of follow-up were significantly higher in patients with hydronephrosis. Adherence to follow-up was poor. We present a large cohort of patients with ketamine uropathy from a small town in the UK which is unusual. The incidence appears to be rising, in-keeping with increasing recreational ketamine use and should be of concern to urologists. Abstinence is a key aspect of management, and a multi-disciplinary approach works best particularly as many patients are lost to follow-up. The development of formal guidance would be helpful.

Каменеутворення в аугментованому сечовому міхурі в дитячому віці: сучасний стан проблеми

Purpose - to analyze the current state of the problem patients’ treatment with stones in the augmented bladder and recommend optimal approaches for their elimination, based on the literature data. Augmentation cystoplasty is a surgical procedure used in adults and children with refractory bladder dysfunction, including, in particular, small bladder capacity, in whom conservative treatment has failed. The leading pediatric pathologies for which enterocystoplasty performed are neuropathic bladder and bladder exstrophy. The article examines the complications that arise, and the possibilities and advantages of endoscopic techniques in children compared to open surgery in view of compromised tissues due to congenital defects and previous surgical interventions. The cause of the main postoperative complications, such as metabolic disorders, hematuria syndrome, calculi formation, mucus formation, enteric fistulae, bladder rupture, intestinal obstruction and the development of malignant neoplasms, are mainly related to the use of gastrointestinal tract tissues in the bladder. As an example of modern surgical and minimally invasive methods application, considered the case of treatment of a child with urinary bladder exstrophy, in which later stones were formed. Conclusions. The stones formation in an augmented bladder is a fairly common problem, difficult to prevent and effectively treat. Timely complete bladder emptying and adequate treatment of bladder infections are the keys to preventing the formation of stones in an augmented bladder. Modern minimally invasive technologies make it possible to effectively, minimally traumatical and safely treat patients with calculi of various localizations of the urinary system, as well as patients who have previously undergone complex plastic surgery. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors.

Characteristics of neurogenic lower urinary tract dysfunction patients at Cipto Mangunkusumo Hospital

BACKGROUND Neurogenic lower urinary tract dysfunction (NLUTD) is an abnormal function of the bladder, urethra (and/or prostate in males) in patients with a clinically confirmed relevant neurologic disorder. Hence, accurate diagnosis and management of NLUTD is crucial. This study aimed to recognize the characteristics of NLUTD to identify, manage, and prevent the associated complications.&#x0D; METHODS This retrospective study was conducted at the Outpatient Clinic of the Department of Urology, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from January 2011 to December 2021. The study analyzed data collected from voiding dysfunction patients with upper motor neurological disorders who underwent urodynamic studies during the study period. Incomplete data in the medical records were excluded.&#x0D; RESULTS Mean age of the participants was 50.7 (18–95) years old. The most common cause of NLUTD was stroke (26.6%), followed by unspecified groups and spinal cord injury. Patients under 20 years old were affected by trauma and congenital defects. Of the patients, 34.0% had urinary retention, and 18.1% had incontinence. Small bladder capacity occurred in patients with stroke, Parkinson’s disease, and spinal/cerebral tumors, leading to decreased bladder compliance.&#x0D; CONCLUSIONS NLUTD was associated with aging, with upper motor neurological lesions such as trauma, stroke, and spinal/cerebral injury being the most common etiologies. Most patients with NLUTD had small bladder capacity and decreased compliance based on urodynamic result.

V04-07 ROBOTIC ASSISTED SIDE-TO-SIDE REFLUXING NON-DISMEMBERED URETEROCYSTOTOMY FOR MANAGEMENT OF AN OBSTRUCTED MEGAURETER

You have accessJournal of UrologyCME1 Apr 2023V04-07 ROBOTIC ASSISTED SIDE-TO-SIDE REFLUXING NON-DISMEMBERED URETEROCYSTOTOMY FOR MANAGEMENT OF AN OBSTRUCTED MEGAURETER Hailey Silverii, Xinyuan Zhang, and Nicolas Fernandez Hailey SilveriiHailey Silverii More articles by this author , Xinyuan ZhangXinyuan Zhang More articles by this author , and Nicolas FernandezNicolas Fernandez More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Obstructed megaureters can often be safely observed; however, when there are associated changes in renal function or recurrent infections, surgical intervention is indicated. Surgical management options include: endoscopic intervention, diversion with cutaneous ureterostomy, non-refluxing ureteral reimplantation, or refluxing ureteral reimplantation with an end-to-side or side-to-side approach. Determining factors for management include the circumstance for which intervention is indicated, age and size of the patient, degree of ureteral dilation and obstruction, and bladder size. In this video, we present a robotic assisted side-to-side refluxing non-dismembered ureterocystotomy for an infant with a ureterovesical junction (UVJ) obstruction. METHODS: A 4-month-old, 6.6 kg male with a history of antenatally diagnosed hydroureteronephrosis presents with a 3 month interval renal ultrasound demonstrating worsened degree of right hydroureteronephrosis with debris and increased parenchymal thinning. He has no prior history of urinary tract infections. A MAG3 renal scan demonstrated normal differential function and an obstruction at the level of the right UVJ. Given the patient’s young age and small bladder capacity, a non-refluxing ureteral reimplantation was not felt to be a feasible option. A side-to-side ureterocystotomy was recommended to which the family consented. After further counseling, a robotic approach was agreed upon and completed with the assistance of the Da Vinci XI platform (Intuitive Surgical, Sunnyvale, CA). RESULTS: The case began with a cystoscopy and right retrograde pyelogram which confirmed the level of the obstruction at the UVJ. Three supraumbilical 8 mm ports were placed prior to docking the Da Vinci system. Console time was 60 minutes. The tension free side-to-side anastomosis was completed in an interrupted fashion between the bladder and the dilated distal ureter. Estimated blood loss was less than 5 cc. The patient was discharged on post-operative day one after Foley catheter removal and the patient is doing very well. CONCLUSIONS: In conclusion, a robotic approach to a refluxing non-dismembered ureterocystotomy can safely be employed in small infants with adaptations in port placement, dissection, and anastomosis given small working space and risk to injuring nearby structures. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e340 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hailey Silverii More articles by this author Xinyuan Zhang More articles by this author Nicolas Fernandez More articles by this author Expand All Advertisement PDF downloadLoading ...

PD06-03 BLADDER OUTLET PROCEDURES WITHOUT AUGMENTATION CYSTOPLASTY: EXTENDED LONG-TERM OUTCOMES AND RISKS ASSOCIATED WITH PREOPERATIVE BLADDER COMPLIANCE

You have accessJournal of UrologyCME1 Apr 2023PD06-03 BLADDER OUTLET PROCEDURES WITHOUT AUGMENTATION CYSTOPLASTY: EXTENDED LONG-TERM OUTCOMES AND RISKS ASSOCIATED WITH PREOPERATIVE BLADDER COMPLIANCE Alexandra Carolan, Shane Batie, Yvonne Chan, Micah Jacobs, and Bruce Schlomer Alexandra CarolanAlexandra Carolan More articles by this author , Shane BatieShane Batie More articles by this author , Yvonne ChanYvonne Chan More articles by this author , Micah JacobsMicah Jacobs More articles by this author , and Bruce SchlomerBruce Schlomer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003230.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A bladder outlet procedure (BOP) without augmentation cystoplasty (AC) for incontinence due to neurogenic bladder (NGB) is associated with risk of upper tract changes, chronic kidney disease (CKD), and need for additional surgeries. A cohort of patients who underwent BOP without AC from 2000-2013 was previously reported. From 2014 to present, BOP without AC has been used selectively. Here, we present extended outcomes, hypothesizing that BOP without AC in patients with high preoperative compliance (≥20 mL/cm H2O) is associated with fewer adverse outcomes. METHODS: A retrospective chart review was performed and longitudinal dataset created. Cumulative incidence of outcomes up to 15 years were calculated. The association of preoperative bladder compliance with adverse outcomes was studied by log-rank test. RESULTS: 120 patients underwent BOP without AC from 2000-2020 at a median age of 7.5 years (Interquartile range (IQR) 5.8-11.5), with a median follow up of 10.1 years (IQR 7.1-13.3). Table 1 displays the 1, 5, 10, and 15 year cumulative incidences of outcomes. At 15 years, the cumulative incidence of AC was 42% and CKD was 48%. The most common indications for AC were small bladder capacity (25/37 patients, 76%), elevated detrusor pressure (24/37, 73%), incontinence (20/37, 61%), and new or worsening renal scarring (8/37, 24%). Of 87 patients with preoperative urodynamics available, a preoperative bladder compliance ≥ 20 mL/cm H2O (32/87, 37%) was associated with a lower incidence of subsequent AC and abnormal DMSA (Figure 1). CONCLUSIONS: BOP without AC carries a significant risk of adverse outcomes including additional surgeries, upper tract changes, and CKD when used non-selectively. Patients with a preoperative bladder compliance ≥20 mL/cm H2O may have a lower risk of adverse outcomes. These results support the selective use of BOP without AC in NGB patients with large, compliant bladders but long-term monitoring is needed. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e156 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexandra Carolan More articles by this author Shane Batie More articles by this author Yvonne Chan More articles by this author Micah Jacobs More articles by this author Bruce Schlomer More articles by this author Expand All Advertisement PDF downloadLoading ...

MP70-12 THE WIDE URETER AND THE SMALL BLADDER, THE CUFF-NIPPLE REIMPLANTATION RATHER THAN URINARY DIVERSION

You have accessJournal of UrologyCME1 Apr 2023MP70-12 THE WIDE URETER AND THE SMALL BLADDER, THE CUFF-NIPPLE REIMPLANTATION RATHER THAN URINARY DIVERSION Moneer Hanna and Wael Abosena Moneer HannaMoneer Hanna More articles by this author and Wael AbosenaWael Abosena More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003338.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reimplantation of a dilated Ureter into an infantile small capacity bladder represents a surgical challenge. The surgical options for reflux megaureters who developed breakthrough urinary infections while on prophylaxis are temporary diversion (vesicostomy for bilateral and ureterostomy for unilateral megaureters). In cases of obstructed megaureter the options are ureterostomy and refluxing reimplantation. METHODS: Between 1995 and 2021, 46 infants aged 3 and 12 months were referred for surgical management following recurrent pyelonephritis while on prophylaxis (30 infants) and for worsening hydronephrosis (16 infants). There were 32 boys and 14 girls. The diagnosis was bilateral reflux megaureters in 18 and unilateral in 8 children. The other twenty children had bilateral obstructed megaureter in 9 and unilateral in 11 children. The radionuclide renal scan was performed in 43 children, and it showed reflux nephropathy in 35 kidneys with VUR and reduced function of more than 20% in 9/11 obstructed kidneys. A total of 73 megaureters were operated on. The ureteral tortuosity was straightened, and the caliber was reduced when indicated. Each ureter was reimplanted in a short (1 cm) submucosal tunnel, a cuff-nipple ureteral orifice was created in 62/73 ureters. Simple cuff-nipple without submucosal tunnelling in 11 ureters. RESULTS: The postoperative course was uneventful in all children and follow up US & VCUG were done at four months. Thereafter the follow-up continued by the pediatric nephrology service. The post operative US showed improved hydronephrosis in 59/73 kidneys and stable in 14 units. The VCUG showed no evidence of VUR in 58/62 (93%) of the group who had short tunnel and cuff-nipple reimplantation, in 4 ureters the VUR was downgraded to grade II. 10/11 (91%) of the ureters with the cuff-nipple without tunneling showed no evidence of VUR, and one ureter the VUR was grade II. 7 children had significant reflux nephropathy outgrew their renal function and underwent renal transplantation CONCLUSIONS: The time -tested Paquin dogma of tunnel length/width ratio of 5/1 was challenged by Lyons et.al, the latter contention was that the shape of the ureteral orifice (UO) is more important than the length of the tunnel for reflux prevention, (the cuff-nipple creates a volcano like UO). Recently Villaneuva et.al performed a parametric simulation study of ureteral collapse (LS-DYNA finite-element software). They confirmed Lyons observation. These observations would explain the high success rate which was achieved by the cuff-nipple technique. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1008 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Moneer Hanna More articles by this author Wael Abosena More articles by this author Expand All Advertisement PDF downloadLoading ...

Retrospective analysis of bladder perforation risk in patients after augmentation cystoplasty using an extraperitoneal approach

Initial management of pediatric patients with neurogenic bladder is focused on clean intermittent catheterization and medical therapies. Those with more hostile or small capacity bladders require surgical intervention including bladder augmentation that can result in significant clinical sequelae. This study examines a rarely described approach wherein the bladder reconstruction is extraperitonealized by bringing bowel segments through a peritoneal window and then closed. The aim of this study was to determine if the rate of bladder rupture and subsequent morbidity differed between patients who have undergone an intraperitoneal versus extraperitoneal bladder augmentation. We hypothesized that an extraperitoneal approach reduced the risk of intraperitoneal bladder perforation, downstream Intensive Care Unit (ICU) admission, small bowel obstruction (SBO) requiring exploratory laparotomy, and ventriculoperitoneal (VP) shunt-related difficulties as compared to the standard intraperitoneal technique. A retrospective chart review was conducted to assess surgical approach and outcomes in patients who underwent bladder augmentation performed between January 2009 and June 2021. Patients were identified through an existing database and manual chart review was conducted to extract data through imaging studies, operative notes, and clinical documentation. The primary outcome was bladder perforation. Secondary outcomes were ICU admission, exploratory laparotomy, and VP shunt externalization, infection, or revision for any cause. Nonparametric statistical analyses were performed. A total of 111 patients underwent bladder augmentation with 37 intraperitoneal and 74 extraperitoneal procedures. Median follow up was 5.8 years [IQR 3.0-8.6 years] and did not vary between groups (P=0.67). Only one patient was found to have a bladder perforation in the intraperitoneal group (log-rank P=0.154). There were no significant differences in time to post-augmentation ICU admission, exploratory laparotomy, or VP shunt events between the two groups (log-rank P=0.294, log-rank P=0.832, and log-rank P=0.237, respectively). Furthermore, a Kaplan-Meier analysis assessing time to composite complication demonstrated no significant difference between the two techniques (log-rank P=0.236). This study provides important data comparing the rate of bladder perforation and subsequent morbidity between intraperitoneal and extraperitoneal bladder augmentation. As expected, with a complex procedure, both groups suffered complications, but these data showed no difference between the two procedures. Rates of prior (abdominal) surgery may influence the decision to perform this procedure extraperitoneal. Outcomes related to bladder perforation and secondary consequences do not differ significantly between patients who had bladder augmentation performed with an intraperitoneal versus extraperitoneal approach. Given the low number of adverse events in this study, larger studies are warranted.

Ureteral Obstruction Due to Inadvertent Placement of the Suprapubic Catheter and Bladder Indwelling Catheter: Presentation of Two Clinical Cases and Review of the Literature

Introduction: Suprapubic catheter (SPC) and bladder indwelling catheter (BIC) placement are among the most common urological procedures. Inadvertent misplacement of the catheter tip into the ureteral orifice is an infrequent event with potentially critical complications. Case Presentation: We describe two cases of inadvertent intraureteral misplacement of an SPC and a BIC. A 66-year-old man with chronic kidney disease (CKD) stage G3b, urethral stenosis, long-term SPC who attended the emergency room (ER) 6 hours after the last catheter replacement due to low back pain, fever, deterioration of the general condition, anuria, acute kidney injury (AKI); CT-scan revealed a left uretero-hydronephrosis secondary to obstruction of the catheter balloon misplaced inside the distal ureter. A 59-year-old woman with CKD stage G3b, post-radiotherapy cystitis, and small capacity bladder, long-term BIC who attended the ER a few hours after the last BIC replacement due to abdominal pain, anuria, AKI; CT-scan revealed left hydronephrosis secondary to catheter obstruction within the distal ureter. In both patients, management was conservative, consisting of removing the catheter and repositioning it inside the bladder, in addition to hydration and antibiotherapy. Conclusions: These cases illustrate that awareness of this rare complication can be prevented by confirming the correct positioning of SPC or BIC after its replacement. Early detection and management of this complication can prevent a serious clinical setting.

Current Understanding of the Pathophysiology and Novel Treatments of Interstitial Cystitis/Bladder Pain Syndrome.

The pathophysiology of interstitial cystitis/bladder pain syndrome (IC/BPS) is multifactorial. Identifying the clinical characteristics and cystoscopic findings of bladder-centered IC/BPS facilitates optimal treatment strategies targeting the diseased urinary bladder. Patients with Hunner’s lesion (HIC) and without Hunner’s lesion (NHIC) should be treated differently. Based on the histopathological findings, NHIC can be treated with intravesical instillation of urothelial protective agents, such as hyaluronic acid, to cover the urothelial defects. In non-responders, chronic inflammation and higher urothelial dysfunction can be treated with intravesical botulinum toxin A injection, platelet-rich plasma injection, or low-energy shock wave treatment to reduce inflammation, increase tissue regeneration, and improve the urothelial barrier. Patients with HIC should be treated with electrocauterization first; augmentation enterocystoplasty should only be used in end-stage HIC when the contracted bladder is refractory to other treatments. The antiviral agent, valacyclovir, can be used in patients with HIC, small bladder capacity, and high-grade glomerulations. In addition, behavioral modification is always recommended from the beginning of treatment. Treatment with cognitive behavioral therapy interventions in combination with bladder therapy can reduce anxiety and improve treatment outcomes. Herein, recent advances in the pathophysiology and novel treatments for IC/BPS are reviewed.

P8.137: Bladder Evaluation in Transplant Patients: Are We Overdoing It?

Introduction: It is a common practice to perform detailed bladder evaluation(DBE) in patients awaiting transplant surgery, with previous research by some noted authors Yang(1994), Peter(2004), Antoniewicz(2015) supporting this. ESRD patients on maintenance haemodialysis for more than a year eventually become anuric. For their bladder evaluation, it becomes imperative to catheterize and fill the bladder retrogradely. Catheterization thus may need to be done as high as three times, for ultrasonography (USG), micturating cystourethrogram (MCU) and uroflowmetry (UFR). This leads to bacterial colonization in bladder and results in colonisation of the lower tract and a nidus for repeated reinfection. Aim of our study is thus to find out the necessity for detailed bladder evaluation in all patients & how low-capacity poor flow bladders fare post-operatively. Methods: We studied 80 patients retrospectively for detailed reports on bladder evaluation and their follow up till one year post transplant. Results: A very high incidence of pyelonephritis (70%) in our post- transplant patients who has undergone DBE. Additionally, some patients are still advised bladder cycling. 85%(68) of patients even with no prior history of lower urinary tract dysfunction (LUTD) or Genitourinary Tuberculosis(GUTB) had a small capacity bladder on USG and/or poor flow pre-operatively. However, in majority (90%) of them, bladder capacity and urine flow normalize as soon as urine production starts. Only a few (7 out of 68) having healthy but low capacity bladder with poor flow required some form of intervention. Conclusions: Patients who have healthy bladders prior to progressing to ESRD and becoming anuric fare well in post-transplant period as soon as urine production starts even if they are found to have small capacity, low flow in pre-transplant period. DBE in such patients can not only lead to overtreatment, waste resources but also increases infectious complications. Thus, we can omit MCU& UFR in pre transplant evaluation. Only baseline USG to measure bladder capacity and thickness is all that is required. Detailed evaluation reserved only for patients having past-history of LUTD, GUTB, or bladder dysfunction like posterior urethral valves. Thus, by carefully selecting the patient, we minimized the post-transplant pyelonephritis infectious complications to 29%. Dr. Tukaram Jamale, Professor and Head, Department of Nephrology, Seth GSMC & KEMH All Urology and Nephrology Residents.

Step-wise Treatment of Bladder Pain Syndrome: Case Report

Bladder pain syndrome/interstitial cystitis is a condition characterized by chronic pelvic and bladder pain (lasting longer than 6 months) accompanied by urinary symptoms (urinary frequency, urgency and nocturia). It can have a highly negative effect on the quality of life. The treatment of this disease is impeded by lack of understanding of its etiology. Therefore, treatment recommendations and information about their efficacy are scarce. The American Urological Association recommends a step-wise therapeutic approach starting from mere patients’ lifestyle modification to pharmacological therapy or to even more complex methods, such as intravesical botulinum toxin-A injections. We present here a case of a 60-year old woman, who presented in 2020 with tiresome symptoms characteristic to bladder pain syndrome lasting for two years. Previous treatments with antibiotics, anti-inflammatory, analgesic and anticholinergic medications were unsuccessful; urine culture was negative. During the cystoscopy in our center small bladder capacity and minute glomerulations were observed. Urodynamic tests (cystometry) were performed showing hypersensitive bladder with small capacity. Bladder hydrodistention procedure was performed twice; however the positive effects only lasted up to one month each time. Therefore, it was decided to perform an intravesical botulinum toxin-A injection into bladder trigonal area after which the patient experienced a significant relief in bladder pain, reduced urinary frequency during the day and night and improved quality of life.

Role of physiotherapy in preventing tears rolling down the legs in an eight year old girl: A case report

Urinary incontinence in children is an underdiagnosed symptom in India with a prevalence of 7%. An appropriate diagnosis and early intervention can help prevent the progression of the disorder. Here we present a case reportof an 8-year-old girl referred for physiotherapy with the chief complaint of urinary incontinence. She had a wide bladder neck along with leaking urine and a small bladder capacity. She was managed conservatively with medications and comprehensive physiotherapeutic assessment and management that included a combination of electrotherapy, pelvic floor training, balance and postural exercises and other interventions that gave a positive outcome in terms of eliminating the dribbling episodes and improvement in her quality of life.

Augmentation Cystoplasty in Children: Institute of Kidney Diseases Peshawar Experience

Objective: The aim of this study is to share our single-center experience of Augmentation Cystoplasty (AC) in children regarding indications, bowel segment used, associated procedures, and its complications. Materials and Methods: We analyzed data of all pediatric patients who underwent AC at Institute of Kidney Diseases (IKD), Peshawar between July 2017 and March 2020. Results: A total of 18 pediatric patients are included in the study who underwent Bladder augmentation (BA) either isolated in 1 (5.5%), or along with other associated procedures like Mitrofanoff 17 (94.4%), Antegrade Continent Enema (ACE) 6 (33.3%), Bladder Neck Reconstruction (BNR) 5 (27.7%) and Bilateral ureteric Re-implantation (B/L UR) in 3 (16.6%). Indication for Bladder augmentation were Neurogenic bladder (NGB) 13 (72.2%), Exstrophy Epispadias Complex (EEC) 3 (16.6%) and Posterior urethral value with small functional capacity bladder 2 (11.1%). Small gut used in 15 (83.3%) and large gut in 3 (16.6%) for BA. For Mitrofanff associated with bladder augmentation, Appendix was used in 14 (82.35%) and small gut (Monti) in 3 (17.6%) cases. For ACE associated with BA, in 4 (66.6%) Appendix used as right-sided ACE and in 2 (33.3%) small gut (Monti) as left-sided ACE. No intraoperative complications noted, while early post-op complications, 2 wound infection and 1 urinary leakage from wound, were noted in 3(16.6%) cases and late post-op complications (stomal stenosis) in 4(22.2%) patients.

Assessment of Correction of Female Stress Urinary Incontinence with Trans Obturator Tape; Traditional versus Tailored

Abstract Background: Female genuine stress urinary incontinence (SUI) affects a great number of females, with important social and economic consequences. SUI is more frequent after several deliveries, after menopause as a result of changes in the urethral support or the sphincter mechanism. Aim of Study: To compare traditional tension free trans-obturator tape (TOT) and surgeon tailored mesh (STM) in treatment of female stress urinary incontinence as regard of safety, efficacy, side effects, cost, and follow-up. Patients and Method: Prospective randomized study was done on sixty three female patients were suffered SUI with determining of eligibility of the study as shown in COSORT flow chart Fig. (1) at Al Zahraa University Hospital, Al Azhar University from December 2016 to April 2019. All patients subjected to full history, general, and local examination (cases of cystocele, rectocele, or previous vaginal surgeries were excluded). Cystometrogram (CMG) was done for exclusion of uninhibited detrusor contractions, small bladder capacity ( 100 CC) assessed by ultrasonography were excluded from this study. All patients requested surgical treatment and provided informed written consent, and the study was approved by the ethical committee. With follow-up for six month post-operatively. Results: Depending on subjective criteria obtained from the Patric questionnaire, and objective criteria from physical examination.As regards traditional tape group, 13 patients (43.33%) were cured; two patients (6.67%) improved with no failed cases and STM group 14 patients (46.67%) were cured; one patient (3.33 %) improved with no failed cases (p-value 0.542, Pearson Chi-Square test). Conclusions: TOT (outside in technique) using both STM and traditional tape are minimally invasive techniques and are equally effective and safe in treatment of pure female SUI, with short hospital stay which reduces the cost of surgery. Both techniques could be used in treatment of pure SUI with good outcome. This technique is more economical due to the cheap ordinary polypropylene mesh. So, it should be considered as a low-cost alternative to the available commercial kits in the treatment of female SUI, mainly for public health systems with few financial resources.

Robot-Assisted Buccal Mucosa Graft Ureteroplasty for Bilateral Long Segment Mid-Ureteral Strictures

Abstract Background/Objective: Managing long-segment bilateral ureteral strictures in the mid/upper ureters with chronic renal insufficiency (CRI) and small bladder capacity is challenging. A Boari...

Features of Various Bladder Lesions and Their Impact on Clinical Symptoms and Recurrence in Interstitial Cystitis

We aimed to investigate the impact of various bladder lesions on the clinical symptoms and recurrence of interstitial cystitis (IC). Patients with IC who underwent transurethral resection and cauterization for Hunner lesions (HLs) were enrolled. Features of HLs-noninflamed, inflamed, and gradually inflamed-and associated cystoscopic findings, including waterfall bleeding (none, focal or extensive), submucosal hemorrhage, and mucosal streak, were analyzed to investigate their association with preoperative symptoms and recurrence. We included 272 procedures from 141 patients (male:female ratio 37:104) with a mean±SD age of 61.4±10.5 years. Recurrence was observed in 160 procedures after a mean of 15.6 months (range 0.7-91.7); repeat transurethral resection and cauterization was performed in 131 cases. The number of HLs observed at each procedure was variable, and sufficient bladder filling revealed hidden lesions in 10.7% of cases. Waterfall bleeding was frequently accompanied with inflamed/gradually inflamed HLs. Inflammatory HLs were associated with smaller functional bladder capacity and preoperative urgency (p=0.007). Extensive waterfall bleeding was associated with smaller functional bladder capacity (p=0.006). On multivariate analysis, initially inflamed HLs (HR: 1.675, 95% CI: 1.022-2.746, p=0.041) and gradual inflammatory changes in HLs (HR: 1.893, 95% CI: 1.050-3.410, p=0.034) were found to be risk factors for recurrence. Sufficient bladder filling revealed hidden HLs. The features of HLs were not associated with subjective symptoms; inflamed changes were a predictive factor for IC recurrence, and associated with frequent urgency episodes and smaller bladder capacity.