Lower urinary tract dysfunction and quality of life in cervical cancer survivors after concurrent chemoradiation versus radical hysterectomy

Introduction and hypothesis

Lower urinary tract dysfunction (LUTD) is a common morbidity. Due to the different pathophysiology of LUT injury, we compared LUTD between patients who received concurrent chemoradiation (CCRT) and radical hysterectomy (RH).

Methods

Seventy cervical cancer survivors were evaluated with multichannel urodynamic studies. The CCRT group received a total dose of 54 Gy pelvic radiation with 2–3 high-dose-rate brachytherapy, concurrent with platinum-based chemotherapy. The RH group underwent type III RH without pre- or postoperative radiation.

Results

Overall, LUTD was insignificantly different between CCRT and RH (60 % and 68.6 %). Voiding dysfunction was significantly higher in RH, particularly high postvoid residual urine and void with abdominal straining. However, storage dysfunction, particularly low bladder compliance and increased bladder sensation, were significantly more prevalent in CCRT; urinary incontinence was not significantly different between groups.

Conclusion

LUTD was prevalent in cervical cancer survivors. Different profiles of dysfunction were demonstrated. Voiding dysfunction was higher followng RH, but storage dysfunction was higher following CCRT.     

The Role of Non-invasive Testing in Evaluation and Diagnosis of Pediatric Lower Urinary Tract Dysfunction

Purpose of Review

The symptoms of lower urinary tract dysfunction (LUTD) including urinary incontinence, frequency, and urgency are among the most common reasons children are referred to pediatric urologists. Despite this, the workup for LUTD is often time consuming and a source of frustration for patients, parents, and clinicians alike. In the current review, we summarize the important role non-invasive testing plays in the diagnosis and management of children with LUTD and to show how use of these tests can help avoid the need for more invasive testing in the majority of children.

Recent Findings

Non-invasive tests such urine studies, uroflowmetry ± simultaneous electromyography, assessment of post-void residual, renal/bladder ultrasound, and pelvic ultrasound when used appropriately can provide valuable information to facilitate decision making during the evaluation of children with LUTD. While these tests should be employed prior to more invasive testing such as urodynamic studies, they can often act as a surrogate for the more invasive tests.

Summary

Non-invasive tests can help us in our goal of improving diagnostic ability to better classify the child’s LUTD into an actual condition which allows targeted treatment in the hope of better outcomes and more satisfied patients and families.

     

International prostate symptom score for assessing lower urinary tract dysfunction in women

Introduction and hypothesis

Some lower urinary tract dysfunction (LUTD) subtypes may have similar symptoms. This study aimed to investigate the feasibility of using the International Prostate Symptom Score (IPSS) to evaluate lower urinary tract symptoms (LUTS) in women.

Methods

All consecutive women with non-stress urinary incontinence LUTS who visited the urologic clinics for treatment were prospectively enrolled. LUTS include urinary storage, voiding, and post-micturition symptoms. All enrolled patients were requested to complete the Overactive Bladder Symptom Score (OABSS) and the modified Indevus Urgency Severity Scale (IUSS) questionnaires as well undergo uroflowmetry and post-void residual testing. A videourodynamic study was also performed, if indicated, for LUTD.

Results

A total of 222 women were enrolled, including 60 with overactive bladder (OAB) dry, 42 with OAB wet, 78 with bladder oversensitivity, and 42 with voiding dysfunction. A significantly higher IPSS voiding to storage subscore ratio (IPSS-V/S) and IPSS voiding score were found in the voiding dysfunction group. IPSS-V/S was found to have the highest area under the receiver-operating characteristic curve for predicting voiding LUTD than other noninvasive methods, and an IPSS-V/S of ≥1.33 had the best predictive value for female voiding LUTD with a high negative predictive value (97.4 %). In addition, significantly higher IPSS storage subscore (IPSS-S) values were found in the OAB wet subgroup, and the IPSS-S was well correlated with the OABSS and IUSS.

Conclusions

The IPSS can be used to evaluate female LUTD. IPSS-V/S may provide an initial guide for the treatment of voiding dysfunction in women. In addition, IPSS-S may be used for evaluating storage LUTD in women.

     

The role of serum C-reactive protein in women with lower urinary tract symptoms

Introduction and hypothesis

Some lower urinary tract dysfunction (LUTD) subtypes may be associated with low-grade inflammation. This study aimed to investigate the role of serum C-reactive protein (CRP) levels in women with lower urinary tract symptoms (LUTS).

Methods

A total of 197 consecutive women with non-stress urinary incontinence (non-SUI) LUTS and 18 healthy women without LUTS (normal controls) were enrolled. LUTS include urinary storage, voiding, and post-micturition symptoms. Patients with previous bladder or urethral surgery, active urinary tract infections, or possible neurogenic lesions were excluded. Serum CRP levels were measured before any treatment was given. Patients were stratified to LUTD subgroups based on a 3-day voiding diary, uroflowmetry, and selective videourodynamic studies.

Results

Median CRP levels were significantly higher in women with overactive bladder (OAB) wet (i.e., with urgency incontinence, n?=?30, 0.12 mg/dl) than those in women with bladder oversensitivity (n?=?68, 0.075 mg/dl, P?=?0.008) and the control group (0.055 mg/dl, P?=?0.032). Further analysis revealed that body mass index and maximum flow rate were two independent factors that affected CRP levels. The area under the receiver-operating characteristic curve for using CRP to predict OAB wet was 0.55, and the most predictive cutoff point for CRP was 0.15 mg/dl (sensitivity 43.5 %, specificity 72.7 %).

Conclusions

High serum CRP levels were found in women with OAB wet, and they were related to lower maximum urinary flow rates and higher body mass indices in non-SUI LUTD. However, serum CRP is not a suitable biomarker for discriminating between subtypes of non-SUI LUTD.     

Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis

Context

Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear.

Objective

To assess the efficacy and safety of SNM for neurogenic LUTD.

Evidence acquisition

Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis.

Evidence synthesis

Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half (n = 13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase (n = 4) or permanent SNM (n = 9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50–87) and 92% (95% CrI, 81–98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0–2%) for the test phase and 24% (95% CrI, 6–48%) for permanent SNM.

Conclusions

There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.     

15 years of continent urinary diversion and enterocystoplasty in children and adolescents: the Würzburg experience

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To assess the long‐term results of continent urinary diversion (CUD) and enterocystoplasty (ECP) in children with irreversible lower urinary tract dysfunction (LUTD).

PATIENTS AND METHODS

The study included 44 children with irreversible LUTD who had a CUD or ECP between 1992 and 2007. Patients were followed for the functional outcome of surgery with a focus on complications related to the reservoir, bowel, uretero‐intestinal anastomosis and upper urinary tract. Data were collected prospectively and outcomes were evaluated using a standardized protocol.

RESULTS

The median (range) follow‐up was 7.3 (3.5–17) years. Complete continence was achieved in 94% overall, i.e. in 95% of patients with continent cutaneous diversion, 83% with ECP and all children with continent anal diversion. Upper urinary tract and renal function remained stable in 89% and 95%, respectively. Surgical intervention was required for adhesive small bowel ileus in 6%, stoma‐related complications in 39%, ureteric stenosis in 8%, and stone formation in 19%. Of these complications, 54% required only minor interventions; 41% of patients needed prophylactic alkaline substitution. Bowel habits remained unchanged or improved in 68%.

CONCLUSION

Our results show that CUD and ECP in children are effective procedures with acceptable long‐term complication rates. However, conclusions from our data might be limited, as this was a small study including highly selected patients treated at one tertiary academic centre. Being an audit of practice in our institution and given the variety of concepts, these results might differ from those centres using other approaches in the surgical treatment of LUTD. Importantly, this type of surgery should be restricted to carefully selected patients in whom all attempts of restoring the LUT failed.     

EAU Guidelines on vesicoureteral reflux in children

Context

Primary vesicoureteral reflux (VUR) is a common congenital urinary tract abnormality in children. There is considerable controversy regarding its management. Preservation of kidney function is the main goal of treatment, which necessitates identification of patients requiring early intervention.

Objective

To present a management approach for VUR based on early risk assessment.

Evidence acquisition

A literature search was performed and the data reviewed. From selected papers, data were extracted and analyzed with a focus on risk stratification. The authors recognize that there are limited high-level data on which to base unequivocal recommendations, necessitating a revisiting of this topic in the years to come.

Evidence synthesis

There is no consensus on the optimal management of VUR or on its diagnostic procedures, treatment options, or most effective timing of treatment. By defining risk factors (family history, gender, laterality, age at presentation, presenting symptoms, VUR grade, duplication, and other voiding dysfunctions), early stratification should allow identification of patients at high potential risk of renal scarring and urinary tract infections (UTIs). Imaging is the basis for diagnosis and further management. Standard imaging tests comprise renal and bladder ultrasonography, voiding cystourethrography, and nuclear renal scanning. There is a well-documented link with lower urinary tract dysfunction (LUTD); patients with LUTD and febrile UTI are likely to present with VUR. Diagnosis can be confirmed through a video urodynamic study combined with a urodynamic investigation. Early screening of the siblings and offspring of reflux patients seems indicated.Conservative therapy includes watchful waiting, intermittent or continuous antibiotic prophylaxis, and bladder rehabilitation in patients with LUTD. The goal of the conservative approach is prevention of febrile UTI, since VUR will not damage the kidney when it is free of infection. Interventional therapies include injection of bulking agents and ureteral reimplantation. Reimplantation can be performed using a number of different surgical approaches, with a recent focus on minimally invasive techniques.

Conclusions

While it is important to avoid overtreatment, finding a balance between cases with clinically insignificant VUR and cases that require immediate intervention should be the guiding principle in the management of children presenting with VUR.     

Effect of estrogen and ovariectomy on response of the female rabbit urinary bladder to two forms of in vitro oxidative stress

Introduction and hypothesis

There are several lower urinary tract dysfunctions (LUTD) that are more common in women than in men including incontinence, interstitial cystitis, and recurrent urinary tract infection. There is increasing evidence that these dysfunctions are associated with reduced blood flow, ischemia, hypoxia, and reperfusion resulting in free radical generation and oxidative damage. The goal of the current study was to determine if the level of circulating estrogen affects the response of the bladder muscle and mucosa to two in vitro models of oxidative stress: Incubation in the presence of hydrogen peroxide (H₂O₂) is the first model; the second is ischemia followed by reperfusion which results in the direct production of damaging free radicals. The motivation for this study is the current literature linking female-related LUTD with oxidative stress.

Methods

Eighteen female New Zealand white rabbits were divided into three groups: control, ovariectomized, and ovariectomized receiving continuous estrogen. Eight bladder strips from each of three rabbits per group were taken for in vitro ischemia/reperfusion (I/R) physiological experiments, while eight strips from the three remaining rabbit bladders per group were taken for in vitro H₂O₂ experiments. All tissue was analyzed for total antioxidant activity (AA) and malondialdehyde (MDA) levels. In addition, the organ bath buffer was also analyzed for AA.

Results

In vitro H₂O₂ was found to target the nerve, muscarinic receptor, and membrane equally causing more damage to bladder tissue than in vitro I/R. Ovariectomy resulted in lower contractility and higher lipid peroxidation. However, estrogen supplementation following ovariectomy protected the bladder against both models of oxidative stress by maintaining contractile responses to stimulation and decreasing lipid peroxidation.

Conclusions

The primary conclusion from this study is high estrogen protects the bladder from oxidative stress, whereas low estrogen makes the bladder more susceptible.     

Nonpharmacological treatment of lower urinary tract dysfunction using biofeedback and transcutaneous electrical stimulation: a pilot study

OBJECTIVE

To report a series of children with lower urinary tract dysfunction (LUTD) whose urge syndrome was treated by electrical stimulation, and their voiding dysfunction by biofeedback; none of the children were using anticholinergic drugs during treatment.

PATIENTS AND METHODS

In all, 36 children who presented with symptoms of urinary urgency and/or daily incontinence completed the treatment and were prospectively evaluated. The mean (range) follow‐up was 13.8 (4–24) months, and their mean age 7 (3–14) years, 17 children were aged <5 years. The children were divided into two groups: group 1, with urge syndrome treated with superficial parasacral electrical stimulation, and group 2, with voiding dysfunction, treated with biofeedback.

RESULTS

In group 1, the mean (range) number of electrical stimulation sessions was 13.1 (4–20). Of the 19 children treated, 12 had a complete clinical improvement, six a significant improvement, and one a mild improvement. In group 2, the mean (range) number of biofeedback sessions was 6 (4–14). Of the 17 children treated, there was complete improvement of symptoms in 10, significant improvement in two and mild improvement in five. Six children who had no resolution of symptoms after biofeedback had salvage therapy with electrical stimulation, after which four had complete improvement of symptoms, and two a 90% and 40% improvement, respectively. Taking the two groups together, after treatment, four children developed isolated episodes of urinary tract infection. Of 21 children with nocturnal enuresis, bed‐wetting continued in 13 (62%) after treatment.

CONCLUSION

In this short‐term follow‐up, the nonpharmacological treatment of voiding dysfunction using biofeedback, and of urge syndrome by electrical stimulation, was effective for treating LUTD in children.

     

Lower Urinary Tract Reconstruction for Ectopic Ureterocele: What Happens in the Long-term Follow-up?

BackgroundWe aimed to analyze the long-term clinical and lower urinary tract function outcomes in children with duplex system ectopic ureterocele who underwent ureteroneocystostomy and ureterocelectomy.MethodsFifty-one patients (28 females, 23 males) who underwent a series of surgical interventions including lower urinary tract reconstruction in childhood for duplex system ectopic ureterocele in our center between 1998 and 2019, were retrospectively reviewed. The demographic and clinical data, surgical history, and the indication for ureterocelectomy were noted. Lower urinary tract dysfunction (LUTD) status was assessed through dysfunctional voiding symptom scores (DVSS) and uroflowmetry in all patients at the last follow-up. The clinical outcomes, and LUTD were evaluated.ResultsAt the last visit at a mean follow-up of 117.18 ± 57.87 months after ureterocelectomy, ipsilateral persistent lower pole VUR was detected in 5.6% (3/54 renal units, 2 females and 1 male) of the cases, who were treated using the subureteric injection. Abnormal DVSS (median 11, range 9–15) was detected in 27.4% (14/51 pts) of the patients. Out of these, 57.1% (8/14 pts) had storage symptoms, 35.7% (5/14 pts) had voiding symptoms, and 7.1% (1/14 pts) had both storage and voiding symptoms while 71.4%(10/14 pts) had abnormal uroflowmetry findings (plateau shaped flow curve in 2, staccato shaped curve with sustained EMG activity in 3, tower shaped curve in 2, interrupted shaped curve in 3 patients). Five patients had elevated residual volume. Anticholinergics were administered to six patients who had overactive bladder symptoms. In addition, two girls required open bladder neck reconstruction due to stress incontinence caused by bladder neck insufficiency.ConclusionsOur findings showed that clinical success was achieved using the lower urinary tract reconstruction with no need for re-operation in 90.2% of patients with duplex system ectopic ureterocele. However, LUTD was present in 27.4% of our patients in the long-term follow-up. Therefore, LUTD should be carefully assessed in the long-term follow-up of these patients.     

Interventions for impaired bladders in paediatric renal transplant recipients with lower urinary tract dysfunction

Dysfunctional bladders in paediatric patients were thought to be a contraindication for renal transplantation, but advances in surgical techniques have meant that surgical correction can allow safe transplantation. This study compares the outcomes of renal transplantation for different interventions, and the timing of such interventions, in relation to transplantation. We identified all paediatric renal transplant recipients with LUTD that received intervention for their impaired bladders at two hospitals between 2002 and 2010. Outcome measures included patient and graft survival, perioperative complications, UTI incidence, acute rejection episodes and serum creatinine levels. A total of 288 allografts were transplanted, 77 were in 75 children with LUTD, of which 46 received intervention. Patient survival was 100% in the intervention group and 97% in the nonintervention group (P = 0.815). Death‐censored graft survival was 96% and 100% respectively (P = 0.688). In the groups receiving intervention pretransplant or post‐transplant, graft survival rates were 95% and 100% respectively (P = 0.476). The follow‐up serum creatinine levels were higher in the pretransplant intervention group (P < 0.001). Interventions for dysfunctional bladders can be performed safely in paediatric renal transplant recipients. The mode of intervention and timing of intervention, in relation to transplant, do not influence outcomes if guided by careful assessment and investigation.     

Manipulator‐driven selection of semi‐active MR‐visible markers

Background

A method for the identification of semi‐active fiducial magnetic resonance (MR) markers is presented based on selectively optically tuning and detuning them.

Methods

Four inductively coupled solenoid coils with photoresistors were connected to light sources. A microcontroller timed the optical tuning/detuning of coils and image collection. The markers were tested on an MR manipulator linking the microcontroller to the manipulator control to visibly select the marker subset according to the actuated joint.

Results

In closed‐loop control, the average and maximum were 0.76° ± 0.41° and 1.18° errors for a rotational joint, and 0.87 mm ± 0.26 mm and 1.13 mm for the prismatic joint.

Conclusions

This technique is suitable for MR‐compatible actuated devices that use semi‐active MR‐compatible markers.     

The accuracy of a novel self-tapping bone fiducial marker for frameless robot-assisted stereo-electro-encephalography implantation and registration techniques

Background

We aimed to evaluate the accuracy and safety of a novel self-tapping bone fiducial as a registration technique for stereoelectroencephalography (SEEG) implantation.

Methods

Each patient was installed with five bone fiducial markers. All procedures were performed using the same Sinovation robot system. The accuracy was determined by calculating the target point error (TPE) and the entry point error (EPE) of electrodes.

Results

Fourteen patients underwent SEEG implantation surgery; and the average installation time of the markers per patient was 86.1 s. In the operating theatre, the average registration time was 206.6 s, and the average registration error was 0.18 mm. The average TPE of 174 electrodes was 1.98 mm and the average EPE was 0.88 mm.

Conclusion

Our study provided a bone fiducial marker installation and registration technique that was convenient and fast, highly accurate in registration, and highly tolerated by patients.     

Perioperative infusion of dexmedetomidine at a high dose reduces postoperative analgesic requirements: a randomized control trial

Purpose  

We hypothesized that a high dose of dexmedetomidine (1 μg/kg/h) could reduce postoperative analgesic requirements of patients.     

Administration of nonsteroidal anti-inflammatory drugs accelerates spontaneous healing of osteoid osteoma

Introduction  

It has been reported that osteoid osteoma may heal spontaneously.     

Evaluation and application of CO2 laser fiber delivery for single port transoral robotic surgery

Background

Transoral robotic surgery (TORS) using the Single-Port system (SPS) relies on electrocautery, limiting its applications in the upper aerodigestive tract. We evaluated the feasibility of a CO₂ delivery system for the SPS.

Methods

Otolaryngology residents performed a cutting exercise using a handheld CO₂ laser and participated in a cadaveric oropharyngeal dissection using the SPS with monopolar cautery (SP + EC) and CO₂ laser (SP + CO₂). Residents completed the System Usability Scale (SUS) questionnaire to evaluate these techniques.

Results

The same laser fiber was used for all combined dissections. The handheld CO₂ laser, SP + EC, and SP + CO₂ demonstrated similar SUS scores. On individual domain scores, SP + CO₂ received less favorable ratings compared to the handheld CO₂ laser for complexity, integration, and cumbersome experience (p < 0.05). On subgroup stratification, less TORS experience was associated with worse SUS scores.

Conclusion

SP-guided CO₂ laser delivery is a viable alternative to electrocautery in robotic surgery, and should be considered when performing TORS.     

Improving pancreas graft utilization through importation

Background

We analyze our outcomes utilizing imported allografts as a strategy to shorten wait list time for pancreas transplantation.

Methods

This is an observational retrospective cohort of 26 recipients who received either a locally procured (n = 16) or an imported pancreas graft (n = 10) at our center between January 2014 and May 2017. Wait list times of this cohort were compared to UNOS Region 9 (New York State and Western Vermont). Hospital financial data were also reviewed to analyze the cost‐effectiveness of this strategy.

Results

Imported pancreas grafts had significantly increased cold ischemia times (CIT) and peak lipase (PL) levels compared to locally procured grafts (CIT 827 vs 497 minutes; P = .001, PL 563 vs 157 u/L; P = .023, respectively). There were no differences in graft or patient survival. The median wait time was significantly lower for simultaneous kidney‐pancreas transplants at our center (518 days, n = 21) compared to Region 9 (1001 days, n = 65) P = .038. Despite financial concerns, the cost of transport for imported grafts was offset by lower standard acquisition costs.

Conclusions

Imported pancreas grafts may be a cost‐effective strategy to increase organ utilization and shorten wait times in regions with longer waiting times.     

Microperforation of the colon: animal model in rats to reproduce mucosal thermal damage

Background

The aim of the present study was to develop a rat model of colonic microperforation secondary to thermal injury for future studies to assess new treatments.

Methods

Twenty-four male Sprague–Dawley rats were used in this study. Hot biopsy forceps were used for all treatments. All lesions were created in proximal left colon using the soft coagulation setting. The power setting tested was 40 W, and the durations of monopolar soft coagulation application evaluated were 2, 3, and 4 s.

Results

In the acute phase, 48 h after thermal injury, durations of cautery of 2 and 3 s resulted in transmural necrosis, whereas with 4 s microperforation was obtained. In the late phase, 7 d after the damage, only duration of cautery of 4 s showed deep cautery effects, with signs of peritonitis.

Conclusions

We determined optimal power settings and duration of therapy in a rat model for producing electrocautery that involves transmural necrosis with microperforation.     

Preoperative hesitating urinary stream is associated with postoperative voiding dysfunction and surgical failure following Burch colposuspension or pubovaginal rectus fascial sling surgery

Introduction and hypothesis  

We hypothesized that certain preoperative voiding symptoms would be correlated with poorer post-continence surgery outcomes in women.     

Cholecystocolonic fistula prevents upper intestinal obstruction by a large gallstone after perforation into the duodenum

Background  

Bilioenteric fistulas are rare complications of cholecystolithiasis that are associated with high morbidity and mortality and mainly appear in elderly patients.