Measurement of post-void residual urine

Protocol for a Series of Systematic Reviews and Network Meta-analyses of Randomized Controlled Trials of Medications for Patients with Overactive Bladder Symptoms

Multiple randomized controlled trials (RCTs) have examined first-line pharmacological agents such as anticholinergics and β3 agonists for the management of overactive bladder symptoms (OAB). Although earlier systematic reviews and (network) meta-analyses aimed to summarize the evidence, a substantial number of trials were not included, so a comprehensive and methodologically rigorous evaluation of the comparative effectiveness of all first-line pharmacological treatments is lacking. We aim to conduct a series of systematic reviews and network meta-analyses (NMAs) for a comprehensive assessment of the effectiveness and safety of first-line pharmacological treatments for OAB. Eligible studies will include RCTs comparing anticholinergics and β3 agonists to one another or to placebo in adults with OAB or detrusor overactivity. Pairs of reviewers with methodological training will independently evaluate candidate studies to determine eligibility and extract relevant data. We will incorporate patient-important outcomes, including urinary urgency episodes, urgency incontinence episodes, any type of incontinence episodes, urinary frequency, nocturia, and adverse events. We will conduct the NMAs using a frequentist framework and a graph theory model for each outcome. Analysis will follow rigorous methodologies, including handling of missing data and assessment of the risk of bias. We will conduct sensitivity and subgroup analyses and will apply the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to rate evidence certainty. Our approach aims to address the knowledge gap in the treatment of OAB by synthesizing evidence from RCTs worldwide. We will employ robust statistical methods, including frequentist NMA, to general clinically relevant and patient-important insights. Sensitivity and subgroup analyses will enhance the robustness and generalizability of our findings. Our reviews strive to inform evidence-based decisions in the management of OAB, to ultimate improve patient outcomes. Our study results may guide health policy decisions, such as reimbursement policies, and future studies in functional urology. The protocol for the review series is registered on PROSPERO as CRD42023266915.

Outcomes of bladder outlet obstruction following extensive vaginal pelvic reconstruction surgery on patient with advanced pelvic organ prolapse

OBJECTIVE

To evaluate the impact of extensive vaginal pelvic reconstruction surgery (PRS) on advanced pelvic organ prolapse (POP) patients with bladder outlet obstruction (BOO).

METHODS

We conducted a single-center, retrospective analysis of women who received extensive vaginal pelvic reconstruction surgery for advanced POP (POP-Q ≥3) with BOO from January 2006 to January 2016. Data regarding preoperative evaluation, surgical procedure, and postoperative management were abstracted from medical records. Patients were considered to have BOO when detrusor pressure at maximum flow (Dmax) was ≥20 cm H2O and peak flow rate (Qmax) was ≤15 mL/s. Patients with postoperative value of Dmax lower than 20 cm H2O or Qmax higher than 15 mL/s were regarded as objectively cured.

RESULTS

A total of 1894 patients with POP stages III or IV were assessed. The incidence of BOO was 22.8% (431/1894) within this patient population of advanced POP. One year after the vaginal PRS, the objective cure rate of BOO was 98.1%. Urodynamic parameters showed a significant increase in Qmax (P < 0.001), while Dmax (P < 0.001) and postvoid residual urine (PVR) (P < 0.001) were significantly decreased. Previous POP surgery, native tissue repair (NTR), PVR ≥200 mL, and maximal cystometric capacity (MCC) ≥500 mL increase the likelihood of persistent BOO in patients.

CONCLUSION

Vaginal PRS demonstrated effectiveness in treating BOO in patients with advanced POP. Irrespective of the types of transvaginal mesh (TVM), using TVM achieved better outcome than did NTR. Previous POP surgery, preoperative PVR ≥200 mL, and MCC ≥500 mL were the risk factors predicting the failure of PRS in improving BOO.

Improved bladder diagnostics using multiparametric ultrasound

This comprehensive review examines recent advancements in the integration of multiparametric ultrasound for diagnostic imaging of the urinary bladder. It not only highlights the current state of ultrasound imaging but also projects its potential to further elevate standards of care in managing urinary bladder pathologies. Specifically, contrast-enhanced ultrasound (CEUS) and elastography show significant improvements in detecting bladder tumors and assessing bladder wall mechanics compared to traditional methods. The review also explores the future potential of ultrasound-mediated nanobubble destruction (UMND) as an investigational targeted cancer therapy, showcasing a novel approach that utilizes nanobubbles to deliver therapeutic genes into tumor cells with high precision. Emerging AI-driven innovations and novel techniques, such as microvascular ultrasonography (MVUS), are proving to be powerful tools for the non-invasive and precise management of bladder conditions, offering detailed insights into bladder structure and function. These advancements collectively underscore their transformative impact on the field of urology.

New compact micro-hole zone catheter enables women to achieve effective bladder emptying without flow-stops

BACKGROUND

Clean intermittent self-catheterisation (CISC) with conventional eyelet catheters (CECs) is associated with urine flow-stops, which require the catheter to be repositioned so flow can resume. Flow-stops often occur because bladder mucosa is sucked into the eyelets.

AIMS

This investigation aimed to compare the bladder-emptying performance of the micro-hole zone catheter (MHZC) with the CEC.

METHODS

This was a multi-centre, randomised, open-label, controlled cross-over study with 82 women comparing the MHZC to the CEC. The endpoints relating to bladder-emptying performance included the residual volume at first flow-stop, the number of flow-stops and the proportion of successful treatment responses. The women's perception of the catheters was assessed as well as device discomfort.

FINDINGS

Catheterisations with MHZC significantly reduced the risk of flow-stops, with relative risk results showing a 2.74 times lower risk of flow-stops with a health professional-led catheterisation and a 2.52 times lower risk during self-catheterisation. There was no statistical difference in residual urine volume at first flow-stop between the two catheters. Catheterisations with the MHZC were significantly more likely to achieve zero flow-stops and a residual urine volume of <10 ml at first flow-stop. The women had a significantly more positive perception of the MHZC than the CEC in areas including handling, confidence, sensation and satisfaction.

CONCLUSION

The MHZC enabled effective bladder emptying without catheters needing to be repositioned, supporting the women by simplifying the procedure and making them feel confident that their bladders were empty.

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

AIMS

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Can we predict whether a man with acute or chronic urinary retention will void after bladder outflow resistance reduction surgery? ICI-RS 2023

AIMS

To address the predictive factors of a successful voiding after bladder outflow resistance reduction surgery (BORRS) in men presenting with acute or chronic urinary retention (UR).

METHODS

A think tank (TT) of ICI-RS was gathered in 2023, Bristol, UK, to discuss several aspects of the problem, such as the pathophysiology of UR, the clinical and urodynamic evaluation of men with UR and whether it is possible to predict which men will be able to successfully void after treatment with contemporary surgical options.

RESULTS

The TT agreed that successful voiding after BORRS depends on several factors but that a strong recommendation cannot be made regarding preoperative evaluation and whether there are predictive factors of success because of the heterogeneity of patients and methodology in published trials. The diagnosis of obstruction in men with UR may be challenging when there is apparent reduced detrusor contraction during urodynamic studies. Even in the absence of bladder contractility there is documentation of such cases that have voided adequately after BORRS. Still, detrusor underactivity and inadequate relief of prostatic obstruction are the main causes of an unsuccessful voiding after BORRS. Conventional resection and enucleation methods remain the most successful surgeries in relieving UR in men, whereas the efficacy of minimally invasive surgical treatments needs to be assessed further.

CONCLUSION

Research is needed to understand the pathophysiology of UR and the predictors of successful voiding after different types of BORRS in men with UR.

Association Between Residual Urine Volume and Recurrence Among Patients at High Risk of Non-Muscle-Invasive Bladder Carcinoma With Versus Without Bacillus Calmette-Guérin Treatment

Non-muscle-invasive bladder carcinoma often occurs in older adults, who often also have urinary dysfunction. The residual urine volume is an important indicator of urinary dysfunction. However, the impact of the residual urine volume on intravesical recurrence remains unclear. In the present study, we analyzed the data of 372 patients at high or very high risk of cancer progression according to the Japanese Urological Association classification who had undergone transurethral resection of a bladder tumor. In univariate analysis, postoperative absence of intravesical Bacillus Calmette-Guérin (BCG) induction was an independent risk factor for intravesical recurrence (hazard ratio 1.94, absence versus presence, p = 0.0019). The incidence of intravesical recurrence did not significantly differ between the mild, intermediate, and severe residual urine groups in the total cohort. Among the BCG-treated cohort, the three groups showed similar trends. Among the non-BCG-treated cohort, although the patients with more than 100 ml of residual urine tended to have more intravesical recurrence than patients with a smaller residual urine volume, this difference did not reach statistical significance. BCG treatment is recommended for patients at high risk of bladder carcinoma. Patients with a large residual urine volume without BCG treatment may be at high risk of intravesical recurrence.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients

Background

Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively.

Methods

Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics.

Results

Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02).

Conclusions

PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Post-Voided Residual Ratio Does Not Predict Trifecta Outcome after Transurethral Resection of Prostate

The purpose of this study was to assess the importance of the post-void residual (PVR) ratio (PVR ratio) in achieving a favorable trifecta outcome for patients suffering from lower urinary tract symptoms and benign prostatic enlargement (LUTS-BPE) who undergo transurethral resection of the prostate (TURP). Starting from 2015, a series of patients with LUTS-BPE who underwent TURP were included in a forward-looking study. These patients were assessed using the international prostate symptom score (IPSS) screening tool, uroflowmetry, and a transrectal ultrasound to measure prostate volume (TRUS). Both the PVR urine volume and the PVR ratio (PVR-R), which is the PVR as a percentage of total bladder volume (voided volume + PVR), were measured. The assessment of outcomes was based on the trifecta favorable outcome, defined as meeting all of the following criteria: (1) absence of perioperative complications, (2) a postoperative IPSS of less than eight, and (3) a postoperative maximum urinary flow rate (Qmax) greater than 15 mL/s. A total of 143 patients were included, with a median age of 70 years (interquartile range 65-73). Of these, 58% (83/143) achieved a positive trifecta outcome. Upon conducting a multivariate analysis, both IPSS and Qmax were identified as predictors of a positive trifecta outcome, whereas the PVR-R did not prove to be an independent predictor. In summary, it was found that preoperative IPSS and Qmax are indicative of a trifecta outcome following TURP, whereas PVR-R is not.

Normal postvoid residual urine in healthy adults

OBJECTIVE

To establish a normal reference value of postvoid residual (PVR) urine volume in "healthy" adults.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Transurethral columnar balloon dilation of the prostate combined with holmium laser incision for bladder neck contracture in day-surgery mode

The study aimed to investigate the clinical effect of transurethral columnar balloon dilation of the prostate combined with holmium laser in the treatment of bladder neck contracture (BNC). This retrospective study included 41 patients with BNC, who had been treated with transurethral columnar balloon dilation and holmium laser in our hospital from June 2020 to June 2022. Admission, operation, and discharge of all the patients were completed in 24 h. The patients' satisfaction, postoperative complications, and chronic pain after operation were followed up. Clinical parameters, such as International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL), and post-void residual volume (PVR) in pre-operation, 1 month and 6 months after operation were recorded. All patients underwent the operations successfully. Six patients experienced urge incontinence and one patient experienced recurrence of BNC after 12 months. At 1 month and 6 months after the operation, IPSS, QoL, PVR, and Qmax of the patients were significantly better than those before the operation (P < 0.05). Transurethral columnar balloon dilation of the prostate combined with holmium laser can effectively treat BNC with simple performance and satisfactory clinical effects. It is a minimally invasive treatment that can be conducted by simple day surgery.

A Lightweight Deep Learning Network on a System-on-Chip for Wearable Ultrasound Bladder Volume Measurement Systems: Preliminary Study

Bladder volume assessments are crucial for managing urinary disorders. Ultrasound imaging (US) is a preferred noninvasive, cost-effective imaging modality for bladder observation and volume measurements. However, the high operator dependency of US is a major challenge due to the difficulty in evaluating ultrasound images without professional expertise. To address this issue, image-based automatic bladder volume estimation methods have been introduced, but most conventional methods require high-complexity computing resources that are not available in point-of-care (POC) settings. Therefore, in this study, a deep learning-based bladder volume measurement system was developed for POC settings using a lightweight convolutional neural network (CNN)-based segmentation model, which was optimized on a low-resource system-on-chip (SoC) to detect and segment the bladder region in ultrasound images in real time. The proposed model achieved high accuracy and robustness and can be executed on the low-resource SoC at 7.93 frames per second, which is 13.44 times faster than the frame rate of a conventional network with negligible accuracy drawbacks (0.004 of the Dice coefficient). The feasibility of the developed lightweight deep learning network was demonstrated using tissue-mimicking phantoms.

Age- and gender-specific normal post void residual urine volume in healthy adolescents

INTRODUCTION

Elevated post void residual (PVR) is a significant risk factor for urinary tract infections (UTI). It is also a significant predictor of treatment outcomes in cases of vesicoureteral reflux, pediatric enuresis, and non-neurogenic LUT dysfunction. However, the absence of age-specific nomograms for adolescents may limit PVR's use in clinical practice.

OBJECTIVE

To establish age- and gender-specific normal PVR urine volume in adolescents.

MATERIAL AND METHODS

Healthy adolescents aged 12-18 years were recruited to undergo two uroflowmetry and PVR studies whenever they felt the urge to urinate. Adolescents with neurological disorders, known LUT dysfunction or UTI were excluded.

RESULTS

A total of 1050 adolescents were invited, but only 651 consented. Fourteen participants were excluded due to low bladder volume (BV < 100 ml) in both assessments (n = 12), BV < 100 ml in one assessment (n = 1), or failure to provide relevant history (n = 1). From the 1084 uroflowmetry and PVR obtained from 637 adolescents, 190 results were further excluded due to artefacts (n = 152), BV < 100 ml (n = 27), PVR >100 ml (n = 5) and missing information (n = 6). Ultimately, 894 uroflowmetry and PVR from 605 adolescents (mean age 14.6 ± 1.5 years) were analyzed. PVRs were higher in adolescents aged 15-18 years than in those aged 12-14 years (P < 0.001). Moreover, they were higher in females than in males (P < 0.001). Multivariate analysis revealed that PVR was positively influenced by age (P = 0.001) and BV (P < 0.001). The age- and gender-specific percentiles of PVR in ml and percentage of BV were calculated. We recommend a repeat PVR and close monitoring if PVR is above the 90th percentile, i.e., PVR >20 ml (7% BV) for males of both the age groups, and PVR >25 ml (9% BV) and PVR >35 ml (>10% BV) for females aged 12-14 and 15-18 years, respectively. Further investigation may be warranted if the repeat PVR is above the 95th percentile, i.e., PVR >30 ml (8% BV) and >30 ml (11% BV) for males aged 12-14 and 15-18 years, respectively, and PVR >35 ml (11% BV) and >45 ml (13% BV) for females aged 12-14 and 15-18 years, respectively.

CONCLUSION

PVR increases with age and varies by gender; thus, age-and gender-specific reference values should be used. Further data from other countries is required to determine whether the study's recommendations can be applied globally.

ROLE OF BLADDER EMPTYING ON OUTCOMES OF TRANSURETHRAL RESECTION OF THE PROSTATE

OBJECTIVE

To assess the role of bladder emptying on outcomes of males undergoing transurethral resection of the prostate (TURP).

MATERIALS AND METHODS

This prospective study involved candidates for TURP (January 2017-January 2018) with a follow-up of 3 yrs. Preoperative and follow-up evaluation comprised: UF, simple PVR (S-PVR), PVR-Ratio (PVR-R) as the ratio of PVR to bladder volume (BV: voided volume (VV) + PVR), Bladder voiding efficiency (BE) as the ratio between VV and BV -(voided volume/total bladder capacity) X 100 - and the IPSS. Patients were stratified for S-PVR, PVR-R and BVE.

RESULTS

Patients recruited were 100 (mean ± SD age: 68.8 ± 8.7 yrs). No patient had severe complications, re-admission, nor needed blood transfusion. At baseline, 38% of the patients showed S-PVR ≤ 50 ml, 62% a S-PVR ≤ 100 ml, and 25% a S-PVR >150 ml. In both pre- and post-operative evaluation there were no significant differences in Qmax and IPSS score among the groups. In each group we found a significant improvement in Qmax, IPSS score and S-PVR, PVR-R and BVE after TURP (except for PVR in group with lowest pre-operative S-PVR). Analysing a pre-operative S-PVR threshold >100 ml, PVR-R significantly increased and BVE significantly decreased after TURP. Conversely, when pre-operative S-PVR was >100 ml, PVR-R and BVE relevantly but non significantly improved after surgery.

CONCLUSION

Bladder emptying is only partially related to TURP outcomes and other pre-operative parameters. Patients with baseline S-PVR lower than 100 ml had the chance of greater recovery of bladder emptying after TURP.

Mesenchymal Stromal Cell Therapy Reverses Detrusor Hypoactivity in a Chronic Kidney Patient

Detrusor hypoactivity (DH) is characterized by low detrusor pressure or a short contraction associated with low urinary flow. This condition can progress to chronic renal failure (CRF) and result in the need for dialysis. The present case report demonstrates that a patient diagnosed with DH and CRF who received two transplants with 2 × 10⁶ autologous mesenchymal stromal cells at an interval of 30 days recovered the contractile strength of the bladder and normalized his renal function. The patient had a score of 19 on the ICIQ-SF before cell therapy, and that score was reduced to 1 after transplantation. These results demonstrate that there was an improvement in his voiding function, urinary stream and urine volume as evaluated by urofluxometry. In addition, a urodynamic study carried out after treatment showed an increase in the maximum flow from 2 mL/s to 23 mL/s, the detrusor pressure in the maximum flow from 21 cm H₂O to 46 cm H₂O and a BCI that went from 31 to 161, characterizing good detrusor contraction. Thus, in the present case, the transplantation of autologous mesenchymal stromal cells proved to be a viable therapeutic option to allow the patient to recover the contractile strength of the bladder, and reversed the CRF.

Effect of vacation on urinary symptoms in health care workers: an Italian multicenter study

BACKGROUND

Aim of our study was to assess the impact of vacation on urinary symptoms in health care workers.

METHODS

Between March 2018 to October 2019 a survey was carried out by enrolling health care system workers in three centers. Demographic and clinical characteristics of health care workers (i.e. age, smoking status, medical history) were collected. Lower urinary tract symptoms (LUTS) and work related quality of life were assessed before and after vacation with validated questionnaires: Overactive Bladder Questionnaire Short Form (OABq-sf), International Prostate Symptom Score (IPSS), Work-related Quality of Life (WRQOL) and SF-36 questionnaires. As well, night shift workers (NSWs), defined as working at least one time a week from 8 pm to 8 am, were compared to traditional workers (TWs).

RESULTS

A total of 236 participants (118 males and 118 females) with a median of 41 (32/49 IQR) years old were included in the survey. Healthcare workers presented after vacation an improvement in LUTS, in work related quality of life and overall health. Overall, 89 (37%) were NSWs and 147 (62%) subjects were TWs. NSWs reported a significant higher median OABq Total Score and IPSS than TWs: respectively, 27 (IQR 23-34) vs. 20 (IQR 19-24) P=0.01, 2 (0/6) vs. 0 (0/2) (P<0.01). No significative differences were found for WRQOL and SF36, respectively 66 (IQR 59/77) vs. 67 (IQR 61/82) (P<0.29) and 98 (97/101) vs. 98 (97/100) (P<0.79).

CONCLUSIONS

NSWs present worst urinary symptoms when compared to TWs. Vacation has a beneficial effect, particularly in NSWs, on urinary symptoms and work-related quality of life.

COVID-19- associated Guillain–Barrè Syndrome and urinary dysfunction: A case report

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection can cause multiple systemic and neurological complications, including Guillain–Barrè Syndrome (GBS). In this report we describe for the first time, urinary dysfunction in a patient with COVID-19. We reported a 41-years-old female patient with complaints of an increased generalized muscular weakness associated with progressive difficulty in walking. Four days earlier, patient complained of fever, diarrhea, and general weakness, and the RT-PCR was positive for COVID-19 infection. Due to the worsening of neurological symptoms, a neurophysiological examination on nervous conduction was performed and the diagnosis was suggestive of GBS. Two weeks later, patient developed two consecutive episodes of acute urinary retention that requested the placement of indwelling transurethral catheter. Patient started assuming selective alpha-1 adrenergic antagonist in association with 4 clean intermittent catheterization/die. Four months later, women continued the therapy and the ultrasound evaluation revealed non-pathologic post-void residual volume. Therefore, patient started to void spontaneously again and alpha-blockers were discontinued. We report for the first time a case of severe voiding disorder in a patient with COVID-19 associated GBS. Timely bladder drainage should be adopted to avoid irreversible detrusor damage.

Covert postpartum urinary retention: causes and consequences (PAREZ study)

Introduction and hypothesis

Increased post-voiding residual volume (PVRV), known as covert postpartum urinary retention (PUR), is an asymptomatic condition with unknown long-term adverse effects. The objectives were to determine the frequency of this phenomenon 3 days after delivery and to examine the associated risk factors and consequences of the increased residuum on women´s health 6 weeks postpartum.

Methods

We carried out a prospective observational study including a total of 926 primiparous women, giving birth to singletons. All participants underwent ultrasound determination of PVRV on day 3 postpartum. Then, risk factors were determined using logistic regression analysis. After 6 weeks, participants were invited to return for PVRV determination and to complete urogynecological and general health questionnaires. Using these data, the consequences of increased PVRV were determined.

Results

A total of n=90 women were diagnosed with abnormal PVRV. Mean age in the studied population was 30.4 years, BMI prior to delivery 27.8, weight of the newborn 3,420 g, and percentage of cesarean sections 15.9%. Gestational week (p=0.043), vaginal tear (p=0.032), and induction of labor (p=0.003) were risk factors for covert PUR. Puerperal incidence of urinary tract infection was 1.1% (6 out of 526) and of urinary incontinence 29.2% (155 out of 530), with no differences between the groups. In the second examination, covert PUR was no longer present, and the values of residual urine decreased for all patients in the case group. No statistically significant differences were observed in questionnaire scores in general health and wellbeing perceptions between the groups.

Conclusions

We have found a few significant obstetrical–pediatric risk factors for abnormal PVRVs. Data from the follow-up suggest that covert PUR has no impact on morbidity and quality of life 6 weeks postpartum. Therefore, abnormal PVRV is a self-limited phenomenon with a tendency toward self-correction. Our findings support those of previous studies that advocate against screening for asymptomatic retention in the postpartum period, despite some similar previous recommendations.

Postpartum urinary retention: what are the sequelae? A long-term study and review of the literature

INTRODUCTION AND HYPOTHESIS

Postpartum urinary retention (PUR) may cause long-term urogenital tract morbidity. The incidence ranges from 0.18 to 14.6%, but the importance of prompt diagnosis and appropriate management is often underappreciated. The paucity of data on long-term outcome after PUR contributes to these drawbacks. The aim of this study was to assess long-term persistence of elevated PVR (post-void residual urine) volume after PUR. Pathophysiology, risk factors and management of PUR are reviewed.

METHODS

In our tertiary referral urogynecology unit in the University Women's Hospital of Bern, Switzerland, all patients who were referred for PUR were asked to participate in this study. PVR was measured sonographically every 2 days until day 15, then after 6, 12, 24 and 36 months and, if increased, the patients were instructed to perform clean intermittent self-catheterization. If retention persisted longer than the lactation period, multichannel urodynamics was performed.

RESULTS

Sixty-two patients were included. The median PVR normalized at day 7. Long-term voiding disorders were found in 8.2%, 6.7%, and 4.9% after 1, 2, and 3 years respectively. Multichannel urodynamics confirmed in all patients with persisting retention an acontractile detrusor and de novo stress urinary incontinence in 4 cases. Quantile regression did not reveal any factor contributing to earlier recovery. Eighty-nine percent of the patients with PUR had operative vaginal deliveries, emphasizing the importance of this risk factor for PUR.

CONCLUSIONS

In most cases PUR resolves early, but voiding difficulties persist more often than previously thought, and for these patients the consequences are devastating. Obstetric awareness, early active management, and developing management strategies in the postpartum period might preclude lower urinary tract morbidity.

Can portable ultrasound bladder scanner be applied to young children less than three years old?

INTRODUCTION

The bladder scanner (BS), a portable ultrasound device specialized in bladder volume measurement, has been developed and applied to clinical assessment of postvoid residual urine, which is a requisite in evaluating patients with voiding dysfunction. However, experiences in the application of the BS to the pediatric population remain limited despite commonly encountered reluctance to catheterization. This prospective observational study aimed to evaluate the correlation and accuracy of the newly developed pediatric module of the BS (BioCon-900) in measuring bladder volume in children 0-6 years old.

MATERIALS AND METHODS

This study included 29 patients scheduled to undergo preventive untethering for their spinal dysraphism. When they undergo cystometry for the confirmation of normal neurologic function, bladder volume was measured by BS when recorded volume infusion reached each quartile of the age-adjusted estimated bladder capacity (EBC). The difference (bias) between measured and infused volume was expressed as a percentage of EBC (%EBC). The correlation coefficient and the Bland-Altman plot were obtained to determine the discriminating power and accuracy, respectively. The acceptable limit was set as 30%EBC.

RESULTS

A strong correlation between the measured and infused volume (r = 0.95, P < 0.001) was found for the entire age range. This excellent correlation remained comparable between children less than three years and the older ones. Bladder volume tended to be overestimated, and the mean bias was 33 ± 22.3%EBC, and it became higher with increasing quartiles. The accuracy was acceptable in all ranges of measurement in the older group and first and second quartiles in the younger one.

DISCUSSION

We have first evaluated the potential use of BS in 0-3 years old children and compared the results with 4-6-year-old children in whom the accuracy of BS has been demonstrated. The strong point of our study was the inclusion of data spanning all quartiles of bladder volume. The use of infused volume as reference enabled us to assess the accuracy in a more precise way than the use of ultrasound. Despite the good discriminating power, the accuracy was not acceptable in higher quartiles in the younger group. If the trend of overestimation especially higher volume, could be understood prior to measurement, it would be helpful to assume the real val.

CONCLUSIONS

The children's module in BS showed excellent discriminating power and generally acceptable accuracy in more than four-year-old children. This may lose accuracy in higher quartiles among less than three years old children.

Repeatability of Ultrasound-Defined Bladder Shape Metrics in Healthy Volunteers

Purpose

Patients and Methods

Results

Conclusion

Muscarinic-3-receptor positive allosteric modulator ASP8302 in patients with underactive bladder. A randomized controlled trial

AIM

The aim of this study is to evaluate safety and efficacy of ASP8302, a novel positive allosteric modulator for the muscarinic M3 receptor (M3-PAM), in patients with underactive bladder (UAB).

METHODS

A randomized, double-blind, placebo-controlled multicenter study was performed in adult male/female subjects with UAB, defined as incomplete bladder emptying (postvoid residual volume [PVR] > 100 ml) without significant bladder outlet obstruction and/or overactive bladder. Subjects were randomized (1:1) to receive 4-week oral once-daily administration of 100 mg ASP8302 or matching placebo. Primary endpoint was a change from baseline in PVR measured by catheterization after standardized bladder filling (PVR_C2 ). Other endpoints included PVR and bladder voiding efficiency (BVE) measured in various ways, uroflowmetry, bladder diary, and questionnaires. Pressure-flow studies were performed in a subgroup.

RESULTS

One hundred and thirty-five patients were randomized (ASP8302 group: 65 patients, placebo group: 70 patients). The median change in PVR_C2 was -40.0 ml (ASP8302) versus -35.0 ml (placebo) and the difference between groups was -5.0 ml (p = 0.960). In males, functional and symptomatic outcomes improved, for example, maximum urine flow rate (Q_max ) and detrusor pressure at Q_max (P_det.Qmax ) increased (mean difference in change ASP8302 vs. placebo: 3.8 ml/s, p = 0.031 and 12.7 cm H₂ O, p = 0.034, respectively). Urinary incontinence episodes/24 h decreased in males with preexisting incontinence (mean difference: -0.35; p = 0.028). The incidence of adverse events was similar between study groups (ASP8302: 33.3%, placebo: 31.4%). In the included subjects, both baseline urine flow and bladder voiding pressure was low. Compared with PVR, simultaneous BVE measurements were more consistent between various methods (spontaneous vs. standardized bladder filling, catheterization vs. ultrasound [US]).

CONCLUSIONS

ASP8302 was safe and well tolerated in patients with UAB identified by nonurodynamic clinical criteria, but it did not show efficacy in the primary endpoint. However, in males it showed improvement of symptoms and functional parameters. BVE (using US) is a more optimal outcome measure than PVR in UAB.

The effect of biofeedback treatment for children with non-neurogenic voiding dysfunction: A systematic review and meta-analysis

BACKGROUND

Children's non-neurogenic voiding dysfunction (NVD) is a syndrome characterized by lower urinary tract symptoms (LUTs) because of the inability to relax the external sphincter. Patients with NVD always suffer from urinary tract infections (UTI), incontinence, constipation. The aim of this study is to assess the efficacy of biofeedback treatment for children's NVD.

METHODS

PubMed, Embase, Cochrane library database were searched for all relevant studies. Two independent reviewers decided whether to include the study, conducted quality evaluation, and extracted article data. A random-effects model was used to calculate overall effect sizes. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) served as the summary statistics for meta-analysis. And sensitivity analysis was subsequently performed.

RESULTS

Fifteen studies and 1274 patients were included in the systemic review, seven RCTs and 539 patients were included in meta-analysis. Meta-analysis showed efficacy of biofeedback treatment in following aspects, (1) relieving UTI (RR: 1.71, 95% CI: 1.11 to 2.64), (2) reducing PVR (MD: 9.51, 95% CI: 2.03 to 16.98), (3) increasing maximum urine flow rate (MD: 4.28, 95% CI: 2.14 to 6.42) and average urine flow rate (MD: 1.49, 95% CI: 0.53 to 2.46), (4) relieving constipation (RR: 1.59, 95% CI: 1.12 to 2.26)，(5) improving abnormal voiding pattern (RR: 1.75, 95% CI: 1.30 to 2.36) and abnormal EMG during voiding (RR: 1.55, 95% CI: 1.25 to 1.91). The improvement of UTI symptoms, maximum urine flow rate and average urine flow rate took a longer time (12 months). In terms of daytime incontinence (RR: 1.20, 95% CI [0.96, 1.50], p = 0.11), nighttime incontinence (RR: 1.20, 95% CI [0.62, 2.32], p = 0.58), no significant difference was found between biofeedback treatment and standard urotherapy. The qualitative analysis showed that biofeedback treatment was beneficial for NVD.

CONCLUSION

Compared with standard urotherapy, biofeedback treatment is effective for some symptoms, such as UTI and constipation, and can improve some uroflowmetric parameters, such as PVR. Biofeedback treatment seems to have a better long-term effect.

Team Approach: Spinopelvic Dissociation

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Spinopelvic dissociation is a complex and variable injury pattern that requires an integrated, multidisciplinary team including orthopaedic trauma and spine surgeons.

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Protocols and efficient channels of communication should be in place at tertiary Level-I trauma centers to ensure appropriate and timely treatment of patients with spinopelvic dissociation.

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Patients with spinopelvic dissociation may present with acute neurological deficits and impending cauda equina syndrome, necessitating urgent, coordinated care.

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Lumbopelvic fixation with sacroiliac screws yields a stable, multiplanar construct that connects the spine to the pelvis and allows for early mobilization.

Initial experience with holmium laser enucleation of the prostate in a urology specialist hospital in Nigeria

Background

Holmium laser enucleation of the prostate (HoLEP) is a more recent procedure for the management of Benign Prostatic Hyperplasia compared to open prostatectomy or Transurethral Resection of the Prostate. HoLEP is not commonly done in Nigeria. The objective of the study was to determine whether our initial experience with HoLEP in Abuja, favourably compared to those of other centres across the world.

Methods

A retrospective study was done on 40 patients who had HoLEP between October 2018 and December 2019. Pre- and post-operative International Prostate Symptom Score (IPSS), prostate-specific antigen (PSA), prostate sizes, maximum flow rate (Qmax) and post-void residual urine volume (PVR) were collated. The duration of irrigation, catheterization and length of hospital stay were also recorded and analysed. Complications were documented.

Results

There were improvements in IPSS from 19.67 to 5.41, PSA from 8.07 to 2.03 ng/ml,Qmax from 11.27 to 29.67 ml/min, PVR from 88.99 to 32.8 ml, while average prostate sizes reduced from 116.54 to 30.3 g after surgery. Following HoLEP, the duration of irrigation was 18.00 h, catheterization was 26.76 h and length of hospital stay was 1.82 days. Two (5.0%) patients were recatheterized, 4 (10.0%) developed post-operative bladder neck stenosis.

Conclusions

The outcome of HoLEP in our experience compared favourably with those from other centres. With adequate training and requisite equipment in resource-poor environments, technical procedures like HoLEP can be embarked on with favourable results.

Post-void residual urine ratio: A novel clinical approach to the post-void residual urine in the assessment of males with lower urinary tract symptoms

Purpose

To assess the correlation between post-void residual urine ratio (PVR-R) and pathological bladder emptying diagnosed by pressure-flow studies (PFS) in males with lower urinary tract symptoms (LUTS).

Materials and Methods

PVR-R and PVR urine were evaluated in 410 males underwent PFS for LUTS. PVR-R was the percentage of PVR to bladder volume (voided volume+PVR). Schafer and International Continence Society (ICS) nomograms, Bladder Contractility Index (BCI) were used to diagnose bladder outlet obstruction (BOO) and detrusor underactivity (DUA). We subdivided the cohort in 4 groups: Group I, BOO+/DUA+; Group II, BOO-/DUA+; Group III, BOO+/DUA−; Group IV, BOO−/DUA− (control group). We subdivided the 4 groups according to PVR-R strata: (1) 0%–20%; (2) 21%–40%; (3) 41%–60%; (4) 61%–80%; (5) 81%–100%.

Results

Group I had a greater median PVR-R (50%) with a >40% in 61.4% of the cohort. Median PVR-R was 16.6% in Group II, 24% in Group III, and 0% in the control Group. According to ICS nomograms and BCI, median PVR-R and PVR were significantly higher (p<0.001) in obstructed and underactive males. PVR-R threshold of 20% allowed to recognize males with voiding disorders with high sensibility, specificity, PPV, and NPV. A PVR-R cut-off of 40% identified males with associated BOO and DUA and more severe voiding dysfunction.

Conclusions

A higher PVR-R is related to a more severe pathological bladder emptying, and to the association of BOO and DUA. PVR-R may have a clinical role in first assessment of males with LUTS and severe voiding dysfunction.

Long-term effects of laparoscopic lateral pelvic lymph node dissection on urinary retention in rectal cancer

BACKGROUND

The addition of lateral pelvic lymph node dissection (LPLND) in rectal cancer surgery has been reported to increase the incidence of post-operative urinary retention. Here, we assessed the predictive factors and long-term outcomes of urinary retention following laparoscopic LPLND (L-LPLND) with total mesorectal excision (TME) for advanced lower rectal cancer.

METHODS

This retrospective single-institutional study reviewed post-operative urinary retention in 71 patients with lower rectal cancer who underwent L-LPLND with TME. Patients with preoperative urinary dysfunction or who underwent unilateral LPLND were excluded. Detailed information regarding patient clinicopathologic characteristics, post-void residual urine volume, and the presence or absence of urinary retention over time was collected from clinical and histopathologic reports and telephone surveys. Urinary retention was defined as residual urine > 100 mL and the need for further treatment.

RESULTS

Post-operative urinary retention was observed in 25/71 patients (35.2%). Multivariate analysis revealed that blood loss ≥ 400 mL [odds ratio (OR) 4.52; 95% confidence interval (CI) 1.24-16.43; p = 0.018] and inferior vesical artery (IVA) resection (OR 8.28; 95% CI 2.46-27.81; p < 0.001) were independently correlated with the incidence of urinary retention. Furthermore, bilateral IVA resection caused urinary retention in more patients than unilateral IVA resection (88.9% vs 47.1%, respectively; p = 0.049). Although urinary retention associated with unilateral IVA resection improved relatively quickly, urinary retention associated with bilateral IVA resection tended to persist over 1 year.

CONCLUSION

We identified the predictive factors of urinary retention following L-LPLND with TME, including increased blood loss (≥ 400 mL) and IVA resection. Urinary retention associated with unilateral IVA resection improved relatively quickly. L-LPLND with unilateral IVA resection is a feasible and safe procedure to improve oncological curability. However, if oncological curability is guaranteed, bilateral IVA resection should be avoided to prevent irreversible urinary retention.

Post-void residual and voiding dysfunction symptoms in women with pelvic organ prolapse before and after vaginal surgery. A multicenter cohort study

OBJECTIVES

The present study evaluates the impact of vaginal surgery for pelvic organ prolapse (POP) on voiding dysfunction (VD) symptoms and post-void residual (PVR) one year after the intervention.

MATERIAL AND METHODS

Epidemiological, longitudinal, prospective study. Thirty-nine gynecology units included women with symptomatic POP grade 2 or higher according to the Pelvic Organ Prolapse Quantification (POP-Q) system, who would undergo surgery for vaginal prolapse (CIRPOP-IUE study). Sociodemographic and clinical variables were collected before and after the intervention. At both visits, patients completed the 'Epidemiology of Prolapse and Incontinence Questionnaire' (EPIQ) and 'Pelvic Floor Distress Inventory' (PFDI-20) questionnaire. PVR volume was measured by bladder catheterization immediately after spontaneous urination.

RESULTS

VD symptoms were present in 50% cases before the intervention. PVR was measured in 277 women of which 116 (41.87%) were >50ml and 42/277 (15.2%) were >100ml. Objective and subjective reduction in VD symptoms was observed one year after the intervention. Mean PVR volume was reduced with statistical significance, from a mean (SD) of 66.4 (68.9)ml to 48.3 (51.3)ml. The number of patients who reported difficulty in emptying and sensation of incomplete emptying on the EPIQ and PFDI-20 questionnaires also decreased.

CONCLUSIONS

In general, improved voiding functions were observed in the CIRPOP-IUE study through a decrease in specific VD symptoms and a reduction in mean PVR volume.

Prevalence of nocturia after brain injury: a cross-sectional study in a single rehabilitation center

Aim: to analyze the prevalence of nocturia and its possible neuro-urological correlations in patients with a history of acquired brain injury (ABI).Methods: a single-centre population-based prospective study involving outpatients who were previously admitted to our Rehabilitation Hospital for acute ABI ≥ 18 months and ≤2 years prior. Impact of nocturia on QoL was evaluated by the standardized International Consultation on Incotinence Nocturia Quality of Life (ICIQ N-QoL). All participants were given a three-day frequency chart. Probability value <0.05 was statistically significant.Results: 48/138 subjects (35%) showed nocturia at 2-year follow-up visit. No, significant differences in age, gender, duration of coma, state of consciousness, disability, cognitive impairment and stroke severity were found in patients with or without nocturia. Subarachnoid haemorrhage (ESA) was the main reason for ABI in subjects showing nocturia (p = .037). The overall ICIQ N-QOL score ranged from 12 to 50 (mean 30.12 ± 8.87). Of them, 75% showed a total score >26. Increased diurnal frequency and small bladder capacity was statistically significantly associated with nocturia (p < .05).Conclusions: the rate of nocturia 2 years following ABI was lower compared to other neurological populations, although it was significantly associated with other storage urinary symptoms.

Fecal impaction is associated with postoperative urinary retention after hip fracture surgery

BACKGROUND

Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce.

OBJECTIVE

The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients.

METHODS

All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume > 400 ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis.

RESULTS

A total of 256 patients were included (mean [SD] age 86 [6] years), 76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78 [95% confidence interval 2.44-9.71], P<0.001.

CONCLUSIONS

FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

Transcutaneous Electrical Nerve Stimulation and Percutaneous Tibial Nerve Stimulation to Treat Idiopathic Nonobstructive Urinary Retention: A Systematic Review

CONTEXT

Transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS) provide minimally invasive ways to treat idiopathic nonobstructive urinary retention (NOUR).

OBJECTIVE

To assess the efficacy of TENS and PTNS for treating idiopathic NOUR.

EVIDENCE ACQUISITION

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Embase, Medline, Web of Science Core Collection, and the Cochrane CENTRAL register of trials were searched for all relevant publications until April 2020.

EVIDENCE SYNTHESIS

A total of 3307 records were screened based on the title and abstract. Eight studies met the inclusion criteria and none of the exclusion criteria. Five studies, all from the same group, reported the efficacy of PTNS and two that of TENS in adults with idiopathic NOUR. One study reported the efficacy of TENS in children with idiopathic NOUR. Objective success was defined as a ≥50% decrease in the number of catheterizations per 24 h or in the total catheterized volume in 24 h. The objective success rate of PTNS ranged from 25% to 41%. Subjective success was defined as the patient's request for continued chronic treatment with PTNS, and ranged from 46.7% to 59%. Eighty percent of women who underwent transvaginal stimulation reported an improvement such as a stronger stream when voiding. TENS in children reduced postvoid residual and urinary tract infections.

CONCLUSIONS

The efficacy of TENS and PTNS in the treatment of idiopathic NOUR is limited and should be verified in larger randomized studies before application in clinical practice.

PATIENT SUMMARY

The outcomes of transcutaneous electrical nerve stimulation and percutaneous tibial nerve stimulation for the treatment of urinary retention of unknown origin were reviewed. Whether these treatments are superior to other treatments could not be established.

Clinical Protocol for Identifying and Managing Bladder Dysfunction during Acute Care after Traumatic Spinal Cord Injury

Bladder dysfunction is widespread following traumatic spinal cord injury (TSCI). Early diagnosis of bladder dysfunction is crucial in preventing complications, determining prognosis, and planning rehabilitation. We aim to suggest the first clinical protocol specifically designed to evaluate and manage bladder dysfunction in TSCI patients during acute care. A retrospective cohort study was conducted on 101 patients admitted for an acute TSCI between C1 and T12. Following spinal surgery, presence of voluntary anal contraction (VAC) was used as a criterion for removal of indwelling catheter and initiating trial of void (TOV). Absence of bladder dysfunction was determined from three consecutive post-void bladder scan residuals ≤200 mL without incontinence. All patients were reassessed 3 months post-injury using the Spinal Cord Independence Measure (SCIM). A total of 74.3% were diagnosed with bladder dysfunction during acute care, while 57.4% had a motor-complete TSCI. Three months later, 94.7% of them reported impaired bladder function. None of the patients discharged from acute care after a functional bladder was diagnosed reported impaired bladder function at the 3-month follow-up. A total of 95.7% patients without VAC had persisting impaired bladder function at follow-up. The proposed protocol is specifically adapted to the dynamic nature of neurogenic bladder function following TSCI. The assessment of VAC into the protocol provides major insight on the potential for reaching adequate bladder function during the subacute phase. Conducting TOV using bladder scan residuals in patients with VAC is a non-invasive and easy method to discriminate between a functional and an impaired bladder following acute TSCI.

Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer

Objective

Total laparoscopic nerve-sparing radical hysterectomy (TL-NSRH) has been considered a promising approach, however, surgical, clinical, oncological and functional outcomes have not been systematically addressed. We present a large retrospective multi-center experience comparing TL-NSRH vs. open abdominal NSRH (OA-NSRH) for early and locally-advanced cervical cancer, with particular emphasis on post-surgical pelvic function.

Methods

All consecutive patients who underwent class C1-NSRH plus bilateral pelvic + para-aortic lymphadenectomy for stage IA2–IIB cervical cancer at 4 Italian gynecologic oncologic centers (Negrar, Varese, Bologna, Avellino) were enrolled. Patients were divided into TL-NSRH and OA-NSRH groups and were investigated with preoperative questionnaires on urinary, rectal and sexual function. Postoperatively, patients filled a questionnaire assessing quality of life, taking into account sexual function and psychological status. Oncological outcomes were analyzed using Kaplan-Meyer method.

Results

301 consecutive patients were included in this study: 170 in the TL-NSRH group and 131 in the OA-NSRH group. Patients in the OA-NSRH group were more likely to experience urinary incontinence and (after 12-months follow-up) urinary retention. No patient in the TL-NSRH group vs. 5 (5.5%) in the OA-NSRH group had complete urinary retention (at the >24-month follow-up [p=0.02]). A total of 20 (11.8%) in the TL-NSRH and 11 (8.4%) patients in the OA-NSRH had recurrence of disease (p=0.44) and 14 (8.2%) and 9 (6.9%) died of disease during follow-up, respectively (p=0.83).

Conclusion

Our study shows that TL-NSRH is feasible, safe and effective and conjugates adequate radicality and improvement in post-operative functional outcomes. Oncological outcomes of laparoscopic procedures deserve further investigation.

Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia: a two-center 3-year comparison

PURPOSE

To compare surgery outcomes and safety of button bipolar enucleation of the prostate vs laparoscopic simple prostatectomy in patients with large prostates (> 80 g) in a two-center cohort study.

METHODS

All patients with lower urinary tract symptoms due to benign prostatic enlargement (Prostate volume > 80 cc) undergoing button bipolar enucleation of the prostate (BTUEP) or laparoscopic simple prostatectomy (LSP) in two centers were enrolled. Data on clinical history, physical examination, urinary symptoms, uroflowmetry and prostate volume were collected at 0, 1, 3 6, 12, 24 and 36 months. Early and long-term complications were recorded.

RESULTS

Overall, 296 patients were enrolled. Out of them, 167/296 (56%) performed a LSP and 129/296 (44%) performed a BTUEP. In terms of efficacy both procedures showed durable results at three years with a reintervention rate of 8% in the LSP group and of 5% in the BTUEP group. In terms of safety, BTUEP and LSP presented similar safety profiles with a 9% of transfusion rate and no major complications.

CONCLUSION

LSP and BTUEP are safe and effective in treating large-volume adenomas with durable results at three years when performed in experienced centers.

Relationship between post-void residual urine volume, preoperative pyuria and intravesical recurrence after transurethral resection of bladder carcinoma

OBJECTIVES

To evaluate the relationship between residual urine volume, pyuria and bladder carcinoma recurrence.

METHODS

The clinical data of 305 patients who had post-void residual urine volume measured and preoperative pyuria were retrospectively collected. The patients were classified into three risk groups based on the presence of residual urine and pyuria: good (negative residual urine and pyuria), intermediate (positive residual urine or pyuria) and poor (positive residual urine and pyuria). Predictive factors for intravesical recurrence-free survival were statistically analyzed using Cox proportional hazard models and Kaplan-Meier methods. The propensity score matching method was used to adjust the patients' backgrounds.

RESULTS

The median follow-up period for all patients was 44 months. The presence of residual urine (P = 0.0164) and pyuria (P = 0.0233) were two independent prognostic factors for recurrence. After patients were classified into risk groups, the poor-risk group showed significantly shorter recurrence-free survival compared with that of the good- (P = 0.0002) and intermediate-risk groups (P = 0.0090). Even after matching, the presence of residual urine was related to short recurrence-free survival in male patients (P = 0.0012). When stratified by European Organization for Research and Treatment of Cancer risk groups, the presence of pyuria was related to short recurrence-free survival, especially for intermediate-risk patients without bacillus Calmette-Guérin treatment.

CONCLUSIONS

Post-void residual urine and preoperative pyuria are two risks for recurrence-free survival in non-muscle-invasive bladder cancer.

Predictors of voiding dysfunction following Uphold™ mesh repair for the treatment of pelvic organ prolapse

OBJECTIVE

To identify factors associated with voiding dysfunction after Uphold™ transvaginal mesh (TVM) repair in women with pelvic organ prolapse (POP).

STUDY DESIGN

We performed a retrospective analysis of 110 women with symptomatic pelvic organ prolapse (POP), anterior vaginal wall prolapse and/or apical prolapse (stage II to IV) who were scheduled for Uphold™ mesh surgery from September 2015 through December 2016. All subjects underwent urinalyses, UDI-6, IIQ-7, ICI-Q, POPDI-6, and pelvic examinations using the POP quantification (POP-Q) staging system before and after surgeries, with follow-up durations ranging from 24-36 months.

RESULTS

A total of 12 (10.9 %) of 110 women reported voiding dysfunction after Uphold™ mesh surgery. Using univariate analysis, there were no differences in body mass index and urodynamic parameters between normal voiding group and dysfunctional voiding group (P > 0.05). However, in patients aged above 71, POPDI-6 score≧13, preoperative concomitant urinary hesitancy, and incomplete emptying were found to be significant predictors of voiding dysfunction following Uphold™ mesh surgeries (P < 0.05).

CONCLUSION

In patients aged above 71, POPDI-6 score≧13, preoperative concomitant urinary hesitancy, and incomplete emptying were significant predictors of voiding dysfunction after Uphold™.

[Sophisticated surgical management of distinctive patients with benign prostatic hyperplasia (BPH)]

Herein we describe four clinical scenarios. For the standard patient (prostate volume 30-80 ml, life expectancy >10 years) transurethral resection of the prostate (TURP) remains the standard of care, while endoscopic enucleation is a valuable alternative. Patients with a relevant middle lobe profit most from TURP, endourological enucleation procedures, or laser vaporization. In the case of the absence or a moderate-sized middle lobe and the absence of severe bladder outlet obstruction (BOO), minimally invasive procedures such as Rezūm®, UroLift® or prostate artery embolization (PAE) can be offered. Patients have to be informed that long-term data on this specific indication are lacking. Particularly younger men requiring BPH surgery are interested in preserving ejaculatory function. In the presence of severe BOO, ejaculatory-protective TURP or endoscopic enucleation by preserving the pericollicular region or aquablation are the methods of choice providing an antegrade ejaculation in 60-90% of cases. Rezūm®, AquaBeam®, and UroLift® enable preservation of ejaculation in almost 100%; data on PAE with this respect are more controversial. For patients with a small prostate and significant post void residual, a thorough preoperative work-up, including urodynamics and bladder/detrusor wall thickness measurement, is of great importance. Desobstructive surgery provides satisfactory short- and midterm outcome, yet the long-term outcome is disappointing and remains to be determined in greater detail. The broad spectrum of therapeutic options enables today an individualized minimally invasive or surgical management of BPH considering patient wishes, anatomical factors or urodynamic factors. The time of a "one therapy fits all" strategy is definitely history.

Levator ani muscle avulsion: a risk factor for persistent postpartum voiding dysfunction

INTRODUCTION AND HYPOTHESIS

Persistent postpartum voiding dysfunction (P-PPVD) is defined as the inability to empty the bladder properly 72 h after delivery despite the use of intermittent urinary catheterization. Our aim was to find predictive factors for P-PPVD and to compare its urogynecologic outcomes with transient dysfunctions.

MATERIALS AND METHODS

A case-control study was performed in a university hospital center between January 2018 and April 2019. The case group included women diagnosed with P-PPVD after vaginal delivery, and the control group included women with PPVD that resolved before 72 h. Patients were followed up at 12 weeks and 12 months postpartum, including an ultrasound assessment of the levator ani muscle (LAM).

RESULTS

Of 2308 deliveries, 1894 (81%) were vaginal, 75 (3.85%) presented PPVD, and 1 lasted > 72 h (0.69% P-PPVD). LAM avulsion (OR 6.3, 95% CI 1.24-32.01) was the only independent risk factor for P-PPVD found. No significant differences in urogynecologic symptoms between transient and persistent PPVD were found in the short and the long term, except that women with P-PPVD had a lower prevalence of urinary incontinence at 12 weeks postpartum.

CONCLUSIONS

PPVD is a common, self-limited event, but in 17.3% of cases persists > 3 days. Levator ani muscle avulsion acts as an independent risk factor for P-PPVD. Early diagnosis and appropriate treatment of P-PPVD can help minimize any clinical implications for long-term urogynecologic disorders.

Soft sensors for a sensing-actuation system with high bladder voiding efficiency

Sensing-actuation systems can assist a bladder with lost sensation and weak muscle control. Here, we advance the relevant technology by integrating a soft and thin capacitive sensor with a shape memory alloy-based actuator to achieve a high-performance closed-loop configuration. In our design, sensors capable of continuous bladder volume detection and actuators with strong emptying force have been used. This integration has previously hindered performance due to large bladder volume changes. Our solution integrates sensing-actuation elements that are bladder compatible but do not interfere with one another, achieving real-time bladder management. The system attains a highly desirable voiding target of 71 to 100% of a rat's bladder with a volume sensitivity of 0.7 μF/liter. Our system represents an efficient voiding solution that avoids overfilling and represents a technological solution to bladder impairment treatment, serving as a model for similar soft sensor-actuator integration with other organs.

Circadian Patterns in Postvoid Residual and Voided Percentage Among Older Women with Urinary Incontinence

Background: Women with urinary incontinence incur an increased risk of elevated postvoid residual (PVR) volume and impaired voiding efficiency (i.e., voided percentage (Void%)), but the clinical significance of these parameters remains poorly described. Further characterization of PVR and voiding efficiency may thus be useful in refining the evaluation and management of urinary incontinence. This study aims to explore possible circadian variations in PVR and Void% in older women with stress (SUI), urge (UUI) and mixed urinary incontinence (MUI). Methods: A single center prospective study which enrolled a convenience sample of 90 older women who consulted a tertiary referral hospital for urinary incontinence. Participants underwent an extensive medical interview and were hospitalized to complete a 24-h frequency-volume chart (FVC) with PVR measurement after each void (FVC_PVR). Results: FVC_PVR analysis demonstrated no differences in mean PVR and Void% between patients with SUI, UUI and MUI. Likewise, no daytime or nighttime differences were observed in mean PVR or Void% within or between groups. Conclusions: No evidence of circadian variation in PVR or Void% was observed in older women with SUI, UUI or MUI.

Bladder cancer and its mimics: a sonographic pictorial review with CT/MR and histologic correlation

Bladder cancer is the most common cancer of the urinary system and often presents with hematuria. Despite its relatively high incidence, bladder cancer is often under-recognized sonographically. Moreover, even when bladder abnormalities are identified, numerous other entities may mimic the appearance of bladder cancer. Given the incidence and prevalence of bladder cancer, it is important to recognize its variable appearance sonographically and distinguish it from its common mimics. We review the sonographic appearance of bladder cancer and its mimics, providing correlative CT/MR imaging as well as pathology. We stress the importance and advantage of ultrasound as a dynamic imaging modality, with the ability to optimize distinguishing bladder cancer from similar-appearing entities.

Impact of post-void residual urine volume on intravesical recurrence after nephroureterectomy for upper urinary tract urothelial carcinoma

OBJECTIVE

To examine the impact of post-void residual urine volume on the risk of postoperative recurrence of intravesical carcinoma in patients with upper urinary tract urothelial carcinoma undergoing nephroureterectomy.

METHODS

We retrospectively reviewed the data of 81 patients who were admitted to Chiba University Graduate School of Medicine Hospital and underwent nephroureterectomy for upper urinary tract urothelial carcinoma without bladder carcinoma. We assessed the predictive factors for intravesical recurrence after nephroureterectomy in all patients. Next, we compared patients with and without a residual urine volume using propensity score-matching analysis. The presence of a residual urine volume was defined as ≥30 mL.

RESULTS

The median follow-up period among all patients was 48 months. The presence of pyuria and a residual urine volume were associated with bladder recurrence in the multivariate analysis. A total of 19 patients each were selected after matching, and we confirmed a significant difference between the presence and absence of a residual urine volume (P = 0.0291). The 2-year postoperative recurrence-free rate of patients with and without a residual urine volume was 32% and 82%, respectively.

CONCLUSIONS

This is the first study to evaluate the post-void residual urine volume and intravesical recurrence rate after nephroureterectomy for upper urinary tract urothelial carcinoma. The presence of residual urine might be a risk factor for postoperative recurrence of intravesical carcinoma.

The Distribution of Post-Void Residual Volumes in People Seeking Care in the Symptoms of Lower Urinary Tract Dysfunction Network Observational Cohort Study With Comparison to Asymptomatic Populations

OBJECTIVE

To describe the distribution of post-void residual (PVR) volumes across patients with and without lower urinary tract symptoms (LUTS) and examine relationships between self-reported voiding symptoms, storage symptoms, and PVR.

METHODS

PVR and demographic data were obtained from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) observational cohort study. Self-reported symptoms were collected using the American Urological Association Symptom Index and the LUTS Tool. PVR values were obtained from 2 other cohorts: living kidney donors with unknown LUTS from the Renal and Lung Living Donors Evaluation Study (RELIVE), and continent women in the Establishing the Prevalence of Incontinence (EPI) study, a population-based study of racial differences in urinary incontinence prevalence.

RESULTS

Across the 3 studies, median PVRs were similar: 26 mL in LURN (n = 880, range 0-932 mL), 20 mL in EPI (n = 166, range 0-400 mL), and 14 mL in RELIVE (n = 191, range 0-352 mL). In LURN, males had 3.6 times higher odds of having PVR > 200 mL (95% CI = 1.72-7.48). In RELIVE, median PVR was significantly higher for males (20 mL vs 0 mL, P= .004). Among women, only the intermittency severity rating was associated with a probability of an elevated PVR. Among men, incomplete emptying and burning severity rating were associated with a higher odds of elevated PVR, but urgency severity ratings were associated with lower odds of elevated PVR.

CONCLUSION

Care-seeking patients have PVRs similar to those in people with unknown history of LUTS (RELIVE) and without self-reported LUTS (EPI). Although PVR was correlated with voiding symptoms, the mean differences only explain ∼2% of the variance.

Intra- and inter-rater reliability of post-void residual bladder volume with ultrasound

INTRODUCTION AND HYPOTHESIS

The purpose of the present study was to test the intra- and inter-rater reliability of the measurement of post-void residual bladder volume using ultrasound.

METHODS

Two evaluators performed three measurements of the height, width, and length of the empty bladder using ultrasound. The voiding residual volume was calculated using the equation: volume = length × width × height × 0.52. Intraclass correlations (ICC) were calculated considering: ICC ≥ 0.75 excellent, 0.40 ≤ ICC < 0.75 satisfactory, and ICC <0.40 poor, with a significance level of 5% and analysis of confidence intervals (95% CI).

RESULTS

Twenty women participated, with an average age of 27.95 ± 3.15 years. The inter-rater ICCs for height, width, and length were 0.96 (CI 0.89-0.98), 0.88 (CI 0.71-0.95), and 0.84 (CI0.60-0.94) respectively. For the intra-rater ICCs, the values were 0.97 (CI 0.95-0.99), 0.98 (CI 0.96-0.99), and 0.97 (CI 0.94-0.99) for evaluator 1 and 0.99 (CI 0.97-0.99), 0.97 (CI 0.94-0.99), and 0.95 (CI 0.90-0.98) for evaluator 2, for height, width, and length, respectively. The residual inter-test volume was 0.96 (CI 0.90-0.99) and the intra-test volume was 0.99 (CI 0.97-0.99). All analyses presented p < 0.0001.

CONCLUSIONS

The intra- and inter-rater reliability for both the post-void residual volume and measurement of the bladder dimensions showed excellent agreement.

[Fake News BPH - what is really true!]

BACKGROUND

Lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH) is the fourth most common and the fifth most costly disease in men aged 50 years or older. Despite the high prevalence of LUTS/BPH in clinical practice and evidence-based guideline recommendations, there are still plenty of misconceptions on the terminology and pathophysiology of the disease, leading to false assumptions and malpractice.

OBJECTIVES

Listing of commonly used false assumptions and clarification of the correct terminology and pathophysiology.

MATERIALS AND METHODS

Critical reflection of 12 selected fake news based on PubMed search.

RESULTS

Average prostate weight in healthy men is 20 g but varies between 8-40 g. The BPH-disease does not progress in stages; therefore, the BPH-classifications according Alken or Vahlensieck should not be used anymore. There is only a weak and inconsistent relationship between bladder outlet obstruction (BOO) and prostate size, diverticula/pseudo-diverticula, postvoid residual, urinary retention or renal insufficiency, which is too unreliable for BOO-diagnosis in the individual patient. Urethro-cystoscopy with grading of the degrees of occlusion of the prostatic urethra and bladder trabeculation is insufficient for BOO-diagnosis. There is no clinically relevant reduction of BOO with licensed BPH-drugs and no convincing data that prostate resection (TURP) has to be complete until the surgical capsule in order to obtain optimal results.

CONCLUSIONS

The reasons for the persistent use of wrong terminology and pathophysiology are diverse. One reason is lack of implementation of evidence-based guidelines into clinical practice due to lack of knowledge, individual beliefs, costs, availability and reimbursement policies. Another reason is the increasing focus on oncology, coupled with underrepresented education and training on BPH.

Protracted postpartum urinary retention-a long-term problem or a transient condition?

INTRODUCTION AND HYPOTHESIS

Protracted postpartum urinary retention (P-PUR) is a rare puerperal complication of overt urinary retention that proceeds beyond the 3rd postpartum day. Long-term consequences of P-PUR are poorly reported. The objective of the study was to compare the long-term outcome of patients with P-PUR with a matched control group, using a validated pelvic floor distress questionnaire.

METHODS

All medical files of women diagnosed with P-PUR between 2005 and 2016 were reviewed. The control group was comprised of women who had a consecutive birth, matched in a 1:2 ratio, by maternal age, parity, neonatal birth weight, analgesia, and route of delivery. All women were evaluated for long-term symptoms of urinary or fecal incontinence and pelvic-organ-prolapse-related complaints by a telephone interview, at least 1 year following their delivery, using the Pelvic Floor Distress Inventory-Short Form (PFDI-20) questionnaire.

RESULTS

During the study period, there were 27 cases of P-PUR out of 52,662 deliveries (0.051%). There were no differences between the study group (n = 27) and controls (n = 54) in age, BMI (kg/m²), parity, birth weight, route of delivery, and rate of episiotomy. The majority of patients in both groups opted for epidural analgesia. Second stage of labor was longer in the study group than in controls, 134.1 ± 74.6 min vs. 73.4 ± 71.6 min, respectively, p < 0.001. The scores of the PFDI-20, UDI-6, and POPDI-6 did not differ between the groups. However, the study group had minimally elevated scores on the CARDI-8 scale (1.0 ± 2.6 vs. 0.0 ± 0.0, p = 0.012).

CONCLUSIONS

P-PUR is a rare postpartum complication, yet this disturbing condition has negligible if any clinical impact on long-term urogynecologic disorders. These findings carry a reassuring message to both patients and their health care providers.

Expectant long-term follow-up of patients with chronic urinary retention

AIMS

To describe urologic complications in patients with chronically elevated post-void residual (PVR) volumes and to evaluate other related risk factors during a long-term follow-up in patients managed conservatively.

METHODS

Non-neurogenic patients who refused surgical intervention of the prostate and had PVR volumes >300 mL on two or more separate occasions at least 6 months apart were included. We followed this cohort over time, recorded complications and evaluated risk factors for complications.

RESULTS

Twenty-eight men with a mean age of 74 were followed for a median of 56 months (IQR: 26-101 months); 26 had benign prostatic hyperplasia with a median prostate size of 55 cc. Baseline median PVR was 468 cc (IQR: 395-828) and follow-up median PVR was 508 cc (IQR: 322-714). During follow-up, 13 patients (46%) had at least one complication with acute urinary retention being the most common occurring in 10 patients (36%) with 15 episodes. Other complications presented in less than 15%, and no patients developed permanent renal insufficiency. Patients with prostate size ≥ 100 cc had significantly higher total number of acute retention episodes (P-value: 0.01).

CONCLUSIONS

Although the presence of CUR could commonly predispose to episodes of acute retention, severe complications are infrequent although present. Additionally, prostate size may play a role in increasing some adverse outcomes. With proper counseling about different complications, patients with retention who denied surgical treatment can be safely followed for at least 5 years without renal deterioration.