From wires to waves, a novel sensor system for in vivo pressure monitoring

Pressure monitoring in various organs of the body is essential for appropriate diagnostic and therapeutic purposes. In almost all situations, monitoring is performed in a hospital setting. Technological advances not only promise to improve clinical pressure monitoring systems, but also engage toward the development of fully implantable systems in ambulatory patients. Such systems would not only provide longitudinal time monitoring to healthcare personnel, but also to the patient who could adjust their way-of-life in response to the measurements. In the past years, we have developed a new type of piezoresistive pressure sensor system. Different bench tests have demonstrated that it delivers precise and reliable pressure measurements in real-time. The potential of this system was confirmed by a continuous recording in a patient that lasted for almost a day. In the present study, we further characterized the functionality of this sensor system by conducting in vivo implantation experiments in nine female farm pigs. To get a step closer to a fully implantable system, we also adapted two different wireless communication solutions to the sensor system. The communication protocols are based on MICS (Medical Implant Communication System) and BLE (Bluetooth Low Energy) communication. As a proof-of-concept, implantation experiments in nine female pigs demonstrated the functionality of both systems, with a notable technical superiority of the BLE.

Nomogram predicting the efficacy of transurethral surgery in benign prostatic hyperplasia patients

PURPOSE

This study aimed to develop and validate a nomogram for predicting the efficacy of transurethral surgery in benign prostatic hyperplasia (BPH) patients.

METHODS

Patients with BPH who underwent transurethral surgery in the West China Hospital and West China Shang Jin Hospital were enrolled. Patients were retrospectively involved as the training group and were prospectively recruited as the validation group for the nomogram. Logistic regression analysis was utilized to generate nomogram for predicting the efficacy of transurethral surgery. The discrimination of the nomogram was assessed using the area under the receiver operating characteristic curve (AUC) and calibration plots were applied to evaluate the calibration of the nomogram.

RESULTS

A total of 426 patients with BPH who underwent transurethral surgery were included in the study, and they were further divided into a training group (n = 245) and a validation group (n = 181). Age (OR 1.07, 95% CI 1.02-1.15, P < 0.01), the compliance of the bladder (OR 2.37, 95% CI 1.20-4.67, P < 0.01), the function of the detrusor (OR 5.92, 95% CI 2.10-16.6, P < 0.01), and the bladder outlet obstruction (OR 2.21, 95% CI 1.07-4.54, P < 0.01) were incorporated in the nomogram. The AUC of the nomogram was 0.825 in the training group, and 0.785 in the validation group, respectively.

CONCLUSION

The nomogram we developed included age, the compliance of the bladder, the function of the detrusor, and the severity of bladder outlet obstruction. The discrimination and calibration of the nomogram were confirmed by internal and external validation.

Surgical Outcomes and Predictive Factors in Patients With Detrusor Underactivity Undergoing Bladder Outlet Obstruction Surgery

PURPOSE

This study was conducted to evaluate the efficacy of bladder outlet surgery in patients with detrusor underactivity (DU) and to identify factors associated with successful outcomes.

METHODS

We conducted a retrospective review of men diagnosed with DU in urodynamic studies who underwent bladder outlet surgery for lower urinary tract symptoms between May 2018 and April 2023. The International Prostate Symptom Score (IPSS) questionnaire, uroflowmetry (UFM), and multichannel urodynamic studies were administered. Successful treatment outcomes were defined as either an IPSS improvement of at least 50% or the regaining of spontaneous voiding in patients urethral catheterization prior to surgery.

RESULTS

The study included 93 male patients. Men diagnosed with significant or equivocal bladder outlet obstruction (BOO) experienced significant postoperative improvements in IPSS (from 20.6 to 6.0 and from 17.4 to 6.5, respectively), maximum urine flow rate (from 5.0 mL/sec to 14.4 mL/sec and from 8.8 mL/sec to 12.2 mL/sec, respectively) and voiding efficiency (from 48.8% to 86.0% and from 61.2% to 85.1%, respectively). However, in the group without obstruction, the improvements in IPSS and UFM results were not significant. The presence of detrusor overactivity (odds ratio [OR], 3.152; P=0.025) and preoperative urinary catheterization (OR, 2.756; P=0.040) were associated with favorable treatment outcomes. Conversely, an unobstructed bladder outlet was identified as a negative prognostic factor.

CONCLUSION

In men with DU accompanied by equivocal or significant BOO, surgical intervention to alleviate the obstruction may enhance the IPSS, quality of life, and UFM results. However, those with DU and an unobstructed bladder outlet face a comparatively high risk of treatment failure. Preoperative detrusor overactivity and urinary catheterization are associated with more favorable surgical outcomes. Consequently, active deobstructive surgery should be considered for patients with DU who are experiencing urinary retention.

The design and evaluation of a quick checklist for urodynamic quality control: A prospective single-center small sample study

PURPOSE

To design a quick checklist for urodynamic study (UDS), aiming to reduce the occurrence of errors in the process, which may help to increase the quality of UDS. And further to analyze the effectiveness of this quick checklist for UDS quality control.

METHODS

First, a quick checklist for uroflow study and pressure-flow study was developed, based on the International Continence Society-Good Urodynamic Practice standards, our previous studies, and recent literature, as well as expert suggestions. Then, patients who underwent UDS between January 2023 to February 2023 were randomly assigned to a study group or a control group. For the study group, the quick checklist was used throughout the UDS process, while the control group did not. The main artefacts were chosen to verify the effectiveness of the quick checklist for improving the UDS quality.

RESULTS

The quick checklist comprised three subtypes: checklist for patients, checklist for environment and device, and checklist for UDS test process. 38 UDS traces per group were included. The incidence of missing the standard cough test decreased significantly from 18.4% to 0 (p = 0.012), with the checklist implementation. The baseline drift frequency rate also declined significantly from 39.5% to 5.3% (p < 0.05). Volume < 150 mL on uroflow study occurred in 68.4% of cases and its frequency rate decreased significantly with checklist implementation (p < 0.05).

CONCLUSION

A quick checklist for quality control of UDS was developed. The quick checklist as a convenient, quick, and easy used urodynamic quality control method, may help to reduce the technical artefacts and improve fundamental urodynamic quality control. Future research with a larger sample size is needed to confirm the effectiveness of the checklist.

A feasibility study of three-dimensional ultrasound imaging of the vagina under distension

BACKGROUND

The distension properties of the vagina are critical to its function including support of surrounding organs, childbirth, and intercourse. It could be altered by many pathophysiological processes like pregnancy, radiotherapy, and reconstruction surgery. However, there are no clinically available diagnostic tools capable of quantifying the distension properties of the vagina.

PURPOSE

A proof-of-concept study was designed to assess the feasibility of a novel three-dimensional (3D) ultrasound imaging technique that allows quantitative evaluation of the vagina under distension.

METHODS

Patients with symptomatic pelvic organ prolapse (POP) were recruited for the study. An ultrathin, oversized bag was inserted into the vagina and filled with water using a modified urodynamics system. The instilled water volume and intravaginal pressure were continuously recorded. At maximum vaginal capacity, 3D transintroital ultrasound of the distended vagina and surrounding pelvic structures was performed. Exams were performed in duplicate for each patient, two hours apart (round A and round B). Following the development of a 3D surface model of the distended vagina from each scan, several measurements were obtained, including cross-sectional area, anteroposterior (AP) length and lateral width in the plane of minimum hiatal dimensions (PMHD), AP and lateral diameter at the pubic symphysis (PS) level, maximum and minimum diameter, and maximum vertical length. To assess repeatability between measurements in two rounds, the coefficient of variation (CV) and the intraclass correlation coefficient (ICC) were calculated for each measurement. Correlations between physical measurements including the pelvic organ prolapse quantification (POP-Q) system and vaginal diameter measurements, and obtained metrics were also assessed.

RESULTS

Sixteen patients with POP (average age 69 years) completed both rounds of imaging. There was sufficient echogenicity on 3D transintroital ultrasound of the distended vaginal wall to establish boundaries for 3D surface models of the vagina. Overall, all metrics had good or excellent reliability (ICC = 0.77-0.93, p < 0.05; CV = 3%-18%) except maximum diameter, which demonstrated only moderate reliability (ICC = 0.67, p = 0.092). Strong correlations were found between physical exam measurements including D point of POP-Q, introitus diameter and lateral diameter at apex, and maximum vaginal capacity, maximum vertical length, lateral diameter at PS, minimum diameter, and distended PMHD measurements. The results demonstrated that this system could generate 3D models of the shape of the distended vagina and provide multiple metrics that could be reliably calculated from automated analyses of the models.

CONCLUSIONS

A novel system for evaluation of the distension properties of the vagina was developed and preliminary evaluation was performed. This system may represent a technique for evaluation of the biomechanical and structural properties of the vagina.

ICS-SUFU standard: Theory, terms, and recommendations for pressure-flow studies performance, analysis, and reporting. Part 1: Background theory and practice

AIMS

The working group (WG) initiated by the International Continence Society Standardization Steering Committee and supported by the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction has revised the (1997) ICS Standard for pressure flow studies.

METHODS

Based on the ICS standard for developing evidence-based standards, the WG developed this new ICS standard in the period from May 2020 to December 2022. A draft was posted on the ICS website in January 2023 to facilitate public discussion and the comments received have been incorporated into this final release.

RESULTS

The WG summarizes the theory and recommends the practice and the terms used for the diagnosis of voiding dysfunction for adult female and male patients without relevant neurological abnormalities, in part 1 of this standard. The WG has also recommended standard principles and parameters for objective and continuous grading of urethral resistance and detrusor voiding contraction on the basis of pressure flow studies in part 2. The recommendations for practice in this part have also the aim to increase the understanding of the physiology as well as the psychology of voiding. The potential effects of the laboratory situation of the test on the voiding as well as the role of the urodynamicist in this regard are discussed. The WG has recommended to use for diagnosis only the voidings that are considered representative by the patient.

CONCLUSION

A pressure flow study is the gold standard to assess voiding function and to quantify dysfunction. This part of the standard explains the clinical background, gives recommendations for the execution of a pressure flow study and lists relevant terms, parameters, and units of measurements.

Recently urodynamic and quality of life assessment in the non-menopausal women with cervical cancer after radical hysterectomy

PURPOSE

The aim of this study was to evaluate the pre- and postoperative changes in the recently urodynamic and quality of life (QoL) in nonmenopausal women diagnosed with cervical cancer and treated with radical hysterectomy (RH).

PATIENTS AND METHODS

Twenty-eight nonmenopausal women (28-49 years) with cervical carcinoma (FIGO stage Ia2-IIa) underwent a radical hysterectomy. Urodynamic studies were performed 1 week before (U0) and 3-6 months (U1) after surgery. A self-administered condition-specific QoL questionnaire (PFDI-20, PFIQ-7) was applied at U0 and U1.

RESULTS

Data from the urodynamics analysis performed at U1 showed that the average first sensation volume (119.39 ± 12.28 ml vs 150.43 ± 31.45 ml, P < 0.001), the residual urine volume (6.39 ± 10.44 ml vs. 42.32 ± 33.72 ml, P < 0.001), and the time of urination (46.10 ± 16.65 s vs. 74.31 ± 23.94 s, P < 0.001) were increased, while the bladder volume at a strong desire to void (448.89 ± 86.62 ml vs. 322.82 ± 50.89 ml, P < 0.001), the bladder compliance (82.63 ± 58.06 ml/cmH₂O vs. 37.45 ± 28.66 ml/cmH₂O, P < 0.001), the average flow rate (Qave) (23.86 ± 4.25 ml/s vs. 12.57 ± 2.37 ml/s, P < 0.001), the maximum natural flow rate (Qmax) (25.42 ± 6.46 ml/s vs. 14.43 ± 5.32 ml/s, P < 0.001), and the pressure at a peak flow rate (PdetQmax) (36.53 ± 11.20 cmH₂O vs. 31.43 ± 10.56 cmH₂O, P < 0.05) were decreased. At the same time, functional pelvic problems derived from prolapse (PFDI-20 scores) and their impact on the patients' Qol (PFIQ-7 score) were significantly improved at 3-6 months postoperation.

CONCLUSION

Radical hysterectomy results in urodynamic changes, and 3-6 months postoperation may be an important period for changes in bladder dysfunction after RH. Urodynamic and QoL analyses may provide methods for assessing symptoms.

The Utility of Urodynamic Studies in Neuro-Urological Patients

INTRODUCTION

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review.

METHODS

For this narrative review, a PubMed^® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

ANALYSIS

Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities.

CONCLUSION

Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

Does the Polydimethylsiloxane Urethral Injection (Macroplastique®) Improve Sexual Function in Women, in Fertile Age, Affected by Stress Urinary Incontinence?

Background and Objectives: Stress urinary incontinence (SUI) negatively affects women’s quality of life, including sexual function. The aim of the current study was to evaluate the effect of polydimethylsiloxane (Macroplastique®) on sexual function in women of fertile age affected by SUI. Materials and Methods: Single-center prospective study. Sexually active women of fertile age with symptoms of pure SUI, which were urodynamically proven, were submitted to intraurethral Macroplastique® injection. At 6-months follow-up, their sexual function was evaluated with Female Sexual Function Index (FSFI), while the SUI cure rate was objectively assessed through a negative stress test and subjectively by a Patient Global Impression of Improvement (PGI-I) score < 3. The difference of coital incontinence prevalence was assessed between the baseline and the 6-month follow-up. Peri- and postoperative complications of Macroplastique® injection were recorded and classified according to the Clavien–Dindo system. Results: Twenty-one women fulfilled inclusion criteria and were submitted to Macroplastique® procedure. The concerning sexual function, desire, satisfaction, and overall FSFI score significantly improved. Since other domains were less impaired at the baseline, we could not assess significant improvement for all of them. We observed a complete regression of coital incontinence (0/21, 0%) in comparison with the baseline (5/21, 23.8%; p = 0.04). The objective SUI cure rate was 76% (16/21), while the subjective SUI cure rate was 80.9% (17/21). One woman developed de novo overactive bladder, and two women developed postoperative voiding dysfunction (self-solved in 24 h). Conclusions: The Macroplastique® urethral injection was demonstrated to be safe and effective in improving sexual function in sexually active women of fertile age affected by pure SUI, urodinamically proven at 6-months follow-up.

Pressure Measurement in a Bladder Phantom Using Contrast-Enhanced Ultrasonography-A Path to a Catheter-Free Voiding Cystometrogram

OBJECTIVES

The long-term goal of this study is to investigate the efficacy of a novel, ultrasound-based technique called subharmonic-aided pressure estimation (SHAPE) to measure bladder pressure as a part of a cystometrogram (CMG) in a urodynamic test (ie, pressure-flow study). SHAPE is based on the principle that subharmonic emissions from ultrasound contrast microbubbles (MBs) decrease linearly with an increase in ambient pressure. We hypothesize that, using the SHAPE technique, we can measure voiding bladder pressure catheter-free. This is of importance because the CMG catheter, due to its space-occupying property and non-physiological effects, can undermine the reliability of the test during voiding and cause misdiagnosis. In this study, we tested this hypothesis and optimized the protocol in a controlled benchtop environment.

MATERIALS AND METHODS

A bladder phantom was designed and built, capable of simulating clinically relevant bladder pressures. Laboratory-made lipid-shelled MBs (similar in composition to the commercial agent, DEFINITY) was diluted in 0.9% normal saline and infused into the bladder phantom using the CMG infusion system. A typical simulated CMG consists of 1 filling and 4 post-filling events. During CMG events, the bladder phantom is pressurized multiple times at different clinically relevant levels (small, medium, and large) to simulate bladder pressures. Simultaneous with pressurization, MB subharmonic signal was acquired. For each event, the change in MB subharmonic amplitude was correlated linearly with the change in bladder phantom pressure, and the SHAPE conversion factor (slope of the linear fit) was determined. In doing so, a specific signal processing technique (based on a small temporal window) was used to account for time-decay of MB subharmonic signal during a simulated CMG.

RESULTS

A strong inverse linear relationship was found to exist between SHAPE and bladder phantom pressures for each of the CMG filling and post-filling events ( r2> 0.9, root mean square error < 0.3 dB, standard error <0.01 dB, and P < 0.001). SHAPE showed a transient behavior in measuring bladder phantom pressure. The SHAPE conversion factor (in dB/cm H 2 O) varied between filling and post-filling events, as well as by post-filling time. The magnitude of the SHAPE conversion factor tended to increase immediately after filling and then decreases with time.

CONCLUSIONS

Microbubble subharmonic emission is an excellent indicator of bladder phantom pressure variation. The strong correlation between SHAPE signal and bladder phantom pressure is indicative of the applicability of this method in measuring bladder pressure during a CMG. Our results suggest that different SHAPE conversion factors may be needed for different events during a CMG (ie, at different time points of a CMG). These findings will help us better protocolize this method for introduction into human subjects and allow us to take the next step toward developing a catheter-free voiding CMG using SHAPE.

Risk factors for upper urinary tract deterioration in adult patients with spina bifida

PURPOSE

Neurogenic bladder associated with spina bifida disease remains a major cause for mortality or morbidity due to kidney damages. However, we currently do not know which urodynamic findings are associated with an higher risk of upper tract damages in spina bifida patients. The objective of the present study was to evaluate urodynamic findings associated with functional kidney failure and/or with morphological kidney damages.

METHODS

A large single-center restrospective study was conducted in our national referral center for spina bifida patients using our patients' files. All urodynamics curves were assessed by the same examinator. Functional and/or morphological evaluation of the upper urinary tract were done at the same moment as the urodynamic exam (between 1 week before and 1 month after). Kidney function was assessed using creatinine serum levels or 24 h urinary creatinine levels (creatinine clearance) for walking patients, or with the 24 h urinary creatinine level for wheelchair-users.

RESULTS

We included 262 spina bifida patients in this study. Fifty-five patients had a poor bladder compliance (21.4%) and 88 of them had detrusor overactivity (33.6%). Twenty patients had a stage 2 kidney failure (eGFR < 60 ml/min) and 81 patients out of 254 (30.9%) had an abnormal morphological examination. There were three urodynamic findings significantly associated with UUTD: bladder compliance (OR = 0.18; p = 0.007), Pdetmax (OR = 14.7; p = 0.003) and detrusor overactivity (OR = 1.84; p = 0.03).

CONCLUSION

In this large series of spina bifida patients, maximum detrusor pressure and bladder compliance are the main urodynamic findings determinants of UUTD risk.

Intravesical Injection of Botulinum Toxin Type A in Patients with Refractory Overactive Bladder-Results between Young and Elderly Populations, and Factors Associated with Unfavorable Outcomes

Intravesical botulinum toxin type A (BoNT-A) injection has been recognized as the standard treatment for refractory overactive bladder (OAB). However, its therapeutic efficacy and safety have not been thoroughly reviewed in elderly patients. This study aims to provide treatment outcomes for patients aged ≥75 years, and to identify factors associated with unfavorable outcomes. Patients receiving intradetrusor injections of 100 U onabotulinumtoxinA for refractory OAB between 2011 and 2021 were retrospectively reviewed. Urodynamic parameters, underlying comorbidities, subjective success, and unfavorable outcomes were assessed. A total of 192 patients were included, and 65 of them were classified into the elderly group. For the elderly group, 60.0% experienced subjective dryness, and 84.6% remained subjective success at 6 months after the injections. The prevalence rates of common unfavorable outcomes, including urinary tract infections, large post-void residual urine volume, and urinary retention, were 9.2%, 27.7%, and 12.3%, respectively. Multivariate analysis revealed that female, baseline urodynamic parameters, and diabetes mellitus were associated with unfavorable outcomes in the elderly group. Intravesical BoNT-A injections provide comparable therapeutic efficacy and safety concerns in elderly patients with refractory OAB. A thorough consultation for treatment benefits and possible adverse events is mandatory before the procedure.

Translabial ultrasound evaluation after tension-free transobturator tape technique: Outcomes based on the tape's position

OBJECTIVE

The purpose of this study was to evaluate the feasibility and accuracy of postoperative translabial ultrasound to assess the position of the tape implanted with the tension-free transobturator tape technique.

METHODS

We enrolled women with clinically and urodynamically proven type I or II stress urinary incontinence who were referred for transobturator tape treatment.

RESULTS

A total of 50 women underwent a transobturator tape procedure and were included in the analysis. We divided the patients into two study groups (group A and group B), characterized by normal and obstructed flow at least 30 days after the surgical procedure visit, respectively. We performed a translabial ultrasound evaluation to assess the suburethral localization of the sling. On the longitudinal scan, the distance between the bladder neck and the suburethral sling was >10 mm in all patients in group A (16.7 ± 1.6). On the contrary, the values in group B were ≤10 mm (5.3 ± 4.8).

CONCLUSION

Our findings highlight the role of a skilled sonographic operator performing translabial ultrasound as a first-line method for evaluating postoperative transobturator tape procedure and sling positioning. Moreover, translabial ultrasound could be helpful to determine a "cutoff" of the bladder neck to sling distance, as this is related to the onset of the obstruction.

Factors associated with low-compliance bladder in end-stage renal disease patients and development of a clinical prediction model for urodynamic evaluation: the DUDi score

OBJECTIVES

To investigate factors associated with low-compliance bladders (LCB) in pretransplant patients with end-stage renal disease (ESRD) and develop a clinical prediction model for urodynamic studies.

METHODS

This study was a prospective cohort study. Patients with ESRD on the renal transplantation waiting list were recruited and underwent the urodynamic study. Demographics data, predictor factors related to the bladder compliance such as underlying disease of the lower urinary tract disease (LUTD), duration of urine < 250 mL/day, type and duration of renal replacement therapy (RRT), urine volume per day and urodynamic study information were collected. Univariable and multivariable logistic regression models were used to assess the independence of explanatory factors, then we developed the clinical prediction model.

RESULTS

One hundred fifty-two patients participated in the study: 94 patients in the normal bladder group and 58 patients in LCB group. Demographic data were not significantly different between the two groups, except diabetes. Cystometric capacity, detrusor pressure, compliance were significantly different. From the univariate analysis, DM status, duration of RRT, and passing < 100 mL of urine per day were related to LCB. We named the prediction model, the DUDi score based on the predictors (Duration of RRT, Urine volume/day, Diabetes). Higher scores predicted a higher risk of low-compliance bladder [P value = 0.464 according to the Hosmer-Lemeshow test, and the AUC was 0.87 (95% CI 0.81-0.92)].

CONCLUSIONS

Our clinical prediction model is easy to use and provides a high predictive value that is appropriate for patients who have no known LUTD to identify low-compliance bladder. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: This study was approved by the Thai Clinical Trials Registry Committee on 09 February 2021. The TCTR identification number is TCTR20210209006.

Is Sacral Neuromodulation a Treatment Option for Primary Bladder Neck Obstruction?

Here, we present the first reported case that used sacral neuromodulation as a treatment option for bladder neck obstruction in a 48-year-old man who presented with a long-standing history of lower urinary tract symptoms such as storage and voiding symptoms unresponsive to conservative and medical treatments, including chemodenervation. The patient was diagnosed with primary bladder neck obstruction (PBNO) using a urodynamic study, voiding cystourethrography, and cystoscopy. Sacral neuromodulation was used because the patient refused bladder neck incision because of the risk of retrograde ejaculation. The patient reported significant improvement in symptoms with no obstructive pattern on follow-up uroflowmetry after six months. The use of alpha-blockers, bladder neck incision, and Botox injection into the bladder neck to treat PBNO has been reported. The successful use of sacral neuromodulation to treat PBNO has not been reported before.

Video-urodynamics efficacy of sacral neuromodulation for neurogenic bladder guided by three-dimensional imaging CT and C-arm fluoroscopy: a single-center prospective study

To assess the efficacy of sacral neuromodulation (SNM) for neurogenic bladder (NB), guided by intraoperative three-dimensional imaging of sacral computed tomography (CT) and mobile C-arm fluoroscopy through video-urodynamics examination. We enrolled 52 patients with NB who underwent conservative treatment with poor results between September 2019 and June 2021 and prospectively underwent SNM guided by intraoperative three-dimensional imaging of sacral CT and mobile C-arm fluoroscopy. Video-urodynamics examination, voiding diary, quality of life questionnaire, overactive bladder symptom scale (OABSS) scoring, and bowel dysfunction exam were completed and recorded at baseline, at SNM testing, and at 6-month follow-up phases. Finally, we calculated the conversion rate from period I to period II, as well as the treatment efficiency and the occurrence of adverse events during the testing and follow-up phases. The testing phase of 52 NB patients was 18–60 days, with an average of (29.3 ± 8.0) days. Overall, 38 patients underwent SNM permanent electrode implantation, whose follow-up phase was 3–25 months, with an average of (11.9 ± 6.1) months. Compared with baseline, the voiding times, daily catheterization volume, quality of life score, OABSS score, bowel dysfunction score, maximum detrusor pressure before voiding, and residual urine volume decreased significantly in the testing phase. The daily voiding volume, functional bladder capacity, maximum urine flow rate, bladder compliance, and maximum cystometric capacity increased significantly in the testing phase. Besides, the voiding times, daily catheterization volume, quality of life score, OABSS score, bowel dysfunction score, maximum detrusor pressure before voiding, and residual urine volume decreased further from the testing to follow-up phase. Daily voiding volume, functional bladder capacity, maximum urine flow rate, bladder compliance, and maximum cystometric capacity increased further from testing to follow-up. At baseline, 10 ureteral units had vesicoureteral reflux (VUR), and 9 of them improved in the testing phase. Besides, there was 1 unit that further improved to no reflux during the follow-up phase. At baseline, 10 patients had detrusor overactivity (DO), and 8 of them improved in the testing phase. Besides, 1 patient’s symptoms further improved during the follow-up phase. At baseline, there were 35 patients with detrusor-bladder neck dyssynergia (DBND); 14 (40.0%) of them disappeared during the testing phase. Among 13 cases who had DBND in the testing phase, 6 (46.2%) disappeared during the follow-up phase. Of the 47 patients with detrusor-external sphincter dyssynergia (DESD) at baseline, 8 (17.0%) disappeared during the testing phase. Among 26 cases who had DESD in the testing phase, 6 (23.1%) disappeared during the follow-up phase. The effective rate of this study was 88.5% (46/52), and the conversion rate from phase I to phase II was 73.1% (38/52). Additionally, the efficacy in a short-term follow-up was stable. SNM guided by intraoperative three-dimensional imaging of sacral CT and mobile C-arm fluoroscopy is an effective and safe treatment option for NB in short time follow-up. It would be well improved in the bladder storage function, sphincter synergetic function and emptying efficiency by video-urodynamics examination in this study.

Trial registration: Chinese Clinical Trial Registry. ChiCTR2100050290. Registered August 25 2021. http://www.chictr.org.cn/index.aspx.

Influence of urodynamic conditions on bladder sensations and detrusor activity in patients with multiple sclerosis

AIMS

The study aimed to assess the impact of bladder filling rate and fluid temperature during urodynamics on bladder sensations and volume of apparition of detrusor overactivity in patients with multiple sclerosis (PwMS).

METHODS

Consecutive PwMS assessed with a standardized urodynamic test including three consecutive cystometries (20 ml/min, 100 ml/min, and 100 ml/min with 4°C fluid (Ice water test [IWT]) between June 2020 and March 2022 were included in this retrospective study. Data collected were bladder sensation with first desire to void (FDV) and strong desire to void (SDV). The presence of detrusor overactivity (DO) and the volume of the first uninhibited detrusor contraction were recorded.

RESULTS

One hundred and fifty-seven patients (mean age 47.4 ± 11.8 years, median EDSS 3 IQR[2-5], 73.9% of women) were included. Increased filling rate induced delayed bladder sensations (FDV 219 ± 109 ml vs. 194 ± 100 ml; SDV 349 ± 113 ml vs. 322 ± 124 ml for 100 ml/min and 20 ml/min filling rate, respectively, p < 0.001). Ice water increased bladder sensations with earlier reports of needs to void (FDV 163 ± 99 ml vs. 218 ± 117 ml; SDV 263 ± 104 ml vs. 351 ± 112 ml respectively; p < 0.001). Thirty-four patients had DO during both 20 ml/min and 100 ml/min fillings, without difference in the volume of apparition (p = 0.78). Forty-four patients had DO during both 100 ml/min and IWT. Detrusor overactivity appeared for a reduced volume during IWT compared with room temperature fluid perfusion (-68 ml [-95 to -41]; p < 0.001).

CONCLUSION

Filling rate and fluid temperature impact bladder sensations during cystometry in PwMS. Ice water decreased the volume of the first uninhibited detrusor contraction.

[Is pressure transmission quality during cystometry dependent on the type of effort?]

INTRODUCTION

The International Continence Society (ICS) recommends a control of the good pressure transmission by a coughing effort during cystometry. While poor transmission is sometimes observed in routine practice, other maneuvers can also be proposed. The main objective of this study was to determine if there is a better maneuver to evaluate the pressure transmission ratio between the abdominal cavity and the bladder.

METHODS

We performed a prospective, consecutive, single-center study in a tertiary neuro-urology department in 31 subjects. During a cystometry, each patient was asked to perform at 0ml and 100ml of bladder filling, a cough effort, an abdominal push and a Valsalva maneuver controlled by a manometer. The value of the bladder pressure to abdominal pressure ratio was collected manually. The average variations were compared between each maneuver for the same volume of replenishment and between the 2 volumes of replenishment studied.

RESULTS

At 0ml of filling, the difference in pressure variation between the Pves and the Pabd is significantly higher during the cough maneuver compared to the Valsalva (P=0.015), which is not found at 100ml of filling.

CONCLUSION

During bladder filling, the pressure transmission ratios during the 3 maneuvers are equivalent. Coughing or abdominal thrusting, which are easier to perform than the Valsalva maneuver, should be recommended to check the quality of the recording during cystomanometry.

LEVEL OF EVIDENCE: 4

Urodynamic findings in patients with nocturia and their associations with patient characteristics

INTRODUCTION

This study identified associations between lower urinary tract pathology confirmed on urodynamic testing, baseline characteristics, and symptoms for adults with nocturia. Nocturia frequency was examined for predictors.

METHODS

This retrospective study from 2012-2019 analyzed adult patients with nocturia (waking to void ≥2x/night) referred for urodynamic testing (UDS). Data on baseline characteristics, symptoms, UDS parameters, and lower urinary tract pathology were recorded. Males and females were analyzed separately, and univariable analyses were conducted, stratified by lower urinary tract pathology. Multivariable regression models were fit. Nocturia frequency was analyzed for associations with clinical parameters.

RESULTS

Altogether, 372 patients were included (159 men and 213 women). More men had detrusor overactivity (DO) (p<0.001) and bladder outlet obstruction (BOO) (p<0.001). DO was associated with storage symptoms (odds ratio [OR] 5.19, p<0.001), in addition to older age (p=0.009) and being male (p<0.001). Detrusor under-activity (DU) was associated with voiding symptoms (OR 1.92, p=0.004), older age (p<0.001), and being female (p=0.018). BOO was associated voiding symptoms (OR 2.09, p=0.023), younger age (p=0.018), and being male (p<0.001). The quantity of lower urinary tract symptoms was associated with DU and DO. Nocturia frequency was not associated with baseline variables or underlying pathologies. A substantial number of patients were diagnosed with DU alone (n=69, 18.7%) or associated with other diagnoses (n=108, 29.3%).

CONCLUSIONS

Careful assessment of risk factors and symptoms may help identify underlying lower urinary tract pathology for adults with nocturia. DU is found in a significant proportion of patients with nocturia, a previously under-reported result.

Effectiveness of repetitive transcranial magnetic stimulation against poststroke urinary incontinence: a study protocol for a randomized controlled trial

Background and purpose

Poststroke urinary incontinence (PSI) is prevalent in stroke survivors, and high-quality evidence is required to guide clinical practice. Previous studies have demonstrated the curative effect of repetitive transcranial magnetic stimulation (rTMS) for urinary incontinence in individuals with multiple sclerosis (MS), Parkinson’s disease (PD), and spinal cord injury (SCI). Here, we describe the protocol for a randomized controlled trial to evaluate the efficacy and safety of low-frequency rTMS on the contralesional primary motor cortex (M1) for the treatment of PSI.

Methods and analysis

In this single-centre randomized controlled trial for poststroke urinary incontinence, a total of 140 eligible patients will be randomly allocated into two groups. The rTMS group (n = 70) will receive low-frequency rTMS at the M1 along with routine medical care, while the control group will receive sham rTMS along with routine medical care. All participants will undergo 20 treatment sessions, five times a week for 4 weeks. The primary outcome measures will be the changes in the urodynamic test at baseline versus 4 weeks after intervention. The secondary outcomes include the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), Overactive Bladder Symptom Score (OABSS), and pelvic floor muscle function.

Ethics and dissemination

The Institutional Review Board and Hospital Research Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University approved this trial, and the approval number is No. 2020-153. All methods will be carried out in accordance with the principles of the Declaration of Helsinki and relevant ethical guidelines covering informed consent, confidentiality, and data storage. After the study had been thoroughly described to the participants by a physician, all participants will provide written informed consent indicating their willingness to participate. The results will be disseminated to most of the population, including participants, researchers, healthcare providers, and sponsors.

Trial registration

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2100042688. Date of Registration: 2021-01-26.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06535-y.

[Home uroflowmetry technics and clinical relevance: A narrative review]

INTRODUCTION

Urine flowmetry (UF) is a key non-invasive urodynamic test for the evaluation of the voiding phase in patients with lower urinary tract symptoms (LUTS). Traditional free urodynamic testing (FUT) performed on a one-time basis in the office is limited by difficulty in capturing normal voiding and high intrapatient variability in urine flow parameters. Home measurement of urine flow by the patient could be a way to obtain multiple data in real-life conditions, addressing its limitations. The objective of this article was to review the literature on the different techniques of home uroflowmetry (HUF) and their clinical interest in comparison with FUT.

MATERIAL AND METHODS

A search on the PubMed database using the key words "Urodynamics, Uroflowmetry, non-invasive urodynamics, Ambulatory urodynamics, bladder outlet obstruction, male LUTS" was performed to find articles in English or French that had been published with no time limit and March 2022. The sorting by reading the abstract allowed the selection of all articles describing and/or evaluating a HUF technique that were read entirely according to the same collection grid to propose a narrative synthesis.

RESULTS

Thirty-one articles were identified, selected, and analyzed. Simple and inexpensive techniques by timing or use of funnels reliably and reproducibly estimate the average and maximum urine flow in relation to the FUT, without providing a complete flow curve. More sophisticated electronic or sonometric methods, some using connected mobile applications, present results that are more consistent with ICS recommendations for flow measurement. With the possibility of studying the average of several values of the maximum urinary flow (Qmax) captured during micturition in physiological conditions, some studies suggest a gain in diagnostic value in the evaluation of the emptying phase and lower urinary tract symptoms in men. However, the literature is sparse, old and the clinical benefits are not yet proven.

CONCLUSION

There is a wide range of techniques for measuring urine flow in the patient's home, all of which aim to fill the gaps in conventional urine flow measurement. Further studies are needed to demonstrate the acceptability of this type of measurement by patients, the existence of a real clinical benefit, to assess the cost/benefit balance and finally to define a possible place for home uroflowmetry in daily practice, compared with traditional free flowmetry and invasive urodynamics (pressure-flow test).

Sacral neuromodulation for neurological disease-induced lower urinary tract symptoms in Saudi Arabia: a single-centre experience

Objective

To evaluate the effectiveness of sacral neuromodulation therapy (SNM) for lower urinary tract symptoms (LUTS) caused by neurological diseases.

Methods

This prospective cohort study enrolled patients that developed LUTS secondary to neurological disorders. All patients underwent staged SNM. A 5-day voiding diary was used to evaluate their response to the stage 1 procedure. Implantation of the full system during the stage 2 procedure was undertaken in patients that had ≥50% improvement on their voiding diary.

Results

Twenty-one patients were included in the study with the following neurological aetiologies: diabetes mellitus (n = 2), myelitis (n = 3), multiple sclerosis (n = 5), spinal cord injury (n = 10) and cerebrovascular accident (n = 1). Fifteen patients underwent the stage 1 procedure successfully; their mean age was 47.5 years and the mean follow-up was 29 months. SNM resulted in significantly increased voided volume/void/day, decreased leaking episodes/day, decreased postvoiding residual/day and decreased number of clean intermittent catheterization/day compared with baseline. Five patients were highly satisfied, nine were moderately satisfied and one patient was not satisfied with the therapy.

Conclusion

SNM was an effective therapy for LUTS caused by neurological disease and there was a high rate of patient satisfaction.

COMPARATIVE STUDY BETWEEN BLADDER DIARY AND URODYNAMIC STUDY TO IDENTIFY LOWER URINARY TRACT SYMPTOMS

Objective: To identify the similarity of lower urinary tract symptoms presented in the urodynamic study compared to the urinary diary. Method: This is a comparative study carried out in an urodynamics clinic in southern Santa Catarina, Brazil, with 44 patients who underwent the examination. Data collection was carried out by applying a questionnaire and a 72-hour bladder diary and comparing it with the findings of the urodynamic study using the SPSS for Windows and Stata/SE v.14.1 programs. Results: The bladder diary showed high specificity, sensitivity, and accuracy for identifying detrusor hyperactivity and stress urinary incontinence. There was no difference for bladder capacity (p* 0.198). It pointed to bladder sensitivity with a volume smaller than that presented by the urodynamic study (p*<0.001). It was able to identify lower urinary tract symptoms that were not present in the urodynamic study. Conclusion: The bladder diary was effective for identifying lower urinary tract symptoms and can be used to define first-line treatment with a broader range of population diagnosis, shorter time between complaints and treatment, cost reduction for the system, and less discomfort for the patient.

ESTUDO COMPARATIVO ENTRE DIÁRIO VESICAL E ESTUDO URODINÂMICO PARA IDENTIFICAÇÃO DE SINTOMAS DO TRATO URINÁRIO INFERIOR

Objetivo:Avaliar a efetividade do diário vesical para identificar sintomas do trato urinário inferior, em comparação ao estudo urodinâmico. Método: Trata-se de estudo observacional de corte transversal realizado em uma clínica de urodinâmica do sul catarinense com 44 pacientes submetidos ao exame. A coleta de dados deu-se por aplicação de questionário de dados epidemiológicos e de sintomas e diário vesical de 72 horas e comparação deste com os achados do estudo urodinâmico por meio do programa Stata/SE v.14.1. Resultados: O diário vesical apresentou alta especificidade, sensibilidade e acurácia para identificação de hiperatividade detrusora e incontinência urinária de esforço. Não apresentou diferença para capacidade vesical (p* 0,198) e apontou sensibilidade vesical com volume menor do que o apresentado pelo estudo urodinâmico (p*<0,001). Foi capaz de identificar sintomas de trato urinário inferior que não haviam se revelado no estudo urodinâmico. Conclusão: O diário vesical mostrou-se tão efetivo quanto o estudo urodinâmico para identificação de sintomas de trato urinário inferior, podendo ser utilizado para definição de tratamento de primeira linha com maior abrangência de diagnóstico populacional, menor tempo entre queixa e tratamento, redução de custo para o sistema e menor desconforto para o paciente.

Use of Urodynamics by Gynecologists and Urologists in Brazil

OBJECTIVE

 Urodynamic studies (UDSs) are a set of tests that assess the storage and emptying of urine, and they are widely used by gynecologists and urologists in the management of urinary incontinence (UI), despite the discussion about its indications. The objectives of the present study were to verify whether UDSs are routinely used in the conservative and surgical approaches to female UI, their other clinical indications, and to compare the responses of Brazilian gynecologists and urologists.

METHODS

 The present is an opinion survey applied from August 2020 to January 2021 through a semistructured questionnaire about the clinical practice sent by e-mail to all participants. The responses were compared through statistical analyses.

RESULTS

 Of the 329 participants, 238 were gynecologists (72.3%) and 91, urologists (27.7%). Most gynecologists (73.5%) and urologists (86.6%) do not request UDSs before the conservative treatment of UI; but UDSs are indicated in the preoperative period of anti-incontinence surgeries. Most participants request UDSs in the initial approach to overactive bladder (gynecologists: 88.2%; urologists: 96.7%), and the urologist has greater chance to request this study (odds ratio [OR] = 3.9). For most participants, it is necessary to request uroculture before the UDSs.

CONCLUSION

 Most Brazilian gynecologists and urologists who participated in the present study do not request UDSs before the conservative treatment of UI, according to national and internacional guidelines, and often request it before the surgical treatment for female UI. The indication of this exam in the initial approach of idiopathic overactive bladder should be reviewed by the participants.

Prostate resection weight matters in severely obstructed men undergoing transurethral resection of the prostate

OBJECTIVES

Transurethral resection of the prostate (TURP) remains one of the goldstandard surgical treatments for benign prostatic hyperplasia/lower urinary tract symptoms. The usefulness of a complete adenoma resection is questionable, with studies reporting no impact of the amount of resected tissue on surgical outcomes, irrespective of prostate volume. The aim of this study was to assess whether in less obstructed patients a less extensive TURP may be considered.

MATERIALS AND METHODS

Retrospective analysis of 185 men undergoing TURP in one university hospital. Retrieved data included pre-operative prostate volume and Qmax, as well as resected prostate weight and post-operative Qmax. Patients were divided in two groups according to pre-operative Qmax < 10mL/s and ≥ 10 mL/s.

RESULTS

A correlation was found between absolute resected prostate weight and post-operative Qmax in the group of patients with pre-operative Qmax < 10 mL/s (r2 = 0.038, p = 0.032), independently of the pre-operative prostate volume. This association was neither observed in the group of patients with pre-operative Qmax ≥ 10 mL/s (r2 = -0.033, p = 0.796) nor in whole population analysis (r2 = 0.019, p = 0.064). Likewise, in the group of patients with pre-operative Qmax < 10 mL/s, the improvement in Qmax was correlated with absolute resected weight and percentage of prostate resected weight (r2 = 0.036, p = 0.037 and r2 = 0.040, p = 0.029, respectively). None of these correlations was found in the group of patients with pre-operative Qmax ≥ 10 mL/s (r2 = 0.009, p = 0.463 and r2 = -0.018, p = 0.294, respectively).

CONCLUSIONS

Patients with pre-operative Qmax ≥ 10 mL/s may do well with less profound prostate resections, whereas patients with lower pre-operative Qmax seem to benefit from a complete adenoma resection.

Technique, outcome and changes in prostate dimensions in patients with urinary retention managed by aquablation

Purpose

This study aimed to investigate the functional and urodynamic outcome of Aquablation in patients with acute urinary retention (AUR) on catheters.

Methods

Men aged 50–70 who failed medical treatment of BPO with AUR failing to wean off urethral catheter were recruited to undergo Aquablation. Individuals were assessed pre-operatively and at 3 and 6 months after surgery. The primary outcome was defined by the success rate of weaning off catheter. Secondary outcomes were measured by a change in prostate size, symptom scores and urodynamic parameters.

Results

Twenty patients underwent Aquablation between June 2019 and September 2020. Mean duration of the urethral catheter in-situ was 5.9 ± 4.9 weeks and mean prostate size of the cohort pre-operatively was 60.8 ± 15.8 cc. A second pass Aqaublation treatment was performed in 14 patients. Five patients failed to wean off the catheter on the first attempt after surgery, requiring another attempt 1 week later which were all successful. At 3 months after the operation, a significant reduction in prostate volume was observed (60.8 ± 15.8 cc vs 24.9 ± 10.3 cc, p < 0.001). No change in international index of erectile function (IIEF) was found (baseline: 16.1 ± 5.8; 3-month: 14.9 ± 6.4; p = 0.953). Mean bladder outlet obstruction index was 14.2 ± 23.0 at 6 months upon urodynamic assessment with 75% of patients had a resolution of detrusor overactivity. Reduction in prostate length was found to be more significant than a reduction in width and height after Aquablation (R = 0.693, p = 0.039).

Conclusion

From the early data of a single centre, Aquablation was shown to provide a consistent improvement in symptoms, uroflowmetry and urodynamic parameters in patient with a urethral catheter. Results from our study suggest that improvement from Aquablation is reproducible in patients with AUR.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11255-022-03244-y.

Safe urodynamic practices in times of COVID-19: What can be accomplished and what can be added?

AIM

To present feedback, after applying national and international urodynamic study (UDS) recommendations for safe practice during the COVID-19 pandemic.

METHODS

We created a checklist to assess the feasibility of performing UDS recommendations for safe practice during the COVID-19 pandemic from the first week of May 2021 to the last week of July 2021.

RESULTS

One hundred patients were analyzed during the study period. We observed that all preventive recommendations for the steps that precede UDS could be followed in full. However, some guidelines for performing the exam were not feasible in all patients. We have successfully adopted other safety measures for all patients.

CONCLUSIONS

The COVID-19 pandemic will likely persist for several more years. We believe that continuous improvement, revision, and updating of existing protocols and guidelines for the safe practice of UDS in times of COVID-19, as we propose in this study, should be encouraged.

Significance of a decrease in the proportion of detrusor muscle to bladder wall for non-invasive diagnosis of detrusor underactivity in men with lower urinary tract symptoms

To investigate the significance of detrusor muscle thickness (DMT) to bladder wall thickness (BWT) ratio as a detrusor-sarcopenia and a consistently applicable factor for noninvasive diagnosis of detrusor underactivity (DU). We prospectively performed a urodynamic study of 100 male with medical refractory lower-urinary-tract-symptoms during 2017–2019. The DMT, BWT and DMT/BWT ratio were measured by ultrasonography every 50 mL during bladder filling, and were analyzed for non-invasive diagnosis of DU and prediction of prostate surgery outcome with questionnaire and the maximum-flow-rate. Of the 94 patients, DU was urodynamically diagnosed in 24 (25.5%). The DMT/BWT ratio was maintained in all patients until the 50% of the maximum cystometric capacity (MCC), and then rapidly decreased. At 20% of the MCC, the DMT/BWT ratio was significantly lower in the DU group (44.0 ± 4.9% vs. 49.4 ± 6.7%, p = 0.008). The DMT/BWT ratio of less than 47.5% at 20% of the MCC showed the ideal accuracy for diagnosing DU (AUC = 0.763), and was a predictor of failure at 12 months after prostate surgery (OR 8.78, p = 0.024). A DMT/BWT ratio of less than 47.5% at 20% of the MCC is a consistently applicable factor for non-invasive diagnosis of DU and could also be considered detrusor-sarcopenia.

The safety cutoff storage pressure for preventing upper urinary tract damage in neurogenic bladder from spinal cord pathology and risk factor analysis

INTRODUCTION

Low-compliance bladder or high bladder pressure undoubtedly leads to hydronephrosis and renal impairment. As four decades have elapsed since a previous study found a detrusor leak-point pressure (DLPP) >40 cm H₂ O to result in hydronephrosis, we suspected the possibility of hydronephrosis or vesicoureteral reflux occurring at any point below the 40 cm H₂ O DLPP reference. Therefore, this study aimed to determine the storage detrusor pressure value and risk factors related to upper urinary tract damage (UUTD).

MATERIALS AND METHODS

This study retrospectively reviewed the hospital records of 110 patients who visited the Neurogenic Bladder TU Service of Excellence Unit, Thammasat University Hospital, Pathum Thani, Thailand, and were diagnosed with neurogenic bladder between 2016 and 2020. The inclusion criteria were as follows: patients who were diagnosed with neurogenic bladder from spinal cord problems (spinal dysraphism, spinal cord disease [tumor, degenerative, arteriovenous malformation, etc.], or traumatic spinal cord injury) and underwent a complete examination, including urodynamic study and renal ultrasound. The exclusion criteria were as follows: patients who had previous pelvic irradiation, other concomitant neurological disease (stroke, Parkinson's disease, etc.), or other urological diseases (stone, tumor, etc.), and those who had an indwelling suprapubic or urethral catheter. We identified the cutoff point for storage pressure related to UUTD using receiver operating characteristic (ROC) curve analysis to identify the value that produced maximum sensitivity and specificity. To identify risk factors for developing UUTD, we included seven risk factors: intravesical pressure, poor compliance, detrusor overactivity (DO), detrusor sphincter dyssynergia (DSD), level of the spinal cord pathology, male sex, and spontaneous voiding in univariable and multivariable regression analyses.

RESULTS

Of the 110 patients who met the inclusion criteria, 22 were excluded from the study. Fifty-nine patients had a normal upper urinary tract, and 29 had UUTD. The mean age, sex, voiding pattern, type of spinal cord pathology, and level of spinal cord lesions were not different between the two groups. After performing ROC curve analysis, a cutoff value for daily storage pressure ≥15 cm H₂ O provided 79.31% sensitivity and 67.80% specificity (area under the ROC curve: 0.73) for UUTD development. From univariable analysis, low compliance (cutoff values at <12.5 and <20 ml/cm H₂ O) and a storage pressure ≥15 cm H₂ O was related to UUTD with statistical significance (risk ratio [RR]: 3.16, 2.3, and 3.6, respectively [p < 0.05]). After performing multivariable analysis, a storage pressure ≥15 cm H₂ O and both cutoff values for low compliance were related to UUTD with statistical significance (RR: 3.9, 2.4, and 3.2, respectively [p < 0.05]). However, other factors, including male sex, spontaneous voiding, suprasacral lesion, DSD, and DO, were not related to UUTD.

CONCLUSION

Our results demonstrated that low compliance and a storage pressure ≥15 cm H₂ O were significantly associated with UUTD. Various bladder-management strategies have been developed to prevent UUTDs. However, the main concept continues to be the maintenance of a low storage pressure.

Pad test for urinary incontinence diagnosis in adults: Systematic review of diagnostic test accuracy

INTRODUCTION

The pad test is an assessment tool for urinary incontinence (UI) severity classification and therapeutic response monitoring. However, the reliability and reproducibility of this test have been questioned.

OBJECTIVES

To summarize the evidence regarding the accuracy measures and reproducibility of different pad test protocols for assessing UI.

METHODS

A systematic review of the diagnostic accuracy of this tool was performed (CRD42020219392). Eligibility criteria: Studies reporting data on the accuracy measures and reproducibility of the pad test when used for detecting UI in adult men and women.

DATA SOURCES

MEDLINE, Science Direct, Cochrane, Web of Science, LILACS, and Pedro.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened the articles, extracted the data, and evaluated the risk of bias (RoB) using the QUADAS-2 tool.

RESULTS

From 1048 studies, 18 studies were included. Eight of these reported accuracy data, and 12 reported reproducibility properties. A total of 1070 individuals were analyzed, whose mean age ranged from 20 to 90 years. The accuracy of the long-duration protocols was generally moderate to high (sensitivity, 60%-93%; specificity, 60%-84%). The 1-h protocols obtained higher accuracy values. The overall reproducibility was moderate to high (κ ≥ 0.66).

LIMITATIONS

The RoB was high and, due to different cutoff points adopted by studies, the bivariate model was not satisfied to perform a meta-analysis.

DISCUSSION

The 1-h pad test was more accurate but less reproducible when compared to the long-duration tests. Pad test results should be used with caution in clinical practice.

Bristol UTraQ: A proposed system for scoring the technical quality of urodynamic traces

AIM

To develop and test a scoring system for the technical quality of a urodynamic trace METHODS: Rasch analysis was used to select the most discriminating questions relating to good urodynamic practices. The questions were taken from International Continence Society standard documents and tested on 60 traces of varying quality and from different sources.

RESULTS

Twenty-five questions were selected by this process. These were tested with 10 traces by seven scorers, and with 60 traces by a single scorer. A pass quality score of 75% resulted in good discrimination between good and poor traces. Further editing and clarification resulted in a final score sheet of 23 Yes/No questions.

CONCLUSION

A proposed scoring system, "Bristol UTraQ," for the technical quality of urodynamic traces has been developed and tested. We suggest a score above 75% indicates acceptable trace technical quality. High technical quality is the essential first step in ensuring that urodynamic studies can answer the urodynamic questions for every patient. Plans for further validation are outlined.

Detrusor overactivity assessment using ultrasound bladder vibrometry

Objective. Detrusor overactivity (DO) is a urodynamic observation characterized by fluctuations in detrusor pressure (Pdet) of the bladder. Although detecting DO is important for the management of bladder symptoms, the invasive nature of urodynamic studies (UDS) makes it a source of discomfort and morbidity for patients. Ultrasound bladder vibrometry (UBV) could provide a direct and noninvasive means of detecting DO, due to its sensitivity to changes in elasticity and load in the bladder wall. In this study, we investigated the feasibility and applying UBV toward detecting DO.Approach. UBV and urodynamic study (UDS) measurements were collected in 76 neurogenic bladder patients (23 with DO). Timestamped group velocity squared (cg2) data series were collected from UBV measurements. ConcurrentPdetdata series were identically analyzed for comparison and validation. A processing approach is developed to separate transient fluctuations in the data series from the larger trend of the data and a DO index is proposed for characterizing the transient peaks observed in the data.Main Results.Applying the DO index as a classifier for DO produced sensitivities and specificities of 0.70 and 0.75 forcg2data series and 0.70 and 0.83 forPdetdata series respectively.Significance. It was found that DO can be feasibly detected from data series of timestamped UBV measurements. Collectively, these initial results are promising, and further refinement to the UBV measurement process is likely to improve and clarify its capabilities for noninvasive detection of DO.

Diagnosis and Non-Surgical Management of Urinary Incontinence - A Literature Review with Recommendations for Practice

Urinary incontinence (UI) is a bothersome symptom with population studies suggesting a prevalence of 13.1% in women and 5.4% in men. While a significant cohort of patients with this complaint may ultimately require surgical management to achieve complete continence, a number of non-surgical measures exist to improve symptoms and quality of life. A range of guidelines exist on this topic, including those published by the European Association of Urology (EAU), the International Continence Society (ICS), the American Urological Association (AUA) and the UK's National Institute for Health and Care Excellence (NICE). The aim of our study is to provide an overview of the initial assessment of patients with UI including history taking, examination and basic investigations. Our review outlines non-surgical management strategies for UI, including conservative measures, behavioral and physical therapies and drug treatment. We shall also examine the above guidelines and present a narrative overview of the literature surrounding the diagnosis and non-surgical management of urinary incontinence.

Mobile sonouroflowmetry using voiding sound and volume

Uroflowmetry (UF) is a common clinic-based non-invasive test to diagnose Lower Urinary Tract Dysfunction (LUTD). Accurate home-based uroflowmetry methods are needed to conveniently conduct repeated uroflowmetries when patients are physiologically ready to urinate. To this end, we propose and evaluate a novel mobile sonouroflowmetry (SUF) method that estimates the urinary flow rate from a sound signal recorded using a mobile phone. By linearly mapping the total sound energy to the total voided volume, the sound energy curve is transformed to a flow rate curve allowing the estimation of the flow rate over time. An evaluation using data from 44 healthy young men showed high similarity between the UF and SUF flow rates with a mixed-effects model correlation coefficient of 0.993 and a mean root mean square error of 2.37 ml/s. Maximum flow rates were estimated with an average absolute error of 2.41 ml/s. Future work on mobile uroflowmetry can use these results as an initial benchmark for flow rate estimation accuracy.

Relationship between the types of urinary incontinence, handgrip strength, and pelvic floor muscle strength in adult women

AIM

To investigate the relationship between handgrip strength with types of urinary incontinence (UI) and pelvic floor muscle strength (PFMS) in women.

METHODS

Ninety-two women, who presented to the geriatric and urology outpatient clinics complaining of UI between July 2019 and February 2020 and had indicated to undergo urodynamic assessment after basic neurourological evaluation, were included in this cross-sectional study. The presence and types of UI were identified by clinical examination and urodynamic studies. Demographic parameters, anthropometric data, comorbidities and medications were recorded. The International Consultation on Incontinence Questionnaire-Short Form was applied. Handgrip strength (HGS) was measured by a hand dynamometer. The PFMS was subjectively assessed via vaginal digital palpation and measured quantitatively by the vaginal probe of the perineometer.

RESULTS

Thirty-eight urodynamic stress, 28 detrusor overactivity, 26 urodynamic mixed UI patients were reported. Perineometer measurements were significantly lower in the urodynamic stress UI group compared to the other two groups (p = 0.020). There was no relationship between the types of urinary incontinence and HGS. However, a positive correlation was found between PFMS and HGS (p = 0.045, r = 0.298).

CONCLUSION

The positive correlation between HGS and PFMS indicates that low HGS may be a marker for PFMS weakness. Furthermore, the association between sarcopenia and UI may be explained by this condition.

Correlation Between Nitric Oxide and Urodynamics in Men With Bladder Outlet Obstruction

Purpose

To investigate the correlation between nitric oxide (NO) and urodynamics in men with bladder outlet obstruction (BOO) by analyzing nitric oxide synthase (NOS) in the urothelium.

Methods

We prospectively enrolled 25 men who planned to undergo surgical treatment for benign prostatic obstruction and identified as BOO in the preoperative urodynamics. Bladder tissue was taken during surgical prostate resection. Expressions of endothelial NOS (eNOS), inducible NOS (iNOS), and neuronal NOS (nNOS) in the urothelium were analyzed, and their correlation with urodynamic parameters was also assessed in all patients. We also compared the expressions of eNOS, iNOS, and nNOS between BOO with detrusor underactivity (DU) group and BOO without DU group.

Results

In all patients, the level of eNOS positively correlated with maximal flow rate and with maximum cystometric capacity (MCC). The level of iNOS positively correlated with MCC. nNOS levels were positively correlated with detrusor pressure at maximal flow and with bladder contractility index in all patients. The level of eNOS, iNOS, and nNOS did not significantly differ between BOO without DU group and BOO with DU group.

Conclusions

This study suggests that NO was correlated with bladder dysfunction in men with BOO. Particularly, nNOS may reflect the change in detrusor function.

Metformin ameliorates bladder dysfunction in a rat model of partial bladder outlet obstruction

Alteration of bladder morphology and function was the most important consequence of bladder outlet obstruction (BOO). Using a rat model of partial BOO (pBOO), we found that rats treated with metformin showed lower baseline pressures with a reduced inflammatory reaction in the early phase (2 wk) after pBOO. The NLR family pyrin domain containing 3 inflammasome pathway was inhibited in pBOO rat bladders with treatment of metformin in the early phase. Metformin reduced the activity of NLR family pyrin domain containing 3 in primary urothelial cells. In the chronic phase (9 wk after pBOO), metformin treatment ameliorated bladder fibrosis and improved the reduced compliance. Treatment with metformin suppressed the activation of Smad3 and compensated the diminished autophagy in 9-wk pBOO rat bladders. Autophagy was inhibited with upregulation of profibrotic proteins in primary fibroblasts from chronic pBOO bladders, which could be restored by administration of metformin. The antifibrotic effects of metformin on fibroblasts were diminished after silencing of AMP-activated protein kinase or light chain 3B. In summary, this study elucidates that oral administration of metformin relieves inflammation in the bladder during the early phase of pBOO. Long-term oral administration of metformin can prevent functional and histological changes in the pBOO rat bladder. The current study suggests that metformin might be used to prevent the development of bladder dysfunction secondary to BOO.NEW & NOTEWORTHY The present study in a rat model showed that oral administration of metformin alleviated inflammation following partial bladder outlet obstruction in the early phase and ameliorated bladder fibrosis as well as bladder dysfunction by long-term treatment. Our study indicated that metformin is a potential drug to inhibit bladder remodeling and alleviate bladder dysfunction. Clinical trials are needed to validate the effect of metformin on the bladder dysfunction and bladder fibrosis in the future.

False-negative finding in urodynamic study for the chief complaint. Does it interfere with the clinical outcomes for the treatment of SUI or OAB syndromes?

Purpose:

False-negative urodynamic findings may mislead or prevent planned treatments due to unmatched findings with the clinical presentation. We hypothesized that the absence of urodynamic demonstration of SUI or OAB on urodynamics would interfere with clinical outcomes.

Materials and Methods:

Materials and Methods: We prospectively studied 124 women with (94) or without (30) demonstrable SUI after sling operations. Similarly, 64 women with OAB syndrome with (38) or without (26) demonstrable DO were also compared after treatment with anticholinergic agents. Patients were assessed with the UDI-6 and IIQ-7 questionnaires 3 and 6 months after treatment.

Results:

Only 76% of SUI patients demonstrated urine leakage during urodynamics. The UDI-6 score was higher in the demonstrable-SUI and demonstrable-DO groups, while the IIQ-7 score was comparable within the incontinence or urgency/frequency groups. Demonstrable and non-demonstrable SUI-operated patients showed similar outcomes. Patients with urgency syndromes with or without demonstrable DO had a similar rate of improvement with anticholinergic therapy.

Conclusions:

Women with clinical complaints of SUI objectively demonstrated on urodynamics presented the same subjective clinical outcome as those with SUI lacking objective demonstration when measured by the UDI-6 and IIQ-7 questionnaires. Similarly, patients with OAB syndrome with or without demonstrable DO had similar clinical improvement when treated with anticholinergics and measured using the same questionnaires.

Computational Tools for the Investigation of the Male Lower Urinary Tract Functionality in Health and Disease

Purpose

This paper aims to show the potentialities of computational bioengineering in the field of lower urinary tract pathophysiology. Engineering methods allow the investigation of urine flow in healthy and pathologic conditions and the analysis of urethral occlusion by means of artificial urinary sphincters.

Methods

Computational models of bladder and urethra were developed and exploited to investigate the lower urinary tract physiology in health and in disease. Average male morphometric configurations were assumed, together with typical properties of both biological tissues and fluids. The reliability of the models was assessed by the mutual comparison of results and the investigation of data from experimental and clinical activities.

Results

The developed models allowed to analyze typical situations, such as the micturition in health and in disease, and the lumen occlusion by external devices. The models provided information that clinical and experimental tests barely provide, as the occurrence of turbulent phenomena within urine flow, the shear stresses at the lumen wall, the external pressure that is strictly required to occlude the lumen.

Conclusions

The methods of bioengineering allow broadening and deepening the knowledge of the lower urinary tract functionality. More in detail, modeling techniques provide information that contributes to explain the occurrence of pathological situations, and allows to design and to optimize clinical-surgical procedures and devices.

Is Nocturia Associated With Detrusor Underactivity?

OBJECTIVES

Detrusor underactivity (DU) is diagnosed using urodynamic testing. We hypothesized that nocturia is associated with detrusor underactivity.

METHODS

We performed a retrospective chart review of all women who underwent urodynamic testing at our institution between 2016 and 2018. Uroflowmetry and pressure-flow study parameters were compared between women with nocturia (≥2 voids/night) and without nocturia (0-1 void/night). Detrusor underactivity was diagnosed using 3 different criteria: (1) bladder voiding efficiency (BVE) of <90%, (2) bladder contractility index of <100, and (3) a composite of three urodynamic measures (Gammie criteria).

RESULTS

Of 358 women, 172 (48%) were in the nocturia group and 186 (52%) were in the no nocturia group. On uroflowmetry, median postvoid residual volume was similar (20 mL) in both groups. Median maximum flow rate (15 vs 17 mL/s, P < 0.05) and average flow rate (6 mL/s vs 7 mL/s, P < 0.05) were significantly lower in the nocturia group compared with the no nocturia group. During pressure-flow study, a significantly greater proportion of women with nocturia were unable to void around the catheter (30% vs 27%, P < 0.01). The overall rate of DU varied with the criteria used: BVE (54%), bladder contractility index (41%), and Gammie criteria (7%). The rate of DU using the BVE criteria was significantly higher in the nocturia group (63% vs 48%, P < 0.01), but no significant differences were noted using the other criteria.

CONCLUSIONS

Nocturia is associated with reduced voiding efficiency in women. The diagnosis of DU using urodynamics is challenging.

A retrospective review of the long term clinical outcomes of patients with neurogenic lower urinary tract dysfunction following transverse myelitis

AIMS

Transverse myelitis (TM) is an inflammation of the spinal cord which causes neurological deficit in motor, sensory, and autonomic pathways. Persistent neurogenic lower urinary tract dysfunction (NLUTD) is common even where motor and sensory impairment is recovered. Long term follow-up is required to ensure optimal bladder management and protection of the upper tracts. We describe the clinical outcomes for a cohort of patients with TM who have received neurourological follow-up in a specialist center.

METHODS

A retrospective review of TM patient records was performed. Current pharmaceutical and surgical management, upper tract status, and patient reported symptoms are reported. Changes in urodynamic parameters and bladder emptying technique between current and baseline were analyzed.

RESULTS

Sixty patients with NLUTD following TM were identified. The mean age at onset of NLUTD was 29 years (0-77 years). The mean follow-up was 13 years. 55% of patients were taking antimuscarinic medication, 53% of patients had intradetrusor botulinum toxin injections and 5% had bladder augmentation surgery. Forty-one patients had a baseline and recent urodynamic study which could be compared. Fifty-three of fifty-eight patients with a recent renal ultrasound had normal renal appearance. Four had mild hydronephrosis and one more extensive hydronephrosis.

CONCLUSION

TM can have a persistent effect on lower urinary tract function. There is potential for upper tract damage if bladder management is not optimized. We have demonstrated that in a specialist neurourology unit within a tertiary center, one can provide acceptable long term outcomes following international guidelines.

[Urodynamics: All the nurse needs to know]

Urodynamic (UD) is an exam intended to explore the mechanisms underlying lower urinary tract symptoms (LUTS) or urinary incontinence (UI). It involves the measurement of bladder and sphincter pressures using uretrovesical and rectal catheters with pressure transducers, but also the measurement of urinary flow and bladder sensation during filling. UD is far from being systematic in the assessment of LUTS or UI and must seek to tackle a specific clinical or therapeutic question. Thus, history taking, physical examination, voiding diary and questionnaires are essential prerequisites to UD per se. UD steps include a free (unintubated) uroflowmetry, a cystometry, post-void residual measurement±an urethral profilometry, a pressure-flow study or sensitization tests. The pressures are set to zero before to start the study and the validity of the equipment is tested. This control is continued throughout the procedure to ensure the quality of the recording. Any event (e.g., urine leakage, change of position, urgency) is noted during the study. A final report is made by the doctor. The competence of the nurse ensures the reliability, reproducibility and interpretability of the UD study and the nurse's humanity guarantee f an atmosphere as favourable as possible for this uncomfortable and invasive test.

Urodynamic assessment of bladder storage function after radical hysterectomy for cervical cancer

BACKGROUND

After radical hysterectomy for cervical cancer, the most common complication is lower urinary tract symptoms. Post-operatively, bladder capacity can alter bladder function for a prolonged period. This study aimed to identify factors affecting bladder storage function.

METHODS

A multicenter, retrospective cohort study was conducted. Information of patients with stages IA2 to IIB cervical cancer with urodynamic study results were retrospectively collected from nine hospitals between June 2013 and June 2018 according to the inclusion criteria. Demographic, surgical, and oncological data were collected. The univariate and multivariate logistic regression was used to identify clinical factors associated with bladder storage function.

RESULTS

Two hundred and three patients with cervical cancer had urodynamic testing post-operatively. Ninety-five (46.8%) patients were diagnosed with stress urinary incontinence (SUI). The incidence of low bladder compliance (LBC) was 23.2%. Twenty-seven (13.3%) patients showed detrusor overactivity (DO). Fifty-seven patients (28.1%) presented with a decreased maximum cystometric capacity (DMCC). The probability of composite bladder storage dysfunction was 68.0%. Multivariate analysis confirmed that laparoscopy represents a protective factor for SUI with an odds ratio of 0.498 (P = 0.034). Patients who underwent a nerve-sparing procedure were less odds to experience SUI (P = 0.014). A significant positive correlation between LBC and DO was observed (P < 0.001). A greater length of the resected vagina and chemoradiotherapy were common risk factors for LBC and DO, while radiotherapy exerted a stronger effect than chemotherapy. Additionally, patients who received chemoradiotherapy frequently developed a DMCC. The follow-up time was not correlated with bladder storage function.

CONCLUSION

A nerve-sparing procedure without longer resected vagina is recommended for protecting the bladder storage function.