Lower Urinary Tract Symptoms in a prospective cohort of COVID-19 survivors

PURPOSE

To analyze the prevalence of lower urinary tract symptoms (LUTS) in patients who survived moderate and severe forms of COVID-19 and the risk factors for LUTS six months after hospitalization.

MATERIALS AND METHODS

In this prospective cohort study, patients were evaluated six months after hospitalization due to COVID-19. LUTS were assessed using the International Prostate Symptom Score. General health was assessed through the Hospital Anxiety and Depression Scale and the EQ5D-L5 scale, which evaluates mobility, ability to perform daily activities, pain and discomfort and completed a self-perception health evaluation.

RESULTS

Of 255 participants, 54.1% were men and the median age was 57.3 [44.3 - 66.6] years. Pre-existing comorbidities included diabetes (35.7%), hypertension (54.5%), obesity (30.2%) and physical inactivity (65.5%). One hundred and twenty-four patients (48.6%) had a hospital stay >15 days, 181 (71.0%) were admitted to an ICU and 124 (48.6%) needed mechanical ventilation. Median IPSS was 6 [3-11] and did not differ between genders. Moderate to severe LUTS affected 108 (42.4%) patients (40.6% men and 44.4% women; p=0.610). Nocturia (58.4%) and frequency (45.9%) were the most prevalent symptoms and urgency was the only symptom that affected men (29.0%) and women (44.4%) differently (p=0.013). LUTS impacted the quality of life of 60 (23.5%) patients with women more severely affected (p=0.004). Diabetes, hypertension, and self-perception of worse general health were associated with LUTS.

CONCLUSIONS

LUTS are highly prevalent and bothersome six months after hospitalization due to COVID-19. Assessment of LUTS may help ensure appropriate diagnosis and treatment in these patients.

Conformity of ChatGPT recommendations with the AUA/SUFU guideline on postprostatectomy urinary incontinence

INTRODUCTION

Artificial intelligence (AI) shows immense potential in medicine and Chat generative pretrained transformer (ChatGPT) has been used for different purposes in the field. However, it may not match the complexity and nuance of certain medical scenarios. This study evaluates the accuracy of ChatGPT 3.5 and 4 in providing recommendations regarding the management of postprostatectomy urinary incontinence (PPUI), considering The Incontinence After Prostate Treatment: AUA/SUFU Guideline as the best practice benchmark.

MATERIALS AND METHODS

A set of questions based on the AUA/SUFU Guideline was prepared. Queries included 10 conceptual questions and 10 case-based questions. All questions were open and entered into the ChatGPT with a recommendation to limit the answer to 200 words, for greater objectivity. Responses were graded as correct (1 point); partially correct (0.5 point), or incorrect (0 point). Performances of versions 3.5 and 4 of ChatGPT were analyzed overall and separately for the conceptual and the case-based questions.

RESULTS

ChatGPT 3.5 scored 11.5 out of 20 points (57.5% accuracy), while ChatGPT 4 scored 18 (90.0%; p = 0.031). In the conceptual questions, ChatGPT 3.5 provided accurate answers to six questions along with one partially correct response and three incorrect answers, with a final score of 6.5. In contrast, ChatGPT 4 provided correct answers to eight questions and partially correct answers to two questions, scoring 9.0. In the case-based questions, ChatGPT 3.5 scored 5.0, while ChatGPT 4 scored 9.0. The domains where ChatGPT performed worst were evaluation, treatment options, surgical complications, and special situations.

CONCLUSION

ChatGPT 4 demonstrated superior performance compared to ChatGPT 3.5 in providing recommendations for the management of PPUI, using the AUA/SUFU Guideline as a benchmark. Continuous monitoring is essential for evaluating the development and precision of AI-generated medical information.

The landscape of biomedical research funding in Brazil: a current overview

OBJECTIVE

The objective of this narrative review is to discuss the current state of research funding in Brazil.

MATERIALS AND METHODS

This study is based on the most recent edition of the course Funding for Research and Innovation in the University of Sao Paulo School of Medicine which was a three-day course with 12 hours of instruction. The course brought together leading experts in the field to comprehensively discuss the current state of research funding in Brazil. Each speaker provided a presentation on a specific topic related to research funding. After the workshop, speakers assembled relevant topics in this manuscript.

RESULTS

collaborative research is critical for securing research funding. It optimizes proposal competitiveness, amplifies societal impact, and manages risks effectively. As such, fostering and supporting these collaborations is paramount for both researchers and funding agencies. To maintain the highest integrity in research, investigators involved in these collaborations must disclose any relationships that could potentially influence the outcomes or interpretation of their projects.

CONCLUSIONS

In Brazil, the mainstay of research funding stems from public entities, with agencies such as CNPq, CAPES, and state bodies like FAPESP, FAPERJ, FAPEMIG and others at the forefront. Concurrently, industry funding offers viable pathways, especially through industry-sponsored studies, investigator-led projects, and collaborative initiatives. The Brazilian funding landscape is further enriched by innovative platforms, including crowdfunding and the contributions of institutions like the Serrapilheira Institute. Internationally, esteemed organizations such as the National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation stand out as potential funders.

Long-term efficacy of complete trigonal electrofulguration for women with recurrent urinary tract infections

INTRODUCTION AND OBJECTIVE

Recurrent urinary tract infections (R-UTIs) have a negative impact on quality of life and contribute to antimicrobial resistance. Long-term antibiotic therapy is the main treatment alternative but, in some cases, this approach may not be accepted by the patient, is ineffective or poorly tolerated. In selected women, electrofulguration (EF) of trigonal lesions has been shown to reduce urinary tract infection (UTI) episodes.

METHODS

Between August 2006 and December 2017, 73 women with R-UTI had their data collected prospectively and analyzed. We evaluated the rate of UTIs during the initial 2 years of follow-up after fulguration based on symptoms and a positive urine culture. All patients failed with multiple antibiotic courses and were offered endoscopic electrofulguration of the entire trigonal and bladder neck mucosa with a rollerball probe. We present our long-term results using a strategy of complete fulguration of the trigone in women with R-UTIs.

RESULTS

The median age was 64 years (range: 17-76 years) and the median follow-up time after EF was 4.2 years (range: 2.5-14 years). Overall, 70 patients (96%) remained free of UTI episodes during the first year of follow-up, at 2 years of follow-up, 57, 53% remained infection-free. Currently, UTIs are typically sparse, mild, and caused by multisensitive bacteria.

CONCLUSIONS

Complete trigonal and bladder neck mucosal fulguration promoted a significant reduction of UTI episodes during the first 2 years of follow-up. Prospective controlled studies are needed to determine the role of EF in women with R-UTI.

Current pharmacotherapy of overactive bladder

Overactive bladder is a symptom complex consisting of bothersome storage urinary symptoms that is highly prevalent among both sexes and has a significant impact on quality of life. Various antimuscarinic agents and the beta-3 agonists mirabegron and vibegron are currently available for the treatment of OAB. Each drug has specific pharmacologic properties, dosing schedule and tolerability profile, making it essential to individualize the medical treatment for the patient's characteristics and expectations. In this manuscript, we review the most important factors involved in the contemporary pharmacological treatment of OAB.

Compensated hypogonadism in men with sickle cell disease

OBJECTIVE

To evaluate the prevalence of hypogonadism in a population of men with SCD and characterize its aetiology. Sickle cell disease (SCD) is associated with the development of hypogonadism, but there is still controversy regarding its aetiology and clinical implications.

METHODS

We performed a cross-sectional study of 34 men with SCD aged > 18 years. Sociodemographic and clinical data, including anthropometric measurements (weight, height and BMI), were obtained. Early morning, blood samples were collected and total testosterone (TT), free testosterone (FT), luteinizing hormone (LH), follicle stimulating hormone (FSH), a complete blood count and haemoglobin electrophoresis were measured. Eugonadism was defined as T ≥300 ng/dL and LH ≤9.4 mUI/mL; primary hypogonadism as T < 300 ng/dL and LH > 9.4 mUI/mL; secondary hypogonadism as T < 300 ng/dL and LH ≤ 9.4 mUI/mL; and compensated hypogonadism as T ≥ 300 ng/dL and LH > 9.4 mUI/mL.

RESULTS

Median age was 33 (26-41) years, and SS genotype was the most frequent (73.5%). The prevalence of eugonadism, compensated hypogonadism and secondary hypogonadism was 67.5%, 26.4% and 5.88%, respectively. No men with primary hypogonadism were identified in our sample. Those with compensated hypogonadism had also higher FSH levels (>7.8 mUI/mL, P < .0001).

CONCLUSION

In our study population of men with SCD, a high prevalence of compensated hypogonadism was identified, which is a controversial and distinct clinical entity that warrants monitoring and further research.

Impact of COVID-19 on education, health and lifestyle behaviour of Brazilian urology residents

Objectives:

To evaluate the impact of COVID-19 on clinical and surgical practice, educational activities, health and lifestyle behavior of Brazilian urology residents.

Materials and Methods:

A web-based survey was sent to 468 Brazilian urology residents from postgraduate years (PGY) 3 to 5 to collect data on clinical practice and training after 4 months of COVID-19. We also assessed health-related and behavior changes, rate of infection by SARS-CoV-2, deployment to the front line of COVID-19, residents’ concerns, and access to personal protective equipment (PPE).

Results:

Massive reductions in elective and emergency patient consultations, diagnostic procedures and surgeries were reported across the country, affecting PGY 3 to 5 alike. Most in-person educational activities were abolished. The median damage to the urological training expected for 2020 was 6.0 [3.4 – 7.7], on a scale from 0 to 10, with senior residents estimating a greater damage (P< 0.001). Educational interventions developed included online case-based discussions, subspeciality conferences and lectures, and grand rounds. Most senior residents favored extending residency to compensate for training loss and most younger residents favored no additional training (p< 0.001). Modifications in health and lifestyle included weight gain (43.8%), reduced physical activity (68.6%), increased alcoholic intake (44.9%) and cigarette consumption (53.6%), worsening of sexual life (25.2%) and feelings of sadness or depression (48,2%). Almost half were summoned to work on the COVID-19 front-line and 24.4% had COVID-19. Most residents had inadequate training to deal with COVID-19 patients and most reported a shortage of PPE. Residents’ concerns included the risk of contaminating family members, being away from residency program, developing severe COVID-19 and overloading colleagues.

Conclusions:

COVID-19 had a massive impact in Brazilian urology residents´ training, health and lifestyle behavior, which may reflect what happened in other medical specialties. Studies should confirm these findings to help developing strategies to mitigate residents’ losses.

Severe urinary tract damage secondary to primary bladder neck obstruction in women

Objective

To present the clinical and radiological characteristics of women with severe structural deterioration of the bladder and upper urinary tract secondary to Primary Bladder Neck Obstruction (PBNO), and their outcomes after bladder neck incision (BNI).

Methods

Retrospective evaluation of adult women who underwent BNI for PBNO at one institution. Patients were assessed for symptoms, renal function, structural abnormalities of the urinary tract and video-urodynamics. PBNO diagnosis was confirmed with video-urodynamics in all patients. BNI was performed at the 4–5 and/or 7–8 o’clock positions. Postoperative symptoms, PVR, uroflowmetry and renal function were evaluated and compared to baseline.

Results

Median patient age was 56.5 years (range 40–80). All presented with urinary retention–four were on clean intermittent Catheterization (CIC) and two with a Foley catheter. All patients had bladder wall thickening and diverticula. Four women had elevated creatinine levels, bilateral hydronephrosis was present in five (83.3%). After BNI, all patients resumed spontaneous voiding without the need for CIC. Median Qmax significantly improved from 2.0 [1.0–4.0] mL/s to 15 [10–22.7] mL/s (p = 0.031). Median PVR decreased from 150 to 46 [22–76] mL (p = 0.031). There were no postoperative complications. Creatinine levels returned to normal in 3/4 (75%) patients.

Conclusion

PBNO in women may result in severe damage to the bladder and upper urinary tract. Despite severe structural abnormalities of the bladder, BNI was effective in reducing symptoms and improving structural and functional abnormalities of the lower and upper urinary tract.

Impact of a 1-day urodynamic course on knowledge, perceptions, and attitudes of urology residents

AIMS

No evidence-informed educational curriculum is available for designing urodynamics (UDS) courses. We evaluated the learning outcomes of a short-lasting urodynamic course for urology residents.

METHODS

Urology residents of postgraduate years 4 and 5 (n = 13 and n = 1316, respectively) attended a 1-day urodynamic course. Learning objectives included patient preparation, indication and technique, terminology, trace interpretation, and impact on patient management. Instructional methods consisted of short lectures (3 h) and case-based discussions (7.5 h). Learners' reactions, modifications of perceptions and attitudes, and acquisition of knowledge and skills were assessed by three written tests with a single group, pretest, posttest 1, and posttest 2 design. Tests were conducted precourse, 1 week after, and 4 months after the course.

RESULTS

All participants felt more confident in several urodynamic competencies after the course, including patient preparation, urodynamic indication and technique, terminology, trace interpretation, and impact for patient management. These perceptions remained unchanged after 4 months. Most became stricter in the indication of UDS, including 20 (87.0%) at posttest 1 and 8 (66.7%) at posttest 2. The mean number of correct answers in the knowledge evaluation was 52.2% versus 61.4% versus 56.7%, respectively at pretest, posttest 1, and posttest 2; p = 0.535). All participants rated the course as very useful or useful in both posttest evaluations.

CONCLUSIONS

Our study demonstrates that a 1-day urodynamic course can promote lasting improvements in self-reported perceptions, attitudes, and urodynamic-related competencies of urology residents. Further studies using evidence-informed educational principles are needed to determine the effect of specific educational interventions on urodynamic competencies in different contexts.

Impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists

OBJECTIVES

To evaluate the impact of COVID-19 on clinical practice, income, health and lifestyle behavior of Brazilian urologists during the month of April 2020.

MATERIALS AND METHODS

A 39-question, web-based survey was sent to all urologist members of the Brazilian Society of Urology. We assessed socio-demographic, professional, health and behavior parameters. The primary goal was to evaluate changes in urologists' clinical practice and income after two months of COVID-19. We also looked at geographical differences based on the incidence rates of COVID-19 in different states.

RESULTS

Among 766 urologists who completed the survey, a reduction ≥ 50% of patient visits, elective and emergency surgeries was reported by 83.2%, 89.6% and 54.8%, respectively. An income reduction of ≥ 50% was reported by 54.3%. Measures to reduce costs were implemented by most. Video consultations were performed by 38.7%. Modifications in health and lifestyle included weight gain (32.9%), reduced physical activity (60.0%), increased alcoholic intake (39.9%) and reduced sexual activity (34.9%). Finally, 13.5% of Brazilian urologists were infected with SARS-CoV-2 and about one third required hospitalization. Urologists from the highest COVID-19 incidence states were at a higher risk to have a reduction of patient visits and non-essential surgeries (OR=2.95, 95% CI 1.86 - 4.75; p< 0.0001) and of being infected with SARS-CoV-2 (OR=4.36 95%CI 1.74-10.54, p=0.012).

CONCLUSIONS

COVID-19 produced massive disturbances in Brazilian urologists' practice, with major reductions in patient visits and surgical procedures. Distressing consequences were also observed on physicians' income, health and personal lives. These findings are probably applicable to other medical specialties.

Transcultural adaptation and validation of the questionnaire "Urgency, Weak stream, Incomplete emptying and Nocturia (UWIN)" for the Brazilian Portuguese

Lower urinary tract symptoms (LUTS) are common complaints in the adult male population and have a negative affect in the quality of life and represent an economic burden for the healthcare system worldwide. The International Prostatism Symptom Score (IPSS) is a validated tool for assessing these symptoms, but patients with low literacy may have difficulties comprehending and completing it accurately. The Urgency, Weak Stream, Incomplete Emptying, and Nocturia (UWIN) questionnaire was developed as a shorter tool in the assessment of LUTS to improve accuracy and minimize error. This study aimed at performing cross-cultural adaptation to Brazilian Portuguese and validation of UWIN questionnaire for patients with LUTS. The cross-cultural adaptation followed the steps of conceptual, item, semantic, operational, and pre-test equivalence to obtain the UWIN-Br version. The IPSS (gold standard) and UWIN-Br were coadministered, and information regarding the uroflowmetry examination was also recorded. We evaluated 306 men, median age 59 [52-66] years. There was a positive correlation r = 0.804 (p < 0.001) between the total IPSS score and the total UWIN-Br score, as well as the quality of life question (r = 0.761) (p < 0.001). The Bland-Altman plot showed good agreement between. Also, we observed that the maximum flow values decreased with the severity of the LUTS. UWIN-Br demonstrated excellent diagnostic accuracy in detecting the most severe cases. The area under the ROC curve was 89% [81–97%] 95% CI. 280 (91.5%) subjects completed the questionnaires without help, while 26 (8.5%) did so through an interview. The response time was 1.2 [1.0–1.5] min for UWIN-Br and 2.8 [2.2–3.4] min for IPSS (p < 0.001). UWIN-Br presents satisfactory and similar psychometric properties to the IPSS in the evaluation of LUTS and quality of life and is suitable for use in both clinical practice and research in our country.

Management of Patients with Overactive Bladder in Brazil: A Retrospective Observational Study Using Data From the Brazilian Public Health System

INTRODUCTION

In Brazil, current data on the use of healthcare resources to manage individuals with overactive bladder (OAB) are lacking. This study aimed to characterize contemporary treatment and the economic burden among patients with OAB managed under the Brazilian public health system (Sistema Único de Saúde [SUS]).

METHODS

Population-based data from January to December of 2015 were acquired from Brazil's public health database. Adults at least 18 years of age with an ICD-10 diagnostic code for OAB within the period were included. Records of outpatient visits, hospitalizations, and onabotulinumtoxinA injections were used to calculate estimates of resource use and costs (in Brazilian reals [R$]) among those with OAB (frequency [%] and mean (standard deviation [SD]) as appropriate). Patient identifiers were not available, so a record linkage methodology was used to match medical encounters to individuals. Pharmacologic management of OAB was informed by government medication purchases available from the official Brazilian government databases.

RESULTS

During 2015, 26,640 patients with OAB were identified. All cohort members had at least one outpatient visit and 15,349 (57.6%) were hospitalized. Of the study cohort, 10.0% visited a general practitioner (GP), 41.3% visited a specialist, and 52.0% visited other non-medical healthcare practitioners within the year. Mean (SD) healthcare costs among the study cohort totaled R$355 (R$866) per patient per year; and were R$291 (R$654), R$27 (R$130), R$27 (R$30), and R$11 (R$17) for hospitalizations, GP, specialist, and non-medical healthcare practitioner visits per patient per year, respectively. Regional analysis of reported government medication purchases suggested that access to OAB treatments is highly limited.

CONCLUSIONS

High resource use and costs were estimated among patients with OAB managed within the SUS. These data provide a snapshot of the management of patients with OAB in Brazil, with the patients seeking treatment under SUS likely representing a more burdened subpopulation.

The creation and validation of a short form of the Neurogenic Bladder Symptom Score

AIM

To develop a short form (SF) of the 24-item Neurogenic Bladder Symptom Score (NBSS).

METHODS

We used three previously published datasets. First, we selected the most responsive questions within each of the domains. Internal validity of the NBSS-SF was assessed using Cronbach's α. External validity was assessed by evaluating hypothesized relationships with other questionnaires and testing correlations with the full NBSS domains. Test-retest reliability of the NBSS-SF domains was determined using an intraclass coefficient (ICC).

RESULTS

Using data from a prior responsiveness study, we selected questions for the NBSS-SF from the incontinence domain (three), storage/voiding domain (three), consequences domain (two); these would make up the NBSS-SF. We used the original NBSS validation cohort of 230 patients with multiple sclerosis (MS), spinal cord injury (SCI), or spina bifida, and found the Cronbach's α was .76 for the NBSS-SF; the external validity was high, with correlations between specific NBSS-SF domains/total scores and the Qualiveen-SF, ICIQ, and AUASS generally similar to those seen with the NBSS. Correlations between the NBSS-SF domains and the full NBSS domains were high. The NBSS-SF ICC in a subset of 120 patients was 0.84. The NBSS-SF performed similarly in two additional independent datasets.

CONCLUSIONS

The total score of the NBSS-SF has appropriate validity, reliability, and could be used instead of the full NBSS to minimize the assessment burden. The full NBSS may be better suited if the primary focus of the study is on neurogenic bladder symptoms, or if individual NBSS domains are of interest.

Diagnostic accuracy of tests for leprosy: a systematic review and meta-analysis

OBJECTIVES

Owing to difficulties in the clinical diagnosis of leprosy, several complementary tests have been developed and used. The aim was to systematically summarize the accuracy of diagnostic tests for leprosy.

METHODS

We searched for relevant articles in Embase, Medline, and Global Health databases, until June 2017. Studies evaluating the accuracy of any diagnostic techniques for differentiating between people with and without leprosy were included. Studies solely focusing on differentiating between the separate forms of leprosy were excluded. Our protocol was registered on PROSPERO (CRD42017071803). We assessed study quality using the QUADAS-2 checklist. A bivariate random effects regression model was used for the meta-analyses.

RESULTS

We included 78 studies, most of those evaluating the detection of IgM antibodies against phenolic glycolipid I using ELISA. Sensitivity of the 39 studies evaluating ELISA was 63.8% (95% CI 55.0-71.8); specificity 91.0% (95% CI 86.9-93.9). The lateral flow test (nine studies) and the agglutination test (five studies) had a slightly higher sensitivity and a slightly lower specificity. Sensitivity of qPCR was (five studies) 78.5% (95% CI 61.9-89.2) and specificity 89.3% (95% CI 61.4-97.8). Sensitivity of conventional PCR was (17 studies) 75.3% (95% CI 67.9-81.5) and specificity 94.5% (95% CI 91.4-96.5).

CONCLUSIONS

Although the test accuracy looks reasonable, the studies suffered from heterogeneity and low methodological quality.

Impact of LUTS on treatment-related behaviors and quality of life: A population-based study in Brazil

AIMS

To report on the impact of lower urinary tract symptoms (LUTS) on treatment-related behaviors and quality of life in Brazilian adults greater than or equal to 40 years.

METHODS

Data were from a computer-assisted telephone survey conducted in Brazil between 1 September and 31 December 2015 (Brazil LUTS study). Participants were adults greater than or equal to 40 years with landlines living in major cities from five geographical regions in Brazil. Participants rated how often they experienced individual LUTS during the previous month and associated bother, and the impact on quality of life (QoL), treatment seeking, treatment, treatment satisfaction, and treatment discontinuation. Multiple logistic regression models were adjusted to analyze the simultaneous effects of predictor variables on each dependent variable.

RESULTS

When the presence of LUTS was defined as symptoms occurring less than half the time or more, one-quarter of respondents sought treatment but 6% fewer actually received treatment. Of these, around 25% reported dissatisfaction with treatment and almost 10% reported treatment discontinuation. The occurrence of some symptoms and, in particular, the resultant bother were significantly related to worse QoL and to treatment-related outcomes, such as treatment seeking, actual treatment, treatment dissatisfaction, and treatment discontinuation. Symptoms of all three categories were associated with all these domains for both sexes.

CONCLUSIONS

This is the first population-based study carried out in South America showing that treatment seeking and treatment rates for LUTS are low. Since the LUTS prevalence is high, this reinforces the importance of a comprehensive medical assessment, focusing on the resulting bother, for more appropriate and personalized patient management.

NF-κB and GATA-Binding Factor 6 Repress Transcription of Caveolins in Bladder Smooth Muscle Hypertrophy

Caveolins (CAVs) are structural proteins of caveolae that function as signaling platforms to regulate smooth muscle contraction. Loss of CAV protein expression is associated with impaired contraction in obstruction-induced bladder smooth muscle (BSM) hypertrophy. In this study, microarray analysis of bladder RNA revealed down-regulation of CAV1, CAV2, and CAV3 gene transcription in BSM from models of obstructive bladder disease in mice and humans. We identified and characterized regulatory regions responsible for CAV1, CAV2, and CAV3 gene expression in mice with obstruction-induced BSM hypertrophy, and in men with benign prostatic hyperplasia. DNA affinity chromatography and chromatin immunoprecipitation assays revealed a greater increase in binding of GATA-binding factor 6 (GATA-6) and NF-κB to their cognate binding motifs on CAV1, CAV2, and CAV3 promoters in obstructed BSM relative to that observed in control BSM. Knockout of NF-κB subunits, shRNA-mediated knockdown of GATA-6, or pharmacologic inhibition of GATA-6 and NF-κB in BSM increased CAV1, CAV2, and CAV3 transcription and promoter activity. Conversely, overexpression of GATA-6 decreased CAV2 and CAV3 transcription and promoter activity. Collectively, these data provide new insight into the mechanisms by which CAV gene expression is repressed in hypertrophied BSM in obstructive bladder disease.

Diagnostic accuracy of Onen's Alternative Grading System combined with Doppler evaluation of ureteral jets as an alternative in the diagnosis of obstructive hydronephrosis in children

Introduction

Ureteropelvic junction obstruction (UPJO) is a common congenital anomaly leading to varying degrees of hydronephrosis (HN), ranging from no apparent effect on the renal function to atrophy. Evaluation of these children is based on Diuretic Renal Scintigraphy (DRS) and Ultrasonography (US). Recent studies have suggested that new parameters of conventional and color Doppler ultrasonography (CDUS) may be useful in discriminating which kidneys are obstructed. The present study aims to assess the diagnostic accuracy of such parameters in the diagnosis of obstruction in children with UPJO.

Methods

We evaluated 44 patients (33 boys) with a mean age of 6.53 ± 4.39 years diagnosed with unilateral high-grade hydronephrosis (SFU grades 3 and 4). All underwent DRS and index tests (conventional US and CDUS to evaluate ureteral jets frequency) within a maximum interval of two weeks. Hydronephrotic units were reclassified according to the alternative grading system (AGS) proposed by Onen et al. Obstruction in the DRS was defined as a differential renal function <40% on the affected side and/or features indicating poor drainage function like T1/2 >20 minutes after the administration of furosemide, and a plateau or ascending pattern of the excretion curve.

Results

Nineteen hydronephrotic units (43.1%) were obstructed. Some degree of cortical atrophy—grades 3 (segmental) or 4 (diffuse)—was present in those obstructed units. AGS grades had 100% sensitivity, 76% of specificity and 86.4% of accuracy. The absence of ureteral jets had a sensitivity of 73.68%, a specificity of 100% with an accuracy of 88.6%. When we analyzed the two aspects together and considered obstructed the renal units classified as AGS grade 3 or 4 with no jets, sensitivity increased to 78.9%, accuracy to 92%, remaining with a maximum specificity of 100%. These features combined would allow us to avoid performing DRS in 61% of our patients, leaving more invasive tests to inconclusive cases.

Conclusions

Although DRS remains the mainstay to distinguishing obstructive from non-obstructive kidneys, grade of hydronephrosis and frequency of ureteral jets, independently or in combination may be a reliable alternative in the mostly cases.This alternative approach has high accuracy, it is less invasive, easily reproducible and may play a role in the diagnosis of obstruction in pediatric population.

Accuracy of qPCR for quantifying Leishmania kDNA in different skin layers of patients with American tegumentary leishmaniasis

OBJECTIVES

Superficial swab sampling of American tegumentary leishmaniasis (ATL) lesions shows higher amounts of Leishmania than those from biopsy. Subcutaneous involvement is also important in ATL, but parasite quantification according to lesion depth has not been evaluated. We aim to present the best depth at which sampling should be performed for molecular exams of ATL.

METHODS

Patients with a clinical presentation compatible with ATL were allocated to ATL and control groups. Qualitative and quantitative qPCR assays were performed using SYBR Green and primers amplifying the kDNA minicircle of Leishmania spp. in different skin layers, including the epidermis, the superior dermis, the inferior dermis, and the hypodermis.

RESULTS

Fifty-nine patients were included in this study, including 40 who had been diagnosed with ATL and 19 controls. The number of parasites was greater in samples of the epidermis and superior dermis (159.1 × 10⁶, range 4.0-781.7, and 75.4 × 10⁶, range 8.0-244.5, mean Leishmania parasite equivalents per μg of tissue DNA, respectively) than those in samples of the inferior dermis and hypodermis (54.6, range 8.0-256.6, and 16.8 × 10⁶, range 8.0-24.1, mean Leishmania parasite equivalents per μg of tissue DNA, respectively). The best diagnostic accuracy was achieved in the superior dermis (77.9%) and was significantly greater than that in the hypodermis (63.3%; p 0.039).

CONCLUSIONS

We conclude that superficial sampling can retrieve a greater quantity of parasites. Future studies of the role of transepidermal elimination as a mechanism of host defence in ATL must be performed as there is a considerable quantity of Leishmania kDNA in the epidermis.

Erectile Function Predicts Sexual Satisfaction in Men With Spinal Cord Injury

INTRODUCTION

Spinal cord injury (SCI) is usually a sudden traumatic event and has a negative effect on sexual function.

AIM

To evaluate the characteristics of sexual activity in men with SCI and identify predictors of being sexually active and having a satisfactory sex life.

METHODS

We assessed sexual activity profiles of men with SCI from a Brazilian tertiary rehabilitation center from February to August 2012. All patients older than 18 years with SCI for longer than 1 year were invited to participate. We analyzed age, time since SCI, patient age at SCI, employment status, partner status, completeness of lesion, functional independence, urinary continence, and Sexual Health Inventory for Men (SHIM) score.

MAIN OUTCOME MEASURES

The SHIM was used to assess erectile function (EF). Satisfaction with sex life was analyzed as a dichotomous variable. Predictors of an active and satisfactory sex life were identified using univariable and multivariable analyses.

RESULTS

We evaluated 295 men with mean age of 40.7 ± 14.5 years. Most patients had a complete SCI (65.1%) and 159 (53.9%) were incontinent. The median SHIM score was 5 (interquartile range = 0-16) and only 71 men (24.1%) had a SHIM score of at least 17. Of these men, 159 (53.9%) were sexually active. Only 63 men (39.6%) were satisfied with their sex life after SCI. In univariable analysis, all variables were associated with an active sex life. Those with a SHIM score of at least 17 had a greater likelihood of being sexually active (odds ratio = 116, 95% confidence interval = 14-432). EF was the only parameter associated with a satisfactory sex life (odds ratio = 1.3, 95% confidence interval = 1.2-1.4).

CONCLUSIONS

Most men with SCI were sexually inactive and/or dissatisfied with their sex life. Age, duration of SCI, completeness of SCI, continence, having a partner, and good EF were identified as predictors of an active sex life. However, only EF was a predictor of a satisfactory sex life. Gomes CM, Miranda EP, de Bessa J, et al. Erectile Function Predicts Sexual Satisfaction in Men With Spinal Cord Injury. Sex Med 2017;5:e148-e155.

Lower urinary tract symptoms in children and adolescents with Williams-Beuren syndrome

INTRODUCTION

Williams-Beuren syndrome (WBS) is a genetic condition caused by a microscopic deletion in the chromosome band 7q11.23. Individuals with WBS may present with congenital cardiovascular defects, neurodevelopmental disturbances and structural abnormalities of the urinary tract. Lower urinary tract symptoms (LUTS) seem to be frequent in this population, but studies on this topic are scarce and based on small case series.

OBJECTIVE

To systematically evaluate the prevalence of lower urinary tract symptoms (LUTS) and the acquisition of bladder control in a large population with WBS.

STUDY DESIGN

A cross-sectional study evaluating 87 consecutive patients with WBS; there were 41 girls and 46 boys. Genetic studies confirmed WBS in all patients. Subjects were clinically evaluated with: a history of LUTS obtained from the parents and child, a structured questionnaire of LUTS, a 3-day urinary frequency-volume chart, a quality of life question regarding LUTS, and physical examination. A history regarding the acquisition of bladder control was directly evaluated from the parents.

RESULTS

Mean age of patients was 9.0 ± 4.2 years, ranging from 3 to 19 years. Based on the symptoms questionnaire and the frequency-volume chart, 70 patients (80.5%) were symptomatic. The most common symptom was urgency, affecting 61 (70.1%) patients, followed by increased urinary frequency in 60 (68.9%) patients, and urge-incontinence in 53 (60.9%), as shown in Summary Fig. More than half of the children reported nocturnal enuresis, including 61% of the girls and 52% of the boys. Twenty-three patients (25.6%) had a history of urinary tract infections. The mean age for acquisition of dryness during the day was 4.4 ± 1.9 years. Parents of 61 patients (70.1%) acknowledged that LUTS had a significant impact on the quality of life of their children.

DISCUSSION

A high prevalence of LUTS was confirmed with a significant negative impact on quality of life in a large population of children and adolescents with WBS. It was shown for the first time that the achievement of daytime bladder control is delayed in children with WBS. Although LUTS are not recognized as one of the leading features of the syndrome, it is believed that it should be considered as a significant characteristic of the clinical diagnosis of WBS.

CONCLUSIONS

LUTS are highly prevalent in children and adolescents with WBS and have a significant negative impact on patient's quality of life.

Congenital genitourinary abnormalities in children with Williams-Beuren syndrome

OBJECTIVE

Williams-Beuren syndrome (WBS) is an autosomal dominant disorder caused by a gene deletion on chromosome 7q11.23. Patients with WBS usually show a group of features such as developmental delay, cardiovascular anomalies, mental retardation, and characteristic facial appearance. Abdominal wall defects, external genitalia anomalies, and structural abnormalities of the urinary tract have been scarcely evaluated and were the focus of our study.

MATERIALS AND METHODS

We prospectively evaluated 41 boys and 38 girls with WBS, with a mean age of 8.8 ± 4.1 (range 3-19 years). All patients were examined for the evaluation of inguinal and umbilical hernias and genital anomalies. All patients were offered a radiological evaluation, including urinary tract ultrasound, voiding cystourethrogram, and dimercaptosuccinic acid renal scintigraphy (DMSA scan).

RESULTS

Of the 41 boys, 30 (73.1%) had abnormalities on physical examination, including bilateral undescended testis in 13 (31.7%), retractile testis in four (9.7%), hypospadias in four (9.7%), and unilateral cryptorchidism in three (7.3%) patients. Of the 38 female subjects, 17 (44.7%) had at least one abnormality, including umbilical hernia in 11 (28.9%), unilateral inguinal hernia in four (10.5%), and bilateral inguinal hernia in three (7.8%) patients. Uroradiological abnormalities were found in 41 patients (51.9%). On sonography, six (7.6%) patients had unilateral hydronephrosis, three (3.8%) had a duplicated collecting system, and two (2.5%) had kidney stones. On DMSA, performed in 36 patients, four (11.1%) had unilateral renal scarring and two (5.5%) had bilateral renal scarring. Cystourethrography was obtained from 56 patients, of whom 27 (48.2%) had bladder diverticulum, 18 (32.1%) had bladder wall trabeculation, and three (5.3%) had vesicoureteral reflux. We found no association of urological abnormalities with cardiovascular defects.

CONCLUSIONS

Patients with WBS have a high prevalence of abdominal wall, external genitalia, and urological abnormalities, emphasizing the importance of proper physical examination and radiological investigation in this population.

Leishmania braziliensis amastigotes stimulate production of IL-1β, IL-6, IL-10 and TGF-β by peripheral blood mononuclear cells from nonendemic area healthy residents

Leishmania (Viannia) braziliensis causes cutaneous and mucosal leishmaniasis in several countries in Latin America. In mammals, the parasites live as amastigotes, interacting with host immune cells and stimulating cytokine production that will drive the type of the specific immune responses. Generation of Th17 lymphocytes is associated with tissue destruction and depends on IL-1β, IL-6, TGF-β and IL-23 production, whereas IL-10 and TGF-β are associated with tissue protection. Here, we evaluate whether amastigotes stimulate peripheral blood mononuclear cells (PBMCs) from healthy donors to produce the major cytokines responsible for the generation of Th17. Seven L. (V.) braziliensis isolates from patients with different clinical forms of leishmaniasis were expanded in interferon-γ knockout mice to obtain amastigotes and in culture to get promastigotes. The parasites were used to stimulate PBMCs from healthy donors, and cytokine production was evaluated by ELISA or qPCR. Amastigotes and promastigotes induced IL-10 production in PBMCs; however, only amastigotes induced IL-1β, IL-6 and TGF-β. These data demonstrate for the first time that L. (V.) braziliensis amastigotes directly stimulate production of a unique pattern of cytokines that could contribute to the generation of Th17.

The influence of treatment on the development of leishmaniasis recidiva cutis: a 17-year case-control study in Midwestern Brazil

BACKGROUND

The recurrence of American cutaneous leishmaniasis (ACL) in patients experiencing a long-term cure is often called leishmaniasis recidiva cutis (LRC). LRC is considered an unusual form of ACL.

OBJECTIVE

This study aims to estimate the incidence of LRC in ACL patients evaluated at a tertiary dermatologic centre in Midwestern Brazil. We also aim to evaluate the association between various treatment regimens and the development of LRC using multivariate analysis in a case-control study.

METHODS

We performed a 17-year epidemiological study using data from patients treated at our dermatologic centre from July 1994 to December 2011. A retrospective analysis was then performed to estimate risk and protective factors related to clinical presentation. We also assessed the influence of treatment regimens in the development of LRC.

RESULTS

The incidence of LRC among ACL patients was 1.34%. The analysis included 105 patients; 82 patients (78%) were in the control group, and 23 patients (22%) were in the LRC case group. The data analysis indicated that the standard treatment N-methylglucamine antimoniate (N-MA) reduced the development of LRC in bivariate (odds ratio (OR) = 0.34; 95% CI = 0.13-0.91) and multivariate analyses (OR = 0.16; 95% CI = 0.03-0.86; P = 0.03). However, no differences in LRC incidence were observed when the standard treatment N-MA and alternative drugs, such as pentamidine and amphotericin B, were considered (OR = 0.47; 95% CI = 0.16-1.35) CONCLUSION: We conclude that the standard treatment N-MA, as proposed by the Brazilian Ministry of Health, is effective in the prevention of LRC. Although other drugs have shown promising results in LRC, more scientific evidence is needed to assess their efficacy compared with N-MA.

Simultaneous Upper and Lower Urinary Tract Obstruction Associated with Severe Genital Prolapse: Diagnosis and Evaluation with Magnetic Resonance Imaging

Genital prolapse causing both urethral and ureteral obstruction is an infrequent occurrence, especially in the absence of uterine prolapse. We report on a patient with massive genital prolapse causing both urethral and ureteral obstruction in whom magnetic resonance imaging demonstrated the level of obstructive uropathy and, after surgical repair of the prolapse, confirmed restoration of the normal pelvic and upper urinary tract anatomy.

Neurological status predicts response to alpha-blockers in men with voiding dysfunction and Parkinson's disease

OBJECTIVES

To evaluate predictors of the response to doxazosin, a selective alpha-adrenoceptor antagonist, when used for the treatment of lower urinary tract symptoms in men with Parkinson's disease.

METHODS

In a prospective study, 33 consecutive men (mean age 59.2 ± 7.0 years) with Parkinson's disease and lower urinary tract symptoms were evaluated. Neurological dysfunction was assessed with the Unified Parkinson's Disease Rating Scale. Urological assessment was performed at baseline and after 12 weeks of treatment with 4 mg/day of extended-release doxazosin, including symptom evaluation with the International Continence Society male short-form questionnaire, an assessment of the impact of lower urinary tract symptoms on quality of life and urodynamics. Clinical and urodynamic predictors of response were specifically evaluated.

RESULTS

Compared with the score at baseline, the total International Continence Society male short-form score was reduced after doxazosin administration, from 17.4 ± 7.5 to 11.1 ± 6.9 (p<0.001). The impact of lower urinary tract symptoms on quality of life was also significantly reduced, from 1.8 ± 1.1 to 1.0 ± 1.0 (p<0.001) and the maximum urinary flow varied from 9.3 ± 4.4 to 11.2 ± 4.6 ml/s (p=0.025). The severity of neurological impairment was the only predictor of the clinical response. Additionally, patients with a Unified Parkinson's Disease Rating Scale score lower than 70 had a significantly higher chance of clinical improvement with doxazosin treatment than those with higher Unified Parkinson's Disease Rating Scale scores did (RR=3.10, 95% CI=[1.15 to 5.37], p=0.011).

CONCLUSIONS

Doxazosin resulted in the improvement of lower urinary tract symptoms and the maximum flow rate and was well tolerated in men with Parkinson's disease. The response to treatment is dependent on the severity of neurological disability.

Early postoperative pelvic-floor biofeedback improves erectile function in men undergoing radical prostatectomy: a prospective, randomized, controlled trial

Erectile dysfunction (ED) and urinary incontinence are common complications following radical prostatectomy (RP). Although pelvic-floor biofeedback training (PFBT) may improve urinary continence following RP, its effects on the recovery of potency are unknown. Fifty-two patients selected for RP were prospectively randomized for a treatment group (n=26) receiving PFBT once a week for 3 months and home exercises or a control group (n=26), in which patients received verbal instructions to contract the pelvic floor. Erectile function (EF) was evaluated with the International Index of Erectile Function-5 (IIEF-5) before surgery and 1, 3, 6 and 12 months postoperatively. Patients were considered potent when they had a total IIEF-5 score>20. Continence status was assessed and defined as the use of no pads. Groups were comparable in terms of age, body mass index, diabetes, pathological tumor stage and neurovascular bundle preservation. A significant reduction in IIEF-5 scores was observed after surgery in both groups. In the treatment group, 8 (47.1%) patients recovered potency 12 months postoperatively, as opposed to 2 (12.5%) in the control group (P=0.032). The absolute risk reduction was 34.6% (95% confidence interval (CI): 3.8-64%) and the number needed to treat was 3 (95% CI: 1.5-17.2). A strong association between recovery of potency and urinary continence was observed, with continent patients having a 5.4 higher chance of being potent (P=0.04). Early PFBT appears to have a significant impact on the recovery of EF after RP. Urinary continence status was a good indicator of EF recovery, with continent patients having a higher chance of being potent.

Urogenital tuberculosis: patient classification in seven different groups according to clinical and radiological presentation

PURPOSE

To describe and classify 80 cases of urogenital tuberculosis in seven groups of similar clinical and radiological presentation.

MATERIALS AND METHODS

80 patients (56 males, 70%; median age 34 years; age range 12 to 75) with urogenital tuberculosis were retrospectively reviewed. The patients were divided in seven groups: 1) Bilateral parenchymatous renal lesions; 2) No or minimal changes on radiographic examination; 3) Unilateral renal tuberculosis; 4) Contracted bladder; 5) Contracted bladder with renal failure; 6) Tuberculosis on a transplanted kidney; 7) Isolated genital tuberculosis.

RESULTS

1) Seven (8.8%) patients had multiple bilateral parenchymatous renal lesions with fever and malaise, characteristic of miliary tuberculosis. Three of these patients had AIDS. 2) Six (7.5%) cases had an early diagnosis, with minimal or no radiographic lesions. Two did not have any urologic symptoms. 3) Twelve (15%) patients had unilateral renal tuberculosis with partial (1 case) or total non-function kidney. 4) Thirty-seven (46.3%) patients had contracted bladder associated with unilateral partial (1 case) or total non-function kidney. 5) Ten (12.5%) patients had end stage renal disease due to tuberculosis with contracted bladder. 6) Four (5.0%) patients had tuberculosis on a transplanted kidney, with graft loss in half the cases. 7) Four (5.0%) patients had prostate or epididymis tuberculosis without associated renal lesion.

CONCLUSIONS

Urogenital tuberculosis is a destructive disease of the urogenital tract with variable clinical and radiographic presentation. A classification according to similar patterns correlating with disease stage is feasible although early diagnosis is the only prevention of the most severe forms.

A better understanding of urogenital tuberculosis pathophysiology based on radiological findings

PURPOSE

To assess the radiological findings of urogenital tuberculosis (UGT) in patients at different disease stages, for a better understanding of its pathophysiology.

PATIENTS AND METHODS

We retrospectively reviewed the radiological exams of 20 men (median age 41 years; range: 28-65) with urogenital tuberculosis diagnosis. The patients were classified in the following groups: (1) bilateral renal tuberculosis with predominantly parenchymatous involvement; (2) unilateral renal tuberculosis; (3) unilateral renal tuberculosis with bladder tuberculosis and (4) bilateral renal tuberculosis with bladder tuberculosis.

RESULTS

One AIDS patient had multiple bilateral renal tuberculosis abscesses (group 1). Six patients had unilateral renal tuberculosis with hydronephrosis due to stenosis and thickening of the collecting system, without involvement of the bladder or contralateral kidney (group 2). Six patients had bladder tuberculosis with diffuse thickening of the bladder wall, with one very low or no function kidney while the other kidney was normal (group 3). Seven patients had bladder tuberculosis associated to a very low or no function kidney with the other kidney with high-grade vesicoureteral reflux-associated ureterohydronephrosis (group 4). In two patients, sequential exams showed evolution of tuberculosis from a unilateral renal and ureteral lesion to contracted bladder and dilatation of the contralateral kidney secondary to high-grade reflux.

CONCLUSIONS

UGT may have variable radiological presentations. However, in two of our cases we have seen that tuberculosis involvement of the urinary tract may be sequential. Further evidences are necessary to confirm this hypothesis.

Urodynamic evaluation of patients with lower urinary tract symptoms and small prostate volume

INTRODUCTION

The relevance of prostate size in the pathophysiology of lower urinary tract symptoms (LUTS) is controversial. We evaluated the urodynamic findings in patients with LUTS and small prostate volumes.

MATERIALS AND METHODS

84 patients aged >or=50 years with LUTS and prostates <40 ml were evaluated. All had an International Prostate Symptom Score (IPSS) >or=8. Average age was 62.0 +/- 8.1 years. We evaluated the impact of bladder outlet obstruction (BOO) and detrusor overactivity (DO) on the voiding symptoms and urodynamic findings.

RESULTS

Mean prostate volume was 29.2 +/- 7.2 ml and mean IPSS was 13.5 +/- 4.6. BOO was the main finding, affecting 42 (50.0%) patients, followed by detrusor underactivity (DU) in 41 (48.8%) and DO in 28 (33.3%) patients. Patients without BOO were significantly older than the obstructed (64.0 +/- 8.8 and 60.1 +/- 6.9 years, respectively; p = 0.026) and had an increased prevalence of DU (76.2 and 21.4%, respectively; p < 0.001). Comparison of patients with and without DO showed reduced bladder capacity and compliance in the DO group (p < 0.001). No other comparisons were significant.

CONCLUSION

Half of the patients with LUTS and small prostates are not obstructed and may have DO or decreased detrusor contractility as the basis for their voiding symptoms. Our results emphasize the value of urodynamics in this population, especially when invasive treatments are being considered.

Urogenital involvement in the Klippel-Trenaunay-Weber syndrome. Treatment options and results

OBJECTIVE

Klippel-Trenaunay-Weber syndrome (KTWS) is a congenital condition characterized by vascular malformations of the capillary, venous and lymphatic systems associated to soft tissue and bone hypertrophy in the affected areas. This syndrome may involve bladder, kidney, urethra, ureter and genitals. We report the treatment of 7 KTWS patients with urogenital involvement.

MATERIALS AND METHODS

From 1995 to 2005, 7 patients with KTWS were evaluated and the charts of these patients were reviewed.

RESULTS

Patients' median age was 19-years (range 4 to 46-years) and only 1 was female. The clinical presentation included genital deformities in 3 cases, hematuria in 2 and urethrorragia in 2, one of which associated with cryptorchidism and phimosis. Three patients had an association of pelvic and genital malformations, including 2 patients with hematuria due to vesical lesions and 1 patient with left ureterohydronephrosis due to a pelvic mass. Two patients had urethral lesions. Treatment included endoscopic laser coagulation for 1 patient with recurrent hematuria and 1 patient with urethrorrhagia, pelvic radiotherapy for 1 patient with hematuria and circumcision in 2 patients with genital deformities. One patient required placement of a double-J catheter to relieve obstruction. Hematuria and urethrorragia were safely and effectively controlled with laser applications. Circumcision was also effective. The patient treated with radiotherapy developed a contracted bladder and required a continent urinary diversion.

CONCLUSIONS

Urogenital involvement in patients with KTWS is not rare and must be suspected in the presence of hematuria or significant cutaneous deformity of the external genitalia. Surgical treatment may be warranted in selected cases.