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.

Association of physical therapy techniques can improve pain and urinary symptoms outcomes in women with bladder pain syndrome. A randomized controlled trial

Purpose:

to verify the effects of biofeedback (BF) and manual therapy (MT) associated with transcutaneous electrical nerve stimulation (TENS) or postural exercises (PE) in the treatment of bladder pain syndrome (BPS) in women regarding pain and urinary symptoms.

Materials and Methods:

a parallel-randomized controlled trial was conducted in BPS patients diagnosed according to NIH clinical criteria. Two specialized physiotherapists applied demographic and validated questionnaires of perineal and suprapubic pain (VAS), urinary symptoms and problems (ICSI and ICPI) and sexual function (FSFI) and a physical assessment was made to identify myofascial trigger points. Thirty-one women, mean age 51.8 ± 10.9 were randomized in three groups of treatment consisting of ten weekly sessions of BF and MT (Conventional group); BF, MT, and TENS (TENS group); and BF, MT, and PE (Postural group).

Results:

Postural group improved perineal and suprapubic pain after treatment (p<0.001 and p=0.001, respectively), and the suprapubic pain improvement remained persistent at 3 months of follow up (p=0.001). Postural group improved urinary symptoms and problems after treatment (p<0.001 and p=0.005, respectively) and during follow up (p<0.001 and p=0.001).

Conclusions:

Biofeedback and manual therapy associated with postural exercises showed a significant improvement in perineal and suprapubic pain and urinary symptoms after treatment and during follow-up. Both results suggest a possible role for the use of this physiotherapy technique to treat BPS patients. Longer follow-up and a larger number of patients are necessary to confirm these conclusions.

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.

Cross-cultural adaptation and validation of the neurogenic bladder symptom score questionnaire for Brazilian Portuguese

OBJECTIVE

To cross-culturally adapt and check for the reliability and validity of the neurogenic bladder symptom score questionnaire to Brazilian portuguese, in patients with spinal cord injury and multiple sclerosis.

MATERIALS AND METHODS

The questionnaire was culturally adapted according to international guidelines. The Brazilian version was applied in patients diagnosed with neurogenic bladder due to spinal cord injury or multiple sclerosis, twice in a range of 7 to 14 days. Psychometric properties were tested such as content validity, construct validity, internal consistency, and test-retest reliability.

RESULTS

Sixty-eight patients participated in the study. Good internal consistency of the Portuguese version was observed, with Cronbach α of 0.81. The test-retest reliability was also high, with an Intraclass Correlation Coefficient of 0.86 [0.76 - 0.92] (p<0.0001). In the construct validity, the Pearson Correlation revealed a moderate correlation between the Portuguese version of the NBSS and the Qualiveen-SF questionnaire (r = 0.66 [0.40-0.82]; p<0.0001).

CONCLUSIONS

The process of cross-cultural adaptation and validation of the NBSS questionnaire for the Brazilian Portuguese in patients with neurogenic lower urinary tract dysfunction was concluded.

Single nucleotide polymorphism analysis in interstitial cystitis/painful bladder syndrome

INTRODUCTION

Interstitial Cystitis (IC) is a chronic condition diagnosed based on the presence of symptoms, such as suprapubic/ pelvic pain, pressure or discomfort in association with urgency and increased urinary frequency. Confusable diseases must be excluded. However, there is no objective test or marker to establish the presence of the disease. Diagnosis and patient management is often difficult, given the poor understanding of IC pathogenesis and its unknown etiology and genetics. As an attempt to find biomarkers related to IC, we assessed the association between 20 selected single nucleotide polymorphism (SNPs) with IC and pain severity.

OBJECTIVES

To assess the presence of SNPs in IC patients' blood samples and correlate them with the disease and chronic pain condition.

METHODS

A case-control study was conducted. We selected 34 female patients with IC diagnosed according to NIDDK criteria and 23 patients in the control group (previously healthy women with only stress urinary incontinence). IC patients were allocated into two groups according to reported chronic pain severity. We selected the following SNPs for analysis: rs1800871, rs1800872, rs1800896, rs1800471, rs1800629, rs361525, rs1800497, rs6311, rs6277, rs6276, rs6313, rs2835859, rs11127292, rs2243248, rs6887695, rs3212227, rs1799971, rs12579350, rs3813034, and rs6746030. Genotyping was performed by real-time PCR (q-PCR).

RESULTS

The polymorphic allele of SNP rs11127292 exhibited a higher frequency in subjects with IC than in controls (p:0.01). The polymorphic allele of SNP rs6311 was more frequent in patients with severe pain (p:0.03). The frequency of the wild-type allele of SNP rs1799971 was higher in patients with mild to moderate pain (p:0.04).

CONCLUSION

The results indicated differences in SNP frequency among subjects, suggesting that SNPs could serve either as a marker of IC or as a marker of pain severity in IC patients. The study showed promising results regarding IC and polymorphism associations. These associations have not been previously reported.

Surgical treatment of post-prostatectomy stress urinary incontinence in adult men: Report from the 6th International Consultation on Incontinence

AIMS

To report the recommendations of the 6th International Consultation on Incontinence (ICI) on post-prostatectomy urinary incontinence.

METHODS

The 6th ICI committee on surgical treatment of urinary incontinence in men assessed and reviewed the outcomes of surgical therapy and updated the prior recommendations published in 2013. Articles from peer-reviewed journals, abstracts from scientific meetings, and literature searches by hand and electronically formed the basis of this review. The resulting guidelines were presented at the 2016 ICI meeting in Tokyo, Japan.

RESULTS

Voiding diary and pad tests are valuable for assessing quantity of leakage. Cystoscopy and/or urodynamics may be useful in guiding therapy depending on the type of incontinence and presumed etiology. Artificial Urinary Sphincter (AUS) is the preferred treatment for men with moderate to severe stress urinary incontinence (SUI) after RP. Male slings are an acceptable approach for men with mild to moderate SUI. Much discussion centers on the definition of moderate SUI. Injectable agents have a poor success rate in men with SUI. Options for recurrent SUI due to urethral atrophy after AUS implantation include changing the pressure balloon, downsizing the cuff and increasing the amount of fluid in the system. Infection and/or erosion demand surgical removal or revision of all or part of the prosthesis.

CONCLUSIONS

Although there are several series reporting the outcomes of different surgical interventions for PPUI, there is still a need for prospective randomized clinical trials. Recommendations for future research include standardized workup and outcome measures, and complete reporting of adverse events at long-term.

Update on complications of synthetic suburethral slings

Synthetic suburethral slings have become the most widely used technique for the surgical treatment of stress urinary incontinence. Despite its high success rates, significant complications have been reported including bleeding, urethral or bladder injury, urethral or bladder mesh erosion, intestinal perforation, vaginal extrusion of mesh, urinary tract infection, pain, urinary urgency and bladder outlet obstruction. Recent warnings from important regulatory agencies worldwide concerning safety issues of the use of mesh for urogynecological reconstruction have had a strong impact on patients as well as surgeons and manufacturers. In this paper, we reviewed the literature regarding surgical morbidity associated with synthetic suburethral slings.

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.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

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.

Periurethral muscle-derived mononuclear cell injection improves urethral sphincter restoration in rats

AIMS

Investigate the effect of a novel cell-based therapy with skeletal muscle-derived mononuclear cells (SMDMCs) in a rat model of stress urinary incontinence.

METHODS

Male Wistar-Kyoto rats' hind limb muscles were enzymatically dissociated, and SMDMCs were isolated without needing expansion. The cell population was characterized. Twenty female rats underwent urethrolysis. One week later, 10 rats received periurethral injection of 10⁶ cells (SMDMC group), and 10 rats received saline injections (Saline group). Ten rats underwent sham surgery (Sham group). Four weeks after injection, animals were euthanized and the urethra was removed. The incorporation of SMDMCs in the female urethra was evaluated with fluorescence in situ hybridization for the detection of Y-chromosomes. Hematoxylin and eosin, Masson's trichrome staining, and immunohistochemistry for actin and myosin were performed. The muscle/connective tissue, actin and myosin ratios were calculated. Morphological evaluation of the urethral diameters and fractional areas of the lumen, mucosa, and muscular layer was performed.

RESULTS

SMDMCs population was consistent with the presence of muscle cells, muscle satellite cells, perivascular cells, muscle progenitor cells, and endothelial cells. SMDMCs were incorporated into the urethra. A significant decrease in the muscle/connective tissue ratio was observed in the Saline group compared with the SMDMC and Sham groups. The proportions of actin and myosin were significantly decreased in the Saline group. No differences were observed in the morphometric parameters.

CONCLUSIONS

SDMSC were incorporated into the rat urethra and promoted histological recovery of the damaged urethral sphincter, resulting in decreased connective tissue deposition and increased muscle content.

Evaluation of Sexual Dysfunction in Men With Spinal Cord Injury Using the Male Sexual Quotient

OBJECTIVE

To assess different aspects of sexual function in men with spinal cord injury (SCI) using the Male Sexual Quotient (MSQ), a newly developed tool to assess sexual function and satisfaction.

DESIGN

Cross-sectional study.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Patients (N=295) older than 18 years (mean age ± SD, 40.7±14.5y) with SCI for more than 1 year (median time since SCI, 3.6y; range, 1.6-7.0y) were assessed from February to August 2012. Patients completed the MSQ questionnaire and the Sexual Health Inventory for Men (SHIM).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Performance in various domains of sexual function was evaluated using the MSQ and SHIM questionnaires.

RESULTS

Erectile function, ejaculation, and orgasm were the most severely affected domains. The median MSQ score was 40 (range, 8-66), and the median SHIM score was 5 (range, 0-16). The diagnostic properties of the 2 instruments were similar in the discrimination of sexually active subjects. The area under the receiver operating characteristic curve was .950 (95% confidence interval [CI], .923-.979) for the MSQ and .942 (95% CI, .915-.968) for the SHIM. There was a strong correlation between the 2 instruments (r=.826; 95% CI, .802-.878).

CONCLUSIONS

Different domains of sexual function are severely impaired in men with SCI, although their sexual interest remains high. The MSQ and SHIM scores strongly correlate, but the MSQ provides a more comprehensive assessment of sexual dysfunction in male patients with SCI.

The Bacterial Spectrum and Antimicrobial Susceptibility in Female Recurrent Urinary Tract Infection: How Different They Are From Sporadic Single Episodes?

OBJECTIVE

To analyze and compare the etiological uropathogens and the susceptibility profile findings on urine culture between sporadic cases of community-acquired, uncomplicated urinary tract infection (UTI) and recurrent UTI cases in women.

MATERIALS AND METHODS

We retrospectively analyzed the clinical data of 1629 women with uncomplicated UTI evaluated at our hospital between January 2007 and December 2012. Patients were divided into 2 groups: (1) no recurrent UTI and (2) recurrent UTI. We analyzed the microbiological findings and compared susceptibility profiles between groups.

RESULTS

A total of 420 women were included. Group 1 had 233 (55.5%) patients and group 2 had 187 (44.5%). Escherichia coli was the most common agent in both groups (76.4% and 74.3%, respectively; P = .625), whereas Staphylococcus saprophyticus (8.2%) was the second most common in group 1, and Enterococcus faecalis was the second most common in group 2 (8.0%). Nitrofurantoin was the only oral agent that maintained the susceptibility profile in both groups (87.1% and 88.7%, respectively; P = .883). For E coli infections, only nitrofurantoin and amoxicillin/clavulanate maintained susceptibility rates more than 90% in both groups.

CONCLUSION

UTI episodes in patients with recurrent UTI had similar bacterial spectra, but different susceptibility profiles compared with those from patients with nonrecurrent infections. The susceptibility rate for nitrofurantoin in patients with recurrent UTI remained high and comparable to the observed in patients with sporadic UTI, reinforcing its indication for empirical treatment while waiting for urine culture results.

A guideline for the management of bladder dysfunction in Parkinson's disease and other gait disorders

Parkinson's disease (PD) is a common neurodegenerative disorder, and lower urinary tract (LUT) dysfunction is one of the most common autonomic disorders with an estimated incidence rate of 27-80%. Studies have shown that bladder dysfunction significantly influences quality-of-life (QOL) measures, early institutionalisation, and health economics. We review the pathophysiology of bladder dysfunction in PD, lower urinary tract symptoms (LUTS), objective assessment, and treatment options. In patients with PD, disruption of the dopamine D1-GABAergic direct pathway may lead to LUTS. Overactive bladder (OAB) is the most common LUT symptom in PD patients, and an objective assessment using urodynamics commonly shows detrusor overactivity (DO) in these patients. The post-void residual (PVR) volume is minimal in PD, which differs significantly from multiple system atrophy (MSA) patients who have a more progressive disease that leads to urinary retention. However, subclinical detrusor weakness during voiding may also occur in PD. Regarding bladder management, there are no large, double-blind, prospective studies in this area. It is well recognised that dopaminergic drugs can improve or worsen LUTS in PD patients. Therefore, an add-on therapy with anticholinergics is required. Beta-3 adrenergic agonists are a potential treatment option because there are little to no central cognitive events. Newer interventions, such as deep brain stimulation (DBS), are expected to improve bladder dysfunction in PD. Botulinum toxin injections can be used to treat intractable urinary incontinence in PD. Transurethral resection of the prostate gland (TURP) for comorbid BPH in PD is now recognised to be not contraindicated if MSA is excluded. Collaboration of urologists with neurologists is highly recommended to maximise a patients' bladder-associated QOL. Neurourol. Urodynam. 35:551-563, 2016. © 2015 Wiley Periodicals, Inc.

Contemporary Trends in the Epidemiology of Traumatic Spinal Cord Injury: Changes in Age and Etiology

Background: Epidemiological features of spinal cord injury (SCI) have been changing over the last decades. We evaluated the contemporary trends in the epidemiology of traumatic SCI patients from a rehabilitation center. Methods: In a cross-sectional study, a consecutive series of 348 patients with traumatic SCI were evaluated. Variables were collected through an epidemiological form, which included gender, age at injury, duration and cause of SCI. We investigated SCI epidemiological trends over time including the association between gender and age at injury with SCI features such as etiology, injury severity and level. Results: The mean age at SCI has increased from 26.0 ± 11.8 in patients with SCI before 2003 to 37.9 ± 15.7 in those with SCI after 2009 (p < 0.001). Gunshot wounds were the main cause of injury in patients with SCI before 2003, dropping from 40.6 to 16.9% after 2009 and being surpassed by road traffic injuries (38.6%) and falls (31.4%) after 2009 (p < 0.001). Gender, SCI severity and level have not changed significantly over the time. Conclusions: There was a major increase in the average age of patients as well as changes in the etiology of SCI over the past fifteen years, including a significant decrease in gunshot wounds and an increase in the frequency of road traffic injuries and falls. These changes and accompanying risk factors must be taken into consideration when planning measures to prevent SCI.

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.

Voiding dysfunction in patients with neuromyelitis optica spectrum disorders

AIMS

We assessed the lower urinary tract symptoms (LUTS) and urodynamic findings in patients with neuromyelitis optica spectrum disorders (NMO-SD), a recently defined neurological disease.

METHODS

We prospectively evaluated seven men and 23 women (mean age 41.1 ± 13.5 years) with an established diagnosis of NMO-SD who were invited to participate irrespective of the presence of LUTS. Neurological evaluation was assessed with the Expanded Disability Status Scale (EDSS) and LUTS were evaluated with the Overactive Bladder questionnaire (OAB-V8) and the International Prostate Symptom Score (I-PSS). All patients underwent videourodynamics, transabdominal urinary tract sonography, urine culture, and serum creatinine levels.

RESULTS

The mean time of disease duration was 33.8 ± 30.8 months. Neurological evaluation showed a mean EDSS score of 5.3 ± 1.8. The most frequent videourodynamic findings were detrusor-sphincter dyssynergia (DSD) and detrusor overactivity (DO) in 11 (36.6%) patients, DSD without DO in seven (23.3%) and DO without DSD in six (20.0%) patients. Voiding dysfunction assessed by I-PSS and OAB-V8 increased with the degree of neurological impairment (P = 0.018; r = 0.42 and P = 0.006; r = 0.48 respectively). Patients with DSD had higher I-PSS (18.5 ± 11.4 vs 7.0 ± 9.2; P = 0.029) and OAB-V8 scores (22.8 ± 15.8vs 9.1 ± 7.8; P = 0.008), and worse neurological impairment (mean EDSS 5.9 ± 1.8 vs 4.5 ± 1.5; P = 0.027).

CONCLUSIONS

Most patients with NMO-SD have LUTS and voiding dysfunction, with DSD and DO as the main urodynamic findings. The severity of the neurological disease is a predictive factor for the occurrence of voiding dysfunction and detrusor-sphincter dyssynergia.

Evaluation of the metabolism of glycosaminoglycans in patients with interstitial cystis

INTRODUCTION

Painful bladder syndrome/interstitial cystitis (PBS/IC) pathogenesis is not fully known, but evidence shows that glycosaminoglycans (GAG) of bladder urothelium can participate in its genesis. The loss of these compounds facilitates the contact of urine compounds with deeper portions of bladder wall triggering an inflammatory process. We investigated GAG in urine and tissue of PBS/IC and pure stress urinary incontinence (SUI) patients to better understand its metabolism.

MATERIALS AND METHODS

Tissue and urine of 11 patients with PBS/IC according to NIDDK criteria were compared to 11 SUI patients. Tissue samples were analyzed by histological, immunohistochemistry and immunofluorescence methods. Statistical analysis were performed using t Student test and Anova, considering significant when p < 0.05.

RESULTS

PBS/IC patients had lower concentration of GAG in urine when compared to SUI (respectively 0.45 ± 0.11 x 0.62 ± 0.13 mg/mg creatinine, p < 0.05). However, there was no reduction of the content of GAG in the urothelium of both groups. Immunofluorescence showed that PBS/IC patients had a stronger staining of TGF-beta, decorin (a proteoglycan of chondroitin/dermatan sulfate), fibronectin and hyaluronic acid.

CONCLUSION

the results suggest that GAG may be related to the ongoing process of inflammation and remodeling of the dysfunctional urothelium that is present in the PBS/IC.

Uncomplicated Urinary Tract Infections in Women in a Sao Paulo Quaternary Care Hospital: Bacterial Spectrum and Susceptibility Patterns

Uncomplicated urinary tract infections (UTI) in women are very common. Regular analysis of bacterial flora is important to formulate updated guidelines. The objective of this study is to determine and compare the microbiology of UTIs and their susceptibility patterns in a quaternary care hospital. In a seven-year review, the urine culture results of 480 female patients with uncomplicated UTIs were analyzed. Patients were divided into three groups according to their diagnosis and treatment characteristics: Group 1, cystitis at outpatient basis; group 2, cystitis at the Emergency Unit; and group 3, pyelonephritis. Group 1 included older patients, with a higher incidence of concomitant diabetes mellitus and recurrent UTIs. E. coli was the most common pathogen, responsible for 75.1% of cases, mainly for pyelonephritis (87.3%). Of the oral antimicrobials tested for cystitis, amoxicillin/clavulanate and nitrofurantoin had the highest susceptibility profiles (84.4% and 87.3%, respectively). For E. coli only, their susceptibility profiles were as high as 90.8% and 97.4%, respectively. For pyelonephritis treatment, fluoroquinoles had a susceptibility profile <90%, while ceftriaxone and gentamicin had susceptibility >90%. Uncomplicated UTI treatment is becoming more challenging because the susceptibility profiles of oral antimicrobials are increasingly resistant. In our environment, cystitis can still be managed with nitrofurantoin. Uncomplicated pyelonephritis should be managed with ceftriaxone or gentamicin.

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.

Adhesion molecules of detrusor muscle cells are influenced by a hypercholesterolemic diet or bladder outlet obstruction in a Wistar rat model

Background

Cell adhesion molecules (CAMs) are essential for maintaining tissue integrity by regulating intercellular and cell to extracellular matrix interactions. Cadherins and catenins are CAMs that are located on the cell membrane and are important for adherens junction (AJ) function. This study aims to verify if hypercholesterolemic diet (HCD) or bladder outlet obstruction (BOO) promotes structural bladder wall modifications specific to alterations in the expression of cadherins and catenins in detrusor muscle cells.

Methods

Forty-five 4-week-old female Wistar rats were divided into the following three groups: group 1 was a control group that was fed a normal diet (ND); group 2 was the BOO model and was fed a ND; and group 3 was a control group that was fed a HCD (1.25% cholesterol). Initially, serum cholesterol, LDL cholesterol and body weight were determined. Four weeks later, groups 1 and 3 underwent a sham operation; whereas group 2 underwent a partial BOO procedure that included a suture tied around the urethra. Six weeks later, all rats had their bladders removed, and previous exams were repeated. The expression levels of N-, P-, and E-cadherin, cadherin-11 and alpha-, beta- and gamma-catenins were evaluated by immunohistochemistry with a semiquantitative analysis.

Results

Wistar rats fed a HCD (group 3) exhibited a significant increase in LDL cholesterol levels (p=0.041) and body weight (p=0.017) when compared to both groups that were fed a normal diet in a ten-week period. We found higher β- and γ-catenin expression in groups 2 and 3 when compared to group 1 (p = 0.042 and p = 0.044, respectively). We also observed Cadherin-11 overexpression in group 3 when compared to groups 1 and 2 (p = 0.002).

Conclusions

A HCD in Wistar rats promoted, in addition to higher body weight gain and increased serum LDL cholesterol levels, overexpression of β- and γ-catenin in the detrusor muscle cells. Similar finding was observed in the BOO group. Higher Cadherin-11 expression was observed only in the HCD-treated rats. These findings may be associated with bladder dysfunctions that occur under such situations.

Laparoscopic ureteropyeloanastomosis in the treatment of duplex system

PURPOSE

Duplex system is one of the most common anomalies of upper urinary tract. Anatomical and clinical presentation determine its treatment. Usually, the upper moiety has a poor function and requires resection, but when it is not significantly impaired, preservation is recommended. Laparoscopic reconstruction with upper pole preservation is presented as an alternative treatment.

MATERIALS AND METHODS

Four female patients with duplex system, one presenting with recurrent urinary tract infection and the others with urinary incontinence associated to infrasphincteric ectopic ureter, were treated. Surgical procedure envolved a laparoscopic ureteropyeloanastomosis of the upper pole ureter to the pelvis of the lower moiety, with prior insertion of a double J stent.

RESULTS

Surgical time varied from 120 to 150 minutes, with minimal blood loss in all cases. Follow-up varied from 15 to 30 months, with resolution of the clinical symptoms and preservation of the upper moiety function.

CONCLUSION

Laparoscopic ureteropyeloanatomosis is a feasible and safe minimally invasive option in the treatment of duplex system.

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.

Influence of a hypercholesterolemic diet on the collagen composition of the bladder wall extracellular matrix in rats

PURPOSE

To investigate the effects of hypercholesterolemic diet on the collagen composition of urinary bladder wall.

MATERIALS AND METHODS

Forty-five female 4-week-old Wistar rats were divided into three groups: 1) control group fed a normal diet (ND); 2) model of bladder outlet obstruction (BOO) group fed a ND; and 3) group fed a HCD (1.25% cholesterol). Total serum cholesterol, LDL cholesterol and body weight were assessed at baseline. Four weeks later, group 2 underwent a surgical procedure resulting in a partial BOO, while groups 1 and 3 underwent a sham similar surgical procedure. Six weeks later, all animals had their bladders removed; serum cholesterol and LDL cholesterol levels and body weights were measured. Morphological and morphometric analysis was performed by Picrosirius staining and collagen types I and III were identified by immunofluorescence. Statistical analysis was completed and significance was considered when p<0.05.

RESULTS

Rats fed an HCD exhibited a significant increase in LDL cholesterol levels (p<0.001) and body weight (p=0.017), when compared to the groups fed a ND during the ten-week study period. Moreover, the HCD induced morphological alterations of the bladder wall collagen, regarding thin collagen fibers and the amounts of type III collagen when compared to the control group (p=0.002 and p=0.016, respectively), resembling the process promoted in the BOO model.

CONCLUSIONS

A hyper-cholesterolemic diet in Wistar rats promoted morphological changes of the bladder types of collagen, as well as increases in body weight and LDL cholesterol.

[Conservative treatment of severe renal trauma after extracorporeal shockwave lithotripsy]

Subcapsular and perinephric hematomas are relatively common after shock-wave lithotripsy, but high-grade kidney injuries are extremely rare. We present the first case of a high-grade kidney injury after shock-wave lithotripsy managed conservatively. A 57-year-old white female patient with left 1.5cm superior ureteral calculi was submitted to shock-wave lithotripsy.

Cranberries and lower urinary tract infection prevention

Lower urinary tract infections are very common diseases. Recurrent urinary tract infections remain challenging to treat because the main treatment option is long-term antibiotic prophylaxis; however, this poses a risk for the emergence of bacterial resistance. Some options to avoid this risk are available, including the use of cranberry products. This article reviews the key methods in using cranberries as a preventive measure for lower urinary tract infections, including in vitro studies and clinical trials.

Learning curve for radical retropubic prostatectomy

PURPOSE

The learning curve is a period in which the surgical procedure is performed with difficulty and slowness, leading to a higher risk of complications and reduced effectiveness due the surgeon's inexperience. We sought to analyze the residents' learning curve for open radical prostatectomy (RP) in a training program.

MATERIALS AND METHODS

We conducted a prospective study from June 2006 to January 2008 in the academic environment of the University of Sao Paulo. Five residents operated on 184 patients during a four-month rotation in the urologic oncology division, mentored by the same physician assistants. We performed sequential analyses according to the number of surgeries, as follows: ≤ 10, 11 to 19, 20 to 28, and ≥ 29.

RESULTS

The residents performed an average of 37 RP each. The average psa was 9.3 ng/mL and clinical stage T1c in 71% of the patients. The pathological stage was pT2 (73%), pT3 (23%), pT4 (4%), and 46% of the patients had a Gleason score 7 or higher. In all surgeries, the average operative time and estimated blood loss was 140 minutes and 488 mL. Overall, 7.2% of patients required blood transfusion, and 23% had positive surgical margins.

CONCLUSION

During the initial RP learning curve, we found a significant reduction in the operative time; blood transfusion during the procedures and positive surgical margin rate were stable in our series.

Desmopressin versus behavioral modifications as initial treatment of primary nocturnal enuresis

The purpose of this study was to compare the effectiveness of desmopressin to behavioral modifications as the initial treatment of primary monosymptomatic nocturnal enuresis (PMNE). Study results determined that either intervention led to a significant reduction in PMNE episodes. These results suggest that either method is equally effective for treatment of PMNE.

PSA levels in men with spinal cord injury and under intermittent catheterization

AIM

To evaluate serum PSA levels of patients with spinal cord injury (SCI) submitted or not to CIC in comparison to those of the general population.

METHODS

We retrospectively studied 140 men with SCI admitted in our department from January 2005 to May 2009. Thirty-four SCI patients had PSA levels available, comprising 21 under CIC and 13 without CIC. Patients under CIC performed it 4-6 times a day and mean time of catheterization was 72.4 months (range 30-192). The most common etiology of SCI was fall from height (33%), followed by car/motorcycle crashes (15%). Control group was composed by 670 healthy men that were referred to our service to evaluation of Kidney donation or cancer prostate screening. We used Student's t-test and variance analysis (ANOVA) for age and PSA comparison between the groups.

RESULTS

Overall, patients with SCI and controls had similar mean age (54 vs. 57 years old, P = 0.11) and mean PSA level (1.81 vs. 1.95  ng/ml, P = 0.66). SCI patients were divided into with and without CIC. Patients without CIC had similar mean age (60 vs. 57 years old, P = 0.11) and similar PSA values when compared to controls (1.72 vs. 1.95  ng/ml, P = 0.89). Patients under CIC were compared to controls with similar age (50 vs. 47 years, P = 0.0332) and their PSA levels were greater (1.86 vs. 0.79  ng/ml, P = 0.026).

CONCLUSION

Clean intermittent catheterization increased PSA levels approximately doubling its value.

Use of an inflatable silicone balloon improves the success rate of bladder autoaugmentation at long-term followup

PURPOSE

Most groups have reported disappointing results with autoaugmentation or detrusor myectomy for low capacity/compliance neuropathic bladders. Failure may be due to an ischemic diverticulum or mucosal shrinkage. We investigated whether a Silimed® silicone balloon placed in the bladder after autoaugmentation could prevent these problems, improving surgical results.

MATERIALS AND METHODS

We compared the results of standard bladder autoaugmentation in 12 children (group 1) with those in 10 (group 2) who underwent the same surgery using a bladder conformer. The conformer was a silicone balloon filled with saline that remained in the bladder for 2 weeks. All patients had a neuropathic bladder with poor capacity and compliance, resulting in urinary leakage between catheterizations. Preoperative and postoperative evaluation included a voiding diary, ultrasound, voiding cystourethrogram and urodynamics.

RESULTS

In group 1 only 1 patient became dry, 4 had little improvement in continence, 4 remained unchanged and 3 became worse. In group 2, 6 patients (60%) become continent without medication, 2 (20%) become continent with oxybutynin and 2 remained unchanged. Bladder capacity and compliance did not change significantly in group 1. However, in group 2 capacity changed from a mean of 140 to 240 ml and mean ± SD compliance increased from 15.6 ± 16.8 to 34.3 ± 22.8 ml/cm H(2)O (p = 0.02).

CONCLUSIONS

The inflatable balloon improved our long-term results of bladder auto-augmentation. A larger series may be necessary to confirm procedure efficacy and safety.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

Twenty six trials involving 2284 women were included. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6-24 months.One medium sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of mixed urinary incontinence patients. Surgery appeared to be more effective than drugs in treating patient-reported incontinence (n = 75, Risk Ratio (RR) 0.18, 95% Confidence Interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21; 95% CI 0.09 to 0.21), and also cheaper on average cost.Seven trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations.These seemed to be equally effective in the short term (RR for incontinence within first year 0.97; 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Patient-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45; 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Goretex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting patient characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long term adverse event profile is still unclear. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Is the ultrasound-estimated bladder weight a reliable method for evaluating bladder outlet obstruction?

OBJECTIVE

• To evaluate the correlation between ultrasound-estimated bladder weight (UEBW) in patients with different degrees of bladder outlet obstruction (BOO).

METHODS

• We evaluated 50 consecutive non-neurogenic male patients with lower urinary tract symptoms (LUTS) referred to urodynamic study (UDS). All patients self-answered the International Prostate Score Symptoms (IPSS) questionnaire. After the UDS, the bladder was filled with 150 mL to determine UEBW. • Patients with a bladder capacity under 150 mL, a previous history of prostate surgery or pelvic irradiation, an IPSS score <8, a bladder stone or urinary tract infection were excluded. • After a pressure-flow study, the Schafer linear passive urethral resistance relation nomogram was plotted to determine the grade of obstruction: Grades I-II/VI were defined as mild obstruction, Grades III-IV/VI as moderate obstruction, and Grades V-VI/VI as severe obstruction.

RESULTS

• The UEBW was 51.7 ± 26.9, 54.1 ± 30.0 and 54.8 ± 28.2 in patients with mild, moderate and severe BOO, respectively (P= 0.130). The UEBW allowed us to define four groups: (i) UEBW <35 g; (ii) 35 g ≤ UEBW < 50 g; (iii) 50 g ≤ UEBW < 70 g; and (4) UEBW ≥ 70 g. • We did not find any differences in age, prostate weight, IPSS, PVR, cystometric bladder capacity, presence of detrusor overactive and degree of obstruction in the aforementioned groups.

CONCLUSION

• Despite the fact that some studies have emphasized the value of UEBW as an efficient non-invasive method for evaluating lower urinary tract obstruction, our study suggests that UEBW does not present any individual correlation with LUTS or objective measurements of BOO.