A prospective assessment of the validity of the CUA neurogenic bladder guideline

INTRODUCTION

The Canadian Urological Association (CUA) neurogenic bladder guideline surveillance strategy for neurogenic lower urinary tract dysfunction (NLUTD) has not been formally evaluated. Our objective was to evaluate the validity of the risk stratification suggested in these guidelines.

METHODS

This was a prospective, observational cohort study of adult NLUTD patients with spinal cord injury, multiple sclerosis, or spina bifida who required urodynamics. Patients with a requirement for immediate bladder surgery (not suitable for surveillance) were excluded. Patients completed standardized medical history/questionnaires, baseline urodynamics, renal imaging, and creatinine tests. The primary outcome was the need for different types of urological management between the high-risk and moderate-risk groups.

RESULTS

We enrolled 68 patients; most commonly, these were spinal cord injury patients, and most people were using intermittent catheters. At baseline, 62% (40/68) were classified as high-risk. In this group, there was a numerically greater proportion who received a recommendation for a new urological medication (48% vs. 25%, p=0.06) or a change to their bladder management (45% vs. 36%, p=0.44). A total of 26 high-risk and 23 medium-risk NLUTD patients had a one- year followup visit. A larger proportion of the high-risk patients had a recommendation for a new bladder medication (15.4% vs. 8.7% p=0.47), intravesical onabotulinum toxin (34.6% vs. 13% p=0.08), or an alternate method of bladder management (15.4% vs. 4.3%, p=0.2). Mean creatinine change was slightly greater in the high-risk group (+6.1 vs. +0.4 umol/L, p=0.05). Approximately 1/3 of both high-risk and moderate-risk patients didn't accept the recommended interventions.

CONCLUSIONS

A higher proportion of high-risk NLUTD patients had urology-relevant interventions recommended, both at baseline and at their one-year followup visit. This supports the general concept of risk stratification and the variables used to define high-risk in the CUA's neurogenic bladder guideline.

Retroperitoneal hematoma post percutaneous sacral nerve evaluation: A case report

Sacral neuromodulation is an accepted therapy for various voiding dysfunction. We report a 71-year-old male with a history of BPH post TURP and overactive bladder. He was on anticoagulants for atrial fibrillation. He underwent uneventful percutaneous sacral nerve evaluation. Five days later, he showed no improvement. Temporary lead was removed in clinic without complications. On day ten, he developed lower abdominal, and genital skin bruising. CT scan showed presacral retroperitoneal hematoma. His Hemoglobin dropped. He was admitted, managed conservatively and discharged with a stable hemoglobin. Retroperitoneal hematoma post PNE is rare. Management is conservative. Angioembolization is reserved for unstable patients.

Development and characterisation of functional cultured buttermilk fortified with flaxseed

Cultured buttermilk is a dairy beverage with a high nutritive value. In the current study, functional cultured buttermilk was formulated using probiotic Lactobacillus plantarum and flaxseed fortification to improve the potential health benefits. The cultured buttermilk samples were analysed for pH, lactic acidity, colour, phase separation, viscosity, microbiology and sensory properties. The results showed non-significant changes in acidity and pH. However, flaxseed fortification decreased phase separation and increased viscosity of buttermilks. In addition, a significant difference in colour attributes was revealed between samples. Sensory characteristics of cultured buttermilks were acceptable to produce a functional food.

Multicenter Study for the Effect of COVID-19 Lockdown on Patients With Sacral Neuromodulation Implants

Introduction

The massive spread of COVID-19 affected many aspects of medical and surgical services. Many patients with sacral neuromodulation (SNM) devices needed integrated follow-up and close communication regarding the programming of the device. In this study, we aimed to explore the effect of COVID-19 lockdown on patients with SNM devices.

Materials and Methods

This was a multicenter study designed and conducted in four centers performing SNM (Toronto Western Hospital, Toronto, Canada; King Abdulaziz University Hospital, Jeddah, Saudi Arabia; Al-Amiri Hospital, Kuwait City, Kuwait; and Austin and Western Health, University of Melbourne, Australia). An online questionnaire was created through Google Forms and circulated among patients with SNM devices in all four mentioned centers. The questionnaire was sent to patients during the forced lockdown period in each country.

Results

A total of 162 responses were received by September 2020. Data showed that most patients had their device implanted before the lockdown period (92.5%, 150/162). Most patients did not experience any contact difficulties (91.9%, 149/162). When patients were requested for their preference of programming, 89.5% (145/162) preferred remote programming. Correlation analysis did not show any significant relation between patient diagnosis and COVID-19–related difficulties or preferences.

Conclusion

The difficulties with access to care experienced during the pandemic and the patient’s expressed willingness to participate in virtual care should provide impetus for manufacturers of SNM devices to move forward with developing remote programming capabilities.

In vitro assessment of health-promoting benefits of sheep ‘Testouri’ cheese

This study aimed to produce probiotic ‘Testouri’, traditional Tunisian sheep cheese, by direct-to-vat inoculum of probiotic adjuncts.

The potential of Testouri sheep cheeses was evaluated by an assessment of gross composition and proteolytic, antibacterial, antidiabetic and antioxidant activities during storage at 4 °C for 28 days. Results highlighted that no significant differences were observed in compositional parameters of the samples at day 0. Probiotic counts in cheeses remained at 8 log CFU g−1 during storage. Probiotic cheeses exhibited measurable antibacterial activities with the maximum value (diameter of 12 ± 0.07 mm) on Staphylococcus aureus strain. Also, α-glucosidase and α-amylase inhibitions ranged from 42 ± 0.77 to 58 ± 0.88% and 20 ± 0.9 to 47 ± 1.3%, respectively, during storage. Additionally, cheeses inoculated with probiotics exhibited significant increases in proteolytic and antioxidant activities compared to the control sample.

Therefore, Testouri cheese can be considered a good carrier of probiotics and can be promoted for commercial uses.

Effects of Chia Seed Levels on Quality and Bio-Functional Profile of Stirred Yoghurt

Yoghurt is considered as a healthy food. Thus, it could convey functional and bioactive ingredients. Chia seeds are of great interest due to their ability to improve consumer health. In this study, chia seeds were added to stirred yoghurt at different doses (1.5, 3, 4.5, or 6%). The effects of chia seeds on physicochemical, microbiological, and sensory qualities were assessed during 28 days of refrigerated storage. The results showed that chia seeds slightly decreased post-acidification, the lowest value was obtained in yogurt with 3% chia seeds (24°D), but syneresis rose significantly (P<0.05) when 6% of chia seeds was added. Furthermore, chia seeds promote viability of yoghurt bacteria, and antioxidant activity reached 62.20±0.02% in yoghurt added with 1.5% chia seeds. However, proteolysis is not affected. The effects of chia seeds were not dose dependent as 4.5% and 6% did not follow trend. These findings were affirmed by sensory characteristics. Thus, stirred yoghurt containing 1.5 or 3% of chia seeds proved to be the most adequate choices.

Development of Aloe vera (Aloe barbadensis Miller) probiotic lassi using Lactobacillus fermentum bacteria

The aim of this research was to investigate the effect of Aloe vera gel on the quality of probiotic lassi. Probiotic lassi was prepared by adding 15% of Aloe vera gel and inoculating with probiotic Lactobacillus fermentum strain. Results showed that physicochemical properties of fortified probiotic lassi were not affected by these modifications during the storage period (P>0.05), however, antioxidant activities, texture and aroma sensory parameters differed significantly (P<0.05). Lactobacillus and Streptococcus counts exhibited same behavior in Aloe vera probiotic lassi products as in control (P>0.05) after 21 days of storage. Aloe vera probiotic lassi has a beneficial effect on human health.

Conception and development of Urinary Tract Infection indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Urinary tract infections (UTI) are the most frequent secondary health condition following spinal cord injury or disease (SCI/D) that adversely impact overall health and quality of life, and often result in rehabilitation service interruptions, emergency department visits, and urinary sepsis. Methods: Experts in Urohealth and/or UTI recognition and management and the SCI-High Project Team used a combination of evidence synthesis and consensus methods for developing the UTI indicators. A systematic search and a Driver diagram analysis were applied to identify key factors influencing UTI. This Driver diagram guided the UTI Working Group when defining the construct, specifying the aim for the UTI SCI/D quality indicators, and developing the UTI diagnostic checklist and fever definition. Results: The structure indicator was the proportion of patients with a health care professional (i.e. family physician or urologist) able to follow-up with the patient regarding urine culture and sensitivity results within 48-72 h of collection. The Working Group knowingly adopted a single checklist for UTI diagnosis, recognizing the stark contrast in the complexity of diagnosis in acute versus community settings. The process indicator is the proportion of SCI/D rehabilitation inpatients with UTI as defined by the UTI diagnostic checklist. The outcome indicator is the proportion of SCI/D rehabilitation inpatients with inappropriate antibiotic prescription. Conclusion: UTI can be diagnosed using the developed symptoms and signs checklist. These structure, process, and outcome quality indicators will ultimately reduce inappropriate antibiotic therapy for UTI and the rising incidence of antibiotic resistance among community-dwelling individuals with chronic SCI/D.

On the solution of fractional order SIS epidemic model

We consider the fractional order epidemic model based on assumption that people will recover after disease and may be infected again on a time interval of non fatal disease. Our mathematical formulation is based on the fractional Caputo derivative. The existence and uniqueness of the solution is discussed. Furthermore, numerical solution is studied by variational iteration method and Euler method. Consequently, some numerical results are presented within.

The role of the neurometer CPT/C in sacral neuromodulation

Objective

The aim of the current research project was to study the role of the Neurometer^® as a tool to predict responders to sacral neuromodulation therapy (SNM).

Material and methods

This was a prospective, open study in male and female patients, aged 18 and over with voiding dysfunction [non-obstructive retention and/or frequency/ urgency syndrome]. The first group underwent a screening test to evaluate percutaneous nerve functions (PNE) and to determine whether they are candidates for SNM with the InterStim^®. Prior to PNE testing, all patients were evaluated with the pain tolerance test (PTT) using the electro-diagnostic Neurometer^® CPT/C device. An InterStim^® implant was placed in patients who were responders to PNE testing underwent. On the other hand, non-responders underwent a staged implant placement. The second group consisted of patients who already had InterStim^® implanted for voiding dysfunction. During the routine office follow-up, the patients implanted with Interstim^® underwent a PTT using the Neurometer^® CPT/C device. All the testing using the Neurometer CPT/C was performed on the day of the PNE for the first group, and the day of the routine follow-up visit for the second group. All of the results for the Neurometer^® testing were kept blinded from the PNE results, and those of the outcome of the follow-up visit. The study received approval by the Research Ethics Board of the University Health Network (No. 14-8196).

Results

We recruited a total of 123 patients. The results presented here include 110 patients who completed the study, 48 of whom were in the first group, and 62 in the second group. The statistical analysis used was as follows: Group 1: Simple linear regression analysis and the linear discriminate analysis were preformed. It was found that for patients without the InterStim^® implant with a combined CPT/CPD of 800 and above, the Neurometer^® could predict the test screening results with an accuracy of 71%. Group 2: Same analysis and tests were conducted for patients with the InterStim^® implant, and the results showed that if the patient had a combined CPT/CPD of 600 and above, the Neurometer^® could predict the patients satisfaction or dissatisfaction with an accuracy of 72%.

Conclusion

Neurometer^® may play a role in predicting test trial positive responders and patient satisfaction after the placement of InterStim^® implant.

Characterizing the transcutaneous electrical recruitment of lower leg afferents in healthy adults: implications for non-invasive treatment of overactive bladder

BACKGROUND

As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg.

METHODS

In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 μs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance.

RESULTS

All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve.

CONCLUSIONS

Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

Exploring daily blood pressure fluctuations and cardiovascular risk among individuals with motor complete spinal cord injury: a pilot study

BACKGROUND

Clinically silent autonomic dysfunction with bowel and bladder care, are postulated to contribute to cardiovascular disease after chronic spinal cord injury (SCI).

OBJECTIVE

We describe the frequency and severity of dysreflexic episodes, termed transient blood pressure elevations (T-BPE) over 48 hours in adults with cervical or high-thoracic motor-complete SCI.

SETTING

Tertiary SCI Rehabilitation Centre in Toronto, Canada.

PARTICIPANTS

Individuals with chronic SCI, C1-T3 AIS A or B, >1 year post-injury, living in the community (n=19).

OUTCOME MEASURES

Data were obtained via 48-hour ambulatory blood pressure (BP) and heart rate (HR) monitoring, with data captured at 10-minute intervals and a concurrent diary describing activities of daily living, and bladder/bowel routines. T-BPE were defined as a ≥ 40 mmHg elevation in systolic blood pressure (SBP) above the participant's supine baseline. Severe (≥ 60-79 mmHg) and Extreme ≥80 mmHg elevations in SBP were described.

RESULTS

Thirteen participants experienced T-BPE within the assessment period, with 7/13 experiencing "severe", and 3/13 experiencing "extreme" SBP elevations. The median number of T-BPE was 8 (IQR = 3), and the mean ± SD SBP during T-BPE was 150 ± 16 mmHg, These T-BPE were verified as dysreflexic events using a conservative definition of a >40 mmHg increase in SBP, with a concurrent 10 bpm decrease in HR, above the 48-hour average SBP, yielding 12/19 participants with T-BPE.

CONCLUSIONS

T-BPE were frequent, often with severe or extreme elevations in SBP, despite few reported symptoms. Recognition and management of these dysreflexic events associated with T-BPE are needed, which may ameliorate cardiovascular disease risk.

Laparoscopic Single Site Surgery for Repair of Retrocaval Ureter in a Morbidly Obese Patient

This is to describe a case of a morbidly obese (BMI = 40) female with retrocaval ureter treated with laparoendoscopic single-site surgery. A JJ stent was positioned. A 2 cm umbilical access was created. A single port platform was positioned. The entire ureter was mobilized posterior to the vena cava and transected where the dilated portion ended. The distal ureter was repositioned lateral to the inferior vena cava. Anastomosis was done. A 3 mm trocar was used to assist suturing. At 4-month follow-up, CT revealed no evidence of obstruction of the right kidney and the patient was symptomless. Although challenging, in a morbidly obese patient, LESS repair for retrocaval ureter is feasible.

Best available technology for European livestock farms: Availability, effectiveness and uptake

Concerns over the negative environmental impact from livestock farming across Europe continue to make their mark resulting in new legislation and large research programs. However, despite a huge amount of published material and many available techniques, doubts over the success of national and European initiatives remain. Uptake of the more cost-effective and environmentally-friendly farming methods (such as dietary control, building design and good manure management) is already widespread but unlikely to be enough in itself to ensure that current environmental targets are fully met. Some of the abatement options available for intensive pig and poultry farming are brought together under the European IPPC/IED directive where they are listed as Best Available Techniques (BAT). This list is far from complete and other methods including many treatment options are currently excluded. However, the efficacies of many of the current BAT-listed options are modest, difficult to regulate and in some cases they may even be counterproductive with respect to other objectives ie pollution swapping. Evaluation of the existing and new BAT technologies is a key to a successful abatement of pollution from the sector and this in turn relies heavily on good measurement strategies. Consideration of the global effect of proposed techniques in the context of the whole farm will be essential for the development of a valid strategy.

Sacral Neuromodulation for Genitourinary Problems

Sacral neuromodulation (SNM) is a minimally invasive therapeutic option for many voiding dysfunction conditions. It is approved by the US FDA for refractory overactive bladder with and without incontinence and nonobstructive retention. Since SNM has shown a favorable response for these approved indications, other therapeutic applications have been proposed for various conditions such as painful bladder syndrome, chronic pelvic pain and neurological voiding dysfunction in both adult and pediatric age groups. SNM therapy with the most commonly used dedicated SNM device (InterStim) involves insertion of electrode(s) in the third and/or fourth sacral foramen next to the nerve root. The electrode is then connected to a battery-operated pulse generator. All patients need to have a test trial period before definitive device insertion. Here we discuss SNM therapy in functional urinary disorders and the technique of device insertion with the potential pitfalls.

Effect of sacral neuromodulation on female sexual function and quality of life: Are they correlated?

INTRODUCTON

Sacral neuromodulation (SNM) has become an established therapy for voiding dysfunction. Additional benefits, such as improved bowel functions and bladder pain, have been reported. Improvement in female sexual function after SNM treatment has been suggested; however, reports examining the effects of SNM on female sexual functions are scarce. We evaluate the effects of SNM on female sexual function and its impact on quality of life and analyze any correlation.

METHODS

Data were collected from January 2010 to May 2012 for all female patients who underwent SNM InterStim (Medtronic, Minneapolis, MN) therapy at a single centre in Canada. They were treated for voiding dysfunction, including refractory over-active bladder, frequency-urgency syndrome and non-obstructive urinary retention. Patients were screened by percutaneous nerve evaluation (PNE) to assess their response to therapy using a 4-day voiding diary. Patients who experienced 50% or more improvement in their voiding parameters were permanently implanted. All patients completed the Female Sexual Function Index (FSFI), Short-Form Health Survey (SF-36), and incontinence questionnaires (Urinary Distress Inventory [UDI]-6) preoperatively and 4 months postoperatively.

RESULTS

A total of 33 female patients had SNM therapy; 10 were excluded from the study because they were not sexually active. The indications were: refractory overactive bladder in 19, frequency-urgency syndrome in 2, and non-obstructive urinary retention in another 2 patients. SNM therapy significantly improved the total FSFI score (p = 0.011); the components of desire and orgasm showed significant improvement (p = 0.014 and p = 0.035, respectively). Age, body mass index, diagnosis, and urinary symptoms did not show significant correlation with FSFI score improvement. Quality of life showed significant improvement after SNM treatment in 5 categories. There was no correlation between improvement in quality of life and FSFI.

CONCLUSION

SNM may improve female sexual function and quality of life, yet there is no correlation between the improvement in FSFI and quality of life.

Maintaining an active lifestyle is always good

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Sacral neuromodulation and refractory overactive bladder: an emerging tool for an old problem

Overactive bladder (OAB) syndrome negatively affects the daily life of many people. Conservative treatments, such as antimuscarinics, do not always lead to sufficient improvement of the complaints and are often associated with considerable side effects resulting in treatment failure. In the case of failure or intolerable side effects, sacral neuromodulation (SNM) and botulinum toxin intravesical injections are minimally invasive and reversible alternatives. Currently, both SNM and botulinum toxin injection have FDA approval for use in OAB patients. This mini-review attempts to provide an update on SNM as a second-line management of adults with refractory OAB, based on the available clinical evidence concerning the efficacy and safety.

Mammalian target of rapamycin (mTOR) induces proliferation and de-differentiation responses to three coordinate pathophysiologic stimuli (mechanical strain, hypoxia, and extracellular matrix remodeling) in rat bladder smooth muscle

Maladaptive bladder muscle overgrowth and de-differentiation in human bladder obstructive conditions is instigated by coordinate responses to three stimuli: mechanical strain, tissue hypoxia, and extracellular matrix remodeling.( 1,2) Pathway analysis of genes induced by obstructive models of injury in bladder smooth muscle cells (BSMCs) identified a mammalian target of rapamycin (mTOR)-specific inhibitor as a potential pharmacological inhibitor. Strain-induced mTOR-specific S6K activation segregated differently from ERK1/2 activation in intact bladder ex vivo. Though rapamycin's antiproliferative effects in vascular smooth muscle cells are well known, its effects on BSMCs were previously unknown. Rapamycin significantly inhibited proliferation of BSMCs in response to mechanical strain, hypoxia, and denatured collagen. Rapamycin inhibited S6K at mTOR-sensitive phosphorylation sites in response to strain and hypoxia. Rapamycin also supported smooth muscle actin expression in response to strain or hypoxia-induced de-differentiation. Importantly, strain plus hypoxia synergistically augmented mTOR-dependent S6K activation, Mmp7 expression and proliferation. Forced expression of wild-type and constitutively active S6K resulted in loss of smooth muscle actin expression. Decreased smooth muscle actin, increased Mmp7 levels and mTOR pathway activation during in vivo partial bladder obstruction paralleled our in vitro studies. These results point to a coordinate role for mTOR in BSMCs responses to the three stimuli and a potential new therapeutic target for myopathic bladder disease.

Erectile dysfunction in spinal cord injury: a cost-utility analysis

BACKGROUND

There is a high incidence of erectile dysfunction after spinal cord injury. This can have a profound effect on quality of life. Treatment options for erectile dysfunction include sildenafil, intracavernous injections of papaverine/alprostadil (Caverject), alprostadil/papaverine/phentolamine ("Triple Mix"), transurethral suppository (MUSE), surgically implanted prosthetic device and vacuum erection devices. However, physical impairments and accessibility may preclude patient self-utilization of non-oral treatments.

METHODS

The costs and utilities of oral and non-oral erectile dysfunction treatments in a spinal cord injury population were examined in a cost-utility analysis conducted from a government payer perspective. Subjects with spinal cord injury (n=59) reported health preferences using the standard gamble technique.

RESULTS

There was a higher health preference for oral therapy. The cost-effectiveness results indicated that sildenafil was the dominant economic strategy when compared with surgically implanted prosthetic devices, MUSE(R) and Caverject. The incremental cost-utility ratios comparing sildenafil with triple mix and vacuum erection devices favoured sildenafil, with ratios less than CAN$20,000 per quality adjusted life year gained.

CONCLUSION

Based on this study, we conclude that sildenafil is a cost-effective treatment for erectile dysfunction in the spinal cord injury population.

Parameters of successful sacral root neuromodulation of the pelvic floor: a retrospective study

INTRODUCTION/OBJECTIVE

Neuromodulation of the pelvic floor (InterStim) is a relatively new technique in the field of urology. We present our observations for effective neuromodulation on our patient population.

MATERIALS AND METHODS

In a retrospective case review study, we studied the charts of 67 patients, who underwent InterStim operations between the years 1993 to 2002. All patients had a good response to InterStim. Patients with inefficient or inconclusive responses were not included in the study. All the relevant patient data was recorded from their charts. For each patient, the following was recorded; the amplitude in volts, the pulse width (in microseconds) and rate, the mode (cycling versus continuous), the electrodes and their position, the load impedance, and the change in amplitude over time.

RESULTS

Amplitude over time showed an initial plateau, followed by a small increase that gets larger.

CONCLUSIONS

Long-term management of InterStim recipients requires increasing amplitude following the implantation of the IntreStim to maintain the same satisfactory levels of urinary control.

Update on sacral neuromodulation: Indications and outcomes

Tanagho and Schmidt first introduced sacral nerve neuromodulation in 1981. Since then, it has become increasingly popular and the indications for this procedure are growing. The purpose of this article is to discuss the established indications for sacral nerve stimulation (SNS). The outcomes of the most recent studies and trials dealing with SNS are presented. An overview of the most recent techniques used for neuromodulation is detailed.

Investigation of the spread of human visceral leishmaniasis in central Tunisia

The epidemiology, clinical patterns, and spatial spread of Mediterranean visceral leishmaniasis were retrospectively studied in central Tunisia. The clinical profile of the disease was typical of the Mediterranean infantile form. Malnutrition and associated infectious diseases were observed in 62.5% and 55% of cases, respectively. The case-fatality rate was 6.2% and resistance to meglumine antimonate was observed in 1.6% of patients. The annual incidence of cases increased from approximately 10 cases per year before 1991 to approximately 50 cases per year between 1992 and 1994. The cumulative incidence was 133.7/100,000 among children aged < 15 years. This increase was preceded by 3 years of high mean annual rainfall in the region. The spatial distribution of the incidence of the infection through time showed an aggregation of cases in the northern part of the area where intensive agriculture projects took place during the last 10 years, leading to the establishment of a stable Leishmania infantum transmission cycle below the Atlas mountain chains, and an evident tendency to a progressive extension to the south.

Selective arterial embolization for post-traumatic high flow priapism

We report on a 23 year old patient with high flow priapism following blunt perineal trauma in which arterial-cavernosal fistula was missed by penile Doppler ultrasonography but was successfully localized by arteriography and embolized using Gelfoam pledgets. Detumescence was complete in 2 days and sexual function returned to the premorbid state after 4 weeks. The diagnosis, pathophysiology, and treatment of high flow priapism and review of the literature are discussed.

Rotational Spectrum of CBr by Kinetic Microwave Spectroscopy of 193-nm Photolysis Products of Bromoform

We have measured the first millimeter-wave spectrum of CBr. The radical was produced by pulsed UV-laser photolysis of bromoform at 193 nm and detected using kinetic spectroscopy. We have significantly improved the rotational and fine structure constants for the ground vibrational state. The hyperfine structure due to the bromine nucleus has been resolved and quadrupole and magnetic hyperfine parameters evaluated for the first time. Copyright 2000 Academic Press.

Urodynamic findings in adults with the tethered cord syndrome

PURPOSE

We evaluated bladder function in adults with the tethered cord syndrome using multichannel urodynamics.

MATERIALS AND METHODS

A total of 21 patients a mean 39.6 years old (range 20 to 62) with a tethered cord were evaluated. Of the patients 13 were diagnosed with a tethered cord as an adult and 8 had undergone previous spinal surgery. The tethered cord syndrome was diagnosed by magnetic resonance imaging in 20 patients and computerized tomography myelogram in 1. All patients underwent complete neurological and urological evaluation, including multichannel urodynamics. Needle electromyography and video urodynamics were performed in select cases. Microsurgical release of the tethered cord was performed in 19 patients and 2 refused surgery. Urodynamics were done before surgery in 16 of 19 patients and a median of 12.5 months (range 1 to 40) after surgery in 14. In addition, intraoperative urodynamic monitoring and nerve root stimulation were done in 14 patients to prevent nerve root injury at surgery.

RESULTS

At presentation urgency (67%) and urge incontinence (50%) were the most common findings in 18 patients with urinary symptoms. Pretreatment urodynamics in 18 of 21 patients revealed hyperreflexia in 13 (72%), external detrusor-sphincter dyssynergia in 4 (22%), decreased sensation in 4 (22%), decreased compliance in 3 (17%) and hypocontractile detrusor in 2 (11%). Postoperative urodynamic findings were improved in 4 patients (29%) and unchanged in 10 (71%). Preoperative external detrusor-sphincter dyssynergia in 4 patients resolved postoperatively in 3 and was unchanged in 1. Urinary symptoms were improved in 19% of patients (4), unchanged in 76% (16) and worse in 5% (1). To date 7 patients require anticholinergics, 4 require clean intermittent catheterization and 1 is taking an alpha-blocker.

CONCLUSIONS

Adults with the tethered cord syndrome are less likely to have urodynamic or symptom improvement after cord release and most often present with irreversible findings which rarely become worse after surgery. These patients need to have careful and continuous followup, including urodynamic studies, due to possible re-tethering with time.

Hyperreflexia of the urinary bladder: possible role of the efferent function of the capsaicin sensitive primary afferents

PURPOSE

Capsaicin sensitive primary afferents (CSPA) have been implicated in the pathogenesis of hyperreflexia after spinalization. In this study we investigated the role of the efferent function of these fibers in detrusor hyperreflexia and its effect on detrusor physiology and pharmacology.

MATERIALS AND METHODS

Four groups of female Sprague Dawley rats were included in our study. These groups were normal controls, capsaicin treated normal rats, spinalized rats and capsaicin treated spinalized rats. Six weeks following spinalization, animals were subjected to cystometric study, and bladders were obtained for either in vitro detrusor contractility study or substance P (SP), neurokinin A (NKA) and calcitonin gene related peptide (CGRP) quantification by radioimmunoassay.

RESULTS

Spinalized animals consistently developed hyperreflexia after spinalization in the form of uninhibited contractions more than 15 cm. water in amplitude. This was accompanied by increased urinary bladder total content of the neuropeptides but without any change in the detrusor contractility or neurokinin receptor pharmacology as shown by responses to KCl, electric field stimulation and neurokinin receptor selective agonists in the in vitro study. In the control group, urinary bladder total content of SP, NKA and CGRP was 0.19+/-0.03, 0.15+/-0.01 and 0.84+/-0.1 pmol/bladder respectively. In contrast, in the spinalized animals, these were 0.44+/-0.07, 0.21+/-0.03 and 2.28+/-0.34 pmol/bladder for the same peptides, respectively. Capsaicin treatment abolished hyperreflexia, which corresponded with the decrease in the neuropeptide content of the urinary bladder. The number and amplitude of the uninhibited contractions decreased dramatically. SP, NKA and CGRP reached 0.06+/-0.01, 0.07+/-0.01 and 0.44+/-0.18 pmol/bladder 2 weeks after capsaicin treatment in spinalized animals. This was associated with the occurrence of detrusor super-sensitivity to both neurokinin receptor selective agonists.

CONCLUSION

This study demonstrates the importance of the efferent function of the CSPA in the pathogenesis of hyperreflexia. On the other hand, detrusor changes were shown to be a noncrucial factor in the development of hyperreflexia.

Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: an acute study

Detrusor-sphincter dyssynergia is a main problem in supra-sacral spinal cord injured patients. The problem of high pressure voiding is also encountered in most electrically induced micturition because of the mixed somatic and autonomic fiber components of the ventral sacral root. We studied the effect of selective high-frequency blockade at the sacral nerve root in an acute spinalized canine model to prevent the deleterious consequences associated with the elevated bladder outlet resistance. A new functional electrical stimulation system which can generate one signal composed of two independent adjustable current waveforms delivered via a single bipolar electrode was used in 11 dogs. The selectivity resulted from the inhibition of the sphincteric somatic innervation by a high frequency pulse while the low frequency stimuli activated the bladder autonomic fibers. Bladder and urethral pressure as well as electromyograms of external urethral sphincter were recorded to determine whether selective high-frequency blockade occurred. Our experiments showed that we were able to achieve selective blockade of the external urethral sphincter during the simultaneous detrusor stimulation, thus obtaining a more physiologic voiding.

Reduction of bladder outlet resistance by selective sacral root stimulation using high-frequency blockade in dogs: an acute study

Detrusor-sphincter dyssynergia is a main problem in supra-sacral spinal cord injured patients. The problem of high pressure voiding is also encountered in most electrically induced micturition because of the mixed somatic and autonomic fiber components of the ventral sacral root. We studied the effect of selective high-frequency blockade at the sacral nerve root in an acute spinalized canine model to prevent the deleterious consequences associated with the elevated bladder outlet resistance. A new functional electrical stimulation system which can generate one signal composed of two independent adjustable current waveforms delivered via a single bipolar electrode was used in 11 dogs. The selectivity resulted from the inhibition of the sphincteric somatic innervation by a high frequency pulse while the low frequency stimuli activated the bladder autonomic fibers. Bladder and urethral pressure as well as electromyograms of external urethral sphincter were recorded to determine whether selective high-frequency blockade occurred. Our experiments showed that we were able to achieve selective blockade of the external urethral sphincter during the simultaneous detrusor stimulation, thus obtaining a more physiologic voiding.

Sacral root neuromodulation in idiopathic nonobstructive chronic urinary retention

PURPOSE

Sacral root neuromodulation is becoming a superior alternative to the standard treatment of idiopathic nonobstructive urinary retention. We report results in 20 successive patients who underwent sacral foramen implantation to restore bladder function.

MATERIALS AND METHODS

After an initial, thorough baseline assessment 20 patients 19.43 to 55.66 years old with idiopathic nonobstructive urinary retention underwent percutaneous nerve evaluation. Response was assessed by a detailed voiding diary. Responders underwent implantation with an S3 foramen implant, and were followed 1, 3 and 6 months postoperatively, and every 6 months thereafter.

RESULTS

Sacral root neuromodulation restored voiding capability in these patients. Bladders were emptied with minimal post-void residual urine, which decreased from 78.3 to 5.5 to 10.2% of the total voided volume from baseline to postoperative followup. These results were reflected in uroflowmetry and pressure-flow studies, which were almost normal after implantation. Furthermore, the urinary tract infection rate decreased significantly and associated pelvic pain improved substantially. The Beck depression inventory and SF-36 quality of life questionnaire indicated some improvement but reached significance in only 1 item. In addition, cystometrography showed no significant difference after 6 months of implantation compared with baseline values. Complications were minimal and within expectations.

CONCLUSIONS

Sacral root neuromodulation is an appealing, successful modality for nonobstructive urinary retention. Only patients who have a good response to percutaneous nerve evaluation are candidates for implantation. The high efficacy in patients who undergo implantation, relative simplicity of the procedure and low complication rate make this a treatment breakthrough in this difficult group.

Sacral nerve root neuromodulation: an effective treatment for refractory urge incontinence

PURPOSE

Sacral foramina implants have been recognized recently as a method for treatment of refractory urinary urge incontinence. We study the outcome of the procedure with in-depth analysis of the results of 18 implanted cases.

MATERIALS AND METHODS

Patients with urinary urge incontinence were subjected to percutaneous nerve evaluation of the S3 roots as a temporary screening test to determine response to neuromodulation. Satisfactory responders were implanted with permanent sacral root neuroprosthesis. The study design included comprehensive voiding diaries for 4 consecutive days twice as a baseline, 1 with percutaneous nerve evaluation screening, 1 after the percutaneous nerve evaluation, 1 at the 1, 3 and 6 post-implantation visits, and every 6 months thereafter. Uroflowmetry and quality of life questionnaires were performed at the same intervals. Urodynamic study was done as a baseline and 6 months after implantation of the neuroprosthesis.

RESULTS

All 18 patients (16 women and 2 men) with refractory urge incontinence received a sacral foramina neuroprosthesis after demonstrating a good response to the percutaneous nerve evaluation. Average patient age at presentation was 42.3+/-3.3 years (range 22 to 67) and duration of urinary symptoms was 6.6+/-1.3 years (range 1.2 to 18.8). Average followup was 18.8 months (range 3 to 83). Neuromodulation in these patients showed a marked reduction in leakage episodes from 6.49 to 1.98 times per 24 hours and in the leakage severity score. Eight patients became completely dry and 4 had average leakage episodes of 1 or less daily. Patients showed as well a decrease in urinary frequency with an increase in functional bladder capacity. Associated pelvic pain improved substantially. Cystometrograms demonstrated increased volume at first sensation by 50% and increased cystometric capacity by 15% with the disappearance of uninhibited contractions in 1 of the 4 patients who presented with it preoperatively. There was also noticeable improvement in the quality of life. Complication rate was low and none was life threatening.

CONCLUSIONS

Sacral root neuromodulation is an appealing modality for treatment of urge incontinence refractory to conventional pharmacotherapy. The relative simplicity of the technique, promising results and low complication rate make this therapy a likely alternative.

Alternatives for the pharmacologic management of urge and stress urinary incontinence in the elderly

Urinary incontinence in the elderly is a common but typically remediable condition that is frequently managed by pharmacotherapy. However, because of age-related changes, the response to a specific dosage of a certain drug administered to an elderly person may be quite different than the response experienced by a younger individual. This article will review general principles of pharmacotherapy in the elderly patient and pharmacologic alternatives for the management of urge and stress urinary incontinence.