Postoperative interventions for preventing bladder dysfunction after radical hysterectomy in women with early-stage cervical cancer

BACKGROUND

Bladder dysfunction is a common complication following radical hysterectomy, caused by the damage to pelvic autonomic nerves that innervate the muscles of the bladder, urethral sphincter, and pelvic floor fasciae. Bladder dysfunction increases the rates of urinary tract infection, hospital visits or admission, and patient dissatisfaction. In addition, bladder dysfunction can also negatively impact patient quality of life (QoL). Several postoperative interventions have been proposed to prevent bladder dysfunction following radical hysterectomy. To our knowledge, there has been no systematic review evaluating the effectiveness and safety of these interventions for preventing bladder dysfunction following radical hysterectomy in women with cervical cancer.

OBJECTIVES

To evaluate the effectiveness and safety of postoperative interventions for preventing bladder dysfunction following radical hysterectomy in women with early-stage cervical cancer (stage IA2 to IIA2).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to April week 2, 2020), and Embase via Ovid (1980 to 2020, week 16). We also checked registers of clinical trials, grey literature, conference reports, and citation lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) evaluating the effectiveness and safety of any type of postoperative interventions for preventing bladder dysfunction following a radical hysterectomy in women with stage IA2 to IIA2 cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected potentially relevant RCTs, extracted data, assessed risk of bias, compared results, and made judgments on the quality and certainty of the evidence. We resolved any disagreements through discussion or consultation with a third review author. Outcomes of interest consisted of spontaneous voiding recovery one week after the operation, quality of life (QoL), adverse events, post-void residual urine volume one month after the operation, urinary tract infection over the one month following the operation, and subjective urinary symptoms.

MAIN RESULTS

We identified 1464 records as a result of the search (excluding duplicates). Of the 20 records that potentially met the review criteria, we included five reports of four studies. Most of the studies had unclear risks of selection and reporting biases. Of the four studies, one compared bethanechol versus placebo and three studies compared suprapubic catheterisation with intermittent self-catheterisation. We identified two ongoing studies. Bethanechol versus placebo The study reported no information on the rate of spontaneous voiding recovery at one week following the operation, QoL, adverse events, urinary tract infection in the first month after surgery, and subjective urinary symptoms for this comparison. The volume of post-void residual urine, assessed at one month after surgery, among women receiving bethanechol was lower than those in the placebo group (mean difference (MD) -37.4 mL, 95% confidence interval (CI) -60.35 to -14.45; one study, 39 participants; very-low certainty evidence). Suprapubic catheterisation versus intermittent self-catheterisation The studies reported no information on the rate of spontaneous voiding recovery at one week and post-void residual urine volume at one month following the operation for this comparison. There was no difference in risks of acute complication (risk ratio (RR) 0.77, 95% CI 0.24 to 2.49; one study, 71 participants; very low certainty evidence) and urinary tract infections during the first month after surgery (RR 0.77, 95% CI 0.53 to 1.13; two studies, 95 participants; very- low certainty evidence) between participants who underwent suprapubic catheterisation and those who underwent intermittent self-catheterisation. Available data were insufficient to calculate the relative measures of the effect of interventions on QoL and subjective urinary symptoms.

AUTHORS' CONCLUSIONS

None of the included studies reported rate of spontaneous voiding recovery one week after surgery, time to a post-void residual volume of urine of 50 mL or less, or post-void residual urine volume at 6 and 12 months after surgery, all of which are important outcomes for assessing postoperative bladder dysfunction. Limited evidence suggested that bethanechol may minimise the risk of bladder dysfunction after radical hysterectomy by lowering post-void residual urine volume. The certainty of this evidence, however, was very low. The effectiveness of different types of postoperative urinary catheterisation (suprapubic and intermittent self-catheterisation) remain unproven.

A randomized controlled trial of cystoinflation to prevent bladder injury in the adhesive disease of multiple caesarean sections

Caesarean sections carry the risk of urinary bladder injury due to formation of adhesions obscuring pelvic planes. Visualizing bladder during retro-fill (cystoinflation) makes it recognizable as it rises into the abdomen taking a tense rounded contour. We conducted a prospective randomized controlled trial to find out whether improved identification of bladder margins by cystoinflation could decrease bladder injury rate and blood loss without causing urological complications. This study included 214 healthy women with previous operative deliveries undergoing elective caesarean section and found to have dense pelvic adhesions. The subjects were randomly allocated into cystoinflation and control groups. Adhesiolysis was performed using bladder retro-fill with 300 cc saline in cystoinflation group, and without retro-fill in control. The bladder injury rate was significantly lower in cystoinflation group compared to control (2.8% vs 20.6%, P < .0001) with lesser blood loss in cystoinflation group (585.33 cc vs 797.10 cc, P < .0001). Mean operative time was similar in both groups. Urinary tract infection and micturition problems occurred more frequently in control group than cystoinflation group (16.8% vs 1.9%, P = .001 and .47 ± 1.63% vs 077 ± .633%, P = .021 respectively) with fistula in one subject compared to none in cystoinflation group. In this study, cystoinflation was effective to significantly reduce bladder injury rate and blood loss. This technique may also prove useful in the fields of surgery, urology and urogynecology.

Nerve-Sparing Radical Hysterectomy: A Pilot Study

Nerve-sparing radical hysterectomy has increasingly been used for cervical cancer, with less morbidity. We aimed with this study: i) to describe an alternative technique of nerve-sparing radical Piver III hysterectomy, using the CUSA®, in which attention was given to the uterosacral ligament and cardinal ligament; ii) to evaluate the feasibility of this new nerve-sparing technique; iii) to describe the surgical anatomy of the autonomic nervous system; iv) to assess the early incidence of bladder dysfunction. Twelve consecutive patients with local-regional advanced cervical cancer were enrolled in the study on nerve-sparing radical hysterectomy with extended pelvic lymphadenectomy. The mean age was 44 years (range, 30–59), mean body mass index was 24 kg/m2 (range, 18–30), mean operating time was 217 mins (range, 195–240), and mean blood loss was 437 cc (range, 200–750). The average hospitalization time was 9 days (range, 5–15 days). Two patients presented pathologically positive parametrium. Two of 12 (17%) patients were discharged with self-catheterism. In the first outpatient follow-up, 1 patient had recovered spontaneous voiding. The nerve-sparing technique with CUSA® can be an option to reduce radical hysterectomy-related morbidity. The technique proved to be feasible, with promising results in terms of preventing bladder dysfunction. An elevated body mass index and large tumors can impair the performance of the technique. Further studies clarifying neuroanatomy and neurophysiology of autonomic nervous structures, as well as a prospective controlled trial on nerve-sparing radical hysterectomy should be carried out to confirm our data.

Aqueous extract from Orthosiphon stamineus leaves prevents bladder and kidney infection in mice

BACKGROUND

Extracts from the leaves of Orthosiphon stamineus are used in phytotherapy for treatment of uncomplicated urinary tract infections.

PURPOSES

Evaluation of an aqueous extract against infection with uropathogenic Escherichia coli in vivo; investigation of underlying microbiological mechanisms.

STUDY DESIGN

In vivo studies in mice and in vitro investigations on cytotoxicity, antiadhesive potential, influence on bacterial gene expression and quorum sensing.

METHODS

Extract OWE was prepared by hot water extraction. For in vivo studies BALB/c mice were used in an UPEC infection model. The effect of OWE on bacterial load in bladder/kidney tissue was monitored in pre- and posttreatment. Cytotoxicity of OWE against different UPEC strains, T24 bladder/A498 kidney cells, gene expression analysis, monitoring of phenotypic motility and quorum sensing was investigated by standard methods of microbiology.

RESULTS

OWE was quantified (UHPLC) according to the content of rosmarinic acid, cichoric acid, caffeic acid. Three- and 5-day treatment of animals with OWE (750mg/kg) after transurethral infection with UPEC CFT073 reduced the bacterial load in bladder and kidney, similar to norfloxacin. Four- and 7-day pretreatment of mice prior to the infection with UPEC NU14 reduced bacterial bladder colonization. In vitro investigations indicated that OWE (≤2mg/ml) has no cytotoxic or proliferation-inhibiting activity against different UPEC strains as well as against T24 bladder and A498 kidney cells. OWE exerts a dose dependent antiadhesive activity against UPEC strains NU14 and UTI89. OWE reduced gene expression of fimH, but evoked increase of the expression of motility/fitness gene fliC. Increase of bacterial motility on gene level was confirmed by a changed bacterial phenotype by an increased bacterial motility in soft agar assay. OWE inhibited in a concentration-dependent manner bacterial quorum sensing.

CONCLUSION

OWE is assessed as a strong antiadhesive plant extract for which the traditional use in phytotherapy for UTI might be justified.

Lidocaine-prilocaine cream reduces catheter-related bladder discomfort in male patients during the general anesthesia recovery period: A prospective, randomized, case-control STROBE study

Urethral catheterization is a predictor of agitation during the general anesthesia recovery period. The aim of this study was to determine the effect of intraurethral 5% lidocaine and 25 mg/g prilocaine cream in reducing catheter-related bladder discomfort (CRBD) in male patients during the general anesthesia recovery period. Adult male patients undergoing elective operations that required urinary catheterization under general anesthesia were enrolled and assigned randomly to 2 groups. In the lidocaine-prilocaine cream group (n = 72), approximately 5 g of topical cream was spread in the preputial sac, the glans, the meatus, and on the urinary catheter surface before urinary catheterization. In the control group (n = 74), the urinary catheter was lubricated with lidocaine gel. The incidence and severity of CRBD were assessed 15, 30, 45, and 60 minutes postoperatively. We found that the incidence of CRBD in the lidocaine-prilocaine cream group was significantly lower than in the control group. Multivariate logistic regression analysis showed that lidocaine-prilocaine cream applications reduced moderate or severe CRBD. Thirty minutes postoperation was the most frequent time point for the incidence of CRBD. Application of lidocaine-prilocaine cream on the surface of the urinary catheter is an efficient and safe method to reduce the incidence and severity of CRBD.

Strategies for the prevention of catheter-related bladder discomfort: A PRISMA-compliant systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The ideal measures to prevent postoperative catheter-related bladder discomfort (CRBD) remain unestablished. We conducted the systematic review and meta-analysis to clarify the significance of potential interventions.

METHODS

We followed the Preferred Reporting Items for Systematic review and Meta-Analysis statement guidelines, and searched databases from MEDLINE, EMBASE, and referred Cochrane Library for randomized clinical trials (RCTs) published before December 2014. Reference lists from reviews or related articles were screened and checked for the related RCTs. Data extraction was performed carefully by 2 authors, respectively, and methodological quality was assessed by scoring system. Meta-analysis was applied for studies using the similar strategies or same reagents on the similar participants focused on CRBD. The primary outcome measure was the incidence of postoperative CRBD.

RESULTS

We identified 8 RCTs with interventions ranging from perioperative managements to pharmacological or multicomponent interventions. Meta-analysis showed ketamine was associated with less incidence of CRBD compared with placebo (pool risk ratio [RR] = -0.75, 95% confidence interval [CI] = 0.17-3.44, P < 0.01) at 0 hour, 1 hour (RR = -0.26, 95%CI = -0.38 to -0.13, P < 0.01), and 2 hours (RR = 0.31, 95%CI = 0.17-0.55, P < 0.01) and 6 hours (RR = 0.23, 95% CI = 0.11-0.49, P < 0.01) after operation. Oxybutynin did not affect the incidence of CRBD (RR = 0.46, 95%CI = 0.20-1.03, P = 0.06). Anticholinergic drugs also lower the incidence of CRBD at 0 hour (RR = 0.52, 95% CI = 0.38-0.71, P < 0.01), 1 hour (RR = 0.66, 95% CI = 0.51-0.86, P < 0.01), 2 hours (RR = 0.62, 95% CI = 0.46-0.84, P < 0.01), and 6 hours (RR = 0.56, 95%CI = 0.38-0.81, P < 0.01) postoperatively. Tramadol and gabapentin were also useful in lower the incidence and severity of CRBD in a RCT with 50 patients.

CONCLUSION

The included studies showed great effectiveness in incidence of postoperative CRBD. Meta-analysis supported that ketamine, oxybutynin, and anticholinergic reagents interventions were useful in preventing postoperative catheter-related bladder discomfort.

Suppression of the PI3K pathway in vivo reduces cystitis-induced bladder hypertrophy and restores bladder capacity examined by magnetic resonance imaging

This study utilized magnetic resonance imaging (MRI) to monitor the real-time status of the urinary bladder in normal and diseased states following cyclophosphamide (CYP)-induced cystitis, and also examined the role of the phosphoinositide 3-kinase (PI3K) pathway in the regulation of urinary bladder hypertrophy in vivo. Our results showed that under MRI visualization the urinary bladder wall was significantly thickened at 8 h and 48 h post CYP injection. The intravesical volume of the urinary bladder was also markedly reduced. Treatment of the cystitis animals with a specific PI3K inhibitor LY294002 reduced cystitis-induced bladder wall thickening and enlarged the intravesical volumes. To confirm the MRI results, we performed H&E stain postmortem and examined the levels of type I collagen by real-time PCR and western blot. Inhibition of the PI3K in vivo reduced the levels of type I collagen mRNA and protein in the urinary bladder ultimately attenuating cystitis-induced bladder hypertrophy. The bladder mass calculated according to MRI data was consistent to the bladder weight measured ex vivo under each drug treatment. MRI results also showed that the urinary bladder from animals with cystitis demonstrated high magnetic signal intensity indicating considerable inflammation of the urinary bladder when compared to normal animals. This was confirmed by examination of the pro-inflammatory factors showing that interleukin (IL)-1α, IL-6 and tumor necrosis factor (TNF)α levels in the urinary bladder were increased with cystitis. Our results suggest that MRI can be a useful technique in tracing bladder anatomy and examining bladder hypertrophy in vivo during disease development and the PI3K pathway has a critical role in regulating bladder hypertrophy during cystitis.

Long-term caloric restriction in rats may prevent age related impairment of in vitro bladder function

PURPOSE

Bladder function is often impaired with aging. In other organs caloric restriction has had a prophylactic effect on the biological changes associated with aging. We tested the hypothesis that long-term caloric restriction can prevent age related impaired bladder function in the rat.

MATERIALS AND METHODS

Fisher 344 male rats were divided into 3 groups, including 16 young rats at age 6 months with free access to normal food, 15 old rats at age 25 to 28 months with free access to normal food and 16 old rats at age 25 to 28 months fed with normal food 3 days per week since age 6 weeks (caloric restriction). We performed frequency volume measurements, in vitro organ bath functional studies using full-thickness longitudinal detrusor strips, evaluation of muscarinic and purinergic receptor mRNA expression, and histological examination with Masson trichrome staining of bladder tissue.

RESULTS

Frequency volume changes did not significantly differ among the 3 groups. The old group fed normal food showed weaker contractile responses to carbachol and electrical field stimulation (especially in the cholinergic component), lower M3 receptor mRNA expression and higher collagen deposition compared to the young group. These age related bladder changes were milder in the old group with caloric restriction than in the old group fed normal food.

CONCLUSIONS

This study suggests that in the rat long-term caloric restriction has a preventive effect against age related functional and morphological bladder changes. These changes include impaired detrusor contractility that may be related to decreased expression of M3 receptors and to bladder wall fibrosis.

The efficacy of pregabalin for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled double-blind study

OBJECTIVE

The present study evaluated the efficacy of preoperative pregabalin for prevention of catheter-related bladder discomfort.

DESIGN

Prospective, randomized, placebo controlled, double blinded study.

MATERIALS AND METHODS

Sixty patients of either sex undergoing elective spine surgery and requiring urinary bladder catheterization were randomly assigned to two groups. The patients in Group P (pregabalin group) received 150 mg of pregabalin orally 1 h prior to induction of anesthesia with sips of water and the patients in Group C (control group) received placebo. Anesthesia technique was identical in both the groups. Catheter-related bladder discomfort (CRBD) was evaluated on a 4-point scale (1 = no discomfort, 2 = mild, 3 = moderate, 4 = severe), on arrival (0 h) and again at 1, 2, and 6 h postoperatively. Patients were provided patient-controlled analgesia with fentanyl for postoperative pain relief.

RESULTS

The incidence of CRBD was significantly less in the pregabalin group compared with the control group at all time intervals (P < 0.05). The severity of CRBD was reduced in the pregabalin group compared with the control group at all time intervals except 6 h. The postoperative consumption of fentanyl was significantly less in group P, while the sedation score was significantly higher in the group P compared to group C.

CONCLUSION

Pretreatment with pregabalin 150 mg prevents CRBD and also decreases postoperative fentanyl consumption. ClinicalTrials.gov identifier: (ref: CTRI/2013/11/004170).

Impact of behaviour and lifestyle on bladder health

Bladder conditions, including UTI, UI, and bladder cancer, are highly prevalent and affect a wide range of populations. There are a variety of modifiable behavioral and lifestyle factors that influence bladder health. Some factors, such as smoking and obesity, increase the risk or severity of bladder conditions, whereas other factors, such as pelvic floor muscle exercise, are protective. Although clinical practice may be assumed to be the most appropriate ground for education on behavioral and lifestyle factors that influence bladder health, it is also crucial to extend these messages into the general population through public health interventions to reach those who have not yet developed bladder conditions and to maximize the prevention impact of these behaviors. Appropriate changes in these factors have the potential for an enormous impact on bladder health if implemented on a population-based level.

A healthy bladder: a consensus statement

A panel of experts in urology, urogynecology, nursing, and behavioral therapy convened in 2010 to discuss the importance of a healthy bladder on overall health. They determined that a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors, and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions. In this statement, 'healthy' bladder function is described, as well as internal and external factors that influence bladder health. It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. This education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviors, awareness of risk factors, healthcare seeking, and clinician engagement and reducing stigma and other barriers to treatment. Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment. While adopting healthy bladder habits and behaviors and behaviors may improve or maintain bladder health, it is important to recognize that certain symptoms may indicate the presence of conditions that require medical attention; many bladder conditions are treatable with a range of options for most bladder conditions. Lastly, the authors propose clinical directives based on persuasive and convergent research to improve and maintain bladder health. The authors hope that this statement will lead to promotion and achievement of optimal bladder health, which may improve overall health and help minimize the effects of bladder conditions on the public, healthcare professionals, educators, employers, and payors. The advisors are in consensus regarding the recommendations for improving and maintaining bladder health presented herein.

Ketorolac or fentanyl continuous infusion for post-operative analgesia in children undergoing ureteroneocystostomy

BACKGROUND

children undergoing ureteroneocystostomy suffer from post-operative pain due to the surgical incision and bladder spasm. A single-shot caudal block is a common technique for paediatric analgesia, but a disadvantage is the limitation of a short duration in spite of the additives co-administered. A few clinical trials have shown that ketorolac provides an effective post-operative analgesia and reduces the bladder spasms after ureteral implantation in children. We compared the efficacy of a continuous infusion of ketorolac and fentanyl in post-operative analgesia and bladder spasm in children who underwent ureteroneocystostomy.

METHODS

fifty-two children were allocated to the ketorolac group (Group K, n=26) and fentanyl group (Group F, n=26). After general anaesthesia, a caudal block was performed with 1.5 ml/kg of 0.15% ropivacaine. At the beginning of surgery, an infusion was started after the bolus injection of ketorolac 0.5 mg/kg or fentanyl 1 microg/kg. An infusion device was programmed to deliver ketorolac 83.3 microg/kg/h or fentanyl 0.17 microg/kg/h for 48 h.

RESULTS

two of Group F and three of Group K were excluded from the study. Post-operative pain scores were similar between the two groups. One of Group K (4%) and seven of Group F (30.4%) experienced bladder spasms. The rescue analgesic requirements were significantly less in Group K.

CONCLUSIONS

a Continuous infusion of ketorolac provided effective analgesia after operation in children who underwent ureteroneocystostomy as well as a low dosage of fentanyl. Ketorolac was more effective in reducing the frequency of bladder spasms and rescue analgesic requirements.

Effect of melatonin on the expression of Nrf2 and NF-kappaB during cyclophosphamide-induced urinary bladder injury in rat

Urotoxicity is one of the major problems associated with cyclophosphamide (CP) chemotherapy in cancer patients. Melatonin is a potent antioxidant and reduces CP-induced urotoxicity. However, the molecular mechanisms of protection offered by melatonin are not yet clear. The present study investigated the role of nuclear erythroid 2-related factor 2 (Nrf2) and nuclear factor-kappa B (NF-kappaB) on melatonin-mediated protection against CP-induced urotoxicity. CP was administered intraperitoneally at the dose of 150 mg/kg to induce urotoxicity in male Sprague-Dawley rats. Melatonin treatment (10 mg/kg) was initiated 3 days before and continued for 1 day after the CP administration. Melatonin treatment reduced the CP-induced oxidative stress and DNA damage in the urinary bladder as observed by abrogation in thiobarbituric acid-reactive substances and glutathione levels as well as comet and modified comet assay parameters. Melatonin treatment reduced the bladder damage and apoptosis as observed by histological analysis and TUNEL assay. Melatonin increased the expression of transcription factor Nrf2 as well as associated phase-II enzymes NADPH: quinone oxidoreductase-1 and heme oxygenase-1. Further melatonin treatment reduced the expression of transcription factor NF-kappaB. The results of the present study provide evidence that melatonin treatment favorably alters Nrf2 and NF-kappaB expression and, this appears to be at least in part responsible for observed protection against CP-induced urotoxicity.

[Nerve-sparing radical hysterectomy and radical hysterectomy: a retrospective study]

OBJECTIVE

To compare Piver radical hysterectomy (RH) with nerve-sparing radical hysterectomy (NSRH) for cervical cancer patients in terms of postoperative physiology of pelvic autonomic nerve and perioperative complications.

METHODS

Ninety-three consecutive patients with invasive cervical cancer underwent RH (69 cases) or NSRH (24 cases) from March 2005 to March 2006 at Fudan University Cancer Hospital. The postoperative function of bladder, bowel and sexual function and perioperative morbidity were assessed.

RESULTS

Compared with patients received RH, patients underwent NSRH presented a significantly prompter recovery of bladder function (8.7 vs. 14.8 days, P < 0.01) and bowel function (2.9 vs. 3.2 days, P < 0.01). However, there were not significant difference in terms of operative time (146.7 vs. 143.3 minutes, P > 0.05), estimated blood loss (441.7 vs. 565.9 ml, P > 0.05) and hospital stay (10.21 vs. 10.19 days, P > 0.05). No positive surgical margin was found in both groups. No surgery complication was found in NSRH group, while there were 1 case presented the infection of lymphocyst and 1 case presented intestinal obstruction in RH group. After following up postoperative 6 months, the patients received NSRH had a higher rate of satisfaction at sex activity than those received RH (29% vs. 9%, P = 0.042).

CONCLUSION

NSRH is safe and feasible surgical management for cervical cancer patients, which would improved the physiology of pelvic autonomic nerve postoperatively.

[Control of postoperative bladder spasm by caudal anesthesia in children undergoing ureteral reimplantation]

BACKGROUND

For management of postoperative bladder spasm by the ureteral reimplantation, general anesthesia and epidural anesthesia are selected in many hospitals, but epidural anesthesia is not a common technique for various complications and risks. We examined whether postoperative bladder spasms can be prevented by general anesthesia combined with single shot caudal anesthesia.

METHODS

We studied 18 patients undergoing ureteral reimplantation. Premedicated by diazepam syrup (0.5 mg x kg(-1), maximum dose 10 mg). In combination with caudal anesthesia with 0.3% ropivacaine (3 mg x kg(-1), maximum dose 60 mg), general anesthesia was maintained with oxygen, nitrous oxide and sevoflurane. For the evaluation of pain relief we used face pain scale when the patients returned to the ward, postoperative 5 hours, 24 hours and at discharge.

RESULTS

At postoperative 5 and 24 hours, some patients had a pain scale of above 3. But, those under pain scale 1 was 83%. At discharge, all patients were evaluated as pain scale 0 or 1.

CONCLUSIONS

General anesthesia combined with single shot caudal anesthesia suppressed postoperative bladder spasm. All patients were discharged within 3 postoperative days.

Natural approaches to prevention and treatment of infections of the lower urinary tract

Infections of the lower urinary tract are common occurrences in young women, during pregnancy, and in peri- and postmenopausal women. Because of the chronic nature of urinary tract infections (UTIs) and the potential for antibiotic resistance, a natural approach to prevention and treatment is desirable. Clinical research suggests the best natural options for long-term prevention include cranberry, mannose, and probiotics. Botanicals that can be effective at the first sign of an infection and for short-term prophylaxis include berberine and uva ursi. Estriol cream and vitamins A and C have also been shown to prevent UTIs, while potassium salts can alkalinize the urine and reduce dysuria.

Grapes and human health: a perspective

Grapes are a valuable source of numerous phytonutrients, including the intensively studied constituent, resveratrol. A question worth addressing is the potential of dietary grape consumption to positively modulate human health. Many studies have suggested cardiovascular benefits, and some work has indicated cancer chemopreventive activity. Data are particularly compelling in the area of skin cancer prevention. With financial support provided by the California Table Grape Commission, novel and exciting preliminary data are emerging from independent research suggesting beneficial activity against other less prevalent but devastating illnesses, such as Alzheimer's disease and urinary bladder dysfunction. It is further suggested that some of the copious amounts of data obtained with resveratrol may be relevant to grape consumption, especially responses that can be mediated by low concentrations of the substance. Whether future specific health claims will be sought from or allowed by regulatory authorities is not known, but based on existing data, it is clear that grapes should be considered an integral component of fruit and vegetable enriched diets that are recommended by health authorities and widely accepted as beneficial for human health and disease prevention.

[Urinary functional and urodynamic preoperative evaluation of patients with deep pelvic surgical endometriosis: about 12 cases]

OBJECTIVES

Laparoscopic surgery of deep endometriosis, including uterosacral ligament and rectal localisation, generally induces postoperative urinary disorders, caused by sacral plexus nerve lesions. However, during presurgical consultation, patients with these symptoms frequently present some urinary disorders. Our objective was to prospectively evaluate the reality of pre-existant urinary disorders by performing urodynamic tests.

PATIENTS AND METHODS

This study is a prospective, descriptive and non-comparative study about 12 consecutive patients consulting for a surgical assumption of deep endometriosis, including clinical and radiological lesions on the uterosacral ligaments, on the uterine torus and/or on the rectum.

RESULTS

A total of 12 patients whose ages ranged from 24 to 42 (mean age 34.6 +/-5.3 years). The mean parity was 0.5+/- 0.8 children (0-2). A clinical examination and multiple preoperative imaging techniques (abdominopelvic ultrasonography [US] and Magnetic Resonance Imaging [MRI]) were used to diagnose a deep endometriosis. During consultation, four patients presented no urinary dysfunction (33%). The eight other patients presented at least one of the following symptoms: increased daytime frequency, urinary incontinence, straining, increased night time frequency, urgency, mictional burns, bladder cramps, reduction in the bladder sensation. Any urinary infection was systematically eliminated. Multiple imaging techniques allowed to diagnose: an adnexal lesion in three cases (25%), adenomyosis in three cases (25%). Endometriosis was detected on the rectum in eight cases (66.7%), on the uterine torus in nine cases (75%) and on the uterosacral ligaments in 10 cases (83.3%). No vesical localisation was found. The urodynamic tests performed before surgery were totally normal in only two cases (16.7%). Three patients had a true postmictional residue (25%), but only one was pathological (more than 100 mL). The mean urethral fence pressure was 87.8 +/- 33.5 cm H20 (38-150). Four patients had a urethral hypertonia (30%), three patients a urethral instability (25%), three patients a dysuria (25%), two patients a hypersensitive bladder (16.7%), two patients had an insufficiency of the urethral sphincter (16.7%), one patient a big hypoesthetic bladder (8.3%) and one patient a small bladder capacity.

DISCUSSION AND CONCLUSION

Patients with deep endometriosis on the uterosacral ligaments and/or on the former face of the rectum frequently have urinary disorders. Consulting such patients is fundamental since it allows to diagnose them but it is not sufficient. Performing urodynamic tests can precisely determine and quantify real disorders. These disorders are neurological, probably related to lesions of the inferior hypogastric plexus and not to a lesion of the bladder. In this prospective study, there is no correlation between the preoperative disorders and the localisation of the lesions. A further study on a greater number of patients is necessary to define possible improvements and complications related to the surgery.

Effects of poly(ADP-ribose) polymerase inhibition in bladder damage caused by cyclophosphamide in rats

It was previously shown that nitric oxide produced by inducible nitric oxide synthase (iNOS) and peroxynitrite are responsible for cyclophosphamide (CP)-induced cystitis. Since endogenous production of peroxynitrite is known to lead to poly(ADP-ribose) polymerase (PARP) activation, in this study, the aim was to evaluate whether the PARP activation pathway is also included in the pathogenesis of CP-induced bladder ulceration in rats. A total of 48 male albino Wistar rats were divided into 5 groups. Group 1 served as control and was given 2 ml saline; four groups received a single dose of CP (200 mg/kg) with the same time intervals. Group 2 received CP only; Group 3, selective iNOS inhibitor 1400W (20 mg/kg); Group 4, peroxynitrite scavenger ebselen (30 mg/kg); and Group 5, PARP inhibitor 3-aminobenzamide (20 mg/kg). CP injection resulted in severe cystitis with continuous macroscopic hemorrhage, strong edema, inflammation, and ulceration. Moreover, bladder iNOS activation and urine nitrite-nitrate levels were dramatically increased. Histologically, 1400W protected bladder against CP damage and decreased urine nitrite-nitrate levels and bladder iNOS induction. Ebselen has shown similar histologic results with 1400W without changing urinary nitrite-nitrate level and iNOS activity. Furthermore in the 3-aminobenzamide group, beneficial effects had also occurred including decreased ulceration. These results suggest that PARP activation involves pathogenesis of CP-induced bladder ulceration. Furthermore, PARP is not only important for ulceration but also for bladder edema, hemorrhage, and inflammation because of broken uroepithelial cellular integrity.

Expression of transforming growth factor β1 gene, basic fibroblast growth factor gene and hydroxyproline in diabetes-induced bladder dysfunction in a rat model

AIMS

To investigate the content of hydroxyproline (Hyp) and the expression of transforming growth factor beta1 (TGF beta1) and basic fibroblast growth factor (bFGF) in the bladder 8 weeks after diabetes induction.

METHODS

Thirty wistar rats were divided into three groups: control (n = 10), streptozotocin-induced diabetic group (n = 10), TAD group (n = 10; diabetic rats were fed with Tadenan 100 mg kg(-1) day(-1)). Eight weeks later, the bladders were dissected. RT-PCR, immunohistochemistry, and ELISA were used to detect the expression of TGF beta1 and bFGF in the bladder. Also hydroxyproline (Hyp) was measured using a method based on alkaline hydrolysis.

RESULTS

The content of hydroxyproline in the diabetic group was greater than that of control group (P < 0.05); we found significantly increased expression of TGF beta1 mRNA and bFGF mRNA in the bladder from the diabetic group compared with the control group; immunohistochemical and ELISA studies showed a statistically significant increased expression of TGF beta1 protein and bFGF protein in the bladder from the diabetic group compared with the control group (P < 0.05). The content of hydroxyproline in TAD group was less than that of diabetic group (P < 0.05); mRNA expression of TGF beta1 and bFGF greatly decreased in TAD group compared with that of the diabetic group; immunohistochemical and ELISA studies showed decreased levels of TGF beta1 protein and bFGF protein in the bladder from TAD group compared with the diabetic group (P < 0.05).

CONCLUSIONS

Rats with streptozoticin-induced diabetes mellitus showed significant increase in hydroxyproline, TGF beta1 and bFGF levels in their bladders, which may be an important mechanism inducing diabetic cystopathy. Tadenan could effectively reduce hydroxyproline, TGF beta1, and bFGF levels.

TLR4-initiated and cAMP-mediated abrogation of bacterial invasion of the bladder

The remarkable resistance of the urinary tract to infection has been attributed to its physical properties and the innate immune responses triggered by pattern recognition receptors lining the tract. We report a distinct TLR4 mediated mechanism in bladder epithelial cells (BECs) that abrogates bacterial invasion, a necessary step for successful infection. Compared to controls, uropathogenic type 1 fimbriated Escherichia coli and Klebsiella pneumoniae invaded BECs of TLR4 mutant mice in 10-fold or greater numbers. TLR4 mediated suppression of bacterial invasion was linked to increased intracellular cAMP levels which negatively impacted Rac-1 mediated mobilization of the cytoskeleton. Artificially increasing intracellular cAMP levels in BECs of TLR4 mutant mice restored resistance to type 1 fimbriated bacterial invasion. This finding reveals a novel function for TLR4 and another facet of bladder innate defense.

Montelukast reduces ischaemia/reperfusion-induced bladder dysfunction and oxidant damage in the rat

The present study aimed to investigate the possible beneficial effects of the cysteinyl leukotriene-1 receptor antagonist montelukast on contractility and oxidant damage after ischaemia/reperfusion (I/R) of rat urinary bladder. The abdominal aorta of Sprague-Dawley rats was occluded to induce I/R. Montelukast (10 mg kg(-1)) or saline was administered intraperitoneally before I/R. In the sham-operated group, the abdominal aorta was left intact and the animals were treated with montelukast or saline. After decapitation, the bladder was removed and the tissue was either used for functional studies or stored for biochemical assays. In the I/R group, the isometric contractile responses of the bladder strips to carbachol (10(-8)-10(-4) M) were lower than those of the control group and were reversed by treatment with montelukast. Lipid peroxidation and myeloperoxidase activity of the bladder tissues in the I/R group were greater than in the sham-operated group. Montelukast treatment in the I/R group decreased these parameters compared with I/R alone. Similarly, the significant decrease in tissue glutathione level in the I/R group compared with controls was also prevented by montelukast. Treatment with montelukast almost completely reversed the low contractile responses of rat urinary bladder to carbachol and prevented oxidative tissue damage following I/R.

Not to knot a catheter. Case report of the knotting of a suprapubic catheter

A 20-month-old boy, who underwent left nephrectomy, had a suprapubic catheter inserted that knotted within the bladder. This case report identifies possible causes for such occurrences and how best to manage them.

Minimizing bladder injury in laparoscopically assisted vaginal hysterectomy among women with previous cesarean sections

BACKGROUND

This study demonstrated a method to prevent bladder injury during laparoscopically assisted vaginal hysterectomy (LAVH) to patients with vesicocervical adhesion after previous cesarean deliveries.

METHODS

Between July 2004 and July 2005, 50 women with vesicocervical adhesion who had given birth by cesarean delivery underwent LAVH. To minimize the chance of bladder injury, transvaginal lateral intervention was used to enter the anterior cul-de-sac during laparoscopic intrafascial hysterectomy. The lateral windows of the vesicocervical space were opened first. Usually, the potential spaces lateral to the adhesions could be developed easily by blunt finger dissection. Once adequate lateral spaces were created, an index finger was swept medially to define the margin of the midline adhesions secondary to the cesarean delivery scar. Under direct vision and finger guidance, the dense adhesions were dissected with more confidence and safety. Subsequently, the bladder was pushed gently aside to avert unexpected tearing or injury along the intrafascial hysterectomy. Because the vesico-uterine fold had been cut open previously under laparoscopy, the anterior cul-de-sac could be entered without much resistance.

RESULTS

The average age of the patients was 45 +/- 7 years, and the extirpated uterine weight was 323 +/- 170.8 g (range, 85-730 g). Intraoperatively, the mean operation time was 124.6 +/- 28.5 min (range, 80-235 min), and the average blood loss was 79.1 +/- 47.8 ml (range, 20-250 ml). The mean intramuscular meperidine requirements were 1.2 +/- 0.8 ampules (range, 0-2 ampules) (1 ampule = 50 mg), and the average hospital stay was 3.2 +/- 0.9 days (range, 2-5 days). Of these 50 patients, 24 (48%) had one, 22 (44%) had two, and 4 (8%) had three previous cesarean deliveries. No bladder injury occurred among the patients, and there was no other complication.

CONCLUSION

Transvaginal lateral intervention may help to minimize bladder injuries during LAVH for patients with previous cesarean deliveries.

Prevention of complications in laparoscopic hysterectomy: Experience with 1120 cases performed by a single surgeon

STUDY OBJECTIVE

The aim of this study is to describe a safe technique without any ureteral, bladder, and major vessel injuries in laparoscopic hysterectomy with a CO2 laser technique.

DESIGN

Prospective study (Canadian Task Force classification II-3).

SETTING

Centre Hospitalier Interrégional Edith Cavell, Department of Obstetrics and Gynecology, Endoscopic Laser Surgery Center, Bruxelles, Belgium; and Kadir Has University, Metropolitan Florence Nightingale Hospital, Istanbul, Turkey.

PATIENTS

One thousand one hundred twenty women with benign diseases.

INTERVENTIONS

Laparoscopic-assisted vaginal hysterectomy (LAVH) or laparoscopic hysterectomy (LH).

MEASUREMENTS AND MAIN RESULTS

Between 1992 and 2004, in 1120 women with benign diseases, consecutive LAVH or LH was planned. During laparoscopic hysterectomy, at all stages, bipolar forceps was used for hemostasis, and a CO2 laser was used for vaporization and excision. The total operating time was 35 to 180 minutes, with a median of 52 minutes (range 35-163) for LAVH (n = 542) and 55 minutes (range 42-180) for LH (n = 552). Operations were successfully completed laparoscopically in 98.8% of the patients. The mean hospital stay was 2 days. The overall major complication rate was 1%. No ureteral, bladder, or major vascular injury occurred.

CONCLUSION

The technique we used in our study is safe and effective in the prevention of ureteral, vesical, and vascular injuries during LAVH and LH; moreover, the use of bipolar coagulation and a CO2 laser in endoscopic surgery results in a shorter duration of operation. This technique provides all the advantages of both laparoscopic and vaginal surgery.

Intravesical explosions during transurethral endoscopic procedures

Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a "pop". Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermyIntravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising.

Surgical modifications in bladder neck reconstruction and vesicourethral anastomosis during radical retropubic prostatectomy to reduce bladder neck contractures

PURPOSE

We describe surgical modifications in radical retropubic prostatectomy (RRP) which have significantly reduced the incidence of bladder neck contractures (BNC).

MATERIALS AND METHODS

Between March 1994-July 2005, 977 men underwent a RRP by a single surgeon. Group I comprised 548 patients operated upon July 1994-December 1999, without the modifications described below. Group II comprised 429 men operated upon January 2000-December 2004, with the following surgical modifications: 1) reconstruction of the bladder neck (BN) to a diameter of 28 French; 2) placement of the posterior (6 o'clock) vesicourethral suture on mild traction before placing this suture into the bladder, allowing inspection and, if necessary, replacement of any of the previously placed sutures; 3) bladder displacement when tying the vesicourethral sutures which allows the sutures to be tied under direct vision and prevents incorporation of extraneous tissue. Data were retrospectively analyzed.

RESULTS

Demographic data were comparable between groups. In group I, 31/548 (5.7%) developed a BNC compared to 1/429 (0.2%) in Group II, p < 0.001. Urinary continence (no pads/maximum of one light pad for security in 24 hours) at 12 months in the 32 patients who developed a BNC was worse when compared to patients who did not develop a BNC (58% versus 80%, p = 0.003). After excluding the patients who developed a BNC, continence rates were comparable between both groups. The positive margin rate at the BN was not adversely affected by these modifications.

CONCLUSIONS

Simple, easily applied modifications to the management of the BN and vesicourethral anastomosis can substantially reduce the incidence of BNC.

Aqueous extract of Trigonella foenum-graecum L. ameliorates additive urotoxicity of buthionine sulfoximine and cyclophosphamide in mice

Cyclophosphamide (CP) is a commonly used anti-cancer drug which causes toxicity by its reactive metabolites such as acrolein and phosphoramide mustard. In the present study modulation of toxicity caused by concomitant exposure to CP and l-buthionine-SR-sulfoximine (BSO) by fenugreek (Trigonella foenum-graecum L.) extract was evaluated by measuring lipid peroxidation (LPO) and anti-oxidants in urinary bladder in mice. Fenugreek, a common dietary and medicinal herb, showed protective effect not only on LPO but also on the enzymatic anti-oxidants. CP-treated animals exhibited a significant decrease in the activities of glutathione S-transferase (GST), glutathione reductase (GR), glutathione peroxidase (GP) and catalase (CAT) when compared to the controls. Level of reduced glutathione (GSH) was also reduced with an increase in LPO in CP-treated animals. BSO treatment depicted an additive toxic effect in CP-treated animals. Pre-treatment of herbal extract restored activities of all the enzymes and thus showed an overall protective effect on additive effect of CP and BSO. Restoration of GSH by extract treatment may play an important role in reversing CP-induced apoptosis and free radical-mediated LPO in urinary bladder. Fenugreek, known for its hypoglycemic, anti-inflammatory and immunomodulatory activity, may be a promising protective medicinal herb for consideration in complementary therapy in cancer patients under chemotherapeutic interventions.

Preventive effects of cyclohexenonic long-chain fatty alcohol on diabetic cystopathy in the rat

In this study, we investigated the preventive effect of n-hexacosanol on diabetes-induced bladder dysfunction in the rat. Diabetes was induced in 8-week-old male Sprague-Dawley rats by administering an injection of streptozotocin (50 mg/kg, i.p.). The rats were randomly divided into 4 groups (age-matched control rats, diabetic rats without treatment with n-hexacosanol, and diabetic rats treated with n-hexacosanol (2 and 8 mg/kg, i.p. every day)) and maintained for 4 weeks. The serum glucose and serum insulin levels were determined, and the functions of bladder were estimated by voiding behavior, cystometric, and functional studies to carbachol and KCl. Furthermore, we examined possible diabetic induced histological changes in these rats. Treatment with n-hexacosanol did not alter diabetic status including body mass, bladder mass, and serum glucose and serum insulin levels, but significantly improved the maximum contraction pressure of the detrusor and residual urine volume in cystometric studies and Emax values to carbachol in functional studies in a dose-dependent manner. Diabetes induced bladder smooth muscle hypertrophy, which tended to be ameliorated by treatment with n-hexacosanol in a dose-dependent manner. Treatment with n-hexacosanol did not alter the diabetic status, but significantly improved diabetic cystopathy in a dose-dependent manner.

Catheter valves for indwelling urinary catheters: a systematic review

This mini-review aimed to systematically review the evidence on the effect of catheter valves compared to free drainage into a bag for patients with indwelling urinary catheters. Data sources used were Medline, British Nursing Index, CINAHL, Ahmed, EMBASE, EBM Reviews, the Cochrane Library and reference lists of relevant papers. Papers considered were controlled trials comparing the use of a catheter valve with the catheter bag that were published as a full report, or detailed abstract (containing sufficient information to critique) in Dutch, German or English. Two studies with a total of 122 subjects were identified. The main outcome measures considered were reduction of incidence of bladder spasm and urinary tract infection (UTI) and patient preference. No statistically difference in the incidence of bladder spasm or UTI was demonstrated but patients showed a clear preference for the valve. Further research into catheter valves is needed, with larger study groups, which include housebound male and female patients, and longer follow-up period.

[Local application of dimethyl sulfoxide at different concentrations to the prevention of radiation-induced damages in patient with cancer of the cervix uteri]

OBJECTIVE

to study the efficacy of dimethyl sulfoxide ((DMSO) at different concentrations in preventing radiation-induced rectal and urinary bladder damages in patients with cervix uteri cancer (CUC).

MATERIAL AND METHODS

combined radiation therapy (RT) was performed in 807 patients with CUC. In the control group (n = 221), RT was made, without applying radio-modified agents. An hour prior to a session of intracavitary irradiation, 10% DMSO solution was instilled into the rectum and urinary bladder in 113 patients and applications of metronidazole (MN) dissolved in 100% DSMO were made in 473 patients. Teleradiotherapy was performed, by using megavolt irradiation sources in the conventional fractionation mode; the total focal dose (TFD) was increased up to 40-46 Gy. Intracavitary irradiation was carried out on "AGAT-V" and "AGAT-VU" devices once weekly; the single focal dose in point A was 7 Gy; TFD was 49-56 Gy.

RESULTS

10% DMSO instillations reduced the incidence of late radiation-induced damages to the rectum and urinary bladder. In the control group, the incidence of these conditions was 19.0 and 9.5%, respectively; with the use of 10% DMSO, that was 8.8 and 7.1%. Applications of MN dissolved in 100% DMSO reduced the incidence of late radiation-induced damages to 1.7%.

CONCLUSION

Local application of DMSO is a method for preventing late radiation-induced damages to the rectum and urinary bladder in patients with CUC. When the concentration of DMSO is increased, its preventive effect increases.

Characterization and optimization of experimental variables within a reproducible bladder encrustation model and in vitro evaluation of the efficacy of urease inhibitors for the prevention of medical device-related encrustation

This study presents a reproducible, cost-effective in vitro encrustation model and, furthermore, describes the effects of components of the artificial urine and the presence of agents that modify the action of urease on encrustation on commercially available ureteral stents. The encrustation model involved the use of small-volume reactors (700 mL) containing artificial urine and employing an orbital incubator (at 37 degrees C) to ensure controlled stirring. The artificial urine contained sources of calcium and magnesium (both as chlorides), albumin and urease. Alteration of the ratio (% w/w) of calcium salt to magnesium salt affected the mass of encrustation, with the greatest encrustation noted whenever magnesium was excluded from the artificial urine. Increasing the concentration of albumin, designed to mimic the presence of protein in urine, significantly decreased the mass of both calcium and magnesium encrustation until a plateau was observed. Finally, exclusion of urease from the artificial urine significantly reduced encrustation due to the indirect effects of this enzyme on pH. Inclusion of the urease inhibitor, acetohydroxamic acid, or urease substrates (methylurea or ethylurea) into the artificial medium markedly reduced encrustation on ureteral stents. In conclusion, this study has described the design of a reproducible, cost-effective in vitro encrustation model. Encrustation was markedly reduced on biomaterials by the inclusion of agents that modify the action of urease. These agents may, therefore, offer a novel clinical approach to the control of encrustation on urological medical devices.

Comparison of efficacy of oxybutynin and tolterodine for prevention of catheter related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

BACKGROUND

Bladder discomfort related to intraoperative catheterization of urinary bladder is a distressing symptom and more so in patients awakening from anaesthesia. These symptoms are similar to symptoms of overactive bladder. Muscarinic receptor antagonists have been reported to be effective in the treatment of overactive bladder. This study was therefore undertaken to evaluate the efficacy of oxybutynin and tolterodine in preventing catheter related bladder discomfort.

METHODS

Two hundred and thirty-four consecutive adult patients, ASA I and II, of either sex, undergoing elective percutaneous nephrolithotomy surgery requiring urinary bladder catheterization were randomized into three equal groups of 78 each. Group C (control) received placebo, Group O (oxybutynin) received oxybutynin 5 mg and Group T (tolterodine) received tolterodine 2 mg orally 1 h before surgery. After induction of anaesthesia patients were catheterized with a 16 Fr Foley's catheter and the balloon was inflated with 10 ml distilled water. The bladder discomfort was assessed at 0, 1, 2 and 6 h after patient's arrival in the post-anaesthesia care unit. Severity of bladder discomfort was graded as mild, moderate and severe.

RESULTS

Incidence of bladder discomfort observed in the control group was higher, i.e. 58% (45/78), compared with oxybutynin and tolterodine groups where it was 35% (28/78) and 33% (26/78), respectively (P<0.05). Significant reduction in the severity of bladder discomfort was also observed after oxybutynin and tolterodine therapy compared with control (P<0.05).

CONCLUSION

Pretreatment with either oxybutynin or tolterodine reduces the incidence and severity of catheter related bladder discomfort.

Galangin protects pig detrusor nerves from repetitive field stimulation and anoxia/glucopenia injury

OBJECTIVES

To test the capability of the flavonoid galangin to protect pig urinary bladder from damage due to a period of repetitive field stimulation as well as a period of anoxia/glucopenia and reperfusion.

METHODS

Smooth muscle strips of the pig bladder were mounted for tension recording in small organ baths and the strips underwent either 1.5 hours of repetitive field stimulation at 32 Hz for 15 seconds every 5 minutes or under anoxia/glucopenia and reperfusion conditions. Galangin, at different concentrations, was added to the reperfusion Krebs solution to check the effect of this flavonoid compared with untreated strips under the same conditions. A group of experiments was performed to examine its possible underlying mechanisms.

RESULTS

Repetitive field stimulation for 1.5 hours caused a progressive decrease in the maximal contractile response to electrical field stimulation (34% decrease). Galangin (10(-7) M) partially prevented the progressive decrease in the contractile response. This effect was significantly reduced when verapamil was added to the solution. Galangin significantly improved the response of strips to electrical field stimulation under anoxia/glucopenia and reperfusion conditions compared with untreated tissues.

CONCLUSIONS

Galangin has a protective effect on bladder contractility by an action that at least, in part, depends on l-type calcium channels. Furthermore, galangin protects detrusor nerves against the anoxia/glucopenic and reperfusion damage.

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05).

IMPLICATIONS

Bladder discomfort secondary to an indwelling urinary catheter is distressing to patients. In the present study, we observed that tolterodine (2 mg), a competitive muscarinic receptor antagonist administered 1 h before surgery, reduced both the incidence and severity of bladder discomfort secondary to bladder catheterization.

Inhibition of substance P activity prevents stress-induced bladder damage

Substance P is a neuropeptide involved in inflammation, immune regulation and stress response. Stress may induce bladder damage by stimulating inflammatory response such as mast cell activation. We here examined the role substance P during stress-induced mast cell degranulation and urothelial injury in rat bladder. Adult Sprague-Dawley rats (200-270 g) were either exposed to cold-immobilization stress or substance P (SP) intracerebroventricularly. Different doses of substance P receptor (NK1R) antagonist CP 99994 were administered peripherally or centrally before the stress exposure. From each group, samples of the bladder were examined with light and electron microscope. Stress- and SP-injected centrally, increased the number of both granulated and degranulated mast cells. Ultrastructurally, urothelial degeneration with vacuolization in the cytoplasm and dilated intercellular spaces were seen. Both central and peripheral injection of CP 99994 prevented stress-induced urothelial degeneration as well as stress-induced mast cell degranulation. In conclusion, centrally and peripherally released substance P is involved in stress-induced bladder damage. Inhibition of NK1R prevents stress-induced pathological changes of urinary bladder and NK1R antagonist can be considered for the treatment of inflammatory bladder diseases.

Effect of ethanol on protection of urinary bladder function by grape suspensions

OBJECTIVES

To compare the protective effects of grape suspensions prepared in an aqueous vehicle with grape suspensions prepared in an 8% ethanol vehicle in rabbits subjected to partial outlet obstruction. The hypothesis was that the presence of ethanol would increase the absorption of the beneficial components of the grape suspensions and thus increase their protective ability. The use of ethanol in these studies was not to simulate wine.

METHODS

A total of 48 New Zealand white rabbits were separated into eight groups of 6 rabbits each. Groups 1 and 3 were pretreated by oral gavage for 3 weeks with grape suspensions in water; groups 2 and 4 were treated with vehicle. Groups 5 and 7 were treated with the grape suspensions in 8% ethanol, and groups 6 and 8 were treated with ethanol vehicle. Groups 1, 2, 5, and 6 underwent sham operations, and groups 3, 4, 7, and 8 underwent partial outlet obstruction. Three weeks after surgery, the rabbits were evaluated.

RESULTS

The bladder weight had significantly increased in all obstructed groups. The contractile responses to field stimulation and carbachol were reduced in all obstructed groups, although the responses in both grape-treated groups were greater than both vehicle-treated groups. The contractile responses to potassium chloride were significantly reduced by partial outlet obstruction in both obstructed groups similarly.

CONCLUSIONS

Both grape suspensions provided protection against obstructive-induced bladder dysfunction. The ethanol preparation of the grape suspension was not better than the aqueous preparation.

[Etiology and treatment of bladder spasm associated with benign prostatic hyperplasia]

OBJECTIVE

To investigate the etiology and treatment of bladder spasm associated with benign prostatic hyperplasia (BPH).

METHODS

Urodynamic tests were performed in 102 cases of BPH before operation. The correlation of bladder spasm with aging, international prostate symptom score (IPSS), quality of life, prostatic volume, operation methods and urodynamic indexes was studied by t and chi2 tests.

RESULTS

The incidences of bladder spasm in the lower compliant bladder and unstable bladder were 32.1% (9/28) and 42.5% (13/20), and those after suprapubic prostatectomy and transurethral resection of the prostate (TURP) were 50.9% (26/51) and 23.3% (12/51). There was significant difference between operation methods (P < 0.05).

CONCLUSION

Bladder spasm easily develops in the lower compliant bladder and unstable bladder, especially after suprapubic prostatectomy. TURP might decrease the incidence of bladder spasm after BPH operation.

Bladder spasm following transurethral surgery

This article describes a study carried out to determine the incidence of bladder spasm and any common factors among patients presenting with bladder spasm in the recovery unit following transurethral surgery. Data was collected retrospectively from 200 sets of patient notes. The findings suggest that bladder spasm is common following transurethral surgery and that certain surgical procedures are more likely to result in bladder spasm.

Anti-inflammatory effect of the latex from Calotropis procera in three different experimental models: peritonitis, paw edema and hemorrhagic cystitis

Latex from Calotropis procera is widely used in folk medicine as a rich source of biologically active compounds capable of promoting diverse benefits such as control of dermal fungal infections, antimicrobial activities and pain relief among other useful properties. The aim of this work was to characterize the anti-inflammatory effect of a non-dialysable protein fraction recovered from the rubber-free latex using three different experimental models when administrated intravenously. In vivo neutrophil migration induced by carrageenin (500 microg) was severely inhibited by doses of latex proteins reaching maximum inhibition (80%) at 100 mg/kg. Paw edema exacerbated by the effect of carrageenin was almost completely suppressed after 4 hours and was controlled within the first hour following latex protein administration. However, the same latex fraction was completely unable to control the paw edema invoked with dextran stimulation (400 microg), suggesting that the inhibitory effect of the latex is likely to be cell-mediated. Iphosphamide-induced vesical edema in mice was also largely prevented by the latex protein fraction. These results indicate that an effect similar to that of mesna, the classical drug used for this purpose, is operative. Our findings suggest that the sample tested seems to act over a wide spectrum as a novel anti-inflammatory agent. The results also suggest that the active molecules are of a proteinaceous nature despite the presence of numerous secondary metabolites naturally occurring in the C. procera latex.

Catechins prevents substance P-induced hyperactive bladder in rats via the downregulation of ICAM and ROS

We previously reported substance P (SP) via neurokinin type 1 receptor facilitates bladder afferent signaling and reactive oxygen species (ROS) formation in bladder connected with neurogenic inflammation [Am. J. Physiol. Renal Physiol. 284 (2003) F840]. Increased intercellular adhesion molecule expression and subsequent leukocyte adhesion in the inflamed bladder contribute to SP-induced oxidative injury. Here we investigate the effect of green tea extract (catechins) on SP-induced bladder hyperactivity. We evaluated isovolumetric cystometrogram, adhesion molecular expression, and ROS activity in anesthetized rat bladder with SP stimulation. Our results showed that SP increased the amount of leukocyte ROS production in vitro in a dose-dependent manner and the enhanced ROS can be inhibited by catechins treatment. Exogenous SP increased ROS in vivo in the bladder via increased intercellular adhesion molecule expression and subsequent leukocyte adhesion, a primary source of ROS in the inflamed bladder. Two weeks of catechins pretreatment reduced SP-induced bladder intercellular adhesion molecule expression and ROS amount and ameliorated the hyperactive bladder response. These results indicate that catechins pretreatment can ameliorate SP-induced neurogenic inflammation via the action of antioxidant, anti-adhesion, and anti-inflammatory activity.

[The medication-induced dysfunction of the urinary bladder]

Bladder dysfunction can result from pathological changes in the bladder itself, of its central neurological regulation, (BPS), or of non-urological diseases such as diabetes or heart failure. Medication-induced bladder dysfunction can mostly be treated by simple changes in the pharmacological therapy. Bladder dysfunction can be induced pharmacologically by activating or inhibitory influences on adrenergic, sympathetic, beta-receptor-induced relaxation of the detrusor, alpha-receptor-induced contraction of the bladder neck, or cholinergic, parasympathetic, muscarinic receptor-induced contraction of the detrusor. Diuretics can increase urine production, thus possibly leading to incontinence. If incontinence occurs in patients, treatment should be stopped if possible and additional pharmacological therapy should not be started before medication-induced bladder dysfunction is excluded.

Early treatment of benign prostatic hyperplasia: implications for reducing the risk of permanent bladder damage

A significant change has occurred in the management of symptomatic benign prostatic hyperplasia (BPH) since effective pharmacological treatment became available and led to a significant decrease in the number of surgical procedures in many Western countries. The hypothesis of a causative role of benign prostatic enlargement and bladder outflow obstruction (BOO) in lower urinary tract symptoms (LUTS) was based on the association between prostate growth and symptoms of prostatism in elderly men and on the dramatic reduction of LUTS upon relief of obstruction. Careful investigation into the epidemiology of LUTS and BPH failed to confirm such an association and opened new perspectives in the pathophysiology of lower urinary tract dysfunction and symptoms. The observation that LUTS were equally distributed in male and female cohorts, when matched for age, moved attention away from the prostate and towards the urinary bladder and its aging-related disorders. When BPH surgery was developed, the management of the disease was aimed at preventing death from chronic renal failure, but the picture has changed and modern medical treatment is now aimed at improving the patient's quality of life. The increasing size of elderly populations in the Western world and the consequent financial constraints of national healthcare systems have raised the question of when pharmacological treatment of symptomatic BPH should be initiated. Retrospective and prospective analysis of various BPH populations and clinical studies has clearly defined the capacity of pharmacological treatment to reduce the incidence of complications of BPH, such as acute urinary retention and the need for surgery, but the cost/benefit ratio is unclear. Notwithstanding the limitations inherent in the experimental models, there is evidence from various animal models, investigating the pathophysiology of the urinary bladder in the presence of outflow obstruction, to indicate that a cause and effect relationship between BOO and bladder decompensation has been established and to support the hypothesis that permanent bladder damage may occur when the obstruction is not relieved early enough. Preliminary experimental evidence also suggests that alpha(1)-adrenoceptor antagonists may have a role in reducing the damaging effects of BOO on the urinary bladder. At present, there is no evidence to support the need for early pharmacological treatment of symptomatic BPH with no BOO beyond the obvious target of improving the patient's quality of life. The evidence for early treatment of BOO and the need to preserve bladder function is clear. Further experimental and clinical research is required to identify markers of early bladder damage and decompensation which can be used to select patients for early pharmacological treatment of BPH.

Class solutions for conformal external beam prostate radiotherapy

PURPOSE

To determine a class solution coplanar plan from comparisons of three-field (3F), four-field (4F), and six-field (6F) plans in conformal non-intensity-modulated prostate radiotherapy.

METHODS AND MATERIALS

Doses to two clinical target volumes, prostate only (PO) and prostate plus seminal vesicles (PSV) were evaluated in each of 10 patients using a variety of 3F, 4F, and 6F plans with a planning target volume margin of 10 mm. All plans were prescribed to 64 and 74 Gy. The class solution plan for each of 3F, 4F, and 6F was chosen from a variety of symmetrical and asymmetrical field arrangements that had been previously assessed. The class solution plans, 3F (0, 90, 270 degrees ), 4F (35, 90, 270, 325 degrees ), and 6F (50/lat/25) were compared with reference plans: 3F (0, 120, 240 degrees ), 4F (0, 90, 180, 270 degrees ), and 6F (55, 90, 125, 235, 270, 305 degrees ). Rectal volumes irradiated to greater than 50% (V(50)), 80% (V(80)), and 90% (V(90)) of the prescribed dose, normal tissue complication probabilities (NTCP) for rectum, bladder, and femoral heads (FH), and tumor control probabilities (TCP) were assessed. FH tolerance was set at 52 Gy to 10% volume.

RESULTS

The field arrangement that gave the lowest irradiated rectal volume with acceptable bladder and FH doses was a 3F (0, 90, 270 degrees ) class solution plan. This plan gave a reduction in rectal V(80) of 1.2-12.4% for the PO group and 2.3-23.8% for the PSV group compared with the other plans. The reduction in rectal V(90) was 0.2-11.9% for the PO group and 1.5-23.3% for the PSV group using the 3F (0, 90, 270 degrees ) plan. This plan provided one of the lowest rectal NTCPs, but the difference was not significant when compared with the 4F class solution plan. When target volumes with 10-mm margins remain unchanged to 74 Gy, the irradiated rectal volumes for all plans were higher and rectal NTCPs can be trebled.

CONCLUSION

The use of appropriate beam arrangements can provide a class solution plan using only 3 fields compared with 4 or 6 fields for the parameters considered. Both 3F (0, 90, 270 degrees ) and 4F (35, 90, 270, 325 degrees ) plans can be used as a class solution plan. Other practical issues that may influence the choice of class solution include delivery time with smaller number of fields, ease of verification, the use of 10-mm multileaf collimation vs. conformal blocks, and field shape fitting limitations when using dynamic wedges.