Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review

AIM

The main goals of neurogenic lower urinary tract dysfunction (NLUTD) management are preventing upper urinary tract damage (UUTD), improving continence, and quality of life. Here, we aimed to systematically assess all available evidence on urodynamics predicting UUTD in patients with NLUTD.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in March 2017. Only neuro-urological patients assessed by urodynamics were included. Any outcome of upper urinary tract function were evaluated.

RESULTS

Forty-nine studies (1 randomized controlled trial, 9 prospective, and 39 retrospective case series) reported urodynamic data on 4930 neuro-urological patients. Of those, 2828 (98%) were spina bifida (SB) children. The total number of adults was 2044, mainly having spinal cord injury (SCI) (60%). A low bladder compliance was found in 568 (46.3%) and 341 (29.3%) of the paediatric and adult population, respectively. Hydronephrosis (HDN) was detected in 557 children (27.8%) in 19/28 studies and 178 adults (14.6%), mainly SCI, in 14/21 studies. Nine out of 30 multiple sclerosis (MS) patients affected by HDN (16.8%) showed low compliance in 4/14 studies.

CONCLUSIONS

Patients with SB and SCI have a higher risk of developing UUTD (mainly reported as HDN) compared to those with MS. Reduced compliance and high DLPP were major risk factors for UUTD. Although our findings clarify the mandatory role of urodynamics in the management of NLUTD, standardization and better implementation of assessments in daily practice may further improve outcomes of neuro-urological patients based on objective measurements, that is, urodynamics.

Long-term effectiveness and complication rates of bladder augmentation in patients with neurogenic bladder dysfunction: A systematic review

AIMS

To systematically evaluate effectiveness and safety of bladder augmentation for adult neuro-urological patients.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement was followed for review of publications. The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched until January 2015. No limitations were placed on date or language. Non-original articles, conference abstracts, and publications involving children and animals were excluded. Risk-of-bias and confounder assessment was performed.

RESULTS

A total of 20 studies including 511 patients were eligible for inclusion. The level of evidence for the included studies was low, most level 4 studies with only one level 3 study. The data were narratively synthesized. Across all studies high risk-of bias and confounding was found. Primary outcomes were assessed in 16 of the 20 studies and showed improved quality of life and anatomical changes as well as stable renal function. The secondary outcomes were reported in 17 of the 20 studies and urodynamic parameters and continence all demonstrated improvement after bladder reconstruction. Long-term complications continued up to 10 years post-operatively, including bowel dysfunction in 15% of the patients, stone formation in 10%, five bladder perforations and one bladder cancer.

CONCLUSIONS

Available studies are not plentiful and of relatively poor quality, appropriately designed prospective studies are urgently needed. Despite this, bladder augmentation appears to be a highly effective procedure at protecting the upper urinary tract and improving quality of life. However, it is associated with relatively high morbidity in both the short and long term.

Transcutaneous Electrical Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review

CONTEXT

Transcutaneous electrical nerve stimulation (TENS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option in patients with an underlying neurological disorder.

OBJECTIVE

We systematically reviewed all available evidence on the efficacy and safety of TENS for treating neurogenic lower urinary tract dysfunction.

EVIDENCE ACQUISITION

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

EVIDENCE SYNTHESIS

After screening 1943 articles, 22 studies (two randomised controlled trials, 14 prospective cohort studies, five retrospective case series, and one case report) enrolling 450 patients were included. Eleven studies reported on acute TENS and 11 on chronic TENS. In acute TENS and chronic TENS, the mean increase of maximum cystometric capacity ranged from 69ml to 163ml and from 4ml to 156ml, the mean change of bladder volume at first detrusor overactivity from a decrease of 13ml to an increase of 175ml and from an increase of 10ml to 120ml, a mean decrease of maximum detrusor pressure at first detrusor overactivity from 18 cmH20 to 72 cmH20 and 8 cmH20, and a mean decrease of maximum storage detrusor pressure from 20 cmH20 to 58 cmH2O and from 3 cmH20 to 8 cmH2O, respectively. In chronic TENS, a mean decrease in the number of voids and leakages per 24h ranged from 1 to 3 and from 0 to 4, a mean increase of maximum flow rate from 2ml/s to 7ml/s, and a mean change of postvoid residual from an increase of 26ml to a decrease of 85ml. No TENS-related serious adverse events have been reported. Risk of bias and confounding was high in most studies.

CONCLUSIONS

Although preliminary data suggest TENS might be effective and safe for treating neurogenic lower urinary tract dysfunction, the evidence base is poor and more reliable data from well-designed randomised controlled trials are needed to make definitive conclusions.

PATIENT SUMMARY

Early data suggest that transcutaneous electrical nerve stimulation might be effective and safe for treating neurogenic lower urinary tract dysfunction, but more reliable evidence is required.

Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review

AIMS

To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients.

METHODS

The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO).

RESULTS

After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies.

CONCLUSIONS

CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.

A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review

CONTEXT

Impaired sexual function has a significant effect on quality of life. Various patient-reported outcome measures (PROMs) are available to evaluate sexual function. The quality of the PROMs to be used for neurologic patients remains unknown.

OBJECTIVE

To systematically review which validated PROMs are available to evaluate sexual function in neurologic patients and to critically assess the quality of the validation studies and measurement properties for each identified PROM.

EVIDENCE ACQUISITION

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The included publications were assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist.

EVIDENCE SYNTHESIS

Twenty-one studies for PROMs regarding sexual function were identified for the following patient groups: spinal cord injury (11 studies), multiple sclerosis (MS; 6 studies), Parkinson's disease (2 studies), traumatic brain injury (1 study), and epilepsy (1 study). The evidence for the quality of PROMs was found to be variable, and overall evaluation of measurement properties was lacking in 71% of the studies. The measurement error and responsiveness were not studied in any of the publications.

CONCLUSIONS

Several PROMs have been identified to evaluate sexual function in neurologic patients. Strong evidence was found only for the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 for patients with MS, although evidence was lacking for certain measurement properties as well. Future research should focus on identifying relevant PROMs and establishing adequate quality for all measurement properties in studies with high methodological quality.

PATIENT SUMMARY

A quality assessment of patient-reported outcome measures (PROMs) for sexual function in neurologic patients was made. The evidence found for good PROMs was limited. Studies with high methodological quality are needed to improve the quality of PROMs to evaluate sexual function in neurologic patients.

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review

CONTEXT

Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).

OBJECTIVE

To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.

EVIDENCE ACQUISITION

A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

EVIDENCE SYNTHESIS

A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.

CONCLUSIONS

The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.

PATIENT SUMMARY

Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review

AIMS

To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients.

METHODS

This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017.

RESULTS

A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found.

CONCLUSIONS

We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.

The International Continence Society (ICS) report on the terminology for male lower urinary tract surgery

INTRODUCTION

In the development of terminology of the lower urinary tract (LUT), due to its increasing complexity, the terminology for male LUT surgery needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization Committee of the International Continence Society in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 14 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male LUT and pelvic floor surgery, encompassing 149 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in male LUT surgery. Figures have not been included to avoid any preference or bias towards a specific procedure.

CONCLUSIONS

A consensus-based Terminology Report for male LUT surgery has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

A Comparison of UK versus European guidelines in neuro-urology

Two primary guidelines, written by the European Association of Urology (EAU) and National Institute of Clinical Excellence (NICE), have been designed to aid British urologists with managing neuro-urological patients. The EAU guidelines are updated annually, and cover incontinence, sexual function and infertility in the adult neuropathic population. The NICE guidelines, applicable to England, are periodically updated, with the last update being in 2012. The NICE guideline covers adults and children with neurological incontinence. There are fundamental differences in the recommendations of the panels. EAU advocate upfront urodynamics and ultrasound assessment in all patients and treatment recommendations are based on urodynamic findings rather than patient symptoms on which the NICE guidelines are based. The patient group covered comprises a heterogeneous population, including patients at high risk of renal deterioration without urological intervention. Due to this, both guidelines recommend initial risk stratification to determine assessment and follow-up regimens. The reason for variation may be due to the NICE guidelines having an added dimension, in that they ensure all interventions are cost effective for a publicly funded national health service. Both guideline panels acknowledge the paucity of scientific research in the field of neuro-urology and consequently both guidelines are based upon expert opinion and limited retrospective evidence. There is an urgent need to undertake prospective research in this field. A first step can be an establishment of prospective registries among various neuro-urological units.

Malignant features of a benign waiting list

Objective:

Transurethral resection of the prostate (TURP) operations are frequently deferred. Consequently, patients awaiting TURP have multiple urology-related admissions for problems such as urinary retention. This audit aims to determine the effect of TURP deferments on the frequency and duration of urology-related admissions, as well as the financial implication in our institution over a three-month period.

Patients and methods:

A retrospective, electronic database review of patients who received a TURP at Northwick Park Hospital, between 1 January 2014–31 March 2014, was carried out. The following data were extracted: (a) date the patient was listed for TURP; (b) date patient underwent TURP; (c) number of deferments between a patient being listed for surgery and receiving their operation; (d) reason(s) for deferment; and (e) number, duration and indication of urology-related inpatient admissions whilst awaiting TURP. Using this data, we calculated the cost of urology-related admissions whilst awaiting surgery.

Results:

In total, 44 patients underwent a TURP operation. Of these, 21 patients had their TURP deferred. There were 23 urology-related admissions whilst patients awaited a TURP. Fifteen of these admissions were attributed to eight patients with deferments to surgery. They spent a total of 45 days/30 nights in hospital. The remaining eight urology-related admissions were accounted for by six patients with no deferments to surgery. They spent 12 days/3 nights in hospital. We approximate a daily cost of £250 for an NHS bed. This equates to a total cost of £11,250 (£1406 per patient) for the eight patients who had TURPs deferred versus £3000 (£500 per patient) for those six patients without deferments.

Conclusion:

Patients who have their TURP operations deferred have an increased frequency and duration of urology-related admissions, associated with an additional cost of at least £900 per patient.

The autologous rectus fascia sheath sacrocolpopexy and sacrohysteropexy, a mesh free alternative in patients with recurrent uterine and vault prolapse: A contemporary series and literature review

Introduction:

About 40% of women suffer pelvic organ prolapse (POP) in a lifetime. The current standard intervention for vault prolapse is a mesh sacrocolpopexy or sacrohysteropexy. However, patients and surgeons are increasingly hesitant to use mesh given recent the UK and Food and Drug Administration warnings and litigation. A possible alternative is to use autologous tissue to support the vault, as a mesh-free solution. We report the outcomes from an initial series of autologous rectus fascia sheath (RFS) sacrocolpopexy and sacrohysteropexy in patients with complex pelvic floor dysfunction.

Patients and Methods:

All patients had previous, multiple urological/gynecological surgery and declined standard mesh repairs. All had preoperative videourodynamics and defecating magnetic resonance imaging evaluation. The autologous POP repair was performed using 10–18 cm of rectus sheath with a similar technique to that employing mesh to support the anterior-posterior vaginal walls or encircle the cervix and secured to the sacral promontory.

Results:

Seven patients with a mean age of 52 (33–64) years underwent autologous RFS POP repair between 2014 and 2017. Mean follow-up is 16 (range 2–33) months. All patients have durable result at last follow-up. No significant complications are reported.

Conclusions:

This is the first report of patients with complex pelvic floor dysfunction and apical POP being managed with autologous RFS sacrocolpopexy/sacrohysteropexy, and only the second report of a free graft being utilized with success. Autologous RFS sacrocolpopexy/sacrohysteropexy avoids the 10%–15% risks of mesh-related complications. Further studies of long-term durability are needed.

Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review

CONTEXT

Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group.

OBJECTIVE

To present all used definitions of UTIs in neurourological patients.

EVIDENCE ACQUISITION

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated.

EVIDENCE SYNTHESIS

After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low.

CONCLUSIONS

Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

PATIENT SUMMARY

Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE  HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

Three's a crowd: A very rare form of polyorchidism with sertoli cell adenomas

Polyorchidism is rare with fewer than 200 cases reported in literature. We present a case of a 26 year old male with chronic pain secondary to a very rare form of polyorchidism, with histology showing Sertoli cell adenomas. Orchiectomy should be considered in patients with chronic pain due to polyorchidism.

Quality of pre-operative assessment for mid urethral slings in women who present with mesh complications

OBJECTIVE

To study quality of pre- and post-operative evaluation in women undergoing mid-urethral synthetic sling surgery who subsequently have complications.

MATERIALS AND METHODS

Study inclusion was chart availability for preoperative clinical history, examination, urodynamics and/or post-operative visit in women with mesh complications 2014-2021 in a tertiary practice. The primary outcome was compliance with quality indicators and guidelines for preoperative and post-operative clinical evaluation and urodynamics.

RESULTS

122 women had preoperative, 102 urodynamic reports and 108 post-operative charts available for review. Only clinical history and examination showed moderate compliance (71% nature, 57% severity, 87% exam) with quality indicators, all other quality indicators were low. including documentation of counselling of mesh risks (11%) and risks of incontinence surgery (17%) . Compliance with guidelines (optimal care) was also low (bladder diary 61%, all others ≤41%). Post-operative evaluation did not comprehensively screen for complication e.g., flow rate/post-void residual performed in 9%. A significant proportion had an early adverse symptom (55%) or intervention e.g. trimming of exposure (40%) CONCLUSION: Compliance with quality indicators and guidelines was generally low for pre-operative evaluation and urodynamic testing. There was inadequate content and length of post-operative evaluation despite a significant proportion presenting with adverse symptoms at first postoperative follow-up. Future research could target these areas for development of tools to improve compliance and education of health providers.

Female urethral stricture from chronic graft-versus-host disease

Female urethral strictures are rare with limited literature to guide management. We present a case of a 27 year old female diagnosed with a urethral stricture secondary to chronic graft-versus-host disease. This diagnosis should be considered in females presenting with obstructive voiding symptoms and have risk factors for stricture development.

Does videourodynamic classification depend on patient positioning in patients with stress urinary incontinence?

INTRODUCTION AND AIMS

Videocystometrogram (VCMG) is used to assess patients with SUI. A common classification system of SUI is the Blaivas and Olsson classification. The position this grading is performed in has never been established.

MATERIALS AND METHODS

One hundred twenty-one women complaining of SUI refractory to conservative measures had video-urodynamic assessment prior to operative intervention. Grading of stored video SUI image traces was assessed as per Blaivas and Olsson criteria by two independent investigators whilst women were both lying and standing with bladder at maximum cystometric capacity.

RESULTS

Seventy-two (56.7%) patients' grading remained the same in both lying and standing positions. 49(40.5%) patients' grading altered on standing. twenty had non-demonstrable incontinence converted to demonstrable incontinence and 29 had demonstrable incontinence on lying that changed grading on standing; 22 of these by one grade and seven by two grades (from I to IIb). A Fisher's exact test demonstrated a statistically significant difference in the distribution of SUI grading between supine and standing positions (P < 0.01).

CONCLUSION

40.5% of women have a changed Blaivas and Olsson grade of SUI when assessed standing as opposed to lying. This has implications for surgical treatment options and patient counselling. While the Blaivas and Olsson grading system for SUI is simple and reproducible there is little standardisation as to which position this grading is to be performed. We recommend that an international consensus is agreed upon in order for results to be comparable and to help with future outcome studies.