Tubularized Bladder Flap as a Continent Catheterizable Channel in Adults

OBJECTIVE

To describe a modified, less invasive, surgical technique to create a continent catheterizable channel (CCC) in adults: the tubularized bladder flap (TBF).

MATERIALS AND METHODS

We retrospectively reviewed records of patients in whom a TBF CCC was constructed at adult age between 2019 and 2023. We reported on demographics, operative outcomes, and 30-day and post-30-day complications.

RESULTS

A total of 11 patients (10 female) were described. The median operative time was 96 (range 90-115) minutes in patients with only TBF creation. Estimated blood loss was <100 cc in all patients. Within 30 days postoperatively, 6/11 (55%) patients developed a complication, all grade 1 Clavien Dindo. No bowel complications occurred (paralytic ileus, mechanical obstruction, or leakage/perforation). Median follow-up was 25 (range 6-56) months. In 2/11 (18%) patients surgical revision for stenosis was done; 3/11 (27%) patients underwent surgical revision for stomal leakage.

CONCLUSION

TBF as a means to create a CCC avoids intraperitoneal surgery, and bowel closure (appendicovesicostomy) or anastomosis (retubularized ileum). Postoperative bowel complications were not seen in any of our patients. Surgical revision rates for a TBF CCC appear to be comparable to other CCCs. Therefore, TBF could be considered in patients with sufficient bladder capacity as TBF is less invasive than other CCC techniques and avoids potential bowel complications.

Very long-term follow-up of Indiana Pouches proves durability

INTRODUCTION

An Indiana Pouch (IP) is a heterotopic, continent, urinary diversion from an ileocolonic segment. Numerous studies have investigated its long-term outcomes, albeit none extending beyond a 5-year follow-up period. IPs can be used as urinary diversion for benign indications and as such are constructed in typically young patients. As a consequence of their extended lifespan, there is a need for very long-term (>5 years) IP outcome data and comprehensive complication analysis.

MATERIALS AND METHODS

In this retrospective cohort study, the data of all patients attending our academic functional urology tertiary referral center for surveillance between 2015 and 2022 after an earlier IP procedure without uro-oncological indication were analyzed. The primary objective was to identify the prevalence of complications associated with IP, including stomal stenosis, ureter-pouch stenosis, pouch calculi, stomal leakage, pouch perforation, and parastomal herniation, and to determine the time span between creation of the IP and occurrence of complications.

RESULTS

A cohort of 33 patients (23 female) was analyzed. Median age at IP creation was 38 (range 5-62) years. Median follow-up was 258 (range 24-452) months. During follow-up, 22 (67%) patients underwent at least one surgical revision. In total, 45 revision procedures were performed. The estimated mean revision-free survival was 198 (95%-CI 144-242) months.

CONCLUSION

Two-thirds of our IP patients required surgical revision during very long-term follow-up. However, the mean revision-free survival was 198 months. This establishes the IP as a durable and resilient option for urinary diversion, yet underlines the need for lifelong follow-up as some of these complications and indication were subclinical. These results contribute significantly to patient counseling when discussing different options for urinary diversion, especially at a younger age.

Extracellular matrix analysis of fibrosis: A step towards tissue engineering for urethral stricture disease

The urogenital tract is a target for many congenital and acquired diseases, both benign and oncogenic. In males, the urethra that transports urine and semen can be obstructed by a fibrotic disease called urethral stricture disease (USD). In severe USD, the whole organ including the vascular embedding, the corpus spongiosum (CS), is affected. Recurrent or severe USD is treated by reconstructive surgery. Tissue engineering may improve the outcome of urethral reconstruction in patients with complicated USD. Currently in urethral reconstruction only the epithelial layer is replaced, no substitution for the CS is provided, while the CS is important for mechanical support and vascularization. To develop a tissue engineering strategy for the CS, it is necessary to know the protein composition of the CS. As the extracellular matrix (ECM) plays an important role in the formation of fibrosis, we analyzed the distribution and localization of ECM components in human healthy and fibrotic CS tissue using immunohistology. The morphology of components of the elastic network were affected in USD. After decellularization a clear enrichment of proteins belonging to the ECM was found. In the proteomic analysis collagens COL15A1 and COL4A2 as well as inter-alpha-trypsin inhibitor ITIH4 were upregulated in fibrotic samples. The glycoproteins Periostin (POSTN), Microfibrillar-associated protein 5 (MFAP5) and EMILIN2 are downregulated in fibrotic tissue. To our knowledge this is the first proteomic study of ECM proteins of the CS in healthy and in USD. With these results a regenerating approach for tissue engineered CS can be developed, including relevant ECM proteins that reduce fibrosis and promote healthy healing in urethral reconstructive surgery.

Quantifying bladder outflow obstruction in men: A comparison of four approximation methods exploiting large data samples

INTRODUCTION

A pressure flow study (PFS), part of the International Continence Society standard urodynamic test, is regarded gold standard for the classification and quantification of the urethral resistance (UR), expressed in the bladder outflow obstruction (BOO). For men with benign prostatic hyperplasia, the minimum urethral opening pressure (pmuo ), found at the end of the passive urethral resistance relation is considered the relevant parameter describing BOO. However, in clinical practice, direct measurements of pmuo are easily confounded by terminal dribbling. For that reason, alternative methods were developed to derive pmuo , and thereby assess BOO using the maximum urine flow rate (Qmax ) and the corresponding pressure (pdetQmax ) instead. These methods were never directly compared against a large data set. With the increasing variety of treatments becoming available more precise grading of UR may become of relevance. The current study compares four well-known methods to approximate pmuo and examines the relation between pmuo and pdetQmax .

METHODS

In total, 1717 high-quality PFS of men referred with lower urinary tract symptoms between 2003 and 2020 without earlier lower urinary tract surgery were included. From these recordings, pmuo was calculated according to three one-parameter methods. In addition, a three-parameter method (3PM) was used, based on a fit through the lowest pressure flank of the pressure-flow plot. The estimated pmuo 's were compared with a precisely assessed pmuo . A difference of <10 cmH2 O between an estimate and the actual pmuo was considered accurate. A comparison between the four approximation methods and the actual pmuo was visualized using a Bland-Altman plot. The differences between the actual and the estimated slope were assessed and dependency on pmuo was analyzed.

RESULTS

A total of 1717 studies were analyzed. In 55 (3.2%) PFS, 3PM analysis was impossible because all pressures after Qmax were higher than pdetQmax . The 3PM model was superior in predicting pmuo , with 75.9% of the approximations within a range of +10 or -10 cmH2 O of the actual pmuo . Moreover, pmuo according to urethral resistance A (URA) and linearized passive urethral resistance relation (linPURR) appear equally reliable. Bladder outflow obstruction index (BOOI) was significantly less accurate when compared to all others. Bland-Altman analysis showed a tendency of BOOI to overestimate pmuo in men with higher grades of UR, while URA tended to underestimate pmuo in those cases. The slope between pmuo and pdetQmax -Qmax increased with larger pmuo , as opposed to the constant relation proposed within BOOI. Although significant differences were found, the clinical relevance of those differences is not known.

CONCLUSION

Of the four methods to estimate pmuo and quantify BOO, 3PM was found the most accurate and BOOI the least accurate. As 3PM is not generally available and performance in lower quality PFS is unknown, linPURR is (for now) the most physiologically accurate.

Clomiphene citrate for male infertility: A systematic review and meta-analysis

BACKGROUND

Male infertility is a prevalent and worldwide problem with various difficulties in treatment. Clomiphene citrate is a selective estrogen receptor modulator and may improve semen quality by stimulating hormone synthesis and spermatogenesis. There is lack of evidence on the efficacy of clomiphene citrate as therapy for male infertility.

OBJECTIVES

Therefore, a systematic review and meta-analysis was performed to assess the efficacy of clomiphene citrate on sperm quality in infertile men.

METHODS

A search was conducted in the PubMed, EMBASE and Cochrane databases for effectiveness in infertile males treated with clomiphene citrate. Both intervention and observational studies were included. Primary outcome measures were semen parameters (concentration, motility and morphology). Secondary outcomes included hormonal evaluation, pregnancy rate and side effects. Studies were included for meta-analysis if they provided absolute numbers for outcomes before and during treatment with appropriate SD or SE.

RESULTS

Total 1799 studies were identified during the search, 18 studies remained for qualitative analysis (n = 731) and 15 studies for meta-analysis (n = 566). Study populations ranged between 11 and 140 participants. Sperm concentration was higher during treatment, with a mean difference 8.38 × 106 /ml (95% confidence interval: 5.17-11.59; p < 0.00001; I2  = 87%). Total sperm motility was higher during treatment, with a mean difference of 8.14% (95% confidence interval: 3.83-12.45; p < 0.00001; I2  = 76%). There was no difference in sperm morphology before and during treatment. Total testosterone, follicle-stimulating hormone, luteinizing hormone and estradiol were higher during clomiphene citrate treatment. During follow-up, no serious adverse effects occurred. In 10 studies, pregnancy rate was reported and yielded a mean of 17% during clomiphene citrate treatment (range: 0%-40%).

CONCLUSIONS

Clomiphene citrate increased sperm concentration and motility and could be considered as a safe therapy for improving sperm parameters in infertile males.

Dysfunctional Voiding: Exploring Disease Transition From Childhood to Adulthood

OBJECTIVE

To improve our transitional care, we explored how childhood dysfunctional voiding (DV) develops into adulthood. DV is a common condition in both children and adults. However, the long-term course of childhood DV into adulthood is unknown and treatment over the ages differs.

METHODS

A cross-sectional follow-up was performed in a cohort of 123 females treated from 2000 to 2003 for childhood DV with urinary tract infections (UTIs) and/or daytime urinary incontinence (DUI). The main outcome was a staccato or intermittent urinary flow pattern, possibly indicating persistent or recurred DV according to the International Continence Society criteria. Flow patterns of healthy women were used to compare results.

RESULTS

Twenty-five patients participated in this study, with a mean duration of 20.8 years after urotherapy. In 10/25 (40%) cases, a staccato or interrupted urinary flow pattern was found on the current measurement, compared to 5/47 (10.6%) in the control group. Around 50% (5/10) of the patients with a dysfunctional flow pattern reported UTIs and 50% (5/10) experienced DUI. In the group with a normal flow pattern, 2/15 (13%) reported UTIs and 9/15 (60%) DUI. The impact of DUI on quality of life was moderate to high in both groups.

CONCLUSION

Our results show that 40% of females who had extensive urotherapy for DV in childhood, still have DV according to International Continence Society criteria as an adult, 56% still experience DUI, and 28% UTIs. These data should be taken into account in the counseling of patients and for guiding the process of transition into adulthood.

Familial Male-limited Precocious Puberty (FMPP) and Testicular Germ Cell Tumors

OBJECTIVE

The purpose of this study is to report development of a malignant testicular germ cell tumor (GCT) in 2 young adult males with familial male-limited precocious puberty (FMPP) because of LHCGR pathogenic variants in 2 families. Secondarily, to study the possible relation between FMPP and testicular tumors and to investigate whether FMPP might predispose to development of malignant testicular tumors in adulthood a literature review is conducted.

METHODS

Data on 6 cases in 2 families are obtained from the available medical records. In addition, a database search is performed in Cochrane, PubMed, and Embase for studies that report on a possible link between FMPP and testicular tumors.

RESULTS

The characteristics of 6 males with FMPP based on activating LH receptor (LHCGR) germline pathogenic variants are described, as are details of the testicular GCTs. Furthermore, a literature review identified 4 more patients with signs of FMPP and a (precursor of) testicular GCT in adolescence or adulthood (age 15-35 years). Additionally, 12 patients with signs of precocious puberty and, simultaneously, occurrence of a Leydig cell adenoma or Leydig cell hyperplasia are reported.

CONCLUSION

There is a strong suggestion that FMPP might increase the risk of development of testicular GCTs in early adulthood compared with the risk in the general population. Therefore, prolonged patient monitoring from mid-pubertal age onward including instruction for self-examination and periodic testicular ultrasound investigation in patients with a germline LHCGR pathogenic variant might contribute to early detection and thus early treatment of testicular GCT.

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

Purpose

Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists’ experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice.

Methods

A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used.

Results

Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention.

Conclusion

The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03910-3.

The effect of meatal correction on daytime urinary incontinence in girls with an anterior deflected urinary stream

INTRODUCTION

Girls with an anterior deflected urinary stream (ADUS) are known to wet the toilet rim and their buttocks while voiding. This deviation may prevent adopting an ideal toileting position and can thus develop into a functional voiding disorder. Although surgical correction of the urinary stream by a meatotomy is part of standard care in girls with ADUS and lower urinary tract symptoms (LUTS) at our center, little is known about the effect of this procedure on daytime urinary incontinence (DUI).

OBJECTIVE

To assess the effect of meatal correction on incontinence in girls with ADUS and DUI, and to find predictors for therapy success.

STUDY DESIGN

A retrospective chart study including all girls with ADUS and DUI who underwent a dorsally directed meatal correction at our tertiary referral center between 2005 and 2018 (n = 274). The main outcome measurement was continence according to the International Children's Continence Society criteria, expressed as the percentage of children that were continent at post-surgical follow-up (complete response). Multivariate logistic regression was used to identify predictors of continence.

RESULTS

In 93% of girls, the direction of the urinary stream was no longer anterior deflected. 29% (n=79) of all girls were continent at post-surgical follow-up. We could not find a convincing predicting factor for achieving continence.

DISCUSSION

Although meatal correction is successful on normalizing the direction of the urinary stream, less than one-third of girls became continent. In addition, we were unable to indicate which girls will profit from this procedure in terms of continence. Since not every girl with ADUS develops incontinence complaints, it may also be questionable whether ADUS and incontinence are directly related. Since other, less invasive and more effective treatment options for DUI are available, meatal correction should therefore be considered a last-resort option in the treatment of pediatric DUI in girls with ADUS.

CONCLUSION

Of the 274 girls with ADUS and DUI, 29% did benefit from a meatotomy. No convincing indicator for therapy success could however be found. Therefore, we discourage a meatotomy as standard treatment in girls with ADUS and DUI.

Do previous urethral endoscopic procedures and preoperative self-dilatation increase the risk of stricture recurrence after urethroplasty?

Objective

To evaluate the relation between clinically relevant stricture recurrence after first urethroplasty and prior endoscopic treatments (dilatation and/or direct visual internal urethrotomy) or intermittent self‐dilatation (ISD).

Methods

Patients with bulbar urethral strictures treated with first urethroplasty between 2011 and April 2019 were included in a prospectively gathered database with standardized follow‐up. Stricture recurrence was defined as any need for reintervention. Primary outcome was the analysis of recurrence risk after first urethroplasty in relation with the number of prior endoscopic treatments or performance of ISD. Univariate and multivariate statistical analyses were performed.

Results

Overall, 106 patients were included with a median follow‐up of 12 months (interquartile range 8‐13]. Reintervention was necessary in 16 patients (15%). Recurrence was more prevalent in patients with ≥3 prior endoscopic treatments (28%, P = .009). No increased risk of recurrence was found in patients with 1 or 2 prior endoscopic treatments. The prevalence of prior ISD was twice as high in the stricture recurrence group (56% vs 26%, P = .014), and ISD was performed in 61% of the patients with ≥3 prior endoscopic treatments (P < .001). The number of prior endoscopic interventions and performance of ISD were no independent predictors for recurrence in the multivariable analysis.

Conclusions

This study shows that the risk of recurrence after first urethroplasty is increased in patients with ≥3 prior endoscopic treatments and in those who performed ISD. Patients performing ISD more often had ≥3 prior endoscopic treatments. Prior endoscopic treatment and performance of ISD were not independent predictors of stricture recurrence.

A Retrospective Analysis of Female Müllerian Duct Anomalies in Association With Congenital Renal Abnormalities

STUDY OBJECTIVE

Müllerian (paramesonephric) duct anomalies (MDAs) are associated with several coexisting congenital abnormalities, including renal abnormalities. Although congenital renal abnormalities may remain asymptomatic, the consequences should not be underestimated. In both the literature and clinical practice, it remains necessary to improve awareness of the co-occurrence of different congenital renal abnormalities in women with MDAs. To gain further insight into this co-occurrence and to estimate whether guidelines for women with MDAs should be optimized, this study was performed.

DESIGN

A descriptive retrospective analysis.

SETTING

University Medical Centre Utrecht in the Netherlands.

PARTICIPANTS

Women with MDAs diagnosed or treated between 1980 and 2015.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

The prevalence of the co-occurrence of congenital renal abnormalities in women with MDAs.

RESULTS

Renal status was recorded in 186 of 255 women (72.9%), and the other women (27.1%) did not have a retrievable renal status. Congenital renal abnormalities were present in 90 of 186 women (48.4%) and were observed most frequently in women having a duplex uterus with obstructed hemivagina. The most common renal abnormality was unilateral renal agenesis, which was observed in 58 of 90 women (64.4%).

CONCLUSIONS

MDAs are highly associated with different congenital renal abnormalities, and these results emphasize that women with MDAs should be routinely screened for their co-occurrence. However, these results also highlight that there remains a lack of awareness of this association. Whether all women with congenital renal abnormalities should be routinely screened for MDAs requires further investigation.

Gel Casting as an Approach for Tissue Engineering of Multilayered Tubular Structures

Several urological structures, such as the male urethra, have a tubular organization consisting of different layers. However, in severe urethral disease, urologists are limited to replacing solely the epithelial layer. In case of severe hypospadias and urethral stricture disease, the underlying supporting structure (the corpus spongiosum) is either absent or fibrotic, causing suboptimal vascularization and therefore increasing the risk of graft failure. Recapitulating the multilayered architecture of the urethra, including supporting structure with tissue engineering, might minimize urethral graft failure. However, current tissue engineering applications for complex multilayered tubular constructs are limited. We describe a gel casting method to tissue engineer multilayered tubular constructs based on fiber-reinforced cell-laden hydrogels. For this, a multichambered polydimethylsiloxane mold was casted with fiber-reinforced hydrogels containing smooth muscle cells (SMCs) and a coculture of endothelial cells and pericytes. The cell-loaded hydrogels were rolled, with the fiber mesh as guidance, into a tubular construct. In the lumen, urothelial cells were seeded and survived for 2 weeks. In the tubular construct, the cells showed good viability and functionality: endothelial cells formed capillary-like structures supported by pericytes and SMCs expressed elastin. With a graft produced by this technique, supported with subepithelial vascularization, urethral reconstructive surgery can be improved. This approach toward tissue engineering of multilayered tubular structures can also be applied to other multilayered tubular structures found in the human body. Impact Statement Recapitulating the multilayered architecture of tubular structures found in the human body might minimize graft failure. Current tissue engineering applications for complex multilayered tubular constructs are limited. Here we describe a gel casting approach based on fiber-reinforced cell-laden hydrogels. A multichambered polydimethylsiloxane mold was casted with cell-loaded, fiber-reinforced hydrogels, with the fiber mesh as guidance, into a tubular construct. A graft produced by this technique can improve reconstructive surgery by providing subepithelial vascularization and thereby can reduce graft failure.

Coping styles in patients with hypospadias

OBJECTIVE

The objective of this study is to investigate the coping styles used by patients with hypospadias. Long-term hypospadias studies generally show satisfying outcomes, but some report a lower quality of life (QoL) or poorer psychosocial adjustment, particularly in patients with proximal hypospadias. A lower QoL or psychosocial adjustment was found to be associated with passive coping styles in other pediatric patient populations. Hypothetically, patients with hypospadias also develop different coping styles due to medical experiences in childhood, leading to the lower QoL outcomes on the long term. However, coping styles of patients with hypospadias have never been analyzed.

PATIENTS AND METHODS

Adult men with hypospadias repair in childhood were recruited (n = 55; aged 19.9 [IQR 19.2-22.1]). Coping styles were determined with the Utrecht Coping List (UCL) and results compared with a reference group of male students (n = 55, age 20-30 years, no medical history). Sub analysis of coping styles of the hypospadias groups was done based on three items: severity of hypospadias, time of last hypospadias surgery and occurrence of postoperative complications.

RESULTS

Compared to the reference groups, patients with hypospadias had higher scores on Avoidance (P < 0.05), particularly patients who had ≥1 postoperative complication or proximal hypospadias. Patients with proximal hypospadias also had lower scores on Seeking Social Support compared to the reference group (P < 0.05). Within the hypospadias group, coping style scores did not differ based on severity of hypospadias, timing of surgery or postoperative complications.

CONCLUSION

Patients with hypospadias, particularly those with proximal hypospadias or a postoperative complication, more often use an avoiding coping style compared to a reference population. Attention to coping styles during the follow-up of patients with hypospadias might help to improve the QoL in these patients.

Description of Urological Surveillance and Urologic Ultrasonography Outcomes in a Cohort of Individuals with Long-Term Spinal Cord Injury

Background: Individuals with spinal cord injury (SCI) have an increased risk of developing urological complications. Therefore, long-term routine urological surveillance is recommended. Objective: To describe urological surveillance in individuals with long-term SCI and to determine factors associated with urologic ultrasonography (UU) outcome. Methods: Wheelchair-dependent individuals with an SCI for 10 years or more were included. A medical assessment was done in 8 participating rehabilitation centers. The International Lower Urinary Tract Function Basic SCI Data Set was used to assess bladder-emptying methods and previous surgical procedures on the urinary tract. We studied urological surveillance: whether participants had routine urological checkups (including UU) and when latest urodynamic study was performed. Latest UU (performed <1 year ago) was retrieved or, when lacking, UU was performed as part of our study. Results: Median time since injury (TSI) was 22.0 years. Overall, 39% of the 282 participants did not have routine urological checkups and 33% never had a urodynamic study performed. UU data (N = 243) revealed dilatation of the upper urinary tract (UUT) in 4.5% of the participants and urinary stones in 5.7%. Abnormal UU outcome was associated with increasing TSI, nontraumatic SCI, and previous surgical bladder or UUT stone removal. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Conclusions: Over one-third of Dutch individuals with long-term SCI did not receive routine urological surveillance. UU outcome was not associated with routine urological checkups or type of bladder-emptying method. Further research on the indication and frequency of urological surveillance is recommended.

Proximal hypospadias treated with a transverse preputial island tube: long-term functional, sexual, and cosmetic outcomes

OBJECTIVE

To study long-term urinary and sexual function, and cosmetic outcomes in adult patients who underwent single-stage transverse preputial island tube (TPIT) for proximal hypospadias repair in childhood. Long-term data on outcomes of patients with proximal hypospadias with severe coexisting curvature and insufficient urethral plate are scarce, but are necessary to decide which repair technique is most beneficial.

PATIENTS, SUBJECTS AND METHODS

Patients with proximal hypospadias operated with TPIT (TPIT Group) were compared to patients with distal hypospadias repair (Distal Group) and to a control group of male medical students (Control Group). Participants completed the International Prostate Symptom Score, the International Index of Erectile Function (IIEF-15), additional non-validated questions, and performed uroflowmetry. Cosmesis was assessed in the patients with hypospadias using the Pediatric Penile Perception Score (PPPS); stretched penile length was also measured.

RESULTS

Of the 121 eligible patients with hypospadias, 54 with either TPIT or distal hypospadias repairs participated. The TPIT Group comprised 12 patients (median age of 20.0 years) and the Distal Group comprised 42 patients (median age of 19.6 years). The complication rates were similar, at 8 of the 12 patients in the TPIT Group vs 26/42 (62%) in the Distal Group (P = 0.76). Urinary outcomes were similar in the TPIT, Distal, and the Control (comprised of 148 medical students with a median age of 21.0 years) groups. The TPIT Group had a lower maximum urinary flow rate compared to the Control Group, at 24.1 vs 28.6 mL/s (P < 0.05). IIEF-15 scores were similar in the TPIT, Distal and Control groups, except for 'Orgasmic Function' (7.5 vs 10.0 vs 10.0, respectively; P < 0.01). Although the TPIT Group had a smaller penile length compared to the Distal Group (10.1 vs 12.9 cm, P < 0.01), PPPS outcomes were similar.

CONCLUSION

In these TPIT patients, long-term urinary, sexual and cosmetic outcomes were similar to those in patients with distal hypospadias repairs and controls.

The Long-term Effect of Superficial Bladder Neck Incision on Ejaculation and Incontinence in Boys with Primary and Secondary Bladder Neck Obstruction

OBJECTIVE

Superficial bladder neck incision (SBNI) is controversial at young age, with retrograde ejaculation after puberty as main concern. The aim of the study is to investigate the long-term effect of SBNI on ejaculation and incontinence in boys with primary and secondary bladder neck obstruction (BNO).

MATERIALS AND METHODS

In boys with infravesical obstruction, SBNI was performed in case of a persistent BNO after earlier desobstruction or in case of primary severely obstructive bladder neck. SBNI was performed with a diathermy hook, always superficially (2-3 mm) and unilaterally at 7 O'clock. Males that had SBNI during childhood after posterior urethral valve incision or relief of other obstruction between 1986 and 2003 were included. Evaluation was done by International Continence Society male sex questionnaire, International Prostate Symptom Score, developmental International Consultation Modular Questionnaire on Urinary Incontinence, frequency volume chart, and uroflowmetry.

RESULTS

Of 79 traceable patients, 40 (50.6%) participated. Of these, 37 (92.5%) completed all questionnaires and 28 (70%) performed uroflowmetry. Median age at SBNI was 4.7 years [interquartile range (IQR) 0.6-8.5] and was 19.6 years (IQR 17.3-20.9) at follow-up. All men had antegrade ejaculation, 4/37 (10.8%) reported possibly reduced ejaculatory volume. Eight (22%) had moderate lower urinary tract symptoms and two (5.4%) had moderate incontinence. Median maximum flow rate was 30.1 mL/s (IQR 24.4-42.6).

CONCLUSION

SBNI in boys with severe infravesical obstruction can be done safely with preservation of antegrade ejaculation and no additional lower urinary tract dysfunction.

Bladder-emptying methods, neurogenic lower urinary tract dysfunction and impact on quality of life in people with long-term spinal cord injury

OBJECTIVES

To describe bladder-emptying methods used by people with long-term spinal cord injury (SCI) and to determine usage differences in relation to time since injury, sex, lesion level and completeness of lesion. Furthermore, to evaluate the relationship between bladder-emptying methods and the impact of neurogenic lower urinary tract dysfunction (NLUTD) on quality of life (QoL).

DESIGN

Cross-sectional multicenter study.

SETTING

Dutch community.

PARTICIPANTS

Persons dependent on wheelchairs (N = 282) with traumatic or non-traumatic SCI for ≥10 years and age at injury of 18-35 years.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

The International Lower Urinary Tract Function Basic SCI Data Set and the Short-Form Qualiveen (SF-Qualiveen).

RESULTS

Median time since injury was 22.0 years (IQR: 16.8-30.3). Clean intermittent catheterization (CIC) was most commonly used (42.6%). Longer time since injury was associated with fewer continent urinary diversions and more transurethral catheter use. Transurethral catheter use and continent urinary diversions were more prevalent among women. Participants with tetraplegia were more likely to use reflex voiding or a suprapubic catheter, and participants with paraplegia were more likely to use CIC. Transurethral catheter users reported the highest impact of NLUTD on quality of life (SF-Qualiveen score: 1.9; SD = 0.8). Participants with a continent urinary diversion reported the lowest impact (SF-Qualiveen score: 0.9; SD = 0.6). Higher age and indwelling catheter use versus CIC were associated with a higher impact of NLUTD on QoL.

CONCLUSIONS

CIC is the most common bladder-emptying method in Dutch people with long-term SCI. Clinicians should be aware of the impact of NLUTD on QoL, especially for those using an indwelling catheter.

Systematic Review to Compare Urothelium Differentiation with Urethral Epithelium Differentiation in Fetal Development, as a Basis for Tissue Engineering of the Male Urethra

BACKGROUND

Tissue-engineered (TE) urethra is desirable in men with urethral disease (stricture or hypospadias) and shortage of local tissue. Although ideally a TE graft would contain urethral epithelium cells, currently, bladder epithelium (urothelium) is widely used, but morphologically different. Understanding the differences and similarities of urothelium and urethral epithelium could help design a protocol for in vitro generation of urethral epithelium to be used in TE grafts for the urethra.

PURPOSE

To understand the development toward urethral epithelium or urothelium to improve TE of the urethra.

METHODS

A literature search was done following PRISMA guidelines. Articles describing urethral epithelium and bladder urothelium development in laboratory animals and humans were selected.

RESULTS

Twenty-nine studies on development of urethral epithelium and 29 studies on development of urothelium were included. Both tissue linings derive from endoderm and although adult urothelium and urethral epithelium are characterized by different gene expression profiles, the signaling pathways underlying their development are similar, including Shh, BMP, Wnt, and FGF. The progenitor of the urothelium and the urethral epithelium is the early fetal urogenital sinus (UGS). The urethral plate and the urothelium are both formed from the p63+ cells of the UGS. Keratin 20 and uroplakins are exclusively expressed in urothelium, not in the urethral epithelium. Further research has to be done on unique markers for the urethral epithelium.

CONCLUSION

This review has summarized the current knowledge about embryonic development of urothelium versus urethral epithelium and especially focuses on the influencing factors that are potentially specific for the eventual morphological differences of both cell linings, to be a basis for developmental or tissue engineering of urethral tissue.

Tissue engineering for human urethral reconstruction: systematic review of recent literature

Background

Techniques to treat urethral stricture and hypospadias are restricted, as substitution of the unhealthy urethra with tissue from other origins (skin, bladder or buccal mucosa) has some limitations. Therefore, alternative sources of tissue for use in urethral reconstructions are considered, such as ex vivo engineered constructs.

Purpose

To review recent literature on tissue engineering for human urethral reconstruction.

Methods

A search was made in the PubMed and Embase databases restricted to the last 25 years and the English language.

Results

A total of 45 articles were selected describing the use of tissue engineering in urethral reconstruction. The results are discussed in four groups: autologous cell cultures, matrices/scaffolds, cell-seeded scaffolds, and clinical results of urethral reconstructions using these materials. Different progenitor cells were used, isolated from either urine or adipose tissue, but slightly better results were obtained with in vitro expansion of urothelial cells from bladder washings, tissue biopsies from the bladder (urothelium) or the oral cavity (buccal mucosa). Compared with a synthetic scaffold, a biological scaffold has the advantage of bioactive extracellular matrix proteins on its surface. When applied clinically, a non-seeded matrix only seems suited for use as an onlay graft. When a tubularized substitution is the aim, a cell-seeded construct seems more beneficial.

Conclusions

Considerable experience is available with tissue engineering of urethral tissue in vitro, produced with cells of different origin. Clinical and in vivo experiments show promising results.

Cross-sectional study of determinants of upper and lower urinary tract outcomes in adults with spinal dysraphism--new recommendations for urodynamic followup guidelines?

PURPOSE

Although annual urodynamic study is currently recommended for all adults with spinal dysraphism, this followup might be overly intensive. Therefore, in this cross-sectional study we examine which determinants of upper and lower urinary tract outcomes are associated with relevant urodynamic findings.

MATERIALS AND METHODS

All patients visiting our specialized outpatient clinic for adults with spinal dysraphism during a 26-month period underwent evaluation of the lower urinary tract by (video)urodynamic study. High end filling pressure (40 cm H2O or greater), poor compliance (less than 10 ml/cm H2O) and high detrusor leak point pressure (40 cm H2O or greater) were classified as relevant findings and together called unsafe bladder. Multivariable analysis was performed to reveal determinants of unsafe bladder (type of spinal dysraphism, being wheelchair bound, hydrocephalus, urological symptoms and renal dilatation) and diagnostic accuracy was calculated for the significant determinants.

RESULTS

Of the 134 patients evaluated (median age 31.5 years) 120 underwent complete urodynamic study and were included in this study. In the multivariable model unsafe bladder was significantly associated with being wheelchair bound (OR 5.36, p=0.008). In patients without symptoms who were not wheelchair bound the negative predictive value of urodynamic study for finding an unsafe bladder was high (1.00).

CONCLUSIONS

If an adult patient with spinal dysraphism is not wheelchair bound, unfavorable findings at urodynamic study are unlikely. If these patients are asymptomatic, these findings are even more unlikely. In these patients it is probably not necessary to perform urodynamic study as frequently as is currently recommended. Patients with an unsafe bladder need active surveillance and treatment when upper tract safety is threatened.

A systematic review on the accuracy of diagnostic procedures for infravesical obstruction in boys

Background

Infravesical obstruction leads to kidney and bladder dysfunction in a significant proportion of boys. The aim of this review is to determine the value of diagnostic tests for ascertainment of infravesical obstruction in boys.

Methodology

We searched PubMed and EMBASE databases until January 1, 2013, to identify papers that described original diagnostic accuracy research for infravesical obstruction in boys. We extracted information on (1) patient characteristics and clinical presentation of PUV and (2) diagnostic pathway, (3) diagnostic accuracy measures and (4) assessed risk of bias.

Principal Findings

We retrieved 15 studies describing various diagnostic pathways in 1,189 boys suspected for infravesical obstruction. The included studies reflect a broad clinical spectrum of patients, but all failed to present a standardised approach to confirm the presence and severity of obstruction. The risk of bias of included studies is rather high due to work-up bias and missing data.

Conclusions

As a consequence of low quality of methods of the available studies we put little confidence in the reported estimates for the diagnostic accuracy of US, VCUG and new additional tests for ruling in or ruling out infravesical obstruction. To date, firm evidence to support common diagnostic pathways is lacking. Hence, we are unable to draw conclusions on diagnostic accuracy of tests for infravesical obstruction. In order to be able to standardise the diagnostic pathway for infravesical obstruction, adequate design and transparent reporting is mandatory.

Paucity of evidence for urinary tract outcomes in closed spinal dysraphism: a systematic review

OBJECTIVES

To describe the long-term upper (UUT) and lower urinary tract (LUT) outcomes in patients with closed spinal dysraphism (CSD). CSD differs from open spinal dysraphism (OSD) by its long asymptomatic course and consequent later diagnosis. The outcome of UUT and LUT function in adults with CSD is relatively unknown.

PATIENTS AND METHODS

A systematic review was performed following the standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive search was made of PubMed and EMBASE. Included were papers on adults with any form of primary CSD that described bladder and/or kidney function. Only English and Dutch language papers were included. Excluded were papers on patients aged <18 years and patients with secondary tethered cord following childhood OSD repair. International Continence Society terminology was used to describe LUT outcomes.

RESULTS

Eventually, only seven studies (90 patients) were included and none of these described renal outcomes. Five of the seven papers were on outcomes after untethering surgery during adulthood. Urological complaints were present in 54/79 (68.4%) patients. Urodynamic studies (48 patients available) revealed detrusor underactivity in 46.5% of the evaluated cases, detrusor overactivity in 32.6% and normal findings in 16.3% of the studied patients. Symptomatic improvement after surgery for tethered cord occurred in 33.3-90.0%, depending on the subgroup studied. Urodynamic improvement rates ranged from 11.1% to 54.5% (but based on three studies with only 24 patients). Success of surgery depended on the time between onset of symptoms and operation, and (sometimes) type of lesion.

CONCLUSIONS

Few data are available on long-term urological outcomes in adult patients with CSD. More extensive research on follow-up, including the functional status of the UUT, is recommended. Based upon the little evidence available, we think life-long follow-up (from birth into adulthood) of those with CSD and neurogenic bladder is advisable.

Upper and lower urinary tract outcomes in adult myelomeningocele patients: a systematic review

BACKGROUND

The introduction of sophisticated treatment of bladder dysfunction and hydrocephalus allows the majority of SB patients to survive into adulthood. However, no systematic review on urological outcome in adult SB patients is available and no follow-up schemes exist.

OBJECTIVES

To systematically summarize the evidence on outcome of urinary tract functioning in adult SB patients.

METHODS

A literature search in PubMed and Embase databases was done. Only papers published in the last 25 years describing patients with open SB with a mean age >18 years were included. We focused on finding differences in the treatment strategies, e.g., clean intermittent catheterization and antimuscarinic drugs versus early urinary diversion, with regard to long-term renal and bladder outcomes.

RESULTS

A total of 13 articles and 5 meeting abstracts on urinary tract status of adult SB patients were found describing a total of 1564 patients with a mean age of 26.1 years (range 3-74 years, with a few patients <18 years). All were retrospective cohort studies with relatively small and heterogeneous samples with inconsistent reporting of outcome; this precluded the pooling of data and meta-analysis. Total continence was achieved in 449/1192 (37.7%; range 8-85%) patients. Neurological level of the lesion and hydrocephalus were associated with incontinence. Renal function was studied in 1128 adult patients. In 290/1128 (25.7%; range 3-81.8%) patients some degree of renal damage was found and end-stage renal disease was seen in 12/958 (1.3%) patients. Detrusor-sphincter dyssynergy and detrusor-overactivity acted as adverse prognostic factors for the development of renal damage.

CONCLUSIONS

These findings should outline follow-up schedules for SB patients, which do not yet exist. Since renal and bladder deterioration continues beyond adolescence, follow-up of these individuals is needed. We recommend standardization in reporting the outcome of urinary tract function in adult SB patients.

Urodynamic effects of transrectal intraprostatic Ona botulinum toxin A injections for symptomatic benign prostatic hyperplasia

OBJECTIVE

To investigate urodynamic, symptomatic, and histologic effects of intraprostatic injection with Ona botulinum toxin A for benign prostatic hyperplasia.

METHODS

Patients >55 years with symptomatic benign prostatic hyperplasia failing medical therapy were treated. Inclusion criteria were International Prostate Symptom Score >7, prostate volume 30-50 cm(3), and urodynamic bladder outlet obstruction >Schäfer grade 2. A transrectal intraprostatic injection of 200 IU Ona botulinum toxin A was given. Filling cystometry and pressure flow studies were performed at 3, 6, and 12 months post injection. International Prostate Symptom Score, International Prostate Symptom Score quality of life, prostate-specific antigen, and prostate volume were measured up until 12 months; prostate biopsies before and after Ona botulinum toxin A injection were done for histology and cell proliferation.

RESULTS

Fifteen men (mean age 64.9 years) were included. Ona botulinum toxin A injection was well tolerated with few complications. Postvoid residual improved (170 to 80 mL), but maximum flow rate and bladder outlet resistance parameters did not change during follow-up. International Prostate Symptom Score and International Prostate Symptom Score quality of life improved (22 to 13 and 5 to 2, respectively), whereas prostate-specific antigen and prostate volume remained unaltered. Cell proliferation did not decrease and in 37% and 64% of pre- and posttreatment biopsies, respectively, some degree of prostatitis was found. Ten of 15 patients eventually underwent transurethral prostate resection because of persisting symptoms.

CONCLUSION

Intraprostatic Ona botulinum toxin A for symptomatic benign prostatic hyperplasia did not affect urodynamic outcomes, except for postvoid residual. Although symptom scores improved, we were not able to show change in prostate volume, prostate-specific antigen, or histologic outcomes. A placebo effect of intraprostatic Ona botulinum toxin A could not be ruled out.

Ultrasound imaging of sacral reflexes

OBJECTIVES

To investigate the reliability of examination of the guarding reflex of the pelvic floor by dynamic perineal ultrasonography in children with bladder dysfunction and in controls.

METHODS

A total of 40 patients with nonneurogenic bladder/sphincter dyssynergia, 40 with spina bifida, and 40 controls underwent a dynamic ultrasound examination of the pelvic floor while coughing and while being tapped on the abdominal wall. The reflex action of the puborectal muscle in females, and the combined action of the puborectal muscle and external sphincter muscle in males, were recorded.

RESULTS

Of the 40 patients with nonneurogenic bladder/sphincter dyssynergia, 38 had a normal reflex action of the puborectal muscle during the abdominal tap and 36 had a normal reflex action when coughing. Two of these patients had unexplained underactive bladder syndrome and were using clean intermittent catheterization, and two could not be assessed because of hypermobility of the bladder neck when coughing but had a normal reaction during abdominal tapping. Of the 40 patients with spina bifida, none had puborectal activity during coughing and 5 had some puborectal activity during tapping. Of the 40 controls, 39 had normal reflex activity during both coughing and tapping.

CONCLUSIONS

The question of whether a child has nonneurogenic or neuropathic bladder/sphincter dysfunction is often difficult to answer on the basis of urodynamic studies alone. Dynamic perineal ultrasound recording of the S2-S4 reflex arches provides reliable additional information and is noninvasive to the patient.

Primary repair of bladder exstrophy followed by clean intermittent catheterization: outcome of 15 years' experience

OBJECTIVES

To determine the continence and spontaneous voiding rate after neonatal reconstruction of bladder exstrophy without formal bladder neck reconstruction in patients undergoing primary reconstruction and treated with clean intermittent catheterization (CIC) after closure.

METHODS

From 1987 to 2003, 15 consecutive patients (8 boys and 7 girls) with bladder exstrophy underwent neonatal reconstruction. Reconstruction focused on bringing the bladder neck and proximal urethra intra-abdominally and meticulously closing the pelvic floor muscles around the urethra. Three weeks postoperatively, CIC was started until toilet-training age. Bladder capacity, continence status, renal anatomy and function, and additional urologic surgical procedures during follow-up were analyzed.

RESULTS

Nine patients (60%) became socially continent after primary closure without any additional bladder neck surgery. Twelve patients (80%) were continent when those who underwent endoscopic bulking injection were included. One patient became socially continent after bladder neck reconstruction, and one was dry and used CIC after bladder neck reconstruction and ileocystoplasty. One patient remained incontinent because of the parents' refusal of surgery. Ultimately, of 15 patients, 14 were dry (93%) of whom 10 were completely continent, 3 were partially continent (dry intervals of 1 to 3 hours), and 1 was dry by catheterizable stoma. The bladder capacity was adequate for age in 80% of patients. Febrile urinary tract infection occurred in 33% of patients, and 67% needed endoscopy for urethral stenosis. Upper tract dilation and loss of renal function was not seen.

CONCLUSIONS

The results of our study have shown that primary repair of bladder exstrophy followed by CIC has encouraging continence and bladder capacity rates, with preservation of the upper urinary tract and limited need for additional bladder neck surgery.

Reliability of voiding cystourethrography to detect urethral obstruction in boys

OBJECTIVES

To evaluate the reliability of voiding cystourethrography (VCUG) to diagnose infravesical obstruction in boys.

METHODS

Hard copies of the VCUG findings of 72 boys were assessed by two pediatric radiologists and two pediatric urologists. The investigators were instructed to consider six items related to infravesical obstruction: vesicoureteral reflux, bladder wall thickness, bladder diverticulum, abnormal prostatic urethra, visible urethral obstruction, and obstruction in the sphincter area. Also, a scoring system was developed using these six items. Agreement among the four investigators for evaluation of the items on VCUG and for the scoring system was assessed using the kappa statistic. All boys underwent urethrocystoscopy, and the endoscopic findings were compared with VCUG results. Odds ratios were calculated for the results of VCUG for each investigator to predict the chance of cystoscopic infravesical obstruction.

RESULTS

Agreement among observers for vesicoureteral reflux and bladder diverticulum was good (kappa values for paired observers of 0.82 and 0.79). Agreement for bladder wall thickness, abnormal prostatic urethra, visible urethral obstruction, obstruction in the sphincter area, and the scoring system was poor (kappa values of 0.08, 0.35, 0.33, 0.26, and 0.33, respectively). Consequently, the results of VCUG could not predict for endoscopic infravesical obstruction accurately, although substantial differences occurred among investigators. Items on which investigators reached good agreement were negatively related to the risk of having infravesical obstruction.

CONCLUSIONS

Because agreement among investigators in the assessment of most items on VCUG was poor and because for the items with good agreement, the predictive power was poor, the current clinical use of VCUG for diagnosing infravesical obstruction needs reevaluation.

Lower Urinary Tract Dysfunction in Children With Generalized Hypermobility of Joints

PURPOSE

We assessed the relationship between general joint hypermobility (GJH) and lower urinary tract symptoms presenting as nonneurogenic bladder sphincter dysfunction in children.

MATERIALS AND METHODS

Parents of 89 children 5 to 12 years old who were diagnosed with GJH according to the Beighton and Bulbena scales were asked to fill out a questionnaire concerning symptoms of nonneurogenic bladder sphincter dysfunction, namely daytime urinary incontinence, nighttime urinary incontinence, urinary tract infection, constipation and fecal soiling. The control group comprised 116 healthy schoolchildren 5 to 12 years old.

RESULTS

Constipation was reported in 19% of boys with GJH and 4% of male controls (p = 0.02). Fecal soiling occurred more often in the GJH group than in the control group (34% versus 18%, p = 0.07). In girls daytime and nighttime urinary incontinence was more prevalent in the GJH group (38% and 14%, respectively) than in controls (13% and 2%, respectively, p = 0.004 and p = 0.02, respectively). Of girls with GJH 24% had a history of urinary tract infections compared with 11% of the control group (p = 0.08). CONCLUSIONS In children with generalized hypermobility of joints symptoms of nonneurogenic bladder sphincter dysfunction are more prevalent. In boys this condition manifests as constipation and possibly fecal soiling, and in girls as urinary incontinence and possibly urinary tract infections.

Oxybutynin for diagnosis of infravesical obstruction in boys with urinary incontinence

OBJECTIVES

To investigate whether good suppression of symptoms during anticholinergic therapy in boys with urinary urge incontinence is correlated with anatomic infravesical obstruction.

METHODS

In a prospective study, 65 boys with urge incontinence were treated temporarily with anticholinergics. The effect of therapy was assessed, and a full video-urodynamic evaluation was performed. When obstruction could not be excluded urodynamically, urethrocystoscopy was done to assess the level and severity of obstruction, followed by endoscopic treatment. The effect of oxybutynin on incontinence was compared with the presence or absence of obstruction.

RESULTS

In 49 of 65 boys aged 4 to 14 years with daytime urge incontinence, infravesical obstruction was found. Of the 49 boys, 38 (76%) had a good response to anticholinergic therapy. Of the 16 boys without infravesical obstruction, 12 (75%) did not improve with anticholinergic therapy. When anticholinergic therapy was used as a diagnostic test for infravesical obstruction, we found a positive predictive value and negative predictive value of 90% (95% confidence interval 74% to 96%) and 52% (95% confidence interval 31% to 73%), respectively.

CONCLUSIONS

The effect of anticholinergic therapy on urge incontinence can be used as a diagnostic test to differentiate between anatomic infravesical obstruction and other causes of incontinence in boys.

Ureteral reimplantation in infants and children: effect on bladder function

PURPOSE

We investigate whether early ureteral reimplantation in infants damages the urodynamic behavior of the bladder compared to ureteral reimplantation after age 1 year. We also evaluate changes in bladder behavior after ureteral reimplantation.

MATERIALS AND METHODS

We compared 2 groups of 25 children each who underwent ureteral reimplantation. Group 1 included children younger than 12 months at surgery, and group 2 children were between 1 and 10 years old. All patients had grade III or greater reflux in 1 or 2 ureters, or obstructed megaureters. All patients underwent a complete urodynamic study before and after surgery. We analyzed preoperative and postoperative differences in urodynamic studies in both groups concerning bladder instability, capacity and compliance.

RESULTS

Our analysis of urodynamic data showed that bladder instability was reduced more in group 1 than group 2, although not statistically significant. Parameters for bladder capacity and compliance were comparable for both groups. No statistically significant difference was noted between the urodynamic results in both groups preoperatively and postoperatively.

CONCLUSIONS

No difference in urodynamic parameters could be found between children younger than 12 months compared to those older who underwent ureteral reimplantation. The urodynamic data do not provide any contraindication to ureteral reimplantation performed in early infancy. Moreover, except for a minor reduction in bladder instability, ureteral reimplantation does not alter the urodynamic behavior of the bladder.