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Sartori AM, Kessler TM, Castro-Díaz DM, de Keijzer P, Del Popolo G, Ecclestone H, Frings D, Groen J, Hamid R, Karsenty G, Musco S, Padilla-Fernández B, Pannek J, Schouten N, van der Vorm A, Blok BFM. Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology. Eur Urol 2024; 85:543-555. [PMID: 38594103 DOI: 10.1016/j.eururo.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
- Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Harvard Medical School, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - David M Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Peter de Keijzer
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | - Giulio Del Popolo
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | | | - Dennis Frings
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, UK
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Stefania Musco
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Jürgen Pannek
- Neuro-Urology Department, Swiss Paraplegic Center, Nottwil, Switzerland; Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Natasha Schouten
- European Association of Urology Guidelines Office, Arnhem, The Netherlands
| | | | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
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Samejima S, Shackleton C, Miller T, Moritz CT, Kessler TM, Krogh K, Sachdeva R, Krassioukov AV. Mapping the Iceberg of Autonomic Recovery: Mechanistic Underpinnings of Neuromodulation following Spinal Cord Injury. Neuroscientist 2024; 30:378-389. [PMID: 36631741 PMCID: PMC11107126 DOI: 10.1177/10738584221145570] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Spinal cord injury leads to disruption in autonomic control resulting in cardiovascular, bowel, and lower urinary tract dysfunctions, all of which significantly reduce health-related quality of life. Although spinal cord stimulation shows promise for promoting autonomic recovery, the underlying mechanisms are unclear. Based on current preclinical and clinical evidence, this narrative review provides the most plausible mechanisms underlying the effects of spinal cord stimulation for autonomic recovery, including activation of the somatoautonomic reflex and induction of neuroplastic changes in the spinal cord. Areas where evidence is limited are highlighted in an effort to guide the scientific community to further explore these mechanisms and advance the clinical translation of spinal cord stimulation for autonomic recovery.
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Affiliation(s)
- Soshi Samejima
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Claire Shackleton
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Tiev Miller
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Chet T. Moritz
- Departments of Electrical and Computer Engineering, Rehabilitation Medicine, and Physiology and Biophysics and the Center for Neurotechnology, University of Washington, Seattle, WA, USA
| | - Thomas M. Kessler
- Department of Neuro-urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Klaus Krogh
- Department of Clinical Medicine and Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Andrei V. Krassioukov
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, Canada
- Spinal Cord Program, GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, Canada
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Furrer MA, Kessler TM, Panicker JN. Detrusor Sphincter Dyssynergia. Urol Clin North Am 2024; 51:221-232. [PMID: 38609194 DOI: 10.1016/j.ucl.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
Detrusor sphincter dyssynergia (DSD) is defined as a detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscles typically occurring in a patient with a spinal cord lesion above the sacral cord. Consequently, high urethral closure pressures during the detrusor contraction leads to high intravesical voiding pressure and large postvoid residuals, which can lead to significant complications in up to 50% of patients if DSD is not treated and followed-up regularly. DSD treatment options are centered around symptomatic management rather that addressing the underlying causative mechanisms.
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Affiliation(s)
- Marc A Furrer
- Department of Uro-Neurology, National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London, UK; Department of Urology Inselspital, University of Bern, Bern 3010, Switzerland; Department of Urology, Solothurner Spitäler AG, Kantonsspital Olten, Olten 4600, Switzerland; Department of Urology, Solothurner Spitäler AG, Bürgerspital Solothurn, Solothurn 4500, Switzerland.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich 8008, Switzerland
| | - Jalesh N Panicker
- Faculty of Brain Sciences, UCL Queen Square Institute of Neurology, University College London, London, WC1N 3BG, UK
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Büeler S, Freund P, Kessler TM, Liechti MD, David G. Improved inter-subject alignment of the lumbosacral cord for group-level in vivo gray and white matter assessments: A scan-rescan MRI study at 3T. PLoS One 2024; 19:e0301449. [PMID: 38626171 PMCID: PMC11020367 DOI: 10.1371/journal.pone.0301449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/15/2024] [Indexed: 04/18/2024] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) enables the investigation of pathological changes in gray and white matter at the lumbosacral enlargement (LSE) and conus medullaris (CM). However, conducting group-level analyses of MRI metrics in the lumbosacral spinal cord is challenging due to variability in CM length, lack of established image-based landmarks, and unknown scan-rescan reliability. This study aimed to improve inter-subject alignment of the lumbosacral cord to facilitate group-level analyses of MRI metrics. Additionally, we evaluated the scan-rescan reliability of MRI-based cross-sectional area (CSA) measurements and diffusion tensor imaging (DTI) metrics. METHODS Fifteen participants (10 healthy volunteers and 5 patients with spinal cord injury) underwent axial T2*-weighted and diffusion MRI at 3T. We assessed the reliability of spinal cord and gray matter-based landmarks for inter-subject alignment of the lumbosacral cord, the inter-subject variability of MRI metrics before and after adjusting for the CM length, the intra- and inter-rater reliability of CSA measurements, and the scan-rescan reliability of CSA measurements and DTI metrics. RESULTS The slice with the largest gray matter CSA as an LSE landmark exhibited the highest reliability, both within and across raters. Adjusting for the CM length greatly reduced the inter-subject variability of MRI metrics. The intra-rater, inter-rater, and scan-rescan reliability of MRI metrics were the highest at and around the LSE (scan-rescan coefficient of variation <3% for CSA measurements and <7% for DTI metrics within the white matter) and decreased considerably caudal to it. CONCLUSIONS To facilitate group-level analyses, we recommend using the slice with the largest gray matter CSA as a reliable LSE landmark, along with an adjustment for the CM length. We also stress the significance of the anatomical location within the lumbosacral cord in relation to the reliability of MRI metrics. The scan-rescan reliability values serve as valuable guides for power and sample size calculations in future longitudinal studies.
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Affiliation(s)
- Silvan Büeler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- UCL Queen Square Institute of Neurology, Wellcome Trust Centre for Human Neuroimaging, University College London, London, United Kingdom
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Gergely David
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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5
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Tarcan T, Finazzi-Agrò E, Kessler TM, Serati M, Solomon E, Rosier PFWM. How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence? Neurourol Urodyn 2023; 42:1639-1646. [PMID: 37638391 DOI: 10.1002/nau.25273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/18/2023] [Indexed: 08/29/2023]
Abstract
AIMS Since formal evidence demonstrating the value of urodynamic studies (UDS) in functional urology remains elusive, we aimed to consider how best to design robust research for this purpose in female urinary incontinence. METHODS An expert group was convened to debate the following considerations: (a) precedents for formally proving the value of a gold standard diagnostic test, (b) key research principles, (c) defining a study population, (d) selecting endpoints, (e) defining interventional and controls arms, (f) blinding, (g) powering the study, and (h) duration of follow-up. In each case, we considered the strengths and weaknesses of different approaches in terms of scientific validity, ethical acceptability, practicality, and likelihood of bias. RESULTS We agreed that unlike evaluating therapies, attempting to judge the value of a diagnostic test based on eventual treatment success is conceptually flawed. Nonetheless, we explored the design of a hypothetical randomized controlled trial for this purpose, agreeing that: (1) the study population must sufficiently reflect its real-world counterpart; (2) clinical endpoints should include not only continence status but also other lower urinary tract symptoms and risks of management; (3) participants in the interventional arm should receive individualized management based on their UDS findings; (4) the most scientifically valid approach to the control arm-empiric treatment-is ethically problematic; (5) sufficient statistical power is imperative; and (6) ≥ 2 years' follow-up is needed to assess the long-term impact of management. CONCLUSIONS Although a perfect protocol does not exist, we recommend careful consideration of our observations when reflecting on past studies or planning new prospective research.
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Affiliation(s)
- Tufan Tarcan
- Department of Urology, Marmara University School of Medicine and Koç University School of Medicine, Istanbul, Turkey
| | - Enrico Finazzi-Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and UOSD Urologia, Policlinico Tor Vergata, Rome, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Maurizio Serati
- Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy
| | | | - Peter F W M Rosier
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
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McCallin S, Kessler TM, Leitner L. Management of uncomplicated urinary tract infection in the post-antibiotic era: select non-antibiotic approaches. Clin Microbiol Infect 2023; 29:1267-1271. [PMID: 37301438 DOI: 10.1016/j.cmi.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/29/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Given the high frequency of patients presenting with urinary tract infections (UTIs) and the ensuing high degree of antibiotic prescription, UTI is a critical point of intervention for non-antibiotic treatments to curb the further development of antimicrobial resistance and provide risk-appropriate care for patients. OBJECTIVES To highlight several select non-antibiotic therapies for the treatment of uncomplicated UTI and relevant indications (prevention and complicated UTI) from recent literature. SOURCES PubMed, Google Scholar, and clinicaltrials.gov were searched for clinical trials published in the English language corresponding to non-antibiotic treatments for UTI. CONTENT The focus of this narrative review centres on a limited number of non-antibiotic therapies for the treatment of UTI based on (a) herbal extracts or (b) antibacterial strategies (e.g. bacteriophage therapy and D-mannose). The experience of treatment with non-steroidal anti-inflammatory drugs is also used to fuel discussion on the risk of developing pyelonephritis without antibiotics-compared with the projected harms of continuing their widespread use. IMPLICATIONS Non-antibiotic treatment strategies for UTI have shown varying results in clinical trials, and the current evidence does not yet indicate a clear, better alternative to antibiotics. However, the collective experience with non-antibiotic treatments suggests that there is a need to weigh the actual benefits/risks of unfettered, non-culture-confirmed antibiotic use in uncomplicated UTI. Given the different mechanisms of action of proposed alternatives, more in-depth knowledge on microbiological and pathophysiological factors influencing UTI susceptibility and prognostic indicators are highly needed to stratify patients most likely to benefit. The feasibility of alternatives in clinical practice should also be considered.
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Affiliation(s)
- Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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7
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Botter SM, Kessler TM. Neuro-Urology and Biobanking: An Integrated Approach for Advancing Research and Improving Patient Care. Int J Mol Sci 2023; 24:14281. [PMID: 37762582 PMCID: PMC10531693 DOI: 10.3390/ijms241814281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Understanding the molecular mechanisms underlying neuro-urological disorders is crucial for the development of targeted therapeutic interventions. Through the establishment of comprehensive biobanks, researchers can collect and store various biological specimens, including urine, blood, tissue, and DNA samples, to study these mechanisms. In the context of neuro-urology, biobanking facilitates the identification of genetic variations, epigenetic modifications, and gene expression patterns associated with neurogenic lower urinary tract dysfunction. These conditions often present as symptoms of neurological diseases such as Alzheimer's disease, multiple sclerosis, Parkinson's disease, spinal cord injury, and many others. Biobanking of tissue specimens from such patients is essential to understand why these diseases cause the respective symptoms and what can be done to alleviate them. The utilization of high-throughput technologies, such as next-generation sequencing and gene expression profiling, enables researchers to explore the molecular landscape of these conditions in an unprecedented manner. The development of specific and reliable biomarkers resulting from these efforts may help in early detection, accurate diagnosis, and effective monitoring of neuro-urological conditions, leading to improved patient care and management. Furthermore, these biomarkers could potentially facilitate the monitoring of novel therapies currently under investigation in neuro-urological clinical trials. This comprehensive review explores the synergistic integration of neuro-urology and biobanking, with particular emphasis on the translation of biobanking approaches in molecular research in neuro-urology. We discuss the advantages of biobanking in neuro-urological studies, the types of specimens collected and their applications in translational research. Furthermore, we highlight the importance of standardization and quality assurance when collecting samples and discuss challenges that may compromise sample quality and impose limitations on their subsequent utilization. Finally, we give recommendations for sampling in multicenter studies, examine sustainability issues associated with biobanking, and provide future directions for this dynamic field.
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Affiliation(s)
- Sander M. Botter
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, 8008 Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland;
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Stalder SA, Gross O, Anderson CE, Bachmann LM, Baumann S, Birkhäuser V, Bywater M, Del Popolo G, Engeler DS, Agrò EF, Friedl S, Grilo N, Kiss S, Koschorke M, Leitner L, Liechti MD, Mehnert U, Musco S, Sadri H, Stächele L, Tornic J, van der Lely S, Wyler S, Kessler TM. bTUNED: transcutaneous tibial nerve stimulation for neurogenic lower urinary tract dysfunction. BJU Int 2023; 132:343-352. [PMID: 37204144 DOI: 10.1111/bju.16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To present the protocol for a randomized controlled trial (RCT) evaluating the efficacy and safety of transcutaneous tibial nerve stimulation (TTNS) for refractory neurogenic lower urinary tract dysfunction (NLUTD). STUDY DESIGN AND RESULTS bTUNED (bladder and TranscUtaneous tibial Nerve stimulation for nEurogenic lower urinary tract Dysfunction) is an international multicentre, sham-controlled, double-blind RCT investigating the efficacy and safety of TTNS. The primary outcome is success of TTNS, defined as improvements in key bladder diary variables at study end compared to baseline values. The focus of the treatment is defined by the Self-Assessment Goal Achievement (SAGA) questionnaire. Secondary outcomes are the effect of TTNS on urodynamic, neurophysiological, and bowel function outcome measures, as well as the safety of TTNS. CONCLUSIONS A total of 240 patients with refractory NLUTD will be included and randomized 1:1 into the verum or sham TTNS group from March 2020 until August 2026. TTNS will be performed twice a week for 30 min during 6 weeks. The patients will attend baseline assessments, 12 treatment visits and follow-up assessments at the study end.
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Affiliation(s)
- Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Swiss Paraplegic Research, Nottwil and Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Sarah Baumann
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mirjam Bywater
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Giulio Del Popolo
- Department of Neuro-Urology, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | - Daniel S Engeler
- Department of Urology, School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - Enrico Finazzi Agrò
- Unit of Urology, Department of Surgical Sciences, Tor Vergata University Hospital, Tor Vergata University, Rome, Italy
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Nuno Grilo
- Department of Urology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stephan Kiss
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stefania Musco
- Department of Neuro-Urology, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lara Stächele
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jure Tornic
- Department of Urology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephen Wyler
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Neumeier V, Stangl FP, Borer J, Anderson CE, Birkhäuser V, Chemych O, Gross O, Koschorke M, Marschall J, McCallin S, Mehnert U, Sadri H, Stächele L, Kessler TM, Leitner L. Indwelling catheter vs intermittent catheterization: is there a difference in UTI susceptibility? BMC Infect Dis 2023; 23:507. [PMID: 37533010 PMCID: PMC10398982 DOI: 10.1186/s12879-023-08475-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/20/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Patients with neurogenic lower urinary tract dysfunction (NLUTD) often rely on some type of catheterization for bladder emptying. Intermittent catheterization (IC) is considered the gold standard and is preferred over continuous catheterization, since it is considered to cause fewer urinary tract infections (UTIs) than indwelling catheterization. The main objective of our study was to describe UTI prevalence (at visit) and incidence (within the last 12 months) and urine culture characteristics between patients using an indwelling catheter versus (vs) those performing IC. METHODS In this cross-sectional study, we prospectively evaluated from 02/2020 to 01/2021 patients with NLUTD undergoing urine cultures for prophylactic reasons or due to UTI symptoms. At visit, all patients underwent a standardized interview on current UTI symptoms as well as UTI history and antibiotic consumption within the past year. Patients using an indwelling catheter (n = 206) or IC (n = 299) were included in the analysis. The main outcome was between-group differences regarding UTI characteristics. RESULTS Patients using an indwelling catheter were older (indwelling catheter vs IC: median 66 (Q1-Q3: 55-77) vs 55 (42-67) years of age) and showed a higher Charlson comorbidity index (indwelling catheter vs IC: median 4 (Q1-Q3: 2-6) vs 2 (1-4) (both p < 0·001). A total of 40 patients from both groups were diagnosed with a UTI at visit (indwelling catheters vs IC: 8% (16/206) vs 8% (24/299); p = 0·782), and the number of UTIs within the past 12 months was not significantly different between groups. Overall, Escherichia coli (21%), Enterococcus faecalis (17%), and Klebsiella spp. (12%) were the most frequently detected bacteria. CONCLUSIONS In this cohort of patients with NLUTD, we did not find relevant differences in UTI frequency between groups. These results suggest that UTI-related concerns should not be given undue emphasis when counseling patients for catheter-related bladder emptying methods.
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Affiliation(s)
- Vera Neumeier
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Fabian P Stangl
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Joëlle Borer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
- Department of Urology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Oksana Chemych
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis Missouri, USA
| | - Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lara Stächele
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland.
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10
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Meile S, Du J, Staubli S, Grossmann S, Koliwer-Brandl H, Piffaretti P, Leitner L, Matter CI, Baggenstos J, Hunold L, Milek S, Guebeli C, Kozomara-Hocke M, Neumeier V, Botteon A, Klumpp J, Marschall J, McCallin S, Zbinden R, Kessler TM, Loessner MJ, Dunne M, Kilcher S. Engineered reporter phages for detection of Escherichia coli, Enterococcus, and Klebsiella in urine. Nat Commun 2023; 14:4336. [PMID: 37474554 PMCID: PMC10359277 DOI: 10.1038/s41467-023-39863-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 07/03/2023] [Indexed: 07/22/2023] Open
Abstract
The rapid detection and species-level differentiation of bacterial pathogens facilitates antibiotic stewardship and improves disease management. Here, we develop a rapid bacteriophage-based diagnostic assay to detect the most prevalent pathogens causing urinary tract infections: Escherichia coli, Enterococcus spp., and Klebsiella spp. For each uropathogen, two virulent phages were genetically engineered to express a nanoluciferase reporter gene upon host infection. Using 206 patient urine samples, reporter phage-induced bioluminescence was quantified to identify bacteriuria and the assay was benchmarked against conventional urinalysis. Overall, E. coli, Enterococcus spp., and Klebsiella spp. were each detected with high sensitivity (68%, 78%, 87%), specificity (99%, 99%, 99%), and accuracy (90%, 94%, 98%) at a resolution of ≥103 CFU/ml within 5 h. We further demonstrate how bioluminescence in urine can be used to predict phage antibacterial activity, demonstrating the future potential of reporter phages as companion diagnostics that guide patient-phage matching prior to therapeutic phage application.
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Affiliation(s)
- Susanne Meile
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | - Jiemin Du
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | - Samuel Staubli
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | | | | | | | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | | | - Laura Hunold
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | - Sonja Milek
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | | | - Vera Neumeier
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Angela Botteon
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | - Jochen Klumpp
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland
| | - Jonas Marschall
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, US
| | - Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reinhard Zbinden
- Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Matthew Dunne
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland.
| | - Samuel Kilcher
- Institute of Food Nutrition and Health, ETH, Zurich, Switzerland.
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11
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Du J, Meile S, Baggenstos J, Jäggi T, Piffaretti P, Hunold L, Matter CI, Leitner L, Kessler TM, Loessner MJ, Kilcher S, Dunne M. Enhancing bacteriophage therapeutics through in situ production and release of heterologous antimicrobial effectors. Nat Commun 2023; 14:4337. [PMID: 37474516 PMCID: PMC10359290 DOI: 10.1038/s41467-023-39612-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Bacteriophages operate via pathogen-specific mechanisms of action distinct from conventional, broad-spectrum antibiotics and are emerging as promising alternative antimicrobials. However, phage-mediated killing is often limited by bacterial resistance development. Here, we engineer phages for target-specific effector gene delivery and host-dependent production of colicin-like bacteriocins and cell wall hydrolases. Using urinary tract infection (UTI) as a model, we show how heterologous effector phage therapeutics (HEPTs) suppress resistance and improve uropathogen killing by dual phage- and effector-mediated targeting. Moreover, we designed HEPTs to control polymicrobial uropathogen communities through production of effectors with cross-genus activity. Using phage-based companion diagnostics, we identified potential HEPT responder patients and treated their urine ex vivo. Compared to wildtype phage, a colicin E7-producing HEPT demonstrated superior control of patient E. coli bacteriuria. Arming phages with heterologous effectors paves the way for successful UTI treatment and represents a versatile tool to enhance and adapt phage-based precision antimicrobials.
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Affiliation(s)
- Jiemin Du
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Susanne Meile
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Jasmin Baggenstos
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Tobias Jäggi
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Pietro Piffaretti
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Laura Hunold
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | | | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin J Loessner
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland
| | - Samuel Kilcher
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland.
| | - Matthew Dunne
- Institute of Food Nutrition and Health, ETH Zurich, Zurich, Switzerland.
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12
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Stalder SA, van der Lely S, Anderson CE, Birkhäuser V, Curt A, Gross O, Leitner L, Mehnert U, Schubert M, Tornic J, Kessler TM, Liechti MD. Development of a Sham Protocol to Investigate Transcutaneous Tibial Nerve Stimulation in Randomised, Sham-Controlled, Double-Blind Clinical Trials. Biomedicines 2023; 11:1931. [PMID: 37509569 PMCID: PMC10377596 DOI: 10.3390/biomedicines11071931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/30/2023] Open
Abstract
Transcutaneous tibial nerve stimulation (TTNS) is a promising treatment for neurogenic lower urinary tract symptoms. However, the evidence is limited due to a general lack of randomised controlled trials (RCTs) and, also, inconsistency in the sham and blinding conditions. In the context of much-needed RCTs, we aimed to develop a suitable sham-control protocol for a clinical setting to maintain blinding but avoid meaningful stimulation of the tibial nerve. Three potential electrode positions (lateral malleolus/5th metatarsal/plantar calcaneus) and two electrode sizes (diameter: 2.5 cm/3.2 cm) were tested to determine which combination provided the optimal sham configuration for a TTNS approach, based on a visible motor response. Sixteen healthy volunteers underwent sensory and motor assessments for each sham configuration. Eight out of them came back for an extra TTNS visit. Sensory thresholds were present for all sham configurations, with linear regression models revealing a significant effect regarding electrode position (highest at plantar calcaneus) but not size. In addition, motor thresholds varied with the position-lowest for the 5th metatarsal. Only using this position and 3.2 cm electrodes attained a 100% response rate. Compared to TTNS, sensory and motor thresholds were generally higher for the sham configurations; meanwhile, perceived pain was only higher at the lateral malleolus. In conclusion, using the 5th metatarsal position and 3.2 cm electrodes proved to be the most suitable sham configuration. Implemented as a four-electrode setup with standardized procedures, this appears to be a suitable RCT protocol for maintaining blinding and controlling for nonspecific TTNS effects in a clinical setting.
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Affiliation(s)
- Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Swiss Paraplegic Research, 6207 Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Lucerne, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Centre, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Jure Tornic
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
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13
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Birkhäuser V, Anderson CE, Kozomara M, Bywater M, Gross O, Kiss S, Knüpfer SC, Koschorke M, Leitner L, Mehnert U, Sadri H, Sammer U, Stächele L, Tornic J, Liechti MD, Brinkhof MWG, Kessler TM. Urodynamics Are Essential to Predict the Risk for Upper Urinary Tract Damage after Acute Spinal Cord Injury. Biomedicines 2023; 11:1748. [PMID: 37371843 DOI: 10.3390/biomedicines11061748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
We used clinical parameters to develop a prediction model for the occurrence of urodynamic risk factors for upper urinary tract (UUT) damage during the first year after acute spinal cord injury (SCI). A total of 97 patients underwent urodynamic investigation at 1, 3, 6, and 12 months after acute SCI, within the framework of a population-based longitudinal study at a single university SCI center. Candidate predictors included demographic characteristics and neurological and functional statuses 1 month after SCI. Outcomes included urodynamic risk factors for UUT damage: detrusor overactivity combined with detrusor sphincter dyssynergia, maximum storage detrusor pressure (pDetmax) ≥ 40 cmH2O, bladder compliance < 20 mL/cmH2O, and vesicoureteral reflux. Multivariable logistic regression was used for the prediction model development and internal validation, using the area under the receiver operating curve (aROC) to assess model discrimination. Two models showed fair discrimination for pDetmax ≥ 40 cmH2O: (i) upper extremity motor score and sex, aROC 0.79 (95% CI: 0.69-0.89), C-statistic 0.78 (95% CI: 0.69-0.87), and (ii) neurological level, American Spinal Injury Association Impairment Scale grade, and sex, aROC 0.78 (95% CI: 0.68-0.89), C-statistic 0.76 (95% CI: 0.68-0.85). We identified two models that provided fair predictive values for urodynamic risk factors of UUT damage during the first year after SCI. Pending external validation, these models may be useful for clinical trial planning, although less so for individual-level patient management. Therefore, urodynamics remains essential for reliably identifying patients at risk of UUT damage.
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Affiliation(s)
- Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Swiss Paraplegic Research, 6207 Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Lucerne, Switzerland
| | - Marko Kozomara
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
| | - Mirjam Bywater
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Stephan Kiss
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Stephanie C Knüpfer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Neuro-Urology, Clinic for Urology, University Hospital Bonn, 53127 Bonn, Germany
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Ulla Sammer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Lara Stächele
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Jure Tornic
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, Winterthur Cantonal Hospital, 8400 Winterthur, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, 6207 Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, 6002 Lucerne, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
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14
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Pavese C, Kessler TM. Prediction of Lower Urinary Tract, Sexual, and Bowel Function, and Autonomic Dysreflexia after Spinal Cord Injury. Biomedicines 2023; 11:1644. [PMID: 37371739 DOI: 10.3390/biomedicines11061644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Spinal cord injury (SCI) produces damage to the somatic and autonomic pathways that regulate lower urinary tract, sexual, and bowel function, and increases the risk of autonomic dysreflexia. The recovery of these functions has a high impact on health, functioning, and quality of life and is set as the utmost priority by patients. The application of reliable models to predict lower urinary tract, sexual, and bowel function, and autonomic dysreflexia is important for guiding counseling, rehabilitation, and social reintegration. Moreover, a reliable prediction is essential for designing future clinical trials to optimize patients' allocation to different treatment groups. To date, reliable and simple algorithms are available to predict lower urinary tract and bowel outcomes after traumatic and ischemic SCI. Previous studies identified a few risk factors to develop autonomic dysreflexia, albeit a model for prediction still lacks. On the other hand, there is an urgent need for a model to predict the evolution of sexual function. The aim of this review is to examine the available knowledge and models for the prediction of lower urinary tract, sexual, and bowel function, and autonomic dysreflexia after SCI, and critically discuss the research priorities in these fields.
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Affiliation(s)
- Chiara Pavese
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit of Pavia Institute, 27100 Pavia, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
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15
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Mehnert U, Walter M, Leitner L, Kessler TM, Freund P, Liechti MD, Michels L. Abnormal Resting-State Network Presence in Females with Overactive Bladder. Biomedicines 2023; 11:1640. [PMID: 37371735 DOI: 10.3390/biomedicines11061640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Overactive bladder (OAB) is a global problem reducing the quality of life of patients and increasing the costs of any healthcare system. The etiology of OAB is understudied but likely involves supraspinal network alterations. Here, we characterized supraspinal resting-state functional connectivity in 12 OAB patients and 12 healthy controls (HC) who were younger than 60 years. Independent component analysis showed that OAB patients had a weaker presence of the salience (Cohen's d = 0.9) and default mode network (Cohen's d = 1.1) and weaker directed connectivity between the fronto-parietal network and salience network with a longer lag time compared to HC. A region of interest analysis demonstrated weaker connectivity in OAB compared to HC (Cohen's d > 1.6 or < -1.6), particularly within the frontal and prefrontal cortices. In addition, weaker seed (insula, ventrolateral prefrontal cortex) to voxel (anterior cingulate cortex, frontal gyrus, superior parietal lobe, cerebellum) connectivity was found in OAB compared to HC (Cohen's d > 1.9). The degree of deviation in supraspinal connectivity in OAB patients (relative to HC) appears to be an indicator of the severity of the lower urinary tract symptoms and an indication that such symptoms are directly related to functional supraspinal alterations. Thus, future OAB therapy options should also consider supraspinal targets, while neuroimaging techniques should be given more consideration in the quest for better phenotyping of OAB.
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Affiliation(s)
- Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Matthias Walter
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Urology, University Hospital Basel, University of Basel, 4031 Basel, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, 04103 Leipzig, Germany
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London WC1N 3AR, UK
- Neuroscience Center Zürich, University of Zürich and Swiss Federal Institute of Technology Zürich, 8057 Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
| | - Lars Michels
- Neuroscience Center Zürich, University of Zürich and Swiss Federal Institute of Technology Zürich, 8057 Zürich, Switzerland
- Department of Neuroradiology, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
- Clinical Neuroscience Center, University Hospital Zürich, 8091 Zürich, Switzerland
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16
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Anderson CE, Kozomara M, Birkhäuser V, Bywater M, Gross O, Kiss S, Knüpfer SC, Koschorke M, Leitner L, Mehnert U, Sadri H, Sammer U, Stächele L, Tornic J, Liechti MD, Brinkhof MWG, Kessler TM. Temporal development of unfavourable urodynamic parameters during the first year after spinal cord injury. BJU Int 2023; 131:503-512. [PMID: 36221991 DOI: 10.1111/bju.15918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe the temporal development of and risk factors for the occurrence of unfavourable urodynamic parameters during the first year after spinal cord injury (SCI). PATIENTS AND METHODS This population-based longitudinal study used data from 97 adult patients with a single-event traumatic or ischaemic SCI who underwent video-urodynamic investigation (UDI) at a university SCI centre. The first occurrences of unfavourable urodynamic parameters (detrusor overactivity combined with detrusor sphincter dyssynergia [DO-DSD], maximum storage detrusor pressure ≥40 cmH2 O, bladder compliance <20 mL/cmH2 O, vesico-ureteric reflux [VUR] and any unfavourable parameter [composite outcome]) were evaluated using time-to-event analysis. RESULTS The majority of the population (87/97 [90%]) had at least one unfavourable urodynamic parameter. Most unfavourable urodynamic parameters were initially identified during the 1- or 3-month UDI, including 92% of the DO-DSD (78/85), 82% of the maximum storage pressure ≥40 cmH2 O (31/38), and 100% of the VUR (seven of seven) observations. No low bladder compliance was observed. The risk of DO-DSD was elevated in patients with thoracic SCI compared to those with lumbar SCI (adjusted hazard ratio [aHR] 2.38, 95% confidence interval [CI] 1.16-4.89). Risk of maximum storage detrusor pressure ≥40 cmH2 O was higher in males than females (aHR 8.33, 95% CI 2.51-27.66), in patients with a cervical SCI compared to those with lumbar SCI (aHR 14.89, 95% CI 3.28-67.55), and in patients with AIS Grade B or C compared to AIS Grade D SCI (aHR 6.17, 95% CI 1.78-21.39). No risk factors were identified for the composite outcome of any unfavourable urodynamic parameter. CONCLUSIONS The first UDI should take place within 3 months after SCI as to facilitate early diagnosis of unfavourable urodynamic parameters and timely treatment. Neuro-urological guidelines and individualised management strategies for patients with SCI may be strengthened by considering sex and SCI characteristics in the scheduling of UDIs.
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Affiliation(s)
- Collene E Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Marko Kozomara
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mirjam Bywater
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephan Kiss
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Stephanie C Knüpfer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, Clinic for Urology, University Hospital Bonn, Bonn, Germany
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulla Sammer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lara Stächele
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jure Tornic
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, Winterthur Cantonal Hospital, Winterthur, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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17
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Werneburg GT, Welk B, Averbeck MA, Blok BFM, Hamid R, Kennelly MJ, Liao L, Musco S, Vasudeva P, Kessler TM. Neuro-Urology: Call for Universal, Resource-Independent Guidance. Biomedicines 2023; 11:biomedicines11020397. [PMID: 36830934 PMCID: PMC9953088 DOI: 10.3390/biomedicines11020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/01/2023] Open
Abstract
Neurogenic lower urinary tract dysfunction (NLUTD), the abnormal function of the lower urinary tract in the context of neurological pathology, has been the subject of multiple efforts worldwide for the development of clinical practice guidelines. These guidelines are based on the same body of evidence, and are therefore subject to the same gaps. For example, sexual and bowel dysfunction in the context of NLUTD, optimal renal function assessment in those who are non-ambulatory or with low muscle mass, optimal upper tract surveillance timing, and modification of diagnostic and treatment modalities for low-resource nations and communities are inadequately addressed. In addition, many aspects of the conclusions and final recommendations of the guidelines are similar. This duplicative work represents a large expenditure of time and effort, which we believe could be focused instead on evidence gaps. Here, we call for a global unified approach to create a single, resource-independent, comprehensive guidance on NLUTD, neurogenic sexual, and neurogenic bowel dysfunction. Targeted research addressing the evidence gaps should be called for and pursued. This will allow for focus to shift to filling the gaps in the evidence for future guidelines.
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Affiliation(s)
- Glenn T. Werneburg
- Department of Urology, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Blayne Welk
- Department of Surgery and Epidemiology & Biostatistics, Western University, London, ON N6A 3K7, Canada
| | - Marcio A. Averbeck
- Department of Urology, Moinhos de Vento Hospital, Porto Alegre 90035-000, Brazil
| | - Bertil F. M. Blok
- Department of Urology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Rizwan Hamid
- Department of Neuro-Urology, London Spinal Injuries Unit, Royal National Orthopaedic Hospital, Stanmore HA7 4LP, UK
| | - Michael J. Kennelly
- Department of Urology, Atrium Health, Carolinas Rehabilitation, Charlotte, NC 28203, USA
| | - Limin Liao
- Department of Urology, China Rehabilitation Research Centre and Capital Medical University, Beijing 100068, China
| | - Stefania Musco
- Department of Neuro-Urology, Azienda Ospedaliera Careggi, 50134 Florence, Italy
| | - Pawan Vasudeva
- Department of Urology & Renal Transplant, V.M. Medical College and Safdarjang Hospital, New Delhi 110029, India
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, 8008 Zürich, Switzerland
- Correspondence:
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Liechti MD, van der Lely S, Knüpfer SC, Abt D, Kiss B, Leitner L, Mordasini L, Tornic J, Wöllner J, Mehnert U, Bachmann LM, Burkhard FC, Engeler DS, Pannek J, Kessler TM. Sacral Neuromodulation for Neurogenic Lower Urinary Tract Dysfunction. NEJM Evid 2022; 1:EVIDoa2200071. [PMID: 38319849 DOI: 10.1056/evidoa2200071] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
SNM for Urinary Tract DysfunctionThis study evaluated SNM for neurogenic lower urinary tract dysfunction. A neurostimulator was implanted for permanent stimulation and optimized using subsensory stimulation. It remained on or was switched off, with patients masked to the condition. After 2 months, the SNM ON group had significantly different success compared with the SNM OFF group (76% vs. 42%).
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Affiliation(s)
- Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie C Knüpfer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Department of Urology, University Hospital of Bonn, Bonn, Germany
| | - Dominik Abt
- Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- Department of Urology, Spitalzentrum Biel/Centre Hospitalier Bienne, Biel/Bienne, Switzerland
| | - Bernhard Kiss
- Department of Urology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Livio Mordasini
- Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
- URO-Sursee, Uroviva, Sursee, Switzerland
| | - Jure Tornic
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Clinic for Urology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Jens Wöllner
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Fiona C Burkhard
- Department of Urology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Daniel S Engeler
- Department of Urology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Jürgen Pannek
- Department of Urology, Bern University Hospital, University of Bern, Bern, Switzerland
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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19
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Pavese C, Scivoletto G, Puci MV, Abel R, Curt A, Maier D, Rupp R, Schubert M, Weidner N, Montomoli C, Kessler TM. Prediction of bowel management independence after ischemic spinal cord injury. Eur J Phys Rehabil Med 2022; 58:709-714. [PMID: 35666490 PMCID: PMC10019474 DOI: 10.23736/s1973-9087.22.07366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ischemic spinal cord injury (SCI) belongs to the heterogeneous group of non-traumatic SCI, while the course of sensorimotor and functional recovery is comparable to traumatic SCI. Recently, we derived from data of patients with traumatic SCI a valid model to predict an independent and reliable bowel management one year after SCI. AIM To evaluate the performance of this model to predict an independent and reliable bowel management one year following ischemic SCI. DESIGN Prognostic study - observational study. SETTING European Multicenter Study about Spinal Cord Injury (EMSCI) ClinicalTrials.gov: NCT01571531. POPULATION One hundred and forty-two patients with ischemic SCI of various level and severity of injury. METHODS The prediction model relied on a single predictor collected within 40 days from injury, the International Standards for Neurological Classification of Spinal Cord Injury total motor score. Bowel outcome one year after SCI derived from the dichotomization of the Spinal Cord Independence Measure (SCIM) item 7 scores. We defined a positive outcome as independent bowel management with regular movements and appropriate timing with no or rare accidents (score of 10 in SCIM version II and score of 8 or 10 in version III). RESULTS The model showed a fair discrimination with an area under the receiver operating characteristic (ROC) curve of 0.780 (95% confidence interval=0.702-0.860). In addition, the model displayed an acceptable accuracy and calibration. CONCLUSIONS The study extends the validity of our rule to patients with ischemic SCI, thus providing the first model to predict an independent and reliable bowel management in this population. CLINICAL REHABILITATION IMPACT The model may be employed in clinical practice to counsel patients, to define the rehabilitation aims and to estimate the need of assistance after discharge, as well as in the research field for the optimization of patients' allocation in the design of future clinical trials.
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Affiliation(s)
- Chiara Pavese
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.,Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation and Spinal Unit, Pavia Institute, Pavia, Italy
| | - Giorgio Scivoletto
- Spinal Cord Unit and Spinal Rehabilitation (SpiRe) Lab, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Mariangela V Puci
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Rainer Abel
- Spinal Cord Injury Center, Hohe Warte, Bayreuth, Germany
| | - Armin Curt
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Rüdiger Rupp
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schubert
- Department of Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Norbert Weidner
- Spinal Cord Injury Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Cristina Montomoli
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland -
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20
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Bodmer NS, Wirth C, Birkhäuser V, Sartori AM, Leitner L, Averbeck MA, de Wachter S, Finazzi Agro E, Gammie A, Goldman HB, Kirschner-Hermanns R, F.W.M. Rosier P, Serati M, Solomon E, van Koeveringe G, Bachmann LM, Kessler TM. Randomised Controlled Trials Assessing the Clinical Value of Urodynamic Studies: A Systematic Review and Meta-analysis. EUR UROL SUPPL 2022; 44:131-141. [PMID: 36110903 PMCID: PMC9469658 DOI: 10.1016/j.euros.2022.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 11/18/2022] Open
Abstract
Context The role of urodynamic studies (UDSs) in the diagnosis of lower urinary tract symptoms (LUTS) is crucial. Although expert statements and guidelines underline their value for clinical decision-making in various clinical settings, the academic debate as to their impact on patient outcomes continues. Objective To summarise the evidence from all randomised controlled trials assessing the clinical usefulness of UDS in the management of LUTS. Evidence acquisition For this systematic review, searches were performed without language restrictions in three electronic databases until November 18, 2020. The inclusion criteria were randomised controlled study design and allocation to receive UDS or not prior to any clinical management. Quality assessment was performed by two reviewers independently, using the Cochrane Collaboration’s tool for assessing the risk of bias. A random-effect meta-analysis was performed on the uniformly reported outcome parameters. Evidence synthesis Eight trials were included, and all but two focused on women with pure or predominant stress urinary incontinence (SUI). A meta-analysis of six studies including 942 female patients was possible for treatment success, as defined by the authors (relative risk 1.00, 95% confidence interval: 0.93–1.07), indicating no difference in efficacy when managing women with UDS. Conclusions Although UDSs are not replaceable in diagnostics, since there is no other equivalent method to find out exactly what the lower urinary tract problem is, there are little data supporting its impact on outcomes. Randomised controlled trials have focussed on a small group of women with uncomplicated SUI and showed no added value, but these findings cannot be extrapolated to the overall patient population with LUTS, warranting further well-designed trials. Patient summary Despite urodynamics being the gold standard to assess lower urinary tract symptoms (LUTS), as it is the only method that can specify lower urinary tract dysfunction, more studies assessing the clinical usefulness of urodynamic studies (UDSs) in the management of LUTS are needed. UDS investigation is not increasing the probability of success in the treatment of stress urinary incontinence.
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21
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Sartori AM, Padilla-Fernández B, 't Hoen L, Blok BFM, Castro-Díaz DM, Del Popolo G, Musco S, Hamid R, Ecclestone H, Groen J, Karsenty G, Phé V, Kessler TM, Pannek J. Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review. Eur Urol Focus 2022; 8:1386-1398. [PMID: 34404618 DOI: 10.1016/j.euf.2021.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/09/2021] [Accepted: 07/27/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Bárbara Padilla-Fernández
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain.
| | - Lisette 't Hoen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David M Castro-Díaz
- Department of Urology, Complejo Hospitalario Universitario de Canarias, Universidad de La Laguna, Tenerife, Spain
| | - Giulio Del Popolo
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Stefania Musco
- Department of Neuro-urology, Careggi University Hospital, Florence, Italy
| | - Rizwan Hamid
- Department of Neuro-urology, London Spinal Injuries Centre, Stanmore, UK
| | - Hazel Ecclestone
- Department of Neuro-urology, London Spinal Injuries Centre, Stanmore, UK
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Veronique Phé
- Department of Urology, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Academic Hospital, Sorbonne University, Paris, France
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
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22
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Anderson CE, Birkhäuser V, Jordan X, Liechti MD, Luca E, Möhr S, Pannek J, Kessler TM, Brinkhof MW. Urological Management at Discharge from Acute Spinal Cord Injury Rehabilitation: A Descriptive Analysis from a Population-based Prospective Cohort. EUR UROL SUPPL 2022; 38:1-9. [PMID: 35495286 PMCID: PMC9051958 DOI: 10.1016/j.euros.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2022] [Indexed: 01/06/2023] Open
Abstract
Background There is limited epidemiological evidence describing contemporary neuro-urological management of persons with acute spinal cord injury (SCI). Objective To describe neurogenic lower urinary tract dysfunction (NLUTD) management at discharge from SCI rehabilitation. Design, setting, and participants The population-based Swiss Spinal Cord Injury (SwiSCI) cohort study prospectively collected data from 602 adults undergoing specialized postacute SCI rehabilitation from 2013 to 2020. The management strategy was based on the European Association of Urology (EAU) Guidelines on Neuro-Urology. Outcome measurements and statistical analysis Data were collected at discharge using the International SCI Lower Urinary Tract Function Basic Data Set. Multivariable logistic regression adjusting for demographics, SCI characteristics, and center, with inverse probability weighting accounting for sampling bias, was used to produce prevalence estimates and identify predictors of lower urinary tract symptoms (LUTS) and NLUTD management outcomes. Results and limitations At discharge (median time after SCI: 5.0 mo [Q1-Q3: 3.0–7.2]), the prevalence of LUTS or managed NLUTD was 82% (95% confidence interval [CI]: 79–85%). SCI completeness was the main predictor of LUTS and managed NLUTD. The risk of urinary incontinence was elevated in females (odds ratio 1.98 [95% CI: 1.18–3.32]) and with complete lesions (odds ratio 4.71 [95% CI: 2.52–8.81]). Voiding dysfunction was most commonly managed with intermittent catheterization (prevalence 39% [95% CI: 35–42%]), followed by indwelling catheterization (prevalence 22% [95% CI: 18–25%]). The prevalence of antimuscarinic or mirabegron use was 29% (95% CI: 26–33%). Urodynamic and renal function data were not collected. Conclusions Our population-based description of urological management in Swiss SCI centers utilizing the EAU Guidelines on Neuro-Urology may be used as a reference for evaluation in other settings. Data further indicate a need for sex-specific neuro-urological management research. Patient summary At discharge from spinal cord injury (SCI) rehabilitation, a majority of patients have lower urinary tract problems, especially those with complete SCI. Women have a higher risk of urinary incontinence.
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Affiliation(s)
- Collene E. Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Eugenia Luca
- Clinique Romande de Réadaptation, Sion, Switzerland
| | - Sandra Möhr
- Neuro-Urology, REHAB Basel, Basel, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
- Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin W.G. Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Corresponding author. Swiss Paraplegic Research, Guido A. Zäch Strasse 4, CH-6207 Nottwil, Switzerland. Tel. +41 41 939 65 97; Fax: +41 41 939 66 40.
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23
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Sartori AM, Salemi S, Hofer AS, Baumgartner V, Eberli D, Liechti MD, Schwab ME, Kessler TM. Early Transcutaneous Tibial Nerve Stimulation Acutely Improves Lower Urinary Tract Function in Spinal Cord Injured Rats. Neurotrauma Rep 2022; 3:15-26. [PMID: 35211695 PMCID: PMC8863914 DOI: 10.1089/neur.2021.0058] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Despite the fact that a majority of patients with an injury to the spinal cord develop lower urinary tract dysfunction, only few treatment options are available currently once the dysfunction arises. Tibial nerve stimulation has been used in pilot clinical trials, with some promising results. Hence, we investigated whether the early application of transcutaneous tibial nerve stimulation in the animal model of spinal cord injured rats can prevent the development of detrusor overactivity and/or detrusor-sphincter-dyssynergia. Rats were implanted with a bladder catheter and external urethral sphincter electromyography electrodes. A dorsal over-hemisection, resulting in an incomplete spinal cord injury at the T8/9 spinal level, induced immediate bladder paralysis. One week later, the animals received daily tibial nerve or sham stimulation for 15 days. Effects of stimulation on the lower urinary tract function were assessed by urodynamic investigation. Measurements showed improvements of several key parameters of lower urinary tract function—in particular, non-voiding bladder contractions and intravesical pressure—immediately after the completion of the stimulation period in the stimulated animals. These differences extinguished one week later, however. In the dorsal horn of the lumbosacral spinal cord, a small significant increase of the density of C-fiber afferents layers I-II was found in the stimulated animals at four weeks after spinal cord injury. Tibial nerve stimulation applied acutely after spinal cord injury in rats had an immediate beneficial effect on lower urinary tract dysfunction; however, the effect was transitory and did not last over time. To achieve more sustainable, longer lasting effects, further studies are needed looking into different stimulation protocols using optimized stimulation parameters, timing, and treatment schedules.
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Affiliation(s)
- Andrea M. Sartori
- Institute for Regenerative Medicine, University of Zürich, and Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Souzan Salemi
- Laboratory for Tissue Engineering and Stem Cell Therapy, Department of Urology, University Hospital Zürich, Zürich, Switzerland
| | - Anna-Sophie Hofer
- Institute for Regenerative Medicine, University of Zürich, and Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Valentin Baumgartner
- Laboratory for Tissue Engineering and Stem Cell Therapy, Department of Urology, University Hospital Zürich, Zürich, Switzerland
| | - Daniel Eberli
- Laboratory for Tissue Engineering and Stem Cell Therapy, Department of Urology, University Hospital Zürich, Zürich, Switzerland
| | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin E. Schwab
- Institute for Regenerative Medicine, University of Zürich, and Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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24
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Stieglitz LH, Hofer AS, Bolliger M, Oertel MF, Filli L, Willi R, Cathomen A, Meyer C, Schubert M, Hubli M, Kessler TM, Baumann CR, Imbach L, Krüsi I, Prusse A, Schwab ME, Regli L, Curt A. Deep brain stimulation for locomotion in incomplete human spinal cord injury (DBS-SCI): protocol of a prospective one-armed multi-centre study. BMJ Open 2021; 11:e047670. [PMID: 34593490 PMCID: PMC8487195 DOI: 10.1136/bmjopen-2020-047670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 09/09/2021] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Spinal cord injury (SCI) is a devastating condition with immediate impact on the individual's health and quality of life. Major functional recovery reaches a plateau 3-4 months after injury despite intensive rehabilitative training. To enhance training efficacy and improve long-term outcomes, the combination of rehabilitation with electrical modulation of the spinal cord and brain has recently aroused scientific interest with encouraging results. The mesencephalic locomotor region (MLR), an evolutionarily conserved brainstem locomotor command and control centre, is considered a promising target for deep brain stimulation (DBS) in patients with SCI. Experiments showed that MLR-DBS can induce locomotion in rats with spinal white matter destructions of >85%. METHODS AND ANALYSIS In this prospective one-armed multi-centre study, we investigate the safety, feasibility, and therapeutic efficacy of MLR-DBS to enable and enhance locomotor training in severely affected, subchronic and chronic American Spinal Injury Association Impairment Scale C patients in order to improve functional recovery. Patients undergo an intensive training programme with MLR-DBS while being regularly followed up until 6 months post-implantation. The acquired data of each timepoint are compared with baseline while the primary endpoint is performance in the 6-minute walking test. The clinical trial protocol was written in accordance with the Standard Protocol Items: Recommendations for Interventional Trials checklist. ETHICS AND DISSEMINATION This first in-man study investigates the therapeutic potential of MLR-DBS in SCI patients. One patient has already been implanted with electrodes and underwent MLR stimulation during locomotion. Based on the preliminary results which promise safety and feasibility, recruitment of further patients is currently ongoing. Ethical approval has been obtained from the Ethical Committee of the Canton of Zurich (case number BASEC 2016-01104) and Swissmedic (10000316). Results will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER NCT03053791.
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Affiliation(s)
| | - Anna-Sophie Hofer
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Institute for Regenerative Medicine, University of Zurich, Schlieren, Switzerland
| | - Marc Bolliger
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Linard Filli
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Romina Willi
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Adrian Cathomen
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Christian Meyer
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, Zurich, Switzerland
| | | | - Lukas Imbach
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Iris Krüsi
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Andrea Prusse
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin E Schwab
- Institute for Regenerative Medicine, University of Zurich, Schlieren, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
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25
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Musco S, Ecclestone H, 't Hoen L, Blok BFM, Padilla-Fernández B, Del Popolo G, Groen J, Pannek J, Kessler TM, Karsenty G, Phé V, Sartori AM, Castro-Diaz D, Rizwan H. Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review. Eur Urol Focus 2021; 8:1090-1102. [PMID: 34509413 DOI: 10.1016/j.euf.2021.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/12/2021] [Accepted: 08/13/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Stefania Musco
- Department of Neuro-Urology, Careggi University Hospital, Florence, Italy.
| | - Hazel Ecclestone
- Department of Urology, Taranaki District Health Board, New Plymouth, New Zealand
| | - Lisette 't Hoen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bertil F M Blok
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Barbara Padilla-Fernández
- Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Giulio Del Popolo
- Department of Neuro-Urology, Careggi University Hospital, Florence, Italy
| | - Jan Groen
- Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Gilles Karsenty
- Department of Urology, Aix Marseille University, Marseille, France
| | - Véronique Phé
- Department of Urology, Sorbonne University, Pitié-Salpêtrière Academic Hospital, Assistance-Publique-Hôpitaux de Paris, Paris, France
| | - Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - David Castro-Diaz
- Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Hamid Rizwan
- Department of Urology, University College London and London Spinal Injuries Unit, London, UK
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van der Lely S, Schmidhalter MR, Knüpfer SC, Sartori AM, Schneider MP, Stalder SA, Kessler TM, Liechti MD, Mehnert U. Lower urinary tract electrical sensory assessment: A systematic review and meta-analysis. BJU Int 2021; 130:166-180. [PMID: 34390120 PMCID: PMC9545760 DOI: 10.1111/bju.15574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives To summarize the current literature on lower urinary tract electrical sensory assessment (LUTESA), with regard to current perception thresholds (CPTs) and sensory evoked potentials (SEPs), and to discuss the applied methods in terms of technical aspects, confounding factors, and potential for lower urinary tract (LUT) diagnostics. Methods The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. Medline (PubMed), Embase and Scopus were searched on 13 October 2020. Meta‐analyses were performed and methodological qualities of the included studies were defined by assessing risk of bias (RoB) as well as confounding. Results After screening 9925 articles, 80 studies (five randomized controlled trials [RCTs] and 75 non‐RCTs) were included, comprising a total of 3732 patients and 692 healthy subjects (HS). Of these studies, 61 investigated CPTs exclusively and 19 reported on SEPs, with or without corresponding CPTs. The recording of LUTCPTs and SEPs was shown to represent a safe and reliable assessment of LUT afferent nerve function in HS and patients. LUTESA demonstrated significant differences in LUT sensitivity between HS and neurological patients, as well as after interventions such as pelvic surgery or drug treatments. Pooled analyses showed that several stimulation variables (e.g. stimulation frequency, location) as well as patient characteristics might affect the main outcome measures of LUTESA (CPTs, SEP latencies, peak‐to‐peak amplitudes, responder rate). RoB and confounding was high in most studies. Conclusions Preliminary data show that CPT and SEP recordings are valuable tools to more objectively assess LUT afferent nerve function. LUTESA complements already established diagnostics such as urodynamics, allowing a more comprehensive patient evaluation. The high RoB and confounding rate was related to inconsistency and inaccuracy in reporting rather than the technique itself. LUTESA standardization and well‐designed RCTs are crucial to implement LUTESA as a clinical assessment tool.
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Affiliation(s)
- Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Melanie R Schmidhalter
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie C Knüpfer
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Urology, University Hospital of Bonn, Bonn, Germany
| | - Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, USA
| | - Marc P Schneider
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Kessler TM. Re: Antimicrobial use in a cohort of US nursing homes, 2017. Eur Urol 2021; 80:670. [PMID: 34362579 DOI: 10.1016/j.eururo.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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Pavese C, Scivoletto G, Puci MV, Schubert M, Curt A, Finazzi Agrò E, Montomoli C, Kessler TM. External Validation Confirms Validity of a Simple Model to Predict Bowel Outcome After Traumatic Spinal Cord Injury. Neurorehabil Neural Repair 2021; 35:659-662. [PMID: 34114519 DOI: 10.1177/15459683211023191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The prediction of functional outcomes after spinal cord injury (SCI) is essential to plan the rehabilitation phase and the social reintegration. Recently, 2 models to predict independent and reliable bowel management 1 year after traumatic SCI have been derived and validated in 2 cohorts of patients included in the European Multicenter Study about Spinal Cord Injury (EMSCI). Objective. We aimed to validate 2 prediction models for bowel outcome after traumatic SCI in a patient sample external to EMSCI. Methods. The simplified model (based on a single predictor, the International Standards for Neurological Classification of Spinal Cord Injury [ISNCSCI] total motor score) and the full model (based on 2 predictors, the ISNCSCI total motor score and item 3a of the Spinal Cord Independence Measure) were applied to the retrospectively collected data of 111 patients with traumatic SCI. Results. The simplified and the full models showed excellent discrimination with an area under the receiver operating characteristic curve of .939 (95% confidence interval (CI) .87-1.00) and .922 (95% CI 0.85-.99), respectively. Both models displayed similar results for sensitivity and negative predictive values; however, the simplified model showed higher values for specificity, positive predictive values, and accuracy. The calibration analysis showed a partial overlap between predicted probabilities and observed proportion, with better and acceptable calibration for the simplified model. Conclusions. Using an independent sample, our study demonstrates the validity of a simple model to predict independent and reliable bowel management 1 year after traumatic SCI.
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Affiliation(s)
- Chiara Pavese
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Switzerland.,Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Italy.,Neurorehabilitation Unit, IRCCS ICS Maugeri Spa-SB, Pavia, Italy
| | - Giorgio Scivoletto
- Spinal Cord Unit and Spinal Rehabilitation (SpiRe) Lab, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Mariangela V Puci
- Unit of Bio Statistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Italy
| | - Martin Schubert
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Switzerland
| | - Armin Curt
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Switzerland
| | - Enrico Finazzi Agrò
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy.,Department of Urology, Policlinico Tor Vergata, Rome, Italy
| | - Cristina Montomoli
- Unit of Biostatistics and Clinical Epidemiology, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Italy
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Switzerland
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Leitner L, Wanivenhaus F, Bachmann LM, Liechti MD, Aguirre JA, Farshad M, Kessler TM. Bladder management in patients undergoing spine surgery: An assessment of care delivery. N Am Spine Soc J 2021; 6:100059. [PMID: 35141624 PMCID: PMC8820009 DOI: 10.1016/j.xnsj.2021.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Lower urinary tract dysfunction is common in the early postoperative phase after spine surgery. Although it is essential for an optimal patient management to balance benefits and harms, it is not known which patient benefit from a perioperative indwelling catheter. We therefore evaluated urological parameters prior and after spine surgery performing a quality assessment of our current clinical practice in bladder management. METHODS Preoperatively, all patients completed the International Prostate Symptom Score and were interviewed for urological history. Decision for preoperative urethral catheter placement was individually made by the responsible anesthesiologist according to an in-house protocol. Within and between group analyses using univariate and probability matching statistics were performed for patients with intraoperative urethral catheter-free management (n = 54) and those with a preoperatively placed catheter (n = 46). Post void residual (PVR) was measured prior and after surgery or after removal of the urethral catheter, respectively. The outcome measures consisted of postoperative urinary retention (POUR) and postoperative urological complications (PUC), defined as POUR and any catheter-related adverse events. RESULTS Hundred patients undergoing spine surgery were prospectively evaluated. Sixteen of the 54 (30%) patients with urethral catheter-free management developed POUR. Length of surgery and volume of intravenous infusion were associated with POUR (p < 0.05). In the 46 preoperatively catheterized patients, re-catheterization was required in 6 (13%). In a fairly homogenous subgroup of 72 patients with a probability of PUC between 15 and 40%, no significant association between intraoperative urethral catheter-free management and the occurrence of PUC was found (odds ratio 2.09, 95% confidence interval 0.69 to 6.33; p = 0.193). CONCLUSIONS In case of postoperative PVR monitoring allowing de novo catheterization as appropriate, urethral catheter-free management seems to be a valuable option in spine surgery since it does not to increase PUC but minimizes unnecessary catheterizations with their related complications.
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Affiliation(s)
- Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Florian Wanivenhaus
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - José A. Aguirre
- Department of Anesthesia, Intensive Care and Pain Therapy, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mazda Farshad
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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30
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Leitner L, McCallin S, Kessler TM. Bacteriophages: what role may they play in life after spinal cord injury? Spinal Cord 2021; 59:967-970. [PMID: 33963272 PMCID: PMC8102843 DOI: 10.1038/s41393-021-00636-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022]
Abstract
Bacterial infections are the leading cause of death in people with a spinal cord injury (SCI). Bacteriophages (phages) are viruses that solely infect and kill bacteria. The idea of using phages to treat bacterial infections, i.e., phage therapy, is very promising and potentially allows a more specific and personalized treatment of bacterial infections than antibiotics. While multi-drug resistant infections affect individuals from the general population, alternative therapeutic options are especially warranted in high-risk populations, such as individuals with SCI. However, more clinical data must be collected before phage therapy can be implemented in clinical practice, with numerous possible, subsequent applications.
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Affiliation(s)
- Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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31
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Gross O, Leitner L, Rasenack M, Schubert M, Kessler TM. Detrusor sphincter dyssynergia: can a more specific definition distinguish between patients with and without an underlying neurological disorder? Spinal Cord 2021; 59:1026-1033. [PMID: 33963273 PMCID: PMC8397615 DOI: 10.1038/s41393-021-00635-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
Study design Cross-sectional study. Objectives To evaluate if specific definitions of detrusor sphincter dyssynergia (DSD) might distinguish between individuals with spinal cord injury (SCI) and those with no underlying neurological disorder (NO ND). Setting Single tertiary university SCI center. Methods A series of 153 individuals, 81 with traumatic SCI and 72 with NO ND, were prospectively evaluated and included in this study. All individuals underwent a clinical neuro-urological examination, a neurophysiological work-up and a video-urodynamic investigation and were diagnosed with DSD as defined by the International Continence Society (ICS). We determined the DSD grades/types according to the classifications by Yalla (grade 1–3), Blaivas (type 1–3) and Weld (type 1–2). Distribution of the DSD grades/types were compared between SCI and NO ND individuals. Associations between the various DSD grades/types and clinical parameters, such as risk factors for upper urinary tract damage (all individuals) or lower extremity motor scores, SCI injury levels and severity scores (only SCI group), were assessed. Results The distribution of all DSD types were similar between groups (p > 0.05). None of the DSD classifications allowed risk assessment for upper urinary tract damage. A significant association between DSD type and other clinical parameters could not be found (p > 0.05). Conclusions None of the investigated DSD definitions can distinguish between patients with SCI and with NO ND. The more complex DSD classifications by Yalla, Blaivas or Weld cannot compete with the ICS binary yes-no definition which is pragmatic and straightforward for managing patients in daily clinical practice. Sponsorship None.
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Affiliation(s)
- Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Maria Rasenack
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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Schmid FA, Williams JK, Kessler TM, Stenzl A, Aicher WK, Andersson KE, Eberli D. Treatment of Stress Urinary Incontinence with Muscle Stem Cells and Stem Cell Components: Chances, Challenges and Future Prospects. Int J Mol Sci 2021; 22:3981. [PMID: 33921532 PMCID: PMC8069473 DOI: 10.3390/ijms22083981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 02/06/2023] Open
Abstract
Urinary incontinence (UI) is a major problem in health care and more than 400 million people worldwide suffer from involuntary loss of urine. With an increase in the aging population, UI is likely to become even more prominent over the next decades and the economic burden is substantial. Among the different subtypes of UI, stress urinary incontinence (SUI) is the most prevalent and focus of this review. The main underlying causes for SUI are pregnancy and childbirth, accidents with direct trauma to the pelvis or medical treatments that affect the pelvic floor, such as surgery or irradiation. Conservative approaches for the treatment of SUI are pelvic physiotherapy, behavioral and lifestyle changes, and the use of pessaries. Current surgical treatment options include slings, colposuspensions, bulking agents and artificial urinary sphincters. These treatments have limitations with effectiveness and bear the risk of long-term side effects. Furthermore, surgical options do not treat the underlying pathophysiological causes of SUI. Thus, there is an urgent need for alternative treatments, which are effective, minimally invasive and have only a limited risk for adverse effects. Regenerative medicine is an emerging field, focusing on the repair, replacement or regeneration of human tissues and organs using precursor cells and their components. This article critically reviews recent advances in the therapeutic strategies for the management of SUI and outlines future possibilities and challenges.
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Affiliation(s)
- Florian A. Schmid
- Department of Urology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
| | - J. Koudy Williams
- Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27101, USA; (J.K.W.); (K.-E.A.)
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
| | - Arnulf Stenzl
- Department of Urology, University Hospital Tubingen, University of Tubingen, 72076 Tubingen, Germany; (A.S.); (W.K.A.)
| | - Wilhelm K. Aicher
- Department of Urology, University Hospital Tubingen, University of Tubingen, 72076 Tubingen, Germany; (A.S.); (W.K.A.)
| | - Karl-Erik Andersson
- Institute of Regenerative Medicine, Wake Forest University School of Medicine, Winston Salem, NC 27101, USA; (J.K.W.); (K.-E.A.)
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland;
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Walter M, Leitner L, Betschart C, Engeler DS, Freund P, Kessler TM, Kollias S, Liechti MD, Scheiner DA, Michels L, Mehnert U. Considering non-bladder aetiologies of overactive bladder: a functional neuroimaging study. BJU Int 2021; 128:586-597. [PMID: 33547746 DOI: 10.1111/bju.15354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To better understand the neuropathophysiology of overactive bladder (OAB) in women by characterising supraspinal activity in response to bladder distention and cold stimulation. SUBJECTS/PATIENTS AND METHODS We recruited 24 female participants, 12 with OAB (median [interquartile range, IQR] age 40 [32-42] years) and 12 healthy controls (HCs) without lower urinary tract (LUT) symptoms (median [IQR] age 34 [28-44] years), and assessed LUT and cognitive function through neuro-urological examination, 3-day bladder diary, urodynamic investigation, and questionnaires. Functional magnetic resonance (MR) imaging using a 3-T scanner was performed in all participants during automated, repetitive bladder filling and draining (block design) with 100 mL body temperature (37 °C) saline using a MR-compatible and MR-synchronised infusion-drainage device until strong desire to void (HIGH-FILLING/DRAINING) and bladder filling with cold saline (4 °C, i.e. COLD). Whole-brain and region-of-interest analyses were conducted using Statistical Parametric Mapping, version 12. RESULTS Significant between-group differences were found for 3-day bladder diary variables (i.e. voiding frequency/24 h, P < 0.001; voided volume/void, P = 0.04; and urinary incontinence [UI] episodes/24 h, P = 0.007), questionnaire scores (International Consultation on Incontinence Questionnaire-Female LUT symptoms [overall, filling, and UI scores, all P < 0.001]; the Overactive Bladder Questionnaire short form [symptoms and quality-of-life scores, both P < 0.001]; the Hospital Anxiety and Depression Scale [anxiety P = 0.004 and depression P = 0.003 scores]), as well as urodynamic variables (strong desire to void, P = 0.02; maximum cystometric capacity, P = 0.007; and presence of detrusor overactivity, P = 0.002). Age, weight and cognitive function (i.e. Mini-Mental State Examination, P = 1.0) were similar between groups (P > 0.05). In patients with OAB, the HIGH task elicited activity in the superior temporal gyrus, ventrolateral prefrontal cortex (VLPFC), and mid-cingulate cortex; and the COLD task elicited activity in the VLPFC, cerebellum, and basal ganglia. Compared to HCs, patients with OAB showed significantly stronger cerebellar activity during HIGH-FILLING and significantly less activity in the insula and VLPFC during HIGH-DRAINING. CONCLUSIONS The present findings suggest a sensory processing and modulation deficiency in our OAB group, probably as part of their underlying pathophysiology, as they lacked activity in essential sensory processing areas, such as the insula. Instead, accessory areas, such as the cerebellum, showed significantly stronger activation compared to HCs, presumably supporting pelvic-floor motor activity to prevent UI. The novel findings of the present study provide physiological evidence of the necessity to consider non-bladder aetiologies of bladder symptoms.
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Affiliation(s)
- Matthias Walter
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Urology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Cornelia Betschart
- Department of Gynecology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Daniel S Engeler
- Department of Urology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, UK.,Department of Neurology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Spyros Kollias
- Department of Neuroradiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - David A Scheiner
- Department of Gynecology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Lars Michels
- Department of Neuroradiology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Anderson CE, Birkhäuser V, Stalder SA, Bachmann LM, Curt A, Jordan X, Leitner L, Liechti MD, Mehnert U, Möhr S, Pannek J, Schubert M, van der Lely S, Kessler TM, Brinkhof MWG. Optimizing clinical trial design using prospective cohort study data: a case study in neuro-urology. Spinal Cord 2020; 59:1003-1012. [PMID: 33235299 PMCID: PMC7611589 DOI: 10.1038/s41393-020-00588-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 11/25/2022]
Abstract
Study Design Simulations using data from a prospective cohort study. Objectives To illustrate how prospective cohort data can be employed in randomized controlled trial (RCT) planning to assess feasibility and operational challenges, using TASCI (Transcutaneous tibial nerve stimulation in patients with Acute Spinal Cord Injury to prevent neurogenic detrusor overactivity: a nationwide randomized, sham-controlled, double-blind clinical trial) as a case study. Setting Spinal cord injury rehabilitation centers in Switzerland. Methods TASCI is nested in the multicenter Swiss Spinal Cord Injury Cohort Study (SwiSCI), which prospectively includes patients with acute spinal cord injury. In simulations, data from 640 patients, collected by SwiSCI, were used to investigate different scenarios of patient eligibility and study consent, as well as the performance of the randomization list. Descriptive analysis was used to describe the population of interest and the simulation results; multivariable logistic regression analysis was performed to identify predictors of discharge within the TASCI intervention time period. Results The recruitment target of 114 patients is obtainable within the originally envisioned three-year time period under the most favorable recruitment scenario examined. The distribution of the primary prognostic factor produced imbalance in the randomization lists and informed further discussion of the cut-off values used in stratification. Influxes of patients resulted in overlapping intervention periods for multiple participants, which guided resource allocation. Early discharge was related to the primary prognostic factor and study center, but is only anticipated in about 8% of participants. Conclusions Prospective cohort data are a very valuable resource for planning RCTs.
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Affiliation(s)
- Collene E Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.,Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Armin Curt
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sandra Möhr
- Neuro-Urology, REHAB Basel, Basel, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland.,Department of Urology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Schubert
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland. .,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.
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van der Lely S, Kessler TM, Mehnert U, Liechti MD. Scalp Topography of Lower Urinary Tract Sensory Evoked Potentials. Brain Topogr 2020; 33:693-709. [PMID: 33067692 PMCID: PMC7593393 DOI: 10.1007/s10548-020-00796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 09/01/2020] [Indexed: 11/06/2022]
Abstract
Impaired lower urinary tract (LUT) afferents often cause LUT symptoms. Assessment of LUT afferent pathways is possible using bipolar cortical sensory evoked potential (SEP) recordings with the active electrode at the vertex during electrical stimulation in the LUT. This study aimed to investigate the topographical distribution and microstates of lower urinary tract sensory evoked potentials (LUTSEPs) using different stimulation frequencies. Ninety healthy subjects (18-36 years old, 40 women) were randomly assigned to one of five stimulation locations [bladder dome; trigone; proximal, membranous (men only) or distal urethra]. Cycles of 0.5 Hz/1.1 Hz/1.6 Hz electrical stimulation were applied using a custom-made catheter. Cortical activity was recorded from 64 surface electrodes. Marker setting was performed manually on an individual subject-level for the P1, N1, and P2 components of vertex recordings. N1 and P2 topographies presented with central negativities and positivities around the vertex. Regarding topographical distribution, Randomization Graphical User interface (RAGU) analyses revealed consistent frequency effects and microstates for N1/P2. Higher stimulation frequencies resulted in decreasing map strength for P1, N1, and P2. LUTSEP topographies suggest central generators in the somatosensory cortex, which are not detectable in a bipolar set-up. The observed frequency effect indicates fiber refractoriness at higher frequencies. The multichannel approach allows more comprehensive assessment of LUTSEPs and might therefore be sensitive to pathological changes. Examinations in patients with LUT symptoms are needed to further investigate this biomarker.
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Affiliation(s)
- Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Forchstrasse 340, 8008, Zürich, Switzerland.
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Leitner L, Ujmajuridze A, Chanishvili N, Goderdzishvili M, Chkonia I, Rigvava S, Chkhotua A, Changashvili G, McCallin S, Schneider MP, Liechti MD, Mehnert U, Bachmann LM, Sybesma W, Kessler TM. Intravesical bacteriophages for treating urinary tract infections in patients undergoing transurethral resection of the prostate: a randomised, placebo-controlled, double-blind clinical trial. Lancet Infect Dis 2020; 21:427-436. [PMID: 32949500 DOI: 10.1016/s1473-3099(20)30330-3] [Citation(s) in RCA: 139] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/25/2020] [Accepted: 04/16/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are among the most prevalent microbial diseases and their financial burden on society is substantial. In the context of increasing antibiotic resistance, finding alternative treatments for UTIs is a top priority. We aimed to determine whether intravesical bacteriophage therapy with a commercial bacteriophage cocktail is effective in treating UTI. METHODS We did a randomised, placebo-controlled, clinical trial, at the Alexander Tsulukidze National Centre of Urology, Tbilisi, Georgia. Men older than 18 years of age, who were scheduled for transurethral resection of the prostate (TURP), with complicated UTI or recurrent uncomplicated UTI but no signs of systemic infection, were allocated by block randomisation in a 1:1:1 ratio to receive intravesical Pyo bacteriophage (Pyophage; 20 mL) or intravesical placebo solution (20 mL) in a double-blind manner twice daily for 7 days, or systemically applied antibiotics (according to sensitivities) as an open-label standard-of-care comparator. Urine culture was taken via urinary catheter at the end of treatment (ie, day 7) or at withdrawal from the trial. The primary outcome was microbiological treatment response after 7 days of treatment, measured by urine culture; secondary outcomes included clinical and safety parameters during the treatment period. Analyses were done in a modified intention-to-treat population of patients having received at least one dose of the allocated treatment regimen. This trial is registered with ClinicalTrials.gov, NCT03140085. FINDINGS Between June 2, 2017, and Dec 14, 2018, 474 patients were screened for eligibility and 113 (24%) patients were randomly assigned to treatment (37 to Pyophage, 38 to placebo, and 38 to antibiotic treatment). 97 patients (28 Pyophage, 32 placebo, 37 antibiotics) received at least one dose of their allocated treatment and were included in the primary analysis. Treatment success rates did not differ between groups. Normalisation of urine culture was achieved in five (18%) of 28 patients in the Pyophage group compared with nine (28%) of 32 patients in the placebo group (odds ratio [OR] 1·60 [95% CI 0·45-5·71]; p=0·47) and 13 (35%) of 37 patients in the antibiotic group (2·66 [0·79-8·82]; p=0·11). Adverse events occurred in six (21%) of 28 patients in the Pyophage group compared with 13 (41%) of 32 patients in the placebo group (OR 0·36 [95% CI 0·11-1·17]; p=0·089) and 11 (30%) of 37 patients in the antibiotic group (0·66 [0·21-2·07]; p=0·47). INTERPRETATION Intravesical bacteriophage therapy was non-inferior to standard-of-care antibiotic treatment, but was not superior to placebo bladder irrigation, in terms of efficacy or safety in treating UTIs in patients undergoing TURP. Moreover, the bacteriophage safety profile seems to be favourable. Although bacteriophages are not yet a recognised or approved treatment option for UTIs, this trial provides new insight to optimise the design of further large-scale clinical studies to define the role of bacteriophages in UTI treatment. FUNDING Swiss Continence Foundation, the Swiss National Science Foundation, and the Swiss Agency for Development and Cooperation. TRANSLATIONS For the Georgian and German translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Nina Chanishvili
- Eliava Institute of Bacteriophage, Microbiology, and Virology, Tbilisi, Georgia
| | | | - Irina Chkonia
- Eliava Institute of Bacteriophage, Microbiology, and Virology, Tbilisi, Georgia
| | - Sophia Rigvava
- Eliava Institute of Bacteriophage, Microbiology, and Virology, Tbilisi, Georgia
| | - Archil Chkhotua
- Alexander Tsulukidze National Centre of Urology, Tbilisi, Georgia
| | | | - Shawna McCallin
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc P Schneider
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Wilbert Sybesma
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Yoba for Life Foundation, Amsterdam, Netherlands
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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Birkhäuser V, Sartori AM, Bodmer NS, Conlon T, Thiel J, Kessler TM, Bachmann LM. Metaepidemiological Inventory of Diagnostic Studies on Urodynamics. Eur Urol Focus 2020; 6:880-908. [PMID: 31866095 DOI: 10.1016/j.euf.2019.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/20/2019] [Accepted: 11/30/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Urodynamic investigations have a pivotal role in the diagnosis of lower urinary tract symptoms. Despite expert statements and guidelines supporting their usefulness for clinical decision making in various clinical domains, the academic debate remains controversial. OBJECTIVE To provide a metaepidemiological inventory of studies assessing the diagnostic properties of urodynamic investigations. DESIGN, SETTING, AND PARTICIPANTS Systematic searches without language restrictions were performed in (Pre-)Medline, EMBASE, and the Cochrane Library from inception until August 31, 2018. Checking of reference lists of included studies and reviews complemented searches. Records were compiled and screened for possible inclusion by reading title and abstracts by two teams of two research fellows. Inclusion criteria were as follows: prospective data collection and urodynamic investigations performed either as a diagnostic test or using a therapy monitoring instrument. No a priori selection on clinical domain was done. Double reading was performed on records marked "included." Extraction into a developed and piloted matrix was performed in duplicate and checked by a third research fellow. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Of each included article, study specifics, objective, study design, type of data collection, clinical domain, type and description of test used, and type of outcome were extracted and attributed to a framework. RESULTS AND LIMITATIONS Electronic searches retrieved 20 841 records. After screening, 299 abstracts were considered relevant. The main reasons for exclusion were as follows: animal studies, no primary data, editorial/opinion based on published data or reviews, primary objective of the study being not the assessment of urodynamic investigations, and post hoc (opportunistic) correlation studies. CONCLUSIONS To our knowledge, this is the first comprehensive collection of studies assessing the clinical usefulness of urodynamic investigations. The collection is the starting point for a series of systematic reviews assessing the diagnostic properties of urodynamic investigations. PATIENT SUMMARY The usefulness of urodynamic investigations for clinical decision making is under debate. We established an inventory of diagnostic studies on urodynamics to assess the value of urodynamics in various clinical applications.
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Affiliation(s)
- Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | | | - Tara Conlon
- Medignition Inc., Research Consultants, Zürich, Switzerland
| | - Julien Thiel
- Medignition Inc., Research Consultants, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Liechti MD, van der Lely S, Stalder SA, Anderson CE, Birkhäuser V, Bachmann LM, Brinkhof MWG, Curt A, Jordan X, Leitner L, Mehnert U, Möhr S, Pannek J, Schubert M, Kessler TM. Update from TASCI, a Nationwide, Randomized, Sham-controlled, Double-blind Clinical Trial on Transcutaneous Tibial Nerve Stimulation in Patients with Acute Spinal Cord Injury to Prevent Neurogenic Detrusor Overactivity. Eur Urol Focus 2020; 6:877-879. [PMID: 31601539 DOI: 10.1016/j.euf.2019.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
Transcutaneous tibial nerve stimulation has the potential to revolutionize the management of lower urinary tract dysfunction in patients with acute spinal cord injury. TASCI is a nationwide randomized, sham-controlled, double-blind clinical trial for which the preparatory phase has been successfully completed.
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Affiliation(s)
- Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland
| | - Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Martin W G Brinkhof
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland
| | - Armin Curt
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sandra Möhr
- Neuro-Urology, REHAB Basel, Basel, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland; Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Martin Schubert
- Neurology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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Kessler TM. Neuro-Urology, Quo Vadis? Eur Urol Focus 2020; 6:801-803. [DOI: 10.1016/j.euf.2020.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
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Birkhäuser V, Liechti MD, Anderson CE, Bachmann LM, Baumann S, Baumberger M, Birder LA, Botter SM, Büeler S, Cruz CD, David G, Freund P, Friedl S, Gross O, Hund-Georgiadis M, Husmann K, Jordan X, Koschorke M, Leitner L, Luca E, Mehnert U, Möhr S, Mohammadzada F, Monastyrskaya K, Pfender N, Pohl D, Sadri H, Sartori AM, Schubert M, Sprengel K, Stalder SA, Stoyanov J, Stress C, Tatu A, Tawadros C, van der Lely S, Wöllner J, Zubler V, Curt A, Pannek J, Brinkhof MWG, Kessler TM. TASCI-transcutaneous tibial nerve stimulation in patients with acute spinal cord injury to prevent neurogenic detrusor overactivity: protocol for a nationwide, randomised, sham-controlled, double-blind clinical trial. BMJ Open 2020; 10:e039164. [PMID: 32792454 PMCID: PMC7430472 DOI: 10.1136/bmjopen-2020-039164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Neurogenic lower urinary tract dysfunction (NLUTD), including neurogenic detrusor overactivity (NDO) and detrusor sphincter dyssynergia, is one of the most frequent and devastating sequelae of spinal cord injury (SCI), as it can lead to urinary incontinence and secondary damage such as renal failure. Transcutaneous tibial nerve stimulation (TTNS) is a promising, non-invasive neuromodulatory intervention that may prevent the emergence of the C-fibre evoked bladder reflexes that are thought to cause NDO. This paper presents the protocol for TTNS in acute SCI (TASCI), which will evaluate the efficacy of TTNS in preventing NDO. Furthermore, TASCI will provide insight into the mechanisms underlying TTNS, and the course of NLUTD development after SCI. METHODS AND ANALYSIS TASCI is a nationwide, randomised, sham-controlled, double-blind clinical trial, conducted at all four SCI centres in Switzerland. The longitudinal design includes a baseline assessment period 5-39 days after acute SCI and follow-up assessments occurring 3, 6 and 12 months after SCI. A planned 114 participants will be randomised into verum or sham TTNS groups (1:1 ratio), stratified on study centre and lower extremity motor score. TTNS is performed for 30 min/day, 5 days/week, for 6-9 weeks starting within 40 days after SCI. The primary outcome is the occurrence of NDO jeopardising the upper urinary tract at 1 year after SCI, assessed by urodynamic investigation. Secondary outcome measures assess bladder and bowel function and symptoms, sexual function, neurological structure and function, functional independence, quality of life, as well as changes in biomarkers in the urine, blood, stool and bladder tissue. Safety of TTNS is the tertiary outcome. ETHICS AND DISSEMINATION TASCI is approved by the Swiss Ethics Committee for Northwest/Central Switzerland, the Swiss Ethics Committee Vaud and the Swiss Ethics Committee Zürich (#2019-00074). Findings will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03965299.
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Affiliation(s)
- Veronika Birkhäuser
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Collene E Anderson
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | | | - Sarah Baumann
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Michael Baumberger
- Spinal Cord and Rehabilitation Medicine, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Lori A Birder
- Neuro-Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sander M Botter
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, Zürich, Switzerland
| | - Silvan Büeler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Célia D Cruz
- Instituto de Investigação e Inovação em Saúde, Translational Neuro-urology Group, Universidade do Porto, Porto, Portugal
- Faculdade de Medicina, Departemento de Biomedicina, Unidade de Biologia Experimental, Universidade do Porto, Porto, Portugal
| | - Gergely David
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Oliver Gross
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Knut Husmann
- Swiss Center for Musculoskeletal Biobanking, Balgrist Campus AG, Zürich, Switzerland
| | - Xavier Jordan
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Miriam Koschorke
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Eugenia Luca
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Sandra Möhr
- Clinic of Neurorehabilitation and Paraplegiology, REHAB Basel, Basel, Switzerland
| | - Freschta Mohammadzada
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Helen Sadri
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Andrea M Sartori
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Kai Sprengel
- Department of Trauma, University Hospital Zürich, Zürich, Switzerland
| | - Stephanie A Stalder
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jivko Stoyanov
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Cornelia Stress
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Aurora Tatu
- Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Cécile Tawadros
- Spinal Cord Injury Department, Clinique romande de réadaptation, Sion, Switzerland
| | - Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jens Wöllner
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
| | - Veronika Zubler
- Department of Radiology, Balgrist University Hospital, Zürich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Jürgen Pannek
- Neuro-Urology, Swiss Paraplegic Centre, Nottwil, Switzerland
- Department of Urology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Martin W G Brinkhof
- Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Affiliation(s)
- Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Leitner L, Kessler TM, Klumpp J. Bacteriophages: a Panacea in Neuro-Urology? Eur Urol Focus 2020; 6:518-521. [DOI: 10.1016/j.euf.2019.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/14/2019] [Accepted: 10/28/2019] [Indexed: 01/08/2023]
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Kessler TM. Guidelines on urinary incontinence: it is time to join forces! BJU Int 2020; 125:625-626. [DOI: 10.1111/bju.15075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Thomas M. Kessler
- Department of Neuro-Urology; Balgrist University Hospital; University of Zürich; Zürich Switzerland
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Gammie A, Kessler TM. Half the message is just mess: judging the value of urodynamics based on partial or poor-quality results. BJU Int 2020; 126:4-5. [PMID: 32279404 DOI: 10.1111/bju.15063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Andrew Gammie
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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De Wachter S, Vaganee D, Kessler TM. Sacral Neuromodulation: Mechanism of Action. Eur Urol Focus 2020; 6:823-825. [PMID: 32019718 DOI: 10.1016/j.euf.2019.11.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/17/2019] [Accepted: 11/29/2019] [Indexed: 11/30/2022]
Abstract
Although the mechanism of action of sacral neuromodulation (SNM) is still not fully elucidated, it seems to involve modulation of spinal cord reflexes and brain networks by peripheral afferents according to findings from neurophysiology, electroencephalography, positron emission tomography, and magnetic resonance imaging studies. Moreover, motor effects mediated via efferents on direct stimulation cannot be fully excluded. In this mini-review, we summarize current knowledge on the mechanism of action of SNM. PATIENT SUMMARY: We reviewed the literature on the mechanism of action of sacral neuromodulation, in which electrical stimulation is applied to the nerves that regulate bladder activity. The mechanism seems to involve modulation of spinal cord reflexes and brain networks by peripheral sensory and possibly motor neurons.
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Affiliation(s)
- Stefan De Wachter
- Department of Urology, Antwerp Academic Hospital, Edegem, Belgium; Department of Urology, Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium.
| | - Donald Vaganee
- Department of Urology, Antwerp Academic Hospital, Edegem, Belgium; Department of Urology, Faculty of Medicine and Health Sciences, Antwerp University, Wilrijk, Belgium
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Sartori AM, Kessler TM, Schwab ME. Methods for Assessing Lower Urinary Tract Function in Animal Models. Eur Urol Focus 2020; 7:186-189. [PMID: 31937460 DOI: 10.1016/j.euf.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/17/2019] [Accepted: 12/10/2019] [Indexed: 12/15/2022]
Abstract
Lower urinary tract dysfunction affects a multitude of patients. Current therapeutic approaches are limited and very little is known about the mechanisms in failure of bladder control. Thus, more basic research is clearly needed to elucidate the underlying pathological mechanisms and to develop novel treatment strategies in urology. Noninvasive tests such as the void-spot assay and the metabolic cage and more invasive urodynamics investigations are currently used to assess lower urinary tract function in animals, in particular rodents. The noninvasive tests give some insights into the functionality of the system, whereas urodynamics testing yields an objective evaluation that allows distinction of different pathologies and investigations of the underlying neuronal malfunctions. PATIENT SUMMARY: We briefly summarize methods currently used to assess impairments of bladder function in animal models. Both noninvasive and invasive methods are available and can be used to understand and improve human health. An accurate and detailed diagnosis is, however, possible only with urodynamics assessments.
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Affiliation(s)
- Andrea M Sartori
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland; Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin E Schwab
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
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van der Lely S, Liechti MD, Schmidhalter MR, Schubert M, Bachmann LM, Kessler TM, Mehnert U. Optimized Measurement Parameters of Sensory Evoked Cortical Potentials to Assess Human Bladder Afferents - A Randomized Study. Sci Rep 2019; 9:19478. [PMID: 31863016 PMCID: PMC6925113 DOI: 10.1038/s41598-019-54614-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 11/09/2019] [Indexed: 12/03/2022] Open
Abstract
Overactive bladder and voiding dysfunction are highly prevalent and often associated with malfunction of the bladder afferent pathways. Appropriate diagnostic tools for an objective assessment of afferent nerve function of the human bladder are currently missing. One promising possibility is the assessment of sensory evoked potentials (SEP) during repetitive electrical bladder stimulation, which proved feasible in healthy subjects. For an implementation into clinical practice, however, further refinements for efficient and reliable data acquisition are crucial. The aim of this randomized study was to find the optimal measurement settings regarding stimulation frequency, repetition number, and data acquisition. Forty healthy subjects underwent two visits of SEP (Cz-Fz) assessments using repetitive (500 stimuli) electrical stimulation of 0.5 Hz, 1.1 Hz, and 1.6 Hz and pulse width of 1 ms at the bladder dome or trigone. SEP analyses revealed higher amplitudes and better signal-to-noise ratio (SNR) with lower stimulation frequencies, while latencies remained unchanged. Decreasing amplitudes and SNR were observed with continuing stimulation accompanied by decreasing responder rate (RR). When applying stimuli at a frequency of 0.5 Hz, averaging across 200 stimuli revealed optimal reliability with best SNR, RR and sufficiently high amplitudes. This constitutes an optimal compromise between the duration of the assessment and SEP peak-to-peak amplitudes.
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Affiliation(s)
- Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Melanie R Schmidhalter
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martin Schubert
- Neurophysiology, Spinal Cord Injury Center, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
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van der Lely S, Liechti MD, Bachmann LM, Kessler TM, Mehnert U. Quantitative electrical pain threshold assessment in the lower urinary tract. Neurourol Urodyn 2019; 39:420-431. [PMID: 31821623 DOI: 10.1002/nau.24225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/04/2019] [Indexed: 01/23/2023]
Abstract
AIMS Assessing the reliability of electrical pain threshold (PT) and evaluating the impact of stimulation frequency at different locations in the healthy lower urinary tract (LUT). METHODS Ninety subjects (age: 18.3-35.8 years, 40 females, 50 males) were randomly allocated to one stimulation site (bladder dome [BD], trigone, proximal, membranous (only males), or distal urethra). Using 0.5 Hz/1.1 Hz/1.6 Hz electrical stimulation (square wave, pulse width:1 ms), current perception thresholds (CPTs), PTs and tolerance thresholds were assessed at two visits. Analyses were performed using linear mixed models, intraclass correlation coefficients (ICC) and Bland-Altman method. RESULTS PTs vary in relation to stimulation frequency, location and between genders. PT decreased with higher stimulation frequency. The highest PTs were measured at the BD and membranous urethra with males reporting higher PTs than females. Reliability of PT assessments according to ICC was good to excellent across all frequencies, locations, and genders (ICC = 0.61-0.97), except for BD and distal urethra in females showing poor to fair reliability (BD: all frequencies, distal urethra: 0.5 Hz). CONCLUSIONS PTs can be safely and reliably assessed from bladder and urethral locations. Semi-objective PT assessment may provide additional information on functionality and sensitivity of the LUT slow fiber afferents and complement findings from urodynamic investigations and CPT assessments. In conclusion, the developed methodology may open new opportunities for using electrical stimulation paradigms for LUT PT assessments and diagnostics. All this allows a more precise, location-specific characterization of pain origin and pain reaction towards therapy.
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Affiliation(s)
- Stéphanie van der Lely
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Martina D Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Ulrich Mehnert
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Sartori AM, Schwab ME, Kessler TM. Ultrasound: A Valuable Translational Tool to Measure Postvoid Residual in Awake Rats? Eur Urol Focus 2019; 6:916-921. [PMID: 31813811 DOI: 10.1016/j.euf.2019.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/17/2019] [Accepted: 11/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ultrasound is generally used to measure postvoid residual (PVR) in daily clinical practice for a basic assessment of voiding dysfunction. In animal research, however, PVR is measured mostly by expelling the urine with gentle squeezing of the bladder. OBJECTIVE To assess the translational value of measuring PVR by ultrasound in awake rats with the aim of obtaining directly comparable data sets in patients and rodent models. DESIGN, SETTING, AND PARTICIPANTS A prospective animal study was conducted in 10 rats with large, incomplete thoracic spinal cord injury resulting in severe bladder impairment. Lower urinary tract function was assessed by urodynamics with implanted bladder catheter and external urethral sphincter electrodes, allowing for repeated measurements over time. Immediately after the last micturition cycle in the urodynamic investigation, PVR was first assessed by ultrasound using a 7.5 MHz linear probe and then by manually expelling the urine via gentle pressure on the abdomen. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS PVR was measured by ultrasound and by manually expelling the urine. Paired t test was used to analyze the difference between the two measurements 1 and 2 wk after spinal cord injury. RESULTS AND LIMITATIONS PVR assessed by ultrasound was equal to and not statistically different from the volumes obtained by manual expulsion in intact rats, both before injury and during the first 2 wk after spinal cord injury (intact: 0.16 ± 0.07 vs 0.14 ± 0.09 ml, p = 0.08; week 1: 1.67 ± 0.53 vs 1.71 ± 0.55 ml, p = 0.67; week 2: 1.16 ± 0.35 vs 0.98 ± 0.43 ml, p = 0.11). The main limitation of ultrasound for measuring PVR is the restricted availability of ultrasound machines in animal research laboratories. CONCLUSIONS Ultrasound is a valuable translational tool to measure PVR in awake rats reflecting the situation in humans. PATIENT SUMMARY We measured postvoid residual by ultrasound in awake rats, analogous to clinical examination in humans. Ultrasonography provided similar values to the generally used manual bladder expulsion.
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Affiliation(s)
- Andrea M Sartori
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland; Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Martin E Schwab
- Institute for Regenerative Medicine, University of Zürich, Zürich, Switzerland
| | - Thomas M Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Schmid FA, Wettstein MS, Kessler TM, Hermanns T, Boss A, Hötker AM, Eberli D. Contrast media kinetics in multiparametric magnetic resonance imaging before radical prostatectomy predicts the probability of postoperative incontinence. World J Urol 2019; 38:1741-1748. [DOI: 10.1007/s00345-019-02952-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/05/2019] [Indexed: 01/28/2023] Open
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