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

Risk factors of video urodynamics and bladder management for long-term complications in patients with chronic spinal cord injury

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

[Neuro-urological diagnostics and treatment of non-traumatic/degenerative neurogenic lower urinary tract dysfunction exemplified by multiple sclerosis]

Neurogenic lower urinary tract dysfunction in multiple sclerosis is often underestimated, underdiagnosed, and inadequately treated. Depending on the course of the disease and the location of neural damage, it occurs with varying frequency and types of impairment of urine storage and voiding function. Symptoms such as urinary incontinence, recurrent urinary tract infections, urgency, pollakiuria, reduced urinary flow, hesitancy as well as postvoid residual urine may occur. However, the symptoms do not allow any conclusions to be drawn about the underlying type of neurogenic lower urinary tract dysfunction. Although numerous data, publications, and guidelines are available on this topic today, there continues to be a lack of standardized screening parameters and algorithms that have been tested in prospective studies for multiple sclerosis. This article presents the current diagnostic and therapeutic options of neurogenic lower urinary tract dysfunction in multiple sclerosis. A crucial issue is the initial delay in diagnosis, not least due to a lack of communication between neurologists and urologists. Initial indicators of the presence of neurogenic lower urinary tract dysfunction can be obtained by actively asking about the subjective presence of symptoms such as urinary incontinence or the occurrence of urinary tract infections. However, a subjective lack of symptoms does not rule out a neurogenic lower urinary tract dysfunction. Regardless of the stage of the disease, an early and individualized neuro-urological diagnosis and treatment should be implemented. All aspects of the damage and the extent of functional deficits in other organ systems caused by multiple sclerosis must be included in this neuro-urological treatment decision, which requires a consistent interdisciplinary exchange between neurologists, general practitioners, and urologists. This interdisciplinary and interprofessional way of thinking and acting is key for an optimal treatment using the numerous therapeutic procedures. Lifelong, individual, risk-adapted urological care for the early detection and prevention of neuro-urological complications should be offered to persons with multiple sclerosis.

["Pressure kills kidneys": protection of the upper urinary tract through neuro-urological management]

Low compliance is not an independent disease but a severe manifestation resulting from various disorders of the storage and excretory function of the bladder. Reduced distensibility of the detrusor muscle can lead to a pressure load on the upper urinary tract but also to urge-dominant LUTS and urinary tract infections. Neurogenic causes, especially spinal cord injury/spina bifida but also iatrogenic damage or subvesical obstruction, can contribute to the development. This article is intended to provide information about the epidemiology and complex pathogenetic mechanisms as well as the necessary diagnostic steps. Various medical, interventional and surgical treatment strategies are evaluated on the basis of current scientific findings, thus supporting the reader in the care of this complex patient group.

Long-term complications and outcomes of augmentation cystoplasty in children with neurogenic bladder

Augmentation cystoplasty (AC) is an effective surgical procedure for patients with neurogenic bladder whenever conservative treatments have failed. The present study aimed to determine the risks of metabolic complications, malignancy, long-term outcomes and histopathologic changes of native bladder and the augmented intestine after AC in children with neurogenic bladder. Pediatric patients < 18 years who underwent AC between 2000 and 2020 were enrolled. Early postoperative complications, long-term outcomes and histopathologic changes in mucosal biopsies of native bladder and the augmented intestine after AC were reviewed. Twenty-two patients with a mean age of 7.6 ± 4.4 years were included. The ileum was used in 19 patients and the sigmoid colon in 3 patients. The length of hospital stay was 14.8 ± 6.8 days. Post-operatively, the urinary continence rate improved from 22.7 to 81.8% (p < 0.001). Hydronephrosis resolved in 17 of 19 patients. Vesicoureteral reflux resolved in 16 (64.0%) of the refluxing ureter units and was downgraded in 7 (28.0%). Grades of hydronephrosis and reflux significantly improved following AC (p < 0.001). The estimated glomerular filtration rate also significantly increased (p = 0.012). Formation of urinary tract stones was the most frequent late complication (in 8 patients, 36.4%). Life-threatening spontaneous bladder perforation occurred in 1 patient. After a mean follow-up of 13.4 ± 5.9 years, there were no cases of mortality, new-onset symptomatic metabolic acidosis, or changes in serum electrolytes. Of the 17 patients who were followed for > 10 years, no cases of malignancy or metaplastic changes were identified in the native bladder or augmented bowel epithelium. AC is a safe and effective procedure with low surgical and metabolic complication rates. In addition, AC provides a satisfactory continence rate and long-term protection of renal function, increases functional capacity, and regresses reflux and hydronephrosis. Individualized surveillance is recommended for the early identification of urolithiasis and metabolic disturbances.

Developing new ways to assess neural control of pelvic organ function in spinal conditions: ICI-RS 2023

OBJECTIVES

Several central nervous system (CNS) centers affect muscle groups of the lower urinary tract (LUT) and anorectal tract (ART) via autonomic and somatic pathways, working in different modes (storage or expulsion). Hence spinal cord dysfunction can affect the LUT and ART by several possible mechanisms.

METHODS

This review reports the discussions of a workshop at the 2023 meeting of the International Consultation on Incontinence Research Society, which reviewed uncertainties and research priorities of spinal dysfunction.

RESULTS

Discussion focussed on the levator ani nerve, mechanisms underpinning sensory function and sensation, functional imaging, dyssynergia, and experimental models. The following key research questions were identified. (1) Clinically, how can we evaluate the levator ani muscle to support assessment and identify prognosis for effective treatment selection? (2) How can we reliably measure levator ani tone? (3) How can we evaluate sensory information and sensation for the LUT and the ART? (4) What is the role of functional CNS imaging in development of scientific insights and clinical evaluation? (5) What is the relationship of detrusor sphincter dyssynergia to renal failure?

CONCLUSIONS

Spinal cord dysfunction can fundamentally disrupt LUT and ART function, with considerable clinical impact. The evaluation needs to reflect the full scope of potential problems, and new clinical and diagnostic approaches are needed, for prognosis and treatment. The preclinical science evaluating spinal cord function in both LUT and ART storage and elimination remains a major priority, even though it is a challenging experimental context. Without this underpinning evidence, development of new clinical evidence may be held back.

How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence?

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.

Initial experience with ACT™ periurethral adjustable balloons to treat urinary incontinence due to intrinsic sphincter deficiency in the pediatric population

PURPOSE

To present our initial experience with periurethral adjustable continence therapy (ACT™) for urinary incontinence due to intrinsic sphincter deficiency (ISD) in children.

METHODS

This is an approved prospective non-randomized pilot study (NCT03351634) aiming to treat children born with spinal dysraphism (SD) or exstrophy epispadias complex (EEC) with ACT™. Endpoints were patient-reported changes in daily pad count, 24-h Pad test and complications.

RESULTS

Since April 2018, 13 children (six girls, seven boys) were implanted at the median age of 12 years (5-16). The etiology of incontinence was neurogenic ISD (7/13, 54%) and EEC (6/13, 46%). After ACT™ implantation, continence (no pad or 1 security pad/day) was achieved in 9(69%) patients (5/7 SD, 4/6 EEC). Additionally, two (15%) patients had a significant improvement (decreasing Pad test from 1049 to 310 g at 3 months). One patient (7%) had no improvement. Results were stable at 21 months (6-43) of follow-up. Mean final balloon volume was 2.89 ml (± 0.85) with a median of 3 fillings to obtain continence. We had four revisions due to cutaneous port erosion (n = 3) and balloon migration (n = 1) and two definitive explantations. PinQ score was significantly improved (47 vs 40.5 with balloon, p = ns). Neither degradation of the upper urinary tract nor cystomanometric changes have been observed at 6 and 12 months postoperatively.

CONCLUSION

Urinary incontinence due to ISD owing to EEC or SD can be successfully treated with ACT™ periurethral balloons. Given the minimal invasiveness of this therapy, it might be a first-line option treatment in children with complex stress urinary incontinence.

Prediction of Lower Urinary Tract, Sexual, and Bowel Function, and Autonomic Dysreflexia after Spinal Cord Injury

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.

Assessing Neurogenic Lower Urinary Tract Dysfunction after Spinal Cord Injury: Animal Models in Preclinical Neuro-Urology Research

Neurogenic bladder dysfunction is a condition that affects both bladder storage and voiding function and remains one of the leading causes of morbidity after spinal cord injury (SCI). The vast majority of individuals with severe SCI develop neurogenic lower urinary tract dysfunction (NLUTD), with symptoms ranging from neurogenic detrusor overactivity, detrusor sphincter dyssynergia, or sphincter underactivity depending on the location and extent of the spinal lesion. Animal models are critical to our fundamental understanding of lower urinary tract function and its dysfunction after SCI, in addition to providing a platform for the assessment of potential therapies. Given the need to develop and evaluate novel assessment tools, as well as therapeutic approaches in animal models of SCI prior to human translation, urodynamics assessment techniques have been implemented to measure NLUTD function in a variety of animals, including rats, mice, cats, dogs and pigs. In this narrative review, we summarize the literature on the use of animal models for cystometry testing in the assessment of SCI-related NLUTD. We also discuss the advantages and disadvantages of various animal models, and opportunities for future research.

The Utility of Urodynamic Studies in Neuro-Urological Patients

INTRODUCTION

The utility of a clinical tool lies in its clinical performance evaluation and describes the relevance and usefulness of that tool in a medical setting. The utility of urodynamic and video-urodynamic studies in the management of specific urodynamic profiles in the diagnosis, treatment, and prognostic approach in neuro-urological patients is the focus of the current review.

METHODS

For this narrative review, a PubMed^® search was performed by cross-referencing the keywords "urodynamics", "neurogenic bladder", "utility", "clinical utility" and "clinical performance" with various terms related to the management of neurogenic lower urinary tract dysfunction. Clinical practice guidelines and landmark reviews from the most renowned experts in the field were also used.

ANALYSIS

Assessment of the utility of urodynamic study was performed during the diagnostic, therapeutic and prognostic steps of the neuro-urological patients' management. We focused on its clinical performance in the identification and evaluation of several unfavorable events, such as neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, elevated detrusor leak point pressure and the presence of vesico-ureteral reflux, which may be indicators for a higher risk for the development of urological comorbidities.

CONCLUSION

Despite the paucity of existing literature assessing the utility of urodynamic study-specifically video-urodynamic study-in neuro-urological patients, it does remain the gold standard to assess lower urinary tract function precisely in this patient category. With regard to its utility, it is associated with high clinical performance at every step of management. The feedback on possible unfavorable events allows for prognostic assessment and may lead us to question current recommendations.

Risk factors for upper urinary tract deterioration in adult patients with spina bifida

PURPOSE

Neurogenic bladder associated with spina bifida disease remains a major cause for mortality or morbidity due to kidney damages. However, we currently do not know which urodynamic findings are associated with an higher risk of upper tract damages in spina bifida patients. The objective of the present study was to evaluate urodynamic findings associated with functional kidney failure and/or with morphological kidney damages.

METHODS

A large single-center restrospective study was conducted in our national referral center for spina bifida patients using our patients' files. All urodynamics curves were assessed by the same examinator. Functional and/or morphological evaluation of the upper urinary tract were done at the same moment as the urodynamic exam (between 1 week before and 1 month after). Kidney function was assessed using creatinine serum levels or 24 h urinary creatinine levels (creatinine clearance) for walking patients, or with the 24 h urinary creatinine level for wheelchair-users.

RESULTS

We included 262 spina bifida patients in this study. Fifty-five patients had a poor bladder compliance (21.4%) and 88 of them had detrusor overactivity (33.6%). Twenty patients had a stage 2 kidney failure (eGFR < 60 ml/min) and 81 patients out of 254 (30.9%) had an abnormal morphological examination. There were three urodynamic findings significantly associated with UUTD: bladder compliance (OR = 0.18; p = 0.007), Pdetmax (OR = 14.7; p = 0.003) and detrusor overactivity (OR = 1.84; p = 0.03).

CONCLUSION

In this large series of spina bifida patients, maximum detrusor pressure and bladder compliance are the main urodynamic findings determinants of UUTD risk.

Imaging characteristics predicting elevated detrusor pressures in patients with spina bifida

PURPOSE

Patients with spina bifida require urologic follow up with assessments of bladder and renal function. The ideal screening protocol for bladder compliance remains controversial. This study assessed associations between bladder end filling pressure (EFP) and detrusor leak point pressure (DLPP) on urodynamic studies (UDS) and findings from renal bladder ultrasounds (RBUS) and voiding cystourethrograms (VCUG).

METHODS

Pediatric spina bifida patients who underwent RBUS and/or VCUG within six months of UDS at a single institution from 2015 to 2021 were retrospectively reviewed. Demographics, VCUG and RBUS results, and UDS EFP and DLPP were recorded. Multiple linear regression analyses and Pearson chi-square tests were conducted to correlate RBUS and VCUG findings with DLPP/EFP.

RESULTS

129 patients were included. In adjusted analyses, moderate to severe hydronephrosis on RBUS was significantly associated with elevations in mean DLPP/EFP (p = 0.006). Patients with round bladders had significantly lower mean DLPP/EFP than patients with elongated or conical bladders (p < 0.0001). The presence of trabeculations was associated with increased mean DLPP/EFP (p < 0.0001) and increases in severity of trabeculations were associated with higher DLPP/EFP (p < 0.0001). The presence of vesicoureteral reflux (VUR) on VCUG was not associated with significant differences in mean DLPP/EFP (p = 0.20).

CONCLUSIONS

Abnormal bladder shape and trabeculations on VCUGs in spina bifida patients had significant associations with increased mean bladder pressures on UDS. Assessment of bladder shape and contour by VCUG may be a valuable screening tool in conjunction with routine RBUS in determining the need for further assessment of bladder pressures in patients with spina bifida.

Long-Term Surveillance and Management of Urological Complications in Chronic Spinal Cord-Injured Patients

Bladder dysfunction is a common complication after chronic spinal cord injury (SCI). Patients may experience renal function loss, urinary tract infection (UTI), urolithiasis, bladder cancer, and even life-threatening events such as severe sepsis or renal failure. Suitable patient care may prevent UTI and urinary incontinence, decrease medication use, and preserve renal function. As the primary goal is to preserve renal function, management should be focused on facilitating bladder drainage, the avoidance of UTI, and the maintenance of a low intravesical pressure for continence and complete bladder emptying. Currently, several bladder management options are available to SCI patients: (1) reflex voiding; (2) clean intermittent catheterization; (3) indwelling catheterization. The target organ may be the bladder or the bladder outlet. The purposes of intervention include the following: (1) increasing bladder capacity and/or decreasing intravesical pressure; (2) increasing bladder outlet resistance; (3) decreasing bladder outlet resistance; (4) producing detrusor contractility; (5) urinary diversion. Different bladder management methods and interventions may have different results depending on the patient's lower urinary tract dysfunction. This review aims to report the current management options for long-term bladder dysfunction in chronic SCI patients. Furthermore, we summarize the most suitable care plans for improving the clinical outcome of SCI patients.

Influence of urodynamic conditions on bladder sensations and detrusor activity in patients with multiple sclerosis

AIMS

The study aimed to assess the impact of bladder filling rate and fluid temperature during urodynamics on bladder sensations and volume of apparition of detrusor overactivity in patients with multiple sclerosis (PwMS).

METHODS

Consecutive PwMS assessed with a standardized urodynamic test including three consecutive cystometries (20 ml/min, 100 ml/min, and 100 ml/min with 4°C fluid (Ice water test [IWT]) between June 2020 and March 2022 were included in this retrospective study. Data collected were bladder sensation with first desire to void (FDV) and strong desire to void (SDV). The presence of detrusor overactivity (DO) and the volume of the first uninhibited detrusor contraction were recorded.

RESULTS

One hundred and fifty-seven patients (mean age 47.4 ± 11.8 years, median EDSS 3 IQR[2-5], 73.9% of women) were included. Increased filling rate induced delayed bladder sensations (FDV 219 ± 109 ml vs. 194 ± 100 ml; SDV 349 ± 113 ml vs. 322 ± 124 ml for 100 ml/min and 20 ml/min filling rate, respectively, p < 0.001). Ice water increased bladder sensations with earlier reports of needs to void (FDV 163 ± 99 ml vs. 218 ± 117 ml; SDV 263 ± 104 ml vs. 351 ± 112 ml respectively; p < 0.001). Thirty-four patients had DO during both 20 ml/min and 100 ml/min fillings, without difference in the volume of apparition (p = 0.78). Forty-four patients had DO during both 100 ml/min and IWT. Detrusor overactivity appeared for a reduced volume during IWT compared with room temperature fluid perfusion (-68 ml [-95 to -41]; p < 0.001).

CONCLUSION

Filling rate and fluid temperature impact bladder sensations during cystometry in PwMS. Ice water decreased the volume of the first uninhibited detrusor contraction.

Urinary system complications and long-term treatment compliance in chronic traumatic spinal cord injury patients with neurogenic lower urinary tract dysfunction

Objectives

The aim of this study was to evaluate upper and lower urinary tract complications and the compliance of long-term treatment in patients with spinal cord injury (SCI) by urodynamic examination.

Patients and methods

Between January 1997 and May 2007, a total of 89 patients with SCI (79 males, 19 females; mean age: 39.8±12.2 years; range, 19 to 72 years) who were admitted to physical medicine and rehabilitation clinic were retrospectively analyzed. Demographic, neurological, and urodynamic data of the patients with the diagnosis of neurogenic lower urinary tract dysfunction (NLUTD) in their initial urodynamic examination and without regular follow-up were recorded.

Results

The mean time to the first urodynamic examination was 8.6±5.4 months. Sixty-seven patients who had neurogenic detrusor overactivity (NDO) in their first urodynamic tests were recommended anticholinergics. Clean intermittent catheterization (CIC) was recommended after initial urodynamic examination in all patients. Thirty-nine patients of 67 who had NDO were taking medications, while 28 were not. In the patients who continued anticholinergic treatment, bladder capacity was found to statistically significantly increase, compared to the initial measurement values and detrusor pressures significantly decreased (p<0.001). The compliance rate with CIC and anticholinergic treatment was 79.8% and 58.2%, respectively. Sixteen of the patients had calculus in the urinary system. Forty-two patients had infections more than once a year and used antibiotics.

Conclusion

Neurogenic bladder should be evaluated at the beginning of SCI and, then, followed on a regular basis. Urodynamic tests should be performed immediately after spinal shock and can be repeated, as indicated.

[Prioritization of risk situations in neuro-urology: Guidelines based on the Delphi method from Association française d'urologie (AFU), Association francophone internationale des groupes d'animation de la paraplégie (AFIGAP), Groupe de neuro-urologie de langue française (GENULF), Société française de médecine physique et de réadaptation (SOFMER) and Société interdisciplinaire francophone d'urodynamique et de pelvi-périnéologie (SIFUD-PP)]

PURPOSE

During the COVID-19 pandemic, a care reorganization was mandatory, and affected patients in different areas, including management of neurogenic lower urinary tract dysfunction. This work aims to provide validated schedule concerning the assessment and management of patients in neuro-urology.

METHODS

Based on a literature review and their own expertise, a steering committee composed of urologists and physical medicine and rehabilitation practitioners generated a comprehensive risk-situation list and built a risk scale. A panel of French-speaking experts in neuro-urology was asked to define the timing for each clinical situation and validated these new recommendations through a Delphi process approach.

RESULTS

The 49 experts included in the rating group validated 163 propositions among the 206 initial items. The propositions were divided into four domains - diagnosis and assessment, treatment, follow-up, and complications - and two sub-domains - general (applicable for all neurological conditions) and condition-specific (varying according to the neurological condition (spinal cord injury, multiple sclerosis, brain injury, Parkinsonism, spinal dysraphism, lower motor neuron lesions)).

CONCLUSIONS

This multidisciplinary collaborative work generates recommendations based on expert opinion, providing a validated timing for assessment and management of patients in neuro-urology which may help clinicians to reorganize their patients' list with a personalized medicine approach, in a context of health crisis or not.

Longitudinally extensive transverse myelitis (LETM) secondary to SARS‐CoV‐2 infection: A recent reality in spinal cord injury rehabilitation

Transverse myelitis can be a complication of SARS‐CoV‐2 infection. We report the case of a transverse myelitis related to SARS‐CoV‐2 infection. Beyond the disease itself, neurological involvement affects functionality. In this situation, physical and rehabilitation medicine plays a crucial role in managing patient rehabilitation.

A Study of Urodynamic Parameters at Different Bladder Filling Stages for Predicting Upper Urinary Tract Dilatation

Purpose

To identify more accurate predictors of upper urinary tract dilatation (UUTD) in neurogenic bladder (NB) children, we studied the relationship among urodynamic parameters at different bladder filling stages, detrusor leak point pressure (DLPP) and UUTD.

Methods

A total of 158 children (3–16 years) with NB were included and then divided into 2 groups according to whether their NB diagnosis was complicated with UUTD: the UUTD group (39 patients) and those without UUTD group (control group, 119 patients). The bladder filling phase was divided into 3 equal parts: the early, middle, and end filling stages. The bladder compliance (BC) and detrusor pressure (△P_det) at each phase and DLPP at the end filling stage were recorded.

Results

A BC<8 mL/cm H₂O both in the middle and end stages is more specific than a BC<9 mL/cm H₂O in the end stage (72%, 73%, vs. 66%), and △P_det >8 cm H₂O in the early stage, 20 cm H₂O in the middle stage and 25 cm H₂O in the end stage are more sensitive than △P_det >40 cm H₂O in the end stage (82%, 85%, 85%, vs. 49%). A DLPP cutoff value of 20 cm H₂O showed higher sensitivity for predicting UUTD than 40 cm H₂O.

Conclusions

Low BC and a high △P_det in the middle and end filling stages are more accurate factors than classic indicators for predicting UUTD. In addition, a DLPP value of >20 cm H₂O in the end bladder filling stage shows high sensitivity.

The safety cutoff storage pressure for preventing upper urinary tract damage in neurogenic bladder from spinal cord pathology and risk factor analysis

INTRODUCTION

Low-compliance bladder or high bladder pressure undoubtedly leads to hydronephrosis and renal impairment. As four decades have elapsed since a previous study found a detrusor leak-point pressure (DLPP) >40 cm H₂ O to result in hydronephrosis, we suspected the possibility of hydronephrosis or vesicoureteral reflux occurring at any point below the 40 cm H₂ O DLPP reference. Therefore, this study aimed to determine the storage detrusor pressure value and risk factors related to upper urinary tract damage (UUTD).

MATERIALS AND METHODS

This study retrospectively reviewed the hospital records of 110 patients who visited the Neurogenic Bladder TU Service of Excellence Unit, Thammasat University Hospital, Pathum Thani, Thailand, and were diagnosed with neurogenic bladder between 2016 and 2020. The inclusion criteria were as follows: patients who were diagnosed with neurogenic bladder from spinal cord problems (spinal dysraphism, spinal cord disease [tumor, degenerative, arteriovenous malformation, etc.], or traumatic spinal cord injury) and underwent a complete examination, including urodynamic study and renal ultrasound. The exclusion criteria were as follows: patients who had previous pelvic irradiation, other concomitant neurological disease (stroke, Parkinson's disease, etc.), or other urological diseases (stone, tumor, etc.), and those who had an indwelling suprapubic or urethral catheter. We identified the cutoff point for storage pressure related to UUTD using receiver operating characteristic (ROC) curve analysis to identify the value that produced maximum sensitivity and specificity. To identify risk factors for developing UUTD, we included seven risk factors: intravesical pressure, poor compliance, detrusor overactivity (DO), detrusor sphincter dyssynergia (DSD), level of the spinal cord pathology, male sex, and spontaneous voiding in univariable and multivariable regression analyses.

RESULTS

Of the 110 patients who met the inclusion criteria, 22 were excluded from the study. Fifty-nine patients had a normal upper urinary tract, and 29 had UUTD. The mean age, sex, voiding pattern, type of spinal cord pathology, and level of spinal cord lesions were not different between the two groups. After performing ROC curve analysis, a cutoff value for daily storage pressure ≥15 cm H₂ O provided 79.31% sensitivity and 67.80% specificity (area under the ROC curve: 0.73) for UUTD development. From univariable analysis, low compliance (cutoff values at <12.5 and <20 ml/cm H₂ O) and a storage pressure ≥15 cm H₂ O was related to UUTD with statistical significance (risk ratio [RR]: 3.16, 2.3, and 3.6, respectively [p < 0.05]). After performing multivariable analysis, a storage pressure ≥15 cm H₂ O and both cutoff values for low compliance were related to UUTD with statistical significance (RR: 3.9, 2.4, and 3.2, respectively [p < 0.05]). However, other factors, including male sex, spontaneous voiding, suprasacral lesion, DSD, and DO, were not related to UUTD.

CONCLUSION

Our results demonstrated that low compliance and a storage pressure ≥15 cm H₂ O were significantly associated with UUTD. Various bladder-management strategies have been developed to prevent UUTDs. However, the main concept continues to be the maintenance of a low storage pressure.

Clinical utility of the maximum area of detrusor tracing measurement in the urodynamic studies in pediatric population diagnosed with neuropathic bladder: A pilot study

INTRODUCTION

Neuropathic bladder (NB) is a lower urinary tract dysfunction (LUTD) that may lead to kidney failure. Urodynamic study is the gold standard for its diagnosis and follow-up. A classic prognostic parameter to predict the risk of upper urinary tract damage (UUTD) is the detrusor leak point pressure (DLPP) ≥  40 cmH2O, although this factor alone may lack prognostic value. The area under the curve (AUC) of the detrusor pressure tracing has been recently described as a prognostic factor.

AIM

To analyze the clinical utility of the AUC of the detrusor pressure tracing in the pediatric population (<15 years).

METHODS

Retrospective study of urodynamic recordings in pediatric population with NB from 2011 to 2020. The following variables were evaluated: detrusor leak point pressure ≥ 40 cmH2O, voiding dysfunction, bladder compliance and overactivity. The sample is classified according to clinical-radiological findings at the time of the UD. AUC is calculated using Newton-Cotes rules (trapezium, Simpson's rule) and its indexes are calculated according to bladder capacity (TI: Trapezium Index, SI: Simpson Index). Statistical significance: P < .05.

RESULTS

Fifty-five recordings are analyzed. Unfavorable clinical condition was identified in 41.8% (n = 23) patients. Voiding dysfunction, low compliance and both indexes were associated with an unfavorable clinical condition (P < .05). ROC analysis showed the following AUC for the new indexes: TI (0.736, P = 0.0006), SI (0.755, P = .0001) with a cut-off value of 10,69 and 8 cmH2O·s/cc, respectively. We did not find differences in the diagnostic performance between them (P > .05).

CONCLUSIONS

The analyzed indexes are useful in the diagnosis of patients with NB and unfavorable clinical condition.

Prospective Evaluation of Intradetrusor Injections of OnabotulinumtoxinA in Adults With Spinal Dysraphism

OBJECTIVE

To prospectively evaluate the effectiveness of OnabotulinumtoxinA (BTX-A) on neurogenic overactive bladder (nOAB) in adults with congenital spinal dysraphism (CSD).

METHODS

We conducted a prospective, nonrandomized pilot study of 24 adults with CSD and neurogenic overactive bladder. Patients were evaluated with baseline video-urodynamics (UDS) and validated questionnaires, underwent injection 200U BTX-A, and then underwent repeat evaluation with questionnaires and UDS 1-3 months postinjection. A high-risk subgroup was separately analyzed based on adverse clinical characteristics (ie, decrease bladder compliance, vesicoureteral reflux, hydronephrosis, chronic kidney disease).

RESULTS

BTX-A injection improved patient recorded outcome measures seen in both I-QOL Score total (67.9 vs 75.5, P = .007) and Neurogenic Bladder Symptom Score total (38.0 vs 29.0, P = .001). On UDS, BTX-A injection significantly improved end filling pressure (16.0 vs 8.8, P = .036) and also improved bladder compliance (mL/cm H2O) (89.38 vs 135.81, P = .445). High-risk patients were found to have similar improvements in most subjective questionnaire scoring, a significant decrease in end filling pressures, and improved bladder compliance on UDS.

CONCLUSION

BTX-A can be used as an effective treatment in adults with CSD. We found that BTX-A significantly improved quality of life from patient reported outcome measurements as well as improving end filling pressures and bladder compliance. These improvements were seen even within our high-risk subgroup. Further studies are needed to evaluate long-term efficacy and appropriate follow-up of this at-risk population.

Clinical Predictors of Neurogenic Lower Urinary Tract Dysfunction in Persons with Multiple Sclerosis

Background: Multiple sclerosis patients often develop neurogenic lower urinary tract dysfunction with a potential risk of upper urinary tract damage. Diagnostic tools are urodynamics, bladder diary, uroflowmetry, and post-void residual, but recommendations for their use are controversial. Objective: We aimed to identify clinical parameters indicative of neurogenic lower urinary tract dysfunction in multiple sclerosis patients. Methods: 207 patients were prospectively assessed independent of the presence of lower urinary tract symptoms. We analyzed Expanded Disability Status Scale scores, uroflowmetry, post-void residual, rate of urinary tract infections, standardized voiding frequency, and voided volume in correlation with urodynamic findings. Results: We found a significant correlation between post-void residual (odds ratio (OR) 4.17, confidence interval (CI) 1.20–22.46), urinary tract infection rate (OR 3.91, CI 1.13–21.0), voided volume (OR 4.53, CI 1.85–11.99), increased standardized voiding frequency (OR 7.40, CI 2.15–39.66), and urodynamic findings indicative of neurogenic lower urinary tract dysfunction. Expanded Disability Status Scale shows no correlation. Those parameters (except post-void residual) are also associated with reduced bladder compliance, as potential risk for kidney damage. Conclusion: Therefore, bladder diary and urinary tract infection rate should be routinely assessed to identify patients who require urodynamics.

Upper urinary tract function of patients with multiple sclerosis

BACKGROUND

Neurogenic lower urinary tract dysfunction (NLUTD) is frequent in multiple sclerosis (MS) and renal prognosis is a key point of bladder management.

OBJECTIVE

To assess upper urinary tract damage risk using voiding cystourethrography (VCUG) in patients with (PwMS) and NLUTD.

METHODS

We conducted a retrospective study between 2010 and 2020. Demographic data, urinary symptoms, urinary tract infection (UTI), renal ultrasounds findings, glomerular filtration rate (GFR), VCUG data, and urodynamic parameters were collected in PwMS with NLUTD.

RESULTS

Among 325 PwMS included, 67% were female, mean age was 51.6 ± 12.0 years, and mean EDSS 4.6 ± 1.8. VCUG showed vesicoureteral reflux (VUR) in 18 patients. A link was found between VUR and progressive MS course (p = 0.04), hydronephrosis (odds ratio [OR] = 17.44; 95% confidence interval [CI] = 3.46-87.87; p = 0.001), low GFR (p < 0.001), and detrusor overactivity (p = 0.04). No association with UTIs, EDSS, detrusor sphincter dyssynergia, were elicited. On multivariate analysis, alteration of GFR was independently related to the presence of VUR (OR = 0.95; 95% CI = 0.92-0.98).

CONCLUSIONS

VUR elicited on VCUG is associated with lower GFR and hydronephrosis. However, due to the low prevalence (5.5%) of this abnormality in PwMS, VCUG should be performed in selected cases and not in routinary practice.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Prioritization of risk situations in neuro-urology: guidelines from Association Française d'Urologie (AFU), Association Francophone Internationale des Groupes d'Animation de la Paraplégie (A.F.I.G.A.P.), Groupe de Neuro-urologie de Langue Française (GENULF), Société Française de Médecine Physique et de Réadaptation (SOFMER) and Société Interdisciplinaire Francophone d'UroDynamique et de Pelvi-Périnéologie (SIFUD-PP)

Purpose

The current health crisis has drastically impacted patient management in many fields, including neuro-urology, leading to a mandatory reorganization. The aim of this work was to establish guidelines regarding the prioritization and optimal timing of each step of neurogenic lower urinary tract dysfunction management.

Methods

A steering committee included urologists and physical medicine and rehabilitation practitioners. Based on a literature review and their own expertise, they established a comprehensive risk-situation list and built a risk scale, allowing multiple other experts to score each clinical situation. New recommendations were generated using a Delphi process approach.

Results

Forty-nine experts participated in the rating group. Among the 206 initial items, 163 were selected and divided into four domains, diagnosis and assessment, treatment, follow-up, and complications, and two sub-domains, general (applicable for all neurological conditions) and condition-specific [varying according to the neurological condition (spinal cord injury, multiple sclerosis, brain injury, Parkinsonism, dysraphism, lower motor neuron lesions)]. The resulted guidelines are expert opinions established by a panel of French-speaking specialists, which could limit the scalability of this work.

Conclusions

The present multidisciplinary collaborative work generates recommendations which complement existing guidelines and help clinicians to reorganize their patients’ list in the long term with a personalized medicine approach, in the context of health crisis or not.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03804-4.

The Stockholm Spinal Cord Uro Study: 3. Urodynamic characteristics in a regional prevalence group of persons with spinal cord injury and indications for improved follow-up

AIMS

Examine the outcome of urodynamic studies in a regional prevalence group of patients with traumatic spinal cord injury (SCI), explore relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions, assess the role of urodynamics in SCI follow-up.

METHODS

In a cross-sectional study, 211 patients were included, who attended a yearly check-up and had urodynamics performed as part of the follow-up in addition to S-creatinine, S-cystatin-C, renal ultrasound, and a questionnaire regarding complications. Relationships between urodynamic parameters and renal complications/other SCI-related dysfunctions were explored by descriptive and comparative statistics.

RESULTS

Neurogenic detrusor overactivity (NDO) was found in 150, underactive/acontractile detrusor in 44, normal detrusor function in 17 patients. Maximum detrusor pressures during filling/voiding in NDO attained mean levels of >40 cm H₂O in 68% of patients and >25 cm H₂O in 83%. Reduced compliance of the bladder wall, cystometric bladder capacity <250 mL, and detrusor overactivity leakage during filling were associated with higher detrusor pressures. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications among patients with SCI duration 11-20 years. No significant relationships were found between other urodynamic parameters and renal/other SCI-related complications. Renal complications in underactive/acontractile and normal detrusor function co-varied with evidence of previous NDO and other co-morbidities which may negatively influence kidney function.

CONCLUSIONS

Maximum detrusor pressures during the filling/voiding phases attained high levels in a majority of patients. Detrusor overactivity during more than one-third of the filling phase was significantly related to signs of renal complications.

Tradução para a língua portuguesa do artigo original em inglês “ The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction”

Introdução

No desenvolvimento da terminologia do trato urinário inferior, devido à sua crescente complexidade, a terminologia para os sintomas e a disfunção do trato urinário inferior masculino e assoalho pélvico precisa ser atualizada, utilizando abordagem específica masculina e por meio de um relatório de consenso clinicamente embasado.

Métodos

Este relatório combina a contribuição de membros do Standardisation Committee da International Continence Society em um Grupo de Trabalho com especialistas reconhecidos no campo, assistido por muitos julgadores externos. Categorias clínicas centrais apropriadas e uma subclassificação foram desenvolvidas para fornecer uma codificação numérica para cada definição. Um extenso processo de 22 rodadas de revisão interna e externa foi desenvolvido para examinar exaustivamente cada definição, com tomada de decisão por opinião coletiva (consenso).

Resultados

Um relatório de terminologia para os sintomas e a disfunção do trato urinário inferior e do assoalho pélvico foi desenvolvido, abrangendo cerca de 390 definições/descritores separados. É clinicamente embasado nos diagnósticos mais comuns definidos. A clareza e a facilidade de uso foram os principais objetivos para torná-lo interpretável por profissionais e estagiários em todos os diferentes grupos de especialidades envolvidos na disfunção do trato urinário inferior e do assoalho pélvico masculino. Imagens específicas para homens (ultrassonografia, radiologia, tomografia computadorizada e ressonância magnética) foram um adicional importante, enquanto figuras apropriadas foram incluídas para complementar e ajudar a esclarecer o texto.

Conclusões

Um relatório de terminologia com base em consenso para sintomas e disfunção do trato urinário inferior e do assoalho pélvico masculino foi produzido visando ser um auxílio significativo para a prática clínica e um estímulo para a pesquisa.

Diagnostic Test Characteristics of Ultrasound Based Hydronephrosis in Identifying Low Kidney Function in Young Patients with Spina Bifida: A Retrospective Cohort Study

PURPOSE

Kidney dysfunction in spina bifida is usually detected by low estimated glomerular filtration rate or ultrasound based hydronephrosis. We assessed the diagnostic test characteristics of hydronephrosis for detecting low estimated glomerular filtration rate, hypothesizing that hydronephrosis has low sensitivity compared to cystatin C based estimated glomerular filtration rate.

MATERIALS AND METHODS

We conducted a single center, retrospective cohort study, including patients with spina bifida from 2012-2017 with 2 kidneys and complete data needed to calculate estimated glomerular filtration rate via multiple pediatric (age 1-17.9 years) or adult (age ≥18 years) estimating equations. We evaluated the association of hydronephrosis status (high grade, low grade or none) with estimated glomerular filtration rate, adjusting for small kidney size and scarring, and calculated diagnostic test characteristics of hydronephrosis for low estimated glomerular filtration rate.

RESULTS

We analyzed 247 patients (176 children and 71 adults). Mean±SD age was 13.7±6.6 years, and 81% of patients had myelomeningocele. Hydronephrosis (77% low grade) was found in 35/176 children and 18/71 adults. Hydronephrosis was associated with low estimated glomerular filtration rate in stepwise fashion, independent of kidney size and scarring. However, across cystatin C based pediatric equations, any hydronephrosis (compared to none) had 23%-48% sensitivity, and high grade hydronephrosis (compared to none or low grade) had 4%-15% sensitivity for estimated glomerular filtration rate <90 ml/min/1.73 m2, which remained unchanged after excluding small kidneys and scarring. Across cystatin C based adult equations, any and high grade hydronephrosis had 55%-75% and 40%-100% sensitivity, respectively, for estimated glomerular filtration rate <90 ml/min/1.73 m2, although with wide confidence intervals. Specificity was higher with high grade vs any hydronephrosis. Sensitivities were higher for estimated glomerular filtration rate <60 ml/min/1.73 m2.

CONCLUSIONS

Hydronephrosis was associated with low estimated glomerular filtration rate but had poor sensitivity for cystatin C based estimated glomerular filtration rate <90 ml/min/1.73 m2, especially among children with spina bifida.

Urodynamic utilization in the adult spina bifida patient: An institutional review

PURPOSE

To characterize common clinical indications for urodynamic, a bladder function test, in adults with spina bifida.

METHODS

A retrospective chart review was performed for 215 patients seen in an adult multidisciplinary spina bifida clinic who were registered with the National Spina Bifida Patient Registry from October 2011 to October 2018. Descriptive statistics were used for statistical comparisons.

RESULTS

A total of 52 of 215 patients developed a clinical indication for urodynamics. Of these, 71 (33%) patients (8 of whom underwent testing twice) had urodynamics performed, resulting in a total of 79 urodynamic study encounters that were analyzed. Thirty-four (43%) urodynamic testing cases were performed due to a symptomatic change in lower urinary tract function; 14 (18%) were due to declining renal function or concern for upper tract deterioration based on imaging. The data obtained from urodynamic investigation led to new recommendations for urinary tract management in 59 (75%) of the urodynamic studies performed. A total of 32 of the 90 (35%) recommendations made were surgical interventions and 30 (33%) were for a change in medical management. Interestingly, 8 of the 18 (44%) routine or baseline urodynamic tests performed led to new recommendations in urinary tract management.

CONCLUSION

A total of 24%of patients in the multidisciplinary spina bifida clinic developed an indication for urodynamic testing over a 7-year period which resulted in new recommendations for urinary tract management in most. As more patients with spina bifida enter adulthood, the indications for urodynamic evaluation may become more defined, since the results often lead to alterations in bladder management.

Incidence and predictive factors for developing vesicoureteric reflux in individuals with suprasarcral spinal cord injury: a historical cohort study

STUDY DESIGN

A historical cohort study OBJECTIVES: The aim of the study was to examine the incidence of and predictive factors for VUR in individuals with suprasacral spinal cord injury (SCI).

SETTING

Srinagarind Hospital, Khon Kaen University, Thailand METHODS: Medical records were reviewed for all individuals with SCI and neurogenic bladder admitted for urological check-up between 1996 and 2016. The primary outcome was the cumulative incidence of VUR. The statistical tests used included the Nelson-Aalen Estimator and Cox Proportional Hazard Ratio. Harrell's C concordance statistic was used to evaluate the discrimination ability of the predictive model.

RESULTS

293 participants with SCI (102 tetraplegic and 191 paraplegic) were included. Most participants were male (67%), and the median age was 52 years. The overall incidence of VUR was 7.5 cases per 100 person-years (95% CI, 6.15-9.4). In the multivariate analysis, the predictive factors for VUR were: (1) maximum detrusor pressure at first visit ≥ 75 cm of water (HR_adj: 2.4 [95% CI: 1.4-4.1]); (2) indwelling urethral catheterization (IUC) (HR_adj: 11.1 [95% CI: 3.9-31.7]) and clean intermittent catheterization (CIC) (HR_adj: 6.5 [95% CI: 2.2-18.7]); (3) age ≥ 60 years at onset of SCI (HR_adj: 1.7 [95% CI: 1.1-2.8]); and, (4) absence of antimuscarinic medication (HR_adj: 3.8 [95% CI: 2.4-6.1]). The predictive model had an overall C-index of 0.78.

CONCLUSIONS

The incidence of VUR was high up to 12 years after SCI. High maximum detrusor pressure, IUC, age ≥ 60 years and absence of antimuscarinic medication were predictive factors for VUR.

Robustness of focused and global impedance estimates of bladder volumes against uncertainty of urine conductivity

Bioimpedance measurements are currently used to monitor various biological processes and are potentially useful for studies of urodynamics. Global impedance (GI) and focused impedance measurements (FIM) can be used to monitor bladder volumes, but these are subject to varying conductivity of urine. To address this, we emulated a human bladder using an agar phantom filled with saline solutions of varying conductivities and estimated volumes using a modified FIM-based approach. Using this novel strategy, electrical potentials did not change significantly with constant liquid volumes, even when the conductivity of the saline solutions was varied between 1.027 to 1.877 and 2.610 S/m. Conversely, GI and classic FIM measurements of constant liquid volumes varied with conductivity. These observations suggest that the proposed FIM approach is suitable for bladder volume estimation due to its robustness against uncertainties of conductivity. The bioimpedance hardware used in our experiments comprised 8 electrodes and a a small and low cost impedance measurement system based on an AFE4300 direct impedance measurement device.

Urinary Symptoms and Bladder Dysfunction in Patients with Neuromyelitis Optica Spectrum Disorders: Evaluation with Urodynamics and Management

Objective  To assess lower urinary tract symptoms (LUTSs) in patients with neuromyelitis optica spectrum disorders (NMOSDs) and bladder dysfunction through urodynamics (filling and voiding phase of cystometrography) and management based on findings.

Patients and Methods  The study included 42 (34 females) patients admitted to the rehabilitation department. Neurologic evaluation was performed and severity of myelitis was assessed using the American Spinal Injury Association Impairment Scale. All patients underwent urodynamics, and management was based on the findings.

Results  Mean age was 34.5 years (range: 11–64 years; standard deviation: 13.1). Twenty-three (54.8%) patients had a first episode of myelitis, whereas 19 patients had relapses (number of episodes varying from 2 to 7). Eleven (26%) patients had increased frequency, 16 (37%) had urgency, 12 (28%) had urge incontinence, 8 (18.6%) had stress incontinence, 22 (52.4%) had nocturia, 31 (72%) had retention of urine, 22 (52.4%) had incomplete evacuation, and 14 (33.3%) patients had mixed urinary complaints. The common urodynamic findings were neurogenic detrusor overactivity (NDO) with detrusor-sphincter dyssynergia (DSD) in 14 (33.3%) patients, NDO without DSD in 8 (19%), and acontractile detrusor in 20 (47.6%). Pharmacotherapy was advised to 22 (52.4%) patients, whereas clean intermittent catheterization (CIC)/self-catheterization was advised to 39 (92.9%) patients.

Conclusions  Urinary retention was observed to be the most common urinary complaint in patients with NMOSD followed by NDO with or without sphincter dyssynergia. Urodynamics should be performed in all patients with LUTSs for best management. CIC remains the gold standard for the management of neurogenic bladder dysfunction.

Wireless intravesical device for real-time bladder pressure measurement: Study of consecutive voiding in awake minipigs

Traditional urodynamics have poor correlation with urological symptoms. Ambulatory urodynamics may improve this correlation but the need for a transurethral catheter and the time-consuming nature of this examination limits its use. Therefore, the objective of this study was to develop a wireless real-time bladder pressure measurement device for repeated and prolonged-term measurement of bladder behavior in awake pigs. The Bladder Pill is an intravesical device with a pressure microsensor and a 3-dimensional inductive coupling coil for energy supply. A corresponding external coil provides wireless power transmission and real-time communication of bladder pressure data. To test the correlation between the pressure data measured by the device and by standard methods, we compared static water column pressures with this device and water-filled urodynamic catheter systems. In vivo assessment of awake voiding by the pill was done by introducing the bladder pill into the bladder of Göttingen minipigs. An air-charged urodynamic catheter was introduced transurethrally as control for pressure measurements. The optimal physical configuration of the pill was investigated to maximize the containment in the bladder. We used two versions of external signal receivers (one waistband and one rectangular frame) to test the optimal external signal capture. Next to that, we performed short-term and medium-term comparative pressure studies. The in vitro static pressure measurement demonstrated a mean difference of less than 1 cm H₂O between the methods. The optimal design of the pill for maximal retainment in the bladder proved to be a pigtail configuration. The bending of the device during bladder contractions caused offset of 2.7 +/- 1.4 cm H₂O (mean +/- SD) on the pressure measurements. The rectangular frame performed signal capture during 5 consecutive voids with a good correlation of the pressure measurements. The device can be inserted through the urethra and is retrieved using string or endoscopic extraction. In conclusion, wireless long-term measurement of bladder pressure is demonstrated and yields comparable results to current available catheter methods of measurement in a pig model.

Detrusor overactivity is missed by stopping urodynamic investigation at a bladder volume of 500 mL

OBJECTIVES

To investigate whether detrusor overactivity (DO) is missed in a relevant percentage of patients if the urodynamic investigation (UDI) is stopped at a filling volume of 500 mL due to the fear of bladder overdistention, in patients with lower urinary tract symptoms and high bladder capacity.

PATIENTS AND METHODS

A consecutive series of 1598 patients with a bladder capacity of >500 mL in the bladder diary undergoing UDI due to lower urinary tract dysfunction (LUTD) was prospectively investigated. UDI was performed according to Good Urodynamic Practices recommended by the International Continence Society. UDI was stopped at strong desire to void or in case of autonomic dysreflexia, vesico-uretero-renal reflux, bladder pain or discomfort.

RESULTS

Of the 1598 patients (594 women, 1004 men), 1282 (80%) and 316 (20%) had neurogenic and non-neurogenic LUTD, respectively. Overall, DO was detected in 66% (1048/1598), in 71% (910/1282) with neurogenic and in 44% (138/316) with non-neurogenic LUTD. DO occurred in 16% (263/1598, 95% confidence interval [CI] 14.7-18.4%) only at a bladder volume >500 mL. This phenomenon was significantly (P < 0.001) more frequent in patients with neurogenic (18% [236/1282], 95% CI 16.4-20.6%) compared with non-neurogenic (9% [27/316], 95% CI 5.9-12.1%) LUTD.

CONCLUSIONS

In both neurological and non-neurological patients with high bladder capacity, we strongly recommend not to stop UDI at a bladder volume of 500 mL, as DO might be missed in a relevant percentage leading to inappropriate patient treatment.

The role of urodynamics in females with lower urinary tract symptoms

Objective: To review the role of urodynamic studies (UDS) in females with lower urinary tract symptoms (LUTS), as LUT dysfunction is a common condition. The role of UDS was and continues to be vital in the assessment of such cases; however, utilisation is still debated amongst clinicians as to when and in which conditions it should be used.

Materials and methods: We conducted a literature review using the Medical Literature Analysis and Retrieval System Online (MEDLINE) search engine from year 1990 until August 2018, using the keywords: ‘female urology’, ‘lower urinary tract symptoms’, ‘urodynamic’, ‘incontinence’, ‘overactive bladder’, ‘bladder outlet obstruction’. We also reviewed the latest international guidelines related to the subject including: the International Consultation of Incontinence, American Urological Association, European Urology Association, and International Continence Society.

Results: Using >60 reference articles and international guidelines, our review showed that there is a trend of utilisation of UDS in females with LUTS.

Conclusion: UDS remains a valuable diagnostic test, which provides vital information to both the surgeon and patient prior to invasive treatment, with minimal morbidity.

Abbreviations: DO: detrusor overactivity; LUT(D): lower urinary tract (dysfunction); NLUTD: neurogenic LUTD; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; Q_max: maximum urinary flow rate; UDS: urodynamic studies; (M)(S)(U)UI: (mixed) (stress) (urgency) urinary incontinence

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction

INTRODUCTION

In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

RESULTS

A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text.

CONCLUSIONS

A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Similarity of functional connectivity patterns in patients with multiple sclerosis who void spontaneously versus patients with voiding dysfunction

AIM

To investigate if Multiple Sclerosis (MS) lesion characteristics affect functional brain connectivity (FC) during bladder voiding.

METHODS

Twenty-seven ambulatory female patients with MS completed our functional magnetic resonance imaging (fMRI)/urodynamic testing (UDS) platform. Individual fMRI activation maps were generated at initiation of voiding. FC patterns of these regions were calculated and compared. Similarity of the FC pattern from one patient relative to all others was expressed by a parameter FC_sim. A statistical analysis was performed to reveal the relationship of the existence of an enhancing brain lesion, the size of the largest lesion and the ability to void spontaneously to this FC similarity measure.

RESULTS

FC_sim values were significantly lower for patients with an enhancing MS lesion (11.7 ± 3.1 vs 5.3 ± 2.1 P < 0.001). Lesion size smaller than 20 mm inversely correlated significantly with FC_sim (R = -0.43, P = 0.05). Patients with the ability to void spontaneously had a higher FC_sim value (12.0 ± 2.8 vs 9.3 ± 4.4 s, P = 0.08). Patients that exhibited a decrease of compliance also showed a significantly lower FC_sim value (11.3 ± 3.5 vs 4.7 ± 0.7, P < 1e-5).

CONCLUSION

FC connectivity analysis derived from an fMRI task-based study including repetitive voiding cycles is able to quantify the heterogeneity of connectivity patterns in the brain of MS patients. FC similarity decreased with maximum lesion size or the presence of enhancing lesions affecting the ability to void spontaneously.

Urodynamics Useless in Female Stress Urinary Incontinence? Time for Some Sense-A European Expert Consensus

BACKGROUND

Routine use of urodynamics (UDS) for the assessment of female stress urinary incontinence (SUI) appears to be in decline across Europe. The reasons for this trend appear multifactorial, but the implications are of significant concern.

OBJECTIVES

To achieve an expert consensus viewpoint on the value of UDS in female SUI and current barriers to its use.

METHODOLOGY

A multidisciplinary group of UDS experts from six European countries was convened, and a modified version of the Delphi method was utilised to reach a consensus viewpoint structured around five key questions.

RESULTS

Consensus was achieved on all five questions. The group was unanimous that the decline in routine use of UDS is unjustified and misguided, driven by restrictions in funding and accelerated by the publication-and subsequent influence-of two trials that had major limitations.

LIMITATIONS

The authors comprised a selected group of UDS experts and the analysis is not a formal systematic review.

CONCLUSIONS

Extensive experience and observational studies have demonstrated the value of UDS for the assessment of female SUI and the dangers of empiric management. This evidence base should not be eclipsed by the findings of two randomised controlled trials that had numerous shortcomings.

PATIENT SUMMARY

A group of experts were worried that, even though the cause of incontinence varies, doctors seem to be skipping a diagnostic test called urodynamics (UDS) in some patients and just providing treatment-even surgery-without knowing exactly what is wrong. These experts analysed the situation in detail and reached agreement that UDS testing should not be skipped.

Intradetrusor Injections of Botulinum Toxin A in Adults with Spinal Dysraphism

PURPOSE

The aim of the current study was to determine the outcomes of botulinum toxin A intradetrusor injections in adult patients with spina bifida.

MATERIALS AND METHODS

All patients with spinal dysraphism who underwent intradetrusor injections of botulinum toxin A from 2002 to 2016 at a total of 14 centers were retrospectively included in analysis. The primary end point was the global success of injections, defined subjectively as the combination of urgency, urinary incontinence and detrusor overactivity/low bladder compliance resolution. Univariate and multivariate analysis was performed to seek predictors of global success.

RESULTS

A total of 125 patients were included in study. The global success rate of the first injection was 62.3% with resolution of urinary incontinence in 73.5% of patients. All urodynamic parameters had improved significantly by 6 to 8 weeks compared to baseline, including maximum detrusor pressure (-12 cm H₂O, p <0.001), maximum cystometric capacity (86.6 ml, p <0.001) and compliance (8.9 ml/cm H₂O, p = 0.002). A total of 20 complications (3.6%) were recorded for the 561 intradetrusor botulinum toxin A injections, including 3 muscular weakness complications. The global success rate of the first injection was significantly lower in patients with poor compliance (34.4% vs 86.9%, OR 0.08, p <0.001). On multivariate analysis poor compliance was associated with a lower global success rate (OR 0.13, p <0.001). Female gender (OR 3.53, p = 0.01) and patient age (OR 39.9, p <0.001) were predictors of global success.

CONCLUSIONS

Intradetrusor botulinum toxin A injections were effective in adult patients with spina bifida who had detrusor overactivity. In contrast, effectiveness was much lower in adult patients with spina bifida who had poor bladder compliance. The other predictors of global success were female gender and older age.