Primary cause and treatment of recurrent urinary infection in women: preliminary report

Pyelovesicostomy as an Alternative Surgical Treatment for Complex Ureteral Lesions After Kidney Transplant

OBJECTIVES

We evaluated the feasibility, safety, and long-term outcomes of pyelovesicostomy as an alternative surgical treatment for complex ureteral lesions after kidney transplant.

MATERIALS AND METHODS

A single-center, retrospective, observational cohort study was conducted on 5 adult kidney transplant recipients who underwent pyelovesicostomy between January 2000 and June 2023. The collected data included patient demographics, surgery indication, time from transplant to pyelovesicostomy, procedure details, and kidney function at various time points after surgery. Primary outcomes were allograft function and complications.

RESULTS

The 5 patients (4 female, 1 male) had a mean age of 65.8 years and mean body mass index of 26.8. Indications were complex ureteral lesions. The time between transplant and reoperation ranged from 4 days to 12 years. Renal function improved for all patients, with a progressive decrease in mean serum creatinine concentration. The mean follow-up period extended to 7 years. One patient died with the graft still functional at 20 years after the operation, whereas the remaining 4 patients continue to live with functional grafts.

CONCLUSIONS

Our study suggests that pyelovesicostomy may provide a potent alternative for the management of complex ureteral lesions after kidney transplant. We have observed good short-term and long-term outcomes in specific patients, pointing toward a promising avenue oftreatment worth further exploration. This reaffirms the importance of a personalized approach in medicine, to consider each patient's unique conditions and characteristics during therapeutic decisions.

Urinary Incontinence

Until recently, the impact of urinary incontinence (UI) on working women, a population generally characterized as healthy, has not been the focus of research. Women employed full time at a large university center participated in a cross sectional survey about UI. Of the 1,113 women surveyed, age 18 and older, 21 % (n = 232) reported UI at least monthly. Incontinent women were significantly older and had a higher body mass index than continent women. Using disposable products, limiting fluids, avoiding caffeinated beverages, using voiding schedules, and keeping extra clothes or underwear were strategies used to manage UI at work. Responses to an open ended question related to the impact of UI on working life included: interference with sleep and resulting fatigue at work, embarrassment, alteration of concentration, and emotional distress. Implications for nurses are discussed in relation to assessment, education, and management of UI in the occupational setting.

Mild dehydration: a risk factor of urinary tract infection?

Bacterial growth in the urinary tract is usually prevented by host factors including bacterial eradication by urinary and mucus flow, urothelial bactericidal activity, urinary secretory IgA, and blood group antigens in secretions which interfere with bacterial adherence. Bacterial eradication from the urinary tract is partially dependent on urine flow and voiding frequency. Therefore, it seems logical to postulate a connection between fluid intake and the risk of urinary tract infections (UTIs). However, experimental and clinical data on this subject are conflicting. Experimental studies concerning the effect of water intake on susceptibility and course of UTIs were predominantly performed in the 60s and 70s. Despite many open questions, there has been no continuous research in this field. Only few clinical studies producing contradictory results are available on the influence of fluid intake concerning the risk of UTI. One explanation for the inconsistency between the data might be the uncertainty about the exact amounts of fluid intake, which was mostly recorded in questionnaires. So far, there is no definitive evidence that the susceptibility for UTI is dependent on fluid intake. Nevertheless, adequate hydration is important and may improve the results of antimicrobial therapy in UTI. Results of experimental and clinical studies concerning urinary hydrodynamics are the basis for advice given by expert committees to patients with UTI to drink large volumes of fluid, void frequently, and completely empty the bladder. The combination of the behaviourally determined aspects of host defence and not simply increasing fluid intake is important in therapy and prophylaxis of UTI.

Thirst at work--an occupational hazard?

Of 1492 teachers 791 (53%) responded to a survey addressing whether voiding habits at work or behavioral factors influenced by this occupation predisposed women to urinary tract infection. The mean number of voids during the work day was 2.7 +/- 1.4; 24.5% voided infrequently (never or only once) and 26.5% voided four or more times during the work day; 15.8% had had a urinary tract infection in the preceding year. Half of the respondents made a conscious effort to drink less while working, to avoid needing to use the toilet. There was no association between the prevalence of urinary tract infection and the number of voids or infrequent voiding at work. Compared to women who drank the volume they desired at work, those who drank less had a 2.21-fold higher risk (95% CI 1.45-3.38) of urinary tract infection after controlling for being parous, voiding infrequently at work, and urge incontinence. Further study is warranted to determine whether modification of behavioral factors at work can reduce the incidence of urinary tract infections. If this association holds, public policy must be changed to allow workers more adequate access to toilet facilities.

Vesicopyeloplasty in renal transplant patients: a 20-year followup

Loss of a ureter in a renal transplant patient often results in transplant nephrectomy. In 1973 we used vesicopyelostomy with the bladder directly sutured to the renal pelvis as a method of reconstruction in 2 renal transplant patients following ureteral loss. These patients have been followed for more than 20 years and both renal allografts have functioned well. The status of these patients and a review of the literature on vesicopyelostomy are presented.

"Timed voiding"--a useful tool in the treatment of urinary incontinence

Female patients need more privacy for micturition and are, therefore, more prone to suppress the normal micturition reflex. Due to postponed micturition, their bladders are usually full and during stress conditions urinary incontinence does occur. In 20 patients who had functional stress incontinence, the urologic and urodynamic evaluation was performed. When no major structural deformities were found, the timed voiding was taught to the patients. In 79 per cent of patients the urinary incontinence was cured by timed voiding only. Some of the patients who had positive urinary cultures became sterile following the new voiding patterns. The possible neurophysiologic mechanisms of timed voiding are discussed.

Fate of patients started on clean intermittent self-catheterization therapy 10 years ago

We evaluated 60 patients placed on a clean intermittent catheterization program more than 10 years ago to determine their outcome. To date 27 patients still are performing self-catheterization, 18 have discontinued the procedure and 15 have been lost to followup. No patient has had deterioration in renal function. Prior incontinence was alleviated completely in 10 of the 27 patients still on the program and 10 of the 18 patients no longer on catheterization have returned to normal voiding. Clean intermittent catheterization is an effective treatment modality in properly selected patients, with few complications and excellent long-term results.

Cystometry in upright position: accurate identification of decompensated bladder

Cystometrograms obtained in the physiologic erect position have been found to picture accurately the classic decompensated bladder in women with recurrent urinary tract infections. The standard supine cystometrogram, however, may be inaccurate or normal in females with a history of infrequent voiding and prolonged vesical overdistention.

Transurethral treatment of urethral diverticula in women

Six women with urethral diverticulitis and a history of having had previous operations for diverticula were subjected to transurethral diverticulotomy with a knife electrode. Each patient had multiple diverticula, some compartmented, located in the mid or most proximal segments of the urethra. All patients have been relieved of the symptoms and infection during the postoperative period, varying from 1 1/2 to 7 years.

Cystourethritis

We believe this review lists the major factors and mechanisms considered responsible for producing cystourethritis. Knowledge of these factors and mechanisms is essential before effective investigation of this disease can be undertaken. We suggest a rational scheme for investigation of these patients. We believe successful treatment depends on establishing the probable cause in each individual patient. In view of the multifactorial etiology of the disease, attempts to find a single effective medical or surgical therapy will be doomed to failure.

The influence of bladder fullness on upper urinary tract dimensions and renal excretory function

Nearly full bladders (375 ml.) produced significantly greater dimensions of the renal calices, pelves and ureters on excretory urograms compared to nearly empty bladders. These dimensions were frequently to the point of being considered pathological dilatations. On planimetry the urographic areas of the pelviocaliceal systems decreased by 43 per cent on the right side and 38 per cent on the left side when the nearly full bladder was compared to the nearly empty bladder in 10 patients. Renal excretory function also was affected by nearly full bladders. Urea clearances after 1 hour were 24 per cent lower and creatinine clearances were 9 per cent lower when starting with a nearly full bladder as compared to starting with an empty bladder. The implications of these findings are of potential significance with respect to 1) interpretation of excretory urograms and 2) chronic urine holding in patients with recurrent urinary tract infections, impaired renal function and/or urolithiasis.

Altered bladder function in staghorn calculus disease

Disorders of the lower urinary tract that predispose to urinary infection were identified in 69 per cent of 62 patients with branched renal calculi. Within an average followup of 6.3 years control of these disorders was observed to reduce the rate of reinfection and the frequency of complications after operative stone removal.

Studies of enuresis. VIII. Detrusor and sphincter instability caused by overactivity of integral voiding reflexes

Ninety-one children with nocturnal enuresis or enuresis plus daytime urgency incontinence were studied by cystometry. Seventy-two per cent of the girls and 62 per cent of the boys had evidence of bladder instability. Sixty-eight children in whom abnormalities were found on preliminary voiding urodynamics or voiding cystourethrography also underwent calibration and endoscopic examination under anesthesia. An atropine-suppression test was also performed preoperatively in some children with a markedly unstable bladder demonstrated on preoperative cystometry. In the majority of children tested suppression of bladder instability with atropine was demonstrable. Voluntary detrusor sphincter dyssynergia was demonstrated in a majority of the children with daytime urgency incontinence. Sixty-five per cent of the boys and 81 per cent of the girls were treated for urethral obstructive lesions suspected to be of functional urodynamic significance. Postoperative cystometry showed marked improvement in bladder stability in 57 per cent of the girls and 63 per cent of the boys treated for suspected urethral obstructive pathology. The anticholinergic suppression test was found to have no significant predictive value relative to the cause or surgical curability of bladder instability. The pathophysiologic significance of overactivity of integral voiding reflexes 6 through 11 is described.

Integral storage and voiding reflexes. Neurophysiologic concept of continence and micturition

It is a common clinical misconception to regard the spinal micturition reflex center as fundamentally overactive and dependent on cerebral inhibition. Initiation and cessation of micturition is simplistically viewed as a manifestation of voluntary withdrawal and resumption of inhibitory corticospinal "regulation''. This view is in conflict with basic neurophysiologic experimental data. Actually, the organization of the micturition reflex is extremely complex. It is affected by multiple sources of facilitative and inhibitory influence, peripheral as well as central. During the past half century, at least twelve reflexes involved in urine storage and coordinated micturition have been described by various neurologic investigators. In this article the integral reflexes are identified and described. A functional organization of the integral reflexes which includes a modern concept of their role in the physiology of urine storage and micturition is presented. It is implicit that overactivity or functional failure of any one or combination of the integral reflexes may cause a significant disorder of lower urinary tract function.

Further observations on self-catheterization

A non-sterile technique of intermittent self-catheterization was used for 218 patients with an inability to void in a normal fashion because of obstructive uropathy, decompensated detrusor or neurogenic bladder. Marked improvement was noted in urinary continence, urinary infection, renal function, bladder emptying and, perhaps most important, the mental and emotional status of the patient and/or parents. The extremely low incidence of complications and its therapeutic efficacy clearly make clean, intermittent self-catheterization an outstanding weapon in the urological armamentarium and a most persuasive reminder that host resistance is still the primary factor in the occurrence of infection.