An individual participant meta-analysis of mirabegron in multiple sclerosis and spinal cord injury

INTRODUCTION

Our objective was to conduct an individual patient data meta-analysis (IPDMA) of the two published randomized placebo-controlled trials of mirabegron in people with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) or multiple sclerosis (MS).

METHODS

We identified two randomized, placebo-controlled trials. We extracted individual patient data from the trials and evaluated two primary outcomes: change in maximum cystometric capacity and change in the patient perception of bladder condition (PPBC). We also evaluated several secondary outcomes related to urodynamic function and quality of life. We conducted three exploratory analyses to test hypotheses based on our clinical experiences with mirabegron in NLUTD. Analysis of covariance with adjustment for baseline values was used for the statistical analysis.

RESULTS

Our IPDMA included 98 patients from the two trials. The results showed that mirabegron was associated with a significant improvement in maximum cystometric capacity (+41 mL, p = 0.04) and in the PPBC (-0.8, p < 0.01) compared to placebo. Secondary outcomes including peak neurogenic detrusor overactivity pressure (-20 cm H2O, p < 0.01), incontinence-QOL score (+12, p < 0.01), and 24 h pad weights (-79 g, p = 0.04) also improved significantly compared to placebo. Exploratory analyses found similar improvements in people with MS and SCI; some outcomes improved to a greater degree among people with incomplete SCI, or SCIs that were below T7.

CONCLUSIONS

Our IPDMA provides evidence supporting the use of mirabegron in patients with NLUTD due to SCI or MS. Further work evaluating differential responses in people with different SCI lesion characteristics may be warranted.

Brain Response Induced by Peroneal Electrical Transcutaneous Neuromodulation Invented for Overactive Bladder Treatment, as Detected by Functional Magnetic Resonance Imaging

OBJECTIVES

In this study, we aimed to investigate whether peroneal electrical Transcutaneous Neuromodulation invented for overactive bladder (OAB) treatment elicits activation in brain regions involved in neural regulation of the lower urinary tract.

MATERIALS AND METHODS

Among 22 enrolled healthy female volunteers, 13 were eligible for the final analysis. Functional magnetic resonance imaging (fMRI) (Siemens VIDA 3T; Erlangen, Germany) was used to compare the brain region activation elicited by peroneal electrical Transcutaneous Neuromodulation with the activation elicited by sham stimulation. Each subject underwent brain fMRI recording during eight 30-second periods of rest, alternating with 30-second periods of passive feet movement using the sham device, mimicking the motor response to peroneal nerve stimulation. Subsequently, fMRI recording was performed during the analogic "off-on" stimulation paradigm using peroneal electrical transcutaneous neuromodulation. Magnetic resonance imaging data acquired during both paradigms were compared using individual and group statistics.

RESULTS

During both peroneal electrical Transcutaneous Neuromodulation and sham feet movements, we observed activation of the primary motor cortex and supplementary motor area, corresponding to the cortical projection of lower limb movement. During peroneal electrical Transcutaneous Neuromodulation, we observed significant activations in the brain stem, cerebellum, cingulate gyrus, putamen, operculum, and anterior insula, which were not observed during the sham feet movement.

CONCLUSIONS

Our study provides evidence that peroneal electrical Transcutaneous Neuromodulation elicits activation of brain structures that have been previously implicated in the perception of bladder fullness and that play a role in the ability to cope with urinary urgency. Our data suggest that neuromodulation at the level of supraspinal control of the lower urinary tract may contribute to the treatment effect of peroneal electrical Transcutaneous Neuromodulation in patients with OAB.

Acquired haemophilia as a complicating factor in treatment of non-muscle invasive bladder cancer: A case report

BACKGROUND

Acquired haemophilia (AH) is a serious autoimmune haematological disease caused by the production of auto-antibodies against coagulation factor VIII. In some patients, AH is associated with a concomitant malignancy. In case of surgical intervention, AH poses a high risk of life-threatening bleeding.

CASE SUMMARY

A 60-year-old female patient with multiple recurrences of non-muscle invasive bladder cancer underwent transurethral tumour resection. A severe haematuria developed postoperatively warranting two endoscopic revisions; however, no clear source of bleeding was identified in the bladder. Subsequent haematological examination established a diagnosis of AH. Treatment with factor VIII inhibitor bypass activity and immunosuppressive therapy was initiated immediately. The patient responded well to the therapy and was discharged from the hospital 21 d after the primary surgery. At the 38-mo follow-up, both AH and bladder cancer remained in complete remission.

CONCLUSION

AH is a rare, life-threatening haematological disease. AH should be considered in patients with persistent severe haematuria or other bleeding symptoms, especially if combined with isolated activated partial thromboplastin time prolongation.

Acquired haemophilia as a complicating factor in treatment of non-muscle invasive bladder cancer: A case report

BACKGROUND

Acquired haemophilia (AH) is a serious autoimmune haematological disease caused by the production of auto-antibodies against coagulation factor VIII. In some patients, AH is associated with a concomitant malignancy. In case of surgical intervention, AH poses a high risk of life-threatening bleeding.

CASE SUMMARY

A 60-year-old female patient with multiple recurrences of non-muscle invasive bladder cancer underwent transurethral tumour resection. A severe haematuria developed postoperatively warranting two endoscopic revisions; however, no clear source of bleeding was identified in the bladder. Subsequent haematological examination established a diagnosis of AH. Treatment with factor VIII inhibitor bypass activity and immunosuppressive therapy was initiated immediately. The patient responded well to the therapy and was discharged from the hospital 21 d after the primary surgery. At the 38-mo follow-up, both AH and bladder cancer remained in complete remission.

CONCLUSION

AH is a rare, life-threatening haematological disease. AH should be considered in patients with persistent severe haematuria or other bleeding symptoms, especially if combined with isolated activated partial thromboplastin time prolongation.

Differences between brain responses to peroneal electrical transcutaneous neuromodulation and transcutaneous tibial nerve stimulation, two treatments for overactive bladder

OBJECTIVES

To compare brain responses to peroneal electrical transcutaneous neuromodulation (peroneal eTNM®) and transcutaneous tibial nerve stimulation (TTNS), two methods for treating overactive bladder (OAB), using functional magnetic resonance imaging (fMRI). The present study was not designed to compare their clinical efficacy.

MATERIALS AND METHODS

This study included 32 healthy adult female volunteers (average age 38.3 years (range 22-73)). Brain MRI using 3 T scanner was performed during three 8-min blocks of alternating sequences. During each 8-min block, the protocol alternated between sham stimulation (30 s) and rest (30 s) for 8 repeats; then peroneal eTNM® stimulation (30 s) and rest (30 s) for 8 repeats; then, TTNS stimulation (30 s) and rest (30 s) for 8 repeats. Statistical analysis was performed at the individual level with a threshold of p = 0.05, family-wise error (FWE)-corrected. The resulting individual statistical maps were analyzed in group statistics using a one-sample t-test, p = 0.05 threshold, false discovery rate (FDR)-corrected.

RESULTS

During peroneal eTNM®, TTNS, and sham stimulations, we recorded activation in the brainstem, bilateral posterior insula, bilateral precentral gyrus, bilateral postcentral gyrus, left transverse temporal gyrus, and right supramarginal gyrus. During both peroneal eTNM® and TTNS stimulations, but not sham stimulations, we recorded activation in the left cerebellum, right transverse temporal gyrus, right middle frontal gyrus, and right inferior frontal gyrus. Exclusively during peroneal eTNM® stimulation, we observed activation in the right cerebellum, right thalamus, bilateral basal ganglia, bilateral cingulate gyrus, right anterior insula, right central operculum, bilateral supplementary motor cortex, bilateral superior temporal gyrus, and left inferior frontal gyrus.

CONCLUSIONS

Peroneal eTNM®, but not TTNS, induces the activation of brain structures that were previously implicated in neural control of the of bladder filling and play an important role in the ability to cope with urgency. The therapeutic effect of peroneal eTNM® could be exerted, at least in part, at the supraspinal level of neural control.

Effect duration of the initial course of peroneal electrical Transcutaneous NeuroModulation in patients with overactive bladder

PURPOSE

The aim of this prospective 12-month follow-up study is to evaluate the persistence of the treatment effect achieved during the initial course of peroneal electrical Transcutaneous NeuroModulation (peroneal eTNM^®) in patients with overactive bladder (OAB).

METHODS

This study enrolled 21 female patients who participated in two previous clinical studies designed to assess the efficacy and safety of peroneal eTNM^®. The patients were left without subsequent OAB treatment and were invited to attend regular follow-up visits every 3 months. The patient's request for additional treatment was considered an indicator of the withdrawal of the treatment effect of the initial course of peroneal eTNM^®. The primary objective was the proportion of patients with persisting treatment effect at follow-up visit 12 months after initial course of peroneal eTNM^®. Descriptive statistics are presented using median, correlation analyses were computed using a nonparametric Spearman correlation.

RESULTS

The proportion of patients with persistent therapeutic effect of the initial course of peroneal eTNM^® was 76%, 76%, 62% and 48% at 3, 6, 9 and 12 months, respectively. There was a significant correlation between patient reported outcomes and the number of severe urgency episodes with or without urgency incontinence as reported by patients at each follow-up visit (p = 0.0017).

CONCLUSION

The treatment effect achieved during the initial phase of peroneal eTNM^® persists for at least 12 months in 48% of patients. It is likely that the duration of effects is dependent on the length of the initial therapy.

Prospective, Randomized, Multicenter Trial of Peroneal Electrical Transcutaneous Neuromodulation vs Solifenacin in Treatment-naïve Patients With Overactive Bladder

PURPOSE

We investigated the safety and efficacy of peroneal electrical transcutaneous neuromodulation using the URIS neuromodulation system in a home-based setting in comparison with standard treatment using solifenacin in treatment-naïve female patients with overactive bladder.

MATERIALS AND METHODS

A total of 120 patients were screened, of whom 77 were randomized in a 2:1 ratio to 12 weeks of treatment with daily peroneal electrical transcutaneous neuromodulation or solifenacin 5 mg. The primary endpoint was safety; efficacy assessments included proportion of responders, defined as subjects with ≥50% reduction in bladder diary-derived variables; Overactive Bladder-Validated 8-question Screener, and European Quality of Life-5 Dimensions questionnaire; and treatment satisfaction after 12 weeks of therapy.

RESULTS

Seventy-one out of 77 randomized patients completed the study. In the peroneal electrical transcutaneous neuromodulation group 6/51 (12%) patients reported a treatment-related adverse event vs 12/25 (48%) in the solifenacin group (P < .001). No clinically significant changes were observed in any other safety endpoint. The proportions of responders in the peroneal electrical transcutaneous neuromodulation group vs the solifenacin group were 87% vs 74% with respect to Patient Perception of Intensity of Urgency Scale grade 3 urgency episodes, 87% vs 75% with respect to grade 3+4 urgency episodes, and 90% vs 94% with respect to urgency incontinence episodes. In post hoc analyses we observed significant improvement over time in multiple efficacy variables in both treatment arms.

CONCLUSIONS

Peroneal electrical transcutaneous neuromodulation is a safe and effective method for overactive bladder treatment associated with a significantly lower incidence of treatment-related adverse events compared to solifenacin and a considerably better benefit-risk profile.

Is high accuracy of Vesical Imaging-Reporting and Data System (VI-RADS) sufficient for its implementation in the urological practice?

AIMS

Currently, the only method used to differentiate between MIBC and NMIBC is transurethral resection of the bladder tumour (TURBT). Magnetic resonance and Vesical Imaging-Reporting and Data System (VI-RADS) would allow for discrimination between NMIBC and MIBC. We evaluate the sensitivity and specificity of VI-RADS in the diagnosis of muscle-invasive bladder cancer and discuss its value in everyday urological practice.

METHODS

64 patients with bladder cancer (BC) were enrolled into this prospective study. Multiparametric magnetic resonance imaging (mpMRI) was performed before transurethral resection of the bladder tumour (TURBT) and evaluated using the VI-RADS score. Score were compared to histopathology results. We evaluated the sensitivity, specificity, positive and negative predictive value of this system using both cut-off VI-RADS ≥ 3 and ≥ 4.

RESULTS

Sensitivity of 92.3% (95%CI: 64.0; 99.8), specificity of 81.4% (95%CI: 69.1; 90.3), positive predictive value of 52.2% (95%CI: 30.6; 73.2) and negative predictive value of 98.0% (95%CI: 89.1; 99.9) was determined using cut off VI-RADS ≥ 3, while sensitivity of 76.9% (95%CI: 46.2; 95.0), specificity of 91.5% (95%CI: 81.3; 97.2), positive predictive value of 66.7% (95%CI: 38.4; 88.2), and negative predictive value of 94.7% (95%CI: 85.4; 98.9) was determined using cut-off VI-RADS ≥ 4. Based on our results, we consider the optimal cut-off point to be VI-RADS ≥ 3 with the overall prediction accuracy of 83.3% (95%CI: 72.7; 91.1).

CONCLUSIONS

We acknowledge that mpMRI provides valuable information with regard to BC staging, however, despite its high overall accuracy, we do not consider the VI-RADS could replace TURBT in discrimination between non-muscle invasive and MIBC.

Permanent urethral catheter - a good servant, but bad master: Guidelines for prevention, diagnosis, and treatment of catheter-associated urinary tract infections

Catheter-associated urinary tract infections (CAUTI) are among the most common healthcare-associated infections, which increase morbidity, mortality, prolong the length of hospitalization and have a significant impact on the cost of treatment. The most efficient preventive method is removing catheters as soon as possible and avoid unnecessary catheterizations. Treatment of asymptomatic bacteriuria is not recommended. In cases of serious CAUTI, vigorous antibiotic therapy covering multidrug-resistant uropathogens should be initiated. These recommendations are intended for all medical specialties to improve the care of patients with indwelling catheters in the prevention, diagnosis, and treatment of CAUTI in primary care and subsequent long-term care.

Risk of genitourinary malignancy in patients that receive anticoagulant or antiplatelet therapy

OBJECTIVES

Haematuria is a common indication for a urology evaluation. In many cases, its cause is not determined unequivocally, but it does not pose any threat to the patient. However, it can represent the first symptom of urinary tract cancer.

BACKGROUND

The present study aimed to compare the risk of urological malignancies in patients with haematuria who received antiplatelet or anticoagulant therapy versus those who did not.

METHODS

This prospective study included 562 patients with haematuria during the period of 2018‒2021. Among these, 129 patients had macroscopic haematuria. All patients underwent a urinary tract ultrasound, CT with urography, and cystoscopy. Patients with suspected malignancy underwent an appropriate surgical procedure with a pathology examination. Data were analysed with univariate and multiple logistic regression.

RESULTS

The incidence rates of malignancies were 21.5 % overall, and 44.2 % and 14.8 % among patients with macroscopic and microscopic haematuria, respectively. Univariate regression showed that the odds of malignancy was significantly higher among patients with antiplatelet therapy compared to patients without antiplatelet therapy (OR: 1.88, 95% CI: 1.14‒3.05). In contrast, anticoagulation therapy did not significantly increase the odds of malignancy compared to no anticoagulation therapy (OR: 1.45, 95% CI: 0.74‒2.69). However, a multiple logistic regression model that included other known risk factors (e.g., sex or age) showed similar odds of malignancy among these patient groups.

CONCLUSIONS

Malignancy risk for patients who received anticoagulant or antiplatelet therapy was similar to the risk observed in the general population. Antiplatelet and anticoagulant therapy were not significant risk factors of urological malignancy in patients with haematuria. The results from the present study will be used in a power analysis for an upcoming multicentre study (Tab. 4, Ref. 17). Text in PDF www.elis.sk Keywords: anticoagulation therapy, antiplatelet therapy, cancer, haematuria, risk factor.

Peroneal electrical transcutaneous neuromodulation in the home treatment of the refractory overactive bladder

INTRODUCTION AND HYPOTHESIS

The aim of this prospective, open-label, multicenter, noncomparative study was to evaluate the efficacy and safety of peroneal electrical transcutaneous neuromodulation (peroneal eTNM^®) using the URIS^® neuromodulation system as a home treatment for refractory overactive bladder (OAB).

METHODS

The patients were treated with daily peroneal eTNM^® for 30 min over a 6-week period. The primary endpoint was defined as the proportion of responders, i.e., participants with ≥ 50% reduction in the average daily sum of severe urgency episodes (defined as "I could not postpone voiding but had to rush to the toilet in order not to wet myself") and urgency incontinence episodes. In addition, bladder diary variables, symptom severity (OAB V8 questionnaire), treatment satisfaction (visual analog scale), and pain perception (visual analog scale) were evaluated at baseline (BL), at week 4 (W4), and at the end of treatment (EoT). Safety evaluations included monitoring of the incidence and severity of adverse events (AEs). Changes in time were analyzed using the nonparametric one-way ANOVA Friedman test for categorical variables and the Wilcoxon rank-sum test for the noncategorical variables.

RESULTS

In total, 40 subjects were screened and 29 were included in the full analysis set. The proportion of responders was 86% at W4 and 79% at EoT. There was a significant reduction in frequency (p<0.001), number of severe urgency episodes (p< 0.001), number of urgency incontinence episodes (p=0.001), and number of nocturia episodes (p=0.002). There was a significant improvement in the OAB V8 score and treatment satisfaction (both p<0.001). Two mild treatment-related AEs were recorded. Both patients recovered without sequelae and completed the study.

CONCLUSIONS

Peroneal eTNM^® proved to be a highly effective and safe method for the home treatment of OAB, providing a therapeutic response in approximately 80% of patients.

Clinical Utility of β3-Adrenoreceptor Agonists for the Treatment of Overactive Bladder: A Review of the Evidence and Current Recommendations

This nonsystematic review provides a summary of current evidence on the use of β₃-adrenoreceptor agonists (β₃-ARAs) for the treatment for lower urinary tract symptoms. Soon after their discovery in 1989, β₃-ARs were identified as a predominant adrenoreceptor subtype in the human urinary bladder. Although it is widely believed that β₃-ARAs cause detrusor relaxation, the effect on bladder afferent signaling likely plays an important role in their mechanism of action as well. In 2011 and 2012, mirabegron was approved for clinical use in overactive bladder (OAB) patients. Pooled analysis of data from prospective randomized studies on >60,000 OAB patients showed that when compared to placebo, mirabegron was superior with respect to reducing the frequency, number, and severity of urgency episodes, number of incontinence episodes and increasing dry rate, but not in reduction of nocturia episodes. The only side effect showing significantly higher incidence than placebo was nasopharyngitis. Mirabegron is approved for OAB treatment in all age-groups and in pediatric patients with neurogenic bladder. Vibegron is another β₃-ARA approved for OAB treatment in the US and Japan. Several large, multicenter, double-blind, randomized trials have documented statistically significant superiority of vibegron over placebo on all efficacy end points. Other β₃-ARAs are being developed; however, to date none has been introduced to clinical use. All β₃-ARAs provide efficacy similar to anticholinergics. They have a favorable safety profile and are well tolerated. Due to their different mechanisms of action, combination of β₃-ARAs with anticholinergic compounds allows for increased efficacy.

Peroneal Electrical Transcutaneous NeuroModulation as a New Treatment for Patients with Overactive Bladder: An Initial Clinical Experience

INTRODUCTION

The aim of this study was to determine whether peroneal electrical Transcutaneous NeuroModulation (peroneal eTNM®) using the URIS® neuromodulation system can be used in individuals with refractory overactive bladder (OAB).

METHODS

Eighteen female patients with idiopathic OAB who failed previous behavioral and pharmacological therapy were enrolled. Patients were treated with the URIS® neuromodulation system using active electrodes placed on the popliteal fossa, targeting the peroneal nerve for 30 min once a week for 12 weeks. Changes in OAB symptoms and patient-reported outcomes from baseline to the end of the study were analyzed. A nonparametric Wilcoxon signed-rank test was used to assess changes in variables. Statistical significance was defined as p ≤ 0.05.

RESULTS

We observed a significant reduction in micturition frequency (p = 0.022), number of severe urgency episodes (p < 0.001), urgency incontinence episodes (p = 0.001), and nocturia episodes (p = 0.027). A decrease in Patient Perception of Bladder Condition score (p < 0.001) was also observed. Posttreatment, 15 patients (83.3%) reported a moderate or significant reduction in their bladder bother. Throughout the study, two adverse events were recorded with no causal relationship to the study treatment.

DISCUSSION/CONCLUSIONS

Our study documented a significant reduction in all OAB symptoms and an improvement in all patient-reported outcomes in patients treated with peroneal eTNM® using the URIS® neuromodulation system.

The relationship between lower urinary tract dysfunctions and urinary leakage from ureterocystoneoanastomosis in male patients after kidney transplantation

OBJECTIVES

The aim of this study was to investigate the association of lower urinary tract dysfunctions with urinary leakage from ureterocystoneoanastomosis (UCNA) after kidney transplantation.

BACKGROUND

The UCNA leakage after kidney transplantation can be associated with various conditions while severe lower urinary tract dysfunctions could be one of them.

METHODS

The analysis included all men who underwent kidney transplantation between January 2009 and December 2014. The parameters of storage and voiding functions were evaluated. All patients were monitored during their post-transplantation period for the incidence of urinary leakage from UCNA. Urodynamic parameters were compared between men with and without a documented leakage.

RESULTS

The study cohort included 127 male patients, while UCNA leakage was observed in 11 (8.7 %) patients. Significant differences between both groups of patients were found for storage parameters (patients with leakage had smaller volume at first and a normal desire to void, smaller maximal cystometric capacity, and lower detrusor compliance) and voiding parameters (patients with leakage had a lower maximal flow rate, higher detrusor pressure at maximal flow rate and higher bladder outlet obstruction index).

CONCLUSION

This study shows an association between lower urinary tract dysfunction and UCNA leakage in men without previous urological history (Tab. 2, Fig. 2, Ref. 24). Text in PDF www.elis.sk Keywords: urinary leakage, ureterocystoneoanastomosis, lower urinary tract dysfunctions, kidney transplantation.

Cardiovascular safety of mirabegron in individuals treated for spinal cord injury- or multiple sclerosis-induced neurogenic detrusor overactivity

PURPOSE

To analyze cardiovascular safety of mirabegron in patients with spinal cord injury (SCI)- and multiple sclerosis (MS)-induced neurogenic detrusor overactivity (NDO) in a prospective, randomized, double-blind, placebo-controlled study.

METHODS

Seventy-eight patients were enrolled into the study, and 66 of them were included into the final analysis. In 49 (74.2%), NDO developed due to suprasacral SCI, 17 (25.8%) suffered from NDO due to MS. Eleven patients were previously treated for hypertension and one for arrhythmia. All study participants received placebo for 2 weeks run-in period. Subsequently, eligible subjects were randomized for 4 weeks of active treatment with mirabegron 50 mg once daily (Group A; n = 32) or placebo (Group B; n = 34). Data from resting electrocardiography (ECG), 24-h ECG and blood pressure monitoring, and echocardiographic examination, were used for cardiovascular safety assessment. All reported variables were evaluated at time of randomization and at the end of the study. Longitudinal changes of variables within the groups and differences between the groups were assessed using nonparametric Kruskal-Wallis test, and p ≤ 0.05 was considered statistically significant.

RESULTS

No statistically significant longitudinal changes were found in safety variables, except for prolongation of QT interval in placebo group (p = 0.0328) recorded by resting ECG. No significant difference between the Groups A and B, in any of the variables, was observed. A single cardiovascular study drug-related adverse event was recorded in a patient with cervical SCI (3.13%).

CONCLUSIONS

Our results suggest that mirabegron can be safely used in the treatment of patients with SCI- and MS-induced NDO.

The Effect of Botulinum Toxin Type A Injections on Stricture Formation, Leakage Rates, Esophageal Elongation, and Anastomotic Healing Following Primary Anastomosis in a Long- and Short-Gap Esophageal Atresia Model - A Protocol for a Randomized, Controlled, Blinded Trial in Pigs

BACKGROUND

Esophageal atresia (EA) is a congenital malformation affecting 1:3000-4500 newborns. Approximately 15% have a long-gap EA (LGEA), in which case a primary anastomosis is often impossible to achieve. To create continuity of the esophagus patients instead have to undergo lengthening procedures or organ interpositions; methods associated with high morbidity and poor functional outcomes. Esophageal injections of Botulinum Toxin Type A (BTX-A) could enable primary anastomosis and mitigate stricture formation through decreased tissue tension.

METHODS AND ANALYSIS

In this randomized controlled blinded animal trial, 24 pigs are divided into a long- or short-gap EA group (LGEA and SGEA, respectively) and randomized to receive BTX-A or isotonic saline injections. In the LGEA group, injections are given endoscopically in the esophageal musculature. After seven days, a 3 cm esophageal resection and primary anastomosis is performed. In the SGEA group, a 1 cm esophageal resection and primary anastomosis is performed, followed by intraoperative injections of BTX-A or isotonic saline. After 14 days, stricture formation, presence of leakage, and esophageal compliance is assessed using endoscopic and manometric techniques, and in vivo and ex vivo contrast radiography. Tissue elongation is evaluated in a stretch-tension test, and the esophagus is assessed histologically to evaluate anastomotic healing.

ETHICS AND DISSEMINATION

The study complies with the ARRIVE guidelines for animal studies and has been approved by the Danish Animal Experimentation Council. Results will be published in peer-reviewed journals and presented at national and international conferences.

HIGHLIGHTS

The optimal management of long-gap esophageal atresia remains controversialPrimary anastomosis could improve functional outcomes and reduce complicationsBotulinum Toxin Type A decreases tissue tension and could facilitate anastomosisReduced tension could further abate the risk for anastomotic stricture and leakageWe present a model to evaluate the method in long- and short-gap esophageal atresia.

One-year follow-up after urethroplasty, with the focus on both lower urinary tract and erectile function

Background: Urethral stricture disease (USD) represents a complex urological problem. Urethroplasty is considered the gold standard for the treatment of USD. Most available studies report outcome data obtained from retrograde urethrography and uroflowmetry. Only a limited number of papers describe the effect of urethroplasty on erectile function and their results are inconsistent. The goal of this prospective study was to evaluate the effect of urethroplasty on both lower urinary tract and erectile function using objective parameters and standardized patient-reported outcome measurement tools.Materials and Methods: A total of 55 consecutive patients with USD were enrolled into the study. Patients underwent ventral onlay urethroplasty, urethroplasty according to the Asopa technique, dorsal onlay urethroplasty, cutaneous flap urethroplasty using the Orandi technique or anastomotic repair. All patients were evaluated using uroflowmetry, urethrography, the PROM-USS questionnaire and the International Index of Erectile Function-5 questionnaire (IIEF-5) pre-operatively and consequently post-op, in 3-month intervals. This study presents the comparison of baseline pre-op parameters and parameters 12 months after the surgery using the Wilcoxon signed rank test, Wilcoxon rank sum test and the Kruskal-Wallis one-way analysis of variance.Results: A significant improvement in uroflowmetry parameters, all domains of the PROM-USS questionnaire, as well as the overall score of the IIEF-5 was observed. No statistically significant differences between sub-groups were found when comparing treatment results in patients with short versus long strictures and patients with penile urethra stricture versus bulbar or membranous urethra stricture.Conclusions: Urethroplasty yielded very good functional results with respect to both lower urinary tract and erectile functions.

Alpha-blockers for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review and meta-analysis. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS)

AIM

We aimed to systematically assess the evidence on the efficacy and safety of alpha-blockers in patients with multiple sclerosis (MS) suffering from neurogenic lower urinary tract dysfunction (NLUTD).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to perform this systematic review. An electronic search of Cochrane register, Embase, Medline, Scopus (last search 3 March 2018) and screening of reference lists as well as reviews were used to identify the studies. Articles were included if they reported on efficacy/safety of alpha-blockers for the treatment of NLUTD in patients with MS.

RESULTS

After screening of 7'015 abstracts, three studies enrolling a total of 50 patients were included: one randomized, placebo-controlled, single-blind trial and two prospective cohort studies. Alpha-blocker treatment was successful in 50% to 96% of the patients. Pooling data from the three included studies, the relative risk for successful alpha-blocker treatment was 3.89 (95% confidence interval 2.7-7.0). The general safety profile of alpha-blockers was favorable with 8% of the patients reporting adverse events.

CONCLUSIONS

Alpha-blockers may be effective and safe for treating NLUTD in female and male patients with MS but the studies were small and the overall quality of evidence was low. To make definitive conclusions, well designed randomized controlled trials are highly warranted.

Efficacy and safety of mirabegron for the treatment of neurogenic detrusor overactivity-Prospective, randomized, double-blind, placebo-controlled study

AIMS

To assess the efficacy and safety of mirabegron in the treatment of neurogenic detrusor overactivity.

METHODS

This prospective, multicenter, randomized, double-blind, placebo-controlled study was conducted in three tertiary centers, and included 78 patients suffering from spinal cord injury or multiple sclerosis. Patients were randomized for Mirabegron 50 mg (Group A) or placebo (Group B). Urodynamic parameters, the 24 h pad-weight test, and patient-reported outcomes were assessed. Safety assessments included monitoring the incidence and severity of adverse events. Changes in time and differences between groups were assessed with nonparametric Kruskal-Wallis one-way analysis of variance; P ≤ 0.05 was considered statistically significant.

RESULTS

In total, 66 patients were eligible for inclusion in the final analysis. There was a significant increase of volume at the first detrusor contraction (P = 0.00047) and an improvement in bladder compliance (P = 0.0041) in the mirabegron group compared with the placebo-treated group, whereas the increase in cystometric capacity did not reach statistical significance (P = 0.061). There was a clear tendency to reduced urine leakage (P = 0.056) in Group A. There were significant changes in all the patient-reported outcomes, favoring the mirabegron group. The incidence of drug-related adverse events was 3.13%.

CONCLUSIONS

Mirabegron (50 mg) improved both urodynamic variables and patient-reported outcomes in patients with NDO. The treatment was tolerated well.

Effect of severity of urinary incontinence on quality of life in women

AIMS

While the effect of different types of incontinence on the quality of life (QoL) has been clearly documented, the information about the impact of incontinence severity on QoL in women is lacking. Therefore, we investigated whether increasingly severe degrees of incontinence were linearly correlated with poorer QoL.

METHODS

We included 391 incontinent women and 81 continent volunteers in the study and assessed them in accordance with routine clinical practice. A 24 h pad-weight test was used to objectively quantify the incontinence severity. We then stratified participants according to incontinence type and severity and assessed correlations between incontinence severity and Patient Perception of Bladder Condition (PPBC), International Consultation on Incontinence short-form questionnaire (ICIQ-SF), and King's Health Questionnaire (KHQ) quality of life scores in the entire study population and in individual groups according to incontinence type.

RESULTS

Minimal incontinence was associated with significant negative impact on QoL, as measured by all quality of life assement tools. There were nonlinear correlations between scores on individual questionnaires and daily leakage volumes. Stress urinary incontinence had a weaker impact on quality of life than urge or mixed incontinence, as measured by PPBC (P < 0.0001), KHQ part 1 (P < 0.0001), and KHQ part 2 (P < 0.001). Stress urinary incontinence also had a weaker impact on QoL than mixed incontinence as measured by ICI-Q (P = 0.007).

CONCLUSIONS

This study demonstrated that even mild urinary leakage significantly reduces the QoL, while subsequent increase in the degree of incontinence has only minimal additional effect. There was no linear correlation between incontinence severity and QoL.

The Effects of Diuresis, Duration of Dialysis and Age on Lower Urinary Tract Function in Urologically Healthy Male Patients on the Waiting List for Kidney Transplant

PURPOSE

This work investigated the effects of diuresis, duration of dialysis and age on lower urinary tract function in urologically healthy males on the waiting list for kidney transplant.

MATERIALS AND METHODS

The study included all men who had kidney transplants at our centre between January 2009 and December 2014 who had normal urological findings prior to inclusion on the list. Diuresis, the duration of haemodialysis, age, and parameters of function of the lower urinary tract as determined by filling and voiding cystometry were evaluated.

RESULTS

The study included 127 men (median age, 59 years; median diuresis, 250 mL; median duration of dialysis, 469.5 days). We found that greater diuresis was accompanied by significantly higher FDV, FDV/Cmax, NDV,Cmax and compliance and by significantly lower Pdet.max, PdetQmax and BOOI. Longer duration of dialysis was accompanied by significantly lower FDV, NDV and Cmax, compliance and Qmax.p and with significantlyhigher Pdet.max, PdetQmax and BOOI. Older age was associated with significantly higher Pdet.max and with significantly lower compliance. Worsening of the basic parameters of the storage function of the lower urinary tract occurred when diuresis decreased to 500-750 mL, when the duration of dialysis was one year and when patients were older than 54 years.

CONCLUSION

In healthy male patients on the waiting list for kidney transplant, there were connections between the occurrence of dysfunctions of the lower urinary tract and diuresis, duration of dialysis and age. Patients should be monitored for dysfunctions of the lower urinary tract before and after transplantation.

How durable is the effect of mirabegron in successfully-treated overactive bladder patients? Analysis of a multicentre study

OBJECTIVE

Many clinical studies indicate that pharmacologic treatment of overactive bladder (OAB) is considered effective and safe, but in real clinical practice a substantial proportion of patients discontinues the treatment. The reason for discontinuing the treatment most frequently reported is lack of efficacy and/or side effects. A further significant proportion of patients reports that they stopped the treatment because the symptoms disappeared or were resolved. This &#946;3 agonist seems to be crucial in providing comparable efficacy in the OAB treatment and better tolerance in comparison with anticholinergics. Our aim was to investigate the durability of the mirabegron effect in successfully treated OAB patients and to understand more fully what prompts patients to return to the medication. Is this merely a subjective decision, or is it based on objective worsening of the symptoms?

DESIGN

Analysis of multicentre prospective study.

SETTINGS

Gynaecology and Obstetric Department First Faculty of Medicine, Charles University and General University Hospital, Prague.

METHODS

This is an analysis of longitudinal multicentre study of OAB mirabegron treatment persistence. After continuing mirabegron treatment for more than 18 months patients were assessed by bladder diary and specific questionnaires. Patients with a UB-VAS score (Urgency Bother Visual Analogue Scale) of 50 or less were asked to stop the mirabegron treatment and restart the treatment any time later if they felt the need. Patients recorded the date of return to medication; they kept a daily bladder diary and filled in the same questionnaires as at the time of medication discontinuation. We provide a comparison of symptoms at the time of mirabegron discontinuation and at the time of mirabegron medication restart.

RESULTS

206 patients entered the study. 176 females (85%) and 30 males (15%) with mean age 62.9 ± 12.43, BMI ranging from 16.6 to 48.0 (mean 27.2 ± 4.96). After 18 months 126 patients were persisting with mirabegron treatment. 89 patients had UB-VAS score 50 (89 of 126 patients, i.e. 71%). Those patients were asked to stop the treatment. From the eligible group of 89 patients, 19 patients (21%) were unwilling to stop the treatment and were therefore excluded. There were no significant differences in bladder diary and QoL characteristics between patients who were unwilling to discontinue the treatment and patients who did stop taking the medication. The group who stopping treatment comprised 70 patients. At the time of last follow-up 22 patients (31%) had not restarted the medication, with mean follow-up of 122.6 days. Therapy was restarted by 48 patients (i.e. 69% of 70). The mean time without treatment was 48 days (± 32.0 days), median 53 days. There was significant worsening of OAB symptoms and subjective bother at the time of restarting the medication.

CONCLUSION

Subjective bother based on increase number of frequency, urgency, and nycturia causes patients with positive experience to return to mirabegron treatment. Most patients with successfully-treated symptoms of OAB who discontinue treatment can only do so temporarily. A worsening of the symptoms occurs rather rapidly, because 69% of patients with OAB symptoms successfully treated with mirabegron (UB-VAS 50) are unable to discontinue taking the medication for more than two months.

A rare complication of long-term vaginal prolapse

OBJECTIVE

Description of rare complication of long-term uterine prolaps. Desing: Case report.

SETTING

Department of Obstetric and Gynecology, University Hospital Ostrava.

CASE REPORT

A seventy-years-old pacient with longterm complete uterine prolaps underwent vaginal hysterectomy with colpoclesis at department of Obstetric and Gynecology of university hospital Ostrava in August 2017. The surgery was planned more than year ago, when patient had no symptoms. But due to patient's injury, it was postponed and the condition was already complicated by urine incontinency. The surgery was complicated by bladder lesion, because it was suggested as a pelvis tumor. Correction of cystolithiasis was planned at a second time, when suprapubic cystoli-thotomy was performed after 16 days. Temporary urinary derivation was ensured by bilateral nephrostomy, epicystostomy and urinal catetrization for low residual bladder capacity after surgery.

CONCLUSION

Bladder stones are a rare complication of otherwise relatively frequent complete urogenital prolaps in women. Major causes include micturition disorder and chronic urinary tract infection which is caused by vaginal and uterus descensus.

ICS Educational Module: Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults

AIM

To present the teaching module "Electromyography in the assessment and therapy of lower urinary tract dysfunction in adults." This teaching module embodies a presentation, in combination with this manuscript. This manuscript serves as a scientific background review; the evidence base made available on ICS website to summarize current knowledge and recommendations.

METHODS

This review has been prepared by a Working Group of The ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel.

RESULTS

Electromyography (EMG) is a method to record spontaneous or artificially induced electrical activity of the nerve-muscle unit or to test nerve conductivity. EMG of the anal sphincter using surface electrode is most widely used screening technique to detect detrusor-sphincter dyssynergia in urology. It is non-invasive and easy to perform. EMG methods using needle electrodes are reserved for diagnostics in well selected group of mainly neurogenic patients. These methods require expertise in the field of general EMG and are usually performed by neurologist and neuro-physiologist. The evidence in many aspects of use of EMG in urology remains sparse.

CONCLUSIONS

Currently EMG methods rarely play a decision making role in selecting proper treatment of lower urinary tract dysfunction. With the current efforts to improve phenotyping of these patients in order to provide individualized treatment, the role of EMG could increase.

Impact of clean intermittent catheterization on quality adjusted life years (QALYs) in spinal cord injury patients with neurogenic urinary incontinence

AIMS

The impact of clean intermittent catheterization (CIC) on quality adjusted life years (QALYs) gained in adults' spinal cord injury population with neurogenic urinary incontinence (UI).

METHODS

Patients were recruited from the national registry January-June 2014. The inclusion criteria were adults, neurogenic UI due to spinal cord injury (SCI), use of collection devices and CIC for more than 6 months. The exclusion criteria were inability to perform CIC, cancer of the lower urinary tract and fistulas formation. Measurement tools were the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and an estimation of life expectancy by the national registry. The calculation of the weighting factor (WF) was obtained by linear transformation of the ICIQ-UI SF total score. A score was transformed to the range from 0 (worst impact) to 1 (no impact). The QALYs was calculated as the weighting factor × life expectancy in years.

RESULTS

A total of 229/365 patients were involved in this study (63%). Patients before CIC reached an ICIQ mean score of 14.83, WF of 0.29, and QALYs of 9.02 during life expectancy. After 6 months of follow-up using CIC, ICIQ reached 9.12, WF 0.57 and QALYs 17.45. The number of QALYs increased by 93.5% and UI evaluated with the ICIQ-UI SF decreased by 38.5% (P < 0.01).

CONCLUSIONS

The CIC of the urinary bladder statistically significantly increased the number of QALYs and reduced the degree of UI in SCI patients.

[Cure effect and persistence of treatment with Mirabegron in patients with symptoms of overactive bladder: a multicentre clinical study]

OBJECTIVE

The objective of this study was to monitor and evaluate the persistence and cure effect of Mirabegron in patients with overactive bladder syndrome after 18 months of treatment.

DESIGN

Prospective clinical study.

SETTINGS

10 gynecological and urological departments in CZE.

MATERIALS AND METHODS

This is an analysis of a prospective, multicenter monitoring study from May to September 2014. The patients were 18 years old and had symptoms of OAB for a minimum of three months. Patient check-ups were performed 18 months after the first visit. The dosage of Mirabegron was 50 mg per day in 162 patients, though for 44 of the patients the treatment was changed. During the final check-ups it was ascertained how many patients had discontinued treatment with Mirabegron, at first as a proportion of the whole group of patients and then in relation to gender, age, previous treatment with anticholinergic drugs and changes in the treatment during the study. To evaluate treatment efficacy we employed the TS-VAS and PPBC. During the check-up it was ascertained how many patients had discontinued treatment with Mirabegron, and reasons for this were established. The statistics were calculated using the softwares STATISTICA 12 (Statsoft, USA) and SPSS 20.0 (IBM, v.20.0).

RESULTS

Prospective monitoring was performed on 206 patients. Their mean age was 62.8 years; mean body mass index for the whole group of patients was 27.3. At the check-up 18 months post-initiation of treatment it emerged that 79 (38.3%) patients had discontinued the treatment. The reasons for discontinuation of treatment were insufficient treatment efficacy (35.4% of patients), while 49.4% cited other reasons (hospitalisation, surgery, gravidity) and 15.2% of patients discontinued therapy because of side effects. The evaluation of treatment persistence with Mirabegron in groups with relation to gender, age and previous treatment with anticholinergic drugs did not establish statistically significant differences. However, there was a statistically significant difference between groups in relation to changes of treatment during study. At the evaluation of the efficacy of the treatment during the check-up 18 months after initiation of treatment the mean TS-VAS was 73.4, a decrease of the scale of bothers evaluated by PPBC before treatment from a mean value of 4.6 to a value of 2.7.

CONCLUSIONS

In our clinical study 18 months treatment persistence with Mirabegron was 61.7%. The reasons were reduced side effects and good cure effect of the drug.

[Degree of satisfaction of patients continuing overactive bladder treatment with mirabegron]

OBJECTIVE

Overactive bladder syndrome is chronic disease with high prevalence rate (9-42%). This syndrome requires long term therapy, but the treatment persistence is after 3 months over all 26% with further decline in one-year period as low as 18.5%. Main reasons for stopping the treatment are low efficacy, the medication didnt work as expected and side effects. How much satisfied are patients with mirabegron persisting on its treatment? To answer this question, we provided secondary analysis of multicentre follow-up study of patients on mirabegron. We compared subjective and objective parameters between patients continuing mirabegron treatment and those who discontinued the medication.

DESIGN

Secondary analysis multicentre prospective follow-up.

SETTINGS

Ob/Gyn department First Faculty of Medicine, Charles University and General University Hospital, Prague.

METHODS

It is secondary analysis of multicentre prospective study following patients with mirabegron 50 mg treatment. We have analysed objective data from micturition diary and subjective data using visual analogue scales (UB-VAS - urgency bother visual analogue scale, and TS-VAS - treatment satisfaction visual analogue scale) and compared data between the group of patients continuing mirabegron treatment and patients who stopped the medication during the study.

RESULTS

We included 206 patients (176 women, 30 men) with diagnosis of overactive bladder. Patients continuing the treatment (group n1) had baseline UB-VAS 70.1 vs. 75.0 (p = n.s.) in patients who stopped the medication during the follow-up period (group n2). Baseline episodes of severe urgency and urge incontinence where n1 - 5.1 vs. n2 - 6.2 (p = n.s.). Six months urgency bother score UB-VAS was n1 - 32.4 vs. n2 - 58.9 (p < 0,001). Treatment satisfaction TS-VAS was n1 - 80.3 vs. n2 - 57.7 (p < 0,001). Number of severe urgencies with or without urge incontinence was after 6 months n1 - 2.1 vs. n2 - 3.3 (p = n.s.), lower in group continuing the treatment. When comparing the data between patients stopping the medication for reason of low efficacy (group s1) with patients stopping for other reasons (group s2) UB-VAS bas: s1 - 68.5 vs. s2 - 43.9 (p = 0.001); TS VAS s1 - 45.1 vs. s2 - 58.4 (p = n.s.) and number of severe urgency with or without incontinence s1 - 5.9 vs. s2 - 3.2 (p = 0.009).

CONCLUSION

Our data shows that patients expectation on treatment with mirabegron is not low. Patients accept treatment either without side effects or with decrease of severe urgency with or without urge incontinence around 50%. Regardless the reason the patients continuing the treatment scale treatment satisfaction - TS-VAS over 70 points.

Evaluation of Voiding Parameters in Healthy Women Using Sound Analysis

OBJECTIVES

Sonouroflowmetry represents a novel method for estimating urinary flow parameters. The aim of this study was to compare the urinary flow parameters acquired using sonouroflowmetry with those of standard uroflowmetry in healthy female volunteers.

METHODS

Thirty-six healthy female volunteers (aged 25-54 years) were subjected to standard uroflowmetry. Simultaneously, subjects dialed a dedicated number on a mobile phone and kept recording until urination was finished. Sound data were analyzed and compared to the uroflowmetry data. Of 218 recordings, 183 were included in the final analysis. Thirty-four measurements were excluded for voided volume <150 mL or technical problems during the recording. A linear model was fitted to calculate the urinary flow parameters and the voided volume from data obtained by sonouroflowmetry. Subsequently the matching datasets of UF and SUF were compared with respect to flow time, voided volume, maximum (Q_max ) and average (Q_ave ) flow rate. Pearson's correlation coefficient (PCC) was used to compare parameters recorded by uroflowmetry with those calculated based on sonouroflowmetry recordings.

RESULTS

A strong correlation (PCC = 0.95) was noted between uroflowmetry recorded flow time and duration of the sonouroflowmetry sound signal. The voided volume measured by uroflowmetry showed a moderate correlation (PCC = 0.68) with the calculated area under the sonouroflowmetry curve. Q_max recorded using uroflowmetry and sonouroflowmetry recorded peak sound intensity showed a weak correlation (PCC = 0.38).

CONCLUSIONS

This study validates the basic concept of using sound analysis to estimate urinary flow parameters and voided volume.

Intravesical instillation of onabotulinum toxin A embedded in inert hydrogel in the treatment of idiopathic overactive bladder: A double-blind randomized pilot study

OBJECTIVE

It was hypothesized that increasing the time for which onabotulinum toxin A (OnabotA) is exposed to the urothelium following intravesical instillation will augment its effect. TC-3 is an inert heat-sensitive hydrogel, which creates an intravesical bulk providing a slow release of the embedded drug after instillation. The aim of this study was to evaluate the effect of OnabotA, embedded in inert TC-3 hydrogel, in patients with idiopathic overactive bladder (OAB).

METHODS

In total, 39 female patients (age 30-65, average 53.8 years) with OAB symptoms were randomized for the study into four groups, each receiving 50 ml of the following intravesical instillations: Group A, 0.9% NaCl (placebo, n = 11); Group B, TC-3 gel + 200 U OnabotA (n = 9); Group C, TC-3 gel + 200 U OnabotA + dimethyl sulfoxide (DMSO) (n = 10); and Group D, DMSO (n = 9). The parameters were compared before and 1 month after treatment.

RESULTS

When comparing parameters using conventional statistical methods (Kruskal-Wallis test), no statistically significant changes were observed within the groups. Comparison of the medians using an analysis based on the mathematical gnostics showed the superiority of the method used in Group B over the other groups in the following parameters: number of urgency grade 3 + 4 episodes/72 h, number of leakage episodes/72 h, Overactive Bladder Questionnaire total score and Patient Perception of Bladder Condition total score. Group D showed its superiority over the other groups in respect to the number of nocturia episodes/72 h.

CONCLUSIONS

The results indicate that intravesical instillation of OnabotA, embedded in TC-3 gel, could become an alternative to intramural injection for a well-selected subgroup of patients.

Brain activity on fMRI associated with urinary bladder filling in patients with a complete spinal cord injury

OBJECTIVE

Patients with complete spinal cord injury (SCI) may maintain some perception of bladder fullness. The aim of the study was to evaluate brain activation arising from anticipated extraspinal sensory pathways.

METHODS

Fourteen patients ages 24-54 years were enrolled, all having experienced a complete SCI (ASIA A) at C7 to T5 an average of 17 months before study entry. Urodynamic equipment was used for repeated bladder filling and detrusor activity evaluation. All functional magnetic resonance imaging measurements were performed using a Siemens Trio 3T scanner with the GRE-EPI sequence (field of view = 192 × 192 mm, voxel 3 × 3 × 3 mm, TR/TE = 3000/30 ms, 45 slices). Nine hundred dynamic scans were acquired over 45 min. Statistical analysis was done in SPM8 using a general linear model. Statistics using t-tests were thresholded at P = 0.001.

RESULTS

We excluded results from two patients because of activation artifacts. In 8 of 12 patients, significant brain activity was observed during urinary bladder filling. We found significant activation clusters at the nucleus of the solitary tract (NTS) (3/8), parabrachial nucleus (PBN) (4/8), hypothalamus (4/8), thalamus (6/8), amygdala (7/8), insular lobe (5/8), anterior cingulate gyrus (5/8), and prefrontal cortex (8/8). Activations in nuclei involved in afferents likely from the vagal nerve (NTS and PBN) correlated significantly with reported bladder sensations.

CONCLUSIONS

These data suggest that extraspinal sensory pathways may develop following SCI and that vagal nerve may play a role in re-innervation of the urinary bladder. Neurourol. Urodynam. 36:155-159, 2017. © 2015 Wiley Periodicals, Inc.

[Persistence in the treatment of overactive bladder (OAB) with Mirabegron in a multicentre clinical study]

OBJECTIVE

The objective of this monitoring was to evaluate persistence in the treatment of patients with overactive bladder syndrome (OAB) using mirabegron.

DESIGN

Prospective clinical study.

SETTING

10 gynecological and urological departments in CZE.

MATERIALS AND METHODS

This is an analysis of a prospective, multicenter monitoring which started in May 2014 and will continue for 1 year. This monitoring included patients 18 years old who have had symptoms of OAB for minimum 3 months. The patient check-up was performed 6 months (±2 weeks) after the first visit. The dosage of mirabegron was 50 mg per day. For the evaluation the treatment efficacy we employed the TS-VAS and PPBC. During the check-up it was ascertained how many patients discontinued the treatment with mirabegron, and reasons for this interruption were established. The statistics were calculated using the software SPSS 20.0.

RESULTS

A prospective monitoring was performed on 206 patients. Their mean age was 62.8 years (range 23-89); mean body mass index for the whole group of patients was 27.3. At the check-up 6 months post-initiation of treatment it emerged that 55/206 (27%) patiens had discontinued the treatment. The reasons for discontinuation of treatment were: 24/55 (43%) insufficient treatment efficacy, 29/55 (53%) other reasons (the main reasons here were hospitalisation, surgery, gravidity) and 2/55 discontinued therapy because of side effects. The side effects were tachycardia, eye irritation, lower abdominal pain and vasculitis, and they were mild in nature. The termination of the study was 7/28 (25%) in the group of patients without previous treatment before mirabegron. Discontinuation of the treatment in the group of patients with previous anticholinergic treatment was 48/178 (27%). At the evaluation of the efficacy of the treatment during the check-up 6 months after initiation of treatment the mean TS-VAS was 77.5, a decrease of the scale of bothers evaluated by PPBC before treatment from a mean value of 3.56 to a value of 1.77.

CONCLUSIONS

Our hypothesis, that persistence in treat-ment with mirabegron would be relatively high due to reduced side effects and better cure effect, was confirmed, and this is the reason for higher rates of persistence in the treatment at 6 months check-up (73%).

[Importance of uroflowmetry in lower urinary tract symptoms diagnostics]

OBJECTIVE

To summarize the current state of knowledge on the use of uroflowmetry in diagnosis of lower urinary tract dysfunction in women.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, University Hospital Ostrava and Faculty of Medicine, Ostrava University.

METHODS

Literature review.

RESULTS AND CONCLUSION

Lower urinary tract dysfunction is associated with debilitating symptoms, which negatively affect the quality of life of a large number of patients, and represent a significant health problem. Inaccurate diagnosis leads to delayed therapy, which could cause disease progression and complications. It has been recently recognized that affected patients express a wide variety of clinical phenotypes. Advancements in diagnostic procedures may allow for individualized treatment and improved treatment outcomes. Diagnostic procedures recommended for patients with suspected lower urinary tract disease include directed medical history, urinalysis, voiding diary, as well as non-invasive and invasive urodynamic methods. Additional diagnostic tests may be used in select cases. Uroflowmetry is a basic urodynamic method used for screening. It represents a standard component used in the diagnostic process for patients with lower urinary tract symptoms. Sonouroflowmetry is a new method, which evaluates the urinary flow and lower urinary tract symptoms in a non-invasive manner by analysing the sound generated by a stream of urine striking the water surface in the toilet bowl.

Comparison between uroflowmetry and sonouroflowmetry in recording of urinary flow in healthy men

OBJECTIVES

To evaluate the accuracy of sonouroflowmetry in recording urinary flow parameters and voided volume.

METHODS

A total of 25 healthy male volunteers (age 18-63 years) were included in the study. All participants were asked to carry out uroflowmetry synchronous with recording of the sound generated by the urine stream hitting the water level in the urine collection receptacle, using a dedicated cell phone. From 188 recordings, 34 were excluded, because of voided volume <150 mL or technical problems during recording. Sonouroflowmetry recording was visualized in a form of a trace, representing sound intensity over time. Subsequently, the matching datasets of uroflowmetry and sonouroflowmetry were compared with respect to flow time, voided volume, maximum flow rate and average flow rate. Pearson's correlation coefficient was used to compare parameters recorded by uroflowmetry with those calculated based on sonouroflowmetry recordings.

RESULTS

The flow pattern recorded by sonouroflowmetry showed a good correlation with the uroflowmetry trace. A strong correlation (Pearson's correlation coefficient 0.87) was documented between uroflowmetry-recorded flow time and duration of the sound signal recorded with sonouroflowmetry. A moderate correlation was observed in voided volume (Pearson's correlation coefficient 0.68) and average flow rate (Pearson's correlation coefficient 0.57). A weak correlation (Pearson's correlation coefficient 0.38) between maximum flow rate recorded using uroflowmetry and sonouroflowmetry-recorded peak sound intensity was documented.

CONCLUSIONS

The present study shows that the basic concept utilizing sound analysis for estimation of urinary flow parameters and voided volume is valid. However, further development of this technology and standardization of recording algorithm are required.

Validating of a Novel Method for Electronically Recording Overactive Bladder Symptoms in Men

OBJECTIVE

The goal of this study was to compare a novel wireless phone and web based technology to record and store overactive bladder symptoms (OAB-S) to a traditional pen and paper micturition chart.

METHODS

Overactive bladder symptoms were recorded over a period of 3 days using both an electronic micturition chart (EMC) and the standard pen and paper micturition chart (MC). Twenty-nine men, with lower urinary tract symptoms (LUTS), were included in the study. Dropout rate, patient's preference, and correlation between the quality of life measures (QoL) and symptoms recorded with EMC versus MC, were assessed and compared.

RESULTS

Of the total number of 29 patients enrolled into the study, 24 completed the full 3-day trial using MC and 27 using EMC. MC was preferred by 50%, while EMC was preferred by 50% of participants. Using MC, 21% of patients forgot to record at least one episode of urgency, versus 17% using EMC, 17% forgot to record at least one micturition using MC versus 8% using EMC. A statistically significant correlation was found between lower severity of OAB-S and higher QoL, using both recording methods.

CONCLUSIONS

In this study population, recording symptoms with EMC did not prove to be preferable compared to MC; however, EMC provided the same level of accuracy with the same or better adherence to the study protocol.

[Bulking agents in the treatment of the stress urinary incontinence - current state and future perspectives]

A review focused on minimally invasive treatment of the stress urinary incontinence using bulking agents provides a summary of the current knowledge on this subjects. This paper summarizes the findings on the mechanism of action, indications and applications technique, as well as clinical data on the efficacy and safety of the currently available bulking agents. Attention is also paid to possible future trends of this method. The work is designed to include specific implications for clinical practice.

[Transurethral injection of polyacrylamide hydrogel (Bulkamid®) for the treatment of recurrent stress urinary incontinence after failed tape surgery]

OBJECTIVE

The objective of this study was to evaluate the cure effect of a transurethral injection of Bulkamid® for recurrent female stress and mixed urinary incontinence in women who had undergone failed tape surgery. Our hypothesis was that cure effect of Bulkamid® is positive in patients when previous tape anti-incontinence surgery has been unsuccessful.

DESIGN

Retrospective clinical study.

SETTINGS

Department of Obstetrics and Gynecology, 1st Medical Faculty, Charles University and General Faculty Hospital in Prague.

MATERIALS AND METHODS

This retrospective study featured 34 patients with recurrent urinary incontinence (SUI: 28, mixed: 6 - predominant symptom was SUI) after unsuccessful tape anti-incontinence surgery. 25 of the patients had undergone anti-incontinence surgery more than once. The cure effect of a transurethral injection of Bulkamid® was evaluated an average of 29 months after the surgery; the minimum period after surgery was 6 months. Subjective assessment of the leakage of urine was based on the International Consultation on Incontinence Questionnaire - Short form (ICIQ-UI SF) filled in before and after surgery. An improvement in urinary incontinence was defined as a drop in the score of more than 50%. Objective assessment of leakage of urine was assessed by cough test. The cure effect was evaluated by VAS (Visual Analogue Scale) score and by using the five-point Likert score. Ethical committee approval was obtained, and all subjects gave written informed consent to participate in the study.

RESULTS

The mean age of patients was 71.03 years, mean body mass index (BMI) 29.12 and mean parity 1.91. The cough test showed that 4/34 (11.8%) of patients had negative results for this test after the operation. The ICIQ-UI SF questionnaire showed that 14/34 (41.2%) of our patients were dry or improved after surgery. The mean VAS score was 62.4 after the operation. The Likert score was 4 or 5 (cured or improved) after the operation for 88.2% of patients.

CONCLUSIONS

Our hypothesis that the cure effect of Bulkamid® operation would be positive in patients who have undergone previous unsuccessful tape anti-incontinence surgery was partially confirmed. The Likert and VAS scores indicate that the effect of Bulkamid® surgery is good; however, an evaluation of the cure effect of this procedure based on the ICIQ-UI SF score is less positive. This kind of operation, which is minimally invasive, is less arduous for patients, and it is also suitable for patients who have refused further surgical treatment.

[Urinary incontinence induced by the antidepressants - case report]

AIM

Case study of the patient with urinary incontinence induced by the antidepressant mirtazapin and the review of the related literature.

DESIGN

Case Report.

SETTING

Department of Urology, University Hospital Ostrava-Poruba.

CASE REPORT

A case of 55-years old patiens, who was reffered to the surgical treatment of the urinary incontinence. We found a major discrepancies during the evaluation that led us to suspect that this is not a common uncomplicated case of stress urinary incontinence. Based on the detailed history we identified the antidepressant mirtazapine as a likely causal factor. After discontinuing mirtazapin patient has achieved full control of the continence.

CONCLUSION

Given that antidepressants affects adrenergic and dopaminergic regulatory mechanisms in the central nervous system, they may affect the lower urinary tract function. This work presents a case report where the disclosure of the less common cause of incontinence saved the patientoriginally proposed surgical treatment and allowed the effective restoration of the continence. We emphasize the need to consider the potential interaction of antidepressants with lower urinary tract function in daily practice.

Incidence of the urological tumours in patients suffering from multiple sclerosis

OBJECTIVES

The goal of this study was to evaluate the incidence of urological malignancies in MS patients using active screening.

MATERIAL AND METHODS

A total of 495 MS patients (141 men, 354 women, age of 42±13.4) were included in the study. The duration of disease was 12.3±11 years, and the EDSS score was 4.3 (±2.5). Patients, regardless of specific urological symptoms, were referred for urological evaluation. The outcomes of these evaluations were compared with data from the 2009 National Oncology Register of the Czech Republic.

RESULTS

The standardized incidence ratio (SIR) for the whole MS study population was 38.8 (95% CI 12.6-90.6). This incidence of urological malignancies in the MS study population was higher (statistically significant) than that of the general population. The SIR for females was 66.0 (95% CI 18.0-169.1) in the MS study population, representing a statistically significant increase over that of the general female population. The increase in incidence of urological malignancies in men with MS did not reach statistical significance over that of the general male population (SIR 14.7, 95% CI 0.4-81.7).

CONCLUSIONS

The incidence of urological cancer in MS patients as determined by active screening is significantly higher than that found in general population.

[Intraindividual variability of uroflowmetry in women]

OBJECTIVE

The objective of this study was to determine the intraindividual variability of uroflowmetric measurement in women with normal lower urinary tract function.

DESIGN

Prospective study.

SETTING

Departure of obstetrics and gynecology University Hospital and Medical Faculty Ostrava.

METHODS

35 women without lower urinary tract dysfunction were enrolled into the study. Every subject uderwent 3 uroflowmetric examinations. We processed all numeric results.

RESULTS

We assessed maximum and average urine flow rate - Qmax, Qave, voided volume - VV, corrected maximum urine flow and corrected average urine flow rate in every of 105 uroflowmetric´s measurements. We did not find any statistically significant difference for evaluation of intraindividual dispersion in studied parameters.

CONCLUSION

Intraindividual variability of uroflowmetric´s measurement in healthy female subjects is low. One uroflowmetric´s measurement is adequate for assessment of uroflowmetric´s parameters..

KEYWORDS

uroflowmetry, intraindividual variability, lower urinary tract.

Lower urinary tract functions in a series of Charcot-Marie-Tooth neuropathy patients

OBJECTIVES

To evaluate lower urinary tract (LUT), bowel, and sexual dysfunctions in a series of patients with Charcot-Marie-Tooth disease (CMT).

MATERIALS AND METHODS

A cohort of 58 patients and 54 healthy controls filled out the International Prostate Symptoms Score (IPSS) and the International Consultation on Incontinence Modular (ICIQ) Questionnaires to assess their symptoms and their impact on the patient's quality of life.

RESULTS

On the IPSS questionnaire, CMT patients reported a significantly higher score compared with the healthy controls in 7 of 8 questions. The ICIQ-male LUT symptoms questionnaire revealed a significantly higher score in 7 of 26 questions. In the ICIQ-female LUT questionnaire, a significantly higher score was observed in 13 of 24 questions. When assessing the bowel function in CMT patients using the ICIQ-bowel questionnaire, a significantly higher score in 30 of 40 questions was noted. No differences in sexual function were found in either group.

CONCLUSIONS

The occurrence of the LUT symptoms and bowel dysfunctions in CMT patients was significantly higher when compared with an age-matched control group. The symptoms were more frequent in female patients. The findings suggest that autonomic dysfunction should be evaluated and included in the diagnostic approach and care of CMT patients.

Dynamics of fertility in patients on waiting list for kidney transplantation

OBJECTIVES

To evaluate the presence of hormonal abnormalities and fertility disorders in patients with chronic kidney disease (CKD) awaiting renal transplantation.

METHODS

From September 2009 to April 2011 all male patients with CKD awaiting kidney transplantation were investigated. The following tests were performed: semen analysis, serum concentration of testosterone, SHBG, LH, FSH and prolactin. Differences in hormone levels and sperm count parameters were statistically evaluated between the control group and the patient group.

RESULTS

The group of patients consisted of 74 and the control group of 41 men. Average testosterone levels were lower in patients compared to control group. In patients significantly higher levels of SHBG, LH, FSH and PRL were found, and statistically significantly lower ejaculate volume, total sperm count, sperm concentration, total and progressive sperm motility and sperm morphology than in the control group. Within the group of patients a negative correlation between testosterone and PRL was found and a positive correlation between testosterone and total sperm motility and morphology. A negative correlation was detected between the duration of haemodialysis and testosterone, sperm concentration, total and progressive motility and sperm morphology.

CONCLUSION

Significant changes in hormone levels and impaired fertility are found in haemodialyzed patients on a waiting list for kidney transplantation. The dynamics of these changes are dependent on the duration of haemodialysis (Tab. 4, Fig. 2, Ref. 15). Text in PDF www.elis.sk.

[Nocturia, incidence, ethiology, diagnostics]

Nocturia is the complaint that the individual has to wake at night one or more times to void, according to the International Continence Society definition from the ICS Standardisation of Terminology Report 2002. As the nocturia definition is complicated there are also other slightly modified definitions. It is currently not absolutely clear if prevalence or incidence is more important for epidemiology evaluation of nocturia. Nocturia is a variable symptom and its presence in individuals is reversible therefore it is very difficult to obtain reliable incidence data. Nocturia prevalence varies remarkably in different studies according to evaluation methodology, nocturia definition, methods of data collection and characteristics of evaluated population. There are not enough studies, especially demographic ones, evaluating lower urinary tract symptoms and/or nocturia in males and females. There is relatively large number of comparative studies confirming strong correlation between aging and prevalence of nocturia. Prevalence of two or more voids per night in individuals in their twenties varies between 5-15 %, it progresses with age, and in the seventh decade of life ranges between 35-50 %. Prevalence evaluated by gender is higher among younger women compared to older women and older men compared to younger men. Currently there are only limited sources of data regarding nocturia incidence. Incidence of nocturia (two or more voids per night) in a population older than 60 years is 213 new cases/1000 persons/1 year in two year observation. Incidence of two or more voids per night is 75 new cases/1000 male/1 year in five year observation and 126 new cases/1000 male/1 year in ten year observation in male population. Incidence of nocturia rises significantly with age. Incidence of two or more voids per night increases by 2,7 % in the population of women after child birth during 5 year follow up and by 5,9 % during 12 year follow up. Incidence of nocturia newly diagnosed in a pregnancy drops down by 98% in 3 month after the child birth. The incidence data indicate that incidence of nocturia rises with age and probability of nocturia relief decreases with age. Incidence of mild nocturia is higher compared to incidence of severe nocturia and significant relief of nocturia in women after child birth is very inconsistent compared to increase of other lower urinary tract symptoms. Ethiology of nocturia might be polyuria, nocturnal polyuria or reduced bladder capacity. Nocturia and its ethiology can be determined in most cases with simple and commonly used investigative methods on the out-patients bases. The diagnostic algorithm should lead to verification of nocturia and identifying its cause because treatment of nocturia differs remarkably according to the etiology.

[Nocturnal polyuria, treatment with desmopressin]

Nonpharmacologic and especially pharmacologic treatment options are available for nocturnal polyuria. Desmopressin represents the basis of pharmacologic treatment. Desmopressin acetate is a synthetic analogue of arginine vasopressin with high affinity to V2 receptors with antidiuretic effect. It is the only medicament currently registered for antidiuretic treatment. Desmopressin has not any relevant affinity to V1 receptors, and therefore there is no hypertensive effect in contrary to natural vasopressin. Desmopressin use before a bedtime leads to reduced production of urine during a sleep, therefore time between desires to void is prolonged and number of nocturia is reduced. Clinical effect, in a meaning of reduced urine production and increased osmolality of urine, lasts approximately 8-12 hours. In the treatment of nocturnal polyuria desmopressin is used orally one hour before a bedtime. It is essential to titrate an ideal dose, the initial dose is 60 µg of MELT formula (fast melting oral formulation) and it can be increased according to the clinical effect up to the maximal recommended daily dose 240 µg. Patients treated with desmopressin should cut down a fluid intake 1 hour before and 8 hours after the use of desmopressin. Total number of adverse events connected withdesmopressin treatment in clinical studies was higher compared to placebo but the side effects were mostly mild. The most common adverse events were headaches, nausea, diarrhoea, abdominal pain, dry mouth and hyponatremia both in the short-term and long-term clinical trials. Hyponatremia was observed mainly in patients over 65 year of age. Therefore treatment with desmopressin should not be commended in patients over 65 year of age without close monitoring of the natrium level in serum and all patients should be informed about the first symptoms of hyponatremia - headache, nausea and insomnia. According to Evidence Based Medicine, the level of evidence for treatment of nocturnal polyuria with desmopressin is 1b and the grade of recommendation for treatment is A.

KEYWORDS

nocturnal polyuria - treatment - desmopressin.

Persistence with first line anticholinergic medication in treatment-naïve overactive bladder patients

OBJECTIVE

The aim of this study was to evaluate the persistence of first line anticholinergic medication use by patients with overactive bladder (OAB). Data from a hospital outpatient database were matched with information obtained by a telephone survey of patients to determine which patients discontinued use of anticholinergic medication and to identify the reasons underlying discontinuation.

MATERIAL AND METHODS

The study group included 377 OAB patients (52 men, 325 women) with a mean age of 60.29 ± 13.84 years. In total, 189 patients (50.1%) were treated with trospium (median dose 27.86 ± 12.73 mg), 41 patients (10.9%) with propiverine (28.17 ± 4.97 mg), nine patients (2.4%) with extended-release tolterodine (4.0 ± 0 mg), 48 patients (12.7%) with solifenacin (5.94 ± 1.97 mg) and 90 patients (23.9%) with fesoterodine (6.09 ± 2.01 mg).

RESULTS

The median time for persistence with the first line anticholinergic treatment was 6.53 ± 3.84 months. Persistence was significantly higher in patients treated with anticholinergic medication with an extended-release formulation than in patients treated with immediate-release anticholinergics. The most common reasons for termination of treatment were healing/resolution of symptoms (35.9%), low effectiveness (30.9%) and side-effects (23.7%).

CONCLUSIONS

More than half of the OAB patients were not satisfied with their first line treatment. Other treatment options should be sought, such as changing the medication or dosage, or possibly combining treatments.

Brain activity during bladder filling and pelvic floor muscle contractions: a study using functional magnetic resonance imaging and synchronous urodynamics

OBJECTIVES

To map the brain activity during bladder filling by functional magnetic resonance imaging using a refined scanning protocol including synchronous urodynamics and pelvic floor muscle contractions.

METHODS

A total of 23 healthy female volunteers (age 20-68 years) were enrolled. Participants were asked to contract their pelvic floor muscles. This was followed by a urodynamic examination consisting of repeated filling cycles. Brain activity was measured by functional magnetic resonance imaging using a 3T magnetic resonance system. Measurements of brain activity consisted of 120 functional scans during pelvic floor contractions and 210 scans during bladder filling. Each functional magnetic resonance imaging scan covered the brain with 35 slices. Statistical analyses used the general linear model and independent component analysis. Areas of activation were visualized using group statistics.

RESULTS

The following main clusters of activation were observed during pelvic floor muscle contractions: medial surface of the frontal lobe (primary motor area), bilaterally; supplementary motor area, bilaterally; and left gyrus precentralis. During bladder filling, activation was detected in the inferior frontal lobe bordering the frontal cingulum, left gyrus parietalis superior, left central area, right insula, brainstem and thalamus with subcortical gray matter nuclei.

CONCLUSIONS

Our work extends an existing functional magnetic resonance imaging protocol for researching the neural control of the lower urinary tract. The present results are consistent with the available literature and agree with the present hypothetical functional model of lower urinary tract neural control.