Development of a predictive tool for sacral nerve modulation implantation in the treatment of non-obstructive urinary retention and/or slow urinary stream: a study from the Neuro-Urology Committee of the French Association of Urology

PURPOSE

This study aimed to seek predictive factors and develop a predictive tool for sacral nerve modulation (SNM) implantation in patients with non-obstructive urinary retention and/or slow urinary stream (NOUR/SS).

METHODS

This study was designed as a retrospective study including all patients who have undergone a two-stage SNM for NOUR/SS between 2000 and 2021 in 11 academic hospitals. The primary outcome was defined as the implantation rate. Secondary outcomes included changes in bladder emptying parameters. Univariate and multivariable logistic regression analysis were performed and determined odds ratio for IPG implantation to build a predictive tool. The performance of the multivariable model discrimination was evaluated using the c-statistics and an internal validation was performed using bootstrap resampling.

RESULTS

Of the 357 patients included, 210 (58.8%) were finally implanted. After multivariable logistic regression, 4 predictive factors were found, including age (≤ 52 yo; OR = 3.31 CI95% [1.79; 6.14]), gender (female; OR = 2.62 CI95% [1.39; 4.92]), maximal urethral closure pressure (≥ 70 cmH2O; OR: 2.36 CI95% [1.17; 4.74]), and the absence of an underlying neurological disease affecting the lower motor neuron (OR = 2.25 CI95% [1.07; 4.76]). Combining these factors, we established 16 response profiles with distinct IPG implantation rates, ranging from 8.7 to 81.5%. Internal validation found a good discrimination value (c-statistic, 0.724; 95% CI 0.660-0.789) with a low optimism bias (0.013). This allowed us to develop a predictive tool ( https://predictivetool.wixsite.com/void ).

CONCLUSION

The present study identified 4 predictive factors, allowing to develop a predictive tool for SNM implantation in NOUR/SS patients, that may help in guiding therapeutic decision-making. External validation of the tool is warranted.

[Bladder augmentation in the era of botulinum toxin: Indications and results]

AIM

To determine the surgical indication and results of bladder augmentation (BA) during the last decade in a neurourology center in the era of intradetrusor botulinum toxin injection.

MATERIAL

We conducted a retrospective study that included patients with BA between January 1, 2012 and December 31, 2022 in our centre. We collected pre-operative demographic, clinical, and urodynamic data, BA indication, and associated procedures. We analyzed early and late complications as well as continence and postoperative voiding mode in patients with first BA in a neurological pathology context.

RESULTS

We performed 77 BA over the study period. The main indication was neurogenic overactive bladder, which was secondarily resistant to botulinum toxin. The main associated procedure was continent cutaneous diversion (n=31, 57.4%). Among patients who had a first BA for neurogenic bladder, 34 patients had early complications (50%) including 12 patients with≥Clavien 3 complications (17.6%). After a median follow-up of 33 [14; 55] months, 23 patients had late complications (33.8%) and 59 patients had complete continence (86.8%).

CONCLUSION

In the era of botulinum toxin, the main indication of BA is the secondary failure of botulinum toxin for overactive neurogenic bladder. The BA provided continence in 86.8% of patients. It remains however an intervention with a significant rate of severe complications whose indication must be discussed by a multidisciplinary team.

LEVEL OF EVIDENCE

Weak.

[Home uroflowmetry technics and clinical relevance: A narrative review]

INTRODUCTION

Urine flowmetry (UF) is a key non-invasive urodynamic test for the evaluation of the voiding phase in patients with lower urinary tract symptoms (LUTS). Traditional free urodynamic testing (FUT) performed on a one-time basis in the office is limited by difficulty in capturing normal voiding and high intrapatient variability in urine flow parameters. Home measurement of urine flow by the patient could be a way to obtain multiple data in real-life conditions, addressing its limitations. The objective of this article was to review the literature on the different techniques of home uroflowmetry (HUF) and their clinical interest in comparison with FUT.

MATERIAL AND METHODS

A search on the PubMed database using the key words "Urodynamics, Uroflowmetry, non-invasive urodynamics, Ambulatory urodynamics, bladder outlet obstruction, male LUTS" was performed to find articles in English or French that had been published with no time limit and March 2022. The sorting by reading the abstract allowed the selection of all articles describing and/or evaluating a HUF technique that were read entirely according to the same collection grid to propose a narrative synthesis.

RESULTS

Thirty-one articles were identified, selected, and analyzed. Simple and inexpensive techniques by timing or use of funnels reliably and reproducibly estimate the average and maximum urine flow in relation to the FUT, without providing a complete flow curve. More sophisticated electronic or sonometric methods, some using connected mobile applications, present results that are more consistent with ICS recommendations for flow measurement. With the possibility of studying the average of several values of the maximum urinary flow (Qmax) captured during micturition in physiological conditions, some studies suggest a gain in diagnostic value in the evaluation of the emptying phase and lower urinary tract symptoms in men. However, the literature is sparse, old and the clinical benefits are not yet proven.

CONCLUSION

There is a wide range of techniques for measuring urine flow in the patient's home, all of which aim to fill the gaps in conventional urine flow measurement. Further studies are needed to demonstrate the acceptability of this type of measurement by patients, the existence of a real clinical benefit, to assess the cost/benefit balance and finally to define a possible place for home uroflowmetry in daily practice, compared with traditional free flowmetry and invasive urodynamics (pressure-flow test).

[Learning of self-catheterization: For whom? Why? How?]

Since the 1970s, self-catheterization is the preferred method of urine drainage in case of urinary retention of neurological etiology (paraplegia, multiple sclerosis…) and non-neurological cause (benign prostatic hypertrophy, acontractile bladder of the elderly subject…). The main objective is to allow the physiological alternation of filling and complete emptying phases, in order to preserve the renal function and prevent urinary infections. The learning of self-catheterization is simple but requires a therapeutic education session with trained personnel, at home or in a specialized center. Cognitive disorders, poor vision, lack of dexterity or lack of knowledge of urogenital anatomy are the main limitations to their implementation. Their success depends on the frequency of catheterization (every 4h), which is performed in a clean but non-sterile manner. The benefit/risk ratio is largely in favor of using them to replace the indwelling probe whenever possible.

Primary Complete Transurethral Resection of Bladder Tumor Using Photodynamic Diagnosis for High-Risk Nonmuscle Invasive Bladder Cancer: Is a Restaging Photodynamic Transurethral Resection Really Necessary?

Objectives: To evaluate the risk of residual tumor and tumor upstaging during a second resection after primary complete transurethral resection of bladder tumor (TURBT) using photodynamic diagnosis (PDD) for high-risk nonmuscle invasive bladder cancer (NMIBC). Patients and Methods: From January 2014 to March 2020, a single-institutional study was conducted including consecutive patients with high-risk NMIBC (T1 and/or cis and/or high grade) who underwent a restaging transurethral resection (reTUR) within 12 weeks after a primary complete resection. Each TURBT was performed using blue light after intravesical instillation of hexaminolevulinate. The primary endpoint was detection of residual tumor at reTUR, proved with positive pathology report. Results: A total of 109 consecutive patients with high-risk NMIBC underwent reTUR after a primary complete blue light resection. Pathologic evaluation of the surgical specimens of the primary TURBT revealed stage T1 and high-grade tumors in 69 (68.3%) and 108 (99%) patients, respectively, and concomitant carcinoma in situ was found in 45 patients (41.3%). The median time to reTUR was 8 (6-10) weeks. Residual tumor was detected histopathologically in 64 of 109 patients (58.7%) at the second TURBT with PDD. In five of these patients (4.5%), initial T1 tumors were upstaged to T2 tumors. Conclusions: We examined a contemporary series of patients undergoing reTUR with PDD as management of high-risk NMIBC proven at the first blue light resection. We reported a 54.2% risk of disease persistence and a 4.5% risk of understaging in T1 tumors. These findings support that reTUR is still necessary after initial complete TURBT with PDD. Further studies are needed to assess the long-term oncologic outcomes of reTUR with PDD.

Continuous saline bladder irrigation after blue light transurethral resection of bladder tumor increases recurrence-free survival in low- to intermediate-risk non-muscle invasive bladder cancer

OBJECTIVES

To evaluate the efficacy of Continuous Saline Bladder Irrigation (CSBI) after blue light transurethral resection of bladder tumor (TURBT) to prevent recurrence of low- to intermediate-risk Non-Muscle Invasive Bladder Cancer (NMIBC).

PATIENTS AND METHODS

We conducted a retrospective study including patients with low- to intermediate-risk NMIBC who underwent TURBT in two urological centers between January 2017 and December 2018. Each TURBT was performed using blue light after intravesical instillation of hexaminolaevulinic acid. The experimental group included patients who received CSBI while the control group included patients without CSBI. When practice, CSBI was started immediately after the surgery and was interrupted 24 hours thereafter. Low-risk NMIBC had a surveillance while intermediate NMIBC had 8 adjuvant endovesical instillations of Mitomycin. The primary endpoint was bladder tumor recurrence free-survival which was defined as the time between the initial TURBT and the date of TURBT for bladder recurrence.

RESULTS

A total of 167 patients (median age: 71 years) were included: 20% female, 15% low-risk, 85% intermediate-risk NMIBC. CSBI was performed in 95 cases (57%). No complication related to irrigation was reported. Bladder recurrence was observed in 55 cases (32.9%): 22 (23.1%) in the CSBI group vs. 33 (45.8%) in the control group (P=0.002). Multivariate stepwise logistic regression analysis with backward selection revealed that CSBI (HR 0.47 [0.27-0.81]; P=0.006) and MMC (HR 0.55 [0.31-0.95]; P=0.034) were significantly associated with reduced risk of bladder recurrence.

CONCLUSIONS

Continuous saline bladder irrigation reduced the risk of bladder recurrence after blue light TURBT in patients with low- to intermediate-risk NMIBC while being safe. Prospective randomized study is needed to confirm these results.

LEVEL OF EVIDENCE

3.

[Intradetrusor injections of botulinum toxin A to treat urinary incontinence due to bladder overactivity during idiopathic Parkinson's disease]

INTRODUCTION

During idiopathic Parkinson's disease (IPD), lower urinary tract symptoms and dysfunctions are frequent, dominated by overactive bladder and detrusor overactivity (OAB, DO). Intradetrusor Injection (IDI) of Botulinum Toxin A (BTA) is recommended as second-line treatment for neurogenic urinary incontinence related to DO in multiple sclerosis or spinal cord injury patients. However, there is little data on BTA IDI to treat incontinence owing to OAB and DO during idiopathic Parkinson's disease. The objective of this study is to evaluate efficacy and tolerance of BTA IDI in patients suffering IPD.

PATIENTS AND METHODS

We conducted a retrospective study in IPD patients treated with BTA IDI from 2012 to 2018. For each patient we compared patient clinical and urodynamic data at baseline before the first injection and 8 weeks following the injection. We defined 3 levels of effects (perfect, improved, failure), corresponding to 3-dimension composite criteria: clinical, quality of life (Likert scale), urodynamics.

RESULTS

Sixteen patients were included from 2012 to 2018. The median age was 73 (70-78.25). The median number of micturition/day before and after TBA was 13 (10-16) and 9 (6.75-13.25) (p=0.022). The median number of pad used/day before and after BTA was 5.4 (2-5) and 1 (0-5) (p=0.035). Median USP scores for OAB was 15.5 (11.75-20) and 14 (6.75-15.25). Median score on the Likert scale was 1 (0-1.5) meaning "slight improvement" felt by the patient. The median maximum cystometric capacity raised from 130cm³ (41.25-187.75) to 217cm³ (165-376.75) (p=0,013). Among the patients, 20% had a perfect result, 40% were significantly improved and in 40% TBA injections failed. After TBA 4/14 patients (28%) needed intermittent self-catheterization. No severe side effect was observed.

CONCLUSION

In this retrospective study we observe some short-term efficacy of TBA IDI to treat urinary incontinence owing to OAB/DO in patients with IPD in 60% of patients. These results are consistent with findings from previous retrospective studies. Prospective data coming from larger cohorts are now tremendously needed to clarify the best patient responders profiles, the actual TBA dose, and eventually to define TBA IDI place in the therapeutic algorithm of IPD patients' incontinence.

LEVEL OF EVIDENCE

4.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion

OBJECTIVE

To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use.

PATIENTS AND METHODS

A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC.

RESULTS

Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed.

CONCLUSIONS

For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Efficacy and Safety of Surgery for Benign Prostatic Obstruction in Patients with Preoperative Urinary Catheter

Purpose: To evaluate the efficacy and safety of benign prostatic obstruction (BPO) surgery in patients with preoperative urinary catheterization. Patients and Methods: We conducted a multi-institutional retrospective study including all patients who failed a trial without catheter (TWOC) after acute urinary retention (AUR) between January 2017 and January 2019. Patients with neurogenic bladder, prostate cancer, or urethral stricture were excluded from the analysis. Patients underwent either monopolar/bipolar transurethral resection of the prostate (TURP), photoselective vaporization of the prostate (PVP), prostate artery embolization (PAE), open prostatectomy (OP), or endoscopic enucleation. The primary endpoint was 12-month urinary catheter-free survival without using benign prostatic hyperplasia medications. Results: One hundred seventy-one consecutive men (median age: 71 years; median prostate volume: 75 cm³) underwent BPO surgery, including 48 (28%) TURP, 62 (36.3%) PVP, 21 (12.3%) endoscopic enucleation, 15 (8.8%) PAE, and 25 (14.6%) OP. The median duration of preoperative urinary catheterization was 69 days (interquartile range 46-125). The 12-month urinary catheter-free survival rate was 84.8% (145/171). Satisfactory voiding returned to 121 patients (70.8%). On backward stepwise multivariable analysis, PVP (odds ratio [OR] 0.27 [0.10-0.69]; p = 0.008), PAE (OR 5.27 [1.28-27.75]; p = 0.03), endoscopic enucleation (OR 0.08 [0-0.49]; p = 0.023), OP (OR 0.10 [0.01-0.57]; p = 0.034), Charlson score (OR 1.36 [1.14-1.66]; p = 0.001), and number of preoperative TWOC failure (OR 2.53 [1.23-5.51]; p = 0.014) were significantly associated with catheter-free survival. Conclusions: In this multi-institutional retrospective study, including patients with preoperative catheterization, the overall success rate of BPO surgery was 70.8% after 1-year follow-up. Compared with TURP, enucleation methods and PVP were associated with better catheter-free survival, whereas PAE was associated with higher risk of AUR recurrence.

The prognostic value of serum procalcitonin in acute obstructive pyelonephritis

PURPOSE

To evaluate the prognostic value of procalcitonin (PCT) in the occurrence of infectious complications in the management of acute obstructive pyelonephritis (AOP) compared with other biological parameters (leucocyte count, C-reactive protein [CRP]).

METHODS

We conducted a retrospective study including patients who were treated for AOP and performed serum PCT tests in our center between January 1, 2017 and December 31, 2017. Upper urinary tract obstruction was confirmed by either ultrasound or CT urography. Clinical examinations and laboratory tests including leukocyte count, CRP, urine and blood cultures, and serum PCT measurements were performed in the emergency unit. Treatment included early renal decompression using indwelling ureteral stents or nephrostomy and empiric antibiotic therapy. The primary endpoint was occurrence of severe sepsis (SS), a composite criterion including urosepsis and/or septic shock and/or admission to the intensive care unit (ICU) and/or death.

RESULTS

A total of 110 patients (median age: 61 years) were included, of whom 56.3% were female. SS occurred in 39 cases (35.4%). Multivariate regression analysis showed that serum PCT (OR 1.08; 95% CI 1.03-1.17; p = 0.01), CRP (OR 1.007; 95% CI 1.001-1.015; p = 0.03), and diabetes mellitus (OR 5.1; 95% CI 1.27-27.24; p = 0.04) were independent predictors for SS. Serum PCT was the biological marker associated with the highest accuracy to predict SS (ROC 0.912 (95% CI 0.861-0.962) and was superior to CRP (p < 0.001): the sensitivity and specificity of PCT to predict SS were 95% and 77%, respectively, with a serum PCT cutoff value of 1.12 µg/L.

CONCLUSIONS

PCT levels > 1.12 µg/L could help physicians to identify high-risk patients who could benefit from early and aggressive management in collaboration with intensive care specialists.

Selective Trans-arterial Embolization of Iatrogenic Vascular Lesions Did Not Influence the Global Renal Function After Partial Nephrectomy

OBJECTIVE

To evaluate the renal function outcomes after selective trans-arterial embolization (SAE) of iatrogenic vascular lesions (IVL), including pseudoaneurysm and arteriovenous fistula, following partial nephrectomy (PN).

MATERIALS AND METHODS

A multi-institutional study was conducted including consecutive patients who underwent PN between January 2009 and March 2019. Two surgical approaches were used: open and robot-assisted PN. Patients with SAE were identified and matched (1:2) with patients without IVL. The matching criteria were age, gender, Charlson score, creatinine clearance, RENAL score, and tumor size. The primary outcome was the evolution of global renal function at 6-months postoperatively.

RESULTS

A total of 493 consecutive PN (360 open PN and 133 robot-assisted PN) were included. IVL occurred in 17 cases (3.4%) without statistical difference according to the surgical approach (P = .78). Patients from embolization group were matched to 34 cases without postoperative IVL. Groups were comparable concerning clinical, tumor and surgical characteristics. The clinical success of SAE, defined as the absence of recourse to a second embolization or a total nephrectomy, was obtained in 16 (94.1%) cases. No minor or major complications were reported after SAE. The preoperative estimated glomerular filtration rate (eGFR) was similar between control group (93 [85-102] ml/min) and embolization group (95 [83-102] ml/min) (P = .99). Median (IQR) eGFR between control group (87 [72-95] ml/min) and embolization group (83 [76-93] ml/min) at a follow-up of 6 months showed no significant difference (P = .73).

CONCLUSION

IVL are rare complications of PN. SAE is an effective and minimally invasive management tool, with no deleterious effect on global renal function.

Robot-assisted implantation of an artificial urinary sphincter, the AMS-800, via a posterior approach to the bladder neck in women with intrinsic sphincter deficiency

OBJECTIVES

To describe a new technique for robot-assisted AMS-800 artificial urinary sphincter (AUS) bladder neck implantation in women.

PATIENTS AND METHODS

We reviewed the medical files of patients who underwent robot-assisted AUS implantation between March 2017 and November 2018 at our centre. All of the implantations were performed using a posterior approach to the bladder neck in order to avoid blind dissection and the risk of vaginal and/or bladder injury. This strategy was viewed as an alternative to the anterior robot-assisted implantation recently described. The AUSs were activated 5 weeks after implantation. Patients were followed up at 3, 6 and 12 months, then annually.

RESULTS

Eight patients, with a median age of 64 years, underwent robot-assisted AUS implantation via a posterior approach to the bladder neck. The median preoperative pad weight was 300 g/24 h. The median operating time was 244 min. No peri-operative vaginal and or bladder injuries were observed. At a median of 12 months of follow-up, all the AUSs were functional. Five patients required no protection (62.5%), three had day protection (37.5%), and all said they were satisfied except for one patient (12.5%) who requested treatment for persistent urge incontinence.

CONCLUSION

Robot-assisted AUS implantation in women via a posterior approach to the bladder neck is a procedure that is simple, reproducible and safe. The short-term functional results are satisfactory and comparable to those obtained via an open approach. A more long-term comparison of the efficacy and longevity of AUSs implanted using this posterior approach is needed to confirm its benefit compared with the anterior robot-assisted approach and the classic open technique.

An exceptional migration of ureteral stent after antegrade placement: A case report

We report an exceptional migration of ureteral stent in patient who underwent a robot-assisted laparoscopic right pyelotomy. After stone removal, an antegrade ureteral stenting (7-french; Double J) was performed without fluoroscopic control. A radiographic control was performed the next day and highlighted a migration into the cardiovascular system. The Double J was removed percutaneously through the right femoral vein under fluoroscopic guidance.

Comparative medico-economic study of reusable vs. single-use flexible ureteroscopes

PURPOSE

Reusable flexible-ureteroscopes (fURS) require personnel and budget for processing and repairing, whereas single-use fURS were recently developed. After exclusive reusable fURS since 2011, we experienced high repair costs and single-use fURS were therefore introduced in mid-2017. We aimed to evaluate economic and practical advantages and disadvantages of reusable versus single-use fURS.

MATERIALS AND METHODS

First, we evaluated the incidence of breakage and repairs of reusable fURS in 2017. We assessed the overall operational costs of reusable fURS including purchase, processing, and repairing in our institution from 2011 to 2017. Following our experience, we created a model to compare operation costs/procedure of single-use fURS with reusable fURS depending on repair costs.

RESULTS

In 2017, repair costs of reusable fURS increased by 345% compared with the period 2011-2016, causing: a median unavailability per reusable fURS of 200 days/year (100-249), median number of functioning fURS 0/5-3/5 per operating day, while unavailability of reusable fURS had become the first reason for cancellation of procedure. Since it was introduced, single-use fURS accounted for 59% of the flexible ureteroscopy activity. Taking into account the costs of processing, maintenance and repair, in 2011-2016 versus 2017, the single-use fURS was cost-effective compared with the reusable fURS until the 22nd procedure versus the 73rd procedure, respectively.

CONCLUSIONS

After years of exclusive reusable fURS, the rising incidence of breakage not only increased maintenance costs but also hampered daily activity owing to unavailability of the devices. The introduction of single-use with reusable fURS provided substantial help to maintain our activity.

[Does diagnostic ureterorenoscopy increase the risk of bladder recurrence after total nephroureterectomy? A review of the literature]

OBJECTIVE

The objective of our study was to evaluate, in a review of the literature, the impact of diagnostic ureteroscopy before total nephroureterectomy (NUT) on the risk of bladder recurrence.

METHODS

We conducted a literature review in the Pubmed database in March 2018. Initial research identified 45 publications. Following full text screening, 9 studies were finally included, with a total of 1041 NUT with URS prior versus 2909 NUT alone. The primary endpoint was bladder recurrence. Secondary objectives were specific survival and overall survival.

RESULTS

Bladder recurrence was reported in the 9 studies included. Diagnostic ureteroscopy was significantly associated with an increased risk of post-NUT bladder recurrence (HZ 1.42 [1.29-1.56], P<0.01). The specific survival and overall survival at 5 years, were reported in respectively 4 and 2 studies. There was no impact of the pre-NUT diagnostic URS on the specific survival (HZ 0.75 [0.54-1.03], P=0.08) or post-NUT overall survival (HZ 1.15 [0.68-1.96], P=0.59).

CONCLUSION

The URS diagnostic before NUT for TVEUS is associated with a significant increase in the risk of postoperative bladder recurrence.

Switch to Abobotulinum toxin A may be useful in the treatment of neurogenic detrusor overactivity when intradetrusor injections of Onabotulinum toxin A failed

AIMS

To assess the outcomes of switching to a different brand of botulinum toxin A (BTA, from Botox® to Dysport®) in case of failure of intradetrusor injections (IDI) of Botox® in the treatment of neurogenic detrusor overactivity (NDO).

METHODS

The charts of all patients who underwent a switch to IDI of Dysport® after failure of an IDI of Botox® at six departments of neurourology were retrospectively reviewed. The main outcomes of interest were the bladder diary data and four urodynamic parameters: maximum cystometric capacity (MCC), maximum detrusor pressure (PDET max), and volume at first uninhibited detrusor contraction (UDC).

RESULTS

Fifty-seven patients were included. After the first injection of Dysport®, no adverse events were reported. A significant decrease in number of urinary incontinence episodes per day was observed in 52.63% of patients (P < 0.001) and all patients experienced a reduction in PDET Max (-8.1 cmH20 on average; P = 0.003). MCC significantly increased by a mean of 41.2 (P = 0.02). The proportion of patients with no UDC increased significantly at week 6 after ATA injections (from 15.79% to 43.9%; P = 0.0002). Hence, 32 patients draw clinical and/or urodynamic benefits from the botulinum toxin switch from (56.14%). After a median follow up of 21 months, 87% of responders to BTA switch were still treated successfully with BTA.

CONCLUSION

Most patients refractory to Botox® (56.14%) draw benefits from the switch to Dysport®.

Dietary exposure to silver nanoparticles in Sprague-Dawley rats: effects on oxidative stress and inflammation

Due to undesirable hazardous interactions with biological systems, we evaluated the effect of silver nanoparticles (AgNPs) intake on oxidative stress and inflammation. Rats received for 81 days a standard diet (Controls) or a standard diet plus 500 mg/d/kg BW AgNPs. We assayed plasma lipids, and oxidative stress was assessed by measuring liver and heart superoxide anion production (O₂°⁻) and liver malondialdehyde levels (MDA). Antioxidant status was appraised using plasma paraoxonase activity (PON), plasma antioxidant capacity (PAC) and liver superoxide dismutase activity (SOD). Liver inflammatory cytokines TNFα and IL-6 levels and plasma alanine aminotransferase (ALT) were assayed. Compared with Controls, AgNPs raised cholesterolemia (9.5%), LDL-cholesterol (30%), and lowered triglycerides (41%). They also increased liver (30%) and cardiac (41%) O₂°⁻ production, reduced PON activity (15%) and raised liver TNFα (9%) and IL-6 (∼12%). Plasma ALT activity rose (12%) after treatment with AgNPs. However, PAC and liver MDA and SOD activity were unchanged. These features indicate that exposure to 500 mg/d/kg BW of AgNPs results in liver damage by a dysregulation of lipid metabolism, highlighting liver and heart as the most sensitive organs to the deleterious effects. Our findings also demonstrate for the first time the oxidative and inflammatory effects of dietary AgNPs.

[Treatment of detrusor-striated sphincter dyssynergia with permanent nitinol urethral stent: results after a minimum follow-up of 2 years]

OBJECTIVES

The aim of this study was to assess the outcomes of nitinol permanent urethral stents used in detrusor-striated sphincter dyssynergia (DSD) treatment on male patients with a spinal cord injury.

MATERIALS

We investigated retrospectively all patients treated from 2004 to 2012. A total of 22 patients were included, with an age ranging from 22 to 76 years old. The DSD syndrome was due to spinal cord injury (18) or various spinal cord diseases (four) and treated with a nitinol urethral stent (11 Ultraflex(®) and 11 Mémotherm(®)). Every patient had an urodynamical study. The follow-up reached at least 2 years.

RESULTS

The mean follow-up was 56 months (± 14). Complementary procedures after stenting included: five stent prolongation or displacement (mean interval 7.6 months), six bladder neck incisions (12.2 months), three urethrotomy (42 months), ten obstruction treated by laser (47.3 months). Eight patients had a change of their urinary pattern: four underwent ileal conduit diversion, one had a continent urinary diversion, one chose self intermittent catheterization, two were under indwelling catheterization waiting for another treatment. Stent retrieval was either harmful or impossible for four of them. Three patients were free of complementary procedures.

CONCLUSIONS

Nitinol urethral stent was an effective treatment initially. However, by the third year, urethral stenosis and hypertrophic growth of the urethral mucosa usually require iterative endoscopic procedures (0.31 per patient per year). Patients treated with permanent uretral stent deserve a yearly endoscopic follow-up. Safety and effectiveness of permanent uretral stent compared to surgical sphincterotomy to treat DSD are discussed.

[Female stress incontinence treatment: urethral slings]

Female stress incontinence is often the consequences of obstetrical traumatisms. They are responsible of a weakness of perineal musculoaponevrotic structures. Until 1996, the reference treatment of this pathology was the "Burch" colposuspension, by laparotomy, then laparoscopic way. After 1996, a new procedure was developped by Ulmten, reproducible, easy, safe and mini-invasive: the tension free-vaginal-tape (TVT) followed by the trans-obturator-tape (TOT). This therapeutic tool has become the reference for the treatment of the female stress incontinence. There are now 15 years from the beginning of this procedure and still 80% of the patients are improved.

[Flexible ureteroscopy with laser for upper urinary tract stone]

The treatment of upper urinary tract stone with flexible ureteroscopy is safe and efficient. According to the size and the localization of stone, it is the first-line treatment. The patient must be informed about modalities and risks of this treatment. Urines must be sterile. The fragmentation of stone is made with the energy of Laser Holmium. The knowledge of material and technique allows to obtain a complete treatment in about 80% of cases.

Transient increase in the high affinity [3H]-L-glutamate uptake activity during in vitro development of hippocampal neurons in culture

The glial GLAST and GLT-1 glutamate transporters are transiently expressed in hippocampal neurons as shown by immunocytochemistry (Plachez et al., 2000. J. Neurosci. Res., 59, 587-593). In order to test if this transient expression is associated to a transient glutamate uptake activity, [3H]-glutamate uptake was studied during the in vitro development of embryonic hippocampal neurons cultured in a defined (serum free) medium. In these cultures, the ratio of the number of glial cells to the number of neurons increased from 1.7 to 11.3% during the first 10 days of culture, while 77% of the neurons died. The number of neurons then remains stable up to 23 days of culture. The initial glutamate uptake velocity at 20 and 200 microM [3H]-glutamate usually increased about five times between 1 and 10 days in vitro (DIV). Interestingly, at 2 microM [3H]-glutamate, the uptake initial velocity showed a biphasic pattern, with a transient peak between 1 and 6 DIV, the maximum being reached at 2 DIV and a delayed regular increase from 8 to 23 DIV. The concentration-dependent curves were best fitted with two saturable sites high and low affinities, at both 2 and 10 DIV. To pharmacologically characterize the transient increased glutamate uptake activity, four uptake inhibitors, L-threo-3-hydroxy-aspartic acid (THA), L-trans-pyrrolidine-2,4-dicarboxylic acid (L-trans-2,4-PDC), dihydrokainate (DHK), and DL-threo-beta-benzyloxyaspartate (TBOA) were tested. THA, L-trans-2,4-PDC and DL-TBOA inhibited glutamate uptake both at 2 and 10 DIV, while the GLT-1 selective uptake inhibitor DHK neither strongly affected the uptake at 2, nor at 10 DIV. These data indicated that, besides the regular increase in the glial-dependent glutamate uptake activity, a transient high-affinity, DHK insensitive, glutamate transport activity in hippocampal neurons in culture is present. This latter activity could potentially be related to the transient expression of the glial GLAST transporter in neurons.

Opposite regulation by glucocorticoids of the alpha 1B- and alpha 2A-adrenoreceptor mRNA levels in rat cultured anterior hypothalamic slices

In this study we investigated whether the expression of alpha1B- and alpha2A-adrenoreceptor mRNAs is differently modulated by glucocorticoids in rat cultured anterior hypothalamus slices. Using a semi-quantitative reverse transcription-polymerase chain reaction assay, the level of the alpha1B-adrenoreceptor mRNA was significantly reduced in slices cultured in steroid free-medium when compared with that measured in standard medium (i.e. containing basal adrenosteroid plasma concentrations). In contrast, the expression of the alpha2A-adrenoreceptor mRNA was markedly increased. Finally, the ratio of alpha1B- versus alpha2A-mRNA levels was about 1.7 and 0.7 in standard and steroid-free medium, respectively. These responses were completely reversed by supplementation with corticosterone. These findings provide the first evidence that in vitro glucocorticoids may regulate, in an opposite manner, the expression of the alpha1B-and alpha2A-adrenoreceptor mRNAs in the hypothalamus. This kind of regulation could be related to steroid-dependent changes in the noradrenergic control of neuroendocrine secretions.

Glucocorticoids provoke a shift from alpha2- to alpha1-adrenoreceptor activities in cultured hypothalamic slices leading to opposite noradrenaline effect on corticotropin-releasing hormone release

We have shown previously that noradrenaline (NA) stimulated or inhibited the release of corticotropin-releasing hormone (CRH) according to the availability of adrenal steroids. The aim of the present work was to examine whether the changes in the NA modulation of CRH release from hypothalamic neurons result from a steroid-induced plasticity of the adrenergic transduction pathways. From anterior hypothalamic slices cultured in standard medium (i.e., containing adrenal steroids at a final dilution of 61 +/- 9 ng/ml), (a) the stimulatory effect of NA on CRH release was reversed in a dose-dependent manner by increasing concentrations of the alpha1-adrenoreceptor antagonist prazosin, (b) activation of protein kinase C by acute treatment with phorbol 12-myristate 13-acetate (0.5 microM, 1 h) mimicked NA stimulation of CRH secretion, and (c) the activation of L-type Ca2+ channels by Bay K 8644 also produce an increased CRH secretion. In contrast, the inhibitory effect of NA on CRH secretion from slices cultured in steroid-free medium was markedly reversed by the alpha2-adrenoreceptor antagonist yohimbine, by pretreatment with pertussin toxin, or by the addition of 4-aminopyridine, a K+-channel blocker. Acute treatment with phorbol 12-myristate 13-acetate did not change the inhibitory NA effect. Moreover, all these effects were reversed by daily corticosterone supplementation, for as long as they were tested. These results are consistent with a steroid-dependent change in the nature of adrenergic receptors and its associated transduction pathways involved in the regulation of CRH secretion in the hypothalamus.

Biosynthesis of an endogenous cannabinoid precursor in neurons and its control by calcium and cAMP

Understanding the mechanisms involved in the biogenesis of N-arachidonoylethanolamine (anandamide) and N-palmitoylethanolamine is important in view of the possible role of these lipids as endogenous cannabinoid substances. Anandamide (which activates cannabinoid CB1 receptors) and N-palmitoylethanolamine (which activates a CB2-like receptor subtype in mast cells) may both derive from cleavage of precursor phospholipid, N-acylphosphatidylethanolamine (NAPE), catalyzed by Ca(2+)-activated D-type phosphodiesterase activity. We report here that the de novo biosynthesis of NAPE is enhanced in a Ca(2+)-dependent manner when rat cortical neurons are stimulated with the Ca(2+)-ionophore ionomycin or with membrane-depolarizing agents such as veratridine and kainate. This reaction is likely to be mediated by a neuronal N-acyltransferase activity, which catalyzes the transfer of an acyl group from phosphatidylcholine to the ethanolamine moiety of phosphatidylethanolamine. In addition, we show that Ca2+-dependent NAPE biosynthesis is potentiated by agents that increase cAMP levels, including forskolin and vasoactive intestinal peptide. Our results thus indicate that NAPE levels in cortical neurons are controlled by Ca2+ ions and cAMP. Such regulatory effect may participate in maintaining a supply of cannabimimetic N-acylethanolamines during synaptic activity, and prime target neurons for release of these bioactive lipids.

Lesions of the afferent catecholaminergic pathways inhibit the temporal activation of the CRH and POMC gene expression and ACTH release induced by human interleukin-1beta in the male rat

A number of recent studies have suggested that interleukin-1beta (IL-1beta) is a major mediator contributing to the recruitment of the hypothalamo-pituitary-adrenal (HPA) axis following infectious aggressions. Central catecholamines modulate the response of the HPA axis. To investigate the importance of the afferent catecholaminergic pathways in a pathophysiological situation, we used the intraperitoneal (i.p.) IL-1beta injection (mimicking peripheral infections) and we investigated the effects on the HPA responses to IL-1beta of bilateral neurotoxic (6-OHDA) deletion of the ventral noradrenergic ascending bundle (VNAB-X). The VNAB is an essential stimulating pathway linking the brainstem and the paraventricular nucleus (PVN). We determined the time courses of a number of HPA variables up to 240 min after i.p. injection of IL-1beta. We followed: plasma ACTH and corticosterone (CORT) concentrations, AP POMC nuclear primary RNA transcripts, AP POMC nuclear intermediate transcript RNA, AP POMC cytoplasmic mRNA, and hypothalamus (HT) CRH cytoplasmic mRNA. Compared to sham-lesioned male rats, VNAB-X animals displayed: (1) a reduced increase in plasma ACTH, and to a lesser extent in CORT throughout the experimental period with a 85% inhibition at the peak (90 min); (2) an increase in AP POMC primary nuclear transcript and in AP POMC nuclear intermediate transcript RNAs which last 60 min, instead of sustained significantly higher levels up to 240 min; (3) a similar, although reduced inhibition in the corresponding POMC cytoplasmic mRNA; (4) an almost complete abolishment of the marked biphasic rise in HT CRH mRNA. In conclusion, activation of the HPA axis by peritoneal IL-1beta challenge involves CRH-producing neurons, and afferent catecholaminergic innervation of the PVN plays a crucial role in the signaling machinery linking the peritoneal aggression to the HPA axis.

Deletion of the ventral noradrenergic bundle obliterates the early ACTH response after systemic LPS, independently from the plasma IL-1β surge

We have recently shown that total lesion of the ventral noradrenergic bundle (VNAB-X), enhanced the short-lived (<120 min) triggering effect of intra-arterially (i.a.) given IL-1β on plasma ACTH levels. In the present study we used the same VNAB-X paradigm to explore the mechanisms of the long-lived (480 min) LPS stimulatory effect on plasma ACTH, corticosterone (CORT) and IL-1β levels. In control rats, 25 μg kg(-1) LPS induced a 20-fold increase in ACTH and a 7-fold increase in CORT concentrations at 30 min, which continued to rise until 60 min, before receding to baseline at 480 min. In contrast, the plasma IL-1β concentration started to increase above undetectable levels only at 120 min. In VNAB-X animals, the early (30 min) ACTH/CORT response to LPS was completely blunted, and the ACTH surge was reduced by 75% at 60 min. However, the sustained hormonal response (120 to 480 min) was unaltered. Both the temporal pattern and the amplitude of the plasma IL-1β response were normal. We conclude that (1) the VNAB is involved in the early (first 60 min) ACTH/CORT response to systemic LPS, (2) plasma IL-1β does not appear to be associated with this early corticotropic activation and (3) the later stages of the ACTH/CORT response to LPS (60 to 480 min) appear to be independent of the VNAB control and may therefore involve different control mechanisms, in which the IL-1β, by this stage massively released in the blood, may play a major role.

Removal of adrenal steroids from the medium reverses the stimulating effect of catecholamines on corticotropin-releasing hormone neurons in organotypic cultures

An organotypic culture system of anterior hypothalamic slices was developed for studying the secretory responses of corticotropin-releasing hormone (CRH) neurons to corticosteroid-catecholamine interactions. The standard culture medium included 5% horse serum containing 50 micrograms/l cortisol. In 1- to 3-day cultures, the tissue viability was demonstrated by the presence of arginine vasopressin immunolabeled perikarya and axons in the paraventricular nucleus and by sustained tissue concentrations of CRH (around 50 pg/mg protein). However, immunoreactive CRH neurons were not detectable in cultures in the standard medium. Exposure of cultures to high K+ (56 mM) in the medium induced a ten-fold increase in basal CRH release which was completely abolished in a Ca(2+)-free medium containing 2 mM EGTA. Noradrenaline (NA) triggered CRH release in a dose-dependent (1-20 microM) and time-dependent (0.5-6 h) manner. Removal of corticosteroids from the media by charcoal treatment led to (1) the visualization of immunolabelled CRH perikarya and fibers and a 55% rise in CRH content of the paraventricular nucleus tissue and (2) to a five-fold increase in CRH release. Both effects were reversed by supplementation of the culture medium with corticosterone (50 micrograms/l). Under steroid-free conditions, NA (1-10 microM) not only failed to induce CRH release, but strongly inhibited the consistent baseline in CRH release. This was reminiscent of a similar corticosteroid-dependent inversion of the NA effect on the hypothalamic-pituitary-adrenal axis described in vivo. Overall, these results are direct evidence of complex corticosteroid-catecholamine interrelationships as major regulatory factors of the hypothalamic-pituitary-adrenal axis.

Complex catecholaminergic modulation of the stimulatory effect of interleukin-1 beta on the corticotropic axis

We recently showed that bilateral neurotoxic microlesions (6-OH-DA) of the ventral noradrenergic ascending bundle (VNAB-X) at stereotaxic coordinates that blocked corticotropic stress responses did not affect the ACTH surge after bilateral intra-paraventricular (i.PVN) injections of interleukin-1 beta (IL-1 beta), and that lesioning at these stereotaxic coordinates obliterated the dorsal axonal populations of the VNAB (dVNAB-X), but spared the bundle's most ventral axons (vVNAB). The present study compares the effects of IL-1 beta given i.PVN (2 x 5 ng) of intra-arterially (i.a.) (100 ng) on plasma ACTH in rats with bilateral 6-OH-DA microlesions placed in the dVNAB or the vVNAB, or in an intermediary central position (cVNAB-X). Unlike our previous results, in which dVNAB-X did not alter the biphasic ACTH response to i.PVN IL-1 beta, both vVNAB-X and cVNAB-X reduced by 50-75% the early and delayed ACTH surges which are typical of the i.PVN route. On the other hand the swift monophasic ACTH surge usually occurring after an i.a. injection of IL-1 beta was 65% smaller after dVNAB-X, but was doubled after vVNAB-X or cVNAB-X. Hence, the release of ACTH after both i.PVN or i.a. IL-1 beta requires brainstem afferences conveyed to the hypothalamus by the VNAB. However, the VNAB appears to include at least two functionally different subsets of axons, the roles of which in the ACTH response to IL-1 beta depend on the route by which the cytokine is given.

Effects of discrete lesions in the ventral noradrenergic ascending bundle on the corticotropic stress response depend on the site of the lesion and on the plasma levels of adrenal steroids

Stereotaxic deletion of selected areas of the ventral noradrenergic ascending bundle (VNAB-X) by discrete bilateral injections of 6-hydroxydopamine (6-OHDA; 4 micrograms in 0.2 microliter saline) was used to explore the role of brain catecholamines (CA) and their interaction with corticosteroid feedback in stress responses of the ACTH-corticosterone (CORT) axis. The stereotaxic coordinates used for 6-OHDA lesions and the optimization of postlesion delays were determined by (a) radioautographic labeling of the VNAB axons after tracer injections into the dorsal A2/C2, or the ventral A1/C1 medullary areas, (b) histofluorescence and immunocytochemical location of interrupted CA pathways versus the postlesional scar, and (c) postlesional noradrenaline and adrenaline concentrations in whole hypothalami and paraventricular nuclei (PVN) punch samples. Two sites of 6-OHDA lesions were selected; both led to striking falls in PVN concentrations of both CA. The more dorsal lesion (dVNAB-X) was the same as that of our earlier studies and interrupted pathways originating predominantly in the A2/C2 area; the second more ventral lesion (vVNAB-X) interrupted axons stemming preferentially from the A1/C1 area. Both VNAB lesions inhibited the ether stress-induced ACTH and CORT surges in rats with intact adrenals. But the blockade (overall poststress release, amplitude and swiftness of hormonal responses) by dVNAB-X was greater than by vVNAB-X. The basal ACTH level in adrenalectomized rats (ADX) was elevated 20-fold and ether stress induced a 4-fold ACTH surge. As in sham-ADX rats, vVNAB-X in ADX rats induced only moderate inhibition of the ACTH response versus ADX + sham-vVNAB-X controls. On the other hand ADX + dVNAB-X rats showed a greatly amplified ACTH stress response over the ADX-sham dVNAB-X controls. This amplification was reversed by oral CORT supplementation. The data suggest that the CA pathways of the VNAB participating, directly or indirectly, in the poststress corticotropic activation may include subsets of CA axons of different origins, whose functional roles in stress are modulated in opposite directions by the plasma corticosteroid level.