Prazosin administration increases the rate of recurrent urethral obstruction in cats: 388 cases

OBJECTIVE

To determine if prazosin administration decreased the rate of recurrent urethral obstruction (rUO) before hospital discharge and within 14 days.

ANIMALS

388 cats with urethral obstruction.

PROCEDURES

Veterinarians who either always or never prescribed prazosin (generally, 0.5 to 1 mg, PO, q 12 h for 14 days) were recruited to complete observational surveys. Patient data and characteristics of relieving the obstruction, including perception of a gritty feel within urethra or difficulty unobstructing the cat, were recorded. The rate of development of rUO before hospital discharge and by day 14 was compared between cats that received or did not receive prazosin with the Fisher exact test. Other variables were similarly compared between cats with and without rUO.

RESULTS

302 (78%) cats received prazosin, while 86 (22%) did not. There was no association between prazosin administration and risk of rUO prior to discharge, with 34 of 302 (11.3%) cats receiving prazosin and 5 or 86 (5.8%) not receiving prazosin developing rUO. Within 14 days, a significantly higher proportion of prazosin-treated cats (73/302 [24%]) developed an rUO, compared with the proportion of non-prazosin-treated cats (and 11/86 [13%]). The perception of a "gritty feeling urethra" or difficulty of performing the catheterization was associated with increased risk of rUO.

CLINICAL RELEVANCE

Prazosin administration increased the likelihood of rUO by 14 days; ongoing investigation of other therapies to decrease rUO in cats is warranted. Without specific indications, the use of prazosin for the prevention of rUO should be discouraged.

Fetal lower urinary tract obstruction: a current overview of intrauterine diagnosis and treatment

OBJECTIVE

The aim of this review article is to provide a practical and concise overview of diagnosis and management of pregnancy with fetal lower urinary tract obstruction.

METHODS

Review of literature and current studies.

CONCLUSION

Proper diagnosis and management of isolated fetal lower urinary tract obstruction with oligohydramnios allows appropriate implementation of intrauterine treatment in indicated cases. The treatment is a prevention of pulmonary hypoplasia and also improves renal function; this  finally contributes to the improvement of overall perinatal morbidity and mortality.

In-hospital medical management of feline urethral obstruction: A review of recent clinical research

Evidence-based medical practice requires that clinical research be conducted to help guide veterinary recommendations. Unfortunately, clinical research on the treatment of feline urethral obstruction (UO) is limited. Over the past decade, a body of clinically relevant scientific literature related to the in-hospital management of feline UO has been published. This review of the literature from December 2007 to February 2019 encompasses management options, stabilization, anesthetic considerations, unblocking procedures, urinary bladder lavage, intravesical treatments, post-obstructive diuresis, urinary catheter management, catheter-associated bacterial complications, and oral medications. Studies are briefly summarized with respect to their main findings and limitations. Common recurring limitations observed include small sample sizes leading to insufficient power and potential type II errors, lack of standardized treatment protocols, and assessment of multiple inter-related confounding variables. The authors' intent is for this article to inform practitioners and inspire future clinical research initiatives which address these limitations, possibly with large-scale multicenter studies, standardized treatment protocols, and multivariate regression modeling.

Variables of initial examination and clinical management associated with survival in small ruminants with obstructive urolithiasis

BACKGROUND

Obstructive urolithiasis is a common disease associated with a guarded prognosis in small ruminants.

HYPOTHESIS/OBJECTIVE

The results of physical examination, laboratory analyses, and clinical management of male small ruminants presented to 2 referral clinics were investigated to identify variables significantly associated with disease outcome, so as to provide better recommendations to animal owners regarding the management of these patients.

ANIMALS

Two-hundred ten small ruminants (130 sheep and 80 goats) with confirmed diagnosis of obstructive urolithiasis.

METHODS

Clinical findings (including diagnostic imaging) and laboratory results of the 210 animals were reviewed, and relevant information regarding clinical and laboratory variables recorded upon admission and clinical management was retrieved. The association of the different variables with nonsurvival was investigated by univariable and multivariable logistic regression models.

RESULTS

Only 39% of all patients considered for treatment and 52% of those undergoing tube cystostomy survived to be released from the clinic. Nonsurvival was strongly associated with a very poor clinical condition upon presentation, obesity, castration, and evidence of uroperitoneum. Among blood variables, abnormal PCV, severely increased serum creatinine concentrations, and increased activity of the creatine kinase were associated with increased risk of nonsurvival. Presence of signs of colic or macroscopic appearance of urine was not significantly associated with outcome.

CONCLUSIONS AND CLINICAL IMPORTANCE

The prognosis of obstructive urolithiasis was guarded with survival rates of 39% (overall) to 52% (after tube cystostomy). Intact young males with normal body condition presented early in the course of disease had the best chances of survival.

Fetoscopic laser surgery to decompress distal urethral obstruction caused by prolapsed ureterocele

We report on the successful use of fetoscopic surgery to treat a case of prolapsed ureterocele in a female fetus. At 21 weeks' gestation, a double renal system with an intravesical ureterocele obstructing the bladder outlet was diagnosed, causing severe megacystis, bilateral hydronephrosis and progressive oligohydramnios. Ultrasound evaluation following referral to our center confirmed severe bilateral hydronephrosis with pelvic and calyceal dilatation, but amniotic fluid volume was normal and the ureterocele was not visualized in the bladder. Instead, a cystic mass within the external genitalia was observed, suggestive of a prolapsed ureterocele, causing intermittently severe obstruction of the urethra. The parents were counseled about the uncertain prognosis and fetal surgery to decompress the urinary system was proposed. The procedure involved firing a contact diode laser until perforation of the ureterocele was achieved. Following laser surgery, resolution of megacystis, reduction of hydronephrosis and normalization of amniotic fluid volume were observed. Our report demonstrates that fetoscopic decompression of a distal urethral obstruction is feasible in the rare event of congenital prolapsed ureterocele.

Outcome in fetal lower urinary tract obstruction: a prospective registry study

OBJECTIVE

To describe influences on decision-making and prognostic variables in the prenatal management of fetal lower urinary tract obstruction (LUTO).

METHODS

This was a prospective registry study of pregnant women with a male fetus with LUTO from centers within the British Isles and The Netherlands. Women and/or their clinicians were given the treatment option of either conservative management or vesicoamniotic shunting (VAS). Baseline characteristics of women in the registry, reasons for entry to the registry and pregnancy outcomes were assessed. The main study outcomes were survival to 28 days after delivery, further survival to 2 years and renal function. Logistic regression analysis was used to examine prognostic variables that affected outcome. Results were compared with those of women in a randomized controlled trial (RCT) who were allocated randomly to a treatment option.

RESULTS

Forty-five women were registered, of whom 78% (35/45) underwent conservative management. Twenty-seven women entered the registry owing to their clinician's preference for management and 18 because of their own preference. Compared to the conservative-management group of the RCT, a higher proportion of women in the registry opting for conservative management had a normal amniotic fluid volume at diagnosis (P = 0.05) and a diagnosis of LUTO ≥ 24 weeks' gestation (P = 0.003). On multivariable logistic regression analysis, these variables showed a significant association with perinatal survival (P < 0.001). Survival to 28 days after delivery was higher in the conservative-management group, at 69% (24/35), compared to 40% (4/10) in the VAS group (P = 0.02) but this difference had limited statistical significance owing to small study size (relative risk, 0.58 (95% CI, 0.26-1.29); P = 0.14).

CONCLUSION

In our prospective registry, the majority of fetuses with LUTO received conservative management, which was associated with better short- and long-term outcomes. A significant proportion of these pregnancies had normal amniotic fluid volume and a gestational age at diagnosis of ≥ 24 weeks, characteristics shown to be associated with improved survival.

The management of prostatic obstruction with urethral stents

INTRODUCTION

Elderly men with multiple comorbidities may be unfit to undergo surgical management of benign prostatic obstruction (BPO). Permanent and temporary prostatic stents have been developed as an alternative to chronic indwelling catheters in men unfit for surgery.

MATERIALS AND METHODS

Herein we review the past and present literature on the role and effectiveness of prostatic stents in the treatment of BPO.

RESULTS

Permanent prostatic stents have largely been abandoned in North America due to unfavorable outcomes and improved technologies to allow for treatment of BPO. Currently, the temporary Spanner stent is the only available stent on the market, but its effectiveness has mostly been documented for temporary relief of tissue edema following minimal invasive ablative treatments for BPO.

CONCLUSIONS

The advent of well-tolerated surgical treatments for BPO (KTP laser vaporization, bipolar TURP, urethral lift devices) has diminished the need for permanent prostatic stents. The temporary Spanner stent is an alternative to urethral catheter, but requires adequate detrusor function and can cause irritative symptoms.

Fetal urine biochemistry at 13-23 weeks of gestation in lower urinary tract obstruction: criteria for in-utero treatment

OBJECTIVES

To assess the value of fetal urine biochemistry before 23 weeks of gestation in cases of lower urinary tract obstruction (LUTO) to refine prognosis and to select potential candidates for in-utero intervention.

METHODS

This was a retrospective study including 72 cases of LUTO with fetal urine sampled before 23 weeks and assayed for total protein, β-2-microglobulin, sodium, chloride, calcium, phosphorus, glucose and gamma-glutamyl transpeptidase (GGTP). Two groups were defined according to renal outcome: 1) bilateral renal dysplasia on histological examination or renal failure at birth; 2) normal postnatal renal function or histologically normal appearance of the kidneys. Correlations between fetal urinary biochemical markers and postnatal renal function were studied.

RESULTS

LUTO was isolated in 56/72 (77.8%) cases and was associated with other malformations in 16/72 (22.2%) cases. High GGTP levels (236 IU/L vs 5 IU/L; P < 0.0001) were observed in fetal urine in the five cases of urodigestive fistula. A significant difference between outcome groups was observed for β-2-microglobulin (P = 0.0017), sodium (P = 0.0008), chloride (P = 0.0028) and calcium (P = 0.0092) but not for protein, glucose or phosphorus. Sensitivity and specificity in defining a poor renal prognosis were 80.6% and 89% for β-2-microglobulin, 61.3% and 100% for sodium and 64.5% and 100% for calcium, respectively.

CONCLUSIONS

Fetal urinalysis before 23 weeks of gestation allowed distinction between three groups: 1) fetuses with normal urine biochemistry for which fetal therapy should be discussed; 2) fetuses with abnormal urine biochemistry for which prognosis for renal outcome is poor and for which the benefit of fetal therapy is likely to be compromised; 3) fetuses with urodigestive fistula.

Emerging treatment options for benign prostatic obstruction

Benign prostatic obstruction (BPO) affects an increasing number of men with age. It can cause troublesome lower urinary tract symptoms, can have a negative impact on quality of life, and may be associated with significant morbidity. Currently available medication and surgical treatments are limited by adverse events, invasiveness, and patient compliance. This has driven research into the pathogenesis of benign prostatic hyperplasia and led to the development of novel pharmacological agents and minimally invasive therapeutic interventions. This review highlights emerging treatment options for BPO.

Long-term renal and neurodevelopmental outcome in infants with LUTO, with and without fetal intervention

Congenital lower urinary tract obstruction (LUTO) is a heterogeneous group of pathologies, the most common being posterior urethral valves (PUV) or urethral atresia. The bladder neck obstruction in utero leads to a spectrum of disease including mild oligohydramnios with normal renal function to a picture of severe oligohydramnios associated with chronic obstructive macro/microcystic renal parenchymal disease leading to chronic renal impairment. These anomalies may be isolated or complex; the latter being associated with other structural or chromosomal abnormalities. If isolated, the congenital bladder neck obstruction may be amenable to in-utero therapy. In a significant proportion of babies affected by LUTO there is severe oligohydramnios (occurring before 20 weeks gestation) and associated with pulmonary hypoplasia, a scenario almost always associated with perinatal death. For those babies that survive the perinatal period there is a significant risk of renal impairment, often necessitating renal dialysis or transplantation in childhood. In addition, there may be other morbidities such as chronic filling anomalies of the bladder that may require treatment.

Effectiveness of fetal cystoscopy as a diagnostic and therapeutic intervention for lower urinary tract obstruction: a systematic review

OBJECTIVE

To determine the effectiveness of fetal cystoscopy in the prenatal diagnosis of and intervention for congenital lower urinary tract obstruction.

METHODS

This study was a literature search using MEDLINE, Embase, Cochrane Library, MEDION, Web of Science reference lists and contact with experts. All studies reporting on fetal cystoscopy in lower urinary tract obstruction with data for a 2 × 2 table were selected for review. No language restrictions were applied. There was independent selection of studies, data extraction and quality assessment by two reviewers. Peto odds ratios were calculated as a summary measure of effect.

RESULTS

A total of 2071 citations were identified and 66 papers selected for detailed evaluation, from which four papers with a total of 63 patients were selected for inclusion. Two papers had results for the use of cystoscopy in diagnosis, showing that fetal cystoscopy altered the ultrasound diagnosis of the underlying pathology in 36.4 and 25.0% of fetuses, respectively. Compared to no treatment, fetal cystoscopic intervention demonstrated an odds ratio for improved perinatal survival of 20.51 (95% CI, 3.87-108.69). However, comparing vesicoamniotic shunt (VAS) with fetal cystoscopy there appeared to be no significant improvement in the perinatal survival odds ratio of 1.49 (95% CI, 0.13-16.97). These results had wide CIs and for cystoscopy vs. VAS, all results crossed the line of no effect.

CONCLUSION

There is little published evidence for the effectiveness of therapeutic fetal cystoscopy as an intervention for congenital lower urinary tract obstruction and the quality of this evidence is poor. It should thus be considered to be an 'experimental intervention' and subjected to further investigation.

[Voiding dysfunction after brachytherapy in patients with prostate cancer]

The development of urinary symptoms after brachytherapy is very frequent, reaching a maximum between the first and third month after the implant and returning back to normal around one year. The incidence of acute urinary retention varies between 1.5 and 27% . A low percentage of patients (0-8.7% ) will need surgery to solve an extended urinary retention or severe obstructive voiding symptoms. Alphablockers may be useful to alleviate voiding symptoms after the implant, although they do not reduce the need for surgery. There are several predictive clinical factors for development of urinary complications. A patient with high IPPS score before implant, large size prostate, obstructive functional signs (Low Q max, high postvoid residual, and obstruction urodynamic parameters) has a high risk for urinary retention or extended urinary symptoms. This has repercussion on the quality of life of the patient, making them candidates to other therapies. The performance of a peripheral implant technique (guaranteeing low doses at urethra) and avoiding the urethral plane when inserting the needles may minimize urethral damage associated with development of urinary complications. Urinary incontinence after brachytherapy is a rare complication, but its frequency increases dramatically after transurethral resection of the prostate or requiring it to solve a sustained urinary retention. It is fundamental to know this circumstance to inform the patient adequately and to plan the most careful TURP.

Congenital urinary tract obstruction

Congenital urinary tract obstruction is a heterogenous condition with a varying natural history. Accurate diagnosis within the late-first and second trimesters allows for counselling of the parents and planning of multi-disciplinary care for the pregnancy and newborn. Antenatal investigations to predict postnatal renal function are of varying accuracy. However, some factors have been shown to be predictive of poor outcome in terms of renal function at birth and infancy. There is the possibility of in-utero intervention in these fetuses.

Guarded long-term prognosis in male cats with urethral obstruction

The aim of this study was to evaluate the course of urethral obstruction in cats. Forty-five male cats with urethral obstruction or lower urinary tract signs referable to urethral obstruction were included in the study. Follow-up information was gained by telephone interview in most cases and was available in 39 cats. Of the 22 cats with idiopathic urethral obstruction, eight (36%) re-obstructed after 3–728 days (median 17 days). Of 10 cats with urolithiasis, three (30%) re-obstructed after 10, 13 and 472 days, respectively. Of the seven cats with urethral plugs, three (43%) re-obstructed after 4, 34 and 211 days, respectively. Recurrent signs of lower urinary tract disease including obstruction were common in cats with urethral obstruction (20/39; 51%) and occurred in the same frequency irrespective of the primary cause of the obstruction. Recurrent obstruction (14/39; 36%) was the most common reason for euthanasia and was performed in 8/39 (21%) cats.

[Malformations of urinary system in our series of children--treatment approaches]

The purpose of the study was to analyze treatment approaches in children with malformations of urinary system. The retrospective study comprised 557 children (196 boys and 361 girls) aged 1-18 years with malformations of urinary system hospitalized in 2000-2007 in the Department of Pediatric Nephrology, University Children's Hospital, Lublin. Primary and secondary vesicoureteral reflux (269 children), ureteral obstruction (102 children), urethral obstruction (91 children) and renal duplication (83 children) were the most common malformations observed. In 26 children, multiple urinary system malformations were diagnosed. 332 children required surgery including 113 with vesicoureteral reflux. However, in the majority of children with vesicoureteral reflux, on an average 18-month pharmacologic treatment resulted in complete recovery.

Management of extreme azotemia from urinary tract obstruction without dialysis. Clinical correlates and kinetic modeling of the recovery of renal function

The recovery of renal function following release of urinary tract obstruction with advanced azotemia determines both the need for emergency dialysis in the early post-obstructive period and the long-term planning for chronic kidney disease management. A man with prostatic cancer who presented with 16 days of anuria and a serum creatinine (Scr) of 42.7 mg/dl but had evidence suggesting residual renal function was managed conservatively and reached a steady-state Scr of 1.6 mg/dl within 84 h of urinary bladder catheterization. Modeling of the decrease in Scr taking into account the decline in the body creatinine pool that existed prior to the release of the obstruction and the accumulation in body fluids of creatinine produced after the release of the obstruction suggested that recovery of the value of glomerular filtration rate corresponding to the steady-state Scr occurred at the release of the urinary obstruction. The case illustrates both the clinical factors that may lead to the decision to postpone dialysis in a patient presenting with extreme obstructive azotemia and a novel method of modeling the recovery of renal function after release of the obstruction.

Evaluation of the Effects of Temporary Covered Nitinol Stent Placement in the Prostatic Urethra: Short-Term Study in the Canine Model

PURPOSE

To evaluate the effect of temporary stent placement on the canine prostatic urethra.

METHODS

Retrievable PTFE-covered nitinol stents were placed in the prostatic urethras of 8 beagle dogs under fluoroscopic guidance. Retrograde urethrography was obtained before and after stenting. Retrograde urethrography and endoscopy were performed 1 and 2 months after deployment. The endoscopic degree of hyperplasia was rated on a scale of 0 to 4 (0 = absence, 4 = occlusion). On day 60, stents were removed and urethrography was performed immediately before euthanasia. Pathologic analysis was performed to determine the degree of glandular atrophy, periurethral fibrosis, and urethral dilation.

RESULTS

Stent deployment was technically successful in 7 animals, and failed in 1 dog due to a narrow urethral lumen. Complete migration was seen in 2 animals at 1 month, and an additional stent was deployed. On day 30, endoscopy showed slight hyperplasia (grade 1) in 3 animals. On day 60, moderate hyperplasia (grade 2) was evidenced in 4 cases. No impairment of urinary flow was seen during follow-up. Retrieval was technically easy to perform, and was successful in all dogs. The major histologic findings were chronic inflammatory cell infiltrates; prostate glandular atrophy, with a mean value of 1.86 (SD 0.90); periurethral fibrosis, with a mean ratio of 29.37 (SD 10.41); and dilatation of the prostatic urethra, with a mean ratio of 6.75 (SD 3.22).

CONCLUSION

Temporary prostatic stent placement in dogs is safe and feasible, causing marked enlargement of the prostatic urethral lumen. Retrievable covered stents may therefore be an option for bladder outlet obstruction management in men.

Obstructive uropathy in Sudanese patients

In this paper we describe the causes, patterns of presentation, and management of obstructive uropathy in Sudanese patients in a retrospective multi-center audit. All patients who presented with obstructive uropathy during 2005 were included in this study. All of the patients were subjected to serial investigations including imaging and tests of renal function. Diversion, stenting, and/or definitive surgery were performed in order to relieve the obstruction. Five hundred twenty patients were diagnosed with obstructive uropathy during this period; 345 (66%) patients presented with chronic obstruction and 175 (34%) with acute obstruction. Of the study patients, 210 (40%) presented with significant renal impairment; 50 (23%) of them required emergent dialysis. The patterns of clinical presentation of the obstructed patients included pain at the site of obstruction in 48%, lower urinary tract symptoms in 42%, urine retention in 36.5%, mass effect in 22%, and anuria in 4%. Patients in the pediatric age group constituted 4% of the total. The common causative factors of obstruction included congenital urethral valves, pelvi-ureteral junction obstruction, urolithiasis, and iatrogenic trauma, especially in the obstetric practice. Renal function was completely recovered with early management in 100% of patients with acute obstruction and was stabilized in 90% of patients with chronic obstruction. Four patients were diagnosed with end-stage renal failure; two of them were transplanted. The mortality rate in this study was less than 0.3%.

Simple aspiration technique to address voiding dysfunction associated with transurethral injection of dextranomer/hyaluronic acid copolymer

Dextranomer/hyaluronic acid copolymer (Zuidex) is currently under Food and Drug Administration investigation for use as a transurethral bulking agent to treat female stress urinary incontinence secondary to intrinsic sphincter deficiency. Urethral obstruction is a recognized complication of bulking agents. We describe an aspiration method to address iatrogenic voiding dysfunction resulting from this therapy.

Evaluation of palliative stenting for management of malignant urethral obstructions in dogs

OBJECTIVE

To evaluate use of balloon-expandable and self-expanding metallic stents in management of malignant urethral obstructions in dogs.

DESIGN

Original study.

ANIMALS

12 dogs with malignant urethral obstructions.

PROCEDURES

The extent and location of urethral obstructions and the diameter of adjacent unaffected luminal segments were determined by use of fluoroscopically guided wires and measuring catheters. Stents were chosen to extend approximately 1 cm proximal and distal to the obstruction. Stent diameters were chosen to be approximately 10% greater than the diameter of healthy portions of the urethra to prevent displacement. Stents were placed in the urethra under fluoroscopic guidance to restore luminal patency.

RESULTS

3 dogs received balloon-expandable metallic stents, and 9 dogs received self-expanding metallic stents. The placement procedures were rapid, safe, and effective at restoring luminal patency and were not associated with major complications. Complications included recurrent urethral obstruction secondary to blood clot formation and urethral edema in 1 dog and stent dislodgement into the urinary bladder in 1 dog. All dogs were able to urinate immediately after the procedure. Nine dogs (3/4 females and 6/8 males) were continent or mildly incontinent after stent placement. Of the remaining 3 dogs, 2 developed severe incontinence and 1 had an atonic bladder. Seven dogs were considered to have good to excellent outcome, 3 had fair outcome, and 2 had poor outcome.

CONCLUSIONS AND CLINICAL RELEVANCE

Transurethral placement of metallic stents was a safe and effective palliative treatment option for dogs with malignant urethral obstructions.

Novel everting urologic access sheath: decreased axial forces during insertion

BACKGROUND

Advancement of urologic instruments through the genitourinary tract is associated with significant axial forces that likely contribute to patient discomfort, even after injection of a local anesthetic, and may lead to mucosal trauma, postprocedural dysuria and hematuria, and increased susceptibility to infection and strictures. Placing an everting urethral sheath prior to instrumentation may decrease these problems.

MATERIALS AND METHODS

Two 7-cm-long, 5-mm diameter urethral luminal models were created, one with and one without an artificial stricture. We measured the forces generated during advancement of a novel everting access sheath (Cystoglide; Percutaneous Systems, Mountain View, CA) through the models in comparison with a representative cystoscope and a urologic dilator simulating a traditional access sheath.

RESULTS

The mean force generated during advancement of the everting sheath was significantly less than that of both the representative cystoscope (P<0.01) and the traditional access sheath (P<0.01). This held true for the urethral models both with and without an artificial stricture (P<0.01) and with and without lubrication (P<0.01).

CONCLUSIONS

This novel introduction sheath markedly decreased the axial forces applied to an artificial urethral luminal wall. It is possible that the clinical use of this technology will decrease the discomfort and potential complications associated with lower urinary-tract endoscopy.

Obstruction after Burch colposuspension: a return to retropubic urethrolysis

We compare our postoperative outcomes of a vaginal vs abdominal urethrolysis after an obstructed Burch colposuspension. We performed a retrospective review of all women who had undergone a Burch urethrolysis from 1997 through 2003. Data collected included pelvic examination, cystoscopic and urodynamic findings, surgical morbidity, and pre- and postoperative urogynecologic symptomatology. Sixteen women underwent Burch urethrolysis. Preoperative symptoms were obstructive in 6, overactive in 2, and both (obstructive/overactive) in 8. All had an acute retropubic angulation of the urethral axis as well as a retropexed urethra that prohibited sagittal rotation of a rigid cystoscope. Seventy-eight percent of the women with urodynamic information met urodynamic criteria for urethral obstruction. Average follow-up was 7 months, and of those undergoing a vaginal urethrolysis, three out of seven (43%) had resolution of their obstructive or overactive symptoms postoperatively. In contrast, seven out of nine women (78%) who underwent a retropubic urethrolysis had relief of their obstructive or overactive bladder symptoms. In our cohort study, an abdominal retropubic urethrolysis was more successful in relieving urethral obstruction than a vaginal urethrolysis.

Discordant Lower Urinary Tract Obstruction in Early Twin Gestations

OBJECTIVE

To report our experience with the management of twin pregnancies discordant for lower urinary tract obstruction.

METHODS

Cases of twin pregnancies discordant for lower urinary tract obstruction were identified from our fetal medicine database. Information on ultrasonographic findings, antenatal course, pregnancy complications, and perinatal outcome was obtained by reviewing medical records or contacting the referring obstetricians.

RESULTS

Five twin pregnancies discordant for lower urinary tract obstruction were diagnosed between 11 and 15 weeks of gestation. There were 3 dichorionic and 2 monochorionic pregnancies (1 diamniotic and 1 monoamniotic). The dichorionic pregnancies were managed conservatively, resulting in a pregnancy loss of both twins in 1 case, a single fetal death at 29 weeks in 1 case, and an early neonatal death due to lung hypoplasia of the affected twin in 1 case. On the other hand, both monochorionic twin pregnancies were managed with serial vesicocenteses. In both cases, the prenatal course was complicated, 1 by premature rupture of the membranes and the other by cord entanglement, requiring delivery at 29 and 31 weeks, respectively. Among the 4 continuing pregnancies with complete perinatal outcome, none of the affected twins survived, and the structurally normal twins were delivered between 29 and 36 weeks and discharged from the hospital in good condition.

CONCLUSION

Twin pregnancies discordant for lower urinary tract obstruction are at high risk of perinatal death and premature delivery. Prenatal intervention seems not to be associated with an improved perinatal outcome of the affected twin, but it may be beneficial in selected cases to attain viability of the unaffected twin.

Treatment of postoperative voiding dysfunction following incontinence surgery

Persistent postoperative voiding dysfunction is a known complication following female stress incontinence surgery. Although many variations on surgical technique exist, the most common cause remains attributable to hypersuspension of the urethra. The diagnosis of postoperative voiding dysfunction in this setting can be challenging due to the lack of standardized criteria and varied clinical presentation. Furthermore, patients can present with a wide spectrum of symptomatology, not merely incomplete bladder emptying or outright retention. The symptoms of urethral hypersuspension can range from purely bladder storage symptoms on one hand (frequency, urgency, or urge incontinence), to the more commonly recognized bladder emptying dysfunction on the other hand (incomplete emptying or frank urinary retention). Although most cases of mild postoperative voiding dysfunction appear to resolve with expectant management, a subset of patients clearly benefit from a sling incision or formal urethrolysis. This leads to prompt improvement or resolution of their postoperative bladder symptoms. The timing of surgery must be determined by the clinician's judgment. However, experience would suggest that postoperative bladder symptoms that persist beyond 4 weeks rarely resolve spontaneously. Within the literature, there has been a paradigm shift toward earlier intervention. Indeed, there are some data to suggest that delayed time to urethrolysis can lead to irreversible bladder dysfunction.

Recent trends of genitourinary endoscopy in children

Downsizing and refinement of the pediatric endoscope in video-monitoring systems have facilitated genitourinary endoscopy even in small children without any traumatic instrumentation. Indications for endoscopy in children with hematuria or tractable urinary tract infection have been tailored for the rareness of genitourinary malignancy or secondary vesicoureteral reflux (VUR) as a result of infravesical obstruction. Most mechanical outlet obstructions can be relieved endoscopically irrespective of sex and age. Endoscopic decompression by puncture or incision of both intravesical and ectopic ureteroceles can be an initial treatment similar to open surgery for an affected upper moiety. Endoscopy is necessary following urodynamic study to exclude minor infravesical obstruction only in children with unexplained dysfunctional voiding. Genitourinary endoscopy is helpful for structural abnormalities before and at the time of repairing congenital urogenital anomalies. Endoscopic injection therapy of VUR has been established as a less invasive surgical treatment. Pediatric endoscopy will play a greater role in the armamentarium for most pediatric urological diseases through the analysis of visual data and discussion on the indications for endoscopy throughout the world.

Urinary tract emergencies

A review of common emergencies of the urinary system is presented, with a focus on initial stabilization and treatment. Urethral obstruction, uroperitoneum, and acute renal failure are discussed.

Lateral Excision of Tension-Free Vaginal Tape for the Treatment of Iatrogenic Urethral Obstruction

OBJECTIVE

To report our experience on lateral excision of tape in women with iatrogenic urethral obstruction after the tension-free vaginal tape (TVT) procedure.

METHODS

Seven women had iatrogenic urethral obstruction based on their clinical and urodynamic findings. All underwent lateral excision of the tape using the vaginal approach. Lower urinary tract symptoms, postvoid residual volume and urodynamic data were evaluated before and after excision.

RESULTS

Before excision, all subjects had either irritative symptoms or increased postvoid residual volume (more than 100 mL), and 6 (85.7%) voided with strain. The mean time from initial surgery to tape excision was 28 days (range 4 to 108), with an average follow-up of 32 months (range 24-39). After the excision, voiding dysfunction was resolved in 6 of 7 patients. The remaining patient had significant improvement with only occasional symptoms of irritation. Two (28.6%) women reported recurrent stress incontinence and 1 (14.3%) required surgical treatment. The intervals for the 2 recurrent patients from TVT to excision were 4 days. The intervals for the 5 continent women were 15 to 108 days.

CONCLUSION

Urethral obstruction after TVT is a relatively uncommon condition. It can be effectively treated with transvaginal lateral excision of the tape. Recurrent stress incontinence seems to be less likely to occur when the takedown procedure occurs beyond 14 days after the initial TVT operation.

[Urethral valves. Fate of the bladder and upper urinary tract]

Posterior urethral valve is a condition that leads to characteristic changes in the bladder and upper tracts. The bladder develops hypertrophic changes including muscular hypertrophy, dilatation of the prostatic urethra (keyhole appearance), and progressive hydroureteronephrosis. The voiding cystourethrogram confirms the diagnosis and documents vesicoureteral reflux and accompanying bladder changes. The follow-up of the serum creatinine level is a parameter for renal recovery. In our opinion, primary endoscopic ablation of the valves followed by a wait-and-see attitude is the most efficacious management of posterior urethral valves. The development of the bladder function is controlled by ultrasound and voiding cystourethrogram. Urodynamics provide a formal and objective means of assessing bladder function, but should be carefully applied in infants. Valve ablation in a neonate with significant reflux and a markedly trabeculated bladder can remodel itself remarkably within the 1st year of life. The persistence of hydronephrosis, bladder wall thickening and trabeculation, and persistent elevation of serum creatinine can all be harbingers that a degree of bladder outlet obstruction persists and one needs to rule out a persistent anatomic obstruction. At what point a functional obstruction occurs and which management is reasonable are still issues of debate and require the vigilance of a pediatric urologist to sort out. Dysfunctions of the bladder such as hyperreflexia, hypertonic, small capacity bladder, sphincter incompetence and/or myogenic failure should be adequately treated.

[Prenatal diagnosis of obstructive uropathies - positive predictive value and effect on postnatal therapy]

INTRODUCTION

Prenatal diagnosis of urological anomalies is a standard procedure nowadays. The aim of this study was first to define the frequency of urinary tract anomalies in the selected patients in a level III center for prenatal diagnostics and therapy. The second aim was to show the accuracy of prenatal diagnosis in the special groups of obstructive uropathies.

PATIENTS AND METHODS

Postnatal diagnoses were used for control of the prenatal findings. In the 12-year retrospective study, we analyzed 21 616 pregnancies scanned for fetal anomalies. In 1 574 fetuses pediatric surgical anomalies were diagnosed. Out of 1 077 follow-ups 618 patients with urinary tract anomalies were found.

RESULTS

It could be shown that prenatal ultrasound has a high sensitivity for the diagnosis of obstructive renal tract anomalies. The diagnosis of subpelvine obstruction and muticystic kidney dysplasia can be made with an accuracy of 97 and 98 %. The therapeutic relevance of the diagnosis "isolated hydronephrosis" increases up to 60 % when mild dilatation is neglected. False negative scans for urinary tract anomalies are low at 10 %.

CONCLUSION

Hence, prenatal ultrasound for urinary tract anomalies is a method of high sensitivity. The therapeutic relevance is rather high. The most important question is to find all those patients who need a postnatal therapeutic approach immediately.

Obstructive uropathy in childhood, as seen in University of Port Harcourt Teaching Hospital, Nigeria

BACKGROUND

Obstructive uropathy is a cause of morbidity and mortality in children. In Port Harcourt, data on causes of obstructive uropathies are not readily available. This study was carried out to identify the causes and outcome of obstructive uropathies seen in our children's ward.

METHODS

The case records of children with the diagnosis of obstructive uropathies who were treated at the University of Port Harcourt Teaching Hospital (UPTH) between October 1997 and October 2002 were reviewed.

RESULTS

A total of 20 patients, all males were seen. The ages ranged from 4 weeks to 13 years with a mean of 2.3+/-2.8 years. The causes of obstructive uropathy were posterior urethral valves (PUV) 16 (80%), bladder calculi 2 (10%), bladder rhabdomyosarcoma and urethral stenosis 1 (5%) each. Poor stream of urine and dysuria were the commonest presentation. The duration of symptoms ranged from 2 days to 13 years. None of the patients with PUV was diagnosed prenatally. Hypertension and urinary tract infection each were found in 50% of the patients while 6 (30%) presented with features of renal failure. Seven patients died, giving a mortality rate of 35%. Age at presentation less than one year and duration of symptoms longer than one month was associated with higher mortality although it was not statistically significant.

CONCLUSION

PUV is the commonest cause of obstructive uropathy seen in UPTH. Earlier diagnosis during pre-natal period or when this is not possible, diagnosis within the first week of life should be encouraged. Parents, nurses and attending doctors should ensure they observe the urinary stream of every male child before discharge from the hospital for early detection and management of PUV.

Obstructive uropathy: considerations for the nephrology nurse

Obstructive uropathy is the cause of renal failure in 16.2% of pediatric patients who undergo renal transplantation, 12.9% of those on dialysis, and 23.1% of those with chronic renal insufficiency, according to the annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Successfully caring for patients with obstructive uropathy requires an understanding of the various congenital anomalies that create obstructive uropathy, the urological interventions used to treat them, management of the patient, and the nursing care required.

A novel temporary prostatic stent for the relief of prostatic urethral obstruction

OBJECTIVES

To determine the effect of a novel temporary prostatic stent (The Spanner, AbbeyMoor Medical, Inc., Minnesota, USA) on variables of voiding function and quality of life among patients with prostatic urethral obstruction.

PATIENTS AND METHODS

The stent design is very similar to the proximal 4-6 cm of a Foley catheter; this includes a proximal balloon to prevent distal displacement, a urine port situated cephalad to the balloon, and a reinforced stent of various lengths to span most of the prostatic urethra. There is also a distal anchor mechanism attached by sutures, and a retrieval suture which extends to the meatus and deflates the proximal balloon when pulled. The stent was inserted under topical anaesthesia in 30 patients. The maximum flow rate (Qmax), voided volume (W), postvoid residual (PVR), the International Prostate Symptom Score (IPSS) and stent position were assessed.

RESULTS

Stents remained in situ for a mean (range) of 57 (1-98) days. The mean overall Qmax at baseline and after insertion were 8.2 and 11.6 mL/s, representing a 42% improvement (P < 0.001); the respective mean overall Ws were similar, at 219.7 and 221.6 mL (0.9% increase, not significant) and the PVRs were 312.1 and 112.3 mL, representing a 64% decrease (P = 0.004). The overall mean IPSS declined from 22.3 before to 7.1 after insertion, representing a 68% decrease (P < 0.001). There were only minor adverse events. The stability, patency and lack of migration of the device were confirmed radiographically up to 12 weeks of use.

CONCLUSIONS

This early study shows that this temporary prostatic stent is easily inserted and removed, remains anchored in position, and significantly improves the Qmax, PVR and IPSS while preserving volitional voiding and continence.

[Attentive problem in the clinic about acute obstructive anuria at upper urinary tract]

OBJECTIVE

To improve the understanding of acute obstructive anuria at upper urinary tract in order to cope properly with corresponding clinical problems.

METHODS

The clinical problems of acute obstructive anuria at upper urinary tract in 55 patients was summarized and analysed. Anuria, lumbago, edema and progressive increase of blood creatinine and ureal nitrogen were the main bases of diagnosis. B-typed ultrasonography and plain film of abdomen (KUB) were the first choice in examinations. The treatment principles lied in prompt removal of obstruction as well as effective prevention and treatment of infection to protect renal function to maximum extent.

RESULTS

Forty-three cases (78.2%) recovered normal renal function. Ten cases (18.2%) still had azotemia three months after treatment. Two cases gave up treatment.

CONCLUSIONS

The reason of tumor for anuria should be paid attention to. The first choice in treatments is ureteral intubation by cystoscope. Diuretic should be used cautiously.

Laser Lithotripsy for Treatment of Canine Uroliths

OBJECTIVE

To confirm in vivo optimal laser energy settings previously determined in vitro for lithotripsy, to develop a technique for Ho:YAG laser lithotripsy, and to evaluate acute and chronic tissue effects of laser lithotripsy.

STUDY DESIGN

Prospective, randomized preclinical trial.

ANIMALS OR SAMPLE POPULATION

Nineteen intact, adult male dogs.

METHODS

Via cystotomy, a single urolith was inserted into the urethra to the level of the base of the os penis to simulate obstruction. Uroliths (calcium oxalate, urate, or magnesium ammonium phosphate) were fragmented by Ho:YAG laser, in contact mode through a 320 micro optic fiber, passed through the operating channel of a 2.8 mm flexible endoscope. The time and total energy to fragmentation were recorded. Dogs were euthanatized immediately after lithotripsy (3 dogs) or at 3 days (7 dogs), and urethral lesions and any stone remnants were evaluated. Urethral integrity was also evaluated in 9 other dogs by endoscopy on day 10; these were also monitored clinically for 30 days.

RESULTS

The mean time for adequate fragmentation was 166.7 seconds (range, 47-494.5 seconds). The mean+/-SD energy used was 1418+/-851.2 J. In part 1, 2 dogs were obstructed with urolith fragments at necropsy. Eight dogs had minimal (<30 mg) or no urolith material evident within the urethra. Four dogs had gross focal or circumferential erosion, ulceration, or hemorrhage of the urethral mucosa. Lesions were not associated with the site of laser irradiation in 2 dogs. In dogs observed for 30 days, hematuria, pollakiuria, and stranguria that were observed after lithotripsy, resolved in all affected dogs by day 5. No mucosal lesions were observed by endoscopy and none of the dogs became obstructed.

CONCLUSION

Laser lithotripsy with the Ho:YAG laser in contact mode successfully fragmented obstructive uroliths in male dogs.

CLINICAL RELEVANCE

Laser lithotripsy may be a clinically relevant technique for treatment of urolithiasis in male dogs; clinical studies to evaluate long-term effects on urethral mucosa and the role of repeat treatment for recurrence are indicated.

Does Treatment With Clean Intermittent Catheterization in Boys With Posterior Urethral Valves Affect Bladder and Renal Function?

PURPOSE

In boys with resected posterior urethral valves (PUV) deterioration of renal function is seen during childhood and adolescence, which may partly be caused by bladder dysfunction. We present data on renal and bladder function initially and at followup of boys with PUV in whom the bladder dysfunction has been treated since infancy.

MATERIALS AND METHODS

The study included 35 boys with PUV. Bladder regimen, including early toilet training from the age of 1.5 years and detrusor relaxant drugs for the treatment of incontinence from ages 4 to 6 years, was introduced to all patients. A total of 19 boys were started on clean intermittent catheterization (CIC) at a median age of 8 months due to pronounced bladder dysfunction with poor emptying, unsafe pressure levels, high grade reflux and renal impairment.

RESULTS

No serious complications of CIC have been seen during followup. Of the 19 boys 2 stopped performing CIC due to noncompliance of the parents at 1 and 3 years, respectively. Initial renal function, measured as median glomerular filtration rate (GFR) in percent of expected for age, was 60% in the CIC group and 90% in the nonCIC group. At followup at a median age of 8 years the CIC group (n = 14, 3 transplanted boys excluded) had an increase in median differential GFR (difference between followup and initial GFR) of 7% (p <0.01), which was similar increase to that of the nonCIC group. In the 2 boys who stopped performing CIC renal function deteriorated with a median differential GFR of -24%. In the CIC group detrusor instability decreased. Poor compliance was seen in 6 of the 19 boys initially and only one remained poorly compliant. In 1 of the boys who stopped performing catheterization a low compliant bladder developed. In all of the other cases bladder capacity increased more than expected for age.

CONCLUSIONS

The results suggest that treatment of bladder dysfunction in boys with PUV can counteract the deterioration in renal function seen during childhood but the number of patients in our study is limited.

[Metallic stents as a new therapeutic procedure for urinary tract obstruction]

Tube stents are widely used to achieve internal urinary drainage in the urology field. Recently, in an attempt to improve upon metallic stents, these stents were introduced for use in the obstructed urethra and ureter. We review the current indications and devices for internal urinary drainage using metallic stents. In recent years, intraprostatic metallic stents have been established as a minimally invasive alternative treatment for benign prostatic hyperplasia (BPH). Appropriate patient selection and optimal stent positioning are required. However, intraprostatic metallic stents represent a useful option to BPH therapy for high operative-risk patients. Only limited data exist concerning patency rates and the efficacy of stent treatment of ureteral obstruction, and the indications for the implantation of metallic stents in these patients is controversial. The efficacy of metallic stents in this situation is not clear, but some investigators suggest that the implantation of metallic stents in obstructed ureters may be safely and effectively performed in patients with incurable malignancies.

Management of obstructive voiding dysfunction

Voiding dysfunction may be defined as difficulty in the volitional emptying of the bladder in an efficient and controlled manner that can extend from a spectrum of minor irritative symptoms to complete retention. Resolution of symptoms can be accomplished by correctly identifying the underlying pathology and directing therapy appropriately to restore function and anatomy. Causes and treatments of obstructive voiding dysfunction tend to be gender specific. In approximately one-half of women, the causes of obstructive voiding dysfunction are prior anti-incontinence surgery and pelvic organ prolapse, which will usually lead to a surgical intervention. For men, benign prostate disease is the overwhelming cause of obstructive voiding. Due to its increasing prevalence in the aging male population, a variety of treatments--pharmacological and operative--have been developed, with more on the horizon. This review addresses a wide variety of treatments for the numerous conditions causing obstructive voiding dysfunction in men and women, all of them with the goal in mind of resolve the patient's symptoms without creating de novo pathology.

[Adhesions of the labia minora in three young girls]

Three girls, 2, 5 and 6 years of age, had labial adhesions: one without complaints but whose mother was anxious about abnormal anatomy of the external genitalia, one with urinary problems because of pooling of the urine in the almost completely covered vagina, relapsing after surgical intervention, and one with irregular adhesions because of sexual abuse. In all three, after (repeated) application of oestrogen cream the adhesions reduced or disappeared. Adhesions of the labia minora can often be noticed under the age of 8 years and dissolve after that age during the period of progressive natural oestrogen production. Therapy consists of application of oestrogen cream on the contact surface of the labia minora. Surgical treatment is disputable and causes a high recurrence, probably higher than conservative treatment.