Non-invasive markers in the management of pediatric neurogenic bladder over the last two decades - A review

Neurogenic bladder (NB) is one of the most challenging problems in nephro-urological management in pediatrics. It is an important risk factor of secondary upper urinary tract damage. A complete clinical evaluation is necessary and requires life-long extensive medical attention including invasive procedures that affect patients' quality of life. Potential non-invasive biomarkers would be desirable, especially in the pediatric population. The aim of this review was to analyze two decades of data regarding potential non-invasive biomarkers in the assessment and follow-up of children with NB. This paper summarizes and appraises the knowledge about both biochemical and imaging-based markers in 3 aspects: markers of urinary tract infections (UTIs), bladder and renal function, and this paper looks at their prospective application in everyday clinical care.

Bladder Volume Assessment in Pediatric Patients With Neurogenic Bladder: Is Ultrasound an Accurate Method?

OBJECTIVE

To define the accuracy of ultrasound to determine bladder volume in pediatric patients with neurogenic bladder (NB).

METHODS

Retrospective analysis of children with NB in treatment with urethral clean intermittent catheterization.

EXCLUSION CRITERIA

bladder surgeries, and catheterization through a channel different than urethra. Bladder volume was measured with ultrasound using the formula: anteroposterior bladder diameter by side to side diameter by distance from dome to outlet tract by 0.523 (cm³). In the same act, the patient was performed urethral catheterization and the drained volume was measured in millimeters. Finally, postvoid residual volume (PVR) was assessed with ultrasound.

RESULTS

We performed 318 measurements in 299 patients, mean age was 9.95 years (standard deviation: 4.6), 59% were female. Most frequent etiologies of NB were myelomeningocele and lipomyelomeningocele. Mean ultrasound-determined bladder volume was 213.9cm3 (range: 20-899 cm³) and mean bladder volume drain through catheterization was 336.4 mL (range: 30-1480 mL; P : .0001). In 67.3% of the patients (n: 214) PVR was not significant, and their mean ultrasound volume was 212.7 mL and the volume evacuated by catheterization was 339.9 mL (P : .0001). In all age groups ultrasound-determined bladder volume was statistically lower than catheterized bladder volume (P : .0001). The mean percentage error of the ultrasound-determined bladder volume was 15.58% ± 44.09. Linear regression analysis and Bland-Altman plot showed low agreement between both measurement techniques.

CONCLUSION

In children with NB, ultrasound-determined bladder volume was statistically lower than catheterized bladder volume measured at the same moment, and this relation persisted regardless of sex, age, and the presence of PVR.

Effect of type II diabetes on male rat bladder contractility

Type II diabetes is the most prevalent form of diabetes. One of the primary complications of diabetes that significantly affects quality of life is bladder dysfunction. Many studies on diabetic bladder dysfunction have been performed in models of type I diabetes; however, few have been performed in animal models of type II diabetes. Using the Zucker Diabetic Fatty (ZDF) rat model of type II diabetes, we examined the contractility and sensitivity of bladder smooth muscle in response to mediators of depolarization-induced contraction, muscarinic receptor-mediated contraction, ATP-induced contraction, and neurogenic contraction. Studies were performed at 16 and 27 wk of age to monitor the progression of diabetic bladder dysfunction. Voiding behavior was also quantified. The entire bladder walls of diabetic rats were hypertrophied compared with that of control rats. Contractility and sensitivity to carbachol and ATP were increased at 27 wk in bladder smooth muscle strips from diabetic rats, suggesting a compensated state of diabetic bladder dysfunction. Purinergic signaling was increased in response to exogenous ATP in bladders from diabetic animals; however, the purinergic component of neurogenic contractions was decreased. The purinergic component of neurogenic contraction was reduced by P2X receptor desensitization, but was unchanged by P2X receptor inhibition in diabetic rats. Residual and tetrodotoxin-resistant components of neurogenic contraction were increased in bladder strips from diabetic animals. Overall, our results suggest that in the male ZDF rat model, the bladder reaches the compensated stage of function by 27 wk and has increased responsiveness to ATP.

[Efficacy of combination therapy with mirabegron for anticholinergic-resistant neurogenic bladder: videourodynamic evaluation]

Using a videourodynamic study, we examined the efficacy of combination therapy with mirabegron for anticholinergic-resistant neurogenic bladder. We retrospectively studied 7 patients with neurogenic bladder (5 males and 2 females) who had detrusor overactivity (DO) or low compliance bladder (＜10 ml/cmH2O) despite taking anticholinergic medication. Bladder deformity was categorized from G0 to G3 by Ogawa's classification. Mean age of study patients was 51 years (25-76). Underlying diseases were spinal cord injury in 3 patients, spina bifida in 2, spinal cord infarction in 1, and post-radical hysterectomy in 1. Preceding anticholinergic medication was solifenacin 5 mg in 1 patient, solifenacin 10 mg in 5, and tolterodine 4 mg in 1. Before mirabegron, bladder deformity was G1 in 4 patients, G2 in 1 and G3 in 2, and vesicoureteral reflux (VUR) was detected in 3 patients. Five and 4 patients had detrusor overactivity and low compliance bladder, respectively. Videourodynamic study was reevaluated at a mean of 7 months (2- 12 months) after mirabegron. After mirabegron, urinary incontinence was improved in all patients. G3 bladder deformity was improved to G2 and G1 in one patient each, and VUR disappeared in all 3 patients. DO disappeared in 2 of the 5 patients, and bladder compliance was improved in all 4 patients with low compliance bladder. In conclusion, combination therapy of mirabegron is effective and beneficial for anticholinergic-resistant neurogenic bladder.

Protocol for a prospective magnetic resonance imaging study on supraspinal lower urinary tract control in healthy subjects and spinal cord injury patients undergoing intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity

BACKGROUND

The control of the lower urinary tract is a complex, multilevel process involving both the peripheral and central nervous system. Due to lesions of the neuraxis, most spinal cord injury patients suffer from neurogenic lower urinary tract dysfunction, which may jeopardise upper urinary tract function and has a negative impact on health-related quality of life. However, the alterations to the nervous system following spinal cord injury causing neurogenic lower urinary tract dysfunction and potential effects of treatments such as intradetrusor onabotulinumtoxinA injections on lower urinary tract control are poorly understood.

METHODS/DESIGN

This is a prospective structural and functional magnetic resonance imaging study investigating the supraspinal lower urinary tract control in healthy subjects and spinal cord injury patients undergoing intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity.Neuroimaging data will include structural magnetic resonance imaging (T1-weighted imaging and diffusion tensor imaging) as well as functional, i.e. blood oxygen level-dependent sensitive magnetic resonance imaging using a 3 T magnetic resonance scanner. The functional magnetic resonance imaging will be performed simultaneously to three different bladder stimulation paradigms using an automated magnetic resonance compatible and synchronised pump system.All subjects will undergo two consecutive and identical magnetic resonance imaging measurements. Healthy subjects will not undergo any intervention between measurements but spinal cord injury patients will receive intradetrusor onabotulinumtoxinA injections for treating neurogenic detrusor overactivity.Parameters of the clinical assessment including bladder diary, urinalysis, medical history, neuro-urological examination, urodynamic investigation as well as standardised questionnaires regarding lower urinary tract function and quality of life will serve as co-variates in the magnetic resonance imaging analysis.

DISCUSSION

This study will identify structural and functional alterations in supraspinal networks of lower urinary tract control in spinal cord injury patients with neurogenic detrusor overactivity compared to healthy controls. Post-treatment magnetic resonance imaging measurements in spinal cord injury patients will provide further insights into the mechanism of action of treatments such as intradetrusor onabotulinumtoxinA injections and the effect on supraspinal lower urinary tract control.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01768910.

[Evaluation of the adhesive characteristics of uropathogenic escherichia coli strains in patients with spinal cord injuries]

The adhesion characteristics of 9 clinical E.coli strains, isolated from the urine of 9 patients with spinal cord injuries in late period were evaluated. Patient age was 21 to 54 years. Neurogenic urination disordes observed in patients were the result of a spinal injury in the cervical (5 patients), thoracic (2 patients) and thoracolumbar (2 patients) spine. The duration of disease ranged from 2 to 12 years. Despite primarily a low adhesion activity of tested strains, the formation of biofilm occurs on the surfaces having both hydrophobic (polystyrene) and hydrophilic (cover glass) properties. After 24 h, according to the photometric evaluation, 7 of 9 strains had weak, 1 - medium, and 1 - high ability to form biofilms. After 48 hours, only 4 strains had low ability to form biofilms, of whom 2 had an increase ability compared to the previous period of observation. Other strains possess the medium ability to form biofilm. When quantifying the ability of bacteria to form biofilms on the surface of the cover glass, it was revealed that a large fraction of the area of the field of view was accounted for microcolonies with size 10 microm2 at 24 hours, and microcolony with size from 100 to 1000 microm2 at 48 h. There were number of significant correlations between parameters studied. After 24 h, the correlation coefficient between the optical density (OD630) and the number, OD630 and proportion of microcolonies with size 10 to 10000 microm2 varied from 0.79 to 0.9. After 48 hours, there was a direct correlation between the OD630 and the number (r = 0.73, P = 0.025), OD630 and proportion (r = 0.81, P = 0.009) of microcolonies with size 1,000 to 10,000 mkm2.

Estimation of bladder volume from afferent neural activity

Refractive urinary dysfunction in individuals suffering from neurogenic bladder syndrome can be treated with implanted neurostimulators that restore, to some degree, the control of the urinary bladder. A sensor capable of relaying feedback from bladder activity to the implanted neurostimulator is required to implement a closed-loop system to improve overall implant efficacy and minimize deleterious effects to neural tissue caused by continuous electrical stimulation. In this paper, we present a method that allows real-time estimation of bladder volume from the primary afferent activity of bladder mechanoreceptors. Our method was validated with data acquired from anesthetized rats in acute experiments. It was possible to qualitatively estimate three states of bladder fullness in 100% of trials when the recorded afferent activity exhibited a Spearman's correlation coefficient of 0.6 or better. Furthermore, we could quantitatively estimate bladder volume, and also its pressure, using timeframes of properly chosen duration. The mean volume estimation error was 5.8 ±3.1%. Our results also demonstrate that it is possible to quantify both phasic and tonic bladder responses during slow filling and isovolumetric measurements, respectively.

[Percutaneous radiofrequency sacral rhizotomy in the treatment of neurogenic detrusor overactivity in spinal cord injured patients]

INTRODUCTION

To evaluate the effects of percutaneous radiofrequency sacral rhizotomy in spinal cord injured (SCI) patients on urodynamic parameters (maximum cystometric capacity - MCC and detrusor pressure at maximum cystometric capacity - PdetMCC).

MATERIAL AND METHODS

This prospective study assessed eight patients with SCI (four men and four women) with a mean age of 31.3years (22 to 41). Mean interval period between spinal cord lesion and rhizotomy was 53.5 months (20 to 96). All patients underwent an anesthetic block of the 3rd sacral root bilaterally using 0.5% bupivacaine under fluoroscopic control. Those who responded with an increase on bladder capacity were selected to undergo the percutaneous radiofrequency sacral rhizotomy. All patients underwent urodynamic evaluation at 6 and 12 months following the procedure. MCC and P(det)MCC were recorded.

RESULTS

All patients presented a significant improvement on MCC after 12 months. The mean vesical volume increased from 100.2±57.1 to 282.9±133.4ml (p<0.05). The P(det)MCC reduced from 82.4±31.7 to 69.9±28.7cmH(2)O (p=0.2). Three patients with autonomic dysreflexia had complete relief of symptoms after the procedure. At 12 months, recurrence of detrusor hyperactivity was observed in all patients. One patient presented abolishment of reflex erections after the procedure. No major complications related to the rhizotomy were noted.

CONCLUSIONS

Percutaneous radiofrequency sacral rhizotomy is a minimally invasive technique with low morbidity able to increase MCC. There is a trend towards the reduction of the P(det)MCC in SCI patients at 12 months, although statistical significance was not reached.

Trigonal injection of botulinum toxin-A does not cause vesicoureteral reflux in neurogenic patients

AIMS

We evaluated the effect of botulinum toxin type A (BTX-A) injections in the trigone on the antireflux mechanism and evaluated its short-term efficacy.

MATERIALS AND METHODS

Between April and December 2006, 21 patients (10 men and 11 women) were prospectively evaluated. All were incontinent due to refractory NDO and underwent detrusor injection of 300 units of BTX-A, including 50 units into the trigone. Baseline and postoperative evaluation after eight weeks included cystogram, urinary tract ultrasound and urodynamics.

RESULTS

At baseline, 20 patients had no vesicoureteral (VUR) and one had grade II unilateral VUR. Postoperative evaluation revealed no cases of de novo VUR and the patient with preinjection VUR had complete resolution of the reflux. Ultrasound showed 5 (23.8%) patients with hydronephrosis before BTX-A injection and only one (4.8%) at the followup evaluation (p=0.066). After treatment, 9 (42.8%) patients became dry, 11 (52.4%) were improved and one (4.8%) had no improvement. Improved patients received antimuscarinic treatment and 8 (38.1%) became dry, with a final total continence rate of 80.1%. Cystometric capacity increased from 271+/-92 to 390+/-189 ml (p=0.002), reflex volume varied from 241+/-96 to 323+/-201 ml (p=0.020) and maximum detrusor pressure reduced from 66+/-39 to 38+/-37 cm H(2)O (p<0.001).

CONCLUSIONS

Our results confirm the safety of trigone injections of BTX-A in terms of development of VUR and upper urinary tract damage. Whether they are beneficial for patients with NDO or other causes of voiding dysfunction will need further studies.

Pediatric robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy: complete intracorporeal--initial case report

INTRODUCTION

To the best of our knowledge, we report the first case of complete intracorporeal robotic-assisted laparoscopic augmentation ileocystoplasty and Mitrofanoff appendicovesicostomy in a pediatric patient, outlining the surgical technique and short-term results.

TECHNICAL CONSIDERATIONS

The operative steps of the open procedure were replicated laparoscopically using robotic-assistance. In brief, 5 transperitoneal laparoscopic ports were placed before docking the da Vinci S robotic system. A 20-cm ileal segment was isolated, and the gastrointestinal anastomosis was performed in an end-to-end fashion using intracorporeal suturing. The appendix was anastomosed to the right posterior wall of the bladder over an 8F feeding tube in an extravesical fashion. The bladder was incised in a coronal plane, and the simple ileal on-lay patch was anastomosed to the posterior and anterior walls of the bladder. A suprapubic catheter and pelvic drain were placed, and the Mitrofanoff stoma was then fashioned. Cystography was performed at 4 weeks postoperatively.

CONCLUSIONS

This preliminary first successful report suggests that robotic-assisted ileocystoplasty and appendicovesicostomy is feasible. A reasonable outcome with early recovery, resumption of normal activities, and excellent cosmesis can be achieved in selected patients. However, whether a robotic-assisted approach provides any significant advantages over conventional open procedures is yet to be determined with a large case series.

Neurogenic bladder and chronic urinary retention associated with MDMA abuse

INTRODUCTION

The use of 3,4-methylenedioxymethamphetamine (MDMA, known as "ecstasy"), a synthetic amphetamine and "club drug," has been associated with acute, transient urinary retention. We report a case of neurogenic bladder and chronic urinary retention associated with MDMA abuse.

CASE REPORT

A 21-year-old male presented to the emergency department (ED) because he had abdominal pain and difficulty urinating. He had experienced difficulty in initiating urination over the past 1.5 months, with periods of 24 to 36 hours between voids and large volumes of urine. The patient had a chronic pattern of MDMA use, taking 4 tablets/day for 3 months. Two weeks before coming to the ED, he had been admitted to an inpatient drug rehabilitation center. During the time since that admission, the patient had visited EDs repeatedly for insertion and removal of Foley catheters to relieve the urinary retention until he could be admitted to a urologic service. Cystometrogram was abnormal, finding no sensation of bladder fullness after instillation of 350 mL of saline and inability to generate a voluntary voiding pressure. Cystoscopy revealed no outlet obstruction. The findings were consistent with neurogenic bladder. The patient was given prescriptions for bethanecol and phenazopyridine, and told to continue a 10-day course of sulfamethoxazole/trimethoprim for urinary tract infection. He was discharged with a Foley catheter in place. Symptoms of urinary retention persisted at 1-year follow-up, despite self-catheterization and complete cessation of MDMA use.

CONCLUSION

Chronic MDMA use may lead to neurogenic bladder and chronic urinary retention.

Histological changes in the urothelium and suburothelium of human overactive bladder following intradetrusor injections of botulinum neurotoxin type A for the treatment of neurogenic or idiopathic detrusor overactivity

BACKGROUND

We examined, for the first time in a prospective study, the histological changes in the urothelium and suburothelium of patients with neurogenic (NDO) or idiopathic detrusor overactivity (IDO) after one or repeat treatments with intradetrusor BoNTA.

METHODS

Flexible cystoscopic bladder biopsies were obtained from patients with urodynamically proven intractable spinal NDO or IDO before and 4 and 16 wk after one or repeat treatments with intradetrusor injections of BOTOX1 (NDO 300 U, IDO 200 U). Specimens were stained for haematoxylin-eosin and analysed blindly for inflammatory changes, fibrosis, hyperplasia, and dysplasia in the urothelium and suburothelium. Statistical comparisons were significant at p values less than 0.05.

RESULTS

Signs of chronic inflammation were found in 59.1% of baseline biopsies (65.6% of NDO vs. 50% of IDO, p=0.049), 67.6% of post-first biopsies and 86.4% after repeat injections. The two groups were comparable for degree of baseline inflammation, which did not change significantly after first injection and up to 16 wk after a third injection. Mild fibrosis was found in 2.2% of biopsies examined, equally before and after treatment, but not after repeat injections. No dysplasia or hyperplasia was identified. Eosinophils were identified more frequently in biopsies taken after repeat injections compared with the post-first injection and baseline biopsies (chi2=8.23, p=0.018). No difference existed between NDO and IDO bladders.

CONCLUSIONS

BoNTA injections do not appear to be producing significant inflammatory changes, fibrosis, or dysplastic changes in human bladder urothelium/suburothelium after a single injection and in a limited number of repeat treatment biopsies. The presence of eosinophils might be treatment-related, because they were mostly found in post-treatment biopsies.

Lower urinary tract dysfunctions in women with diabetes mellitus

PURPOSE OF REVIEW

This review discusses published data of the recent advances in understanding lower urinary tract dysfunctions in women with diabetes mellitus.

RECENT FINDINGS

Many studies have shown a relationship between diabetes mellitus and lower urinary tract dysfunctions. Although the pathophysiology of these disorders is multifactorial, microvascular damage and neuropathy causing dysfunctions of smooth muscle, urothelium, and neuronal components in the lower urinary tract are the most likely etiologies.

SUMMARY

Lower urinary tract dysfunctions are common in diabetes mellitus. Screening and effective management of these disorders should be promoted in an effort to decrease morbidity and improve quality of life.

Dorsal rhizotomy combined with anterior sacral root stimulation for neurogenic bladder

A spinal cord lesion (traumatic or not) above the sacral micturition center may induce hyperreflexia of the detrusor, spasticity of the sphincter and vesico-sphincter dyssynergia. Eventually, alterations in the upper urinary tract can be associated with increased mortality in this patient population. Sacral rhizotomies combined with implantation of an anterior sacral root stimulator appear to be an effective method not only for the treatment of voiding dysfunction but also for defecation and sexual disorders. The clinical and electrophysiological checks and the surgical technique are described. In most series, the results show a constant improvement in the patient's functional status. Ninety percent of patients gain satisfactory continence and no longer require an incontinence appliance. Bladder capacity and compliance increase dramatically. As a consequence, urinary infection rate decreases. The majority of patients remain dry, and more than 80% have a complete voiding or a post-void residue of less than 50ml and do not require any catheterization. Anterior sacral root stimulation combined with sacral posterior rhizotomy is a valuable method to restore bladder function in spinal cord-injured patients suffering from hyperactive bladder.

Continuous urinary incontinence presenting as the initial symptoms demonstrating acontractile detrusor and intrinsic sphincter deficiency in multiple system atrophy

Severe stress incontinence due to intrinsic sphincter deficiency may be common in aged women. However stress urinary incontinence could be the initial symptom of severe neurogenic bladder even if no neurological signs have previously been recognized. Urodynamic study is necessary in such a case. Tension-free vaginal tape surgery and intermittent self-catheterization may be one option, but self catheterization might become difficult when the neurological disorders develop. In this case report, we highlight the need for caution in identifying the presence of an occult neurogenic bladder when intending to carry out surgery for patients with severe stress incontinence.

Persistence of the synaptosomal-associated protein-25 cleavage product after intradetrusor botulinum toxin A injections in patients with myelomeningocele showing an inadequate response to treatment

OBJECTIVE To monitor the presence and cleavage of synaptosomal-associated protein of 25 kDa (SNAP-25) by botulinum toxin type A (botox-A), in human detrusor muscle, as the effects of botox-A in the urinary bladder last significantly longer than when applied for disorders of striated muscles. PATIENTS AND METHODS Tissue samples were obtained from eight patients with end-stage neurogenic bladder at different times after injection with botox-A. The resected bladder domes were examined using biochemical and immunohistological techniques. RESULTS The presence of intact SNAP-25 in human bladder was detected, for the first time, in all samples by both Western blotting and immunofluorescence. By contrast, detection of a band potentially representing toxin-cleaved SNAP-25(A) required its enrichment by precipitation with a specific antibody. This putative product was present in four of six patients treated with botox-A 5 weeks to 11 months previously, but could not be detected in one patient 30 months after botox injection, and in an untreated control. Fluorescence microscopy showed no obvious effects of the toxin treatment on the presence and pattern of SNAP-25-positive neurones. CONCLUSIONS A limited amount of SNAP-25 appears to be cleaved in nerves that innervate the smooth detrusor muscle in most patients who had been injected with botox-A; its absolute identification was precluded by the sensitivity of the detection. This protein was detectable much longer after toxin treatment than published for rodent striated muscle, and thus could contribute to the clinically reported longer duration of the effectiveness of botox-A.

Differentially expressed gene networks in cultured smooth muscle cells from normal and neuropathic bladder

Neuropathic bladder dysfunction results from abnormal development of the spine, spinal cord injuries, or diseases such as diabetics. Patients with neuropathic bladders often require surgical intervention such as bladder reconstruction to improve incontinence and prevent renal damage. Tissue engineering with ex-vivo cultured bladder cells has been suggested as one means for improving bladder function. However, we previously demonstrated that cultured bladder smooth muscle cells (SMCs) derived from neuropathic bladder exhibit and maintain altered pathologic phenotypes in culture. To identify genes that are responsible for the abnormal neuropathic phenotypes specifically elevated cell proliferation, the expression levels of 1,185 genes were compared between cultured SMCs derived from normal and neuropathic bladders using a cDNA array consisting of well-annotated genes. The expression data were analyzed using several methods to identify differentially expressed genes. The resulting sets of differentially expressed genes were examined by pathway analysis to identify the networks that remain abnormal in the culture-stable phenotype of neuropathic SMCs. A total of 18 genes that are differentially expressed between cultured normal and neuropathic bladder SMCs were identified. Of these 17 were up-regulated greater than 2-fold in neuropathic bladder SMCs, six of them along with one gene that was not up-regulated greater than 2-fold in cultured neuropathic bladder SMCs were confirmed and identified by more stringent analysis methods including significance analysis of microarrays, class comparison, and class prediction analyses. The major dysregulated pathways include fibroblast growth factor signaling, PTEN signaling, and integrin signaling. Our results further suggest that altered neuropathic bladder SMC phenotypes is stable in the culture environments and that SMCs derived from diseased bladders may not be appropriate for tissue engineering purpose without modification of pathologically altered genes expression.

Surgical results in patients with tuberculosis of the spine and severe lower-extremity motor deficits: a retrospective study of 48 patients

Object

Significant numbers of patients with spinal tuberculosis (TB), especially in developing countries, still present late after disease onset with severe neurological deficits. The authors conducted a study to assess the outcome in these patients.

Methods

Fifty-nine patients with spinal TB and severe motor deficits underwent surgery at the authors' center during the past 10 years. Data obtained in 48 patients with a minimum of 3 months of follow up (mean follow-up period 12.8 months) were analyzed. The disease in 34 patients was characterized by Frankel Grade A/B (Medical Research Council Grade 0/5) and in 14 patients by Frankel Grade C (unable to walk even with support) at admission. Thirty (88%) of the 34 patients with Frankel Grade A/B status and 13 (92.8%) of the 14 patients with Frankel Grade C status at admission experienced improvement to Frankel Grade D/E (walking with or without support) at the last follow-up examination 3 or more months after surgery. The degree of improvement exhibited by patients with a Frankel Grade A/B spinal cord injury was comparable to that shown by patients with Frankel Grade C status. Even patients with flaccid paraplegia, gross sensory deficit, prolonged weakness, spinal cord signal changes demonstrated on magnetic resonance imaging, and bladder involvement have experienced dramatic improvement in motor function since surgery. A significant number of the patients have shown remarkable improvement in other symptoms such as pain (91.6%), spasticity (88%), and bladder symptoms (88%).

Conclusions

A significant proportion of patients with spinal TB and severe motor deficits experience remarkable improvement after surgical decompression and hence should undergo surgery even though they may be suffering from paraplegia of considerable duration.

Structural and functional characterization of bladder smooth muscle in fetal rats with retinoic acid-induced myelomeningocele

Myelomeningocele (MMC) is the most common cause of neurogenic bladder dysfunction (NBD). We recently developed a novel retinoic acid (RA)-induced MMC model in fetal rats. The objective of this study was to use this model to assess functional and structural characteristics of the detrusor muscle in MMC-associated NBD. Time-dated pregnant Sprague-Dawley rats were gavage fed 60 mg/kg RA dissolved in olive oil or olive oil alone [embryonic day 10 ( E10)]. Bladder specimens from olive oil-exposed fetuses (OIL; n = 71), MMC ( n = 79), and RA-exposed-no MMC (RA, n = 62) were randomly assigned for functional and histopathological evaluation and protein analysis. Contractility responses to field and agonist-mediated stimulation (KCl and bethanecol) were analyzed. The expression patterns of α-smooth muscle actin, myosin, desmin, vimentin, and collagen III and I were analyzed by immunohistochemistry and Western blotting. Spatial and temporal distribution of nerve fibers within the detrusor muscle was monitored by neurotubulin-β-III throughout gestation. Neither OIL, MMC, nor RA detrusor responded to field stimulation. MMC bladder strips showed a significant decrease in contractility after KCl and bethanechol stimulation compared with OIL and RA bladders. Bladder detrusor morphology and expression patterns of smooth muscle markers were similar between groups. Detrusor muscles in OIL and RA fetuses were densely innervated, possessing abundant intramural ganglia and nerve trunks that branch to supply smooth muscle bundles. In MMC bladders, neurotubulin-β-III-positive nerve fibers were markedly decreased with advancing gestational age and were almost completely absent at term ( E22). We conclude that the biomechanical properties of fetal rat MMC bladders are analogous to that seen in humans with MMC-associated NBD. Decreased nerve density indicates loss of peripheral neural innervation throughout gestation. The early observation of decreased innervation and decreased contractility in the absence of morphologic abnormalities in muscle structure or extracellular matrix supports a pathophysiological hypothesis that denervation is the primary insult preceding the observed alterations in bladder muscle structure and function.

Time dependent changes in diabetic cystopathy in rats include compensated and decompensated bladder function

PURPOSE

Diabetic bladder dysfunction is among the most common and bothersome complications of diabetes mellitus. While bladder filling and voiding problems have been reported, the precise functional changes in diabetic bladders remain unclear. We investigated time dependent changes in bladder function in streptozotocin induced diabetic rats.

MATERIALS AND METHODS

Cystometrograms and detrusor muscle contractility were examined in male age matched control and diabetic Sprague-Dawley rats (Harlan, Indianapolis, Indiana) 3, 6, 9, 12 and 20 weeks after diabetes induction with streptozotocin.

RESULTS

Diabetes decreased average body weight and increased bladder weight, capacity and compliance. Peak detrusor leak pressure increased gradually from weeks 3 to 6 to 9 in diabetic rats (mean +/- SEM 47.3 +/- 2.5, 50.8 +/- 3.0 and 56.0 +/- 3.6 cm H(2)O) and in controls (36.9 +/- 1.4, 37.7 +/- 1.5 and 41.6 +/- 1.81 cm H(2)O, respectively). However, at 12 and 20 weeks diabetic rats deviated strongly from this trend with peak detrusor leak pressure decreasing vs controls (41.6 +/- 2.8 and 37.3 +/- 0.9 vs 45.2 +/- 1.7 and 49.6 +/- 1.4 cm H(2)O, respectively) and post-void resting pressures increasing from 9-week levels vs controls (interactions p <0.0001). In contractility studies increased contractile force responses of diabetic animals to carbamylcholine chloride, potassium chloride, adenosine 5'-triphosphate and electric field stimulation peaked at 6 or 9 weeks but at 12 to 20 weeks they generally reverted toward those of controls (carbamylcholine chloride and electrical field stimulation interactions p = 0.0022 and 0.01, respectively).

CONCLUSIONS

Diabetic bladders may undergo a transition from a compensated to a decompensated state and transition in the streptozotocin rat model may begin 9 to 12 weeks after induction.

Regulation of bladder muscarinic receptor subtypes by experimental pathologies

1 The M3 muscarinic receptor subtype is widely accepted as the receptor on smooth muscle cells that mediates cholinergic contraction of the normal urinary bladder and other smooth muscle tissues, however, we have found that the M2 receptor participates in contraction under certain abnormal conditions. The aim of this study was to determine the effects of various experimental pathologies on the muscarinic receptor subtype mediating urinary bladder contraction. 2 Experimental pathologies resulting in bladder hypertrophy (denervation and outlet obstruction) result in an up-regulation of bladder M2 receptors and a change in the receptor subtype mediating contraction from M3 towards M2. Preventing the denervation-induced bladder hypertrophy by urinary diversion prevents this shift in contractile phenotype indicating that hypertrophy is responsible as opposed to denervation per se. 3 The hypertrophy-induced increase in M2 receptor density and contractile response is accompanied by an increase in the tissue concentrations of mRNA coding for the M2 receptor subtype, however, M3 receptor protein density does not correlate with changes in M3 receptor tissue mRNA concentrations across different experimental pathologies. 4 This shift in contractile phenotype from M3 towards M2 subtype is also observed in aged male Sprague-Dawley rats but not females or either sex of the Fisher344 strain of rats. 5 Four repeated, sequential agonist concentration response curves also cause this shift in contractile phenotype in normal rat bladder strips in vitro, as evidenced by a decrease in the affinity of the M3 selective antagonist p-fluoro-hexahydro-sila-diphenidol (p-F-HHSiD). 6 A similar decrease in the contractile affinity of M3 selective antagonists (darifenacin and p-F-HHSiD) is also observed in bladder specimens from patients with neurogenic bladder as well as certain organ transplant donors. 7 It is concluded that although the M3 receptor subtype predominantly mediates contraction under normal circumstances, the M2 receptor subtype can take over a contractile role when the M3 subtype becomes inactivated by, for example, repeated agonist exposures or bladder hypertrophy. This finding has substantial implications for the clinical treatment of abnormal bladder contractions.

Aseptic meningo-radiculo-encephalitis presenting initially with urinary retention: a variant of acute disseminated encephalomyelitis

We report three male patients with aseptic meningoencephalo- radiculitis presenting with acute urinary retention. Viral antibody titers for herpes types I and II and the PCR studies were negative. The cerebrospinal fluid revealed elevated myelin basic protein. The serum antibodies against a panel of gangliosides, some of which are known to be associated with acquired demyelinating neuropathies, were all negative. The magnetic resonance imaging (MRI) studies revealed spotty T2 high intensities in the basal ganglia, thalamus and brainstem in two patients. In one patient,meningeal gadolinium enhancement of the conus and cauda equina of the spinal cord was recognized. On urodynamic studies, all patients showed features of atonic bladder with or without detrusor hyperactivity. They were treated conservatively without using steroids or immunoglobulins, and made a remarkable functional recovery with the disappearance of abnormal MRI findings.However, all three were left with erectile dysfunction, and two continued to use self-intermittent catheterization at more than 3-year follow-up. There was no recurrence of symptoms. The underlying causes remain unclear, though they may represent a variant of acute disseminated encephalomyelitis.

Tumor necrosis factor promotes differential trafficking of bladder mast cells in neurogenic cystitis

PURPOSE

IC is often considered neurogenic cystitis, in which mast cells are involved in a positive feedback loop that results in sustained urothelial inflammation. To characterize these processes we developed a murine model of neurogenic cystitis using Bartha's strain of PRV based on a similar model in the rat.

MATERIALS AND METHODS

Female C57BL/6 mice (National Cancer Institute, Bethesda, Maryland) were used in the study. Neurogenic cystitis was induced by the injection of Bartha's strain of PRV (2.2 x 10 pfu) into the abductor caudalis dorsalis tail base muscle. Bladder inflammation was assessed by leukocyte influx and Evans blue dye extravasation. Mast cells were visualized in bladder tissue by staining with 0.1% toluidine blue.

RESULTS

Inoculation with PRV in the abductor caudalis dorsalis resulted in cystitis within 3 days. Coincident with the induction of cystitis mast cells accumulated in the lamina propria due to mast cell trafficking from the proximal detrusor (relative to the lumen), whereas mast cells from the distal detrusor were unchanged and total mast cell counts were not increased. Degranulated mast cells increased approximately 20-fold in the lamina propria of infected mice relative to controls. In TNF receptor 1/2 deficient mice (Jackson Laboratory, Bar Harbor, Maine) mast cell trafficking was not observed in response to PRV and mast cells were not degranulated.

CONCLUSIONS

These data indicate that neurogenic cystitis is associated with the differential trafficking and activation of distinct mast cell pools in the bladder. Since TNF mediates these events, anti-TNF therapy may mitigate the pathogenesis of neurogenic cystitis.

Distribution of neuropeptide Y-containing nerves in the neurogenic and non-neurogenic detrusor

OBJECTIVE

To evaluate the role of neuropeptide Y in the detrusor of patients with neurogenic detrusor overactivity (NDO), as it has an important role in the neural regulation of the lower urinary tract by exerting differential effects on the release of cholinergic and adrenergic transmitters via autoinhibition and heterosynaptic interactions.

MATERIALS AND METHODS

Detrusor biopsies were obtained from 38 patients; 31 had video-urodynamically verified NDO, caused by meningomyelocele in 17 or spinal cord injury in 14. Seven had stress urinary incontinence (SUI) and this group served as a control. All specimens were fixed, paraffin wax-embedded, sectioned and stained with a monoclonal antibody against neuropeptide Y and a general nerve marker protein-gene-product 9.5 (PGP 9.5). The number of PGP 9.5- and neuropeptide Y-containing nerves was quantified by a standardized evaluation using image-analysis software.

RESULTS

The median (range) number of neuropeptide Y-containing nerves in the neurogenic detrusor, at 0.273 (0.126-0.639) per muscle cell nucleus (MCN), was significantly lower (P = 0.014) than that in patients with SUI, at 0.383 (0.267-0.728). In the neurogenic detrusor the number of PGP 9.5-positive nerves, at 0.278 (0.054-0.641)/MCN was also lower (P = 0.111) than in patients with SUI, at 0.368 (0.258-0.497). The ratio of neuropeptide Y to PGP 9.5 counts per biopsy did not differ between the groups (P = 0.628).

CONCLUSIONS

The number of PGP 9.5-positive nerves was not significantly and the number of neuropeptide Y-containing nerves was significantly reduced in patients with NDO. This may have been caused by transynaptic nerve degeneration of the detrusor, as described by in patients with spinal cord injury. As neuropeptide Y inhibits the contractile response of the detrusor the reduction of neuropeptide Y-containing nerves may play a role in the development and persistence of DO.

Accuracy of predicting bladder stones based on catheter encrustation in individuals with spinal cord injury

BACKGROUND

Bladder calculi are the second most common urological complication in those with spinal cord injury (SCI). Detection and removal of bladder stones are important to prevent possible complications.

OBJECTIVE

To determine the accuracy of bladder stone detection based on catheter encrustation in asymptomatic individuals with SCI.

DESIGN

Prospective cohort study.

METHODS

Cystoscopy findings in persons with SCI who were noted to have catheter encrustation at the time of catheter removal for their scheduled cystoscopy were used in this prospective study. Indwelling catheters were examined for encrustation at the time of removal as they were being prepared for cystoscopy. Cystoscopy was performed, and the presence or absence of bladder stones was noted.

MAIN OUTCOME MEASURES

Presence or absence of bladder stones detected with cystoscopy in those with precystoscopy catheter encrustation.

RESULTS

Forty-nine individuals with indwelling catheters were evaluated. Overall, 17/49 (35%) individuals in this study had bladder stones. Catheter encrustation was noted in 13 patients. Of these 13 patients, 11 also had bladder stones. In other words, a positive result for catheter encrustation had a positive result for bladder stones 85% of the time. Thirty-six individuals had no catheter encrustation. Of these, 6 (16%) were found to have bladder stones.

CONCLUSIONS

Encrustation of a catheter is highly predictive of the presence of bladder stones. This suggests that cystoscopy should be scheduled in a person undergoing a catheter change if catheter encrustation is noted.

[Efficacy and problems of bladder volume measurement using portable three dimensional ultrasound scanning device--in particular, on measuring bladder volume lower than 100ml]

OBJECTIVES

Using a portable three dimensional ultrasound scanning device (The Bladder Scan BVI6100, Diagnostic Ultrasound Corporation), we examined measured values of bladder volume, especially focusing on volume lower than 100 ml.

MATERIALS AND METHODS

A total of 100 patients (male: 66, female: 34) were enrolled in the study. We made a comparison study between the measured value (the average of three measurements of bladder urine volume after a trial in male and female modes) using BVI6100, and the actual measured value of the sample obtained by urethral catheterization in each patient. We examined the factors which could increase the error rate. We also introduced the effective techniques to reduce measurement errors.

RESULTS

The actual measured values in all patients correlated well with the average value of three measurements after a trial in a male mode of the BVI6100. The correlation coefficient was 0.887, the error rate was--4.6 +/- 24.5%, and the average coefficient of variation was 15.2. It was observed that the measurement result using the BVI6100 is influenced by patient side factors (extracted edges between bladder wall and urine, thickened bladder wall, irregular bladder wall, flattened rate of bladder, mistaking prostate for bladder in male, mistaking bladder for uterus in a female mode, etc.) or examiner side factors (angle between BVI and abdominal wall, compatibility between abdominal wall and ultrasound probe, controlling deflection while using probe, etc).

CONCLUSIONS

When appropriate patients are chosen and proper measurement is performed, BVI6100 provides significantly higher accuracy in determining bladder volume, compared with existing abdominal ultrasound methods. BVI6100 is a convenient and extremely effective device also for the measurement of bladder urine over 100 ml.

Quantification of bladder smooth muscle orientation in normal and spinal cord injured rats

Spinal cord injuries (SCI) often lead to severe bladder dysfunctions. Our previous studies have demonstrated that following SCI, rat bladder wall tissue became hypertrophied, significantly more compliant, and changed its mechanical behavior from orthotropic to isotropic. In order to elucidate the link between the tissue microstructure and mechanical properties of the wall, we have developed a novel semi-automated image analysis method to quantify smooth muscle bundle orientation and mass fraction in the bladder wall tissues from normal and 10 day-post-SCI rats. Results of the present study revealed that there were significant (p < 0.05) increases in smooth muscle area fractions as well as significantly (p < 0.001) fewer cell nuclei per muscle area in the SCI groups compared to the normal groups. Furthermore, while the normal rat bladders exhibited predominant smooth muscle orientation only in the longitudinal direction, the SCI rat bladders exhibited smooth muscles oriented in both the circumferential and longitudinal directions. These results provide first evidence that bladder smooth muscle cells exhibit hypertrophy rather than hyperplasia and developed a second, orthogonal orientation of smooth muscle bundles following SCI. The results of the present study corroborate our previous mechanical anisotropy data and provide the basis for development of structure-based constitutive models for urinary bladder wall tissue.

ROLE OF BASIC FIBROBLAST GROWTH FACTOR IN THE NEUROPATHIC BLADDER PHENOTYPE

PURPOSE

The neuropathic bladder is characterized by increased muscle mass within the bladder wall and reduced functional capability. The exact cellular mechanisms that regulate these changes have yet to be elucidated. We determine the role of basic fibroblast growth factor (bFGF) in the increased smooth muscle cell (SMC) proliferation seen in the neuropathic bladder.

MATERIALS AND METHODS

Primary human bladder SMC cultures were established from patients with either normal or neuropathic bladders (3 each). Expression of bFGF, smooth muscle markers and bFGF receptor-1 were quantified by immunohistochemistry and Western blot analysis. Cell proliferation was assayed by cell count after stimulation with recombinant bFGF in the presence and absence of a neutralizing anti-bFGF antibody.

RESULTS

Neuropathic bladder SMC expressed higher levels of bFGF than normal bladder SMC. Functional studies using exogenous bFGF demonstrated a significant dose dependent increase in cell proliferation in normal and neuropathic bladder SMC. This stimulatory effect could be completely inhibited by simultaneous addition of anti-bFGF antibodies. Also, the higher rate of baseline cell proliferation in neuropathic bladder SMC could be brought down to normal levels after treatment with anti-bFGF antibodies. The addition of exogenous bFGF showed no effect on the expression of fibroblast growth factor receptor-1 or smooth muscle phenotypic markers, suggesting that bFGF induces cell proliferation in neuropathic bladders in an autocrine fashion.

CONCLUSIONS

These novel findings support the hypothesis that bFGF is over expressed in the neuropathic bladder and directly influences an increase in SMC proliferation.

A comparison between the response of patients with idiopathic detrusor overactivity and neurogenic detrusor overactivity to the first intradetrusor injection of botulinum-A toxin

PURPOSE

Several studies have shown that intradetrusor injections of botulinum neurotoxin type A (BoNT/A) may effectively treat intractable spinal neurogenic detrusor overactivity (NDO), but fewer reports exist on the use of BoNT/A in patients with idiopathic detrusor overactivity (IDO). The purpose of this study was to investigate whether comparable efficacy could be displayed in the response of patients with IDO to those with NDO.

MATERIALS AND METHODS

In a prospective, open label study, patients with urgency, and/or urgency incontinence due to urodynamically proven intractable detrusor overactivity received 300 units (NDO) or 200 units (IDO) of Botox injected into the bladder with a minimally invasive outpatient technique. Urodynamic maximum cystometric capacity and maximum detrusor pressure during filling, frequency of voids (frequency), number of incontinence episodes (leak) and number of voids associated with urgency per 24 hours (urgency) from 4-day voiding diaries were compared between the 2 groups at baseline and for changes at 4 and 16 weeks after treatment.

RESULTS

A total of 44 patients with spinal NDO and 31 with IDO were treated. At 16 weeks, mean +/- standard error maximum cystometric capacity increased from 229.1 +/- 24.8 to 427.0 +/- 26.9 ml, p <0.0001 in NDO and from 193.6 +/- 24.0 to 327.1 +/- 36.1 ml, p=0.0008 in IDO. Maximum detrusor pressure during filling decreased from 60.7 +/- 6.8 to 26.1 +/- 3.7 cm H2O, p <0.0001 in NDO and from 62.1 +/- 10.8 to 45.1 +/- 8.1 cm H2O, p=0.027 in IDO. Frequency decreased from 12.3 +/- 0.7 to 6.6 +/- 0.6 voids per 24 hours, p <0.0001 in NDO and from 13.6 +/- 1.1 to 8.3 +/- 0.7, p=0.0002 in IDO. Leak decreased from 3.9 +/- 0.5 to 0.7 +/- 0.2 incontinence episodes per 24 hours, p <0.0001 in NDO and from 3.2 +/- 0.8 to 0.6 +/- 0.3, p=0.0017 in IDO, and urgency decreased from 7.5 +/- 0.6 to 1.44 +/- 0.3 episodes per 24 hours, p <0.0001 in NDO and from 10.9 +/- 1.7 to 4.9 +/- 1.1, p <0.0001 in IDO. The 2 groups were comparable for baseline data, but percent improvement in urgency was greater in patients with NDO at 4 weeks (78.2% vs 56.3%, p=0.019) and 16 weeks (78.3% vs 50.7%, p=0.013). Of patients with NDO 69% required self-catheterization de novo posttreatment compared with 19.3% of those with IDO.

CONCLUSIONS

Patients with intractable IDO respond to intradetrusor BoNT/A with equally significant improvements in urodynamic and lower urinary tract symptom parameters as those with spinal NDO, despite the lower dose of toxin used.

Decreased sensory receptors P2X3 and TRPV1 in suburothelial nerve fibers following intradetrusor injections of botulinum toxin for human detrusor overactivity

PURPOSE

Botulinum neurotoxin type A (BoNT/A) is effective in the treatment of intractable detrusor overactivity (DO). In addition to its known inhibitory effect on presynaptic release of acetylcholine by motor terminals, there is increasing evidence that BoNT/A may affect sensory fibers. We investigated a possible effect of BoNT/A on human bladder afferent mechanisms by studying the sensory receptors P2X3 and TRPV1 in biopsies from patients with neurogenic or idiopathic DO.

MATERIALS AND METHODS

A total of 38 patients (22 with neurogenic DO, 16 with idiopathic DO) with intractable DO were treated with intradetrusor BoNT/A, and bladder biopsies were taken at 4 and 16 weeks. Urodynamics and voiding diary were also recorded. Specimens were studied immunohistochemically for P2X3, TRPV1 and the pan-neuronal marker PGP9.5, in comparison with controls.

RESULTS

P2X3-immunoreactive and TRPV1-immunoreactive (-IR) fibers were decreased at 4 weeks after BoNT/A, and more significantly at 16 weeks (paired t test p=0.0004 and p=0.0008, respectively), when significant improvements were observed in clinical and urodynamic parameters. P2X3-IR fiber decrease was significantly correlated with reduction of urgency episodes at 4 and 16 weeks (p=0.0013 at 4 weeks and p=0.02 at 16 weeks), but not maximum cystometric capacity or detrusor pressures. TRPV1-IR fiber decrease showed a similar trend. PGP9.5-IR suburothelial fibers remained unchanged after treatment at both followups (p=0.85 and p=0.21 at 4 and 16 weeks, respectively). Urothelial cell P2X3-IR and TRPV1-IR also appeared unchanged.

CONCLUSIONS

Decreased levels of sensory receptors P2X3 and/or TRPV1 may contribute to the clinical effect of BoNT/A in detrusor overactivity.

Myogenic bladder decompensation in boys with a history of posterior urethral valves is caused by secondary bladder neck obstruction?

OBJECTIVE

To investigate whether myogenic bladder decompensation in patients treated for congenital posterior urethral valves (PUV, the most serious cause of infravesical obstruction in male neonates and infants) may be secondary to bladder neck obstruction, as despite prompt ablation of PUV these patients can have dysfunctional voiding during later childhood or adolescence, the so-called 'valve bladder syndrome'.

PATIENTS AND METHODS

The study comprised 18 boys (mean age 14 years, range 6.2-18.5) who had had successful transurethral ablation of PUV between 1982 and 1996, and had completed a follow-up which included serial assessment of serum creatinine, completion of a standard voiding diary, ultrasonography with measurement of urine before and after voiding, a urodynamic examination with simultaneous multichannel recording of pressure, volume and flow relationships during the filling and voiding phases, coupled with video-cystoscopy at least twice. The mean (range) follow-up was 9.3 (6-17) years.

RESULTS

Urodynamic investigation showed myogenic failure with inadequate bladder emptying in 10 patients; five with myogenic failure also had unstable bladder contractions. On video-cystoscopy the posterior bladder neck lip appeared elevated in all patients but in those with myogenic failure it was strongly suggestive of hypertrophy, with evidence of obstruction. At the last follow-up one patient with myogenic failure who had had bladder neck incision and four others who were being treated with alpha-adrenergic antagonists had a significant reduction of their postvoid residual urine.

CONCLUSION

Despite early valve ablation, a large proportion of boys treated for PUV have gradual detrusor decompensation, which may be caused by secondary bladder neck obstruction leading to obstructive voiding and finally detrusor failure. Surgical or pharmacological intervention to improve bladder neck obstruction may possibly avert this course, but further studies are needed to validate this hypothesis.

Which factors predict upper urinary tract deterioration in overactive neurogenic bladder dysfunction?

OBJECTIVES

To determine whether bladder histopathologic changes, detrusor leak point pressure (DLPP), disease duration, and preoperative catheterization time can predict for upper urinary tract (UUT) deterioration in patients with overactive neurogenic bladder dysfunction (ONBD).

METHODS

A total of 39 patients (7 women and 32 men) with ONBD who were treated with augmentation cystoplasty were included in the study. The patients had undergone perioperative full-thickness bladder biopsies during augmentation cystoplasty. Routine evaluation using light microscopy to investigate for inflammation, fibrosis, and mast cell count was done. Statistical analysis was done using the chi-square and Mann-Whitney U tests.

RESULTS

The mean duration of the disease was 8.7 years. Of the 39 patients, 18 (46%) had had indwelling catheters preoperatively. UUT deterioration was found in 16 (41%) of 39 patients. The mean DLPP was 105 cm H2O. The severity of detrusor fibrosis was a significant risk factor for UUT deterioration (P = 0.036). However, the degree of inflammation and the severity of fibrosis did not affect UUT deterioration. A DLPP of more than 75 cm H2O was a statistically significant risk factor (P = 0.04), but the disease duration and preoperative catheterization time were not.

CONCLUSIONS

The results of our study have shown that moderate to severe fibrosis in the detrusor and a DLPP of more than 75 cm H2O are the risk factors for UUT deterioration in patients with ONBD. However, additional studies, including ones with more patients, are needed to determine the relationship between the histopathologic changes and UUT deterioration in ONBD.

Chronic instrumentation with model microstimulators in an animal model of the lower urinary tract

BACKGROUND

Microstimulators are a new type of neuroprosthetic device that should be considered for applications such as micturition control after spinal cord injury (SCI). These devices are small (less than 25 mm by 5 mm) and the electrodes are located on the ends of the stimulator. The aim of the current study was to develop methods for chronic implantation of model microstimulators (M-Micro) on the bladder wall and pelvic plexus of female cats. A postmortem evaluation of the effects of 3 months of implantation is reported.

METHODS

Techniques to produce the M-Micro are described. Four of these devices were implanted in 4 female cats and maintained after the initial instrumentation surgery and a second survival surgery for SCI (at T10). Using a single suture tied around the M-Micro, these devices were secured to the bladder wall or the fat pads adjacent to the pelvic plexus. Additional instrumentation was implanted, including 2 catheters in the bladder, 1 abdominal balloon, and electromyography electrodes in the urethral and anal sphincters. Postmortem observations of the location of the M-Micro on the bladder wall were conducted after fixation.

RESULTS

The animals' conditions were good. One animal was sacrificed early because of a skin infection. A single suture was sufficient to anchor the M-Micro. However, during the surgical implantation the pelvic plexus M-Micro ended up close to the bladder neck. Extensive fibrous connective tissue formed around the M-Micro and implanted catheters on the bladder wall. This appeared to result, in part, from multiple devices implanted on or near the bladder wall.

CONCLUSIONS

These pilot studies showed that the M-Micro could be easily constructed and secured to the bladder wall or fat pads close to the pelvic plexus. There was a concern that the pelvic plexus location for the M-Micro ended near the bladder neck during the surgical implantation; however, these devices did not appear to migrate over this short, 3-month implantation period. The extensive connective tissue responses of the bladder wall to the tubes, wires, and M-Micro was a major concern. The M-Micro appears to be a good device to assess the potential of commercial microstimulators for use in micturition control.

Changes in pituitary adenylate cyclase activating polypeptide expression in urinary bladder pathways after spinal cord injury

These studies examined changes in the pituitary adenylate cyclase activating polypeptide (PACAP) expression in micturition reflex pathways after spinal cord injury (SCI) of various durations. In spinal-intact animals, PACAP immunoreactivity (IR) was expressed in fibers in the superficial dorsal horn in all segmental levels examined (L1, L2, L4-S1). Bladder-afferent cells (35-45%) in the dorsal root ganglia (DRG; L1, L2, L6, S1) from spinal-intact animals also exhibited PACAP-IR. After SCI (6 weeks), PACAP-IR was dramatically increased in spinal segments and DRG (L1, L2, L6, S1) involved in micturition reflexes. The density of PACAP-IR was increased in the superficial laminae (I-II) of the L1, L2, L6, and S1 spinal segments. No changes in PACAP-IR were observed in the L4-L5 segments. Staining was also dramatically increased in a fiber bundle extending ventrally from Lissauer's tract (LT) in lamina I along the lateral edge of the dorsal horn to the sacral parasympathetic nucleus (SPN) in the L6-S1 spinal segments (lateral collateral pathway of Lissauer, LCP). After SCI (range 48 h to 6 weeks), PACAP-IR in cells in the L1, L2, L6, and S1 DRG significantly (P < or = 0.001) increased and the percentage of bladder-afferent cells expressing PACAP-IR also significantly (P < or = 0.001) increased (70-92%). No changes were observed in the L4-L5 DRG. PACAP-IR was reduced throughout the urothelium and detrusor smooth muscle whole mounts after SCI. These studies demonstrate changes in PACAP expression in micturition reflex pathways after SCI that may contribute to urinary bladder dysfunction or reemergence of primitive voiding reflexes after SCI.

P2X3-immunoreactive nerve fibres in neurogenic detrusor overactivity and the effect of intravesical resiniferatoxin

OBJECTIVES

The ATP-gated purinergic receptor P2X3 is expressed by small diameter sensory neurons and has been identified in normal and neurogenic human bladder suburothelial fibres. Animal models have shown that ATP is released by the urothelium during bladder distension, suggesting a mechanosensory role for P2X3 receptors in normal bladder function. Successful treatment of spinal neurogenic detrusor overactivity (NDO) with intravesical resiniferatoxin (RTX), which partly acts on suburothelial C fibres, provides evidence for the emergence of a C fibre-mediated spinal reflex. The aim of this study was to investigate the possible role of P2X3-positive innervation in this pathological voiding reflex by comparing suburothelial P2X3 immunoreactivity of controls and in patients with NDO before and after intravesical RTX.

METHODS

Bladder biopsies were obtained from 8 controls and 20 patients with refractory NDO enrolled in a trial of intravesical RTX. P2X3 nerve fibre density and intensity were studied in the specimens by immunohistochemistry.

RESULTS

P2X3-IR nerve fibres were significantly increased in patients with NDO compared to controls (p=0.014). Thirteen patients had pre- and post-RTX biopsies available for immunohistochemistry; 5 of them responded clinically and 8 were non-responders. In the 5 patients who responded to RTX, there was a significant decrease in P2X3-positive fibres (p=0.032), whereas in non-responders, P2X3-IR nerve fibre density did not change significantly.

CONCLUSIONS

In patients with NDO, the numbers of P2X3-IR nerve fibres were increased in the suburothelium. There was a significant decrease in P2X3 immunoreactivity in responders to RTX, indicating a potential pathophysiological role for the P2X3 expressing fibres.

Mast cell chymase is a possible mediator of neurogenic bladder fibrosis

AIMS

Urinary bladders of patients with myelomeningocele, owing to spina bifida, are often functionally impaired, fibrotic organs. Common to this condition are repeated occurrences of bladder infection and inflammation. Since mast cells have been associated with a fibrogenic response in inflammatory conditions, we investigated the role of mast cell granule product, chymase, as a mediator of myleodysplastic bladder fibrosis.

METHODS

Human control and myelodysplastic bladder tissues were stained with Unna's stain and chymase antibody to determine mast cell number and localization. Cell specific localization of collagen mRNAs was determined by in situ hybridization (ISH). In vitro, normal human bladder fibroblasts were treated with recombinant chymase, heparin and inhibitors, and collagen subtype concentration was determined by enzyme linked immunosorbent assay (ELISA).

RESULTS

Myelodysplastic bladders were characterized by increased mast cells in the detrusor muscle layer compared to control bladders, as well as mast cell degranulation and increased connective tissue deposition. Both types I and III collagen mRNA localized to fibroblasts surrounding detrusor muscle fascicles, whereas only collagen III mRNA localized to cells within connective tissue infiltrated muscle bundles in myelomeningocele bladder tissue. Chymase treatment of bladder fibroblasts, in vitro, was dose-dependent and resulted in significant increases in both types I and III collagen. Heparin did not alter collagen protein expression, whereas heparin-chymase combination modulated type III collagen expression. Serine protease inhibitor, phenylmethylsulfonlyfluoride, did not inhibit collagen synthesis, whereas denatured chymase resulted in decreased collagenous protein levels.

CONCLUSIONS

Bladder fibrosis may be mediated by mast cell chymase stimulation of collagen synthesis.

Bladder cancer in patients with spinal cord injury

OBJECTIVE

The incidence of bladder cancer in spinal cord injury (SCI) is 16 to 28 times higher than that in the general population. The objective of this study was to investigate the characteristics of bladder cancer that are unique to the SCI population.

DESIGN

Retrospective review.

METHODS

The charts of 16 patients diagnosed with bladder cancer from 1982 to 2001 were reviewed for type of cancer, exposure to risk factors, presenting symptoms, and survival time.

RESULTS

The presenting manifestations were gross hematuria in 14 patients, papillary urethral growth in 1 patient, and acute obstructive renal failure in 1 patient. The diagnosis was made on initial cystoscopic evaluation in 16 patients; 3 patients required further evaluation. Eight of the 11 screening cytologies were suspicious for a malignancy prior to the diagnosis. Seven patients had transitional cell carcinoma, 6 patients had squamous cell carcinoma (SCCA), and 3 patients had both. The bladder wasmanaged with chronic indwelling catheter in 12 patients. Nine patients died of bladder cancer metastases and the remaining 3 patients died of other causes. Six patients survived 5 years or more; 4 were still alive at the completion of this study.

CONCLUSION

Gross hematuria in individuals with SCI warrants aggressive assessment for bladder cancer. Chronic indwelling catheter, smoking, and renal and bladder stones are important risk factors for cancer. The incidence of SCCA in the SCI popullation is much higher than in the general population. Cystoscopic and cytologic evaluation in patients with advanced disease may fail to confirm the diagnosis in a high proportion of patients.

Ultrasonic measurement of bladder weight as a novel urodynamic modality

Although pressure-flow studies (PFS) are currently recognized as the gold standard for the diagnosis of infravesical obstruction, their clinical use is limited, due to the invasive nature of procedure. Recently, we developed a new urodynamic parameter, ultrasound estimated bladder weight (UEBW), which was calculated from the bladder wall thickness measured ultrasonically and intravesical volume. Our comparative study between UEBW and PFS showed that UEBW diagnosed infravesical obstruction with a diagnosis accuracy of 73% using a cut-off value of 35 gm. UEBW could also be used as a reliable tool in monitoring therapeutic effects on BPH patients in terms of the relief of obstruction. In addition, UEBW is of clinical use in the management of neurogenic bladder dysfunction, in which there was a significant negative correlation noted between UEBW and bladder compliance. Consequently, UEBW could be a reliable predictor for a low-compliant bladder. Since UEBW can be obtained non-invasively, it is readily applicable to pediatric urology. In healthy children, UEBW increased significantly with age. For the evaluation of UEBW in an individual child patient, the deviation from age-matched UEBW, obtained from the formula of the linear correlation between UEBW and age, was employed. In our recent studies, the deviation from age-matched UEBW is likely to be used as a predictor for bladder dysfunction in children, such as secondary vesicoureteral reflux and a low-compliant bladder. In conclusion, UEBW is promising as a non-invasive urodynamic modality capable of evaluating bladder hypertrophy with its functional abnormalities.

Genitourinary anomaly in congenital varicella syndrome: case report and review

We describe a 1-year-old boy with congenital varicella syndrome who had vesicoureteral reflux (VUR) and neurogenic bladder. His mother had varicella during the 3rd month of pregnancy. At birth the patient presented with right microphthalmia, right microcornea, and persistent hyperplastic primary vitreous of the right eye. He had chronic constipation from 3 months of age. He had urinary tract infection at 1 year of age. Urological investigation revealed left grade V VUR and neurogenic bladder. His varicella zoster virus IgG titer measured by ELISA was 39.4 antibody index (normal <0.1). He had repeated episodes of urinary tract infection despite antibiotic prophylaxis and clean intermittent catheterization, and underwent a uretero-vesiconeostomy at 2 years of age. Maternal infection during early pregnancy and the serological evidence of varicella zoster IgG antibodies without a history of varicella after birth led to the diagnosis of congenital varicella syndrome. Urogenital anomalies have previously been described in 14 cases of congenital varicella syndrome. Most of these patients had neurogenic bladder, the pathophysiology of which could be explained by the known neurotropic nature of the virus.

Brainstem in multiple system atrophy: clinicopathological correlations

1. Multiple system atrophy (MSA) is a sporadic neurodegenerative disorder that manifests with parkinsonism, cerebellar ataxia, and autonomic failure in various combinations. 2. Orthostatic hypotension, neurogenic bladder, laryngeal stridor and sleep apnea, and rapid eye movement (REM) sleep behavior disorder are prominent manifestations of MSA. 3. In MSA, there is severe depletion of catecholaminergic neurons of the C1 and A1 areas in the ventrolateral medulla, and this may contribute to orthostatic hypotension and endocrine disturbances in this disorder, respectively. 4. Loss of corticotrophin-releasing factor (CRF) neurons in the pontine micturition area may contribute to neurogenic bladder dysfunction. 5. Respiratory abnormalities may reflect loss of cholinergic neurons in the arcuate nucleus of the ventral medulla. 6. Loss of cholinergic mesopontine neurons, in the setting of loss of locus ceruleus neurons and preservation of rostral raphe neurons, may contribute to REM sleep abnormalities in MSA.

Increased nerve growth factor expression triggers bladder overactivity

Prior studies have demonstrated an association between visceral inflammation, an increase in nerve growth factor (NGF) expression, and development of hyperalgesia. Because multiple mediators are released during inflammatory processes, we examined the effect of NGF alone using viral gene transfer in vivo. Replication-deficient adenoviral vectors encoding for NGF or beta-galactosidase were injected into the bladder wall. NGF levels were determined with an enzyme-linked immunoabsorbance assay. Cystometrograms were obtained 3 and 5 days after gene transfer by using a surgically implanted bladder catheter in awake male rats. Although the treatment with a control virus did not change NGF levels compared with those of naive animals, the vector encoding for NGF increased NGF protein levels in the bladder 4-fold. Histologically, no evidence of inflammation was noted. Expression of NGF led to bladder overactivity, whereas beta-galactosidase expression was without effect. These data demonstrate that a transient increase in NGF expression without associated inflammation sensitizes visceral reflex pathways, leading to bladder overactivity. Treatment strategies targeting NGF signaling might be useful in disorders involving sensitization of peripheral nerves.

PERSPECTIVE

Growth factors have been implicated in the pathogenesis of inflammatory pain. This study uses gene transfer to demonstrate that NGF sensitizes afferent pathways in the absence of inflammation, making it a potentially relevant treatment target.