Applications of artificial intelligence in urologic oncology

PURPOSE

With the recent rising interest in artificial intelligence (AI) in medicine, many studies have explored the potential and usefulness of AI in urological diseases. This study aimed to comprehensively review recent applications of AI in urologic oncology.

MATERIALS AND METHODS

We searched the PubMed-MEDLINE databases for articles in English on machine learning (ML) and deep learning (DL) models related to general surgery and prostate, bladder, and kidney cancer. The search terms were a combination of keywords, including both "urology" and "artificial intelligence" with one of the following: "machine learning," "deep learning," "neural network," "renal cell carcinoma," "kidney cancer," "urothelial carcinoma," "bladder cancer," "prostate cancer," and "robotic surgery."

RESULTS

A total of 58 articles were included. The studies on prostate cancer were related to grade prediction, improved diagnosis, and predicting outcomes and recurrence. The studies on bladder cancer mainly used radiomics to identify aggressive tumors and predict treatment outcomes, recurrence, and survival rates. Most studies on the application of ML and DL in kidney cancer were focused on the differentiation of benign and malignant tumors as well as prediction of their grade and subtype. Most studies suggested that methods using AI may be better than or similar to existing traditional methods.

CONCLUSIONS

AI technology is actively being investigated in the field of urological cancers as a tool for diagnosis, prediction of prognosis, and decision-making and is expected to be applied in additional clinical areas soon. Despite technological, legal, and ethical concerns, AI will change the landscape of urological cancer management.

Deep Learning Model for Real‑time Semantic Segmentation During Intraoperative Robotic Prostatectomy

Background and objective

Recently, deep learning algorithms, including convolutional neural networks (CNNs), have shown remarkable progress in medical imaging analysis. Semantic segmentation, which segments an unknown image into different parts and objects, has potential applications in robotic surgery in areas where artificial intelligence (AI) can be applied, such as in AI-assisted surgery, surgeon training, and skill assessment. We aimed to investigate the performance of a CNN-based deep learning model in real-time segmentation in robot-assisted radical prostatectomy (RALP).

Methods

Intraoperative videos of RALP procedures were obtained. The reinforcement U-Net model was used for segmentation. Segmentation of the images of instruments, bladder, prostate, and seminal vesicle-vas deferens was performed. The dataset was preprocessed and split randomly into training, validation, and test data in a 7:2:1 ratio. Dice coefficient, intersection over union (IoU), and accuracy by class, which are commonly used in medical image segmentation, were calculated to evaluate the performance of the model.

Key findings and limitations

From 120 patient videos, 2400 images were selected for RALP procedures. The mean Dice scores for the identification of the instruments, bladder, prostate, and seminal vesicle-vas deferens were 0.96, 0.74, 0.85, and 0.84, respectively. Overall, when applied to the test data, the model had a mean Dice coefficient value of 0.85, IoU of 0.77, and accuracy of 0.85. Limitations included the sample size, lack of diversity in the methods of surgery, incomplete surgical processes, and lack of external validation.

Conclusions and clinical implications

The CNN-based segmentation provides accurate real-time recognition of surgical instruments and anatomy in RALP. Deep learning algorithms can be used to identify anatomy within the surgical field and could potentially be used to provide real-time guidance in robotic surgery.

Patient summary

We demonstrate the potential effectiveness of deep learning segmentation in robotic prostatectomy procedures. Deep learning algorithms could be used to identify anatomical structures within the surgical field and may provide real-time guidance in robotic surgery.

Treatment Patterns with Mirabegron and Antimuscarinics for Overactive Bladder: A Prospective, Registry Study in Taiwan and South Korea (FAITH)

INTRODUCTION

This study aimed to assess overactive bladder (OAB) treatment patterns and factors associated with effectiveness and persistence.

METHODS

A prospective, longitudinal, observational registry study of adults starting OAB therapy with mirabegron or antimuscarinics was undertaken. Primary endpoints were time from treatment initiation to discontinuation/switching; proportion who discontinued/switched; and reasons for discontinuation/switching. Secondary endpoints included OAB Symptom Score (OABSS), OAB Questionnaire: Short Form, and OAB Bladder Assessment Tool scores; factors associated with effectiveness and persistence; and safety.

RESULTS

In total, 556 patients initiating mirabegron and 250 initiating antimuscarinics were enrolled. There was no treatment switch, change, or discontinuation in 68.5% of the mirabegron initiator group and median time to treatment change was not reached. Mean initial treatment duration was 130.8 days. In multivariable models, baseline OABSS was the only variable significantly associated with change from baseline in OABSS, and patients with mild and moderate OAB had significantly better persistence with mirabegron than those with severe OAB. Urinary tract infection was the most common adverse event with mirabegron. There was no treatment switch, change, or discontinuation in 60.4% of the antimuscarinics initiator group and median time to treatment change was not reached. Solifenacin was the most frequent initial treatment (66.0%). Mean treatment duration was 122.2 days. In multivariable models, baseline OABSS was the only variable significantly associated with change from baseline in OABSS, while patients with OAB medication in the 12 months before enrollment had significantly better persistence with antimuscarinics than those with no previous OAB medication. Dry mouth was the most common adverse event with antimuscarinics.

CONCLUSIONS

Mirabegron and solifenacin were commonly prescribed as first-line OAB medications. There was no treatment switch, change, or discontinuation in more than 60% of the mirabegron initiator and antimuscarinics initiator groups. Mean initial treatment duration was 130.8 days and 122.2 days for mirabegron and antimuscarinics, respectively. Graphical Abstract available for this article.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03572231.

Benign Prostatic Hyperplasia and the Risk of Falls in Older Men: Insights From a Population-Based Study on Geriatric Morbid Conditions

PURPOSE

The purpose of this study was to explore the association between benign prostatic hyperplasia (BPH) and the incidence of falls from the perspective of geriatric morbid conditions.

METHODS

Data were sourced from the triennial National Survey of Older Koreans conducted by the Ministry of Health and Welfare (2017-2020). In total, 8,135 male participants aged 65 and older were included, and information was gathered through questionnaires and physical measurements. Logistic regression analysis was utilized to determine the impact of BPH on the risk of falls, and subgroup analyses were conducted to examine the influence of BPH on specific types of falls.

RESULTS

Of the participants, 15.2% (1,238 of 8,135) reported that their BPH treatment exceeded 3 months, and 8.0% (648 of 8,135) reported experiencing falls, with 61.4% (398/648) of these falls resulting in injuries. A significant association was identified between BPH and both falls (odds ratio [OR], 1.798; 95% confidence interval [CI], 1.479-2.185) and falls with injuries (OR, 2.133; 95% CI, 1.689-2.694). A subgroup analysis indicated a correlation between BPH and falls in groups having one (OR, 1.912; 95% CI, 1.356-2.694) and 2 or more conditions (OR, 1.856; 95% CI, 1.455-2.367) involving visual and auditory impairments, cognitive decline, depression, lower motor weakness, and limitations in daily activities.

CONCLUSION

The findings indicate that BPH contributes to the incidence of falls among older men, particularly those with comorbid conditions. Considering the heightened fall risk among elderly individuals suffering from multiple morbidities, particularly those with BPH, targeted interventions are essential for mitigating the risk of falls in this vulnerable group.

The association between testosterone deficiency and nocturia: Insights from The National Health and Nutrition Examination Survey data set

AIMS

To examine the association between testosterone deficiency (TD) and nocturia in males, with specific attention to age and cardiovascular disease (CVD) comorbidity.

METHODS

This cross-sectional study utilized the National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2016, assessing 6137 adult male participants. TD was defined by a serum total testosterone (TT) concentration less than 300 ng/dL. Nocturia was determined based on participants' responses to a standard NHANES question regarding the frequency of urination during the night.

RESULTS

The study observed a significant association between TD and nocturia (adjusted odds ratio [95% confidence interval] = 1.211 [1.060-1.384], p = 0.005). Moreover, a U-shape pattern was noted in the relationship between serum TT concentration and the relative odds of nocturia. Subgroup analysis revealed a robust correlation between TD and nocturia in those over 60 years old, and those with hypertension, dyslipidemia, and CVDs.

CONCLUSION

Our findings suggest a positive correlation between TD and nocturia, particularly among elderly individuals with CVD. This association underscores the potential therapeutic significance of addressing TD in the management of nocturia. Furthermore, longitudinal studies are needed to establish a causal relationship between TD and nocturia.

Predictive factors for postoperative medication therapy for overactive bladder symptoms after holmium laser enucleation of prostate

OBJECTIVE

To preoperative factors that could predict the persisting storage symptoms after Holmium laser enucleation of the prostate (HoLEP).

METHODS

Medical records of 257 patients who underwent HoLEP between December 2014 and January 2021 were reviewed. Participants with a follow-up period exceeding 6 months were included. Preoperative data, including International Prostate Symptom Score (IPSS), uroflowmetry, prostate size, and prostate-specific antigen, were collected. All participants underwent a preoperative urodynamic study. The correlation between perioperative variables and postoperative medication therapy (antimuscarinics or beta-3 agonists) was assessed.

RESULTS

Out of 257 participants in the study, 46 (18.6%) were allocated to the medication group, of which 25 (54.3%) initiated medication therapy postoperatively. The medication group showed worse postoperative IPSS storage symptom score and quality of life score compared to the medication-free group (p = 0.048 and p = 0.002, respectively), but no significant differences were observed in complications or operative variables. In the de-novo medication group, patients had lower preoperative Qmax , larger prostate volume, and smaller maximum cystometric capacity (MCC) compared to the persisting medication group (p = 0.020, p = 0.009, and p = 0.008, respectively). Overactive bladder (OAB) history, terminal detrusor overactivity (DO), and IPSS urgency item were identified as possible predictive factors for post-HoLEP medication use.

CONCLUSIONS

Preoperative factors such as OAB history, terminal DO, and IPSS urgency item may predict the need for post-HoLEP medication therapy. Further follow-up studies are warranted to understand the characteristics of the de-novo medication group due to the significant discomfort it can cause to patients.

Artificial Intelligence-Based Speech Analysis System for Medical Support

PURPOSE

Prior research has indicated that stroke can influence the symptoms and presentation of neurogenic bladder, with various patterns emerging, including abnormal facial and linguistic characteristics. Language patterns, in particular, can be easily recognized. In this paper, we propose a platform that accurately analyzes the voices of stroke patients with neurogenic bladder, enabling early detection and prevention of the condition.

METHODS

In this study, we developed an artificial intelligence-based speech analysis diagnostic system to assess the risk of stroke associated with neurogenic bladder disease in elderly individuals. The proposed method involves recording the voice of a stroke patient while they speak a specific sentence, analyzing it to extract unique feature data, and then offering a voice alarm service through a mobile application. The system processes and classifies abnormalities, and issues alarm events based on analyzed voice data.

RESULTS

In order to assess the performance of the software, we first obtained the validation accuracy and training accuracy from the training data. Subsequently, we applied the analysis model by inputting both abnormal and normal data and tested the outcomes. The analysis model was evaluated by processing 30 abnormal data points and 30 normal data points in real time. The results demonstrated a high test accuracy of 98.7% for normal data and 99.6% for abnormal data.

CONCLUSION

Patients with neurogenic bladder due to stroke experience long-term consequences, such as physical and cognitive impairments, even when they receive prompt medical attention and treatment. As chronic diseases become increasingly prevalent in our aging society, it is essential to investigate digital treatments for conditions like stroke that lead to significant sequelae. This artificial intelligence-based healthcare convergence medical device aims to provide patients with timely and safe medical care through mobile services, ultimately reducing national social costs.

A treatment prediction strategy for overactive bladder using a machine learning algorithm that utilized data from the FAITH study

AIMS

To use machine learning algorithms to develop a model to accurately predict treatment responses to mirabegron or antimuscarinic agents in patients with overactive bladder (OAB), using real-world data from the FAITH registry (NCT03572231).

METHODS

The FAITH registry data included patients who had been diagnosed with OAB symptoms for at least 3 months and were due to initiate monotherapy with mirabegron or any antimuscarinic. For the development of the machine learning model, data from patients were included if they had completed the 183-day study period, had data for all timepoints and had completed the overactive bladder symptom scores (OABSS) at baseline and end of study. The primary outcome of the study was a composite outcome combining efficacy, persistence, and safety outcomes. Treatment was deemed "more effective" if the composite outcome criteria for "successful," "no treatment change," and "safe" were met, otherwise treatment was deemed "less effective." To explore the composite algorithm, a total of 14 clinical risk factors were included in the initial data set and a 10-fold cross-validation procedure was performed. A range of machine learning models were evaluated to determine the most effective algorithm.

RESULTS

In total, data from 396 patients were included (266 [67.2%] treated with mirabegron and 130 [32.8%] treated with an antimuscarinic). Of these, 138 (34.8%) were in the "more effective" group and 258 (65.2%) were in the "less effective" group. The groups were comparable in terms of their characteristic distributions across patient age, sex, body mass index, and Charlson Comorbidity Index. Of the six models initially selected and tested, the decision tree (C5.0) model was chosen for further optimization, and the receiver operating characteristic of the final optimized model had an area under the curve result of 0.70 (95% confidence interval: 0.54-0.85) when 15 was used for the min n parameter.

CONCLUSIONS

This study successfully created a simple, rapid, and easy-to-use interface that could be further refined to produce a valuable educational or clinical decision-making aid.

Pelvic floor muscle exercise and training for coping with urinary incontinence

The pelvic floor consists of levator ani muscles including puborectalis, pubococcygeus and iliococcygeus muscles, and coccygeus muscles. Pelvic floor muscle exercise (PFME) is defined as exercise to improve pelvic floor muscle strength, power, endurance, relaxation, or a combination of these parameters. PFME strengthens the pelvic floor muscles to provide urethral support to prevent urine leakage and suppress urgency. This exercise has been recommended for urinary incontinence since first described by Kegel. When treating urinary incontinence, particularly stress urinary incontinence, PFME has been recommended as first-line treatment. This article provides clinical application of PFME as a behavioral therapy for urinary incontinence. Clinicians and physical therapist should understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly.

Association of nocturia and cardiovascular disease: Data from the National Health and Nutrition Examination Survey

AIMS

To investigate the association of nocturia with the prevalence of cardiovascular disease (CVD) using the National Health and Nutrition Examination Survey (NHANES) data.

METHODS

Among the 40 790 individuals who participated in NHANES from 2005 to 2012, 14 114 adults were analyzed in this study. A participant was considered to have nocturia if they have two or more voiding episodes nightly. In addition, participants with nocturia more than four times in a day were considered to have severe nocturia. A multivariate logistic regression analysis with adjustment for confounding variables, including age, sex, race, body mass index (BMI), smoking status, alcohol consumption, sleeping time, dyslipidemia, hypertension, and diabetes mellitus was performed with 1:1 propensity score matching (PSM).

RESULTS

Nocturia occurred in 4610 individuals (32.7%). The prevalence of CVD was significantly higher in men, older individuals, those with higher BMI, smokers, and those with diabetes, hypertension, and hyperlipidemia. There was also a significantly higher prevalence of nocturia in the participants with CVD. Multivariate analysis showed that odds ratios (ORs) of mild and severe nocturia for CVD were 1.23 (95% confidence interval [CI]: 1.08-1.39) and 1.74 (95% CI: 1.39-2.17), respectively. After 1:1 PSM, the ORs of mild and severe nocturia were 1.27 (95% CI: 1.10-1.48) and 1.73 (95% CI: 1.33-2.26), respectively, showing statistical significance.

CONCLUSION

Data from the NHANES indicate that CVD was significantly associated with the prevalence of nocturia, after taking major confounding factors into account. Furthermore, the risk for CVD increases with increasing nocturia severity.

The impact of urinary incontinence on falls: A systematic review and meta-analysis

OBJECTIVE

Previous studies on the association between urinary incontinence (UI) and falls have reported conflicting results. We, therefore, aimed to evaluate and clarify this association through a systematic review and meta-analysis of relevant studies.

METHODS

We performed a literature search for relevant studies in databases including PubMed and EMBASE from inception up to December 13, 2020, using several search terms related to UI and falls. Based on the data reported in these studies, we calculated the pooled odds ratios (ORs) for falls and the corresponding 95% confidence intervals (CIs) using the Mantel-Haenszel method.

RESULTS

This meta-analysis included 38 articles and a total of 230,129 participants. UI was significantly associated with falls (OR, 1.62; 95% CI, 1.45-1.83). Subgroup analyses based on the age and sex of the participants revealed a significant association between UI and falls in older (≥65 years) participants (OR, 1.59; 95% CI, 1.31-1.93), and in both men (OR, 1.88; 95% CI, 1.57-2.25) and women (OR, 1.41; 95% CI, 1.29-1.54). Subgroup analysis based on the definition of falls revealed a significant association between UI and falls (≥1 fall event) (OR, 1.61; 95% CI, 1.42-1.82) and recurrent falls (≥2 fall events) (OR, 1.63; 95% CI, 1.49-1.78). According to the UI type, a significant association between UI and falls was observed in patients with urgency UI (OR, 1.76; 95% CI, 1.15-1.70) and those with stress UI (OR, 1.73; 95% CI, 1.39-2.15).

CONCLUSIONS

This meta-analysis, which was based on evidence from a review of the published literature, clearly demonstrated that UI is an important risk factor for falls in both general and older populations.

Effect of udenafil administration on postmicturition dribbling in men: a prospective, multicenter, double-blind, placebo-controlled, randomized clinical study

PURPOSE

Postmicturition dribbling (PMD) is a stressful symptom in middle-aged men characterized by urinary leakage after the completion of normal voiding. Appropriate treatments have not yet been introduced. This study assessed the efficacy of treatment of PMD with 75 mg udenafil daily.

MATERIALS AND METHODS

The study included 138 men with regular sexual lifestyles. The Hallym PMD questionnaire (HPMDQ) was used to assess PMD symptoms. After all basic examinations, patients were randomly assigned to either udenafil or placebo. Patients completed the surveys, uroflowmetry (UFM), a bladder scan, and the paper test during the follow-up visit.

RESULTS

The mean age of the patients was 57.6 years. PMD with one of every three urinations was experienced by 59 patients (42.8%), whereas 45 patients (32.6%) experienced PMD with two of every three urinations. PMD with every urination was experienced by 34 patients (24.6%). More than half of the patients (89 patients, 65.4%) indicated that persistent PMD symptoms would likely result in moderate to severe discomfort in their daily activities. As time passed, the udenafil group showed significant improvement in PMD symptoms (p = 0.001).

CONCLUSION

Udenafil 75 mg once daily can be an effective treatment for patients with PMD symptoms.

Efficacy and safety of dose escalation in male patients with overactive bladder showing poor efficacy after low-dose antimuscarinic treatment: A retrospective multicenter study

Purpose

To analyze the efficacy and safety of standard-dose antimuscarinic treatment on male patients with overactive bladder (OAB) symptoms showing poor efficacy after low-dose antimuscarinics.

Materials and Methods

We retrospectively reviewed the data of 566 male patients aged ≥40 with OAB symptoms between January 2017 and June 2018. They were treated with low-dose antimuscarinics for at least 4 weeks and showed poor efficacy; therefore, they were switched to standard dose antimuscarinic treatment (5 mg of solifenacin) for ≥12 weeks. The international prostate symptom score (IPSS) and overactive bladder symptom score (OABSS) at baseline (V0), 4 weeks (V1), and 12 weeks (V2) were analyzed. Post void residual urine volume (PVR) was also recorded.

Results

The median age, body mass index, and prostate-specific antigen levels were 69.0 years, 24.2 kg/m², and 1.24 ng/dL, respectively. The mean value of the total IPSS and OABSS significantly decreased between V0 and V2 (from 16.73 to 13.69 and 7.33 to 5.34, respectively, all p<0.001). All component scores from each questionnaire demonstrated a significant decrease except for numbers three and six on the IPSS questionnaire. PVR was increased from V0 to V2 (36.40 to 68.90 mL, p=0.015). Four and nine patients experienced constipation and thirst, respectively, and all adverse effects were graded as ≤2.

Conclusions

Standard dose antimuscarinic treatment using solifenacin (5 mg) may be a safe and effective treatment for patients with OAB symptoms refractory to low-dose antimuscarinic treatment.

Development and validation of a symptom assessment tool for postmicturition dribble: A prospective, multicenter, observational study in Korea

Objectives

Postmicturition dribble (PMD) is a very common symptom in males with lower urinary tract symptoms (LUTS) worldwide, but there is no adequate questionnaire to assess it. Therefore, we developed a questionnaire named the Hallym Post Micturition Dribble Questionnaire (HPMDQ) to assess PMD, and the aim of this study is to validate it.

Methods

A series of consecutive male patients newly diagnosed with LUTS and over 40 years of age who visited any of 5 medical institutions were included. LUTS were assessed in all patients using the International Prostate Symptom Score (IPSS), and PMD was assessed using the HPMDQ.

Results

In total, 2134 male patients aged 40 to 91 years were included in this study. Of these patients, 1088 (51.0%) reported PMD. In the PMD group, the mean values for HPMDQ-Q1, HPMDQ-Q2, HPMDQ-Q3 and HPMDQ total score were 1.39, 1.10, 1.76 and 4.25, respectively. In the non-PMD group, the mean values of these scores were 0, 0.18, 1.52 and 1.58, respectively. The difference in HPMDQ scores between the 2 groups was statistically significant. PMD was significantly associated with the voiding symptoms of LUTS, prostate size and postvoid residual but not with storage symptoms.

Conclusions

The HPMDQ, which consists of 5 questions (frequency, severity, bother, quality of life and response to treatment for PMD), was developed, and its use for assessing PMD is validated in this study. It may be a useful tool for further research and in clinical practice for PMD.

Analyzing the Factors Associated With Nocturia in Older People in the United States

Background

The risk factors of nocturia in older adults remain unclear. We aimed to investigate factors associated with nocturia using the National Health and Nutrition Examination Survey (NHANES) data.

Methods

Among 40,790 participants, 4,698 participants aged ≥65 years were included from the NHANES dataset between 2005 and 2012. A multivariate logistic regression analysis was performed to determine the odds ratio (OR) for nocturia. A subgroup analysis was conducted based on sex and underlying diseases.

Results

In the multivariate logistic regression model, obesity (OR, 1.46; 95% confidence interval [CI], 1.28–1.68), hypertension (OR, 1.28; 95% CI, 1.07–1.52), and diabetes mellitus (DM) (OR, 1.27; 95% CI, 1.11–1.45) were significantly associated with nocturia. These factors were associated with nocturia regardless of sex. In a subgroup of participants with hypertension, obesity (OR, 1.44; 95% CI, 1.25–1.67) and DM (OR, 1.26; 95% CI, 1.09–1.45) were associated with nocturia. In the additional analysis on patients with DM, nocturia was associated with obesity (OR, 1.33; 95% CI, 1.06–1.67) and duration of DM (OR, 1.02; 95% CI, 1.01–1.03).

Conclusion

This study demonstrated that hypertension, DM, and obesity were significantly associated with the prevalence of nocturia in older adult patients regardless of sex. In particular, obesity was associated with nocturia in every subgroup analysis.

Is A Combination of Antibiotics and Non-Steroidal Anti-Inflammatory Drugs More Beneficial Than Antibiotic Monotherapy For The Treatment of Female Acute Uncomplicated Cystitis? A Randomized Controlled Pilot Study

Purpose: To compare the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) combination therapy to single-agent antibiotic therapy for the resolution of symptoms during two restricted activity days in patients with acute uncomplicated cystitis (AUC)Materials and Methods: We performed a prospective, randomized control pilot study. A total of 55 patients were enrolled. Group I (n=28) was treated with cepodoxime (100 mg twice per day), and Group II (n=27) was treated with cepodoxime (100 mg) and aceclofenac (100 mg) twice per day; both groups were treated for three days. Upon dysuria after each administration, the participants entered a value on a numerical pain scale. The primary outcome was whether there were any differences in the decrease rate in pain scale between the two groups.Result: The average age of the 55 patients was 49.9 ± 13.5 years, and prior to the clinical visit, the patients ex-perienced an average of 2.4 ± 2.2 days of dysuria symptoms. The average numerical pain scale score for dysuria was 4.98 ± 2.18. Thirty-four patients (61.8%) showed positive culture results, and E. coli was the most commonly found bacteria, cultured in 32 patients.Fifty-one patients visited the clinic on day 7, and 42 (76.4%) reported symptom improvement, while nine patients (16.3%) had persistent symptoms. The follow-up numerical pain score was 0.39 ± 1.02 points. The pain score was dramatically decreased after medication. No difference was observed in the magnitude of the pain scale reduction between the two groups (P = 0.134). However, group II showed faster symptom resolution (P = 0.035) at the third administration (day 1.5).Conclusion: Combination therapy with NSAIDs and antibiotics for AUC patients can improve symptoms faster during two restricted activity days when patients have difficulty performing daily living activities.

Association Between Irritable Bowel Syndrome and Overactive Bladder: A Research Survey

OBJECTIVE

To investigate the relationship between irritable bowel syndrome (IBS) and overactive bladder (OAB) in men and women using questionnaires.

MATERIALS AND METHODS

This research survey was based on multicenter data (men and women older than 20 years). The Korean version of the Rome III criteria was used for the diagnosis of IBS, Overactive Bladder Symptom Score (OABSS) was used for screening OAB, Self-Rating Depression Scale was used for depressive symptoms, and International Prostate Symptom Score and Quality of Life were used to determine the degrees of lower urinary tract symptoms.

RESULTS

A total of 609 (men: 257, women: 352) people answered the questionnaire. The prevalence of IBS and OAB was 31.9% (men vs women: 27.3% vs 39.2%) and 19.2% (men vs women: 25.3% vs 18.5%), respectively. The OABSS values of patients with IBS and non-IBS patients were 1.70 ± 2.48 and 2.48 ± 2.79 (P <.001). On the Self-Rating Depression Scale, individuals with IBS had a higher score than non-IBS individuals (n = 201) (44.92 ± 13.71 vs 39.19 ± 10.39, P <.001). In men, non-IBS (n = 56) had higher OABSS and OABSS question number 3 responses than patients with IBS (OABSS: 2.56 ± 2.69 vs 1.57 ± 2.43, P = .01, OABSS Q3: 0.92 ± 1.26 vs 0.66 ± 1.13, P = .17). Also, in women, non-IBS (n = 214) had higher OABSS and OABSS question number 3 responses than patients with IBS (n = 138) (OABSS: 2.40 ± 2.87 vs 1.76 ± 2.52, P = .03, OABSS Q3: 0.83 ± 1.25 vs 0.70 ± 1.18, P = .32).

CONCLUSION

IBS in adults had no relationship with OAB in our study. These data suggest that more studies are needed to determine the relationship between IBS and OAB.

Acid-base disorders after orthotopic bladder replacement: comparison of an ileal neobladder and an ileal conduit

Objectives: For many years, creation of an orthotopic neobladder after cystectomy has been popular. In the present study, we measured the extent of metabolic acidosis in patients with ileal neobladders compared with ileal conduits and defined risk factors for development of metabolic acidosis.

Methods: We retrospectively studied 95 patients, who underwent radical cystectomy and urinary diversion to treat invasive bladder cancer from January 2001 to December 2014 at Hallym University Kangnam Sacred Heart Hospital, through investigation of acid-base balance, serum electrolyte levels and renal function one month and one year after operation.

Results: One month after the operation, metabolic acidosis was found from 18 patients (31.0%) in an ileal neobladder group and from 4 (14.8%) in an ileal conduits group. One year after the operation, the numbers became 11 (22.9%) and 2 (10.0%), respectively. However, there was not a statistical difference. The blood biochemical profiles of the two groups did not differ significantly after urinary diversion. Logistic analysis revealed that lower estimated glomerular filtration rate (eGFR) was associated with metabolic acidosis at one month (odds ratio, OR = 0.94 [0.91–0.97]; p < 0.001) and one year (OR = 0.94 [0.92–0.97]; P = 0.001) after urinary diversion. In multivariate analysis, lower eGFR is a significant risk factor for metabolic acidosis at one month.

Conclusions: Patients with ileal neobladders and conduits are at the similar risk of metabolic acidosis. A close association between renal function and development of metabolic acidosis was observed, especially stronger in an early period after operation.

A sequential comparison of postoperative voiding function between two different transobturator sling procedures

INTRODUCTION

We evaluated sequential postoperative voiding function of two types of sling procedures (Monarc^® and ALIGN^®) in patients with stress urinary incontinence.

METHODS

Ninety-one women diagnosed with urodynamic stress incontinence were randomly assigned to the study. All enrolled patients underwent Monarc or ALIGN procedure. They were postoperatively evaluated at one day, one week, one month, three months, 12 months, and 24 months. The voiding function was evaluated with uroflowmetry and post-void residual urine. Patients were asked if voiding had changed after surgery and had to complete the incontinence quality of life scale (I-QoL) questionnaire at 12 months.

RESULTS

The Monarc (n=47) and ALIGN (n=44) groups had similar demographic characteristics. The maximal flow rate (Qmax) was significantly decreased on the first day after surgery and gradually increased during the following weeks. Comparing the two groups at one week, the ALIGN group had a significantly decreased Qmax than the Monarc group (17.6 ± 5.2 vs. 20.7 ± 5.0; p=0.004). However, at one, three, 12, and 24 months, there were no significant differences between the two groups.

CONCLUSIONS

This study demonstrated that an absorbable tensioning suture in the Monarc mesh could increase Qmax compared to ALIGN at one week after surgery. An absorbable tensioning suture may reduce the risk of an early postoperative voiding dysfunction compared to other meshes that do not have this.

Correlation between overactive bladder symptom score and neuropsychological parameters in Alzheimer's disease patients with lower urinary tract symptom

Purpose

To examine an association between the overactive bladder symptom score (OABSS) and neuropsychological parameters. Moreover, we investigate the factors that affect each item in the questionnaire.

Materials and Methods

A total of 376 patients (males: 184; females: 192) with probable Alzheimer’s disease (AD) were recruited. Cognitive testing was conducted using the Mini Mental Status Examination (MMSE), Clinical Dementia Rating (CDR) scale, Global Deterioration Scale (GDS), and Barthel Activities of Daily Living (ADL). Lower urinary tract symptom (LUTS) was assessed using OABSS and voiding diary.

Results

The prevalence of overactive bladder (OAB) (defined as OABSS ≥3 with an urgency score of ≥2) in patients with AD was 72.6%. Among the OAB subjects, the most common severity of symptom was moderate (72.6%), followed by mild (21.2%), and severe (5.8%). It was found that OABSS had a very high correlation with aging (r=0.75; p<0.001). When compared with neuropsychological parameters, it was found that OABSS was highly correlated with the CDR scores (r=0.446; p<0.001). However, no significant correlation was found between the changes in OABSS scores and those in other neuropsychological parameters. Based on the individual symptom scores, urgency incontinence was highly correlated with the CDR scores (r=0.43; p<0.001).

Conclusions

OABSS is a useful tool in assessing AD patients with LUTS. There was a consistent positive association between OABSS severity, including urgency incontinence, and CDR scores.

Effect of Tamsulosin in Lower Urinary Tract Symptom Patients With Metabolic Syndrome

OBJECTIVE

To investigate the efficacy of tamsulosin, a selective alpha-1 blocker, in lower urinary tract symptoms (LUTS) patients with metabolic syndrome (MS).

PATIENTS AND METHODS

This prospective, multicenter clinical trial included men and women (20-75 years old) with LUTS, with or without MS. Patients were categorized as MS+ or MS-, respectively, and all of them were administered tamsulosin 0.2 mg per oral once daily for 24 weeks. Patients were assessed based on the International Prostate Symptom Score, King's Health Questionnaire (KHQ), Overactive Bladder Questionnaire, uroflowmetry with postvoid residuals, and MS factors (blood pressure, waist-to-hip ratio, and serum levels of fasting blood glucose, triglyceride, and high-density lipoprotein cholesterol) at baseline and at 4, 12, and 24 weeks of treatment.

RESULTS

Ninety-two patients were enrolled in this study (53/92 were MS- [57.6%]; 39/92 were MS+ [42.4%]). After 24 weeks of tamsulosin treatment, fasting blood glucose (P = .02) and triglyceride (P < .001) levels of changes were significantly greater in the MS+ group than in the MS- group. Total International Prostate Symptom Score, total Overactive Bladder Questionnaire score, and the scores of each question on the KHQ showed significant improvement after treatment without intergroup differences. In KHQ, although improvements in emotional status, sleep quality, fatigue, and personal distress were greater in the MS+ group (P = .05), the difference between the groups did not reach statistical significance.

CONCLUSION

Tamsulosin was effective in both LUTS patients with and without MS. Furthermore, tamsulosin had beneficial effects on some of the factors associated with MS.

Does Methylphenidate Affect Cystometric Parameters in Spontaneously Hypertensive Rats?

PURPOSE

Methylphenidate (MPH) is one of the most commonly prescribed psychostimulants for attention deficit hyperactivity disorder (ADHD). However, there is limited research on its effects on lower urinary tract function. This study investigated changes in cystometric parameters after intragastric administration of MPH in conscious spontaneously hypertensive rats (SHRs), an animal model of ADHD.

METHODS

Fourteen- to 16-week-old male SHRs (n=10), weighing between 280 and 315 g, were used. Three micturition cycles were recorded before administering MPH. One hour after each intragastric MPH injection, three cycles of cystometrogram were obtained in the awake condition. Various cystometric parameters were evaluated, including basal pressure (BP), maximal pressure (MP), threshold pressure (TP), bladder capacity (BC), micturition volume (MV), micturition interval (MI), and residual volume (RV). The data were analyzed using paired Student t-tests.

RESULTS

Five SHRs were each administered a dose of 3-mg/kg MPH, and the other five received a dose of 6-mg/kg MPH. BP and MP increased significantly in the rats that received the 3-mg/kg MPH injection, but not in those that received the 6-mg/kg injection. BC, MV, and MI significantly increased in the rats that received the 6-mg/kg MPH injection, but not in those that received the 3-mg/kg injection. There were no significant changes in TP after either injection.

CONCLUSIONS

Significant increases in BC, MV, and MI after the 6-mg/kg MPH injection suggest that the peripheral and the central nervous systems may play important roles in bladder function in those receiving MPH for ADHD.

A current perspective on geriatric lower urinary tract dysfunction

Lower urinary tract dysfunction-such as urinary incontinence (UI), detrusor overactivity, and benign prostatic hyperplasia-is prevalent in elderly persons. These conditions can interfere with daily life and normal functioning and lead to negative effects on health-related quality of life. UI is one of the most common urologic conditions but is poorly understood elderly persons. The overall prevalence of UI increases with age in both men and women. Elderly persons often neglect UI or dismiss it as part of the normal aging process. However, UI can have significant negative effects on self-esteem and has been associated with increased rates of depression. UI also affects quality of life and activities of daily living. Although UI is more common in elderly than in younger persons, it should not be considered a normal part of aging. UI is abnormal at any age. The goal of this review is to provide an overview of the cause, classification, evaluation, and management of geriatric lower urinary tract dysfunction.

Urinary incontinence in Alzheimer's disease is associated with Clinical Dementia Rating-Sum of Boxes and Barthel Activities of Daily Living

INTRODUCTION

Urinary incontinence (UI) and Alzheimer's disease (AD) are common in the elderly population and have increased rapidly in recent decades. This study aimed to evaluate the prevalence of UI and determine the neuropsychological characteristics of patients with AD and UI.

METHODS

A total of 464 patients with probable AD were recruited, and the prevalence and type of UI were evaluated. Neuropsychological evaluation was assessed using the Mini-Mental Status Examination, Clinical Dementia Rating, Clinical Dementia Rating-Sum of Boxes, Global Deterioration Scale, Barthel Activities of Daily Living and Instrumental Activities of Daily Living.

RESULTS

The prevalence of UI in patients with AD was 24.8% (men 29.6%, women 23.0%). The two most common types of UI were urge incontinence (44.3%) and functional incontinence (25.3%). UI in patients with Alzheimer's disease was statistically significantly associated with Clinical Dementia Rating-Sum of Boxes (OR 1.56, 95% CI 1.21-2.01) and Barthel Activities of Daily Living (OR 1.34, 95%CI 1.22-1.47) after adjustment for different covariates.

DISCUSSION

UI commonly occurred in patients with AD. The Clinical Dementia Rating-Sum of Boxes and Barthel Activities of Daily Living could be potential predictors for UI in patients with AD.

The association between an abnormal post-voiding urine volume and a lower estimated glomerular filtration rate in patients with type 2 diabetes with no voiding symptoms

BACKGROUND/AIMS

Diabetic cystopathy is a frequent complication of diabetes mellitus. This study assessed the association between the post-voiding residual (PVR) urine volume and diabetic nephropathy in type 2 diabetics with no voiding symptoms.

METHODS

This study investigated 42 patients with type 2 diabetes who were followed regularly at our outpatient clinic between July 1, 2008 and June 30, 2009. No patient had voiding problems or International Prostate Symptom Scores (IPSSs) ≥ 12. An urologist performed the urological evaluations and the PVR was measured using a bladder scan. A PVR > 50 mL on two consecutive voids was considered abnormal, which was the primary study outcome.

RESULTS

The mean patient age was 60 ± 10 years; the IPSS score was 3.7 ± 3.3; and the diabetes duration was 11.9 ± 7.8 years. Seven of the 42 patients (16.7%) had a PVR > 50 mL. The presence of overt proteinuria or microalbuminuria was associated with an increased risk of a PVR > 50 mL (p < 0.01). Patients with a PVR > 50 mL had a significantly lower estimated glomerular filtration rate (eGFR) compared with those with a PVR ≤ 50 mL (59.2 ± 27.1 mL/min/1.73 m(2) vs. 28.7 ± 23.3 mL/min/1.73 m(2); p < 0.001). Multivariate logistic analysis revealed that a lower eGFR (odds ratio, 0.94; 95% confidence interval, 0.88 to 0.99; p = 0.04) was a significant risk factor for a PVR > 50 mL.

CONCLUSIONS

Patients with diabetic nephropathy had a significantly higher PVR and a lower eGFR was associated with an abnormal PVR.

Our experiences with robot-assisted laparoscopic radical cystectomy: orthotopic neobladder by the suprapubic incision method

PURPOSE

To report our technique for and experience with robot-assisted laparoscopic radical cystectomy (RARC) with orthotopic neobladder (ON) formation in a cohort of bladder cancer patients.

MATERIALS AND METHODS

Between December 2007 and December 2011, a total of 35 patients underwent RARC. The patients' mean age was 63.3 years and their mean body mass index was 23.7 kg/m(2). Thirty patients had a clinical stage of T2 or higher. Postoperative mean follow-up duration was 25.5 months. In 5 patients, a 4-cm midline infraumbilical skin incision was made for an ileal conduit (IC) and the stoma formation was similar to the open procedure. In 30 patients undergoing the ON procedure, the skin for specimen removal and extracorporeal enterocystoplasty was incised infraumbilically in the early 5 cases with redocking (ON-I) and suprapubically in the latter 25 cases without redocking (ON-S).

RESULTS

The mean operative times of the IC, ON-I, and ON-S groups were 442.5, 646.0, and 531.3 minutes, respectively (p=0.001). Mean console and lymph node dissection time were not significantly different between the groups. Mean urinary diversion times in each group were 68.8, 125.0, and 118.8 minutes, respectively (p=0.001). In the comparison between the ON-I and ON-S group, only operative time was significant. Four patients required a blood transfusion. We had no cases of intraabdominal organ injury or open conversion. Thiry-three patients (94.2%) had a pathologic stage of T2 or higher. Two patients (5.7%) had lymph node-positive disease. Postoperative complications included ileus (n=4), stricture in the uretero-ileal junction (n=2), and vesicovaginal fistula (n=1).

CONCLUSIONS

Our robotic neobladder-suprapubic incision without redocking procedure is easier and more rapid than that of infraumbilical incision with redocking.

Correlation of metabolic syndrome with urinary stone composition

OBJECTIVE

To determine the correlation between metabolic syndrome and the distribution of stone components in patients with urolithiasis.

METHODS

Between January 2007 and December 2010, renal or ureteral stones were collected from 712 patients (432 males, 280 females) who underwent surgical intervention at three hospitals in South Korea. Metabolic syndrome was defined according to the latest definition of the International Diabetes Federation, using ethnicity- and sex-specific cut-off values for central obesity. Patients were assessed by factors used in metabolic syndrome. All urinary stones were analyzed using infrared spectrophotometry and categorized according to their main component.

RESULTS

The patients' mean age was 55.9 years (range 19-93 years). Of the 712 patients, 347 (48.7%; 205 males, 142 females) had a diagnosis of metabolic syndrome. Calcium oxalate (71.5%), uric acid (15.3%), carbonate apatite (8.0%) and struvite (4.1%) calculi were found as the main stone components. Overall, the proportion of uric acid calculi was markedly higher in patients with rather than without metabolic syndrome (19.6 vs 11.2%; P=0.002). However, the proportion of calcium oxalate, carbonate apatite and struvite calculi did not differ between the two groups. The multivariable-adjusted odds ratio for uric acid calculi according to the metabolic syndrome components indicated that the presence of metabolic syndrome was associated with a 93% increased odds ratio of uric acid calculi compared with the absence of metabolic syndrome. Impaired fasting glucose and hypertriglyceridemia were independent risk factors for uric acid calculi.

CONCLUSIONS

Metabolic syndrome is associated with a significantly increased risk of uric acid calculi development, especially those with impaired fasting glucose and hypertriglyceridemia.

Is high-sensitivity C-reactive protein associated with lower urinary tract symptoms in aging men? Results from the hallym aging study

Purpose

The pathogenesis of lower urinary tract symptoms (LUTS) is uncertain. We investigated the potential role of inflammation in the development of LUTS, with the use of high-sensitivity C-reactive protein (hsCRP) as an inflammatory marker, in a population-based study of aging men in Korea.

Materials and Methods

Our study used a multistage stratified design to recruit a random sample of 1,510 men aged 45 years or older in Chuncheon, Korea, in 2003. Men with urologic or neurologic diseases that could cause voiding dysfunction were excluded. Also, men with medical conditions that could affect inflammation, such as infection or the use of nonsteroidal anti-inflammatory drugs, were excluded. LUTS were defined according to the International Prostate Symptom Score (IPSS). Various potential confounding factors were included in the analyses.

Results

A total of 330 subjects were included in the final analyses. There were 155 (47.0%) with an IPSS<8 and 175 (53%) with an IPSS≥8. The mean age of all subjects was 69.2±8.4 years. The mean hsCRP level of all subjects was 2.30±3.27 (median, 1.19) mg/l. The hsCRP levels in subjects with an IPSS≥8 differed significantly from those in subjects with an IPSS<8. Also, IPSS, storage symptom, voiding symptom, and quality of life (QoL) scores increased as hsCRP levels increased, respectively. The hsCRP level remained an independent risk factor of LUTS (IPSS≥8, storage symptom score≥4, incomplete voiding, intermittency, and QoL) after adjustment for variable possible confounding factors.

Conclusions

Our results suggest that inflammatory processes may play an important role in the pathogenesis of LUTS and that hsCRP levels may indicate the severity of LUTS in aging men.

Primary malignant melanoma of the female urethra

We report here on a rare case of primary malignant melanoma of the female urethra. A 69-year-old female presented at our hospital with a several month history of dysuria, poor stream, gross hematuria, intermittent blood spots, and a painful mass at the external urethral meatus. The physical examination revealed a soft, small, chestnut-sized lesion through the urethral orifice. The mass was tan colored, ulcerated, covered with necrotic tissue, and protruded from the external urethral meatus. The mass was removed by wide local excision under spinal anesthesia. The pathological diagnosis was malignant melanoma of the urethra. Computed tomography of the abdomen as well as a whole-body bone scan showed no evidence of metastasis. The patient has been free of disease for 6 months postoperatively. We discuss the clinicopathologic features and treatment of this tumor.

Influence of Ureteral Stone Components on the Outcomes of Electrohydraulic Lithotripsy

Purpose

We evaluated the influence of urinary stone components on the outcomes of ureteroscopic removal of stones (URS) by electrohydraulic lithotripsy (EHL) in patients with distal ureteral stones.

Materials and Methods

Patients with a single distal ureteral stone with a stone size of 0.5 to 2.0 cm that was completely removed by use of EHL were included in the study. Operating time was defined as the time interval between ureteroscope insertion and complete removal of ureteral stones. Ureteral stones were classified into 5 categories on the basis of their main component (that accounting for 50% or more of the stone content) as follows: calcium oxalate monohydrate (COM), calcium oxalate dihydrate, carbonate apatite (CAP), uric acid (UA), and struvite (ST).

Results

A total of 193 patients (131 males and 62 females) underwent EHL. The mean operating time was 25.1±8.2 minutes and the mean stone size was 1.15±0.44 cm. Calcium oxalate stones accounted for 64.8% of all ureteral stones, followed by UA (19.7%), CAP (8.3%), and ST (7.2%) stones. The mean operating time was significantly longer in the UA group (28.6±8.3 minutes) than in the COM group (24.0±7.8 minutes, p=0.04). In multivariate analyses, the stone size was negatively associated with the odds ratio (OR) for successful fragmentation. UA as a main component (OR, 0.42; 95% confidence interval, 0.20 to 0.89; p=0.023) was also found to be significantly important as a negative predictive factor of successful fragmentation after adjustment for stone size.

Conclusions

The results of the present study suggest that successful fragmentation by URS with EHL could be associated with the proportion of the UA component.

Stent Position Is More Important than α-Blockers or Anticholinergics for Stent-Related Lower Urinary Tract Symptoms after Ureteroscopic Ureterolithotomy: A Prospective Randomized Study

Purpose

To evaluate the clinical factors that impact ureteral stent-related lower urinary tract symptoms (LUTS) after ureteroscopic ureterolithotomy, including the stent position and medication.

Materials and Methods

Fifty-three patients who underwent ureteroscopic ureterolithotomy with indwelling a stent were distributed into three groups. On demand analgesics were given to the group 1 (n=18). Daily tamsulosin 0.2 mg was added for group 2 (n=15) and daily tamsulosin 0.2 mg and tolterodine 4 mg was added for group 3 (n=20). The patients were also subclassified into appropriate or inappropriate group according to stent position. All the patients completed a visual analogue scale (VAS) and International Prostate Symptom Score (IPSS) on the 1st and 7th postoperative days. The VAS and IPSS were analyzed according to the medication groups and the stent position.

Results

In the appropriate stent potion group, only the storage symptom scores of groups 2 and 3 on the 1st postoperative day were significantly lower than those of the group 1 (p=0.001). This medication effect on LUTS was not observed in the inappropriate stent position group. In this group, total IPSS (p=0.015) and storage symptom scores (p=0.002) were higher than in the appropriate stent position group on the 7th postoperative day.

Conclusions

Correct placement of the stent was more important than medication for lessening stent-related storage symptoms.