Does selective dorsal rhizotomy improve bladder function in children with cerebral palsy?

PURPOSE: To investigate the efficacy of selective dorsal rhizotomy (SDR) on urinary symptoms and bladder function in cerebral palsy children. METHODS: Selective dorsal rhizotomy was performed in 56 children with spastic cerebral palsy. Intraspinal nerve root divisions over the cauda equina from L1/2 to S1/2 levels were performed. Urinary symptoms and urodynamic study (UDS) parameters before and after SDR were analyzed. RESULTS: Fifty-four out of 56 children (mean age 7.7) with SDR performed had complete urinary symptoms for analysis, of which 90 % had diplegic cerebral palsy. Fifty-one children had preoperative UDS performed, and 20 children had both preoperative and postoperative UDS. All UDS were performed within 4 weeks before SDR, and the mean time from SDR to post-op UDS was 8.4 months. Before operation, 22 out of 54 (40.7 %) children had urgency or frequency, and 16 out of 54 (29.6 %) children had incontinence. Twelve out of 22 (54.5 %) children with urgency or frequency became completely asymptomatic after SDR (p = 0.013), while 9 out of the 10 children with residual urgency or frequency had significant improvement. Twelve out of 16 (75.0 %) incontinent children became continent after SDR (p = 0.013). Bladder capacity at first incontinence significantly increased from 70 to 130 ml (p = 0.016). Other parameters had no significant difference after SDR. There was a trend that S2 rootlet division had major contribution in achieving continence. CONCLUSIONS: Selective dorsal rhizotomy significantly improved urgency, frequency, incontinence, and urodynamic bladder capacity at first incontinence in a significant proportion of spastic cerebral palsy children.

Clinical outcomes of augmentation cystoplasty in patients suffering from ketamine-related bladder contractures.

OBJECTIVE: To evaluate the outcomes of augmentation cystoplasty in patients with bladder contractures secondary to chronic ketamine abuse. METHOD: Patients who had received augmentation cystoplasty to treat ketamine-related bladder contractures in two hospitals in our region were reviewed retrospectively. Their history of ketamine consumption, presenting symptoms, history of treatment, surgical information and post-operative conditions were retrieved from clinical records and then summarized. RESULTS: Between 2006 and 2011, four patients (three women and one man), aged 21-30 years (mean 27 years), underwent augmentation cystoplasty for ketamine-related bladder contractures. The duration of ketamine consumption ranged from 3 to 15 years, and all four patients resumed ketamine consumption after surgery. The mean maximal baseline and post-operative bladder capacity was 37.5 cc (range 25-50 cc) and up to 400-500 cc, respectively. Three patients experienced a further deterioration in renal function that was secondary to new-onset ureteral strictures in two cases and to sepsis in the other. At the time of the last follow-up, three patients could void spontaneously and one required regular intermittent catheterization. CONCLUSION: Ketamine cystitis is an emerging medical condition that requires a multi-disciplinary approach to manage the patients. Simple surgical management of the physical component of the contracted bladder may produce only suboptimal results, and could even cause further problems in some patients. The importance of compliance with post-operative care and abstinence from drug use should be stressed to the patients before surgery. In view of the high complication rate, the option of a simple ileal conduit should also be discussed prior to surgical intervention.

Evaluation of the clinical value of a simple flowmeter in the management of male lower urinary tract symptoms.

UNLABELLED: Study Type - Diagnostic (exploratory cohort) Level of Evidence 3b What's known on the subject? and What does the study add? Electronic uroflowmetry reasonably predicts the likelihood of bladder outlet obstruction (BOO) and risk of AUR. This low-cost device, Uflowmeter(™) , allows men to perform uroflowmetry at home with ease and the results are compatible with that of electronic uroflowmentry. It can also estimates risk of AUR and the need for TURP to relieve LUTS. OBJECTIVE: To show the clinical value of a simple flowmeter, which has been devised to measure uroflow on an ordinal scale (<10, 10-15, 15-19 and >19 mL/s) at home, for the management of male lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: A total of 186 men with LUTS were enrolled in the study. The mean (range) follow-up was 220 (68-431) days. The men's mean (range) age was 65.5 (46-83) years, mean (range) maximum urinary flow rate (Qmax) 12.8 (4.3-39.5) mL/s, mean (range) voided volume 294.8 (151-686) mL; mean (range) postvoid residual urine volume (PVR) 50 (0-303) mL and mean (range) International Prostate Symptom Score (IPSS) 13.5 (1-31). The men underwent electronic uroflowmetry ('clinic uroflowmetry') and completed an IPSS questionnaire in the clinic. They then conducted 10 measurements with the device at home ('home uroflowetry'). The uroflowmetry and IPSS questionnaire were repeated 2 weeks later. Quadratically weighted Kappa analysis (κ) of the home uroflowmetry vs. clinic uroflowmetry, and of the sensitivity and specificity of the home uroflowmetry values to correspond to the mean Qmax of clinic uroflowmetry (<10, 10-15, 15-19 and >19 mL/s) was performed. Similar analyses were performed for the IPSS. Kaplan-Meier analysis was performed to evaluate whether home uroflowmetry was able to prognosticate acute urinary retention (AUR) or the need for transurethral resection of the prostate (TURP). RESULTS: The home uroflowmetry values (κ= 0.84, 95% confidence interval [CI]: 0.78-0.90) were superior to the IPSS (κ= 0.083; 95% CI: 0-0.173) in correlating with the mean Qmax of clinic uroflowmetry. Home uroflowmetry was most sensitive in identifying a mean Qmax of >19 mL/s (sensitivity: 0.99; 95% CI:0.97-1.00) and most specific in identifying a mean Qmax of <10 mL/s (specificity: 0.90; 95% CI:0.83-0.94). The home uroflowmetry works best in ruling out a mean Qmax of <19 mL/s (diagnostic odds ratio [DOR]= 349.3; 95% CI:40.24-3037.7), followed by a mean Qmax of <15 mL/s (DOR = 91.02; 95% CI:31.23-265.23) and a mean Qmax of <10 mL/s (DOR = 32.04; 95% CI:14.0-73.19). Men with a home uroflowmetry value ≤10 mL/s were more likely (n= 6; 8.8%) than those with a home uroflowmetry value >10 mL/s (n= 2; 1.7%) to develop AUR or require TURP (log-rank test: P= 0.017; hazard ratio:5.61(95% CI:1.10-28.64)). The IPSS failed to display the same discriminative capability. CONCLUSION: Home uroflowmetry using this simple device is a satisfactory estimation of clinic uroflowmetry using an electronic flowmeter and can predict the significant progression of male LUTS.

Twelve-year follow up of a randomized prospective trial comparing bacillus Calmette-Guerin and epirubicin as adjuvant therapy in superficial bladder cancer.

AIM: To compare bacillus Calmette-Guerin (BCG) with epirubicin in adjuvant therapy of superficial bladder transitional cell carcinoma, with respect to recurrence, progression and survival. Prognostic factors are also evaluated. METHODS: Between October 1991 and September 1999, all patients harboring superficial bladder cancers (Ta or T1) with any of the relevant criteria (stage>a, grade>1, size>1 cm, multiple or recurrent tumors), after complete transurethral resection were randomized to receive either 81 mg Connaught strain BCG or 50 mg epirubicin. Patients with recurrences were eligible to crossover, even repeatedly, until progression. Recurrence, progression and survival were analyzed in relation to initial treatment, patient characteristics and tumor characteristics. RESULTS: There were 209 patients included in the study, 149 men and 60 women. The mean age was 69.9 years (range, 24-92). The BCG group consisted of 102 patients and the epirubicin group contained 107 patients. Final analysis was made at a median follow up of 23, 47 and 61 months for recurrence, progression and survival, respectively. The 10-year Kaplan-Meier estimates for recurrence-free, progression-free and disease-specific survival were 61%, 78% and 80%, respectively, for the BCG group. The corresponding figures were 32%, 74% and 92%, respectively, for the epirubicin group. Time to recurrence differed significantly between two treatment groups (P=0.0004). Multiplicity increased the risk of recurrence, while grading influenced recurrence, progression and disease specific survival. CONCLUSIONS: Bacillus Calmette-Guerin prolonged time to recurrence when compared with epirubicin. Grading was shown to be a universal prognostic factor for recurrence, progression and disease specific survival.

15-year experience on intravesical therapy of T1G3 urinary bladder cancer: a conservative approach.

OBJECTIVE: To report the recurrence, progression and survival in patients with T1G3 transitional cell carcinoma (TCC) of the urinary bladder treated with sequential intravesical bacillus Calmette-Guérin (BCG) and chemotherapeutic agents (doxorubicin or epirubicin) on long-term follow up. METHODS: Between July 1988 and September 1999, all patients in a single center with T1G3 bladder TCC, after complete transurethral resection (TURBT), received either 81 mg of Connaught strain BCG or 50 mg of doxorubicin or epirubicin as adjuvant therapy. A conservative approach was adopted whereby those with superficial recurrences were eligible to crossover, even repeatedly, until progression to muscle invasion. Recurrence, progression and disease-specific survival were analyzed. RESULTS: There were 36 patients included, with 26 males and 10 females. The mean age was 71.6 years (range 53-85 years). Final analysis was made at a median follow-up of 23.5 months (range 0-125 months) for recurrence, 33 months (range 0-125 months) for progression and 45.5 months (range 3-125 months) for survival. Sixteen (44.4%) patients showed recurrence. Nine (25%) of these 16 patients progressed. Five (13.9%) of those who progressed died of TCC. The 10 year Kaplan-Meier estimates for recurrence-free survival, progression-free survival and disease-specific survival were 48, 68 and 81%, respectively. Figures with this conservative approach were comparable to those with more aggressive approaches reported in the literature. CONCLUSIONS: Adjuvant intravesical therapy with either BCG or a chemotherapeutic agent (doxorubicin or epirubicin) and crossover on recurrence was an effective conservative treatment for T1G3 bladder TCC.