Is it Possible to Regenerate the Underactive Detrusor? Part 2 Electrical Stimulation Therapies, Treatment of Bladder Outlet Obstruction, Constipation, and Pelvic Floor Disorders ICI-RS 2024.

INTRODUCTION: Detrusor muscle weakness is commonly noted on urodynamics in patients with refractory voiding difficulty. No clinical therapy has been proven to augment the strength of a detrusor contraction. METHODS: This subject was discussed at a think-tank at the International Consultation on Incontinence-Research Society (ICI-RS) held in Bristol, June 2024. The discussions of the think-tank are being published in two parts. This second part discusses the role of electrical stimulation therapies, treatment of bladder outlet obstruction, constipation, and pelvic floor disorders, in the enhancement of strength of a detrusor contraction. RESULTS: Electrical stimulation therapies, specifically sacral neuromodulation, have long been used in the salvage of patients with refractory nonobstructive voiding dysfunction. Clinical improvements can be noted in men following bladder outlet resistance reduction surgery especially, though not limited to those with demonstrable obstruction. Some patients may also show improvement with pelvic floor relaxation therapies and constipation care. However, there is a lack of high-quality urodynamic data to demonstrate an improvement in the strength of a detrusor contraction with these therapies. The think-tank recommends standards for future clinical studies examining treatments aimed at improving an underactive detrusor. CONCLUSIONS: Studies need to examine whether clinical improvement following treatment of patients with an underactive detrusor is associated with improvement in strength of the detrusor contraction. New therapeutic options should apply specified standards for assessing and reporting the impact on detrusor contraction.

Is It Possible to Regenerate the Underactive Detrusor? Part 1 Molecular and Stem Cell Therapies Targeting the Urinary Bladder and Neural Axis ICI-RS 2024.

INTRODUCTION: Detrusor muscle weakness is commonly noted on urodynamics in patients with refractory voiding difficulty. No approved therapies have been proven to augment the strength of a detrusor voiding contraction. METHODS: This subject was discussed by a think-tank at the International Consultation on Incontinence- Research Society (ICI-RS) meeting held in Bristol, June 2024. The discussions of the think-tank are being published in two parts. This first part discusses molecular and stem cell therapies targeting the urinary bladder and the neural axis. RESULTS: Senescence of the urothelium and extracellular ATP acting through P2X3 receptors might be important in detrusor underactivity. Several molecules such as parasympathomimetics, acotiamide, ASP8302, neurokinin-2 agonists have been explored but none has shown unequivocal clinical benefit. Different stem cell therapy approaches have been used, chiefly in neurogenic dysfunction, with some studies showing benefit. Molecular targets for the neural axis have included TRPV-4, Bombesin, and serotoninergic receptors and TAC-302 which induces neurite growth. CONCLUSIONS: Several options are currently being pursued in the search for an elusive molecular or stem cell option for enhancing the power of the detrusor muscle. These encompass a wide range of approaches that target each aspect of the contraction mechanism including the urothelium of bladder and urethra, myocyte, and neural pathways. While none of these have shown unequivocal clinical utility, some appear promising. Lessons from other fields of medicine might prove instructive. CLINICAL TRIAL REGISTRATION: Not necessary. Not a clinical trial.

Does combination of urodynamic reduced bladder capacity and detrusor overactivity warrant spinal cord magnetic resonance imaging in children with persistan enuresis: a prospective study.

PURPOSE: This study aims to evaluate the necessity of spinal cord magnetic resonance imaging (MRI) in children with persistent enuresis, specifically those presenting with urodynamically reduced bladder capacity (RBC) and detrusor overactivity (DO), in comparison to children with normal urodynamic findings. METHODS: We evaluated 586 children admitted for bedwetting, all of whom received urotherapy and/or pharmacotherapy. Persistent enuresis, lasting for over one year, was identified in 134 patients who were subsequently re-evaluated for occult neurological conditions and recommended for urodynamic studies (UDS). In total, 92 patients provided informed consent and underwent UDS. Of these, 40 patients were divided into two cohorts based on UDS findings. All patients were over 6 years of age and had normal physical examinations. The first cohort consisted of 23 children RBC and DO, while the second cohort included 17 children with normal UDS findings. All participants underwent spinal cord MRI with a 3 Tesla scanner. Urodynamic and MRI results were compared using Fisher's chi-square test. RESULTS: The median age of the cohort was 11 years, with 26 (65%) of the patients being female. Spinal disorders were identified in 10 patients (25%), with 8 cases of spina bifida without neurological compression and 2 cases of tethered cord. In the RBC + DO cohort, 7 out of 23 patients (30.4%) were found to have spinal disorders, compared to 3 out of 17 patients (17.6%) in the normal UDS cohort, with no statistically significant difference between the groups (p > 0.05). CONCLUSION: When evaluating persistent enuresis nocturna, a combination of RBC and DO in children with nocturnal enuresis and daytime symptoms may warrant spinal cord MRI, though with limited cost-effectiveness.

How Can We Show That Artificial Intelligence May Improve Our Assessment and Management of Lower Urinary Tract Dysfunctions?-ICI-RS 2024.

AIMS: The integration of artificial intelligence (AI) into functional urology management must be assessed for its clinical utility, but hopefully will change, perhaps to revolutionize the way LUTD and other conditions are assessed, the aim being to offer patients more rapid and effective management which enhances patient outcomes. The aim of this proposal, discussed at the ICI-RS annual meeting, is to evaluate the available evidence on AI and the way it might change the approach to urodynamic (UDS) diagnoses, including overactive bladder syndrome (OAB), and perhaps other LUTDs such as bladder outflow obstruction. METHODS: A compendium of discussion based on the current evidence related to AI and its potential applications in UDS and OAB. RESULTS: AI-powered diagnostic tools are being developed to analyze complex datasets from urodynamic studies, imaging, and other diagnostic tests. AI systems can leverage large volumes of clinical data to recommend personalized treatment plans based on individual patient profiles to optimize surgical procedures, enhance diagnostic precision, tailor the therapy, reduce the risk of complications, and improve outcomes. In the future, AI will be able to provide tailored counseling regarding the outcomes and potential side effects of drugs and procedures to a given patient. CONCLUSION: AI's role in functional urology has been poorly investigated, and its implementation across several areas may improve clinical care and the pathophysiological understanding of functional urologic conditions.

Prevalence and predictors of detrusor underactivity and bladder outlet obstruction in women with lower urinary tract symptoms.

This study aims to present age-stratified prevalence of women with lower urinary tract symptoms (LUTS) but without cystocele and predict detrusor underactivity (DU) or bladder outlet obstruction (BOO). Between 2005 and 2020, we reviewed women who visited the medical center with LUTS but without cystocele. Positive voiding dysfunction (VD) symptoms were defined as any one or more of the positive descriptions of weak urinary stream, intermittency, strain to urination, and sensation of not emptying. A total of 1,886 women were included in this study. 189 (10.0%) women were diagnosed with DU, and 77 (4.1%) women had BOO. Multivariate logistic regression analysis found that voided volume and VD symptoms were independent predictors for BOO. ROC curve analyses could predict BOO by voided volume ≤ 220 mL derived from uroflowmetry and the presence of VD symptoms with an area under a curve of 0.83. Age and voided volume could predict DU with an area under a curve of 0.82. We found a higher percentage of BOO in women with positive VD symptoms. A non-invasive uroflowmetry with voided volume (≤ 220 mL) and the presence of VD symptoms can predict BOO. DU could be predicted by age and voided volume.

Clinical features and sequelae of detrusor underactivity: a study of possible cause and effect.

PURPOSE: To describe the clinical presentation and urodynamic findings in detrusor underactivity (DU) patients and investigate the association between DU and straining related complications such as pelvic organ prolapse (POP), inguinal hernia, and hemorrhoids. METHODS: We retrospectively reviewed all consecutive patients who underwent urodynamic studies (UDS) from 2012 to 2023, divided into two groups: those with evidence of DU (n = 573), and control subjects with normal voiding parameters (n = 522). Exclusion criteria were patients who lacked sufficient data, those with obstructive voiding parameters, and those who had received intravesical botulinum toxin injections within the previous nine months. Demographic information, clinical presentation, straining related complications, and UDS findings were compared between the two groups using univariate statistical analysis. RESULTS: The male DU group had a statistically significant higher prevalence of spinal disease and previous cerebrovascular accidents, while the female DU group had a statistically significant higher prevalence of spinal disease, multiple sclerosis, diabetes, previous colorectal surgery, previous transabdominal gynecological surgery, POP surgery, and recurrent UTIs. Female DU patients had a higher prevalence of pronounced vaginal bulging symptoms, recurrent POP, inguinal hernia, and hemorrhoids. The predominant LUTS were voiding symptoms (81.2% in males and 77.9% in females), followed closely by storage symptoms (66.2% in males and 74.7% in females). The median Qmax, PdetQmax, and PVR were 6 ml/sec, 18 cmH2O, 190 ml for male DU patients, and 8 ml/sec, 11 cmH2O, and 200 ml for female DU patients, respectively. CONCLUSION: Risk factors for DU that were identified include age, neurological diseases (spinal disease, CVA in men, MS in women), diabetes and transabdominal surgery (colorectal, gynecological) that can cause pelvic denervation in women. DU patients commonly present with both voiding and storage symptoms. There is approximately twice the risk of having POP surgery and inguinal hernia, an eight-fold risk of hemorrhoids, and a three-fold risk of recurrent UTIs for females. This is thought to be secondary to increased intra-abdominal pressure during urinary straining.

Urodynamic and Frequency-Volume Chart Parameters Influencing Anticholinergic Resistance in Patients With Neurogenic Detrusor Overactivity.

PURPOSE: Neurogenic detrusor overactivity (NDOA) is characterized by involuntary detrusor muscle contractions during bladder filling in patients with neurological disorders. Anticholinergic therapy is the primary treatment; however, the reasons for treatment resistance in NDOA are not well understood. This study aimed to identify predictors of treatment failure by comparing urodynamic and frequency-volume chart data between patients with NDOA who respond and patients who do not respond to anticholinergic therapy. METHODS: We reviewed the records of 362 patients presenting with lower urinary tract symptoms and selected 85 who had NDOA and were on anticholinergic therapy. Ultimately, 67 patients were analyzed. We categorized these individuals into responders (group R) and nonresponders (group NR) based on clinical and urodynamic improvements. Three-day frequencyvolume charts and urodynamic study results were retrospectively reviewed. RESULTS: Of the 85 initial patients, 12 refused medication, and 6 were lost to follow-up. Pre- to posttreatment changes differed significantly between groups in the number of urgency urinary incontinence (UUI) episodes per 24 hours (P=0.001), maximum cystometric capacity (mL, P=0.003), NDOA frequency (P=0.004), and bladder compliance (mL/cm H2O, P=0.003). Multivariate analysis revealed that NDOA frequency (P=0.014) and UUI episodes per 24 hours (P=0.002) were significant factors associated with treatment failure. CONCLUSION: NDOA varies according to underlying neurological conditions. The frequencies of UUI episodes and NDOA in urodynamic studies can predict resistance to initial anticholinergic treatment.

The relationship between urodynamic bladder compliance and urinary fibrosis markers in children with neurogenic bladder dysfunction.

BACKGROUND: Decreased bladder compliance is an important risk factor for upper urinary tract in children with neurogenic bladder dysfunction (NBD). Urodynamics is the gold standard in determining bladder compliance. OBJECTIVE: To investigate the relationship between low bladder compliance and urinary fibrosis markers in NBD. STUDY DESIGN: Spina bifida patients with NBD, who admitted between March 2021 and July 2021 were included. Patients with low compliant bladders, no renal scar, no recurrent urinary tract infections formed low compliance, LC group. Normal compliance, NC group, was comprised of patients with normocompliant bladders and the same characteristics. Control group (Group C) consisted of patients for outpatient surgery and had no known bladder dysfunction. Compliance was calculated with the formula ΔV/ΔP and a value of under 15 ml/cmH2O was accepted as low. Age, gender, urine density, serum urea, creatinine levels and urodynamic parameters were noted. Urinary type 1, type 3 collagen and its precursor procollagen type 3 and serum type 1 and 3 collagen were determined by ELISA. RESULTS: 72 patients were included (LC group, n:31, NC group, n:24, C group n:17, mean age 7,39 ± 1,24 years). No significant difference was observed in the comparison of age, gender, urine density and serum urea and creatinine values. No significant difference was observed between the LC and NC groups for urodynamic parameters, except for bladder compliance. Urinary collagen type 1 in LC group (11,71 ± 3,02 ng/ml) was found to be significantly higher than that of the C group (9,45 ± 1,97 ng/ml) (p = 0,03). Urinary procollagen type 3 was significantly higher in LC group (103,15 ± 24 ng/ml) when compared to C group (82,42 ± 22,26 ng/ml) (p = 0.016). Urinary collagen type 1 level above 9.20 ng/ml was 80,6 % sensitive and 70,6 % specific and urinary procollagen type 3 level above 78 ng/ml was 87 % sensitive and 70,6 % specific in predicting low compliance. DISCUSSION: This study seems to be the first study in the literature to evaluate bladder fibrosis and compliance, biochemically, by measuring urinary collagen levels in NBD. Urinary fibrosis markers are not currently an alternative to urodynamics for bladder compliance, but they may have potential to reduce the need for urodynamics with this indication. CONCLUSION: Determination of urinary collagen levels may be a marker of bladder wall fibrosis and may indirectly show decreased bladder compliance. It is plausible to say that invasive methods such as urodynamics may be less preferred for defining bladder compliance, instead, urinary biomarkers may have merit for this purpose in the future.

Male Akita diabetic mice develop underactive bladder independent of NLRP3 that can be prevented with blood glucose control.

Aim: Diabetic bladder dysfunction (DBD) is the most common diabetic complication. Patients present with overactive symptoms, underactive symptoms, or both. While strict glucose control may be expected to reverse DBD, prior studies have not been supportive. However, we hypothesize that strict control, soon after hyperglycemia appears, can prevent DBD development. Moreover, 50% of adult diabetics are poorly-controlled and it is unknown how this effects development of DBD. Thus, we investigated the effect of early glucose control (poor and strict) on DBD in male Akita diabetic mice (type 1). NLRP3-induced inflammation is critical to development of DBD in female Akita. Therefore, we also hypothesized that targeting NLRP3 may control or prevent DBD in male Akita, especially in a poorly-controlled population. Methods: Akita mice (±NLRP3) were stratified into uncontrolled, poorly-controlled and strictly-controlled diabetic groups using insulin treatment (0, 0.125 or 0.25 U/day). Mice were assessed at 15 weeks for blood glucose, HbA1c, Evans blue dye extravasation (a marker of capillary permeability/inflammation) and bladder function. Results: Blood glucose was elevated in diabetics, reduced in an insulin dose-dependent manner, and not affected by NLRP3 deletion. HbA1c levels followed a similar course but were more sensitive to insulin levels. Evans blue dye extravasation was prevented with glucose control and absent in NLRP3-/- mice. Diabetics exhibited signs of underactive bladder (increased void volume, decreased frequency) that was attenuated in the uncontrolled group but absent in the well-controlled group. Deleting NLRP3 did not affect voiding function. Conclusion: Male Akita mice develop an underactive-like bladder, independent of NLRP3, which can be prevented with glucose control.

[Optimization study of an animal model for interstitial cystitis/bladder pain syndrome based on the dose effect of cyclophosphamide].

OBJECTIVE: To evaluate the efficacy of cyclophosphamide (CYP) at different doses in replicating the symptoms of interstitial cystitis/bladder pain syndrome (IC/BPS) in an animal model, thereby providing an experimental basis for understanding the pathophysiology of IC/BPS and assessing treatment strategies. METHODS: Twenty-eight female Sprague-Dawley rats aged seven weeks were divided into four groups: Group a (25 mg/kg CYP), group b (75 mg/kg CYP), group c (125 mg/kg CYP), and group d (a control group). The rats were injected intraperitoneally with either CYP or saline solution. Evaluations included urine spot tests, von Frey filament pain threshold tests, urodynamic examinations, and histological assessments. RESULTS: The study found that the 25 mg/kg CYP dosage significantly outperformed higher doses in simulating bladder dysfunction and inflammatory responses while minimizing the impact on the rats' physiological functions. Specifically, urine spot area, group a showed a significant reduction in urine spot area compared with the control group (P < 0.05), while groups b and c did not show significant differences. Pain threshold: The von Frey filament test indicated increased visceral pain in group a, aligning closely with IC/BPS patient symptoms, without a significant increase in urination frequency. Urodynamic assessments: Group a exhibited decreased bladder compliance and reduced maximum bladder capacity (P < 0.05), with no significant differences in baseline bladder pressure and maximum detrusor pressure across all groups. Histological analysis: Hematoxylin-eosin (HE) staining revealed that bladder tissue in group a had moderate inflammatory reactions, whereas groups b and c showed severe inflammation and tissue damage, correlating with the higher doses of CYP. Furthermore, the urine spot tests and von frey filament tests provided quantitative data supporting the model's reliability, urine spot count, group a had an average urine spot count of (15±3) spots, significantly higher than the control group's (5±2) spots (P < 0.01). Nociceptive score: Group a nociceptive score increased to 0.5±0.1, indicating heightened pain sensitivity compared with the control group 0.10±0.05 (P < 0.01). CONCLUSION: The 25 mg/kg CYP demonstrated significant advantages in simulating the key features of non-ulcerative IC/BPS, summarizing the main aspects of the human condition, including persistent visceral pain and mild inflammatory reactions in bladder tissue. These findings offer substantial experimental support for drug development and treatment research in IC/BPS and provide new insights into the complex patho-physiology of the disease.

A wireless, battery-free device for electrical neuromodulation of bladder contractions.

Lower urinary tract dysfunction (LUTD) is a prevalent condition characterized by symptoms such as urinary frequency, urgency, incontinence, and difficulty in urination, which can significantly impair patient's quality of life and lead to severe physiological complications. Despite the availability of diverse treatment options, including pharmaceutical and behavioral therapies, these approaches are not without challenges. The objective of this study was to enhance treatment options for LUTD by developing a wireless, battery-free device for managing bladder contractions. We designed and validated a compact, fully implantable, battery-free pulse generator using the magnetic induction coupling mechanism of wireless power transmission. Weighing less than 0.2 g and with a volume of less than 0.1 cubic centimeters, this device enables precise stimulation of muscles or neurons at voltages ranging from 0 to 10 V. Wireless technology allows real-time adjustment of key stimulation parameters such as voltage, duration, frequency, pulse width, and pulse interval. Our findings demonstrate that the device effectively controlled bladder contractions in mice when used to stimulate the Major Pelvic Ganglion (MPG). Additionally, the device successfully managed micturition in mice with bilateral transection of the pudendal nerve. In conclusion, the development of this innovative wireless pulse generator provides a safer and more cost-effective alternative to conventional battery-powered neurostimulators for bladder control, addressing the limitations of such devices. We anticipate that this novel technology will play a pivotal role in the future of electrical stimulation therapies for voiding dysfunctions.

Clinical and urodynamic findings in children and adolescents with neurogenic bladder undergoing augmentation cystoplasty: a systematic review.

BACKGROUND: Augmentation cystoplasty (AC) is a procedure to improve the clinical and urodynamic parameters of neurogenic bladder (NB) in children and adolescents refractory to other treatments. We performed a systematic review to investigate these parameters in children and adolescents with NB undergoing AC. METHODS: We followed PRISMA guidelines and searched electronic databases until March 2024 for studies involving patients aged three to 19 years diagnosed with NB undergoing AC. We assessed clinical and urodynamic parameters before and after surgery, focusing on improvements in urinary incontinence, vesicoureteral reflux (VUR), bladder capacity, compliance, and end filling detrusor pressure (EFP). RESULTS: A total of 212 NB patients underwent AC and were evaluated for urinary incontinence before and after surgery. Two studies showed a 76.5% to 78.9% improvement in incontinence without bladder outlet procedures (BOP). Another study found no significant difference in incontinence improvement rates between AC with and without BOP. The VUR resolution rate assessed in three studies ranged from 12.5 to 64%. Three studies showed a variation in bladder capacity from 52.8 to 70% of the expected bladder capacity pre-AC to 95.9 to 119%, post-AC. A fourth study showed a variation in bladder capacity from 87 ml pre-AC to 370 ml post-AC. Two studies showed a variation from 3.2 to 4.6 ml/cm H2O pre-AC to 13.7 to 41.3 ml/cm H2O post-AC in bladder compliance. The EFP in three studies varied from 37.2 to 47.6 cm H2O pre-AC to 11 to 17.4 cm H2O post-AC. CONCLUSION: After AC, urinary incontinence, bladder capacity, EFP, and bladder compliance improved in children and adolescents with NB.

A New Rat Model of Sacral Cord Injury Producing a Neurogenic Bladder and Its Functional and Mechanistic Studies.

Sacral spinal cord injury (SSCI) can disrupt bladder neuromodulation and impair detrusor function. Current studies provide limited information on the histologic and genetic changes associated with SSCI-related neurogenic lower urinary tract dysfunction (NLUTD), resulting in few treatment options. This study aimed to establish a simple animal model of SSCI to better understand the disease progression. Ninety 8-week-old Sprague-Dawley (SD) rats were randomly separated into sham operation and SSCI groups. The SSCI group underwent sacral spinal cord injury, while the sham group did not. Urodynamic and histological assessments were conducted at various intervals (1, 2, 3, 4, and 6 weeks) post-injury to elucidate the disease process. Urodynamic examinations revealed significant bladder dysfunction in the SSCI group compared to the sham group, stabilizing around 3-4 weeks post-injury. Histological examination, including hematoxylin-eosin and Masson's trichrome staining, correlated these functional changes with bladder microstructural alterations. RNA-seq was performed on bladder tissues from the sham group and SSCI group at 6 weeks to identify differentially expressed genes and pathways. Selected genes were further analyzed using polymerase chain reaction (PCR). The findings indicated a pronounced inflammatory response in the first 2 weeks post-SSCI, progressing to bladder fibrosis at 3-4 weeks. In conclusion, this study presents a reliable, reproducible, and straightforward SSCI model, providing insights into bladder functional and morphological alterations post-SSCI and laying the groundwork for future therapeutic research.

Self-adjusted Nitrous Oxide During Urodynamic Studies Reduces Patient Pain Without Compromising Study Quality: A Randomized Controlled Trial.

Background and objective: A urodynamic study (UDS) is a routine clinic procedure that can cause significant discomfort for certain patients, with no satisfactory analgesic alternatives currently available. Our aim was to evaluate the effectiveness of low-dose self-adjusted nitrous oxide (SANO), titrated to the patient's desired effect, on standard metrics for bladder function and on patient-reported pain and anxiety. Methods: We conducted a single-institution, double-blind, randomized crossover trial in adults undergoing UDS. Each patient underwent two consecutive UDS runs, randomized to receive oxygen during the first run followed by SANO during the second run, or vice versa. UDS outcomes (capacity, detrusor strength, residual volume) and patient subjective outcomes (Visual Analog Scale for pain and anxiety, operator assessment of verbal feedback) were compared between the two runs. Secondary analyses were performed to compare outcomes during the first UDS run and adjust for treatment order. A paired Wilcoxon signed rank-sum test and McNemar's χ2 test were used to compare continuous and categorical variables, respectively. Adverse events were recorded. Key findings and limitations: Nineteen patients were randomized (10 to oxygen for the first run, 9 to SANO for the first run). UDS outcomes did not differ between the two arms. Patients reported significantly less pain during the SANO run than during the oxygen run (p = 0.046). Verbal feedback was significantly better with SANO (p = 0.001). Most patients (15/19, 79%) stated that they would prefer to receive SANO during future UDS. There were no significant complications. Conclusions and clinical implications: SANO oxide is a safe and effective means of preserving standard adult UDS metrics while significantly reducing patient-reported pain. Patient summary: Urodynamic tests (UDS) for evaluation of lower urinary tract symptoms can cause discomfort and pain. Our study shows that nitrous oxide gas self-adjusted by patients had no effect on UDS test outcomes or on verbal feedback during the procedure, and reduced discomfort and pain in comparison to oxygen. Nitrous oxide may an attractive option for patients who are reluctant to undergo UDS.

Effects of Mindfulness Meditation on Patient Experience During Urodynamics: A Prospective Study.

INTRODUCTION AND HYPOTHESIS: Urodynamics (UDS) assesses voiding dysfunction using intravesical, vaginal, or rectal catheters, which can be distressing. This study was aimed at utilizing mindfulness to reduce anxiety and pain in patients undergoing UDS. METHODS: A single-institution randomized controlled trial was conducted on 60 patients who underwent UDS. Patients were assigned to a mindfulness group (n = 30) or a control group (n = 30). Before UDS testing, all patients completed validated questionnaires assessing lower urinary tract symptoms (Urogenital Distress Inventory 6, UDI-6), anxiety (State-Trait Anxiety Inventory 6, STAI-6), and pain (Visual Analog Scale, VAS). The mindfulness group listened to a mindfulness audio prompt before UDS. All patients received standardized UDS education before UDS testing in a calm environment. After UDS testing, all patients completed validated UDS-perception questionnaires, STAI-6, Likert scale, and VAS surveys. Statistical analysis was performed using paired t tests, independent t tests, Wilcoxon, and Chi-squared tests. RESULTS: Both groups had similar demographics, history of prior UDS, anxiety, and baseline UDI-6 and STAI-6. Post-UDS, anxiety scores decreased in both groups, with the mindfulness group reporting significant improvement in "calmness" (mean 1.7, SD = 0.84) compared with the control group (mean 2.3, SD = 1.0, p < 0.05). The mindfulness group reported increased relaxation whereas the control group reported decreased relaxation post-UDS. Patients in both groups without a history of UDS had a significant improvement in total anxiety compared with those with a history of UDS. CONCLUSION: Mindfulness meditation may improve calmness and relaxation for patients undergoing UDS.

Urodynamic Profile and Impact of Surgery in Women Affected by Deep Infiltrating Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection. DATA SOURCES: A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024). METHODS OF STUDY SELECTION: We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included. TABULATION, INTEGRATION, AND RESULTS: Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12). CONCLUSION: Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.

Success Rate and Predicting Factors for Repeated High-Dose Intradetrusor Dysport Injections in Children With Neurogenic Bladder: A Retrospective Study.

OBJECTIVES: Evaluating the effectiveness and safety of repeated high-dose intradetrusor abobotulinumtoxin A (Dysport®) injections for the treatment of pediatric neurogenic bladders refractory to medications. DESIGN: Retrospective interventional study. PARTICIPANTS: The cohort included 37 children (22 boys and 15 girls) of median age 9.2 years. Inclusion criteria were diagnosis of neurogenic bladder and failure to respond to medical treatment. Exclusion criteria were augmented bladder, insufficient data, and interval of > 11 months between video-urodynamic study and Dysport injection. INTERVENTIONS: All participants were treated with an intra-detrusor injection of Dysport 30 IU/kg (up to 1000 IU) under general anesthesia. Repeated (second and third) injections were scheduled (6-12 months) in patients who demonstrated an improvement in cystometric parameters. All participants underwent video urodynamic testing before onset of treatment and 4-5 months after subsequent injection. MAIN OUTCOME MEASURES: Success of treatment was defined as a decrease in end filling pressure (EFP) to < 40 cm H2O and/or a 20% increase in maximal cystometric capacity (MCC). These parameters along with initial bladder features were evaluated for ability to predict treatment success. RESULTS: No side effects of Dysport were observed or reported. The overall success rate was 62%. MCC increased by a median of 30% (IQR 200-300, p < 0.001), 37% (IQR 197-310, p = 0.001) and 45% (IQR 245-300, p = 0.025) after the first, second and third injections, respectively. Median EFP decreased from 45 cm H2O to 34 cm H2O (IQR 20-45, p = 0.029), 23 cm H2O (IQR 20-37, p = 0.004), and 20 cm H2O (IQR 12-32, p = 0.049) after the first, second, and third injections, respectively. No predicting factor of success of treatment were found; However, three of five cases of "end stage" bladder showed improvement. CONCLUSIONS: High-dose Dysport injection is safe and effective for the treatment of neurogenic bladder. Studies with larger cohort and a control group would further elucidate which bladders would benefit most. At present, we recommend treating also bladders with "end stage" features with botulinum toxin before considering augmentation.

Reliability of Uroflowmetry Pattern Interpretation in Adult Women.

INTRODUCTION: Uroflowmetry is often used to assess lower urinary tract symptoms (LUTS). Criteria for characterization of flow patterns are not well established, and subjective interpretation is the most common approach for flow curve classification. We assessed the reliability of uroflowmetry curve interpretation in adult women. MATERIALS AND METHODS: Uroflowmetry studies were obtained in 296 women who participated in an observational cohort study. Four investigators with expertise in female LUTS and urodynamics reviewed and categorized each tracing for interrater reliability. A random subset of 50 tracings was re-reviewed by each investigator for intrarater reliability. The uroflowmetry tracings were rated using categories of continuous, continuous fluctuating, interrupted, and prolonged. Other parameters included flow rate, voided volume, time to maximum flow, and voiding time. Agreement between raters is summarized with kappa (k) statistics and percentage where at least three raters agreed. RESULTS: The mean age of participants was 44.8 ± 18.3 years. Participant age categories were 18-24 years: 20%; 25-34 years: 17%; 35-64 years: 42%; 65+ years: 18%. Nine percent described their race as Asian, 31% Black, 62% White, and 89% were of non-Hispanic ethnicity. The interrater reliability was highest for the continuous flow category (k = 0.65), 0.47 for prolonged, 0.41 for continuous fluctuating, and 0.39 for interrupted flow curves. Agreement among at least three raters occurred in 74.3% of uroflow curves (69% for continuous, 33% for continuous fluctuating, 23% for interrupted, and 25% for prolonged). For intrarater reliability, the mean k was 0.72 with a range of 0.57-0.85. CONCLUSIONS: Currently accepted uroflowmetry pattern categories have fair to moderate interrater reliability, which is lower for flow curves that do not meet "continuous" criteria. Given the subjective nature of interpreting uroflowmetry data, more consistent and clear parameters may enhance reliability for use in research and as a screening tool for LUTS and voiding dysfunction. TRIAL REGISTRATION: Parent trial: Validation of Bladder Health Instrument for Evaluation in Women (VIEW); ClinicalTrials.gov ID: NCT04016298.

Myelomeningocele operated in utero and the incontinent bladder pattern: Mid-term follow up of a prospective study.

INTRODUCTION: In-utero myelomeningocele repair is the gold standard treatment after the publication of the MOMS trial. We have performed a retrospective analysis from our prospective in-utero myelomeningocele closure database (started in 2011), and selected only patients with the incontinent bladder pattern according to the Leal da Cruz categorization (Leal da Cruz, et al. J Urol 2015) to review mid-term clinical outcomes. MATERIAL AND METHODS: We identified 30 patients with leaking pressure under 40 cmH20 (incontinent pattern) at first urodynamic evaluation (UE) from the whole cohort of 129 patients who underwent in-utero myelomeningocele closure. We selected patients with a minimum active follow-up of 48 weeks (4 years) to provide mid-term data. Patients were followed according to the same protocol with the proposal of yearly sonogram and UE. All clinical and radiological data were reviewed. RESULTS: We found 11 patients, with a mean age of 10.2 years old, median age at diagnosis of 19 weeks, surgery performed at 25.6 weeks and birth at 33.2 weeks. The mean follow-up was 81.73 months (6.81 years). Mean age at first urological evaluation was 5 months, and UE was 5.6 months. Febrile UTI incidence in the whole observation period was 27.3%. The average initial DLPP was 30 cmH2O. 71.4% of the patients had bladder capacity less than 50% of the expected age. Bladder compliance could not be determined in 63.7% of cases due to leakage. A total of 5.7 urodynamic studies per patient were performed. Surgery was recommended for 8 patients and done in 4 (36.3%). Surgery consisted of Macedo catheterizable reservoir and Macedo-Malone ACE, associated with urethral sling (2 patients) and bladder neck closure (2). It took an average of 5 UE before the final surgical decision was confirmed. Last urodynamic study showed persistent leakage and low DLPP in 3 patients, normal bladder pressure in 2 (under CIC and anticholinergics), and 1 patient changed his bladder pattern into a high risk group. All operated patients are fully continent (urinary >4hs) and fecal. CONCLUSION: Despite initially presenting a low risk for the most patients, we found surgery in 36.3% (4/11) and if we considered all cases with surgery indication proposed to treat urinary incontinence it would be even higher (72.7%).

The 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE): a randomised controlled trial of prostate embolisation vs medication for BPH.

OBJECTIVE: To compare prostate artery embolisation (PAE) to the combination of tamsulosin and dutasteride therapy as a potential first-line therapy for obstructive benign prostatic hyperplasia (BPH) in treatment-naïve patients in the 'Prostate Embolisation AS first-line therapY compAred to meDication in treatment naïVe men with prostAte eNlargement, a randomised ControllEd trial' (P-EASY ADVANCE). PATIENTS AND METHODS: A total of 39 men with enlarged prostates, moderate-severe lower urinary tract symptoms (LUTS) and obstructed/equivocal urodynamic studies (UDS), and who had no prior treatment for BPH, were randomised to receive either combined medical therapy with tamsulosin and dutasteride (medication) or PAE. Follow-up UDS, International Prostate Symptom Score (IPSS), uroflowmetry and ultrasound were performed at short- to medium-term intervals following interventions and compared to baseline. RESULTS: The medication and PAE treatment groups had similar baseline characteristics, including prostate volumes (87.8 and 85.4 mL respectively), maximum urinary flow rate (Qmax; 6.5 and 6.6 mL/s, respectively), IPSS (19.5 and 21, respectively) and obstructed UDS (79% and 74%, respectively). Both interventions improved voiding and bladder outflow obstruction from baseline, with more patients unobstructed after PAE (63%) compared to medication (28%) (P = 0.03). PAE patients had significantly greater reductions in prostate size (P < 0.001), incomplete emptying (P = 0.002), total IPSS (P = 0.032), Qmax (P = 0.006) and quality of life (P = 0.001). Altered ejaculation, erectile dysfunction and nausea were more common in the medication group. CONCLUSION: Prostate artery embolisation was more effective than combined medical therapy at reducing urinary obstruction, decreasing prostate volume and improving LUTS in patients with BPH who had not previously been treated. This is the first randomised control study to compare PAE and combined medical therapy in exclusively treatment-naïve patients and raises the potential of PAE as an alternative early treatment option for BPH. Further randomised comparative trials are planned to further validate the role of PAE in mitigating obstructive BPH.