[Short version of the S2k guideline on drug therapy of neurogenic lower urinary tract dysfunction (NLUTD)]. / Kurzfassung der S2k-Leitlinie medikamentöse Therapie der neurogenen Dysfunktion des unteren Harntraktes (NLUTD).

BACKGROUND: In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare. METHODS: The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, ß3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%). CONCLUSION: Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy.

[Medical quality standards for selected urological aids and devices : Consensus for patients with neurogenic urinary bladder dysfunction]. / Medizinische Qualitätsstandards ausgewählter urologischer Hilfsmittel : Konsens für Patienten mit neurogenen Harnblasenfunktionsstörungen.

BACKGROUND: Using the CE mark of therapeutic appliances is, on its own, not sufficient enough for their appropriate and effective application. In order to treat the patient successfully, not jeopardizing the success of the treatment, medical quality criteria for therapeutic appliances care are necessary to acceptably compensate for a patient's disabilities. OBJECTIVES: Medical quality criteria are formulated for the most frequently used urological aids and devices, considering hygienic requirements, international literature and the practical experience of physicians and nurses with regard to the care of patients with neurogenic urinary bladder dysfunction. METHODS: An expert group of urologists, surgeons, rehabilitation physicians and nurses has developed medical quality criteria via a structured consensus procedure. Developing these criteria, the group has taken into account current jurisprudence, the current resource directory of neurourological relevant aids, data from international literature and hygiene requirements. RESULTS: Medical quality requirements are discussed and defined for selected groups of urological devices (single use catheters, indwelling catheters, external catheters, urine bags, templates and diapers as well as devices for the electrostimulation of nerves). CONCLUSION: The presented quality requirements offer the possibility to stabilize quality of care with neurourological relevant therapeutic appliances. The catalogue of therapeutic appliances must be urgently updated. Urinal catheters for single use must be classified as an individual product group. Devices for anterior root stimulation and neuromodulation must be included in the resource directory. The incontinence severity classification needs to be reviewed.

[Neuro-urological diagnosis and therapy of lower urinary tract dysfunction in patients with spinal cord injury : S2k Guideline of the German-Speaking Medical Society of Paraplegia (DMGP), AWMF register no. 179/001]. / Neuro-urologische Diagnostik und Therapie bei Funktionsstörungen des unteren Harntrakts nach einer Rückenmarkschädigung : S2k-Leitlinie der Deutschsprachigen Medizinischen Gesellschaft für Paraplegie (DMGP), AWMF-Register Nr: 179/001.

BACKGROUND: Most patients with spinal cord injury (SCI) suffer from neurogenic lower urinary tract dysfunction (NLUTD), bowel dysfunction and sexual dysfunction. If these remain untreated, severe medical complications and serious limitations (restrictions) in quality of life are imminent. OBJECTIVES: In the long term, there are considerable differences in the treatment results of highly specialized centers versus other treatment facilities. MATERIALS AND METHODS: Against this background, a consensus-based guideline, according to the AWMF (Association of the Scientific Medical Societies in Germany) criteria (S2k), was developed by the neuro-urology working group of the DMPG (German-Speaking Medical Society of Paraplegia). RESULTS: The guideline defines the principles and objectives of the neuro-urological care of patients with SCI and discusses in detail the principles of diagnosis and therapy of NLUTD. The need for video-urodynamic studies as a basis for the classification of the NLUTD and as a foundation for the development of a treatment strategy is emphasized. Both conservative and surgical therapy options and their indications are explained in detail. Possible complications and their prevention in the long-term course of SCI are presented with a particular consideration of the specific features of urinary tract infections and autonomic dysreflexia. Finally, the principles of the provision of urological appliances are discussed. CONCLUSIONS: The presented S2k guideline provides the current standards in the neuro-urological care of patients with NLUTD due to SCI. Their consistent implementation both in the acute and chronic phase as well as in the context of lifelong surveillance of SCI patients should prevent the impending complications of NLUTD.

[Objective and subjective requirement of aids and appliances in patients with neurogenic lower urinary tract dysfunction : Multicenter study to determinate the daily necessity of urological aids and appliances]. / Objektiver und subjektiver Hilfsmittelbedarf bei Patienten mit neurogenen Harnblasenfunktionsstörungen : Multicenterstudie zur Ermittlung des täglichen Bedarfs an urologischen Hilfsmitteln.

BACKGROUND: The provision of urological appliances for patients with neurogenic lower urinary tract dysfunction (NLUTD) is essential. Hitherto existing standard guidelines for the estimation of monthly material requirements are based solely on estimates. OBJECTIVE: The goal of this work was to define the objective and subsequently subjective requirements for urological appliances on a scientifically validated basis. MATERIALS AND METHODS: Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD were collected through a standardized survey at six different centers in Germany during the period of October to December 2014 and statistically evaluated. RESULTS: In all, 767 patient records were analyzed: 543 men and 221 woman (N/A = 3). The daily disposable catheter consumption of 577 patients who exclusively used intermittent catheterization was 5.13. Patients who used other means of bladder emptying (n = 31) in addition to catheterization consumed on average 3.17 catheters. The margin of deviation was larger for children. Of the 608 patients with intermittent catheterization, 94 (15.5 %) required additional paddings as absorbent aids (on average 2.29 paddings per day), 34 patients (5.6 %) additionally used pants (2.55 per day) and 46 patients (7.6 %) utilized condom catheters (3.81 per day) between catheterization. Among all surveyed patients, 126 (16.4 %) used paddings (5.03 per day) and 51 patients (6.6 %) pants (3.03 per day). Of all male respondents 82 (15.1 %) used condom catheters (2.80 urinary sheaths per day). CONCLUSION: Applying twice the standard deviation of the mean as a measure of assessing the objective requirement of urological appliances and aids for adult patients with NLUTD allows the following daily thresholds to be defined: 1-9 disposable catheters, 0-7 urinary sheaths, 1-9 paddings and 0-7 pants. These thresholds can serve as a basis for estimating the subjective need. They allow for a scientifically validated benchmark for an economically feasible and patient-tailored supply with urological aids and appliances. Individually required appliances and aids have to be recognized. Verifiable quality standards need to be developed.

Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To evaluate the long-term effect of the sacral anterior root stimulator (SARS) on neurogenic bowel dysfunction in a large, well defined spinal cord injury (SCI) cohort. SETTING: Department of Neuro-Urology, Bad Wildungen, Germany. METHODS: Subjects undergone surgery at for SARS-SDAF (sacral deafferentation) between September 1986 and July 2011 (n=587) answered a questionnaire. In total, 277 SARS subjects were available for the baseline (recall) and follow-up comparison. RESULTS: Median age was 49 years (range: 19-80), time from SCI to surgery was 10 years (range: 0-49) and from surgery to follow-up 13 (range: 1-25). Of the responders 73% used SARS for bowel emptying. On visual analog scale (VAS) ranging from 0-10 (best), satisfaction with SARS was 10. Baseline and follow-up comparison showed a decline in the median VAS score 0-10 (worst) for bowel symptoms from 6 (range: 4-8) to 4 (range: 2-6), P<0.0001; median neurogenic bowel dysfunction score from 17 (range: 11-2) to 11 (range: 9-15), P<0.0001; median St Marks score from 4 (range: 0-7) to 4 (range: 0-5), P=0.01; and median Cleveland constipation score from 7 (range: 6-10) to 6 (range: 4-8), P<0.0001. Use of suppositories, digital evacuation and mini enema and subjects totally dependent on assistance during defecation were significantly lower after SARS. CONCLUSIONS: The SARS has the potential to be one of the few treatment methods targeting multiple organ dysfunctions following SCI.

[Botulinum neurotoxin type A in neurogenic detrusor overactivity: consensus paper of the Working Group Neuro-Urology of the DMGP]. / Botulinumneurotoxin Typ A bei neurogener Detrusorüberaktivität: Konsensus des Arbeitskreises Neuro-Urologie der DMGP.

The use of botulinum neurotoxin (BoNT-A) for suppression of neurogenic detrusor overactivity was first reported in 2000. Since that time, this method has gained widespread use. A number of recommendations and consensus statements have already been published. The current practice-oriented consensus paper takes into account recent developments and the over 10-year experience of most members of the Working Group Neuro-Urology of the German-speaking Medical Society for Paraplegia (DMGP) with a focus on the use of BoNT-A in paraplegic patients and in patients with multiple sclerosis.

[Modern neurological treatment strategies for patients with spinal cord injury]. / Moderne neurourologische Therapiestrategien bei Patienten mit Rückenmarksschädigung.

Modern treatment methods for neurogenic bladder dysfunction take into consideration the primacy of obtaining good bladder storage capacity by merely lowering the leak point pressure. The medical benefit for the patient is seen in the stability of renal function and the social advantage in achieving continence. The development of modern findings on the management of neuro-urological disorders in spinal cord injury as well as the underlying principles, indications, and benefits of the most frequently applied treatment approaches are described.

Clinical evaluation of a newly developed catheter (SpeediCath Compact Male) in men with spinal cord injury: residual urine and user evaluation.

OBJECTIVE: To evaluate the performance of a new 30-cm-long, telescoping male intermittent catheter (SpeediCath Compact Male; Coloplast A/S, Humlebæk, Denmark) in urinary bladder emptying, safety and subject acceptance vs a standard-length male intermittent catheter (SpeediCath). MATERIALS AND METHODS: In a prospective, randomized, multicenter, crossover non-inferiority study, 37 male intermittent catheter users self-catheterized three times with the test catheter on one test day and three times with the standard-length male (reference) catheter on another test day. Residual urine (RU) volume in the bladder after catheterization was measured by ultrasound. Safety was assessed in the entire study period in terms of adverse events (AEs) and adverse device events (ADEs). Subjects evaluated their experience, sensation, disposal, bleeding and discomfort with the test and reference catheters and final catheter preference. RESULTS: SpeediCath Compact Male did not differ from the reference catheter in terms of performance (bladder emptying). The upper confidence limit of the mean difference between absolute RU volumes for the test and reference catheter groups did not exceed a pre-established non-inferiority limit of 20 ml, thereby showing the test catheter's non-inferiority to the reference catheter (that is, no worse at bladder emptying). The only AE/ADE reported was one instance of mild urethral burning for 30 min after catheterization, which was judged possibly related to the test catheter but resolved quickly. CONCLUSIONS: The SpeediCath Compact Male catheter is as efficient as a conventional intermittent catheter (SpeediCath) at emptying the bladder with the additional benefit of being more discreet and easier to use.

[Botulinum toxin for the treatment of neurogenic detrusor hyperactivity. Consensus paper on use for neurogenic bladder dysfunction]. / Botulinumtoxin in der Therapie der neurogenen Detrusorhyperaktivität. Konsensuspapier zum Einsatz bei einer neurogenen Blasenfunktionsstörung.

Due to elevated intravesical storage pressures, neurogenic bladder dysfunction carries a high risk of renal damage. Thus, the goals of neurourologic treatment are reduction of intravesical storage pressure and intermittent bladder emptying in order to protect renal function and to achieve continence. If anticholinergic medication is either ineffective or intolerable, several open and controlled studies showed that the injection of botulinum toxin A into the detrusor muscle is a minimally invasive, safe, and effective treatment option. These studies demonstrated an effective reduction of storage pressures and a significant increase in bladder capacity. The effect has been shown to last up to a year. As this treatment is not approved by European administrations, botulinum toxin A treatment fulfills all criteria for "justified off-label use." The reduction of intravesical storage pressure leads to an improvement of life expectancy due to upper urinary tract protection. Furthermore, quality of life can be improved by low incidence of urinary tract infections, secure continence, and physiologic catheterization intervals.

[The laser in urology]. / Laser in der Urologie.

The clinical application of laser in urology has become possible after intensive experimental work. Because of necessary facilities and high costs connected with, the use of laser can be recommended for high specialised medical institutions. At the present time only Neodym-YAG- and Argon-laser meet all the urologic requirements. The CO2-laser is restricted for broad application. Actually tumours of the bladder, urethra, and penis are the fields for laser-application. Treatment of urethral strictures with laser-irradiation seems to be successful too. The photosensitization could being break-through in treatment of superficial tumours.

[Possibilities and problems in the transplantation of kidneys from newborn donors using the minipig as a model]. / Möglichkeiten und Probleme der Transplantation von Spendernieren Neugeborener am Modell des Minischweins.

The importance of kidneys from newborn donors in transplantation has not been clearly defined. The purpose of this study was to investigate the degree of morphological and functional adaptation of the newborn kidney in an adult recipient. 7 MLS-matched kidneys from LEWE minipig puppies (age 3-4 weeks) had been transplanted en bloc to their mothers with immediately bilateral nephrectomy. Preliminary results suggested that arterial vasculature and blood supply are limiting factors in adaption of newborn donor kidneys in adult recipient.