Nerve transfer for restoration of lower motor neuron-lesioned bladder, urethral and anal sphincter function. Part 4: Effectiveness of the motor reinnervation.

In pilot work, we showed that somatic nerve transfers can restore motor function in long-term decentralized dogs. We continue to explore the effectiveness of motor reinnervation in 30 female dogs. After anesthesia, 12 underwent bilateral transection of coccygeal and sacral (S) spinal roots, dorsal roots of lumbar (L)7, and hypogastric nerves. Twelve months postdecentralization, eight underwent transfer of obturator nerve branches to pelvic nerve vesical branches, and sciatic nerve branches to pudendal nerves, followed by 10 mo recovery (ObNT-ScNT Reinn). The remaining four were euthanized 18 mo postdecentralization (Decentralized). Results were compared with 18 Controls. Squat-and-void postures were tracked during awake cystometry. None showed squat-and-void postures during the decentralization phase. Seven of eight ObNT-ScNT Reinn began showing such postures by 6 mo postreinnervation; one showed a return of defecation postures. Retrograde dyes were injected into the bladder and urethra 3 wk before euthanasia, at which point, roots and transferred nerves were electrically stimulated to evaluate motor function. Upon L2-L6 root stimulation, five of eight ObNT-ScNT Reinn showed elevated detrusor pressure and four showed elevated urethral pressure, compared with L7-S3 root stimulation. After stimulation of sciatic-to-pudendal transferred nerves, three of eight ObNT-ScNT Reinn showed elevated urethral pressure; all showed elevated anal sphincter pressure. Retrogradely labeled neurons were observed in L2-L6 ventral horns (in laminae VI, VIII, and IX) of ObNT-ScNT Reinn versus Controls in which labeled neurons were observed in L7-S3 ventral horns (in lamina VII). This data supports the use of nerve transfer techniques for the restoration of bladder function.NEW & NOTEWORTHY This data supports the use of nerve transfer techniques for the restoration of bladder function.

Determination of voiding pressure in infants with normal lower urinary tracts: Exploring the possible effect of sacral development.

OBJECTIVE: To investigate the association between sacral underdevelopment, as defined by subnormal sacral ratio (SR) measurements, with increased maximum detrusor voiding pressure (P det. Max) in infants. METHODS: In this 2007-2015 retrospective cohort study, the medical records of all infants who underwent a pyeloplasty due to congenital ureteropelvic junction obstruction were added. Their P det. Max was evaluated through the suprapubic catheter utilized for urinary drainage intraoperatively, without imposing any additional risk of urethral catheterization on the infant. SR was calculated via the plain kidney, ureter, and bladder (KUB) radiography film obtained during the voiding cystourethrogram (VCUG) evaluation before the surgery. Participants were categorized into SR < 0.74 or SR ≥ 0.74. P det. Max was subsequently compared between these two groups. RESULTS: A total of 45 patients were included in our analysis. Twenty-eight (62.2%) patients had a (SR < 0.74), while 17 (37.8%) had a (SR ≥ 0.74). P det. Max was shown to be significantly higher in the SR < 0.74 compared to the SR ≥ 0.74 group (167.5 ± 60.8 vs. 55.7 ± 17.9 cmH2O, p < 0.001). After adjusting for age and sex, SR remained a significant contributor to P det. Max (p < 0.001). Physiologic detrusor sphincter dyscoordination (PDSD) rate was significantly higher in the SR < 0.74 versus SR ≥ 0.74 group (100.0% vs. 70.6%, respectively; p = 0.005). CONCLUSION: Lumbosacral underdevelopment, as indicated by subnormal sacral ratios, is associated with sphincter-detrusor dyscoordination, which causes PDSD and can ultimately result in higher P det. Max in infants.

Establishing initial resting abdominal pressure in children undergoing urodynamics.

INTRODUCTION: The International Continence Society recommends zeroing of transducers to the atmospheric pressure for invasive urodynamics. The range of abdominal pressure relative to atmospheric pressure is well-known in adults but has not been described in children. This prospective observational study was carried out to establish baseline abdominal in children. MATERIALS AND METHODS: Prospective, multicenter, observational study of 100 children aged 0-18 years undergoing invasive urodynamics using water-filled systems. Initial resting abdominal pressure, intravesical pressure and detrusor pressure were recorded in supine, sitting, and standing position (as age- and diagnosis-appropriate). This data was analyzed using SPSS 20.0.0 with regard to age, gender, height, weight, body mass index, and underlying diagnosis (classified as neurogenic or non-neurogenic). Nonparametric tests were used (2-sided p < 0.05, significant). RESULTS: Initial resting abdominal pressure (inter-quartile range) in children was between 5 and 15 cmH2 O in the supine, 13-20 cmH2 O in the sitting, and 15-21 cmH2 O in the standing position. These pressures were not consistently influenced by age, gender, height, weight or underlying diagnosis. The initial resting detrusor pressure was noted to be 0-4 cmH2 O without any difference based on posture. Limitations include use of two-tube technique, relatively small number of subjects across each age group, wide range of underlying diagnoses and need for manual smoothing of some traces. CONCLUSION: This study defines initial resting abdominal pressure at urodynamics in children and notes that, as with adults, it is possible to define widely applicable ranges regardless of individual characteristics. These pressures appear lower than those noted historically in adults.

Effect of bladder outlet procedures on urodynamic assessments in men with an acontractile or underactive detrusor: A systematic review and meta-analysis.

OBJECTIVE: To review the effect of bladder outlet procedures on urodynamic outcomes and symptom scores in males with detrusor underactivity (DU) or acontractile detrusors (AD). MATERIALS AND METHODS: We performed a systematic review and meta-analysis of research publications derived from PubMed, Embase, Web of Science, and Ovid Medline to identify clinical studies of adult men with non-neurogenic DU or AD who underwent any bladder outlet procedure. Outcomes comprised the detrusor pressure at maximum flow (Pdet Qmax ), maximum flow rate (Qmax ), international prostate symptom score (IPSS), and quality of life (QoL). This study is registered under PROSPERO CRD42020215832. RESULTS: We included 13 studies of bladder outlet procedures, of which 6 reported decreased and 7 reported improved Pdet Qmax after the procedure. Meta-analysis revealed an increase in the pooled mean Pdet Qmax of 5.99 cmH2 0 after surgery (95% CI: 0.59-11.40; p = 0.03; I2 95%). Notably, the Pdet Qmax improved in all subgroups with a preoperative bladder contractility index (BCI) <50 and decreased in all subgroups with a BCI ≥50. All studies reported an improved Qmax after surgery, with a pooled mean difference of 5.87 mL/s (95% CI: 4.25-7.49; I2 93%). Only three studies reported QoL, but pooling suggested significant improvements after surgery (mean, -2.41 points; 95% CI: -2.81 to -2.01; p = 0.007). All seven studies reporting IPSS demonstrated improvement (mean, -12.82; 95% CI: -14.76 to -10.88; p < 0.001). CONCLUSIONS: This review shows that Pdet Qmax and Qmax increases after surgical bladder outlet procedures in men with DU and AD. Bladder outlet procedures should be discussed as part of the shared decision-making process for this group. The evidence was of low to very low certainty.

Mid-short-term risk factors for chronic renal failure in children with posterior urethral valve.

OBJECTIVES: To analyze the mid-short-term risk factors for chronic renal failure (CRF) in children with posterior urethral valve (PUV) after valve ablation. MATERIALS AND METHODS: A retrospective study of 143 patients with PUV who underwent operation was performed. Patients were divided into CRF group (n = 39) and non-CRF group (n = 104). Clinical data of both groups such as the first resection age, last resection age, number of operations, the maximal detrusor pressure (Pdetmax), and vesicoureteral reflux (VUR) were collected and analyzed. RESULTS: The first resection age, last resection age, and the Pdetmax of patients in the CRF group were higher than those of patients in the non-CRF group (P < 0.05). Multiple regression analysis showed that the indicators related to chronic renal failure were last resection age (ß = 1.034, P < 0.05) and Pdetmax (ß = 1.068, P < 0.05). The cut-off value of last resection age was 35.5 months, Pdetmax was 41.65 cmH2O. There was positive correlation of final blood creatinine with last resection age and Pdetmax. CONCLUSION: The last resection age and Pdetmax are the risk factors of chronic renal failure in children with PUV. A Pdetmax of lower than 41.65 cmH2O indicates a good prognosis of renal function in patients with PUV.

Account for high flow rate-low detrusor pressure voids in female: Contribution of VBN model.

INTRODUCTION: Nomograms using the VBN model of women micturition allowed evaluating detrusor contractility (k) and urethral obstruction (U) from pressure-flow (PFs) recordings. While the model worked for most of the patients, an intriguing result, negative U value was observed for patients with high flow-low detrusor pressure (Qp voids). To explain that condition, our hypothesis was a weak urethral resistance to dilatation or increased expansibility (URD). METHODS: The area offered to the fluid at each point of the urethra (its dilatation) is a function of the time depending difference between inside and outside pressures. In the VBN model, this function is sigmoid-like, the same for all women. For Qp voids, Qrecorded was more higher than it would be with the recorded pressure (VBN analysis). So, modeling allowed computing abnormally increased urethral wall expansibility (URD) whose consequence would be an increased flow. RESULTS: Among 222 non-neurologic women referred for investigation of various lower urinary tract symptoms, 27 (mean age 66.3±11.4 y) had Qp void: Qmax=27±6mL/s; pdet.Qmax =7.5±4.7cm H2O. Mean URD value was .36±.67. Introduction of URD in a modeled analysis of urodynamic traces led to a good fitting between recorded and computed traces for the 27 Qp. CONCLUSION: Mathematical modeling of micturition allows proposing an explanation of the unexpected observations of Qp voids. They would be due to abnormal urethral wall elasticity. Despite major challenges measurement of this elasticity would be the next step. LEVEL OF EVIDENCE: 3.

Insight into Posterior Urethral Valve from Our Experience: Paradigm Appended to Abate Renal Failure.

OBJECTIVE: The objective of the study was to share our experience of management of posterior urethral valve (PUV) and to suggest a paradigm to impede upstaging of chronic kidney disease (CKD) and prevent end-stage renal failure (ESRF). PATIENTS AND METHODS: We have treated 332 patient of PUV from March 2005 to April 2016, Of which 272 case records had adequate data to be analyzed. The mean age was 2.48 years (range: 1 day-18 years). We did primary fulguration in 231 patients, of which five patients needed bilateral ureterostomy for obstinate high creatinine level. The remaining 36 patients had primary fulguration done elsewhere. RESULTS: The mean duration of follow-up was 7.8 years (range 3-14 years). In the end of this study, 10 patients had down staging in CKD, 36 patients had up staging in CKD, and 9 patients ended in ESRF (3.8%). CONCLUSIONS: Detection of deterioration of renal function with creatinine clearance along with identifying the causes of deterioration and necessary interventions would help to arrest upstaging of CKD otherwise that might end in ESRF. From this study and reviewing the literature, we presume that the rhabdosphincter spasm underneath actually renders bladder outlet obstruction, and cusps of PUV, particularly in neonates, amplify the obstruction, following that bladder outlet obstruction cascades detrusor hypertrophy, bladder neck hypertrophy/obstructions, and ureterovesical junction obstruction/reflux, causing gradual damage to the bladder and upper tract and deterioration of renal function as a consequence.

Long-term course of sacral anterior root stimulation in spinal cord injured individuals: The fate of the detrusor.

AIMS: To investigate the long-term course of the detrusor pressure during sacral anterior root stimulation in spinal cord injury (SCI) patients. METHODS: Retrospective evaluation of 111 patients who had undergone sacral deafferentation and implantation of an anterior root stimulator at a single SCI rehabilitation center with a minimum follow-up time of 5 years. RESULTS: The median follow-up time was 11.7 years (range 5.0-24.9 years). The maximum detrusor pressure (Pdet_max) during stimulation was higher in men compared to women (P = 0.0004) and decreased over time (P = 0.0006). However, there were no significant (P ≥ 0.06) differences in the median Pdet_max during stimulation between the first measurement time point and any follow-up time point. The Pdet_max during stimulation decreased from 62 cmH2 O (95%CI 57-73 cmH2 O) to 53 cmH2 O (95%CI 47-69 cmH2 O) (P = 0.9). The time had also a significant effect on Pdet_max during the storage phase (P < 0.0001) and bladder compliance (P = 0.0007). The Pdet_max during the storage phase decreased, whereas bladder compliance increased during the follow-up period. There were no significant (P ≥ 0.1) changes over time in bladder capacity, the number of daily stimulations and the residual urine volume after voiding. CONCLUSIONS: The detrusor pressure during sacral anterior root stimulation decreases over time in SCI individuals. However, the changes do not seem to be clinically relevant during the first decade after surgery.

Urinary Tract Infections in Patients Undergoing Invasive Urodynamic Study: A Prospective Observational Study at a Tertiary Care Centre in Eastern India.

OBJECTIVE: The aim of the study was to find the estimate of the prevalence of urinary tract infections following invasive urodynamic studies (UDS) in a hospital setup and to identify the risk factors related to it. METHOD: A total of 100 patients were enrolled in this prospective observational study after standard preoperative work, which included both urine analysis and culture procedure. The study was carried out from April 2022 to April 2023 at the Department of Urology, Indira Gandhi Institute of Medical Sciences, India. Three days following the UDS test, all the patients underwent repeat urine analysis and culture, besides screening for any lower urinary tract symptoms, abdominal pain, and fever. RESULT: Among all, 14 patients (i.e., 6.1% of 85 individuals) had significant bacteriuria, and six patients (4.7%) developed symptoms of UTI. However, a strong association was observed between the maximal detrusor pressure during voiding (Pdet at Q max) and post-void residue (PVR), which were >20 mL before UDS, along with positive urine cultures after UDS, which was significant at <0.05. CONCLUSION: The study demonstrated that the risk of UTIs with this diagnostic technique is minimal and that prophylactic antibiotic medication is not necessary prior to UDS in all patients.

Bladder Compliance: How We Define It and Why It Is Important.

Bladder compliance is the relationship between detrusor pressure and bladder storage volume. We discuss the definition of compliance, how it may be accurately measured, and its clinical relevance. Specifically, we discuss the association between low compliance and upper urinary tract deterioration. We discuss medical and surgical therapies that have been demonstrated to improve compliance and reduce upper tract risk. Finally, we propose a model, which not only considers compliance but also differential pressure between the bladder and ureters, and how this may also be an accurate predictor of upper tract deterioration. We call for further investigation to test this model.

Urodynamics and safety of the ß3-adrenoceptor agonist mirabegron in males with lower urinary tract symptoms and bladder outlet obstruction.

PURPOSE: Bladder outlet obstruction often presents as storage and voiding symptoms. We investigated urodynamic parameters in men with lower urinary tract symptoms and bladder outlet obstruction treated with the ß3 agonist mirabegron, a new therapy for overactive bladder symptoms. MATERIALS AND METHODS: A total of 200 men 45 years old or older with lower urinary tract symptoms and bladder outlet obstruction were randomized to receive once daily mirabegron 50 mg (70) or 100 mg (65), or placebo (65) for 12 weeks. The primary urodynamic parameters assessed were change from baseline to end of treatment in maximum urinary flow and detrusor pressure at maximum urinary flow (noninferiority margins -3 ml per second and 15 cm H2O, respectively). We evaluated adverse events and vital signs. RESULTS: Treatment with mirabegron 50 and 100 mg was noninferior to placebo based on the lower and upper limits of the 95% CI, respectively, for maximum urinary flow and detrusor pressure at maximum urinary flow. The adjusted mean difference vs placebo was 0.40 (95% CI -0.63, 1.42) and 0.62 ml per second (95% CI -0.43, 1.68) for maximum urinary flow, and -5.94 (95% CI -13.98, 2.09) and -1.39 cm H2O (95% CI -9.73, 6.96), respectively, for detrusor pressure at maximum urinary flow. The incidence of adverse events was similar for mirabegron and placebo. CONCLUSIONS: Mirabegron did not adversely affect voiding urodynamics (maximum urinary flow and detrusor pressure at maximum urinary flow) compared with placebo after 12 weeks of treatment.

Detrusor pressure monitoring by electrical bioimpedance in the neurogenic bladder of adult patients.

PURPOSE: Detrusor pressure-volume relationship evaluation by urodynamics provides useful clinical information; however, it is invasive, and requires specific installations. An alternative technique proposed by our research group is the electrical bioimpedance (BI) which is an easily performed and non-invasive method. In this work, we assess the relationship between BI and detrusor bladder pressure in adults with neurogenic lower urinary tract dysfunction. METHODS: A prospective observational study was conducted. 20 patients (11 females and 9 male) previously diagnosed with neurogenic bladder were included. All participants underwent simultaneously a urodynamic evaluation (UDS) and BI determination, and both examination signals were recorded and subjected to Shapiro-Wilks statistical test. A correlational statistical test was used to compare the pressure parameters (detrusor, vesical and abdominal) with their respective BI determinations. Subsequently, a linear regression test was performed to evaluate the concordance between BI and their respective pressure values. RESULTS: From the 20 correlations, between detrusor bladder pressure (PDET) and abdominal bioimpedance determinations (ZABD), obtained for all participants, 16 evidenced significant results over 90% (p < 0.05). CONCLUSIONS: A significantly high correlation between abdominal bioimpedance determinations and the detrusor bladder pressures was evidenced. These results should be confirmed in a larger group of participants.

The Role of Acidic Urine on Detrusor Pressure in Patients with Overactive Bladder: A Urodynamic Evaluation.

OBJECTIVES: To evaluate the relationship between urine pH value and urodynamic parameters in patients with overactive bladder. METHODS: The patients' data whose underwent standard urodynamic study at two tertiary centers in our city. The period between January 2015-January 2021 was reviewed retrospectively. The inclusion criteria were the patients with overactive bladder, over 18 years of age, and with urine analysis before urodynamic study. Patients were divided into two groups as those with acidic urine pH (Group 1) and without (Group 2). The detrusor pressures obtained from filling cystometry were compared between the groups. In addition, the correlation between detrusor pressure and urine pH was examined. RESULTS: The data from 211 patients (109 females, 102 males) were analyzed during the screening period. Eighty-two patients were in Group 1 and 129 patients in Group 2. The mean age was similar between the groups (p = 0.244). The bladder volume at first sensation of filling and urodynamic maximal bladder capacity was lower in Group 1 than Group 2 (p = 0.004; p < 0.001, respectively). The maximum detrusor pressure was higher in the acidic urine pH group (Group 1, 55.8 ± 20.6) than non-acidic urine pH group (Group 2, 14.5 ± 10.2), and it was statistically significant (p < 0.001). In addition, a significant negative correlation was observed between urine pH level and detrusor pressure (p < 0.001). CONCLUSIONS: The presence of acidic urinalysis is associated with many urodynamic findings. Significantly, the patients with detrusor overactivity had more acidic urine than without detrusor overactivity. Therefore, for patients with high detrusor pressure, urinalysis should be evaluated carefully.

A Study of Urodynamic Parameters at Different Bladder Filling Stages for Predicting Upper Urinary Tract Dilatation.

PURPOSE: To identify more accurate predictors of upper urinary tract dilatation (UUTD) in neurogenic bladder (NB) children, we studied the relationship among urodynamic parameters at different bladder filling stages, detrusor leak point pressure (DLPP) and UUTD. METHODS: A total of 158 children (3-16 years) with NB were included and then divided into 2 groups according to whether their NB diagnosis was complicated with UUTD: the UUTD group (39 patients) and those without UUTD group (control group, 119 patients). The bladder filling phase was divided into 3 equal parts: the early, middle, and end filling stages. The bladder compliance (BC) and detrusor pressure (△Pdet) at each phase and DLPP at the end filling stage were recorded. RESULTS: A BC<8 mL/cm H2O both in the middle and end stages is more specific than a BC<9 mL/cm H2O in the end stage (72%, 73%, vs. 66%), and △Pdet >8 cm H2O in the early stage, 20 cm H2O in the middle stage and 25 cm H2O in the end stage are more sensitive than △Pdet >40 cm H2O in the end stage (82%, 85%, 85%, vs. 49%). A DLPP cutoff value of 20 cm H2O showed higher sensitivity for predicting UUTD than 40 cm H2O. CONCLUSION: Low BC and a high △Pdet in the middle and end filling stages are more accurate factors than classic indicators for predicting UUTD. In addition, a DLPP value of >20 cm H2O in the end bladder filling stage shows high sensitivity.

Non-invasive assessment of urinary bladder compliance using ultrasound: first validation study based on clinical urodynamic study.

BACKGROUND: This study aims to validate a recently introduced non-invasive method, ultrasound bladder vibrometry (UBV), for the assessment of detrusor compliance in patients with neurogenic bladders. METHODS: The study was carried out on 79 adult patients with neurogenic bladders (60 male and 19 female). The UBV test was performed on each patient to measure the Lamb wave group velocity (cg ) in the anterior bladder wall at every 50mL volume increment throughout the filling phase. Bladder compliance was assessed based on the trend of Lamb wave group velocity squared (cg 2 ) versus volume. A compliance index was defined to differentiate between the compliant and non-compliant bladders. Results of the UBV compliance assessment were validated using the readings of the corresponding urodynamic studies as the clinical gold standard. RESULTS: The Patients' bladders were divided into non-compliant and compliant groups by an experienced urologist using the information in the urodynamic study (UDS) recordings. The compliance index defined on the basis of cg 2 showed a significant difference (P<0.008) between the compliant and non-compliant groups. The areas under the receiver operating characteristic curve were 0.813, with 95% CI ranging from 0.709 to 0.892. Under the optimal criterion, the bladder was considered as non-compliant if the compliance index was less than 100 mL∙s2/m2, resulting in a sensitivity and specificity of 86.4% and 71.9%, respectively. CONCLUSIONS: The results of this study demonstrate that UBV can be used as a non-invasive method for the determination of bladder compliance; thus, it can potentially serve as an alternative method to UDS for the appropriate patient groups.

Study of correlation of urodynamic profile with symptom scoring and ultrasonographic parameters in patients with benign prostatic hyperplasia.

CONTEXT: Urodynamic study (UDS) and ultrasonography (USG) both are established investigations to assess the patients of benign prostatic hyperplasia (BPH). It is known that the prostate mass (PM) and post-void residual urine volume (PVR) are not significantly related to the patients' symptoms and degree of obstruction; however, the relation between the UDS, USG and patient's International Prostate Symptom Scoring (IPSS) has not been defined. AIMS: To correlate the urodynamic parameters with IPSS, PM and PVR in patients with lower urinary tract symptoms (LUTS) suggestive of BPH. SETTINGS AND DESIGN: An observational study carried out as a thesis project. METHODS AND MATERIALS: Thirty male patients aged more than 40 years with LUTS suggestive of BPH were selected and underwent USG, UDS and IPSS. In UDS, the parameters studied were the maximum flow rate (Qmax), detrusor pressure (Pdet) and bladder compliance (BC). PM and PVR were studied in the USG. STATISTICAL ANALYSIS USED: IBM Statistical Package for the Social Sciences (SPSS) software version 16 (SPSS Inc., Chicago, USA). Pearson's correlation and two-sided significance levels were determined. RESULTS: 1. Significant negative correlation between Qmax and PVRUSG (r = -0.404, P = 0.027); PMUSG (r = -0.655, P = <0.001) and IPSS (r = -0.563, P = 0.001). 2. Significant positive correlation between Pdet and PVRUSG (r = 0.535, P = 0.002); PMUSG (r = 0.719, P = <0.001) and IPSS (r = 0.649, P = <0.001). 3. Significant negative correlation between BC and PVRUSG (r = -0.490, P = 0.006); PMUSG (r = -0.654, P = <0.001) and IPSS (r = -0.667, P = <0.001). CONCLUSIONS: UDS has a significant correlation with IPSS and USG findings and urodynamic parameters give a more specific diagnosis in BPH patients when it is combined with USG and IPSS.

The management of paediatric neurogenic bladder: an approach in a resource-poor setting.

BACKGROUND: If untreated, paediatric neurogenic bladder can cause renal failure and urinary incontinence. It is usually caused by neural tube defects such as myelomeningocele. Children with a neurogenic bladder should be monitored from birth and management should aim to preserve renal function and achieve social continence. This article outlines the management options appropriate for these children in resource-poor settings. ASSESSMENT: In most low- and middle-income countries, a general lack of awareness of the neurological effects on the urinary tract results in late presentation, usually with urological complications even when spina bifida is diagnosed early. Physical examination must include neurological examination for spinal deformities and intact sacral reflexes. About 90% of children with occult spinal dysraphisms will have cutaneous sacral lesions. The work-up includes urinalysis, serial ultrasound of the urinary tracts and urodynamics. Urodynamic assessment is essential for the diagnosis and prognosis of the paediatric neurogenic bladder. In poorly resourced settings, simple eyeball urodynamics can be performed in the absence of a conventional urodynamic set-up. TREATMENT: Clean intermittent catheterisation (CIC), the mainstay of treatment, is most suitable for resource-poor settings because it is effective and inexpensive. Antimuscarinic drugs such as oxybutynin complement CIC by reducing detrusor overactivity. Intravesical injection of Botox and bladder augmentation surgery is required by a small subset of patients who fail to respond to combined CIC and oxybutynin therapy. CONCLUSION: Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence.

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review.

OBJECTIVE: To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research. METHODS: We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: 'detrusor underactivity', 'underactive bladder', 'post voiding residual', 'post micturition residual', 'acontractile bladder', 'detrusor failure', and 'detrusor areflexia'. RESULT: DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function. CONCLUSION: Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.

Current diagnosis and management of primary isolated bladder diverticula in children.

INTRODUCTION: Primary isolated bladder diverticula (PIBD) that are not correlated with the UVJ comprise approximately 10% of all primary bladder diverticulas (PBDs). No guidelines have been established for PIBD repair. It is unknown if infections or voiding dysfunction are impacted by the size of diverticula. PURPOSE: We evaluated the most effective approach to treating PIBD with respect to diverticula size and objective clinical and urodynamic findings. METHODS: We retrospectively evaluated age, sex, chief complaint, UTI diverticula size, clinical and urodynamic findings, and management of 14 consecutive patients diagnosed with PIBD from 1995 to 2013. Urodynamic studies were performed in all PIBD cases, Post micturition residue (PMR), maximum bladder capacity (MBC), voiding detrusor pressure (Pdet), and pressure flow (Qmax) were all measured. Among patients who underwent surgical repair, resected diverticula wall specimens were sent for pathological evaluation. RESULTS: Twelve boys and two girls ranging in age from 2 to 15 years (mean, 6.7 years) were included in this study. The mean follow-up duration was 54.2 months (range, 6-120 months). All diverticula were single, and most occurred in posterolateral locations (Figure). In eight patients with PIBD of <3 cm (range, 15-24 mm; mean, 18 mm), MBC, P det, and Qmax were within reference ranges. None of the patients had PMR, and most developed only one urinary tract infection (UTI) before admission. All patients underwent close follow-up without surgical intervention. Six patients had diverticula of >3 cm (range, 32-72 mm; median, 48 mm). Their MBC was lower (72% of predicted value) than the reference range. The P det was significantly higher than that of patients with diverticula of <3 cm and the Q max was lower in two patients. Four patients had PMR, and all patients developed at least three UTIs before admission to the hospital. This group of patients was treated surgically. All operated children reported improvement after in control urodynamic study over follow-up periods. DISCUSSION: The diverticula layer lacks the contractility that allows the diverticulum to appropriately void into the bladder. This accounts for the urinary retention and dysfunctional voiding. The patients with diverticula larger than 3 cm had PMR. Members of this group had more than three UTIs. In our series, diverticula of >3 cm exhibited an MBC that was lower than the predicted values. The detrusor contracts, but the urine enters the diverticula more easily than it enters the bladder neck. This could inhibit bladder enlargement and may explain the lower MBC in this group. This group also had higher Pdet, and their q max was low. Thus, probably simulating detrusor much higher pressure but undercontractility due to diverticulum. Another possible explanation could be that large PIBD creates a functional obstruction over the bladder neck during voiding. CONCLUSION: PIBD of >3 cm is characterized by UTI development, functional lower urinary tract symptoms, and disorders of bladder storage or emptying. Surgical repair of these diverticula is associated with improvement of voiding dysfunction and elimination of UTIs.

Use of surgeon-tailored polypropylene mesh as a needle-less single-incision sling for treating female stress urinary incontinence: Preliminary results.

OBJECTIVE: To evaluate the safety and efficacy of a procedure using surgeon-tailored polypropylene mesh (STM) through a needle-less single-incision technique for treating stress urinary incontinence (SUI), aiming to decrease the cost of treatment, which is important in developing countries. PATIENTS AND METHODS: In all, 43 women diagnosed using a cough stress test were treated from January 2011 to June 2013 at the Urology and Gynaecology Departments (dual-centre), Cairo University Hospitals. Previous surgery was not a contra-indication. Patients with a postvoid residual urine volume of >100 mL, a bladder capacity of <300 mL, impaired compliance or neurological lesions were excluded. The Stress and Urge incontinence Quality of life Questionnaire (SUIQQ) and urodynamic variables were compared before and after surgery. The variables were compared between the baseline and postoperative follow-up values using a paired t-test, a Wilcoxon signed-rank test or McNemar's test. RESULTS: The mean age was 42.7 years and 20 (47%) patients had associated urgency UI (UUI), whilst 21 (49%) had intrinsic sphincter deficiency. The median (range) operative duration was 14 (5-35) min. There were no complications during surgery. The mean (SD, range) follow-up was 28.1 (5.1, 18-36) months. Postoperative complications were vaginal discharge (5%), failure of wound healing (5%), dyspareunia (5%) and UTI (5%). The sling was removed in one case. SUI, UUI and quality-of-life indices improved significantly after surgery. There were no significant differences in pressure-flow studies before and after surgery. In all, 38 (88%) patients were cured, four (9%) improved and in one only the treatment failed (2%). CONCLUSION: This technique is simple, safe, effective, reproducible and economical for treating SUI. The STM was easy to insert in a short operation.