Is Early Surgical Treatment for Benign Prostatic Hyperplasia Preferable to Prolonged Medical Therapy: Pros and Cons.

Background and objectives: Treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH) has shifted over the last decades, with medical therapy becoming the primary treatment modality while surgery is being reserved mostly to patients who are not responding to medical treatment or presenting with complications from BPH. Here, we aim to explore the evidence supporting or not early surgical treatment of BPH as opposed to prolonged medical therapy course. Materials and Methods: The debate was presented with a "pro and con" structure. The "pro" side supported the early surgical management of BPH. The "con" side successively refuted the "pro" side arguments. Results: The "pro" side highlighted the superior efficacy and cost-effectiveness of surgery over medical treatment for BPH, as well as the possibility of worse postoperative outcomes for delayed surgical treatment. The "con" side considered that medical therapy is efficient in well selected patients and can avoid the serious risks inherent to surgical treatment of BPH including important sexual side effects. Conclusions: Randomized clinical trials comparing the outcomes for prolonged medical therapy versus early surgical treatment could determine which approach is more beneficial in the long-term in context of the aging population. Until then, both approaches have their advantages and patients should be involve in the treatment decision.

Does asymptomatic bacteriuria increase the risk of adverse events or modify the efficacy of intradetrusor onabotulinumtoxinA injections?

AIM: To assess the impact of asymptomatic bacteriuria (ASB) on the safety and efficacy of intradetrusor onabotulinumtoxinA injections in patients with overactive bladder and neurogenic detrusor overactivity. METHODS: We reviewed the medical records of patients who had received onabotulinumtoxinA between 2009 and 2014. Safety analysis was based on the appearance of urinary tract infections (UTIs), hematuria, and need for hospitalization because of related adverse event(s) in the month after injection. Patients who underwent urodynamic study before and 3 months after the first onabotulinumtoxinA treatment were included in efficacy analysis. Changes in maximal cystometric capacity (MCC), bladder compliance (BC), maximal detrusor pressure at maximal involuntary detrusor contraction (Pdetmax), and detrusor leak point pressure (DLPP) were assessed. RESULTS: Totally, 183 patients underwent 457 injection sessions. ASB was found in 38.8% (185) of urine cultures taken before injections. After treatment, 49 patients (with or without ASB) developed UTI. Urosepsis did not occur. The odds ratio of UTI in patients with ASB was 16.48. The efficacy cohort, consisting of 83 patients, showed that ASB had no significant effect on any of the efficacy parameters (MCC-risk ratio [RR]: 0.93, 95% confidence interval [CI]: 0.72-1.21; BC-RR: 0.88, 95% CI: 0.62-1.24; Pdetmax-RR: 0.9, 95% CI: 0.69-1.21; DLPP-RR: 1.69, 95% CI: 0.72-3.97). CONCLUSIONS: ASB is common among patients who are candidates for intradetrusor onabotulinumtoxinA treatment. ASB increases the risk of UTI, but does not heighten the risk of urosepsis, hospitalization, or therapy failure. This study should lead to the reconsideration of current recommendations.

Short-term evaluation of the adjustable bulbourethral male sling for post-prostatectomy urinary incontinence.

OBJECTIVE: The Argus perineal sling is a minimally invasive surgical option to treat post-prostatectomy stress urinary incontinence (PPSUI). This study retrospectively evaluated the short-term clinical outcomes with the Argus sling for PPSUI management and determined the effects of potential preoperative parameters on intraoperative retrograde leak point pressure (RLPP). METHODS: In this retrospective review of 16 men with various degrees of stress incontinence after prostatic surgery who underwent Argus sling, PPSUI was evaluated by pad usage, urodynamics, 24-hour pad weight, and validated questionnaires. Findings before and a minimum of 6 months after sling placement were compared. "Cure" was defined as no pad usage or the use of 1 pad for security; "improvement" was defined as a reduction in daily pad use by >50%. RESULTS: After a mean (±SD) follow-up of 9.75 ± 3.51 months, 62.5% of patients were cured, 18.75% were improved, and 18.75% were still incontinent. Preoperative 24-hour pad weight was positively correlated with RLPP (P = .0121, r = 0.6286). Mean RLPP was 37.93 ± 3.45 cmH2 O. During follow-up, 44% of men had transient perineal or scrotal pain managed conservatively. Sling explantation, reported in 3 of 16 patients, was associated with urethral erosion or previous radiation therapy. CONCLUSION: The Argus male sling can lead to satisfactory results in carefully selected patients. Increased stress urinary incontinence severity based on 24-hour pad weight required higher RLPP to achieve continence. Favorable satisfaction variables and quality of life scores are affected by appropriate intraoperative tensioning pressure.

Recommendations for urological follow-up of patients with neurogenic bladder secondary to spinal cord injury.

PURPOSE: To review currently available guidelines and recommendations regarding urological follow-up of patients after spinal cord injury (SCI) and present an evidence-based summary to support clinicians in their clinical practice. METHODS: Maximum data were collected according to different methods, including searches with multiple and specific keywords, reference checks, gray literature searches (congress reports, working papers, statement documents), and browsing-related Web site access. Obtained data were analyzed with the modified version of the Oxford grading system for recommendations using levels of evidence (LE) and grades of recommendation (GR). RESULTS: Different surveillance strategies exist, but there is no consensus among authors and organizations. As a result, practice patterns vary around the world. The present review indicates that proper urological follow-up of SCI patients should consist of medical history (LE 1-4, GR B-C), clinical examination (LE 4, GR C), renal laboratory tests (LE 1-3, GR B), imaging surveillance of the upper urinary tract (LE 1-3, GR A-B), urodynamic study (LE 2-4, GR B-C), and cystoscopy/cytology (LE 1-4, GR D). Clinicians agree that SCI patients should be followed up regularly with an individually tailored approach. A 1-year follow-up schedule seems reasonable in SCI patients without additional risk factors of renal deterioration (LE 3-4, GR C). In those who manifest risk factors, report changes in bladder behavior, or present with already developed complications of neurogenic bladder dysfunction, follow-up plans should be modified with more frequent checkups (LE 4, GR C). Urodynamic study should be repeated and considered as a routine monitoring strategy. CONCLUSION: Individuals with neurogenic lower urinary tract dysfunction are at increased risk of multiple complications. Nevertheless, proper follow-up after SCI improves the prognosis for these patients and their quality of life.

Revisiting Ureterosigmoidostomy, a Useful Technique of Urinary Diversion in Functional Urology.

Ureterosigmoidostomy has largely been disregarded in recent times but has now seen a resurgence of interest because of its potential applicability to newer, minimally invasive surgical techniques. The advantages of ureterosigmoidostomy over intestinal conduits are urinary continence (obviating the need for stoma and external appliances), ease, and rapidity of performance as well as acceptance by patients. Ureterosigmoidostomy has been characterized by good continence outcomes and it offers good quality of life. Possible complications are anastomosis stenosis, coloureteral reflux, electrolyte imbalance, hydronephrosis, pyelonephritis, chronic renal failure, colorectal cancer, and others. Ureterosigmoidostomy is therefore only advisable for patients ready to accept long-term follow-up.

Lumbar to sacral root rerouting to restore bladder function in a feline spinal cord injury model: Urodynamic and retrograde nerve tracing results from a pilot study.

AIMS: Lumbar to sacral rerouting surgery can potentially allow voiding via a skin-central nervous system-bladder reflex pathway. Here, we assessed if this surgery was effective in treating neurogenic bladder dysfunction/sphincter in felines. METHODS: Eight cats underwent spinal cord transection (SCT) at thoracic level 10/11. Unilateral L7 to S1 ventral root anastomosis was performed 1 month later in six cats. Two cats served as transection-only controls. Electrical and manual stimulation of L6-S1 dermatomes, and urodynamics were performed at 3, 5, 7, and 9/10 months post transection. At 9/10 months, cats were also evaluated by direct electrophysiological testing of anastomosed roots with urodynamics, then tissue collection and examination of the root anastomosis site and lumbosacral cord ventral horns for cells retrogradely labeled from tracer dye injected 2 weeks earlier into the bladder wall. RESULTS: At 9/10 months, four of six rerouted cats exhibited increased detrusor pressure provoked by cutaneous stimulation, one cat bilaterally. Two cats presented with a voiding stream after ipsilateral cutaneous stimulation at 7 and 9 months. All six rerouted animals showed regrowth of axons from the L7 ventral horn to the bladder, although some aberrant axonal regrowth was also observed. CONCLUSION: L7 to S1 ventral root rerouting below the level of SCT showed successful axonal regrowth to the bladder from the L7 spinal cord segment in all rerouted animals, and induced increased detrusor pressure response to cutaneous stimulation in a subset. This feasibility study paves the way for future animal studies for bladder reinnervation.

Structural differences and architectural features of two different polypropylene slings (TVT-O and I-STOP) have no impact on biocompatibility and tissue reactions.

INTRODUCTION: To evaluate the impact of design features of the synthetic mid-urethral slings on tissue integrity and inflammatory responses. MATERIAL AND METHODS: In total 30 female Sprague-Dawley rats were implanted with type I monofilamentous, macroporous polypropylene meshes: Gynecare TVT-Obturator tape® (Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA) and I-STOP® (CL Medical Inc., Lyon, France). All animal groups were sacrificed at set time intervals - 6 weeks, 3 months, 6 months, 9 months and 12 months - and the abdominal wall was harvested with mesh strips for histological evaluation. RESULTS: All mesh strips appeared to be well incorporated into the abdominal wall, and no signs of shrinkage was noticed. All specimens showed a thin/delicate, loose, fibrous interface between the synthetic graft plate and abdominal wall, along with mild inflammatory reactions from 6 weeks to 12 months. CONCLUSIONS: Both mesh brands induced comparable, minimal foreign body reactions and integrated well into the host tissues despite differences in architectural features. TVT-O® and I-STOP® evoked similar low-grade inflammatory responses up to 12 months in this animal model. Structural differences and architectural features of polypropylene slings used in this study have had no impact on tissue integrity and inflammatory responses.

Prospective evaluation of anxiety, pain, and embarrassment associated with cystoscopy and urodynamic testing in clinical practice.

INTRODUCTION: We sought to prospectively assess anxiety, pain, and embarrassment associated with diagnostic cystoscopy and multi-channel urodynamic study (UDS). METHODS: All consecutive patients undergoing diagnostic cystoscopy or UDS in our department over a period of nine months were asked to participate. Two anonymous auto-administered questionnaires were specifically designed to collect basic epidemiological data, document medical history, and assess the quality of information provided, along with prevalence and level (0-10 numerical visual analog rating scale) of anxiety, pain, and embarrassment experienced before and/or during the procedures. Statistical analysis was carried out to identify underlying factors that could have influenced patients' experience and ascertain potential correlations between anxiety, pain, and embarrassment. RESULTS: 101 and 185 patients were respectively evaluated immediately after cystoscopy and UDS. Multivariate analysis repeatedly showed statistical correlations between anxiety, pain, and embarrassment, with regard to prevalence and level of intensity in both cystoscopy and UDS populations. Males and young patients were more likely to present anxiety, pain, or embarrassment during cystoscopy and UDS. Interestingly, patients who reported having received complete information before cystoscopy were significantly more likely to experience anxiety (62.6% vs. 20.0%; p=0.009). CONCLUSIONS: The present study demonstrated the major impact of gender and age on patients' experience. Interestingly, information provided before cystoscopy was reported to have a negative impact on patients' perception of anxiety; this could be partly prevented by optimizing the way information is provided to patients.

Treatment of lower urinary tract symptoms in multiple sclerosis patients: Review of the literature and current guidelines.

Multiple sclerosis (MS) is a unique neurological disease with a broad spectrum of clinical presentations that are time- and disease course-related. Lower urinary tract symptoms (LUTS) are highly prevalent in this patient population, with approximately 90% showing some degree of voiding dysfunction and/or incontinence 6-8 years after the initial MS diagnosis. Major therapeutic goals include quality of life improvement and the avoidance of urological complications Owing to the wide divergence of clinical symptoms and disease course, evaluation and treatment differ between patients. Treatment must be customized for each patient based on disease phase, patient independence, manual dexterity, social support, and other medical- or MS-related issues. Ablative or irreversible therapies are indicated only when the disease course is stable. In most cases of "safe" bladder, behavioural treatment is considered first-line defense. Antimuscarinic drugs, alone or in combination with intermittent self-catheterization, are currently the mainstay of conservative treatment, and several other medications may help in specific disease conditions. Second-line treatment includes botulinum toxin A injection, neuromodulation, indwelling catheters, and surgery in well-selected cases.

Early Fesoterodine Fumarate Administration Prevents Neurogenic Detrusor Overactivity in a Spinal Cord Transected Rat Model.

BACKGROUND: In spinal cord injury, onset of detrusor overactivity (DO) is detrimental for quality of life (incontinence) and renal risk. Prevention has only been achieved with complex sophisticated electrical neuromodulation techniques. PURPOSE: To assess the efficacy of early fesoterodine fumarate (FF) administration in preventing bladder overactivity in a spinal cord transected (SCT) rat model. METHODS: 33 Sprague-Dawley rats were allocated to 6 groups-Group 1: 3 normal controls; Group 2: 6 SCT controls; Group 3: 6 SCT rats + FF 0.18 mg/kg/d; Group 4: 6 SCT rats + FF 0.12 mg/kg/d; Group 5: 6 SCT rats + FF 0.18 mg/kg/d + 72-h wash-out period; Group 6: 6 SCT rats + FF 0.12 mg/kg/d + 72-h wash-out period. SCT was performed at T10. FF was continuously administered. Cystometry was undertaken 6 weeks after SCT in awake rats recording intermicturition pressure (IMP), baseline pressure, threshold pressure (Pthres) and maximum pressure (Pmax). Normal controls and SCT controls were initially compared using the Mann-Whitney U tests in order to confirm the SCT effect on cystometric parameters. The comparisons in cystometric and metabolic cage parameters between SCT controls and treated rats were done using post-hoc Dunn's tests for Kruskal-Wallis analysis. Statistical testing was conducted at the two-tailed α-level of 0.05. RESULTS: Pressure parameters were significantly higher in SCT control group compared to normal controls. Six weeks after SCT, IMP was significantly lower in low dose treated group than in SCT controls. Pmax was significantly lower in 3 treated groups compared to SCT controls. Pthres was significantly lower in full time treated groups than in SCT controls. CONCLUSION: Early administration of FF modulates bladder overactivity in a SCT rat model. Whereas short-term prevention has been demonstrated, the long-term should be further analyzed. Clinical application of these results should confirm this finding through randomized research protocols.

Elastic modulus for long-term evaluation of the tensile properties of polypropylene meshes in an in vivo rat model.

PURPOSE: Mid-urethral slings have become the gold standard treatment of stress urinary incontinence in women. Their tensile properties should be evaluated in order to measure how they wear off with time. Our objective was a long-term assessment of the tensile properties of 2 synthetic tapes (TVT-O and I-STOP) after in vivo implantation in rats in terms of elastic modulus. METHODS: Strips from both meshes were implanted in the abdominal wall of 30 rats, which were sacrificed at 5 time intervals. Their fibers were untangled to single components. Ultimate tensile strength (UTS), strain at UTS and the elastic modulus of each fiber type were measured. RESULTS: I-STOP maintained UTS and strain over time, while TVT-O UTS and strain were significantly reduced. However, the elastic modulus of both tapes remained constant. CONCLUSIONS: Both meshes maintained their stiffness and elasticity with time. Elastic modulus could be an appropriate factor to predict long-term implantation outcomes. The clinical significance of such findings remains to be demonstrated by long-term analysis.

Montreal electronic artificial urinary sphincters: Our futuristic alternatives to the AMS800™.

INTRODUCTION: We aimed to present three novel remotely controlled hydromechanical artificial urinary sphincters (AUSs) and report their in-vitro and ex-vivo results. METHODS: We successively developed three distinct hydromechanical AUSs on the basis of the existing AMS800™ device by incorporating an electronic pump. No changes were made to the cuff and balloon. The AUS#1 was designed as an electromagnetically controlled device. The AUS#2 and AUS#3 were conceived as Bluetooth 2.1 remotely controlled and Bluetooth 4.0 remotely-controlled, adaptive devices, respectively. In-vitro experiments profiled occlusive cuff pressure (OCP) during a complete device cycle, with different predetermined OCP. Ex-vivo experiments were performed on a fresh pig bladder with 4 cm cuff placed around the urethra. Leak point pressure with different predetermined OCP values was successively measured during cystometry via a catheter at the bladder dome. RESULTS: Our in-vitro and ex-vivo experiments demonstrated that these three novel AUSs provided stable and predetermined OCP - within the physiological range - and completely deflated the cuff, when required, in a limited time compatible with physiological voiding cycles. CONCLUSIONS: Our three novel, remotely controlled AUSs showed promising results that should be confirmed by in-vivo experiments focusing on efficacy and safety.

Impact of surgery on quality of life of women with obstetrical fistula: a qualitative study in Burkina Faso.

INTRODUCTION AND HYPOTHESIS: Obstetric fistula, caused by traumatic delivery and patient lack of access to obstetric care, is an important public health concern in developing countries, particularly in Sub-Saharan Africa. This research focuses on the experience of women living with obstetric fistula in Burkina Faso as well as their reintegration into community after surgery. METHODS: This project was funded by the Mères du Monde en Santé (MMS) Foundation and conducted in collaboration with the Boromo Hospital. A qualitative approach based on grounded theory and using the principles of participative action research (PAR) was used with semidirected interviews prior to surgery and follow-up interviews 1-2 years after surgery directly in the women's village of origin. Thirty-nine participants were recruited between 2012 and 2015. RESULTS: The results point to circumstances leading to obstetric fistula development: poverty, gender inequality in terms of decision making, healthcare-system deficiencies, and lack of services for referral and treatment of this condition. Our results reinforce the knowledge about the social and psychological repercussions of fistula by exploring the concepts of gossips, shame and self-exclusion as powerful mechanisms of exclusion, but they also show that social support was conserved for several women through their journey with this disease. There was complete social rehabilitation within the community after surgery; however, persistent barriers in term of anxiety regarding obstetric future and economic insecurity were present. CONCLUSIONS: Early recruitment for surgery and prevention are the main objectives when attempting to reduce the impact of obstetric fistula and facilitate patient reintegration. Improvements in local and governmental public health policies are required.

Is multichannel urodynamic assessment necessary before considering a surgical treatment of BPH? Pros and cons.

PURPOSE: Lower urinary tract symptoms (LUTS) are common in middle-aged men and could be consequences of multiple etiologies responsible for bladder outlet obstruction (BOO), detrusor underactivity (DUA) and/or overactive bladder. When LUTS are suggestive of BOO secondary to benign prostatic hyperplasia, a surgical treatment can sometimes be consider. Even if multichannel urodynamic study (UDS) is currently the gold standard to properly assess LUTS, its use in non-neurogenic men is still a matter of controversy. Here, we aim to explore the evidence supporting or not the use of systematic multichannel UDS before considering an invasive treatment in men LUTS. METHODS: The debate was presented with a "pro and con" structure. The "pro" side supported the systematic use of a multichannel UDS before considering a surgical treatment in men LUTS. The "con" side successively refuted the "pro" side arguments. RESULTS: The "pro" side mainly based their argumentation on the poor correlation of LUTS and office-based tests with BOO or DUA. Furthermore, since a multichannel UDS could allow selecting men that will most benefit of a surgical procedure, they hypothesized that such an approach could reduce the overall morbidity rate and cost associated with. The "con" side considered that, in most cases, medical history and symptoms were reliable enough to consider surgery. Finally, they underlined the UDS limitations and the frequent lack of alternative to surgery in this context. CONCLUSIONS: Randomized clinical trials are being conducted to compare these two approaches. Their results would help the urological community to override this debate.

Neural reconstruction methods of restoring bladder function.

During the past century, diverse studies have focused on the development of surgical strategies to restore function of a decentralized bladder after spinal cord or spinal root injury via repair of the original roots or by transferring new axonal sources. The techniques included end-to-end sacral root repairs, transfer of roots from other spinal segments to sacral roots, transfer of intercostal nerves to sacral roots, transfer of various somatic nerves to the pelvic or pudendal nerve, direct reinnervation of the detrusor muscle, or creation of an artificial reflex pathway between the skin and the bladder via the central nervous system. All of these surgical techniques have demonstrated specific strengths and limitations. The findings made to date already indicate appropriate patient populations for each procedure, but a comprehensive assessment of the effectiveness of each technique to restore urinary function after bladder decentralization is required to guide future research and potential clinical application.

Bladder tissue engineering: a literature review.

PURPOSE OF REVIEW: In bladder cancer and neuro-bladder, reconstruction of the bladder requires bowel segment grafting for augmentation cystoplasty or neo-bladder creation. However, even if currently considered as the gold standard, it is associated with potentially severe short- and long-term adverse effects. Thus, bladder tissue engineering is a promising approach to bladder reconstruction. RECENT FINDINGS: In the last few years, progress has been made with the development of new biomaterials for bladder tissue replacement and in deciphering the role of stem cells as well as their contribution to bladder scaffold integration and tissue regeneration. SUMMARY: This review of recently published articles allows us to forecast the characteristics of efficient and safe bladder biomaterials. However, several factors, such as native bladder traits, the specific involvement of urine, and bladder tissue replacement indications, have to be assessed with caution before including bladder tissue engineering in clinical trials. Many authors agree that these challenging techniques could deliver significant benefits with clinical application, reducing morbidity and global long-term costs.

Tissue engineering of rat bladder using marrow-derived mesenchymal stem cells and bladder acellular matrix.

Bladder replacement or augmentation is required in congenital malformations or following trauma or cancer. The current surgical solution involves enterocystoplasty but is associated with high complication rates. Strategies for bladder tissue engineering are thus actively sought to address this unmet clinical need. Because of the poor efficacy of synthetic polymers, the use of bladder acellular matrix (BAM) has been proposed. Indeed when cellular components are removed from xenogenic or allogeneic bladders, the extracellular matrix scaffold thus obtained can be used alone or in combination with stem cells. In this study, we propose the use of BAM seeded with marrow-derived mesenchymal stem cells (MSCs) for bladder tissue engineering. We optimized a protocol for decellularization of bladder tissue from different species including rat, rabbit and swine. We demonstrate the use of non-ionic detergents followed by nuclease digestion results in efficient decellularization while preserving the extracellular matrix. When MSCs were seeded on acellular matrix scaffold, they remained viable and proliferative while adopting a cellular phenotype consistent with their microenvironment. Upon transplantation in rats after partial cystectomy, MSC-seeded BAM proved superior to unseeded BAM with animals recovering nearly 100% normal bladder capacity for up to six months. Histological analyses also demonstrated increased muscle regeneration.