Comparative anatomy of the ovine and human pelvis for laparoscopic sacrocolpopexy: evaluating the effectiveness of the ovine model.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrocolpopexy (LSC) is a functional reconstructive surgery used to treat pelvic organ prolapse (POP) in middle-aged women. Although LSC is widely used, its implementation is hindered by perceived technical difficulties and surgical learning curves. Surgeons require adequate experience with LSC prior to performing the procedure on patients to improve their quality of life. This study is aimed at demonstrating the effectiveness of the ovine model (OM) for training and research in LSC, while also comparing anatomical differences between ovine and human models during the procedure. METHODS: The animal model and training were provided by the Jesús Usón Minimally Invasive Surgery Centre. Urologists and gynecologists with experience in LSC participated in a course and their findings were recorded and documented. RESULTS: Differences in patient positioning, trocar placement, and reperitonealization were identified between the ovine and human models. Hysterectomy is always performed in the ovine model, whereas it is not mandatory in humans. There are also differences in the dissection of the levator ani muscle and attachment point of the posterior mesh to the uterus between the two models. Despite differences in some areas, the ovine pelvic structure and vagina are similar in size to those of humans. CONCLUSIONS: The ovine model is a valuable tool for surgeons in their learning curve for LSC, allowing for safe and effective practice prior to performing the procedure on patients. The use of the OM can help to improve the quality of life for women affected by pelvic organ prolapse.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa).

Introduction: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement. Results: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or ß 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance. Conclusions: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Dropped abdominal pressure at void in women.

INTRODUCTION AND HYPOTHESIS: "Dropped pabd at void" occurs when pabd decreases below the previous resting pressure during voiding time. We sought clinical factors associated with this phenomenon and evaluated whether its correction modifies the urodynamic diagnosis. METHODS: Retrospective cross-sectional study of non-neurological consecutive symptomatic women. The following definitions were used: "dropped pabd at void": decrease in pabd at Qmax ≥ 5 cmH2O; bladder outflow obstruction (BOO) (pdetQmax ≥ 25 cmH2O + Qmax ≤ 12 ml/s and female BOO index (pdetQmax - 2.2*Qmax) > 18; "low detrusor contraction strength": PIP1 (pdetQmax + Qmax) < 30. In patients with "dropped pabd at void", pdetQmax was corrected. RESULTS: A total of 360 women were analyzed. Ninety-five percent of the women had a variation in pabd at Qmax between -13 and 53 cmH2O. "Dropped pabd at void" was found in 100 women (27.8%). History of stress urinary incontinence (SUI) surgery was significantly higher (p = 0.016) and symptoms of mixed urinary incontinence were significantly lower (p = 0.030) in patients with "dropped pabd at void". On multivariate analysis only the history of SUI surgery maintained its significance (OR = 1.787 [95% CI: 1.058, 3.017], p = 0.030). When correcting pdetQmax in women with "dropped pabd at void", 2 or 5 patients lost BOO diagnosis (depending on how it was diagnosed) and 7 patients gained a "low detrusor contraction strength" diagnosis. CONCLUSIONS: Approximately one-quarter of women had "dropped pabd at void", which was associated with a history of SUI surgery. Correction of pdetQmax would lead to a 2.5% to 3.33% diagnostic modification.

Current Use of the Artificial Urinary Sphincter in Adult Females.

PURPOSE OF REVIEW: The aim of the present report was to review the recent evidences regarding the use of artificial urinary sphincter (AUS) in adult females. RECENT FINDINGS: While the excellent functional outcomes of AUS in female patients with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD) have been reported for decades, its use has remained confidential in most countries likely due to its challenging implantation and inherent morbidity. Over the past few years, laparoscopic and, more recently, robotic techniques of AUS implantation in female patients have been described with promising perioperative outcomes. As a result, the use of AUS has increased in several countries. The indications are mostly recurrent or persistent SUI after previous anti-incontinence procedures and neurogenic SUI. Owing to its unique potential to restore continence while maintaining low outlet resistance during the voiding phase, AUS may be of special interest in female patients with detrusor underactivity. High level of evidence data from trials which are underway, along with developments in robotic surgery and technological refinements of the device, may well, almost 50 years after its introduction, give to the AUS its momentum as a major contributor in the female SUI armamentarium. While the use of AUS in female patients has been restricted to some countries and a few high-volume centers, it has started spreading again over the past few years, thanks to the rise of minimally invasive approaches which facilitate its implantation, and this is yielding promising outcomes.

Bladder diary characteristics and progress in patients with painful bladder syndrome. / Características del diario miccional y su evolución en pacientes con síndrome de dolor vesical.

OBJECTIVES: The utility and importance of the 3-day Bladder Diary (3dBD) for the diagnosis and management of patients with Bladder Pain Syndrome (BPS) was analyzed. MATERIAL AND METHODS: Epidemiological, observational, longitudinal and multicentric study, carried out under usual conditions of clinical practice. 37 Functional Urology and Urodynamics units included 329 women with BPS according to the criteria of the International Society for the Study of Bladder Pain Syndrome (ESSIC). Of all patients included, 319 were evaluable (79 with new diagnosis and 240 in follow-up). Sociodemographic and clinical variables were collected together with variables related to cystoscopy, biopsy and physical examination and BPS diagnostic tests. Patients completed the "Bladder Pain/Interstitial Cystitis - Symptom Score"(BPIC-SS), "Patient Global Impression of Severity" (PGI-S) and "EuroQoL-5D-5L" (EQ-5D-5L) questionnaires besides of the 3dBD. Results of the 3dBD were described according to urinary symptoms and the symptoms reported through questionnaires, in addition their association was studied. RESULTS: In anamnesis, 74.9% of patients reported increased Urinary Frequency (UF), 59.6% urgency and72.7% nocturia compared to 88.7%, 55.9% and 73.6% as reflected in the 3dBD. The highest correlation indexes (CI) were obtained between BPIC-SS and UF/24h (0.45) and between UF/24 h and PGI-S (-0.36) and EQ-5D-5L (-0.33). Mean voiding volume was higher in patients with better BPIC-SS score (163.72 (SD 68.02ml) y 154.1 (SD 70.63 ml)), at 6 and 12 months. CONCLUSIONS: 3dBD has proven to be a useful and complementary tool to the anamnesis in the evaluation of the repercussion of pain in the micturition pattern and for the differential diagnosis of the symptoms of BPS patients. It also allows to obtain complete and objective information about the symptoms. Although it is necessary to incorporate other tools that complete the clinical characterization of these patients.

OBJETIVOS: Se analizó la utilidad e importancia del Diario Miccional de 3 días (DM3d) en el diagnóstico y manejo de las pacientes con Síndrome de Dolor Vesical (SDV).MATERIAL Y MÉTODOS: Estudio epidemiológico, observacional, longitudinal y multicéntrico, realizado en condiciones de práctica clínica habitual. 37 unidades de Urología Funcional y Urodinámica incluyeron 329 mujeres con SDV bajo criterio de la International Society for the Study of Bladder Pain Syndrome (ESSIC). 319 pacientes fueron evaluables (79 de nuevo diagnóstico y 240 en seguimiento). Se recogieron variables sociodemográficas y clínicas, variables relacionadas con la cistoscopia, biopsia y exploración física, y pruebas diagnósticas para el SDV. Las pacientes completaron los cuestionarios "Bladder Pain/Interstitial Cystitis ­Symptom Score" (BPIC-SS), "Patient Global Impression of Severity" (PGI-S), "EuroQoL-5D-5L" (EQ-5D-5L) y el DM3d. Se describieron los resultados del DM3d según los síntomas miccionales y los síntomas comunicados por las pacientes a través de cuestionarios y se estudiós u asociación. RESULTADOS: En la anamnesis, el 74,9% de pacientes reportaron frecuencia miccional (FM) aumentada, 59,6% urgencia miccional y 72,7% nocturia frente al 88,7%, 55,9%, 73,6% que reflejó el DM3d. Los mayores índices de correlación (ICC) se obtuvieron entre las puntuaciones BPIC-SS y FM/24h (0,45) y entre FM/24h y PGI-S (-0,36) y EQ-5D-5L (-0,33). El Volumen Miccional medio fue superior en las pacientes con mejor puntuación en BPIC-SS, a los 6 y 12 meses (163,72 (DE 68,02 ml) y 154,1 (DE 70,63 ml)). CONCLUSIONES: El DM3d ha demostrado ser una herramienta útil y complementaria a la anamnesis en la evaluación de la repercusión del dolor en el patrón miccional y en el diagnóstico diferencial de los síntomas de estas pacientes. Además, permite obtener información completa y objetiva de los síntomas. Si bien es necesario incorporar otras herramientas que terminen de completar la caracterización clínica de estas pacientes.

[Current situation in Urology practice in Spain during the COVID-19 pandemic.] / Situación actual de la urología en España durante la pandemia Covid-19.

INTRODUCTION: On 11th March 2020the WHO declared COVID19 a global pandemic, a challenge previously unseen for sanitary systems, including the activity in Urology departments. MATERIAL AND METHODS: Web and PubMed searchusing the keywords "SARS-CoV-2", "COVID19", "COVID Urology", "COVID surgery", "consensus methods","nominal group", "Delphi method". A narrative revision of the literature until the 20th May 2020, including articles and documents in English and Spanish.;RESULTS: Medical practice in Spain has been forced to rapidly adapt to the pandemic, dedicating most ofits material and human resources to the care of patients infected by SARS-CoV-2. This has meant a significant reduction of the routine practice in Urology, as in other medical specialities, limiting the medical attention tourgent and emergent cases. Programmed activity has been reserved for selected cases in which a delayed attention could compromise survival. Different scientific associations have made a significant effort to adapt their recommendations to the pandemic, prioritizing high-risk oncologic cases, and reducing the use of ventilators and hospital stays to the minimum. These restrictions must be dynamic, adapting to the de-escalating phases as the pandemic is more controlled, widening the range of services available. In this de-escalate there is an additional challenge, being the difficulty in generating quality scientific evidence. In order to obtain such evidence, consensus methods have been used, such as the nominal group technique or the Delphi method. CONCLUSIONS: The COVID19 pandemic has meant a complete disruption in the routine activity in Urologyin Spain, with a need for prioritizing the attention of urgent and high-risk oncologic pathology. These restrictions must be progressively modified according to the de-escalating process in the general population.

INTRODUCCIÓN: El 11 de marzo de2020 la OMS declara el estado de pandemia por COVID19, un reto sin precedentes para los sistemas sanitarios, incluyendo la actividad en el ámbito de la Urología. MATERIAL Y MÉTODOS: Búsqueda web y PubMed empleando las palabras clave "SARS-CoV-2", "COVID19","COVID Urology", "COVID surgery", "consensus methods", "nominal group", "Delphi method".Revisión narrativa de la literatura hasta el 20 de mayo 2020 incluyendo artículos y documentos escritos en españolo inglés. RESULTADOS: La actividad asistencial en España ha debido adaptarse rápidamente a la pandemia, volcandola mayoría de sus recursos materiales y humanos para atender pacientes infectados por SARS-CoV-2. Esto ha supuesto una disminución drástica de la actividad habitual en Urología, al igual que en el resto de especialidades, limitando la atención a casos urgentes y emergentes. La actividad programada ha debido restringirse a sujetos muy seleccionados en los que demorar la atención podría comprometer la supervivencia. Diferentes asociaciones científicas han realizado un esfuerzo importante para adaptar sus recomendaciones a la pandemia, priorizando patología oncológica de mayor riesgo, y reduciendo el uso de respiradores y las estancias hospitalarias al máximo. Esta restricción debe ser dinámica, adaptándose a las fases de desescalada a medida que se vaya controlandola pandemia, ampliando los servicios ofrecidos. Para esta desescalada nos enfrentamos a un reto adicional,que es la dificultad para generar evidencia científica decalidad que guíe las actuaciones de los sanitarios. Para obtener evidencia en este contexto se ha de recurrir a métodos de consenso. CONCLUSIONES: La pandemia por COVID19 ha supuesto una disrupción completa de la actividad habitual en Urología en España, debiendo priorizar la atención de patología urgente y oncológica de riesgo. Estas restricciones deben modificarse progresivamente acorde a la desescalada en la población.

[Functional urology during COVID-19: Recommendations during de-escalation.] / La urología funcional en la era COVID-19. Consejos para la desescalada.

OBJECTIVES: Due to the COVID-19 Pandemic, all surgical activity that was not life threatening was cancelled , as well as most face-to-face consultations. Currently the beginning of the de-escalation phases that will led us to a new normal, forces us to establish some degree of priority in the interventions as well as in the medical consultations. Our objective is to establish some recommendation on Functional Urology office visits and surgical interventions that serve as a tool to facilitate decision-making. MATERIAL AND METHODS: Experts in Functional Urology from different autonomous communities of Spain were contacted to design a strategy to reorganize the activity of both, diagnosis and treatment. A modified nominal group technique has been used due to the extraordinary restrictions of assembly and mobility during the COVID pandemic. The first signer (EMC) made the first draft with the measures adopted and the strategy to be followed during the evolution of the COVID-19 pandemic. The proposal was sent to the rest of the authors, in order to unify criteria and experiences to reach a quick consensus on the relative priority of the different activities, problems and solutions. A final version was approved by all authors May 27, 2020. RESULTS: Tables of recommendation have been prepared for outpatient consultation, surgical and technical interventions, according to de-escalation phases proposed by the Spanish Associations of Surgeons. CONCLUSIONS: The change that COVID-19 Pandemich as involved in our clinical practice force us to seek alternative methods to treat our patients, some of which may already be established. Mean while, a consensusin decision making is necessary. Documents such as the current one, are intended to guide the management of patients with urological functional pathology in exceptional situations. Logically, it should be adapted to material and human availability, and to the idiosyncrasy of each Urology service.

OBJETIVOS: Debido a la Pandemia COVID-19 se suspendió toda actividad quirúrgica que no fuera una urgencia vital, así como la mayoría de consultas presenciales. Actualmente el inicio de las fases dedesescalada que nos llevarán a una nueva normalidad nos obliga a establecer unos grados de prioridad en las intervenciones así como en las consultas médicas. Nuestro objetivo es establecer una serie de recomendaciones sobre las consultas de Urología Funcional y las intervenciones quirúrgicas que sirva como herramientade ayuda en la toma de decisiones.MATERIAL Y MÉTODOS: Expertos en Urología Funcionalde distintas comunidades autónomas de España fueron contactados para diseñar una estrategia parareorganizar la actividad tanto de diagnóstico como de tratamiento. Se ha utilizado una técnica de grupo nominal modificada debido a las restricciones extraordinarias de reunión y movilidad durante la pandemia COVID. El primer firmante (EMC) realizó el primer borrado rcon las medidas adoptadas y la estrategia a seguir durante la evolución de la pandemia COVID19. Se remitió la propuesta al resto de autores, con el fin de unificar criterios y experiencias para llegar a un rápido consenso sobre la importancia relativa de las distintas actividades, problemas y soluciones. Se realizó una versión definitiva, aprobada por todos los autores, el día 27 de mayo de 2020. RESULTADOS: Se han elaborado tablas de recomendaciones tanto para consultas externas, como para intervenciones quirúrgicas y técnicas, de acuerdo con las fases de desescalada propuestas por la Asociación Española de Cirujanos (AEC). CONCLUSIONES: El cambio que ha supuesto la Pandemia COVID-19 en nuestra práctica clínica nos obliga a buscar métodos alternativos para seguir y tratar a nuestros pacientes, algunos de los cuales pueden ya quedar instaurados. Mientras, es necesario un consenso en la toma de decisiones. Documentos como el actual, pretenden orientar en el manejo de los pacientes con patología funcional urológica en situaciones excepcionales. Lógicamente, deberá adaptarse alas disponibilidades materiales y humanas, y a la idiosincrasia de cada servicio de Urología.

[Robotic and laparosocpic urological surgery during COVID-19 pandemia.] / Situación de la cirugía laparoscópica y robótica urológica durante la pandemia COVID-19.

OBJECTIVE: SARS-CoV-2 pandemic hashigh repercussion on urologic minimally invasive surgery (MIS). Controversy about safety of MIS procedures during COVID-19 pandemic has been published. Nowadays, our priority should be create agreement in order to restart and organize MIS with safety conditions for patients and healthcare workers. METHODS: Pubmed and web search was conducted with following terms: "SARS-CoV-2", "COVID19", "COVID19 Urology", COVID19 Surgery", "COVID19 transmission", "SARS-CoV-2 transmission", "COVID19 nd minimally invasive surgery", "SARS-CoV-2 and CO 2insuflation". A narrative review of available literature and scientific evidence summary was done. A modify nominal group technique was used to achieve an expert consensus. First draft was circulated amongst authors. Definitive document was approved in May 26th. RESULTS: Non evidence supports higher risk of SARSCoV-2 healthcare workers infection with MIS compared to open surgery. MIS is associated with shorter hospital stay than open surgery. Modify MIS indications to open surgery, with no scientific evidence, could spend valuable resources in detriment to COVID-19 patients. MIS indications should be prioritized attending to available resources and pandemic intensity. SARS-CoV-2screening 72 hours prior to surgery by clinical and epidemiological questionnaire and nasopharyngeal PCRis recommended, in order to prevent nosocomial transmission, professional infections and to minimize postoperative complications. Intraoperative steps should be established to reduce professional exposure to surgical aerosols, including: surgical room reorganization, adequate personal protective equipment, surgical technique optimization and management of CO2 and surgical smoke. CONCLUSIONS: In COVID-19 pandemic de-escalation, MIS carried out with optimal safety measurements, could contribute to reduce hospital resources utilization. With current evidence, MIS should not be limited or reconverted to open surgery during COVID-19 pandemic.

OBJETIVO: La pandemia provocada por el nuevo coronavirus SARS-CoV-2 ha tenido una elevada repercusión sobre la cirugía mínimamente invasiva (CMI). Ha surgido una importante controversia sobre la realización de CMI durante la pandemia COVID-19. Es prioritario, establecer un consenso sobre la organización y realización con seguridad de la CMI durante la pandemia. MATERIAL Y MÉTODOS: Se realizó una búsqueda web y en PubMed con los términos: "SARS-CoV-2", "COVID19", "COVID19 Urology", "COVID19 Surgery", "COVID19 transmission", "SARS-CoV-2 transmission", "COVID19 and minimally invasive surgery", "SARSCoV-2 and CO2 insuflation". Se realizó una revisión narrativa de la literatura y una síntesis de la evidencia disponible. Se ha utilizado una técnica de grupo nominal modificada, circulando un primer borrador a todos los autores y aprobándose la versión definitiva el día 26 de Mayo de 2020. RESULTADOS: No existe evidencia sobre una mayor exposición a SARS-CoV-2 en CMI respecto a cirugía abierta. La CMI se asocia a una menor estancia hospitalaria por lo que cambiar, sin justificación, la indicaciónde CMI puede retrotraer recursos que podrían ser utilizados para la pandemia COVID-19. Se debe priorizar la CMI según los recursos disponibles y la intensidad de la pandemia en cada momento. Se recomienda realizar despistaje de SARS-CoV-2 mediante cuestionario clínico-epidemiológico y PCR nasofaríngea 72 horas antes de la CMI electiva, para minimizar las complicaciones postoperatorias, evitar la transmisión cruzada entre pacientes y la posible exposición de los profesionales sanitarios. Se recomienda establecer medidas de organización en quirófano, de protección personal, técnica quirúrgica y manejo del CO2 y aerosoles generados para reducir la exposición y riesgos del personal sanitario. CONCLUSIONES: La CMI realizada con las medidasd e seguridad adecuadas para el paciente y profesionales, puede contribuir durante la desescalada a una menor utilización de recursos sanitarios y por tanto, no debe limitarse su utilización o cambiar sus indicaciones.

Management of Female and Functional Urology Patients During the COVID Pandemic.

CONTEXT: Coronavirus disease 19 (COVID-19) has changed standard urology practice around the world. The situation is affecting not only uro-oncological patients but also patients with benign and disabling conditions who are suffering delays in medical attention that impact their quality of life. OBJECTIVE: To propose, based on expert advice and current evidence where available, a strategy to reorganize female and functional urological (FFU) activity (diagnosis and treatment). EVIDENCE ACQUISITION: The present document is based on a narrative review of the limited data available in the urological literature on SARS-Cov-2 and the experience of FFU experts from several countries around the world. EVIDENCE SYNTHESIS: In all the treatment schemes proposed in the literature on the COVID-19 pandemic, FFU surgery is not adequately covered and usually grouped into the category that is not urgent or can be delayed, but in a sustained pandemic scenario there are cases that cannot be delayed that should be considered for surgery as a priority. The aim of this document is to provide a detailed management plan for noninvasive and invasive FFU consultations, investigations, and operations. A classification of FFU surgical activity by indication and urgency is proposed, as well as recommendations adopted from the literature for good surgical practice and by surgical approach in FFU in the COVID-19 era. CONCLUSIONS: Functional, benign, and pelvic floor conditions have often been considered suitable for delay in challenging times. The long-term implications of this reduction in functional urology clinical activity are currently unknown. This document will help functional urology departments to reorganize their activity to best serve their patients. PATIENT SUMMARY: Many patients will suffer delays in urology treatment because of COVID-19, with consequent impairment of their physical and psychological health and deterioration of their quality of life. Efforts should be made to minimize the burden for this patient group, without endangering patients and health care workers.

Position of Ibero-American Society of Neurourology and UroGynecology (SINUG) on the use of vaginal meshes in pelvic organ prolapse.

AIMS: Pelvic organ prolapse (POP) is a very prevalent condition with a great impact on women's quality of life. At present, there is great controversy regarding the use of mesh in POP surgery. To understand the current moment, it is advisable to make a brief summary of the historical evolution of mesh use for pelvic floor pathology. The aim of this paper is to establish the position of the Ibero-American Society of Neurourology and UroGynecology (SINUG for its acronym in Spanish) regarding vaginal mesh reconstructive surgery. METHODS: A working committee from the SINUG's scientific board performed a literature search about the use of vaginal meshes for pelvic organ prolapse reconstructive surgery and about the position of different societies. We analyzed the evolution into three periods: before the Food and Drug Administration (FDA) statement, FDA statement, and after the statement. SINUG drew up a position statement regarding vaginal mesh reconstructive surgery, based on the available scientific evidence and the evolution of its use in different contexts. RESULTS: Before mesh appearance in the 1990s, native tissue repair was the surgical treatment of choice for POP. Vaginal mesh reconstructive surgery has been frequently accompanied by procedure underestimation by inexperienced surgeons, besides inadequate diagnoses and indications. This situation led to the presentation of serious complications including mesh extrusion, exposure, and contraction. CONCLUSIONS: Once reviewed the available evidence and the position of different societies, SINUG presents its vision in this communication, which is a summary of the document prepared by the society's scientific board.

Consensus document on the multidisciplinary management of neurogenic lower urinary tract dysfunction in patients with multiple sclerosis.

AIM: Neurogenic lower urinary tract dysfunction (NLUTD) is very common in multiple sclerosis (MS) patients. Early diagnosis and treatment are crucial to avoid irreversible damage and improve quality of life. Our aim was to develop recommendations to improve NLUTD identification in MS patients, along with their referral and management. METHODS: A multidisciplinary group of 14 experts in the management of patients with MS and NLUTD (nine urologists, three neurologists, and two rehabilitators) was selected. A comprehensive review of the literature was undertaken and a set of recommendations was generated and submitted to a Delphi panel of 114 experts. Recommendations were presented according to the grade of agreement (GA). RESULTS: Early diagnosis in asymptomatic patients with risk factors for complications is recommended (GA 94%). Postvoid residual volume should be measured if changes in urinary symptoms (GA 87%), preferably ultrasound-guided (GA 86%). Early referral to urologist is recommended if urinary incontinence (GA 91%), significant post-void residual volume (94%), quality of life impairment (GA 98%) and recurrent urinary infections (GA 97%). The initial evaluation should include physical examination (GA 99%) and urodynamics including cystometry (GA 89%), pressure-flow study (90%) and electromyography (GA 70%). The panel recommends multidisciplinary collaboration (GA 100%) with a rehabilitation specialist and trained nurses in the management of NLUTD (GA 99%). CONCLUSIONS: Multidisciplinary management for patients with NLUTD due to MS is advised, including urologists, neurologists, rehabilitation, and nurses. Panel recommends early diagnosis with post-void residual volume in symptomatic patients before referring to urologist and urodynamics when referred.

[Intraoperative neurophysiological monitoring in radical prostatectomy and pudendal nerve surgical releasing.] / Monitorización neurofisiológica intraoperatoria en prostatectomía radical y liberación del nervio pudendo.

OBJECTIVE: Intraoperative neurophysiological monitoring (INM) allows obtaining real-time information on the functional integrity of nervous system structures. The objective of this article is to present the role of clinical neurophysiology in Urology in the identification and preservation, on the one hand, of the prostate neurovascular bundles in radical prostatectomy (RP), and of the pudendal nerve in the release of this in Pudendal Nerve Entrapment Syndrome (PNS). METHODS: A bipolar laparoscopic probe was used for intraoperative stimulation for both the identification in PNS and neurovascular bundles in RP, obtaining response at the external anal sphincter in the first one; and intracavernous pressure in the second through needle electrodes. RESULTS: Preservation of the periprostatic neurovascular bundles allows to increase rates of sexual potency and urinary continence after surgery. However, it has been shown that the innervation of the corpora cavernosa and the urinary sphincter has a variable disposition. Intraoperative neurostimulation allows the most precise identification and dissection of the vascular and nervous structures that surround the prostate. In the diagnosis of PNS, the neurophysiological study allows to rule out pathology at other levels, such as, primary muscular pathology of the anal sphincter. There are no pathognomonic neurophysiological findings of PNS. In addition, it allows the identification of the nerve during the laparoscopic release of the nerve at the entrance of the Alcock channel, as well as the evaluation of its functional integrity after the end of the dissection. CONCLUSIONS: The INM is a fundamental tool to allow an improved identification of nerve structures during RP and PNS in order to preserve them. It also helps with the diagnosis of PNS.

OBJETIVO: La monitorización neurofisiológica intraoperatoria (MNI) permite obtener información en tiempo real sobre la integridad funcional de las estructuras del sistema nervioso. El objetivo de este trabajo exponer el papel de neurofisiología clínica en Urología en la identificación y preservación, por un lado, de los haces neurovasculares prostáticos en la prostatectomía radical (PR), y del nervio pudendo en la liberación de este en el Síndrome de Atrapamiento del Nervio Pudendo (SANP).MÉTODOS: Se empleó una sonda bipolar laparoscópica para la estimulación intraoperatoria tanto para la identificación en SANP como de haces neurovasculares en PR obteniéndose respuesta a nivel del esfínter anal en la primera y presión intracavernosa en la segunda por medio de electrodos de aguja. RESULTADOS: La presentación de los haces neurovasculares periprostáticos permite aumentar las tasas de potencia sexual y continencia urinaria. Si bien, posteriormente, se evidenció que la inervación de los cuerpos cavernosos y el esfínter urinario tiene disposición variable. La neuroestimulación intraoperatoria permite la identificación y disección más precisa de las estructuras vasculonerviosas que circundan la próstata. En el diagnóstico del SANP, el estudio neurofisiológico permite descartar patología a otros niveles, como por ejemplo patología primaria muscular del esfínter anal; así como, valorar las ramas del nervio pudendo. No existen hallazgos neurofisiológicos patognomónicos del SANP. Además, permite la identificación del nervio durante la liberación laparoscópica del nervio a la entrada del canal de Alcock, así como la evaluación de su integridad funcional tras finalizar la disección. CONCLUSIONES: La MNI es una herramienta fundamental para permitir una mejora en la identificación de estructuras nerviosas durante PR y SANP para poder preservarlas. Así mismo, ayuda con el diagnóstico de SANP.

Prospective long-term results, complications and risk factors in pelvic organ prolapse treatment with vaginal mesh.

OBJECTIVE: To assess the long-term results and complications of pelvic organ prolapse treatment with transvaginal mesh. STUDY DESIGN: Prospective observational study of 75 women who underwent surgery between 2005 and 2008 by the same surgeon. 44 patients (58,7%) underwent concomitant treatment of stress urinary incontinence. Anatomical criterion for failure was prolapse grade >I in any compartment. Analysis of functional features consisted of an assessment of urinary, sexual, and defecation symptoms, and pelvic pain. Subjective global evaluation of the treatment was carried out through the Visual Analogue Scale (VAS). Analysis of the early and late complications and their medical or surgical management was performed. Evaluation of risk factors for failure of treatment and extrusion was carried out through logistic regression. RESULTS: The median follow-up was 5,3 years. The anatomical results showed correction in 91,3% of the patients. Median subjective VAS evaluation: 9/10. Urinary symptoms improved after the surgery. Constipation and dyspareunia rates worsened. Pelvic pain improved. There were two early complications: one rectal perforation, repaired intraoperatively and one pulmonary embolism, managed medically. Late complications: 9 extrusions (3 managed with topical oestrogen, 3 with expectant management, and 3 reoperated, one twice), one cervix elongation and one forgotten gauze (both reoperated), 4 de novo pain managed successfully conservatively. 58,8% of the complications occurred after one year. Risk factors analyzed showed no statistical significance. CONCLUSIONS: Vaginal mesh provides favorable anatomical, functional and subjective outcomes in long-term follow-up. The number of complications is relatively low, but many complications occurred a long-time after surgery.

[The usefulness of ultrasonography and Doppler ultrasound in renal transplantation]. / Utilidad de la ecografía y el eco-Doppler en el trasplante renal.

OBJECTIVES: The aim of the study is to analyze the usefulness of ultrasound and Doppler ultrasound for the evaluation of transplant donors and recipients, for renal transplant follow-up and for the resolution of surgical complications after renal transplant. METHODS: Abdominal ultrasound was performed in donors and recipients of renal grafts. In the recipients with vascular risk factors a Doppler ultrasound of the iliac and lower limb arteries was systematically done. Doppler ultrasound was performed in the first and seventh day after renal transplant, as well as for graft dysfunction at any moment. RESULTS: Recipient ultrasound informs about the existence of acquired renal cystic disease and Doppler ultrasound allows evaluating the vascular state of high risk recipients. In the immediate post-transplant period ultrasound studies are useful for detection of vascular complications, graft obstruction and to control the evolution of acute rejection and acute tubular necrosis. Finally, ultrasound is the technique of choice in the endourological management of surgical complications after renal transplant. CONCLUSION: Ultrasound under urologic control is essential in the evaluation of the kidney transplant recipient, post-transplant follow-up and in the resolution of surgical complications.