Isolated continent cystostomy on neurologic native bladder: Functional results.

INTRODUCTION: Continent cutaneous urinary diversion (CCUD) is proposed to patients suffering from chronic neurologic retention and undergoing intermittent self-catheterization (ISC). In case of neurogenic detrusor overactivity (NDO), augmentation enterocystoplasty is often required. The aim was to identify the prevalence of urinary stomal and/or urethral leakage in patients who had not undergone enlargement. METHODS: Monocentric, retrospective study of patients who underwent CCUD surgery in a neuro-urological context. Mitrofanoff's, Monti's or Casale's channels were performed. Patients selected had an underactive, stable, or stabilized bladder under adjuvant therapy with proper cystomanometric capacity. Prior or concomitant enterocystoplasty were excluded. Failure was defined as the occurrence of clinical leakage whatever it is through urinary stomal, or urethral. Urodynamic parameters were also reported. RESULTS: Thirty-one patients underwent surgery. Nine women had a concomitant bladder neck sling and 1 urethral closure. The mean follow-up was 7 years. 8/31 (26%) had stomal leakage and 9 urethral leakage (29%). Five spinal cord injured patients (n=14) had stomal leakage (36%) and 6 urethral leakage (43%). Of the 25 postoperative urodynamic parameters, cystomanometric bladder capacity was 419mL (vs. 514mL) and 2 additional patients had de novo NDO (9 vs. 7). DISCUSSION: The morbidity of augmentation enterocystoplasty is weighed against the presence of a well-controlled bladder preoperatively. Our study shows the appearance of leakage in some patients despite a well-balanced bladder, a decrease in mean cystomanometric capacity and an increase in the rate of NDO postoperatively. Good selection criteria for an isolated CCUD should be carefully revised and defined. LEVEL OF EVIDENCE: Grade C - retrospective study.

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]. / Recommandations sur la gestion du risque et la prise en charge urologique du patient adulte atteint de dysraphisme spinal (spina bifida).

INTRODUCTION: Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population. MATERIALS AND METHODS: National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached. RESULTS: Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible). CONCLUSION: Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Is bladder voiding efficiency useful to evaluate voiding function in women older than 65 years?

AIMS: The aims of the study were to evaluate the reproducibility of bladder voiding efficiency (BVE) between free flow (FF) and intubated flow(IF) in old women, and to search for a relationship of this index with complaint and urodynamic diagnosis. METHODS: Urodynamic tracings of non-neurologic women referred for investigation of various lower urinary tract symptoms (LUTS) were analyzed. Urodynamic study included one FF followed by one cystometry and IF. Post void residual volume (PVR) was measured using a Bladder-scan. Exclusion criteria were voided volume<100ml and prolapse of grade>2. RESULTS: One hundred and ninety women met the study criteria. The mean age was 74±6 years [65-96years]. The main complaint was urinary incontinence: stress (26), urge (53) and mixed (56). Forty-four women had various complaints without incontinence. Overall BVE IF (77.6±25.8) was significantly lower than BVE FF (90.4±15.3) (P<.0001). Age sub-groups stratification led similar results. BVE IF was significantly lower than BVE FF in women with incontinence whatever the cause. Urodynamic diagnosis was posed according to the ICS/IUGA recommendations and 2 sub-groups defined according with involvement of detrusor. BVE IF was significantly lower than BVE FF for detrusor dysfunction, except for detrusor overactivity. CONCLUSION: In this large cohort of old non-neurologic women studied urodynamically for a variety of LUTS, BVE is higher when evaluated from a FF whatever age and for complaint of urinary incontinence. In addition, a low BVE value from an IF may suggest a detrusor dysfunction. LEVEL OF EVIDENCE: 4.

Do urodynamics provide a better understanding of voiding disorders in women over 80?

AIMS: Population ageing has as consequence an increasing number of women older than 80 years with lower urinary tract symptoms (LUTS). Despite old age, urodynamic study is often performed to diagnose the cause of LUTS. Our purpose is to discuss the contribution of urodynamics to manage that population. METHODS: Urodynamic studies of 169 consecutive women older than 80 years, respectively 124 non-neurological (non-N) and 45 neurological (N), were retrospectively analysed. RESULTS: Number of co-morbidities was lower in non-N (2.5 vs. 3.1) with predominance of cardiovascular and endocrinology while musculo-skeletal, cognitive and previous pelvic surgery predominated in N. Among main complaint, incomplete retention or dysuria was more frequent in N while incontinence and frequency were predominant in non-N. More frequent urodynamic diagnosis (UD) was "normal" i.e. non contributive (25.0%) and intrinsic sphincter deficiency (ISD=21.7%) in non-N, detrusor overactivity (DO=42.2%) and detrusor underactivity (DU=38.8%) in N. In non-N, there were 94 treatment proposals based on the complaint when UD was "normal" and on UD for DO, DU and ISD. In N, treatment proposals were mainly prompted voiding or self-catheterization based on DU diagnosis. CONCLUSION: Usefulness of urodynamics to manage LUT dysfunction in women older than 80 y is greatly dependent on their neurological status. In non-neurological women this is non debatable but proposed treatment needs to take into account existing co-morbidities. In neurological women the main usefulness is to unmask DU and to propose the best management in order to avoid complete retention. LEVEL OF EVIDENCE: 4.

Usefulness of ice water test to unmask detrusor overactivity.

PURPOSE: Ice Water Test (IWT) is not frequently used today. IWT triggers a non-inhibited involuntary detrusor contraction (NIDC) when the bladder is being filled with cold saline solution. NIDC is unmasked via a segmental reflex loop different from the physiological micturition reflex. Our purpose was to search for usefulness of IWT to expose detrusor overactivity (DO). METHODS: One hundred and seventy-nine IWT performed in patients with overactive bladder syndrome (OAB) and conventional cystometry (CC) non-contributive to diagnosis were retrospectively analyzed. An increase of detrusor pressure of 15cm H2O allowed defining positive IWT (with leakage) or intermediate (without leakage). RESULTS: The population comprised of 131 women (58.2±17.3 years) and 48 men (56.1±15.3 years). Main complaints were mixed or urge incontinence (76/179). Hundred and twenty-four patients had a history of neurological disease. From CC, detrusor behavior was founded uncategorized for 106, normal for 53 patients and underactive for 20. These results did not contribute to diagnose a DO. IWT was positive for 22 patients and intermediate for 20. DO was unmasked by IWT for 42 patients (23.4%) of whom 34 had neurological disease. The positive predictive value was 80.9%, the negative predictive value was 34.3%. CONCLUSION: In patients with OAB syndrome, IWT is contributory to unmask DO when CC is not contributive. Our study underlines the interest to perform IWT when urodynamic diagnosis is unclear.

[Guidelines concerning urinary incontinence in elderly: construction and validation of GRAPPPA algorithm]. / Recommandations concernant l'incontinence urinaire de la personne âgée : construction et validation de l'algorithme décisionnel GRAPPPA.

OBJECTIVES: Provide guidelines presented as an algorithm for practical evaluation and first line therapy of urinary incontinence in elderly. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 40 experts quoting proposals, subsequently reviewed by an independent group of multidisciplinary experts (urologist, general practitioner, neurologist, gynecologist, geriatrist, specialist in physical medicine and rehabilitation). RESULTS: By means of 3 rounds of interrogation of the expert panel, GRAPPPA algorithm was constructed. This algorithm take in account both evaluation and first line therapeutic options in the different type of incontinences observed in this population (urge, stress and mixed incontinence). Initial evaluation consists to track down urinary retention (and subsequently fecal stool impaction, use of anticholinergic or morphinic drugs), urinary tract infection and cognitive impairment. Haematuria, bladder-pelvic pain, history of radiotherapy or recent pelvic surgery, lead to refer the patient to a specialized unit. First line therapy is in all the cases pelvic floor training, use of local oestrogenotherapy and dietetic measures. In urge incontinence, anticholinergic drugs may be used. CONCLUSIONS: Implementation of this algorithm may promote best practice in management of urinary incontinence in elderly.

Urethral pressure response to cough and voluntary perineal contraction in men without previous pelvic surgery.

The aim of this study was to analyze the urethral pressure responses to cough in men to better characterize the neurogenic mechanisms of male urethral function. A prospective study was carried out on 41 men referred for urodynamic assessment. Urethral pressure profiles at rest and during coughing, and urethral pressure response to voluntary perineal contraction were recorded and analyzed in relation to the neurological status of the patients. Voluntary perineal contraction resulted in a urethral pressure increase (delta pU) of approximately 150 cm H2O in neurologically normal patients. Delta pU could be reduced to any degree in patients with either central or peripheral neurological lesions. Urethral pressure response to cough could be easily classified into two main patterns. Pattern I was characterized by a marked increase in urethral closure pressure during the cough (ratio of urethral to rectal pressure increase: 248 +/- 106%), occurring at the distal part of the posterior urethra. All the neurologically normal patients and the majority of those with upper motoneuron lesions had a pattern I response. Pattern II was defined by the absence of any significant increase in urethral closure pressure at any site of the posterior urethra and was observed in 80% of the patients with signs of lower motoneuron lesions. The pattern of the response to cough was significantly related to the neurological status of the patients (P < 0.001). It was dissociated from the response to voluntary contraction, as would be expected for a reflex versus a voluntary response in neurological patients.

Urodynamic parameters in scrapie-affected ewes and their modifications in the course of the disease.

The aim of this study was to determine the urological abnormalities linked to spontaneous spongiform encephalopathy and their occurrence in the course of the disease. The animals used in this were 11 healthy and 20 scrapie-affected ewes. The scrapie-affected ewes were studied at a rate of once a month (1 to 5 measures; mean, 2.55) until they died. Urodynamic explorations were performed. The bladder activity was explored using cystometry. The urethral activity was measured during cystometry and during a urethral pressure profile. Both were analyzed using International Continence Society recommendations. Results showed in scrapie-affected ewes a decrease in functional bladder capacity and an increase in detrusor contraction incidence during filling of the bladder and in the occurrence of significant urethral instability. Bladder abnormalities were seen only in scrapie-affected ewes and worsened during the course of the disease. Urethral instability was not typical of the disease but was significantly more frequent in scrapie-affected ewes. It was concluded that lower urinary tract dysfunction occurred in scrapie-affected ewes and worsened during the course of the disease. This dysfunction is in agreement with overactive detrusor function due to neurological lesions.

[Coccygodynia disclosing Tarlov's cysts]. / Coccygodynies révélant des kystes de Tarlov.

In a 63-year old male patient coccygodynia, initially isolated then complicated by incomplete cauda equina syndrome, could be attributed to large perineurel meningeal cysts on the sacral nerve roots. The diagnosis was suspected at computerized tomography and nuclear magnetic resonance and confirmed by sacculoradiculography. Intradural injections of corticosteroids provided lasting pain relief. Arachnoid cysts are often asymptomatic, by they may be responsible for coccygodynia and/or incomplete cauda equina syndrome. Their presence is suggested by the characteristics of the symptoms which are paroxysmal, exacerbated in standing position, relieved in dorsal position and revived by percussing the sacrum. Treatment is medical in most cases. The decision to operate depends on the persistence and intensity of pain and on whether signs of neurological defecit are present.