Mitochondrial viability in neurogenic bladder urothelium after sigmoidocolocystoplasty. Implications for persistent vesicoureteral reflux.

PURPOSE: We investigated whether inflammatory cell infiltration (ICI), fibrosis, and mitochondrial viability of the neurogenic bladder urothelium are involved in the mechanism of persistent vesicoureteral reflux (VUR) after sigmoidocolocystoplasty (SCP). METHODS: Bladder biopsies obtained 1994-2023 from 62 neurogenic bladder patients were examined by hematoxylin and eosin for ICI, Masson's trichrome for fibrosis, and immunofluorescence for urothelial growth differentiation factor 15 (GDF15; a mitochondrial stress-responsive cytokine) (positive/negative) and heat shock protein 60 (HSP60; a mitochondrial matrix marker) (strong ≥ 50%/weak≤ 50%) expression. GDF15 + /weak HSP60 indicated compromised mitochondrial viability. Cystometry measured neobladder compliance/capacity. RESULTS: Mean ages (years) at SCP and bladder biopsies were 9.4 ± 4.6 and 14.2 ± 7.1, respectively. VUR was present in 38/62 patients (51 ureters) at SCP and resolved with SCP alone in 4/38 patients, with SCP and ureteroneocystostomy in 17/38, and persisted in 17/38. Fibrosis was significantly denser in GDF15 + (n = 24)/weak HSP60 (n = 31) compared with GDF15- (n = 38)/strong HSP60 (n = 31) (p < 0.001 and p < 0.01, respectively). Differences in ICI were significant for GDF15 + vs. GDF15- (p < 0.05) but not for HSP60. Patients with VUR after SCP had higher incidence of GDF15 + /weak HSP60 compared with cases without VUR (p < 0.05 and p < 0.001, respectively). CONCLUSION: Viability of mitochondria appears to be compromised with possible etiologic implications for VUR persisting after SCP.

Timing of Trial of Void After Radical Hysterectomy: Long-Term Urinary Outcomes at Two Academic Tertiary Care Institutions.

INTRODUCTION AND HYPOTHESIS: Many patients develop bladder symptoms after radical hysterectomy. This study compared urinary outcomes following radical hysterectomy based on trial of void (TOV) timing (pre-discharge TOV versus post-discharge TOV). METHODS: A retrospective non-inferiority study of patients at two academic tertiary referral centers who underwent radical hysterectomy between January 2010 and January 2020 was carried out. Patients were stratified according to timing of postoperative TOV: either pre-discharge or post-discharge from the hospital. Short-term urinary outcomes (including passing TOV, representation with retention) and long-term de novo urinary dysfunction (defined as irritative voiding symptoms, urgency, frequency, nocturia, stress or urgency incontinence, neurogenic bladder, and/or urinary retention) were extracted from the medical record. We hypothesized that the proportion of patients who failed pre-discharge TOV would be within a 15% non-inferiority margin of post-discharge TOV. RESULTS: A total of 198 patients underwent radical hysterectomy for cervical (118 out of 198; 59.6%), uterine (36 out of 198; 18.2%), and ovarian (29 out of 198; 14.6%) cancer. One hundred and nineteen patients (119 out of 198, 60.1%) underwent pre-discharge TOV, of whom 14 out of 119 (11.8%) failed. Of the post-discharge TOV patients (79 out of 198, 39.9%), 5 out of 79 (6.3%) failed. The proportion of patients who failed a pre-discharge TOV was within the non-inferiority margin (5.4% difference, p = 0.23). A greater proportion of patients in the post-discharge TOV group developed long-term de novo urinary dysfunction (27.2% difference, p = 0.005). Median time to diagnosis of de novo urinary dysfunction was 0.5 years (range 0-9) in the pre-discharge TOV group versus 1.0 year (range 0-6) in the post-discharge TOV group (p > 0.05). CONCLUSIONS: In this study, pre-discharge TOV had non-inferior short-term outcomes and improved long-term outcomes.

The Long-Term, Real-World Effects of Oxybutynin on Pressure Reservoir Function in the Neurogenic Bladder after Spinal Cord Injury: A Retrospective Cohort Study.

Background/Objectives: Data on the long-term effects of oxybutynin in patients with neurogenic bladder (NGB) due to spinal cord injury (SCI) are limited. This study aimed to evaluate the long-term effects of oxybutynin and the combination of oxybutynin with trospium in these patients, under real-world medical conditions. Methods: A total of 107 patients with NGB due to SCI were included. The mean treatment duration was 2.8 years ± 0.8 years. The patients were categorized into three groups: (1) low-dose oxybutynin (5-15 mg/day), (2) high-dose oxybutynin (20-40 mg/day), and (3) oxybutynin combined with trospium. The main outcomes were maximal detrusor pressure (MDP) and cystometric bladder capacity (CBC). Both were assessed at baseline and at three subsequent follow-up visits. Generalized estimation equation models were used to estimate the overall mean reduction in MDP and CBC for each group. Results: The overall adjusted mean reduction from baseline of MDP in groups 1, 2, and 3 were 2.5 (95% CI: -5.4 to 10.4; p = 0.540), 16.9 (95% CI: 4.4 to 29.4; p = 0.008), and 21.9 (95% CI: 4.1 to 39.8; p = 0.016) cmH2O, respectively. For the CBC, the mean reduction was not significant in any group at any visit, nor were the overall mean reductions. Conclusions: These findings suggest that high-dose oxybutynin and oxybutynin-trospium combination achieve a significant long-term reduction in MDP in patients with NGB after SCI. The effects were sustained across all three follow-up periods.

Permanent cutaneous vesicostomy: a pragmatic approach to safely manage lower urinary tract dysfunction in pediatric patients with chronic and life-limiting conditions and neuropathic bladders.

Introduction: Lower urinary tract dysfunction (LUTD) in cerebral palsy (CP) and other neuromuscular diseases can present with chronic retention that leads to hydronephrosis, recurrent urinary tract infections (UTI), and stone formation. Whenever the conservative treatment of LUTD fails for any reason, it is considered to be complicated LUTD, in which a surgical approach is warranted. Cutaneous vesicostomy (CV) is a simple, well-tolerated, and potentially reversible procedure that protects the upper tracts. We describe our experience using CV for this complex population. Materials and methods: Children with CP and other neuromuscular diseases admitted to pediatric long-term care units for palliative care between 2015 and 2019 were included in the study. They present multi-system involvement, polypharmacy, and Gross Motor Function Classification System levels of 4 or 5. We retrospectively studied this population's indications and results of CV. Results: Of the 52 admitted patients, 18 presented LUTD with UTI (n:18; 100%), stones (n:5; 28%), progressive hydroureteronephrosis (n:3; 17%), or stones (n:2; 11%). Conservative initial management (catheterizations, prophylaxis antibiotics) was effective in half the cases. The remaining nine were defined as complicated LUTD and underwent CV. After a mean follow-up of 11.3 months, the follow-up showed improved hydronephrosis in all nine (100%) patients. Recurrent UTIs were no longer seen in eight of nine patients, although three patients required bladder irrigations; bladder stones did not recur after CV; the kidney stones needed further intervention. Revision of the CV was required in two (11%) cases at 12 and 24 months postoperatively due to stoma stenosis. Conclusion: CV is a relatively simple and effective procedure representing a pragmatic solution for managing complicated LUTD in complex long-term institutionalized pediatric palliative care patients with neuropathic bladders.

Results of a defined surgical protocol for treating pediatric neurogenic bladder incontinence in a single institution.

INTRODUCTION: Incontinent pediatric neurogenic bladder (NB) patients face social ostracization and potential renal deterioration. Reconstructive surgery, after maximal medical therapy, requires a difficult decision-making process. Current literature for NB surgeries is difficult to interpret given definitions of dryness, use of augmentation cystoplasty (AC) and the lack of renal preservation. This study assesses the results of a defined surgical protocol to treat incontinent NB patients, using a new composite outcome measure, which includes upper tracts status and a definition of dryness. MATERIALS AND METHODS: This is a retrospective cohort study assessing 33 consecutive incontinent NB patients (Spina bifida 31, Sacral agenesis- 2) who underwent one of 2 procedures between 2008 and 2021. AC with a Mitrofanoff procedure (MP) was performed in patients who had a high detrusor leak point pressure (DLPP) and significant bladder trabeculations (N = 21, Group 1). Children with a low DLPP and non-trabeculated bladders, underwent a modified Young-Dees-Leadbetter/Mitchell procedure with a 360° autologous rectus fascial sling (BOP) with concomitant AC and MP (N-12, Group 2). Post-operative success was defined using a composite grading of success assessing dryness, upper tract stability and medication use. RESULTS: The mean age at surgery was 11.6 years (SD = 6 years), with 21 in Group 1 and 12 in Group 2. Mean follow-up was 3.25 years, with a minimum 24-month follow-up period. Success rate was 90% in Group 1 and 66% in Group 2. No patient had upper tract deterioration following surgery. Redo-surgical intervention, was required in 38% of Group 1 and 50% of Group 2 patients. These include 3 bladder neck injections in Group 1 and 2 bladder neck closure in Group 2, with a final success rate to 95 % in Group 1 and 83 % in Group 2. DISCUSSION: Achieving dryness and preserving upper tracts is a challenge in incontinent NB patients. Dryness rates achieved in this study is comparable, given complications and redo-surgery. Primary bladder neck closure is a radical intervention, but Group 2 patients, may benefit from an upfront discussion of the pros and cons of a bladder neck closure primarily or as a secondary procedure. CONCLUSIONS: Isolated AC obtains acceptable results for a selected subset of incontinent NB patients with significant bladder trabeculation. For those requiring a BOP, the success rate is relatively lower with the higher rate of potential complications and need for redo-surgery.

Recurrent tethered cord: outcome and follow-up of 20 de-thetering for symptomatic spina bifida: choort study.

OBJECTIVE: The objective of this study was to evaluate the prevalence of tethered cord among patients in the postoperative period of open and occult spina bifida. To identify warning signs for its early diagnosis, as well as outcomes after the new surgical approach. METHODS: Retrospective study of patients followed at the Pediatric Neurosurgery Department of the Federal University of São Paulo with spinal dysraphism. Signs and symptoms indicating reoperation were collected, and postoperative results were classified as improved, unchanged, or worsened. RESULTS: 222 medical records of patients diagnosed with spinal dysraphism were evaluated. Symptomatic Tethered Cord Syndrome (STCS) was identified in 30 patients (13.51%), with clinical manifestations related to orthopedic deformities (66.7%), neurological deficits (56.7%), urological dysfunction (50%), and intestinal dysfunction (40%). 20 cases underwent surgery for tethered cord release. The mean age at the time of surgery was 7.7 ± 4.9 years, with 13 female patients (65%). In the postoperative evaluation, improvement in low back pain (90.9%), urological pattern, and urinary tract infection episodes (45.4%) were particularly noteworthy. 3 patients (33.3%) with constipation showed improvement, and one worsened (11.1%). Improvement in ambulation was seen in two cases (16.7%). Low back pain was the first symptom to improve after surgery, with an average time of 1.3 months, followed by changes in the urological pattern at 15.6 months. Improvement in constipation was observed in the first month in 2 cases (66.7%), positive changes in ambulation were observed around 7 months after surgery, and only one case showed improvement in clubfoot correction. CONCLUSIONS: The prevalence of tethered cord recurrence after primary correction surgery for open or occult neural tube closure defects was similar to that found in the literature. The results were encouraging, with good postoperative evolution of patients, especially in the improvement of low back pain and urological symptoms.

Comparison of quality of life after bladder augmentation in patients previously treated with intradetrusor botulinum toxin A for neurogenic detrusor overactivity.

PURPOSE: To compare the quality of life (QoL) in the same patients first treated with botulinum toxin A (BTA) injections for neurogenic detrusor overactivity (NDO) and then with bladder augmentation (BA). METHOD: Retrospective study of patients who had BA after BTA treatment between January 2012 and December 2022. Qualiveen Short Form questionnaires and a 7-level Likert/PGI-I scale to answer the question "How would you describe your quality of life after surgery compared to when you felt your best with BTA injections?" were collated and analyzed. RESULTS: Fifty-two BAs for neurogenic bladder (NDO or low compliance) were performed in patients with a median age of 43years [33; 52] previously treated with BTA. After a median follow-up of 33.5 [13.8; 54.3] months, the median Qualiveen-SF global score after BA was significantly higher than that obtained at best BTA efficacy (1.63 [1; 2.63] vs. 2.63 [1.88; 3], P=0.012), as were the scores for the fear, constraints/restrictions and limitations/inconvenience domains. The median PGI-I score was +3 [2; 3] (truly better QoL) and 85.4% of patients reported a QoL after BA superior to the best QoL under BTA. CONCLUSION: BA provides a greater range of QoL improvement than BTA injection for patients who have experienced both treatments. Long-lasting effects and absence of need to perform iterative retreatment were the main reasons.

Different Neurogenic Bladders in Patients with Cervical and Thoracic Myelopathy: Direct Comparison from a Prospective Case Series.

Background/Objectives: This study aimed to identify the unique characteristics of neurogenic bladders and associated symptoms in patients with cervical or thoracic myelopathy using clinical surveys and urodynamic studies (UDSs). Methods: Patients with degenerative cervical (DCM) or thoracic (DTM) myelopathy and lower urinary tract symptoms (LUTSs) scheduled for decompressive surgery were prospectively enrolled. A UDS was performed one day preceding surgery to evaluate the preoperative urological function. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) and the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire before surgery and one year postoperatively. Results: Sixty-two patients (DCM: 50, DTM: 12) with a mean age of 63.2 years (men: 30, women: 32) were enrolled. The UDS revealed that 5 (8.1%) patients, all with DCM, exhibited completely normal UDS results, and the remaining 57 had at least one abnormal finding. Based on the International Continence Society classification, an underactive bladder was significantly more common in patients with DTM compared to patients with DCM (75.0% vs. 18.0%, p < 0.001). The results of the questionnaire showed that the voiding symptom IPSS were significantly worse, preoperatively, in patients with DTM (5.0 ± 4.4 [DCM] vs. 8.7 ± 4.5 [DTM]; p = 0.013). One year postoperatively, the IPSS grade of 24.0% of patients with DCM improved, whereas only one (8.3%) patient with DTM showed improvement. Conclusions: Patients with DTM reported worse voiding symptoms and exhibited more underactive bladders on UDS than patients with DCM before decompression. One year postoperatively, more patients with DCM showed subjective improvements in urinary function than those with DTM.

A functional vesicostomy for six decades: A case report.

Vesicostomy is a temporary solution for patients with bladder outlet challenger who are not eligible for catheterization. A 73 year-old man who has successfully managed his bladder using a vesicostomy for 59 years. Complications of prolapse and dermatitis led to vesicostomy closure and cystostomy placement at age 73. Vesicostomy can be safely used to preserve bladder and upper urinary tract health for a lifetime.

An adolescent male with persistent urinary symptoms.

An 11-year-old male child who presented with increased frequency of urination, thirst and feeling of incomplete void was initially diagnosed with diabetes mellitus (DM) based on elevated blood sugar. Polyuria and polydipsia were confirmed even after normalisation of blood sugar. A standardised water deprivation test showed presence of central diabetes insipidus (DI) and patient was started on desmopressin. Presence of DM and DI led to suspicion of DIDMOAD/Wolfram syndrome and ophthalmic examination confirmed bilateral optic atrophy. Despite treatment for DM and DI the urinary complaints persisted, and ultrasound showed persistent bilateral hydronephroureterosis. Bladder workup including voiding cystourethrography (VCUG) and urodynamic study reported thickened trabeculated bladder wall along with overactivity, poor compliance and high bladder pressure. Bladder dysfunction has been documented to be associated with Wolfram syndrome and often may lead to chronic kidney disease which can be prevented by early diagnosis and appropriate management. The case highlights the need for comprehensive evaluation of children with urinary symptoms.

OnabotulinumtoxinA is now an important tool for managing pediatric neurogenic lower urinary tract dysfunction.

Initial urologic management of pediatric neurogenic lower urinary tract dysfunction (NLUTD) includes clean intermittent catheterization (CIC) regimen and use of anticholinergic or beta3 agonist medications. Historically, NLUTD that did not respond to these initial management strategies received open surgical procedures such as augmentation cystoplasty (AC) to increase bladder capacity and create a lower-pressure reservoir. Since its first reported use in 2002, intradetrusor onabotulinumtoxinA (BTX-A) injections has developed an emerging role in management of pediatric NLUTD, culminating in its recent FDA-approval in 2021. In this review, the current evidence regarding the safety, tolerability, and efficacy of BTX-A use in pediatric NLUTD will be summarized. Additionally, we will attempt to define the current role of BTX-A in the management of patients with NLUTD, discuss limitations to the current body of literature, and suggest future avenues of study.

Exploring the DNA Methylation Profile of Genes Associated with Bladder Cancer in Bladder Tissue of Patients with Neurogenic Lower Urinary Tract Dysfunction.

DNA methylation is an epigenetic process that commonly occurs in genes' promoters and results in the transcriptional silencing of genes. DNA methylation is a frequent event in bladder cancer, participating in tumor initiation and progression. Bladder cancer is a major health issue in patients suffering from neurogenic lower urinary tract dysfunction (NLUTD), although the pathogenetic mechanisms of the disease remain unclear. In this population, bladder cancer is characterized by aggressive histopathology, advanced stage during diagnosis, and high mortality rates. To assess the DNA methylation profiles of five genes' promoters previously known to be associated with bladder cancer in bladder tissue of NLUTD patients, we conducted a prospective study recruiting NLUTD patients from the neuro-urology unit of a public teaching hospital. Cystoscopy combined with biopsy for bladder cancer screening was performed in all patients following written informed consent being obtained. Quantitative methylation-specific PCR was used to determine the methylation status of RASSF1, RARß, DAPK, hTERT, and APC genes' promoters in bladder tissue samples. Twenty-four patients suffering from mixed NLUTD etiology for a median duration of 10 (IQR: 12) years were recruited in this study. DNA hypermethylation was detected in at least one gene of the panel in all tissue samples. RAR-ß was hypermethylated in 91.7% samples, RASSF and DAPK were hypermethylated in 83.3% samples, APC 37.5% samples, and TERT in none of the tissue samples. In 45.8% of the samples, three genes of the panel were hypermethylated, in 29.2% four genes were hypermethylated, and in 16.7% and in 8.3% of the samples, two and one gene were hypermethylated, respectively. The number of hypermethylated genes of the panel was significantly associated with recurrent UTIs (p = 0.0048). No other significant association was found between DNA hypermethylation or the number of hypermethylated genes and the clinical characteristics of the patients. Histopathological findings were normal in 8.3% of patients, while chronic inflammation was found in 83.3% of patients and squamous cell metaplasia in 16.7% of patients. In this study, we observed high rates of DNA hypermethylation of genes associated with bladder cancer in NLUTD patients, suggesting an epigenetic field effect and possible risk of bladder cancer development. Recurrent UTIs seem to be associated with increased DNA hypermethylation. Further research is needed to evaluate the impact of recurrent UTIs and chronic inflammation in DNA hypermethylation and bladder cancer etiopathogenesis in NLUTD patients.

[Incidence of urinary tract infection after urodynamics among patients with neurogenic bladder]. / Incidence des infections urinaires post-cystomanométrie chez les patients présentant une vessie neurogène ­ évaluation des pratiques.

OBJECTIVE: The indication for prophylactic antibiotic therapy during cystomanometry to prevent urinary tract infection (UTI) has long been recommended. However, limited data support this approach. Our study aims to evaluate the incidence of UTIs following cystomanometry without prophylactic antibiotics in patients with neurogenic bladder. MATERIALS AND METHODS: This prospective, monocentric study was conducted from February 2023 to March 2023 at a specialized neuro-urology center, including all consecutive patients with lower urinary tract disorders of neurogenic origin referred for cystomanometry. The occurrence of UTIs following cystomanometry was assessed via telephone follow-up on day 14. RESULTS: A total of 100 patients were included, with a median age of 51years, with neurogenic bladder predominantly attributed to spinal cord injury (69/100). Ultimately, 11 patients reported UTIs within 14days post-cystomanometry, with only one being febrile, and none requiring hospitalization. No specific risk factors could be identified. CONCLUSION: According to our study, the incidence of UTIs following cystomanometry without prophylactic antibiotic therapy is 11%, which is equivalent to the incidence with antibiotic prophylaxis. These preliminary results support the lack of benefit of peri-cystomanometry antibiotic therapy.

Emphysematous pyelonephritis and emphysematous cystitis in a patient with neurogenic bladder: A case report.

Emphysematous pyelonephritis and cystitis, rare and potentially life-threatening infections marked by gas accumulation in the urinary tract, are described in a 32-year-old male with a history of myelomeningocele and a neurogenic bladder managed by a Benchekroune valve. Clinical and radiological findings confirmed emphysematous pyelonephritis and cystitis. A conservative approach, including urinary drainage and four-week antibiotic treatment (ceftriaxone and metronidazole), led to rapid clinical improvement. This case underscores the successful management of emphysematous infections in a neurogenic bladder patient, emphasizing the effectiveness of conservative treatment.

Hinman Syndrome: A Rare Entity With Neurogenic Bladder-Like Symptoms.

Hinman syndrome, as is the case with many other rare conditions, is a disease very commonly under-considered or missed in the diagnosis of patients with the presenting symptoms. Clinical and radiographic manifestations of the condition are easily confused with neurogenic bladder without proper history collection and neurological examination. Patients typically present with symptoms including enuresis, urinary retention, reoccurring urinary tract infections, and encopresis. Imaging often shows hydroureteronephrosis and marked bladder wall thickening. While these signs are characteristic of neurogenic bladder, routine neurologic examinations and MRIs of patients with Hinman syndrome often show normal results, and their condition is currently thought to be an acquired behavioral and psychological disorder, often associated with abnormal family dynamics. We present the case of a 14-year-old boy, who presented to the emergency department with nausea, bilateral flank pain, and urinary retention. The patient had an over seven-year history of recurrent urinary tract infections (UTI) and intermittent encopresis and followed up with different providers. Due to the patient's extensive history and the failure of previous treatments, he was evaluated for causes of neurogenic bladder, but the MRI of the lumbar spine was normal. Fluoroscopic voiding cystourethrogram (VCUG) was ordered and demonstrated abnormal and trabeculated contour of the urinary bladder with bilateral vesicoureteral reflux consistent with the diagnosis of Hinman syndrome.

Purely robotic ileocystoplasty in children: why not? First case in Spain. / Ampliación vesical pediátrica mediante abordaje robótico puro: ¿por qué no? Primer caso en España.

INTRODUCTION: We present the first case of pediatric ileocystoplasty using a purely robotic approach in Spain. CASE REPORT: 12-year-old male with neurogenic bladder of low capacity and high pressures. After failure of conservative treatment, bladder augmentation with ileum patch was decided upon. Surgery was carried out using a purely robotic approach with 4 robotic and 2 accessory ports. Surgery duration was 380 minutes in total, without intraoperative complications. He was discharged 2 weeks after cystographic control. During 32-months follow-up, he has remained continent. DISCUSSION: The minimal invasion, surgical precision and ergonomics made the robotic approach an optimal option for complex surgical techniques. Given the little availability of the robot and the low pediatric volume, its standardization is a challenge. Our accumulated experience is consistent with the current literature and shows promising surgical and esthetic results. We hope this case report will contribute to the divulgation and progressive introduction of robotic surgery in our daily lives.

INTRODUCCION: Presentamos el primer caso de abordaje robótico pediátrico puro en España. CASO CLINICO: Varón de 12 años con vejiga neurógena de escasa capacidad y altas presiones sin respuesta al tratamiento conservador, abogando por una ileocistoplastia de aumento. Se lleva a cabo un abordaje robótico puro con 4 puertos robóticos y 2 accesorios, de 380 minutos de duración total sin complicaciones intraoperatorias. Es dado de alta a las 2 semanas previo control cistográfico. Tras 32 meses de seguimiento continúa continente. COMENTARIOS: La mínima invasión, mayor precisión y ergonomía del abordaje robótico, hacen de éste una opción óptima para técnicas quirúrgicas complejas. Dada la difícil disponibilidad del robot y el escaso volumen pediátrico, resulta un reto su normalización en este campo. Nuestra experiencia coincide con la literatura, mostrando resultados quirúrgicos y estéticos prometedores. Esperamos este reporte contribuya a la difusión e introducción progresiva de la cirugía robótica en nuestra rutina.

Bladder height to width ratio as a surrogate marker for non-physiological storage pressures in children with spinal dysraphism.

INTRODUCTION: Spinal dysraphism is the most frequent cause of neurogenic bladder. Urodynamic study (UDS) is an important component of the follow-up of a child with neurogenic bladder. However, it suffers from a lack of widespread availability and is further hampered by technical difficulties and difficulty in its interpretation in children. A neurogenic bladder often appears vertically elongated; only limited and sparse literature is available regarding objectively defining the bladder shape and the urodynamic parameters in the cohort. OBJECTIVES: This study aimed to investigate the usefulness of the bladder's height-to-width ratio (HWR) on cystogram as a screening tool for identifying "non-physiological" bladder pressures in children with spinal dysraphism. A prospective study was undertaken to evaluate children operated for spinal dysraphism. Cystogram, ultrasonography and UDS evaluation were performed. HWR was calculated by the ratio of the maximum height to the maximum bladder width at maximum cystometric capacity (MCC), where MCC was calculated using standard Koff's formula, given by (age in years + 2) *30 ml in children more than one year and weight *7 ml for infants. The children were categorised into groups based on maximum detrusor pressure (MDP) into two groups (MDP ≥ 30 cmH2O and MDP < 30 cmH2O). A receiver-operative characteristic curve was constructed to analyse the sensitivity and specificity of HWR in predicting the MDP. RESULTS: A total of 53 children, operated for spinal dysraphism, met the study criteria during the study period, from March 2021 to September 2022. The median age of children was 4 years (IQR-3-5.5 years). The HWR ratio was compared between the two groups and was significantly higher for the non-physiological pressure bladders than for physiological pressure bladders (mean of 1.55 vs 1.26, p = 0.001). On evaluating the sensitivity and specificity of HWR for discerning children with non-physiological bladder pressures were 87.5% and 48.28%, respectively. The area under the curve (AUC) was 0.781, with a cut-off value of 1.3. DISCUSSION: We attempted to evaluate the HWR based on bladder shape objectively. We demonstrated a moderate correlation between the bladder shape and the bladder pressures. An HWR of 1.3 or higher could be significant for identifying a non-physiological bladder storage pressure. CONCLUSION: The height to width ratio of the bladder on cystogram is a useful tool as a surrogate marker for non-physiological storage pressures in bladders of children with spinal dysraphism.

[Short-term functional outcomes of laparoscopic robotic-assisted cystectomy (RAC) with ileal conduit urinary diversion (ICUD) for lower urinary tract dysfunction (LUTD): A single-center retrospective study]. / Résultats fonctionnels à court terme de la cystectomie avec dérivation urinaire non continente par laparoscopie robot assistée dans le cadre de troubles du bas appareil urinaire : une étude rétrospective monocentrique.

OBJECTIVE: To assess the short-term functional outcomes and morbidity of robotic-assisted cystectomy (RAC) and intracorporeal urinary diversion (ICUD) in patients with lower urinary tract dysfunction (LUTD). METHODS: All consecutive patients who underwent RAC+ICUD for LUTD in a tertiary hospital center, between July 2018 and May 2021 were retrospectively included. Medical records were systematically reviewed and patient, perioperative and postoperative data were collected. A good short-term functional outcome was defined by the combination of a satisfying urostomy equipment (absence of urine leakage and easy appliance of the urostomy bag), the absence of pelvicaliceal system dilatation on sonography, and the absence of renal function decrease at the 2months post-operative consultation. Intraoperative parameters and post-operative complications were collected to assess morbidity. RESULTS: Thirty-five patients were included. Eight (22.8%) patients needed intraoperative conversion to laparotomy. Twenty-five patients (92,5%) met criteria for a good functional outcome 2months post-operatively. The median operative time was 346min (86.5-407.5). The median blood loss was 100mL (100-290) and 5 patients (18.5%) required blood transfusion. The median times to return of bowel function was 3 days (2-4) and the median length of hospital stay was 10 days (10-18). Peri-operative complications were reported in 16 patients (59.2%): 6 (22.2%) minor complications Clavien ≤ II and 10 (37%) major complications Clavien ≥ III. There was no significative decrease of the renal function (mean preoperative creatininemia of 61.2µmol/L (50.5-74.5) vs 64.5µmol/L (47-85.25) postoperatively) CONCLUSION: RAC+ICUD in LUTD can provide good short-term functional outcomes while limiting blood transfusion, time to return of bowel function and the length of hospital stay. These results should be confirmed by larger prospective study.

An individual participant meta-analysis of mirabegron in multiple sclerosis and spinal cord injury.

INTRODUCTION: Our objective was to conduct an individual patient data meta-analysis (IPDMA) of the two published randomized placebo-controlled trials of mirabegron in people with neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) or multiple sclerosis (MS). METHODS: We identified two randomized, placebo-controlled trials. We extracted individual patient data from the trials and evaluated two primary outcomes: change in maximum cystometric capacity and change in the patient perception of bladder condition (PPBC). We also evaluated several secondary outcomes related to urodynamic function and quality of life. We conducted three exploratory analyses to test hypotheses based on our clinical experiences with mirabegron in NLUTD. Analysis of covariance with adjustment for baseline values was used for the statistical analysis. RESULTS: Our IPDMA included 98 patients from the two trials. The results showed that mirabegron was associated with a significant improvement in maximum cystometric capacity (+41 mL, p = 0.04) and in the PPBC (-0.8, p < 0.01) compared to placebo. Secondary outcomes including peak neurogenic detrusor overactivity pressure (-20 cm H2O, p < 0.01), incontinence-QOL score (+12, p < 0.01), and 24 h pad weights (-79 g, p = 0.04) also improved significantly compared to placebo. Exploratory analyses found similar improvements in people with MS and SCI; some outcomes improved to a greater degree among people with incomplete SCI, or SCIs that were below T7. CONCLUSIONS: Our IPDMA provides evidence supporting the use of mirabegron in patients with NLUTD due to SCI or MS. Further work evaluating differential responses in people with different SCI lesion characteristics may be warranted.

Causes and management of urinary system problems in children on long-term home invasive mechanical ventilation.

Many ventilator-dependent children have comorbid conditions including urinary tract disorders. We aimed to present a focused review of the literature describing the causes and management of urinary system problems in children with long-term home mechanical ventilation. We performed a literature search in PubMed/MEDLINE, Scopus, and Web of Science with keywords "children," "home mechanical ventilation," "urinary system," "urinary tract," "neurogenic bladder," "clean intermittent catheterization," "urinary tract infection," "urolithiasis," and "acute kidney injury." We included original articles, reviews, guidelines, and case reports published in English. Ventilator-dependent children may have neurogenic bladder/bowel dysfunction which renders them prone to urinary tract infection, high bladder pressure, vesicoureteral reflux, hydronephrosis, and renal dysfunction. These children require bladder catheterization, medications affecting parasympathetic/sympathetic nervous systems, or surgical procedures to prevent urinary infections, and to maintain continence and renal functions. However, bladder catheterization or surgical procedures like augmentation cystoplasty may also be complicated with urinary infections, urolithiasis, or urethral strictures. Urolithiasis frequency is also increased due to immobilization-related hypercalciuria, hypocitraturia caused by antiepileptic drugs, urinary stasis, and urinary infections. On the other hand, mechanical ventilation can impair renal function by reduction of cardiac output, redistribution of intrarenal blood flow and stimulation of sympathetic and hormonal pathways. Children requiring long-term invasive home mechanical ventilation may have other comorbid conditions, including urinary system diseases, which become manifest as these patients are being kept alive due to the advances in ventilation strategies. These children must be carefully observed for urological complications and managed accordingly to prevent kidney injury.