Bladder dysfunction in human T cell lymphotropic virus infection: A prospective cohort study.

BACKGROUND: While bladder dysfunction is observed in the majority of patients with human T cell lymphotropic virus type 1 (HTLV-1)-associated myelopathy (HAM), it is also observed in patients who do not fulfill all diagnostic criteria for HAM. These patients are classified as having possible or probable HAM/TSP. However, it remains unclear whether the severity and progression of bladder dysfunction occurs similarly between these two groups. OBJECTIVE: Compare the severity and evolution of bladder dysfunction in HTLV-1-infected patients with possible and definite HAM/TSP. METHODS: The present prospective cohort study followed 90 HTLV-1 patients with possible HAM/TSP and 84 with definite HAM/TSP between April 2011 and February 2019. Bladder dysfunction was evaluated by bladder diary, overactive bladder symptoms scores (OABSS) and urodynamic studies. Bladder dysfunction progression was defined as the need for clean self-intermittent catheterization (CIC). RESULTS: At baseline, nocturia, urgency and OABSS scores were worse in definite compared to possible HAM/TSP patients. The main urodynamic finding was detrusor overactivity, present in 77.8% of the patients with definite HAM/TSP versus 58.7% of those with possible HAM/TSP (P = 0.05). Upon study conclusion, the cumulative frequency of patients requiring CIC increased in both groups, from 2 to 6 in possible HAM/TSP and from 28 to 44 in definite HAM/TSP patients. The estimated time to need for CIC was 6.7 years (95%CI 6.5-7.0) in the possible HAM/TSP group compared to 5.5 years (95%CI 4.8-6.1) in the definite HAM/TSP group. CONCLUSIONS: Although both groups showed similarities in bladder dysfunction and tended to progress to requiring CIC over time, patients with possible HAM/TSP presented less severe manifestations at baseline and progressed more slowly than those with definite HAM/TSP.

Functional Outcome and Complications following Ileal Neobladder Reconstruction in Male Patients without Tumor Recurrence. More than 35 Years of Experience from a Single Center.

PURPOSE: There is a lack of data on true long-term functional outcome of orthotopic bladder substitution. The primary study objective was to report our 35-year clinical experience. MATERIALS AND METHODS: Since October 1985, 259 male patients from a large single center radical cystectomy series with complete followup of more than 60 months (median 121, range 60-267) without recurrence, irradiation or undiversion that might have affected the functional outcome, were included. RESULTS: Median age at radical cystectomy and at survey was 63 (range 23-81) and 75 (range 43-92) years, respectively. Overall 87% of patients voided spontaneously and residual-free. This rate decreased with increasing age at the time of surgery (less than 50 years old 94%, 70 years old or older 82%). Overall day/nighttime continence rates were 90%/82%. These rates decreased with increasing age at the time of surgery from 100%/88% to 87%/80%. The overall pad-free rate was 71%/47%. Bicarbonate use decreased from 51% (5 years) to 19% (25 years). Patients with a followup of more than 20 years had the lowest rate of residual urine and clean intermittent catheterization (0.0%) as well as use of more than 1 pad at daytime/nighttime (6.3%/12.5%) and mucus obstruction (0.0%). Serum creatinine showed only the age related increase. The surgical complication rate was 27% and correlated inversely with functional results (chi-squared 11.227, p <0.005), even when the younger age at the time of surgery (younger than 60 years) was related to higher rates of surgical complications (chi-squared 6.80, p <0.05). CONCLUSIONS: The ileal neobladder represents an excellent long-term option for urinary diversion with an acceptable complication rate.

Botulinum Toxin Type A Therapy: Intravesical Injection or Electromotive Drug Administration.

OBJECTIVES: To compare the outcomes of intravesical injection of botulinum toxin A (BoNTA) with intravesical electromotive drug administration (EMDA) of BoNTA on urinary incontinence secondary to neuropathic detrusor overactivity (NDO) in children with myelomeningocele (MMC). MATERIALS AND METHODS: A total of 26 children with MMC (11 boys, 15 girls) who had urinary incontinence secondary to NDO were retrospectively enrolled in the study. Patients in EMDA group (n = 14), using an electrode-catheter, 10 IU/kg of BoNTA were inserted into the bladder for EMDA without anesthesia and on an outpatient basis. The EMDA equipment was connected to the electrode of indwelling catheter and 2 dispersive electrodes, a pulsed current generator delivered 10-20 mA for 20 minutes. Patients in injection group (n = 12) were received interavesical injection of 10 IU/kg of BoNTA via rigid cystoscope on an inpatient basis. All patients had been evaluated by a voiding diary, urodynamic study, renal, and bladder ultrasounds before, 6 months and 1 year after the treatment. RESULTS: Six months after the treatment, 12 of 14 (85.7 %) and 8 of 12 (66.6%) patients in EMDA and injection groups respectively became completely dry between 2 consecutive clean intermittent catheterizations, which maintained in 11 of 14 (78.5%) of patients in EMDA group compared to 6 of 12 (50%) of patients in injection group, 1 year after the treatment. CONCLUSION: Patients in both groups improved after the treatment; however improvement in EMDA group was more prominent with better sustained effects. BoNTA/EMDA is a feasible, reproducible, cost benefit, and pain free method as an outpatient basis and no need for anesthesia.

Change in urodynamic pattern and incidence of urinary tract infection in patients with traumatic spinal cord injury practicing clean self-intermittent catheterization.

Objective: To observe changes in cystometric parameters in individuals with spinal cord injury (SCI) with neurogenic bladder practicing clean intermittent self-catheterization (CIC) and incidence of urinary tract infection (UTI) in such patients.Design: Prospective, observational study.Setting: Tertiary Urban Rehabilitation Hospital.Participants: Persons with neurogenic bladder caused by traumatic SCI and practicing CIC.Interventions: Clinical evaluation, complete urine analysis, urine culture and sensitivity, ultrasonography of the abdomen and urodynamic study were evaluated at baseline and at follow-up (6 months to 1 year).Outcome Measures: Detrusor pattern, cystometric capacity, detrusor compliance, detrusor leak point pressure, residual urine, incidence of UTI.Results: Thirty-one participants were included in the study. The baseline cystometric study showed that 15 had overactive detrusor and 16 had detrusor areflexia. The mean cystometric capacity decreased significantly between baseline and follow-up in both the groups but remained within the normal threshold limit, decline being more marked in the overactive detrusor group, who also had more marked decrease in compliance. Mean detrusor leak point pressure was below 40 cm H2O in all participants in both groups at baseline and follow-up. Mean residual urine improved at follow-up in both groups. Incidence of UTI was 2.29 episodes per patient per year, and more frequent in the overactive detrusor group. Escherichia coli was the causative agent in 45%.Conclusion: The cystometric capacity and compliance decreased significantly though patients were doing regular CIC and managed on antimuscarinics for detrusor overactivity (DO). UTI is more common in individuals with SCI with DO and E. coli is the most common cause of UTI.

Adherence with bladder irrigation following augmentation.

BACKGROUND: Patients with bladder augmentation (BA) are routinely counseled to irrigate their bladders daily. However, reports of adherence with this regimen are lacking. OBJECTIVE: To evaluate adherence to a bladder irrigation protocol and identify risk factors associated with adherence among adults with spina bifida (SB) and BA. STUDY DESIGN: Adults with SB after BA followed in a multidisciplinary clinic were identified (2017-2019). All patients or caregivers were taught the importance of and the technique for the bladder irrigation protocol prior to and after BA. Patient demographics (age, gender, ambulatory status, and presence of a caregiver in clinics) and surgical details (type of BA, age at surgery, length of follow-up, presence of a catheterizable channel, position of stoma, bladder neck surgery, presence of Malone antegrade colonic enema or ventriculo-peritoneal shunt, and number of stone surgeries) were obtained from the medical record. Patients reported other variables in a standardized clinic questionnaire. Answers were confirmed by health care providers. The variables included who performs clean intermittent catheterization (CIC), size of catheter, frequency of CIC, use of overnight catheterization, difficulties with CIC, number of UTIs, and continence per urethra and per catheterizable channel. Adherence to bladder irrigation was also assessed in the questionnaire. ?Strict adherence' was defined as bladder irrigation performed ≥6 times/week with ≥120 mL of saline. For statistical analysis, a more lenient definition of ?higher adherence' was used: bladder irrigation ≥2 times/week with at least 60 mL. ?Lower adherence' was defined as ≤1 time/week or with less than 60 mL. Factors associated with ?higher adherence' were assessed with non-parametric tests (Bonferroni-corrected p-value: 0.002). RESULTS: Adherence was assessed in 87 eligible patients (60.9% females; mean age of 28.8 ± 8.2 years). No patient (0.0%) reported ?strict adherence', and 62 and 25 patients (71.3% and 28.7%) reported ?higher' and ?lower' adherence' to bladder irrigation, respectively. Nine patients (10.3%) in the ?lower adherence' group did not irrigate at all. No variables were statistically significant on univariate analysis, including previous bladder stone surgery or having a channel (p ≥ 0.01). On exploratory analysis, higher adherence was only associated with self-catheterizations versus those performed by caregivers (76.7% vs 33.3%, p = 0.01). CONCLUSIONS: Adherence to a bladder irrigation protocol in adults with SB and BA is poor. A history of bladder stones requiring surgery and the presence of a catheterizable channel do not appear to affect adherence. It remains unclear why some patients are more likely than others to irrigate their bladders. Future work will focus on methods to improve adherence.

Probability of Bladder Augmentation, Diversion and Clean Intermittent Catheterization in Classic Bladder Exstrophy: A 36-Year, Multi-Institutional, Retrospective Cohort Study.

PURPOSE: We assessed the probability of bladder augmentation/diversion and clean intermittent catheterization in classic bladder exstrophy in a multi-institutional cohort. MATERIALS AND METHODS: We included children born from 1980 to 2016 with bladder exstrophy and treated across 5 centers (exclusion criteria less than 1 year followup after birth, isolated epispadias, bladder exstrophy variants etc). Outcomes were probability of bladder augmentation/diversion after bladder closure and proportion of patients performing clean intermittent catheterization at last followup. Survival analysis was used. RESULTS: Of 216 patients 63.4% were male (median followup 14.4 years). Overall 4 patients (1.9%) underwent primary diversion and 212 underwent primary closure (72.6% in first week of life). After primary closure 50.9% underwent augmentation, 4.7% diversion and 44.8% neither. By age 18 years 88.5% underwent a bladder neck procedure (synchronous augmentation 27.3%). On survival analysis the probability of bladder augmentation/diversion was 14.9% by age 5 years, 50.7% by 10 years and 70.1% by 18 years. Probability of bladder augmentation/diversion varied significantly between centers (p=0.01). Probability of bladder augmentation/diversion was 60.7% 10 years after bladder neck procedure. At last followup of the entire cohort 67.4% performed clean intermittent catheterization. Among 95 patients with intact native bladders 30.5% performed clean intermittent catheterization (channel 72.4%). Among 76 adults without a diversion 85.5% performed clean intermittent catheterization (augmented bladder 100.0% clean intermittent catheterization, native bladder 31.3%). Fifteen patients underwent diversion (continent 8, ureterosigmoidostomy 5, incontinent 2). CONCLUSIONS: On long-term followup probability of bladder augmentation/diversion increased with age, with 1 in 2 patients by age 10 years and the majority in adulthood. Probability of bladder augmentation/diversion differed among institutions. Almost a third of patients, including adults, with a closed native bladder performed clean intermittent catheterization. Considering all adults only 14% did not perform clean intermittent catheterization.

Effect of Prenatal Repair of Myelomeningocele on Urological Outcomes at School Age.

PURPOSE: We investigated longer term urological outcomes in patients enrolled in the Management of Myelomeningocele Study (MOMS). MATERIALS AND METHODS: Women who participated in the original trial were asked for consent for followup for their child at age 6 years or older in a single comprehensive study visit to a MOMS center. Participating children underwent urological and radiologic procedures to provide objective evidence of current bladder functioning. Primary urological outcome was defined as any among need for clean intermittent catheterization, vesicostomy, urethral dilatation or augmentation cystoplasty. RESULTS: A total of 156 children were evaluated, with a mean age of 7.4 years. Overall 62% vs 87% in the prenatal and postnatal surgery groups, respectively, were placed on clean intermittent catheterization (RR 0.71, 95% CI 0.58-0.86, p <0.001). Voiding status was significantly different between the groups (p <0.001) as 24% in the prenatal group vs 4% in the postnatal group (RR 5.8, 95% CI 1.8-18.7) were reported to be voiding volitionally. Augmentation cystoplasty, vesicostomy and urethral dilation did not differ between the 2 groups. Aside from a larger post-void residual urodynamic catheterization volume, there were no other statistical differences in videourodynamic data or findings on renal/bladder ultrasound. CONCLUSIONS: Prenatal closure of myelomeningocele resulted in less reported clean intermittent catheterization at school age and the mechanism for this is unclear. Although most children are in diapers or on clean intermittent catheterization, parental reports showed children who underwent prenatal closure may be more likely to void volitionally than the postnatal group. Despite these findings, urological outcomes alone should not be the sole impetus to perform in utero closure in children with spina bifida.

Duration of Catheterization After Retropubic Midurethral Sling.

OBJECTIVE: The objective of this study was to describe the expected duration of self-catheterization in women discharged home performing intermittent self-catheterization (ISC) after retropubic midurethral sling (RMUS). METHODS: We conducted a retrospective cohort analysis of women who underwent an isolated RMUS by 3 providers between 2009 and 2014 at a single institution. A 300 mL retrograde-fill voiding trial (VT) was performed before discharge. Those who failed their VT (postvoid residual [PVR] >1/3 total bladder volume [TBV]) and could perform ISC are included in this analysis. Subjects were categorized into mild retention (PVR >1/3 and <2/3 the TBV) or severe retention (PVR ≥2/3 the TBV). Patients could discontinue ISC after achieving 2 consecutive PVR volumes of less than 75 mL. Duration of catheterization was determined in days. RESULTS: Two hundred women underwent isolated RMUS. Forty-seven (23.5%) failed their VT of whom 39 (included in this analysis) could perform ISC and had complete data. Subjects had a mean ± SD age of 49 ± 11 years. The median (interquartile range) PVR volume postoperatively was 250 (190-325) mL. Median (interquartile range) days of postoperative ISC for the cohort was 2 (1-4); 37.5% were catheterized for 1 day, 32.5% for 2 days, 2.5% for 3 days, and 27.5% for more than 3 days. Seventeen (39.5%) met the criteria for mild retention and 26 (60.5%) met the criteria for severe retention. There was no difference in the postoperative catheterization days between the mild and severe retention groups (P = 0.16). CONCLUSIONS: Urinary retention will resolve within 2 days in the majority (73%) of women discharged performing ISC after RMUS.

Intradetrusor Injections of Botulinum Toxin Type A in Children With Spina Bifida: A Multicenter Study.

OBJECTIVE: To assess the effectiveness of intradetrusor injections of botulinum toxin type A (IDBTX-A) in children with spina bifida. METHODS: All patients aged less than 16 years old who underwent IDBTX-A between 2002 and 2016 at 6 institutions were included in a retrospective study. Our primary endpoint was the success rate of IDBTX-A defined as both clinical improvement (no incontinence episodes between clean intermittent catheterizations [CICs], absence of urgency, and less than 8 CICs per day) and urodynamic improvement (resolution of detrusor overactivity and normal bladder compliance for age) lasting ≥12 weeks. Predictive factors of success were assessed through univariate analysis. RESULTS: Fifty-three patients with a mean age of 8.5 years were included. All patients were under CIC and 88.7% had received anticholinergics with either poor efficacy or bothersome adverse events. The global success rate of the first injection (clinical and urodynamic) was 30%. Patients with closed spinal dysraphism had a significantly better success rate than patients with myelomeningocele (P = .002). The clinical success rate was 66% and was significantly associated with maximum urethral closure pressure (34 cm H2O vs 54.4 cm H2O, P = .02). The urodynamic success rate was 34%. Maximum cystometric capacity (P <.0001) and compliance (P = .01) significantly improved after the first IDBTX-A and maximum detrusor pressure tended to decrease (P = .09) except in the subgroup of patients with poor compliance. After a mean follow-up of 3.7 years, 23 patients (43.4%) required augmentation cystoplasty. Excluding 6 patients who were lost to follow-up, 38.3% of patients were still undergoing botulinum toxin injections at last follow-up. CONCLUSION: In this series, despite the fact that IDBTX-A enabled clinical improvement in 66% patients, urodynamic outcomes were poor resulting in a low global success rate (30%).

Clean intermittent catheterization rates after initial and subsequent treatments with onabotulinumtoxinA for non-neurogenic overactive bladder in real-world clinical settings.

OBJECTIVE: Previous randomized controlled trials have reported a 6.1-6.9% incidence of clean intermittent catheterization (CIC) following treatment with onabotulinumtoxinA in non-neurogenic overactive bladder (OAB) patients who were inadequately managed by ≥1 anticholinergic. A multi-center retrospective chart review assessed the real-world rate of voiding dysfunction requiring catheterization. METHODS: Patients received onabotulinumtoxinA 100 U (approved dose) administered by experienced injectors between January 2013 and June 2015. Patients using CIC or an indwelling catheter for ≥24 hours for voiding dysfunction prior to onabotulinumtoxinA injections were excluded. The primary outcome was post-treatment CIC (lasting >24 hours; per individual physician's clinical judgment considering patient's voiding symptoms, post-void residual [PVR] urine volumes and patient bother). Potential baseline predictors of CIC (history of pelvic prolapse, cystocele, diabetes, PVR urine volume and age) were assessed using multivariable logistic regression. RESULTS: Overall, 299 patients received their first treatment with onabotulinumtoxinA 100 U. Mean age was 66.4 years; 98.3% were female. The incidence of CIC was 2.7% in the total study population after the first treatment with onabotulinumtoxinA. The de novo CIC rate in treatments 2 and 3 combined was similarly low (3.2%). None of the evaluated baseline characteristics were significant predictors of CIC initiation due to the low CIC incidence. CONCLUSIONS: This real-world study of non-neurogenic OAB patients treated with onabotulinumtoxinA suggests that the CIC rate is lower than the rates reported in previous studies. There were no significant correlations between baseline predictors and CIC initiation, although statistical significance may not have been reached because of the low incidence of CIC.

Telenursing Intervention for Clean Intermittent Urinary Catheterization Patients: A Pilot Study.

Telenursing is a promising strategy to make nursing care feasible in different health situations, mainly to help patients with chronic illnesses. The aim in this study was to test the feasibility (acceptability and usability) of a telenursing intervention in care delivery to patients using clean intermittent urinary catheterization. This descriptive study focused on an intervention involving urology outpatients. The telenursing intervention was implemented synchronously by audio calls and chat and asynchronously by e-mail as part of a pilot study. The contact between nurse and patient was undertaken through an active search or on spontaneous demand, in which the patient contacted the nurse when necessary. During the 5 weeks of study, 21 telenursing care sessions took place, including 13 (61.9%) on spontaneous demand and eight (38.1%) on active demand. With regard to the technological resource used, 13 telenursing sessions (61.9%) took place by telephone call and eight (30.1%) by e-mail. The pilot study demonstrated the potential of the telenursing intervention to achieve important results, and as a complement to the patients' traditional health treatment. In addition, it revealed various barriers that need to be overcome for this type of care to take place effectively.

[Importance of nerve-sparing surgical technique in the treatment of deep infiltrating endometriosis]. / Az idegkímélo mutéti technika jelentosége a mélyen infiltráló endometriosis sebészetében.

INTRODUCTION: Traditional surgeries performed in cases of deep infiltrating endometriosis lead to impaired quality of life. AIM: To summarize the postoperative outcome and to compare the rate of postoperative complications after different therapeutic approaches applied in deep infiltrating endometriosis. METHOD: The authors analized the articles published between March 31, 2004 and March 31, 2015, in the database http://www.pubmed.org using the following keywords: endometriosis, deep infiltrating, nerve sparing, surgery. RESULTS: Non-nerve sparing surgery resulted in temporary urinary dysfunction in 19.1-38.5% of patients, while it occurred in 0.61-33.3% of patients after nerve-sparing surgery. Non-nerve sparing surgical technique resulted in an average of 121 days of need for self-catheretisation. When nerve-sparing surgeries were performed the duration of self-catheterisation varied between 7 to 39.8 days. After nerve sparing surgeries, permanent bladder dysfunction was not detected in any case. CONCLUSIONS: Because of the successful treatment of the patients symptoms and the lower postoperative complication rate, nerve-sparing surgical technique leads to a significant improvement of the quality of life.

Continuous use of intermittent bladder catheterization - can social support contribute? / Continuidade do Cateterismo Vesical Intermitente: pode o suporte social contribuir? / Continuidad del cateterismo vesical intermitente - ¿El apoyo social puede contribuir?

OBJECTIVE: to investigate the factors affecting the adequate continuous use of intermittent catheterization and its relation with social support. METHOD: sectional, descriptive and correlational study involving 49 patients with neuropathic bladder caused by spinal cord injury. RESULTS: almost all (92%) participants continued the intermittent catheterization, but 46.9% made some changes in the technique. The complications (28.6% of the sample) were mainly infection and vesicolithiasis. There were high scores for social support in relation to people that were part of the patient's social support. CONCLUSION: All of them noticed great support from the family, but not from the society in general. The difficulties were related to the lack of equipment and inadequate infrastructure, leading to changes that increased urologic complications. .

OBJETIVO: investigar fatores que interferem na adequada continuidade do cateterismo intermitente e sua relação com suporte social. MÉTODO: estudo seccional, descritivo e correlacional, realizado entre 49 pacientes com bexiga neuropática, por lesão medular. RESULTADOS: quase todos (92%) deram continuidade ao cateterismo intermitente, mas 46,9% fizeram alguma modificação na técnica. As complicações (28,6% da amostra) consistiram principalmente em infecção e litíase vesical. O suporte social teve escores altos para quem compunha a rede social do paciente. CONCLUSÃO: todos percebiam ótimo suporte dos familiares, mas não da estrutura social em geral. Dificuldades foram relacionadas à falta de material e de infraestrutura adequada, induzindo modificações, favorecendo complicações urológicas. .

OBJETIVO: investigar factores que interfieren en la adecuada continuidad del cateterismo intermitente y su relación con el apoyo social. MÉTODO: estudio seccional, descriptivo y de correlación, realizado entre 49 pacientes con vejiga neurógena por lesión medular. RESULTADOS: casi todos (92%) dieron continuidad al cateterismo intermitente, sin embargo 46.9% hizo alguna modificación en la técnica. Las complicaciones (28,6% de la muestra) fueron principalmente infección y cálculos en la vejiga. El apoyo social tuvo puntajes altos para quien componía la red social del paciente. CONCLUSIÓN: todos percibían óptimo apoyo de los familiares, sin embargo no de la estructura social en general. Las dificultades fueron relacionadas a la falta de material y a la infraestructura inadecuada que induce modificaciones, favoreciendo complicaciones urológicas. .