Urine Biochemistry of a Human Fetus with Urinary Tract Obstruction - A Case Report.

INTRODUCTION: Fetal lower urinary tract obstruction (LUTO) can be mild or severe with oligohydramnios, renal dysplasia and pulmonary hypoplasia. Fetal urine biochemical markers correlate with fetal prognosis and, if favorable, surgical intervention is feasible. METHODS: We report a patient in her 18th gestational week whose fetus was diagnosed with LUTO and underwent fetal urine sampling for calcium, sodium, chloride, beta2-microglobulin and total protein of the routine LUTO panel, with the addition of creatinine, glucose, phosphate, urea, ammonia, albumin, and NGAL. RESULTS: Although the routine fetal urine biochemistry seemed to be favorably trending favorably, sodium, beta2-microglobulin, glucose, and urea did not decrease to the reference ranges, and ammonia and creatinine were lower than the reference ranges. Ultrasound demonstrated no improvement of the obstruction. CONCLUSIONS: This case highlights the need to acquire further experience with biochemical fetal urine markers in order to better manage LUTO.

Assessment of serum symmetric dimethylarginine and creatinine concentrations in cats with urethral obstruction.

OBJECTIVES: The aims of this study were to evaluate serum symmetric dimethylarginine (SDMA) and creatinine concentrations in cats with urethral obstruction pre- and post-decompression of the obstruction, and to determine if pre-decompression values were predictive of post-decompression renal function, as measured by SDMA and creatinine. METHODS: This was a prospective observational study. Twenty-five client-owned cats with urethral obstruction were hospitalized for decompression of the obstruction. Serum SDMA and creatinine were prospectively assessed at presentation, 24 h post-decompression and 5-20 days post-decompression. Urinalysis and culture were assessed at presentation and at the final follow-up. Exclusion criteria included positive urine culture, reobstruction or failure to obtain required samples. RESULTS: Mean SDMA concentration dropped by 41.8% from an initial pre-decompression concentration of 17.6 µg/dl to 10.3 µg/dl 24 h post-decompression (P <0.001). The mean creatinine value dropped by 38.4% from an initial pre-decompression concentration of 2.5 mg/dl to 1.5 mg/dl 24 h post-decompression (P <0.001). There was no association between SDMA concentration at initial presentation and SDMA concentration 5-20 days after urethral catheterization (Spearman's ρ = 0.205, P = 0.314). Creatinine concentration upon initial presentation was associated with the 5-20 day values after urethral catheterization (Spearman's ρ = 0.583, P <0.002). Twenty percent of cases were excluded due to bacterial growth on initial urine culture. SDMA and creatinine concentrations were significantly higher in these cases (median 59 µg/dl and 10.9 mg/dl, respectively) compared with those with negative cultures (median 14 µg/dl and 1.6 mg/dl [P <0.002 and P <0.001], respectively). CONCLUSIONS AND RELEVANCE: Both SDMA and creatinine decreased significantly after urethral catheterization, suggesting that renal function post-decompression cannot be predicted by the pre-decompression concentrations of these values.

Fetal lower urinary tract obstruction: a current overview of intrauterine diagnosis and treatment.

OBJECTIVE: The aim of this review article is to provide a practical and concise overview of diagnosis and management of pregnancy with fetal lower urinary tract obstruction. METHODS: Review of literature and current studies. CONCLUSION: Proper diagnosis and management of isolated fetal lower urinary tract obstruction with oligohydramnios allows appropriate implementation of intrauterine treatment in indicated cases. The treatment is a prevention of pulmonary hypoplasia and also improves renal function; this  finally contributes to the improvement of overall perinatal morbidity and mortality.

Urinary miRNA profiles discriminate between obstruction-induced bladder dysfunction and healthy controls.

Urgency, frequency and incomplete emptying are the troublesome symptoms often shared between benign prostatic obstruction-induced (BLUTD) and neurogenic (NLUTD) lower urinary tract dysfunction. Previously, using bladder biopsies, we suggested a panel of miRNA biomarkers for different functional phenotypes of the bladder. Urine is a good source of circulating miRNAs, but sex- and age-matched controls are important for urinary metabolite comparison. In two groups of healthy subjects (average age 32 and 57 years old, respectively) the total protein and RNA content was very similar between age groups, but the number of secreted extracellular vesicles (uEVs) and expression of several miRNAs were higher in the young healthy male volunteers. Timing of urine collection was not important for these parameters. We also evaluated the suitability of urinary miRNAs for non-invasive diagnosis of bladder outlet obstruction (BOO). A three urinary miRNA signature (miR-10a-5p, miR-301b-3p and miR-363-3p) could discriminate between controls and patients with LUTD (BLUTD and NLUTD). This panel of representative miRNAs can be further explored to develop a non-invasive diagnostic test for BOO. The age-related discrepancy in the urinary miRNA content observed in this study points to the importance of selecting appropriate, age-matched controls.

Therapeutic intervention for fetal lower urinary tract obstruction: Current evidence and future strategies.

In-utero vesica-amniotic shunting for fetal lower urinary obstruction (LUTO) is known to improve perinatal survival. More recently, studies including centres performing fetal cystoscopy, have suggested benefit on longer-term survival and renal outcome - within the limitations of small numbers and limited follow-up. These interventions carry significant risk, and therefore patient selection, and optimal timing, are key. The aim of this article is to explore ways of improving the accuracy of prenatal diagnosis, and of identifying risk factors for fetal and postnatal renal failure. The next step is that of using established staging and classification systems to select the patient group that may benefit from intervention, based on published outcomes. Several factors come into play when selecting the timing of intervention, especially if the aim is that of renal, and not only pulmonary, preservation. Lastly, current technologies and their shortfalls are discussed.

Partial urethral duplication in a cat.

CASE DESCRIPTION: A 3-year-old neutered male domestic shorthair cat with a history of urethral obstruction was evaluated at a veterinary referral center for acute onset of hunched posture and signs of discomfort on being handled. No evidence of urethral obstruction was found; signs initially responded to medical management, but the cat was presented to the primary care veterinarian < 48 hours after the initial examination with signs suggesting urethral obstruction. CLINICAL FINDINGS: No urinary calculi were detected radiographically. Attempted urinary catheter placement was unsuccessful, and the cat was returned to the referral center for evaluation and treatment of suspected urethral obstruction. Hematologic evaluation revealed hyperglobulinemia and leukocytosis; the cat was febrile, its prepuce was swollen, and its urinary bladder was soft but could not be manually expressed. TREATMENT AND OUTCOME: A urinary catheter was placed; urinalysis revealed hematuria, leukocyturia, and bacteriuria. Medical management included analgesic, antimicrobial, urethral antispasmodic, and IV fluid treatment. Positive-contrast cystourethrography results were equivocal for a congenital anomaly versus urethral rupture. Contrast-enhanced CT revealed a sinus communicating with the dorsal aspect of the urethra, and urethral rupture was ruled out. Partial urethral duplication was confirmed surgically; perineal urethrostomy was performed, creating an opening to the accessory urethra, and the strictured orthotopic urethra was ligated. Four weeks after surgery, the cat was doing well. CLINICAL RELEVANCE: This case highlighted the importance of advanced imaging to distinguish between urethral rupture and a congenital malformation in a cat with signs of lower urinary tract disease. This approach was pivotal to appropriate diagnosis and management and a favorable outcome for the patient.

Anterior Urethral Valve - A Commonly Misdiagnosed Entity in Adolescent Boys.

Anterior urethral valves are a rare cause of obstructed voiding in adolescent children and are often unheard by adult urologists. In this case report, we discuss the management of two adolescent patients who were referred to us with obstructive voiding symptoms with a diagnosis of neurogenic bladder and posterior urethral valves respectively but on evaluation were found to have anterior urethral valves. This article highlights the need for considering anterior urethral valve as an important differential diagnosis in children and adolescents presenting with obstructive voiding symptoms so as to avoid delay in diagnosis and management in young boys.

Adolescent Presentation of Posterior Urethral Valves.

Posterior urethral valves (PUVs) present clinically across a varied spectrum, ranging from severe obstruction with massive distension of the bladder and upper urinary tracts in the fetus, to a much more indolent course with minor secondary changes in the young or older child. Type III (diaphragm) PUVs are relatively uncommon, and are associated with difficulty in passing a transurethral catheter into the bladder as well as smooth dilation of the bladder. The following case examines the unusual experiences of both diagnosing PUVs in a teenager, and capturing visual evidence of type III valves during cystourethroscopy.

Holter Monitoring (24-Hour ECG) Parameter Dynamics in Patients with Ischemic Heart Disease and Lower Urinary Tract Symptoms Due to Benign Prostatic Hyperplasia.

INTRODUCTION: This study examined the dynamics of 24-h electrocardiogram (ECG) monitoring parameters (Holter monitoring) in patients with ischemic heart disease (IHD) before and after conservative or surgical treatment of patients with voiding and storage lower urinary tract symptoms (LTS) due to benign prostatic hyperplasia (BPH). METHODS: A total of eighty-three 57 to 81-year-old (mean age 70.4 ± 5.75 years) patients with LUTS/BPH and accompanying IHD were examined and treated at the Institute of Urology and Human Reproductive Health and Clinic of Cardiology of Sechenov University. All patients received recommended cardiac therapy at least 6 months before inclusion in the study. RESULTS: Our study demonstrated that there is correlation between voiding and storage LUTS/BPH and Holter-detected cardiac impairments in patients with IHD/BPH. These data make it possible to consider LUTS/BPH (voiding and storage) as a factor in the additional functional and psychological load on the activity of patients with ischemic heart disease. Improvement of voiding and storage LUTS due to BPH and objective parameters of urination (Qmax) in patients treated with alpha-1 adrenoceptor blocker tamsulosin correlated with improvement of 24-h ECG monitoring parameters (Holter monitoring) in 72% of patients. Improvement of 24-h ECG monitoring parameters (Holter monitoring) 1 month after transurethral resection of the prostate (TURP) in IHD/BPH patients and indications for surgical treatment was observed in 65.7%. Negative dynamics of the Holter-based ECG was not registered in patients who were operated on. CONCLUSION: Holter monitoring helps to identify groups of patients in whom urinary impairments caused by prostatic hyperplasia negatively affect the course of IHD. Restored urination (either conservatively or operatively) in patients with BPH in 72% of cases decreased the number of fits of angina, thus influencing favourably the course of IHD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03856242.

Voiding urethrocystoscopy: A new concept for benign prostatic obstruction characterization.

AIM: To assess the feasibility of voiding urethrocystoscopy (VUC) in males and describe the characteristics of dynamic movements of the prostatic lobes during micturition. MATERIAL AND METHODS: Patients scheduled for benign prostatic obstruction relief in a tertiary reference center were included in this prospective evaluation. During urethrocystoscopy with a small diameter flexible endoscope, the bladder was filled until desire to void. The patient was asked to void with endoscope in place facing the veru montanum. Movements of the prostatic lobes during micturition were characterized, video-recorded, and categorized based on the dynamics of the lateral lobes, the posterior lobe and the bladder neck. RESULTS: In all, 192 evaluations were conducted. In 161 cases (84%), the patient was able to void. Among these patients, 126 cases were stated as "closed" (coalescent), without opening of the initial part of the urethra and the bladder neck. In 38 cases, there was no opening of the lateral lobes (type 1A), and in 47 cases a partial opening of the distal parts of the lateral lobes was seen (type 1B). In 31 cases, a fixed posterior bladder neck was seen (type 2A) and in 10 cases a mobile median lobe, with a rolling ball effect, was seen (type 2B). In 25 cases, the lumen was completely open and equivocal in 10 cases. CONCLUSIONS: This study demonstrates the feasibility of VUC and describes for the first time the dynamics of prostatic lobes during micturition. This evaluation may lead to a new approach for understanding the mechanical aspects of benign prostatic obstruction. LEVEL OF EVIDENCE: 3.

Correlation between the estimated GFR and SWRD score in patients with posterior urethral valves at King Abdul-Aziz University Hospital.

OBJECTIVE: The aim was to establish the reliability of the SWRD score as a predictor of both renal and bladder outcomes in posterior urethral valves. This retrospective study included 67 patients with PUVs at King Abdul-Aziz University Hospital. The score was calculated from voiding cystourethrogram before and after the relief of obstruction, and estimated glomerular filtration rates (eGFRs) were calculated as well. RESULTS: Based on Spearman correlations, both baseline eGFRs and SWRD scores can be possible predictors of long-term renal outcomes, as a significant positive correlation between the baseline eGFRs and the last eGFRs was found (p = 0.005). A significant negative correlation was also found between the SWRD score calculated before the intervention and the last eGFRs (p = 0.02). Additionally, the baseline SWRD scores can be possible predictors of short-term bladder outcomes, as the correlation analysis showed a positive relationship between the baseline SWRD scores and the SWRD scores calculated within 2 months after the intervention (p < 0.0001). A significant decrease in SWRD scores and eGFRs was found from before to after the intervention, regardless of the type of intervention. In conclusion, the SWRD scoring system proved to be a potentially promising tool in the anticipation of the clinical outcomes of PUVs.

Outcome of posterior urethral valve in 64 children: a single center's 22-year experience.

BACKGROUND: Posterior urethral valve (PUV) is the most serious form of congenital anomalies of kidney and urinary tract (CAKUT) in boys with significant risk of progression to chronic kidney disease (CKD). We present our long-term results in children with PUV. METHODS: Retrospective chart review of 113 children with PUV followed within the years of 1996-2018 was performed. Clinical, laboratory and epidemiologic parameters were analyzed for their impact on renal outcome. RESULTS: The median age of diagnosis was 1.00 month (1.00-132.00) and the median follow-up period was 70 months (60.00-216.00). Antenatal diagnosis was present in 33 patients (51.5%) mainly with bilateral hydronephrosis and oligohydramnios. The most common postnatal presentation was recurrent urinary tract infection (UTI) in 14 cases (21.9%) and incontinence in three cases (4.7%). Vesicoureteral-reflux (VUR) was present in 31 cases (48.4%). All patients had surgery and urinary diversion was needed in 18 (28.2%). Varying stages of chronic kidney disease (CKD) developed in 23 cases (35.9%) and rise in serum creatinine was especially prominent after the 4th year of follow-up. Of 23 CKD patients, seven (10.9%) were in ESRD and on dialysis. Mortality occurred in one (1.5%) patient. Hypertension, proteinuria and high initial serum creatinine (>1.28 mg/dL) were statistically significant risk factors for CKD, as expected. Surprisingly VUR and UTI did not show such a significant impact on CKD development. Antenatal detection was with significantly less risk for CKD. CONCLUSIONS: Our results confirm that PUV has a considerable risk for CKD development. Antenatal diagnosis, management of proteinuria and hypertension may modify this progression. But already injured kidneys still have a potential risk. The need for further research to evaluate the impact of any intervention on long term renal outcome is obvious.

Predicting posterior urethral obstruction in boys with lower urinary tract symptoms using deep artificial neural network.

PURPOSE: To assess the prediction model for late-presenting posterior urethral valve (PUV) in boys with lower urinary tract symptoms (LUTS) using artificial neural network (ANN). MATERIALS AND METHODS: 408 boys aged 3-17 years (median 7.2 years) with LUTS were examined and had bladder diary, ultrasound, uroflowmetry, urine, and urine culture. Cystoscopy was recommended when peak flow rate (Qmax) was persistently ≤ 5th percentile in patients who were unresponsive to urotherapy and pharmacological treatment (oxybutynin). With four-layered backpropagating deep ANN, the probability of finding PUV was estimated using noninvasive, quantitative parameters (age, Qmax, time to Qmax, voided volume, flow time, voiding time, average flow rate). RESULTS: There were 97 patients with low Qmax and 74 were unresponsive. In 41, cystoscopy was performed and PUV was diagnosed in 37 (9.1%). In multivariate analysis, significant variables in favor of PUV were urgency (OR = 3.96, 95% CI = 1.30-12.03, p = 0.015), increased voiding frequency (OR = 3.81, 95% CI = 1.03-14.11, p = 0.045), and weak stream/intermittency (OR = 8.30, 95% CI = 2.49-27.63, p = 0.001). The ANN dataset included 87 uroflows of children with PUV and 114 uroflows classified as normal. The best performance was with two hidden layers with four neurons each. The best test accuracy was 92.7% and AUROC was 98.0%. With cutoff value of 0.8, sensitivity was 100.0%, specificity 89.7%, positive predictive value 80.0%, and negative predictive value 100.0%. CONCLUSIONS: With ANN, we accurately predicted 92.7% of late-presenting PUV using uroflow. Considering the high frequency of PUV in boys with LUTS, especially in cases of urgency, increased voiding frequency, and weak stream or intermittency, accurate prediction could lead to timely treatment.

Neonate with urinary ascites but no hydronephrosis: unusual presentation of posterior urethral valves.

Posterior urethral valves (PUV) are an important cause of paediatric obstructive uropathy. PUV are usually diagnosed by prenatal ultrasonography (US) revealing hydronephrosis and bladder distention. We describe a 17-day-old male infant with abdominal distention who had no hydronephrosis on prenatal US. Laboratory investigations showed serum creatinine of 12 mg/dL, hyperkalaemia and metabolic acidosis. Abdominal US showed large amount of ascites, normal-sized kidneys without hydronephrosis and incompletely distended bladder. Paracentesis revealed clear, yellow ascitic fluid with creatinine level of 27 mg/dL compatible with urinary ascites. Voiding cystourethrogram (VCUG) demonstrated PUV with a dilated posterior urethra, grade 5 right vesicoureteral reflux and a ruptured kidney fornix with peritoneal extravasation of contrast. Foley decompression resulted in normalisation of creatinine within 72 hours. Transurethral resection of PUV was performed, and a repeat VCUG showed recovery of forniceal rupture. This case illustrates an unusual presentation of a potentially life-threatening but treatable cause of urinary tract obstruction.

Patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients' care - a systematic review.

BACKGROUND: Even though evidence based medicine, guidelines and algorithms still represent the pillars of the management of chronic diseases (i.e: hypertension, diabetes mellitus), a patient centred approach has been recently proposed as a successful strategy, in particular to improve drug adherence. Aim of the present review is to evaluate the unmet needs in LUTS/BPH management and the possible impact of a patient centered approach in this setting. METHODS: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published from January 2000 until December 2016 was performed by combining the following MESH terms: patients centred medicine, patient centered care, person centered care, patient centered outcomes, value based care, shared decision making, male, Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, treatment. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). All studies reporting on patient centred approach, shared decision making and evidence-based medicine were included in the review. All original article, reviews, letters, congress abstracts, and editorials comments were included in the review. Studies reporting single case reports, experimental studies on animal models and studies not in English were not included in the review. RESULTS: Overall 751 abstracts were reviewed, out of them 87 full texts were analysed resulting in 36 papers included. The evidence summarised in this systematic review confirmed how a patient centred visit may improve patient's adherence to medication. Although a patient centred model has been rarely used in urology, management of Low Urinary Tract Symptoms (LUTS) and Benign Prostatic Obstruction (BPO) may represent the perfect ground to experiment and improve this approach. Notwithstanding all the innovations in LUTS/BPO medical treatment, the real life picture is far from ideal. CONCLUSIONS: Recent evidence shows a dramatical low drug adherence and satisfaction to medical treatment in LUTS/BPH patients. A patient centred approach may improve drug adherence and some unmet needs in this area, potentially reducing complications and costs. However further well designed studies are needed to confirm this data.

Fibroepithelial polyp causing urethral obstruction: Diagnosis by cystourethrogram.

Fibroepithelial polyps of the urethra are rare benign tumors that predominantly affect males in childhood or adolescence. In this report, we present a case of a 3-year-old boy in acute urinary retention with a urethral fibroepithelial polyp manifesting as a large filling defect on voiding cystourethrogram and successfully managed endoscopically with transurethral resection.

Foreign body urethra misdiagnosed as stricture leading to inadequate management and prolonged treatment duration: a lesson to learn.

Misdiagnosis of a urethral foreign body (FB) as urethral stricture leads to inadequate management and prolonged treatment duration. A 55-year-old male patient was referred with complaints of difficulty in voiding and poor urinary stream for 2 months. He initially presented at a primary healthcare centre and was misdiagnosed as urethral stricture and was scheduled for urethroplasty. Surprisingly, intraoperative cystourethroscopy performed by us revealed that the urethra had been obstructed by an FB. The FB was gently pushed into the bladder and retrieved. The postoperative course was uneventful. The present case represents a rare occurrence of polyembolokoilamania or insertion of a FB into any bodily orifice for sexual gratification.

Urethral intussusception following traumatic catheterization in a male cat.

An 8-year-old, European male shorthair cat was presented with lower urinary tract obstruction. He was catheterized and referred. Retrograde cysto-urethrography suggested a urethral mass. Intussusception of the urethra with a partial rupture of the urethra was visualized. A perineal urethrostomy was performed. The cat was clinically normal at 15 months' follow-up.

Invagination urétrale secondaire à un cathétérisme traumatique chez un chat mâle. Un chat européen male de 8 ans présentant des signes d'obstruction du bas appareil urinaire a été cathéterisé et référé. L'urétrographie rétrograde suggérait une masse urétrale. Une intussusception de l'urètre avec une rupture partielle de l'urètre a été visualisée. Une urétrostomie périnéale a été réalisée. Le chat était cliniquement normal 15 mois après l'intervention.(Traduit par les auteurs).

Lower urinary tract obstruction: fetal intervention based on prenatal staging.

The authors present an overview of lower urinary tract obstruction (LUTO) in the fetus with a particular focus on the insult to the developing renal system. Diagnostic criteria along with the challenges in estimating long-term prognosis are reviewed. A proposed prenatal LUTO disease severity classification to guide management decisions with fetal intervention to maintain or salvage in utero and neonatal pulmonary and renal function is also discussed. Stage I LUTO (mild form) is characterized by normal amniotic fluid index after 18 weeks, normal kidney echogenicity, no renal cortical cysts, no evidence of renal dysplasia, and favorable urinary biochemistries when sampled between 18 and 30 weeks; prenatal surveillance is recommended. Stage II LUTO is characterized by oligohydramnios/anhydramnios, hyperechogenic kidneys but absent renal cortical cysts or apparent signs of renal dysplasia and favorable fetal urinary biochemistry; fetal vesicoamniotic shunting (VAS) or fetal cystoscopy is indicated to prevent pulmonary hypoplasia and renal failure. Stage III LUTO is oligohydramnios/anhydramnios, hyperechogenic kidneys with cortical cysts and renal dysplasia and unfavorable fetal urinary biochemistry after serial evaluation; fetal vesicoamniotic shunt may prevent severe pulmonary hypoplasia but not renal failure. Stage IV is characterized by intrauterine fetal renal failure, defined by anhydramnios and ultrasound (US) findings suggestive of severe renal dysplasia, and is associated with death in 24 h of life or end-stage renal disease (ESRD) within the first week of life; fetal vesicoamniotic shunt and fetal cystoscopy are not indicated.