Standardized single-stage laparoscopic Fowler-Stephens orchiopexy regardless of testis position: Modification of technique eliminates the need for intra-operative decision-making.

Background / Purpose: It is generally perceived that a primary laparoscopic orchiopexy has superior outcomes due to preservation of the testicular artery, and thus should be the choice when achievable. The two-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) is considered superior regarding success rate compared to the one-stage procedure when the artery must be transected. Outcomes can be jeopardized when a primary orchiopexy is ultimately realized to be the incorrect procedure due to insufficient testicular artery length. It is preferable to decide the approach before initiating dissection, however, in reality, this does not always occur. A single uniform approach to all intraabdominal testes (IAT) that takes into consideration the main challenges encountered when performing laparoscopic orchiopexy can simplify the approach and potentially achieve good outcomes. We present our experience with a standardized approach for IAT regardless of testicular position and describe the surgical modification needed to achieve good results with the one-stage LFSO. Materials and Methods: Key surgical maneuvers implicated in the modified one-stage LFSO (M-LFSO) include preservation of a wide peritoneal flap between the vessels and the vas deferens, dissecting the vessels as proximal as possible and avoiding manipulation of the epididymis and vessels between the vas and epididymis when transferring the testis to the scrotum. Results: Our cohort included 55 boys (59 testes). Median age and weight at surgery were 13.3 months (interquartile range [IQR] 9.2-32.4) and 10.4 kg (IQR 9.2-12.6). The mean operative time was 70 min (IQR 60-85). The median follow-up was 11 months (IQR 7-12). There was one case of testicular atrophy (2%) and two cases of suboptimal testicular position in the scrotum at 6 months. Conclusions: M-LFSO is a standardized approach for all cases of IAT regardless of testicular position. Preservation of a wide peritoneal flap and proximal dissection of the vessels may contribute to the adequate testicular blood supply. The proposed approach eliminates the need for intra-operative decision-making and for ancillary procedures.

Bladder outlet obstruction is associated with bladder oversensitivity in women.

INTRODUCTION AND HYPOTHESIS: Bladder outlet obstruction (BOO) in women might be associated with significant lower urinary tract storage symptoms such as increased frequency, urgency, and incontinence. This prospective study was designed to assess whether there is an objective association between BOO and abnormal parameters during filling cystometry in women. METHODS: A total of 169 consecutive women (mean age 56 ± 14 years) who were referred for urodynamic investigation were prospectively recruited. Comprehensive medical, obstetric, and gynecological histories were recorded. All patients underwent physical examination, renal and bladder ultrasound, and filled out the International Prostate Symptoms Score (IPSS) questionnaire. The cohort was divided into obstructed and un-obstructed groups based on pressure flow results (Obstruction: Qmax <12 ml/s and Pdet @ Qmax >25 cmH2O). RESULT: There was no significant difference in the frequency of detrusor overactivity between the obstructed and non-obstructed group (37% vs 32%, p = 0.71). All bladder sensation volumes were significantly lower in obstructed women than non-obstructed women in univariate and multivariate logistic regression analyses. Of the sensation parameters, first desire to void (FDV) had the highest area under the curve (AUC = 0.75, 95% CI = 0.672-0.837, p < 0.001) for predicting BOO. FDV < 105 ml showed a strong association with BOO with OR = 9.84 (95% CI 4.122-23.508, p < 0.0001). On univariate and multivariate analyses adjusted to 50 cc reduction in sensation volume, all sensation parameters, were associated with bladder outlet obstruction. CONCLUSION: Our results suggest that there might be a strong association between bladder oversensitivity and BOO in women. This may shed light on the pathophysiological connection between obstruction and enhanced afferent signaling from the bladder.

Transvaginal surgical repair of large urethral diverticula with bipedicle double-opposing flaps of the periurethral fascia.

PURPOSE: The aims of this study were to describe a novel technique for transvaginal repair of large (> 4 cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up. METHODS: The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4 cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture. RESULTS: All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4 years yielded no recurrence and no other late complications. CONCLUSION: Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA2DS2-VASc score in hemodialysis patients with non-valvular atrial fibrillation.

BACKGROUND: We tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF). METHODS: A retrospective cohort study of a clinical database containing the medical records of 268 MHD patients with non-valvular AF (167 women, mean age 73.4 ± 10.2 years). During the median follow-up of 21.0 (interquartile range, 5.0-44.0) months, 46 (17.2%) ischemic strokes and 24 (9.0%) major bleeding events were reported. RESULTS: Although CHA2DS2-VASc predicted ischemic stroke risk in the study population (adjusted HR 1.74 with 95% CI 1.23-2.46 for each unit of increase in CHA2DS2-VASc score, and HR of 5.57 with 95% CI 1.88-16.49 for CHA2DS2-VASc score ≥ 6), prior ischemic strokes/transient ischemic attacks (TIAs) were non-inferior in both univariate and multivariate analyses (adjusted HR 8.65 with 95% CI 2.82-26.49). The ROC AUC was larger for the prior ischemic stroke/TIA than for CHA2DS2-VASc. Furthermore, the CHA2DS2-VASc score did not predict future ischemic stroke risks in study participants who did not previously experience ischemic strokes/TIAs (adjusted HR 1.41, 95% CI: 0.84-2.36). The HAS-BLED score and its components did not have predictive abilities in discriminating bleeding risk in the study population. CONCLUSIONS: Previous ischemic strokes are non-inferior for predicting of future ischemic strokes than the complete CHA2DS2-VASc score in MHD patients. CHA2DS2VASc scores are less predictive in MHD patients without histories of CVA/TIA. HAS-BLED scores do not predict major bleeding in MHD patients. These findings should redesign approaches to ischemic stroke risk stratification in MHD patients if future large-scale epidemiological studies confirm them.

Nutritional Status and Mortality Predictability for Time-Varying Serum Alkaline Phosphatase in Hemodialysis Patients: A Longitudinal Study.

OBJECTIVE: Higher serum alkaline phosphatase (sALP) levels associate with a poor prognosis in maintenance hemodialysis patients. However, little is known about the meaning of lower sALP in this population. We hypothesized that lower sALP concentrations may express nutritional status and survival accordingly. METHODS: A retrospective, longitudinal cohort study of a clinical database containing the medical records of 554 patients (367 men and 187 women, mean age 67.6 ± 14.2 years) receiving maintenance hemodialysis from November 2007 to July 2018 in a single center was conducted. sALP, nutritional, bone turnover, and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30,and 36 months followed by 58 additional months of clinical observations. RESULTS: The median sALP level was 90.0 (71.0-125.8) U/L. In a linear mixed effects model adjusted for baseline demographics and clinical parameters, each 1.0 U/L increase above the mean sALP at baseline was associated with 0.7% slower rate of decline in geriatric nutritional risk index per 3 years (P = .02 for sALP × time interaction). sALP remained associated with the rate of change in geriatric nutritional risk index, even after controlling for C-reactive protein and intact parathyroid hormone levels. For each 1.0 U/L increase in sALP over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 0.996 (95% confidence interval 0.993-1.000, P = .04). CONCLUSIONS: Increasing longitudinal levels of sALP associate with improved nutritional status and lower mortality rates. sALP can be used as an integrated marker, combining the properties of the nutritional marker, the marker of mineral-bone disease and inflammation, according to its levels.

Serum Obestatin: A Biomarker of Cardiovascular and All-Cause Mortality in Hemodialysis Patients.

BACKGROUND: Recent experimental studies have suggested that obestatin, a proposed anorexigenic gut hormone and a physiological opponent of acyl-ghrelin, has protective cardiovascular effects. We tested the hypothesis that obestatin is independent of inflammatory mediators and/or acyl-ghrelin in predicting outcomes of the maintenance hemodialysis (MHD) population. METHODS: It was a 6-year cohort study on 261 MHD patients. Obestatin, acyl-ghrelin, adipokines (leptin and adiponectin), markers of inflammation and nutrition, prospective all-cause and cardiovascular mortality were studied. RESULTS: During the follow-up, 160 patients died in total, with 74 deaths due to cardiovascular causes. For each ng/mL increase in baseline obestatin level in fully adjusted models (including malnutrition-inflammation score, Interleukin-6 [IL-6], adipokines and acyl-ghrelin), the hazard for death from all causes was 0.90 (95% CI 0.81-0.99) and for cardiovascular death 0.85 (95% CI 0.73-0.99). However, these associations were more robust in the subgroup of patients aged above 71 years: 0.85 (95% CI 0.73-0.98) for all-cause death and 0.66 (95% CI 0.52-0.85) for cardiovascular death. An interaction between high IL-6 (above median) and low obestatin (below median) levels for increased risk of all-cause mortality (synergy index [SI] 5.14, p = 0.001) and cardiovascular mortality (SI 4.81, p = 0.02) emerged in the development of multivariable adjusted models. Interactions were also observed between obestatin, Tumor necrosis factor-alpha, adipokines and acyl-ghrelin, which were associated with mortality risk. CONCLUSION: Serum obestatin behaves as a biomarker for cardiovascular and all-cause mortality in MHD patients. The prognostic ability of obestatin in this regard is independent of inflammation, nutritional status, acyl-ghrelin's and adipokines' activity and is modified by age being very prominent in patients older than 71 years.

Estimating of Residual Kidney Function by Multi-Frequency Bioelectrical Impedance Analysis in Hemodialysis Patients Without Urine Collection.

BACKGROUND/AIMS: Residual kidney function (RKF) is a pivotal predictor of better clinical outcomes in maintenance hemodialysis (MHD) patients. So far there has been no attempt to use bioimpedance analysis (BIA) measurements to calculate residual glomerular filtration rate (GFR) in dialysis population. We hypothesized that performing of multi-frequency BIA at the beginning and end of hemodialysis session can enable us to predict the measured residual GFR in MHD patients. Thus our aim was to develop and validate a new RKF prediction equation using multi-frequency BIA in MHD patients. METHODS: It was diagnostic test evaluation study in a prospective cohort. Participants (n=88; mean age, 66.3±13.2 years, 59.1% males) were recruited from a single hemodialysis center. A new equation (eGFRBIA) to predict RKF, utilizing BIA measurements performed pre- and post-dialysis, was generated and cross-validated by the leave-one-out procedure. GFR estimated as the mean of urea and creatinine clearance (mGFR) using urine collections during entire interdialytic period. RESULTS: A prediction equation for mGFR that includes both pre- and post-dialysis BIA measurements provided a better estimate than either pre- or post-dialysis measurements alone. Mean bias between predicted and measured GFR was -0.12 ml/min. Passing and Bablok regression showed no bias and no significant deviation in linearity. Concordance correlation coefficient indicated good agreement between the eGFRBIA and mGFR (0.75, P<0.001). Using cut-off predicted mGFR levels >2 ml/min/1.73 m2 yielded an area under curve of 0.96, sensitivity 85%, and specificity 89% in predicting mGFR. The κ scores for intraobserver reproducibility were consistent with substantial agreement between first and second estimation of RKF according to eGFRBIA (weighted κ was 0.60 [0.37-0.83]). CONCLUSION: We present a valid and clinically obtainable method to predict RKF in MHD patients. This method, which uses BIA, may prove as accurate, convenient and easily reproducible while it is operator independent.

[POSITION STATEMENT FOR INTERMITTENT CATHETERIZATION OF URINARY BLADDER].

INTRODUCTION: A position paper presents the standpoint of the Israeli Urological Association on clean intermittent catheterization (CIC) for all physicians and nurses. The position paper is based on international guidelines and professional literature and is adapted to medical activities in Israel. CIC is indicated for the treatment of temporary/permanent disability in the emptying of the bladder, which is expressed by large post-voided urine/urine retention and related complications. There are a few contra-indications for CIC (low bladder volume or compliance, pressure sores/external infection of the urethra, anatomical, functional or cognitive disorder that does not allow to perform CIC, recurrent macrohematuria or urethrorrhagia, urethral pain that does not allow frequent catheterization, patient unwillingness to perform CIC by himself or by another person). There are alternatives to performing CIC permanent urethral or suprapubic catheter, urinary tract diversion, sphincterotomy. Before starting to perform CIC, the patient should be verified as being able to perform CIC and adhere to a predetermined schedule. It is recommended to perform the CIC at regular intervals during the day. During training and early stages of the CIC, it is recommended to catheter every 4-6 hours to assess bladder volume at these time intervals (urinary volume per catheterization). It is recommended to record drinking volumes, voiding volumes, and catheterization volumes for adjusting and timing the CIC. In order to determine the right number of catheterizations, several factors should be taken into account, such as the patient's ability to void, bladder capacity, and various urodynamic variables. In some cases additional therapy might be administered to reduce bladder pressure. If a patient cannot perform CIC on his own, a caregiver or a family member may be instructed to perform the procedure. The Committee described the methods and techniques to perform CIC and described possible complications (although rare) such as urinary tract infections (UTI), urethral and/or bladder damage, and the difference between a condition of asymptomatic bacteriuria and UTI. The Committee recommends that preventive antibiotic treatment should not be given to CIC patients. Antibiotic treatment should be given only in the case of UTI. The Committee recommends active participation of medical, nursing, social workers, family members and direct caregivers to improve the quality of life of CIC patients. Long-term follow-up is needed to diagnose and prevent complications of CIC/underlying disease leading to CIC. Different follow-up tests should be performed based on underlying disease, complications or changes in patient symptoms. The Committee described different types of catheters and recommends that the use of single-use catheters is preferable. Pre-shielding should be used before using the catheters without external coating.

Outcomes of different protocols of pelvic floor physical therapy and anti-cholinergics in women with wet over-active bladder: A 4-year follow-up.

AIMS: We investigated the 4-year outcomes of three protocols of pelvic floor physical therapy and anticholinergic drug in women with wet over-active bladder (OAB). METHODS: One hundred and sixty-four women were randomly allocated to one of four interventions: drug therapy (DT), bladder training (BT), pelvic floor muscle training (PFMT), or combined pelvic floor rehabilitation (CPFR) that includes BT, PFMT, and behavioral advice. The active treatment in each group lasted 3 months. Of the 132 women who completed a 1-year follow-up, 120 women (90%) responded to our questionnaires and therefore were included in this study. Outcome measures were the number of voids per day, number of urgency urinary incontinence (UUI) episodes per week, completely dry rate and Incontinence Quality of Life questionnaire (I-QOL) at 4 years. RESULTS: After 4 years of follow-up, the outcome measures improved significantly and equally in all four groups. The median number of UUI episodes/week dropped by 3, 1, 2, and 2 in the DT, BT, PFMT, and CPFR groups, respectively (P = ns). The dry rates were 25%, 31%, 44%, 34% in the DT, BT, PFMT, and CPFR groups, respectively (P = ns). I-QOL scores improved significantly in all four groups. CONCLUSIONS: Women who suffer from wet-OAB may experience the same degree of long-term improvement following various pelvic floor physical therapy protocols as they would from drug therapy. Neurourol. Urodynam. 36:755-758, 2017. © 2016 Wiley Periodicals, Inc.

Interaction between acyl-ghrelin and BMI predicts clinical outcomes in hemodialysis patients.

BACKGROUND: Ghrelin, a gastric orexigenic peptide, and body mass index (BMI) are known as inversely associated to each other and are both linked to cardiovascular (CV) risk and mortality in maintenance hemodialysis (MHD) patients. However, it is unclear whether the interaction between ghrelin and BMI is associated with a risk of all-cause and CV death in this population. METHODS: A prospective observational study was performed on 261 MHD outpatients (39% women, mean age 68.6 ± 13.6 years) recruited from October 2010 through April 2012, and were followed until November 2014 (median follow-up-28 months, interquartile range-19-34 months). We measured acyl-ghrelin (AG) levels, appetite, nutritional and inflammatory markers, prospective all-cause and cardiovascular (CV) mortality. RESULTS: During follow-up, 109 patients died, 51 due to CV causes. A significant interaction effect of high BMI and high AG (defined as levels higher than median) on all-cause mortality was found. Crude Cox HR for the product termed BMI x AG was 0.52, with a 95% confidence interval (CI): 0.29 to 0.95 (P = 0.03). Evaluating the interaction on an additive scale revealed that the combined predictive value of BMI and AG is larger than the sum of their individual predictive values (synergy index was 1.1). Across the four BMI-AG categories, the group with high BMI and high AG exhibited better all-cause and cardiovascular mortality irrespective of appetite and nutritional status (multivariable adjusted hazard ratios were 0.31, 95% CI 0.16 to 0.62, P = 0.001, and 0.35, 95% CI 0.13 to 0.91, P = 0.03, respectively). Data analyses made by dividing patients according to fat mass-AG, but not to lean body mass-AG categories, provided similar results. CONCLUSIONS: Higher AG levels enhance the favourable association between high BMI and survival in MHD patients irrespective of appetite, nutritional status and inflammation.

Provision of information leaflet before urodynamic study reduces the pre-examination anxiety level.

AIMS: To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). METHODS: One hundred and four patients (age 60 ± 15 years) who were referred for multichannel UDS were prospectively recruited and randomized into 2 groups: (1) received a leaflet containing detailed information regarding the examination; (2) did not receive a leaflet. Patients who were unable to complete the questionnaire due to mental disorders and patients who had previously undergone UDS were excluded. The leaflets were mailed to the patients in group 1 one month before the examination. This leaflet included information on how the examination would be performed, its purpose, recommended preparation, potential complications, and common events that might occur in association with the examination, such as incontinence. Emotional distress was measured by the State Anxiety Inventory (SAI)-a validated questionnaire composed of 20 items measuring anxiety. These measures are divided into two psychological domains: (1) positive well being; (2) psychological distress. Patients filled out the SAI immediately before entering the examination room. RESULTS: Demographics and clinical and psychological co-morbidities were similar between the groups. The "psychological distress" score was significantly lower in group 1 (13.1 ± 2.9 vs. 24.8 ± 5.8, P < 0.001), whereas there was no difference in the "positive well being" score. CONCLUSIONS: We recommend providing patients with an information leaflet on UDS since it significantly reduces anxiety levels. Neurourol. Urodynam. 35:805-808, 2016. © 2015 Wiley Periodicals, Inc.

[POSITION STATEMENT ON OVERACTIVE BLADDER].

INTRODUCTION: Bothersome urinary symptoms during the storage phase are common among women and men. These symptoms described as urinary urgency, frequency and nocturia with or without urge urinary incontinence may be caused by various pathologies including bladder overactivity. Diagnosis of an overactive bladder is based on the patient's clinical presentation after exclusion of other disorders that may cause these symptoms. The minimal requirements for a urological evaluation include medical history, physical examination and urinalysis. Behavioral therapies and medical therapy are the mainstay of treatment for an overactive bladder. While the use of minimally invasive procedures are reserved for patients not interested in medications or for those patients in whom symptoms were not improved by other therapies. Treatment outcome is evaluated by documentation of changes in symptoms, signs and quality of life. This position statement paper represents the approach of the Israeli Urological Association regarding the evaluation and treatment of overactive bladder syndrome.

Pain during Female Urethral Catheterization: Intraurethral Lubricant Injection versus Catheter Tip Lubrication--A Prospective Randomized Trial.

PURPOSE: Urethral lubrication during catheterization can be performed by instilling the gel directly in the urethra or by pouring the gel on the catheter tip. In this study we compared the pain level associated with each technique during female urethral catheterization in the setup of a multichannel urodynamic study. MATERIALS AND METHODS: A total of 94 women with a mean ± SD age of 55 ± 14 years who were referred for a multichannel urodynamic study were prospectively randomized into 2 groups according to lubrication technique, including 1) instillation of 5 ml 2% lidocaine gel in the urethra 5 minutes before catheterization or 2) lubrication of the distal part of the catheter with 5 ml 2% lidocaine gel. A visual analog pain scale of 0 to 10 was completed at different time points, including prior to gel instillation (baseline), during gel instillation (group 1), during catheterization, and 5 and 30 minutes after the procedure ended. RESULTS: The study groups did not differ in demographic, clinical or urodynamic parameters. The mean visual analog scale score during catheterization was 2.3 ± 1.4 and 2.4 ± 1.6 in groups 1 and 2, respectively (p = 0.71). There was no difference in the reported visual analog scale score at the other checkpoints. The mean recorded visual analog scale score during instillation of the lubricant in the urethra in group 1 was 1.9 ± 0.9. CONCLUSIONS: The actual act of lubricant instillation in the urethra during catheterization in women causes additional and unnecessary pain. Therefore, it is not recommended. Other than that there is no difference in the urethral pain level between the 2 lubrication techniques.

Liquid paraffin is superior to 2% lidocaine gel in reducing urethral pain during urodynamic study in men: A pilot study.

AIMS: To compare the pain perception between intraurethral instillation of 2% lidocaine gel and liquid paraffin during Urodynamic study in men. METHODS: A randomized, single-blind comparison trial was conducted. Forty men scheduled to undergo multichannel Urodynamic study were randomized to receive either 10 ml of 2% lidocaine gel (group 1, n = 20) or 10 ml of liquid paraffin (group 2, n = 20). Patients recorded their pain on a 0-10 visual analog scale prior to lubricant instillation, immediately after lubricant instillation, after the introduction of the Urodynamic catheter, 5 and 30 min after the catheter was taken out. RESULTS: pain scores were significantly higher in group 1 compared to group 2 immediately after the instillation of the lubricants (4.2 ± 1.5 vs. 2.6 ± 0.9, P < 0.001) and after catheterization (4.8 ± 1.5 vs. 3.5 ± 1.1, P < 0.01). There were no differences in the pain scores between the two groups in the other time points that were evaluated. CONCLUSIONS: Liquid paraffin is more efficient than 2% lidocaine gel in reducing urethral pain during Urodynamic study in men. Pain scores were specifically better during the instillation of the lubricant and during the delivery of the urethral catheter.

Family history associated with pelvic organ prolapse in young women.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) among young women is a relatively rare disorder with a unique clinical background. The objective of our study was to investigate the relative risk factors for POP and the relationship between family history and POP development in young women. METHODS: In a retrospective longitudinal study we investigated 26 young patients (age <45 years) who underwent POP surgery and compared them to a control group of 26 patients (age >55 years) who underwent similar surgery and were matched with regard to parity. All women were interviewed for family history of POP, POP surgery among first-degree relatives, and hernia repair. RESULTS: Family history of POP was five times more prevalent among women in the study group than in the control group (46 % vs. 8 %, P < 0.01). Moreover, POP surgery among the first-degree relatives was significantly more prevalent in the study group (23.1 % vs. 3.8 %, p < 0.05). The prevalence of a family history of POP in more than one first-degree relative (11.5 % vs. 3.84 %, p = 0.3) and the family history of hernia repair among first-degree relatives (11.5 % vs. 15.4 %) did not differ between the groups. CONCLUSIONS: A family history of POP is significantly more common in younger affected women than in older affected women. We suggest that future genetic studies should concentrate on this specific population.

Self-induced plantar-flexion objectively reduces wave amplitude of detrusor overactivity and subjectively improve urinary urgency: a pilot study.

AIMS: To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO). METHODS: Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS). RESULTS: The mean peak detrusor pressure without plantar-flexion was 58 cmH2 O (95% CI: 46.3-69.7) compared to 31 cmH2 O (95% CI: 23.1-38.9) with plantar-flexion (P < 0.001). All patients reported a reduced degree of urgency during plantar-flexion reflected in a significant reduction in mean VAS score from 9.3 (95% CI: 9-9.5) to 4.7 (95% CI: 3.9-5.4; P < 0.0001). CONCLUSIONS: Self-performed plantar-flexion maneuver might reduce the severity of urinary urgency and the magnitude of overactive detrusor contractions, which may have a role in the conservative therapy of detrusor overactivity.

[Position statement for the diagnosis and treatment of men with benign prostate enlargement and lower urinary tract symptoms].

Benign prostate enlargement causing lower urinary symptoms is a common progressive phenomenon in adult men. Lower urinary tract symptoms may emerge during the storage, voiding, and post micturition phases, harm quality of life and may be caused by a variety of factors. The purpose of evaluation is to identify benign prostate enlargement and factors other than enlarged prostate as the cause of symptoms, and recognize the risk factors for progression of the condition. The goal of treatment is to alleviate symptoms and improve quality of life, and to prevent deterioration of symptoms and development of complications. Medical therapy is the basic approach, whereas surgery and minimally invasive procedures are reserved for patients not interested in medical therapy or for those in whom symptoms were not alleviated by means of medical therapy. In the present position statement, we present the approach to the evaluation and treatment of lower urinary tract symptoms in men with benign prostate enlargement.

Reducing fistula rate in hypospadias repair: A comparative study between standard tubularized incised plate repair and incorporation of a layer of spongiosum tissue.

INTRODUCTION: The most prevalent complication in hypospadias repair is fistula formation. Adhering to the principle of providing urethroplasty coverage to mitigate fistula occurrence, we implemented a modification by integrating a spongiosum layer between the urethroplasty and the dartos flap. Our hypothesis posited that this approach would result in a reduced fistula formation rate. METHODS: This study is a comparative analysis involving patients under 18 years of age who underwent primary hypospadias repair. The cases were allocated into two groups. In the study group, in addition to performing tubularized incised plate (TIP) repair, a spongiosum layer harvested from both sides of the urethra was used to cover the urethroplasty (modification of the Y-to-I urethroplasty). The control group underwent a standard TIP repair. The primary outcome was to assess urethrocutaneous fistula formation. Secondary outcomes included evaluating the development of meatal stenosis and glans dehiscence, along with assessing cosmetic results by the Hypospadias Objective Penile Evaluation (HOPE) score. RESULTS: Overall, 154 hypospadias cases were included in the study. Eighty-seven patients (56%) were allocated to the study group, and 67 (44%) were allocated to the control group. Urethrocutaneous fistula developed in 3 (3.4%) and 11 (16.4%) patients in the study and control group, respectively (p = 0.006). Glans dehiscence occurred in 2 (2.3%) patients in the study group and 4 (6%) patients in the control group (p = 0.198). Meatal stenosis was observed in 4 (4.6%) patients in the study group and 5 (7.5%) patients in the control (p = 0.452). The mean HOPE score was 59 in both groups (p = 0.36). DISCUSSION: This study details our encounters with the novel modification and compares the results with standard TIP. Our data suggest that adding a layer of spongiosum tissue over the urethroplasty reduces the complication of urethrocutaneous fistula without increasing the occurrence of dehiscence, significant meatal stenosis, or compromising cosmetic outcomes. CONCLUSION: We advocate for implementing the described surgical modification as a viable option for hypospadias repair.

Use of Validated Questionnaires to Predict Cosmetic Outcomes of Hypospadias Repair.

INTRODUCTION: Hypospadias is a syndrome of penile maldevelopment. The primary goal of hypospadias surgery is to create a penis with normal appearance and function. Historically, the outcome of hypospadias repair has been assessed based on the need for reoperation due to urethroplasty complications (UC), including fistula formation, dehiscence, meatal stenosis, or development of a urethral stricture. The Glans-Urethral Meatus-Shaft (GMS) score is a standardized tool to predict UC. Analysis of the cosmetic outcomes of hypospadias repair based on the appearance of the reconstructed penis has been validated, and standardized scores have been published. The Hypospadias Objective Penile Evaluation (HOPE) score is a validated questionnaire used to assess postoperative cosmetic outcomes. Although predictors of surgical outcomes and UC have been well documented, predictors of optimal cosmetic outcomes are lacking in the literature. Furthermore, reoperation due to cosmetic considerations has been poorly reported. OBJECTIVE: To identify predictors of cosmetic outcomes after hypospadias repair and to assess the reoperation rate according to cosmetic considerations. MATERIALS AND METHODS: This prospective cohort study included 126 boys who underwent primary hypospadias repair. The severity of hypospadias, degree of penile curvature, glans width, preoperative HOPE, and GMS scores were documented. The standard technique for single-stage repairs, the tubularized incised plate urethroplasty, was performed. The primary endpoint was cosmetic outcomes evaluated by the HOPE score questionnaire six months postoperatively. Optimal cosmetic results were defined by HOPE scores ≥ 57. RESULTS: The study population consisted of the following cases: 87 (69%) subcoronal, 32 (25%) shaft, and 7 (6%) proximal hypospadias. Among the study participants, 102 boys (81%) had optimal cosmetic results (HOPE ≥ 57), and 24 boys (19%) had surgeries with suboptimal cosmetic outcomes (HOPE < 57). Ancillary procedures were performed in 21 boys (16%), of which 14 (11%) were solely for cosmetic considerations, and 7 were secondary to UC. Using the Receiver Operating Characteristic analysis of potential predictors of optimal cosmetic outcomes, the preoperative HOPE score had the highest area under the curve (AUC = 0.79; 95% CI 0.69-0.89, p < 0.001). After multivariable analysis, the degree of penile chordee (p = 0.013), glans width (p = 0.003), GMS score (p = 0.007), and preoperative HOPE score (p = 0.002) were significant predictors of cosmetic outcomes. Although meatal location predicted suboptimal cosmetic results in univariate analysis, it was not a factor in multivariable analysis. CONCLUSIONS: Over 80% of boys undergoing hypospadias repair achieved optimal cosmetic outcomes. More than 10% of cases underwent ancillary procedures, secondary solely to cosmetic considerations. Predictors of optimal cosmetic outcomes after hypospadias surgery included degree of chordee, glans width, and preoperative HOPE and GMS scores, which were the best predictors of satisfactory cosmetic results. Although meatal location is the main predictor of UC, it was not a predictor for cosmetic outcomes. Factors affecting cosmetic outcomes should be clearly explained to parents during the preoperative consultation.

Comparison of lower urinary tract symptoms between women with detrusor overactivity and impaired contractility, and detrusor overactivity and preserved contractility.

PURPOSE: We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility. MATERIALS AND METHODS: The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups. RESULTS: Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p <0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p <0.01 and 22% vs 7%, p <0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p <0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p <0.001). CONCLUSIONS: Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.