How to define failure of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity.

INTRODUCTION: Neurogenic detrusor overactivity (NDO) has a major impact on patients' quality of life and can lead to upper urinary tract complications. Intradetrusor botulinum toxin type A injections are administered as second-line treatment to these patients following the failure of anticholinergic agents. The aim of the DETOX 2 study is to propose a consensus definition of the failure of intradetrusor botulinum toxin injections for NDO in patients presenting spinal cord injury, spina bifida, or multiple sclerosis (MS) with self-catheterization. METHOD: This study followed the method adopted by the French National Authority for Health for recommendations by consensus. Based on a review of the literature and a preliminary survey, a steering committee compiled a questionnaire and selected a rating group comprising 16 experts from the Neuro-Urology Committee of the French Urology Association (cnuAFU) and Genulf. The experts were asked to complete the online questionnaire. At the end of the first round, all participants came together to discuss any disagreements and a second-round online questionnaire was completed to reach a consensus. RESULTS: Thirteen of the 16 experts approached completed both rounds of questionnaires. A strong consensus was reached for two proposals (median score = 9/10) which were therefore included in the definition from the first round: at least one repeat injection of the same botulinum toxin at the same dose must be given to rule out failure on technical grounds and a duration of efficacy <3 months must be considered a failure. At the end of round 2, a relative consensus was reached regarding the clinical criterion defining failure (median score = 7/10) and the urodynamic criterion of failure (median score = 8/10). An additional proposal was selected during this second round on the need for a voiding diary (median score = 8/10). CONCLUSION: The first consensus definition of failure of an intradetrusor injection of TB-A for NDO has been achieved with this study: persistence of detrusor overactivity with maximum detrusor pressures >40 cm H2O and/or a compliance issue and/or persistence of urinary incontinence and/or urgency and/or a number of daily self-catheterizations >8/day and/or efficacy <3 months. This study will help to standardize research on the failure of the intradetrusor botulinum toxin for NDO in clinical practice and clinical research.

Risk factors for upper urinary tract deterioration in adult patients with spina bifida.

PURPOSE: Neurogenic bladder associated with spina bifida disease remains a major cause for mortality or morbidity due to kidney damages. However, we currently do not know which urodynamic findings are associated with an higher risk of upper tract damages in spina bifida patients. The objective of the present study was to evaluate urodynamic findings associated with functional kidney failure and/or with morphological kidney damages. METHODS: A large single-center restrospective study was conducted in our national referral center for spina bifida patients using our patients' files. All urodynamics curves were assessed by the same examinator. Functional and/or morphological evaluation of the upper urinary tract were done at the same moment as the urodynamic exam (between 1 week before and 1 month after). Kidney function was assessed using creatinine serum levels or 24 h urinary creatinine levels (creatinine clearance) for walking patients, or with the 24 h urinary creatinine level for wheelchair-users. RESULTS: We included 262 spina bifida patients in this study. Fifty-five patients had a poor bladder compliance (21.4%) and 88 of them had detrusor overactivity (33.6%). Twenty patients had a stage 2 kidney failure (eGFR < 60 ml/min) and 81 patients out of 254 (30.9%) had an abnormal morphological examination. There were three urodynamic findings significantly associated with UUTD: bladder compliance (OR = 0.18; p = 0.007), Pdetmax (OR = 14.7; p = 0.003) and detrusor overactivity (OR = 1.84; p = 0.03). CONCLUSION: In this large series of spina bifida patients, maximum detrusor pressure and bladder compliance are the main urodynamic findings determinants of UUTD risk.

Comparison of early loosening vs delayed section of mid-urethral slings for postoperative voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: Bladder outlet obstruction (BOO) is a common occurrence after midurethral sling (MUS) insertion and can result in acute or chronic urinary retention or de novo lower urinary tract symptoms (LUTS). However, the management of BOO after MUS is not standardised. The objective of this study was to compare two therapeutic strategies for suspected BOO after MUS. METHODS: Patients who had surgical revision for voiding dysfunction with a post-void residual (PVR) ≥100 ml after MUS in five centres between 2005 and 2020 were included in a retrospective study. Patients were divided into two groups: early sling loosening (EL) vs delayed section/excision of the sling (DS). RESULTS: Seventy patients were included: 38 in the EL group and 32 in the DS group. The postoperative complication rate was comparable in both groups (10.5% vs 12.5%; p = 0.99). At 3 months, the rate of withdrawal from self-catheterisation was similar in the two groups (92.1% vs 100%; p = 0.25) as was the PVR (57.5 vs 63.5 ml; p = 0.09). After a median follow-up of 9 months, there were significantly more patients with resolved voiding dysfunction in the EL group (63.2% vs 31.3%; p = 0.01). The rate of persistent/recurrent stress urinary incontinence (SUI) was higher in the DS group (21% vs 43.7%; p = 0.04). In multivariate analysis, the main predictive factor of recurrent SUI was DS (OR 2.87, 95% CI 1.01-8.60, p = 0.048). CONCLUSIONS: Early loosening of MUS in the case of postoperative voiding dysfunction offers better efficacy than DS of the sling, with a lower risk of recurrent/persistent SUI.

Why malnutrition in orthopaedic elective patient is still an issue? A recent review of the literature.

BACKGROUND: Malnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA). The progressive increase in the ageing of world population and in the numbers of TJA, widens the demand for a faster post-operative recovery and function. The aim of this study was to review the literature regarding: post-operative transfusion, infections, wound complications, length of hospital stay (LOS), rate of admission in intensive care unit (ICU), and total patient charges, in malnourished patient undergoing TJA. METHODS: The search reviewed all fields of the available peer-reviewed literature, published in the English language during the last seven years 2015-2022. We started from a total of 745 studies and finally we included in the review 16 articles. RESULTS: In 10 studies, an increased surgical site infection was shown, being by far the most common complication, in 8 studies, malnutrition was associate with the increase of the average length of stay (LOS), and in 5 studies, the major founding was the increase in costs. An increase of the morbidity was found in 3 studies, instead a larger number of transfusions was highlighted in 2 studies. Lastly, one study showed a major unplanned ICU admission rate. CONCLUSIONS: Although the literature trend indicates that the nutritional status of TJA candidate patients is a parameter that influences the surgical outcome, in particular surgical site infections, length of stay, and costs, there are, to the authors' knowledge, no studies aimed at identifying validated and recognized protocols for the correction of malnutrition.

Cystectomy and ileal conduit for neurogenic bladder: Comparison of the open, laparoscopic and robotic approaches.

AIM: The objective of the present study was to compare the outcomes of open versus laparoscopic versus robotic cystectomy and ileal conduit for neurogenic lower urinary tract dysfunction (NLUTD). METHODS: The charts of all patients who underwent cystectomy and ileal conduit for NLUTD between January 2004 and November 2020 in an academic center were retrospectively reviewed. The approach was either open, laparoscopic or robot-assisted depending on the period (i.e., three consecutive era). For the robotic approach, the diversion was done either intracorporeally or extracorporeally. We compared the perioperative and late postoperative outcomes between the three groups. RESULTS: After exclusion of 10 patients with non-neurogenic benign conditions, 126 patients were included over the study period. The most frequent neurological conditions were multiple sclerosis (36.5%) and spinal cord injury (25.4%). The approach was open, laparoscopic or robot-assisted in 31 (24.6%), 26 (20.6%) and 69 (54.7%) cases respectively. Seventy-two patients experienced a 90-day postoperative complication (57.1%) of which 22 had a major complication (Clavien 3 or higher, 17.5%) including one death (0.8%). The rate of major postoperative complications was significantly lower in the robotic group (23% vs. 23% vs. 10%; p = 0.049) while the rate of overall complications was comparable across the three groups (58.1% vs. 53.9% vs. 60.6%; p = 0.84). After a median follow-up of 23 months, 22 patients presented a late complication (17.6%), mainly incisional hernia (5; 4%) and uretero-ileal stricture (9; 7.2%). The rate of late complications did not differ significantly between the three approaches. CONCLUSION: Cystectomy and ileal conduit for neurogenic bladder is associated with a relatively high perioperative morbidity. The robot-assisted approach may decrease the risk of major postoperative complications.

Long-term outcomes of artificial urinary sphincter in female patients with spina bifida.

AIMS: To report the long-term functional outcomes of artificial urinary sphincter (AUS) implantation in female patients with spinal dysraphism and stress urinary incontinence (SUI) related to intrinsic sphincter deficiency (ISD). METHODS: The charts of all spina bifida female patients with SUI due to ISD who underwent AUS (AMS 800) implantation between 2005 and 2019 at three academic departments of urology were retrospectively reviewed. Reoperation was defined as either revision or explantation of the AUS device. Reoperation-free survival of the AUS device was estimated using the Kaplan-Meier method. Continence status as per patients' subjective assessment was categorized as follows: complete continence (no pads), improved continence, unchanged SUI or worsened SUI. RESULTS: Twenty-three patients were included, 69.6% were self-catheterizing. The median follow-up was 14 years. Median time to first reoperation was 10 years. Survival rates without reoperation were 85.9%, 41.8%, 34.6%, and 20.9% at 5, 10, 15, 20 years, respectively. Survival rates without AUS explantation were 90.7%, 66.3%, 55.2%, and 41.4% at 5, 10, 15, 20 years, respectively. None of the patients who underwent device explantation had a new AUS implanted. The only predictive factor of reoperation-free survival was the type of spinal dysraphism (hazards ratio = 3.60 for closed vs. open dysraphism; p = .04). At last follow-up, 17 of the 23 patients were fully continent (73.9%). CONCLUSION: AUS in female patients with spina bifida may be associated with satisfactory long-term functional outcomes and a high reoperation rate. The median time to first reoperation was similar to what is reported in the male AUS literature (10 years).

Medial closure supracondylar femoral osteotomy: an effective solution for long-term treatment of arthritic valgus knee?

PURPOSE: The aim of this work was to retrospectively analyze the clinical, subjective, and radiological results of medial closing-wedge distal femur osteotomy (MCW-DFO) for the treatment of osteoarthritis (OA) in valgus knee at medium- to long-term follow-up. MATERIALS AND METHODS: A total of 57 patients (62 knees) treated with MCW-DFO between 1984 and 2018 were included in the study. Patient age at the time of the surgery ranged between 28 and 61 years (average: 48 years). All patients with a minimum follow-up of 4 years were contacted to request for them to undergo clinical, subjective, and radiological evaluation. Preoperative hip-knee-ankle (HKA) angle (i.e., preoperative valgus malalignment) was 8.6° ± 2°. Patients were evaluated using the following scales: the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Knee Society Score (KSS), the International Knee Documentation Committee (IKDC), the Visual Analog Scale (VAS), and the Numeric Rating Scale 11 (NRS-11). RESULTS: Mean follow-up was 11.6 ± 4.9 years, and a total of 17 patients (20 knees) were available for the last examination. At maximum follow-up, 4 patients underwent conversion to a total knee replacement (20%); their survival rate was 100% at 10 years and 66.7% at 15 years, as estimated using the Kaplan-Meier curve. The subjective Knee Society Score improved on average from 37.7 ± 10 to 63.9 ± 15.4. The objective Knee Society Score improved on average from 42.2 ± 11.7 to 75 ± 22.5. The pain detected through the VAS and NRS-11 scales improved from 56.7 ± 12.9 to 42 ± 17.1 and from 5.8 ± 1.1 to 4.4 ± 1.7, respectively. Thirteen patients (70%) required hardware removal at an average time of 19 ± 4 months due to a local nuisance. CONCLUSIONS: MCW-DFO can improve symptoms in patients with osteoarthritis in a valgus knee at medium- to long-term follow-up, reducing the progression of osteoarthritis in properly selected patients.

Determinants and prognostic value of post-operative maximum urethral closure pressure after artificial urinary sphincter in men.

PURPOSE: To evaluate the determinants and prognostic value of post-operative maximum urethral closure pressure (MUCP) after AUS implantation in male patients. METHODS: The charts of all male patients who had an AUS implantation between 2008 and 2018 at a single center were reviewed retrospectively for an exploratory study. A post-operative urethral profilometry was performed systematically as part of routine daily practice over the study period to assess the post-operative MUCP with the AUS consecutively closed (c-MUCP) and opened (o-MUCP). The difference between c-MUCP and the manufacturer's theoretical pressure objective determined by the pressure regulating balloon (PRB) was calculated (diff-th-MUCP). The primary endpoint was social continence at 3 months defined as 0-1 protection/day. RESULTS: Ninety patients were included. The median age was 71 years, and the median follow-up was 50 months. The etiology of incontinence was radical prostatectomy in 84% of cases, and endoscopic prostate surgery in 6.6% of patients. There were 74.4% of patients who were socially continent at 3 months. The c-MCUP was significantly higher in the continent group (53 [42.2, 60.2] vs 62 [58, 70] p = 0.02). The diff-th-MUCP did not differ significantly between the two groups (18 [0, 23] vs 1 [- 2, 7.7] p = 0.29). The c-MUCP was not statistically associated with the risk of revision and/or explantation. CONCLUSION: The MUCP after AUS implantation in male patients often differs from the manufacturer's pressure objective. The postoperative c-MUCP might be significantly associated with functional outcomes suggesting that it might be a valuable tool for treatment decision-making. This should be confirmed by larger studies.

Urinary biomarkers profiles in patients with neurogenic detrusor overactivity according to their neurological condition.

OBJECTIVES: The aim of this study was to investigate the disease-specific urinary levels variations of neurotrophins (NGF, BDNF), mediators of inflammation (TGFß-1, PGE-2) and markers of extracellular matrix alterations (TIMP-2) in patients with multiple sclerosis (MS) spinal cord injury (SCI), or spina bifida (SB), and neurogenic detrusor overactivity (NDO). METHODS: A prospective single-center study was conducted between March 2015 and March 2017. Patients aged over 18 years old, with neurological disease, with a urodynamic diagnosis of NDO were included. The urinary levels of NGF, BDNF, TIMP-2, PGE 2, and TGF-ß1 were measured using dedicated ELISA kits. RESULTS: Forty-one patients were included: 6 with MS, 20 with SCI, and 15 with spina bifida. The average urinary level of NGF/Cr was significantly higher in MS patients compared to other neurologic populations (8 vs. 0.56 vs. 1.25 pg/mg of creatinine; p = 0.001) as well for the average urinary level of BDNF (88.3 vs. 5 vs. 4.8 pg/mg of creatinine; p < 0.0001). SCI patients had a significantly lower level of TGFß-1 than SB patients (p = 0.04). The urinary level of PGE2 was significantly correlated with the Body Mass Index (r = 0.61; p = 0.0002). CONCLUSION: All NDO may not be created equal from the molecular standpoint. Multiple sclerosis patients had higher urinary levels of neurotrophins than in other neurologic populations with NDO. Urinary TGFß-1, a strong determinant of extracellular matrix, was significantly higher in spina bifida patients compared to SCI patients. These findings underscore the importance of using and interpreting those possible urinary markers in a disease-specific fashion.

Long-Term Discontinuation of Botulinum Toxin A Intradetrusor Injections for Neurogenic Detrusor Overactivity: A Multicenter Study.

PURPOSE: Data are lacking on long-term outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity. The aim of this study was to assess the outcomes of intradetrusor injections of botulinum toxin A for neurogenic detrusor overactivity after more than 10 years of followup. MATERIALS AND METHODS: We retrospectively reviewed the charts of all consecutive neurological patients who had received onabotulinumtoxin A or abobotulinumtoxin A intradetrusor injections for neurogenic detrusor overactivity between January 2002 and November 2007 at a total of 3 academic centers. The primary outcome measure was the 10-year discontinuation rate. Other outcomes of interest were failure, reasons for discontinuation and subsequent treatments of neurogenic detrusor overactivity. Discontinuation-free and failure-free survival was estimated by Kaplan-Meier analyses. RESULTS: A total of 140 patients were included in study. The 10-year discontinuation-free and failure-free survival rates were 49.1% and 73%, respectively. The most common reason for discontinuation was failure in 43.7% of cases, which was primary and secondary in 17.2% and 26.5%, respectively. Secondary failure occurred after a median of 8 injections and a median of 80.1 months from the first injection. Other reasons for discontinuation were patient decision in 28.1% of patients, nonbotulinum toxin A related improvement of urinary incontinence in 14.1%, neurological condition progression in 12.5% and an adverse event in 1.6%. Discontinuation-free survival was significantly poorer in patients with spina bifida than in patients with multiple sclerosis or spinal cord injury (p = 0.02). CONCLUSIONS: More than half of the patients with neurogenic detrusor overactivity discontinued intradetrusor botulinum toxin A within the first 10 years after the initial injection. Patients with spina bifida are at high risk for discontinuation.

Impact of routine imaging in the diagnosis of recurrence for patients with localized and locally advanced renal tumor treated with nephrectomy.

OBJECTIVE: Modalities of surveillance to detect recurrence after nephrectomy for localized or locally advanced renal tumor are not standardized. The aim was to assess the impact of surveillance scheme on oncological outcomes. METHODS: Patients treated for localized or locally advanced renal tumor with total or partial nephrectomy between 2006 and 2010 in an academic institution were included retrospectively. According to the University of California Los Angeles Integrated Staging System (UISS) protocol, follow-up was considered adequate or not. Symptoms, location and number of lesions at recurrence diagnosis were collected. Recurrence-free, cancer-specific and overall survivals were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were calculated to identify prognostic factors. RESULTS: A total of 267 patients were included. Median follow-up was 72 months. Recurrence rate was 23.2% (62/267 patients). Recurrences were local (16%), single metastatic (23%), oligo-metastatic (15%) or multi-metastatic (46%). 72.6% of the recurrences occurred within the 3 years after surgery. No recurrence was diagnosed by chest X-ray or abdominal ultrasound. One hundred and twenty-one patients had inadequate follow-up. They had similar recurrence-free survival, cancer-specific survival and overall survival as patients with adequate follow-up. In multivariable analysis, the presence of multi-metastatic lesions was an independent prognostic factor of worse cancer-specific mortality after recurrence diagnosis (HR = 10.15, 95% CI: 2.29-44.82, p = 0.002). CONCLUSION: Role of chest X-ray and abdominal ultrasound for the detection of recurrences is limited. Rigorous follow-up according to the UISS protocol does not improve oncological outcomes. Follow-up schedules with less frequent imaging should be discussed.

Risk of prolapse and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor using clean intermittent catheterization versus Valsalva voiding.

AIMS: To assess the relative risks of pelvic organ prolapse (POP) and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor voiding with Valsalva versus those using clean-intermittent catheterization (CIC). METHODS: We conducted a retrospective analysis including all spina bifida patients with neurogenic acontractile detrusor with a minimum follow-up of 12 months. Patients were then divided in two groups according to their bladder management: voiding with Valsalva versus CIC. The primary endpoint was any de novo or worsened rectal and/or pelvic organ prolapse (POP) diagnosed during follow-up. The secondary outcome was urinary complications defined as febrile urinary tract infections (UTI) and/or urolithiasis and/or renal failure. RESULTS: Fifty-five patients (50.9% were males) met the inclusion/exclusion criteria: 28 voiding with Valsalva and 27 performing CIC. At baseline, the rates of vaginal prolapse (44.4% vs 50%; P = 0.99), and rectal prolapse/intussusception (25.9% vs 21.4%; P = 0.76) were similar in both groups. After a median follow-up of 80.6 and 65.6 months, respectively (P = 0.29), the rate of de novo or worsened rectal prolapse/intussusception was higher in the Valsalva voiding group than in the CIC group (32.1% vs 3.7%; P = 0.01). De novo or worsened vaginal prolapses were also more common in the Valsalva voiding group, but it did not reach statistical significance (33.3% vs 11.1%; P = 0.29). CONCLUSIONS: Valsalva voiding might be harmful in adult spina bifida patients with neurogenic acontractile detrusor as it may increase the risk of rectal prolapse/intussusception. Overall, the prevalence of POP and rectal prolapse was high in both groups.

Defecation disorders in Spina Bifida: Realistic goals and best therapeutic approaches.

AIMS: Spina Bifida (SB) is a rare congenital condition that frequently impairs the neurological control of both fecal continence and defecation. Several therapeutic strategies have been proposed but impact assessment is lacking. Our objectives were to quantify the symptomatic improvement and to determine the optimal strategy in this rare condition where randomized controlled trials are difficult to conduct. METHODS: Data were extracted from a prospective database. The present analysis focused on patients having undergone at least two gastroenterological assessments. A standardized therapeutic approach was used from the first visit. Improvement was quantified by the variation of quantified symptomatic scores. RESULTS: The data of of 57 adults with SB (gender F/M: 30/27 [52.6/47.4%]; mean age: 33.8 [18.5] years) were extracted. After a mean follow-up of 46 months, 23/57 patients (40.4%) had at least improvement of one point of the Cleveland Clinic Incontinence score (CCIS); 13/57 (22.8%) reported a significant improvement of continence (delta score >50%). Five of the twelve patients (41.6%) with CCIS < 5 at baseline became incontinent over time. The neurological level was not associated with a worse continence outcome. Work on stool consistency and transanal irrigation were the most useful strategies in those with significant improvement of continence. CONCLUSIONS: Using conventional strategies, a benefit on fecal continence occurs in only one out of five patients suffering from Spina Bifida and continent patients at baseline can develop fecal incontinence over time. A strategy targeting improved control of defecation (transanal irrigation) and a standardization of follow-up protocol might be beneficial.

Urinary TIMP-2 and MMP-2 are significantly associated with poor bladder compliance in adult patients with spina bifida.

AIMS: To assess the predictive values of six urinary markers (nerve growth factor [NGF], brain-derived neurotrophic factor [BDNF], matrix metalloproteinase 2 [MMP-2], tissue inhibitor metalloproteinase 2 [TIMP-2], transformation growth factor ß-1 [TGF-B1], and prostaglandin 2 [PGE2]) for adverse urodynamic features and for upper urinary tract damage in adult patients with spina bifida. MATERIALS AND METHODS: A single-center prospective trial was conducted from March 2015 to March 2017 including all consecutive adult patients with spina bifida seen for urodynamic testing. The urine was collected and stored at -80°C. A urodynamic and an upper urinary tract were systematically performed. At the end of the inclusion period, urines were defrosted and urinary nerve growth factor, BDNF, TIMP-2, and TGF-B1 were assessed using validated ELISA kits. The urinary markers levels were adjusted on the urinary creatinine level. Urinary MMP-2 levels were assessed by zymography. RESULTS: Fourty patients were included. Only TIMP-2 and MMP-2 were significantly associated with poor bladder compliance (P = .043 and P = .039, respectively). TIMP-2 was also the only urinary marker significantly associated with upper urinary tract damage on imaging (OR = 19.81; P = .02). Of all urodynamic parameters, bladder compliance and maximum detrusor pressure were the only ones associated with upper urinary tract damage on imaging (P = .01 and P = .02), The diagnostic performances of urinary TIMP-2 for upper urinary tract damage were slightly superior to PdetMax and bladder compliance with an area under the curve of 0.72. CONCLUSION: Urinary TIMP-2 and MMP-2 were significantly associated with poor bladder compliance and urinary TIMP-2 was significantly associated with upper urinary tract damage. These findings support a pathophysiological role of extracellular matrix remodeling in poor bladder compliance of adult patients with spina bifida.

AMS-800 Artificial urinary sphincter in female patients with stress urinary incontinence: A systematic review.

AIMS: To perform a systematic review of studies reporting the outcomes of AMS-800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD). METHODS: A systematic literature search of the Medline and Embase databases was performed in June 2018 in accordance with the PRISMA statement. No time limit was used. The protocol was registered in PROSPERO (CRD42018099612). Study selection and data extraction were performed by two independent reviewers. RESULTS: Of 886 records screened, 17 were included. All were retrospective or prospective non-comparative case series. One study reported on vaginal AUS implantation, 11 on open AUS implantation, two on laparoscopic AUS implantation, two on robot-assisted AUS implantation and one compared open and robot-assisted implantations. The vast majority of patients had undergone at least one anti-incontinence surgical procedure prior to AUS implantation (69.1-100%). The intraoperative bladder neck injury rates ranged from 0% to 43.8% and the intraoperative vaginal injury rates ranged from 0 to 25%. After mean follow-up periods ranging from 5 to 204 months, the complete continence rates ranged from 61.1% to 100%. The rates of explantation, erosion and mechanical failure varied from 0% to 45.3%, 0% to 22.2% and 0% to 44.1%, respectively. CONCLUSIONS: AMS-800 AUS can provide excellent functional outcomes in female patients with SUI resulting from ISD but at the cost of a relatively high morbidity. High level of evidence studies are needed to help better define the role of AUS in the female SUI armamentarium.

Italian consensus statement for the use of allografts in ACL reconstructive surgery.

PURPOSE: Graft choice for primary anterior cruciate ligament reconstruction (ACL-R) is debated, with considerable controversy and variability among surgeons. Autograft tendons are actually the most used grafts for primary surgery; however, allografts have been used in greater frequency for both primary and revision ACL surgery over the past decade. Given the great debate on the use of allografts in ACL-R, the "Allografts for Anterior Cruciate Ligament Reconstruction" consensus statement was developed among orthopedic surgeons and members of SIGASCOT (Società Italiana del Ginocchio, Artroscopia, Sport, Cartilagine, Tecnologie Ortopediche), with extensive experience in ACL-R, to investigate their habits in the use of allograft in different clinical situations. The results of this consensus statement will serve as benchmark information for future research and will help surgeons to facilitate the clinical decision making. METHODS: In March 2017, a formal consensus process was developed using a modified Delphi technique method, involving a steering group (9 participants), a rating group (28 participants) and a peer-review group (31 participants). Nine statements were generated and then debated during a SIGASCOT consensus meeting. A manuscript has been then developed to report methodology and results of the consensus process and finally approved by all steering group members. RESULTS: A different level of consensus has been reached among the topics selected. Strong agreement has been reported in considering harvesting, treatment and conservation methods relevant for clinical results, and in considering biological integration longer in allograft compared to autograft. Relative agreement has been reported in using allograft as the first-line graft for revision ACL-R, in considering biological integration a crucial aspect for rehabilitation protocol set-up, and in recommending a delayed return to sport when using allograft. Relative disagreement has been reported in using allograft as the first-line graft for primary ACL-R in patients over 50, and in not considering clinical results of allograft superior to autograft. Strong disagreement has been reported in using allograft as the first-line graft for primary ACL-R and for skeletally immature patients. CONCLUSIONS: Results of this consensus do not represent a guideline for surgeons, but could be used as starting point for an international discussion on use of allografts in ACL-R. LEVEL OF EVIDENCE: IV, consensus of experts.

Artificial Urinary Sphincter in Male Patients with Spina Bifida: Comparison of Perioperative and Functional Outcomes between Bulbar Urethra and Bladder Neck Cuff Placement.

PURPOSE: We evaluated the perioperative and long-term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism. MATERIALS AND METHODS: We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation-free and revision-free device survival was estimated by the Kaplan-Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure. RESULTS: A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision-free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation-free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75). CONCLUSIONS: In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

Intradetrusor Injections of Botulinum Toxin A in Adults with Spinal Dysraphism.

PURPOSE: The aim of the current study was to determine the outcomes of botulinum toxin A intradetrusor injections in adult patients with spina bifida. MATERIALS AND METHODS: All patients with spinal dysraphism who underwent intradetrusor injections of botulinum toxin A from 2002 to 2016 at a total of 14 centers were retrospectively included in analysis. The primary end point was the global success of injections, defined subjectively as the combination of urgency, urinary incontinence and detrusor overactivity/low bladder compliance resolution. Univariate and multivariate analysis was performed to seek predictors of global success. RESULTS: A total of 125 patients were included in study. The global success rate of the first injection was 62.3% with resolution of urinary incontinence in 73.5% of patients. All urodynamic parameters had improved significantly by 6 to 8 weeks compared to baseline, including maximum detrusor pressure (-12 cm H2O, p <0.001), maximum cystometric capacity (86.6 ml, p <0.001) and compliance (8.9 ml/cm H2O, p = 0.002). A total of 20 complications (3.6%) were recorded for the 561 intradetrusor botulinum toxin A injections, including 3 muscular weakness complications. The global success rate of the first injection was significantly lower in patients with poor compliance (34.4% vs 86.9%, OR 0.08, p <0.001). On multivariate analysis poor compliance was associated with a lower global success rate (OR 0.13, p <0.001). Female gender (OR 3.53, p = 0.01) and patient age (OR 39.9, p <0.001) were predictors of global success. CONCLUSIONS: Intradetrusor botulinum toxin A injections were effective in adult patients with spina bifida who had detrusor overactivity. In contrast, effectiveness was much lower in adult patients with spina bifida who had poor bladder compliance. The other predictors of global success were female gender and older age.

Fecal incontinence in patients with spina bifida: The target is the rectum.

AIMS: The prevalence rate of severe fecal incontinence (FI) in adults with spina bifida (SB) is high. The physiological basis of FI in SB has not been clearly established, which contributes to inadequate care. The aim was to better characterize a large cohort of adults with special consideration of anorectal physiology. METHODS: A multidisciplinary team from a French referral centre for SB prospectively collected data on patients who had an anorectal manometry. Factors associated with severe FI (Cleveland clinical incontinence score ≥ 9) were assessed in a multivariate analysis model. RESULTS: A total of 132 adults with SB (sex ratio M/F: 55 [41.7%]/77 [58.3%]; mean age of 38.2 [11.6] years old) were assessed. Among these patients, 83/132 (62.9%) suffered from severe FI. Rectal perception was not evaluable among 17 patients who had a latex allergy. Overall, 29/115 (25.2%) had maximal tolerable volume (MTV) > 330 mL or no sensation. The absence of anal canal sensitivity, MVT > 330 mL and the amplitude of the recto-anal inhibitory reflex (RAIR) >75% after a rectal isovolumic inflation of 50 mL were significantly associated with severe FI in the multivariate analysis model. Neither neurological level nor other neurological features were associated with severe FI. CONCLUSIONS: This study showed that FI in patients with SB is mainly associated with rectal abnormalities. This should be taken into consideration to improve incontinence management of patients with SB.

Switch to Abobotulinum toxin A may be useful in the treatment of neurogenic detrusor overactivity when intradetrusor injections of Onabotulinum toxin A failed.

AIMS: To assess the outcomes of switching to a different brand of botulinum toxin A (BTA, from Botox® to Dysport®) in case of failure of intradetrusor injections (IDI) of Botox® in the treatment of neurogenic detrusor overactivity (NDO). METHODS: The charts of all patients who underwent a switch to IDI of Dysport® after failure of an IDI of Botox® at six departments of neurourology were retrospectively reviewed. The main outcomes of interest were the bladder diary data and four urodynamic parameters: maximum cystometric capacity (MCC), maximum detrusor pressure (PDET max), and volume at first uninhibited detrusor contraction (UDC). RESULTS: Fifty-seven patients were included. After the first injection of Dysport®, no adverse events were reported. A significant decrease in number of urinary incontinence episodes per day was observed in 52.63% of patients (P < 0.001) and all patients experienced a reduction in PDET Max (-8.1 cmH20 on average; P = 0.003). MCC significantly increased by a mean of 41.2 (P = 0.02). The proportion of patients with no UDC increased significantly at week 6 after ATA injections (from 15.79% to 43.9%; P = 0.0002). Hence, 32 patients draw clinical and/or urodynamic benefits from the botulinum toxin switch from (56.14%). After a median follow up of 21 months, 87% of responders to BTA switch were still treated successfully with BTA. CONCLUSION: Most patients refractory to Botox® (56.14%) draw benefits from the switch to Dysport®.