Incontinence outcomes in women undergoing retropubic mid-urethral sling: a retrospective cohort study comparing Safyre™ and handmade sling

ABSTRACT Purpose This study examined and compared efficacy, safety, satisfaction, and complications of the retropubic Safyre™ sling and a retropubic hand-made synthetic sling (HMS) in a short-, mid- and long-term follow-up. Methods We retrospectively reviewed a prospectively maintained database of women who underwent Safyre™ or HMS between March 7ths 2005 and December 27ths, 2017. Patients had first assessment (7-10 days), second (40-45 days), and third (sixth month) postoperatively. Between September and December 2018, patients who completed at least one year of surgery, received a telephone call. Follow-up compared quartiles of follow-up time to determine complications (Clavien-Dindo), success rates (International Consultation on Incontinence Modular Questionnaire for Urinary Incontinence Short Form - ICIQ-UI SF), and patient satisfaction. Results Three hundred fifty-one patients underwent surgery and 221 (63%) were evaluated after a median of 78.47 (± 38.69) months, 125 (55%) in the HMS, and 96 (45%) in the Safyre™ group. Higher intraoperative bladder injury was observed with Safyre™ (0% vs. 4.2%, p=0.034), and a tendency for urinary retention, requiring indwelling urinary catheter over 24 hours (2.4% vs. 8.3%, p=0.061). Both HMS (p<0.001) and Safyre™ (p<0.001) presented improvements on ICIQ-UI SF. There were no differences in satisfaction, subjective cure rates, ICIQ-UI SF, or complications between groups. Conclusions Both HMS and Safyre™ have similar satisfaction and subjective cure rates, with marked ICIQ-UI SF score improvement. Higher rates of intraoperative bladder injury were seen in patients who received Safyre™ retropubic sling.

Is there a role for sacral neuromodulation in patients with neurogenic lower urinary tract dysfunction?

ABSTRACT Purpose To review current literature regarding sacral neuromodulation (SNM) for neurogenic lower urinary tract dysfunction (NLUTD) focused on indications, barriers and latest technological developments. Material and Methods A PubMed database search was performed in April 2020, focusing on SNM and various neuro-urological conditions. Results SNM has been increasingly indicated for lower urinary tract dysfunction (LUTD) in neuro-urological patients. Most studies are cases series with several methodological limitations and limited follow-up, lacking standardized definition for SNM clinical success. Most series focused on neurogenic overactive bladder in spinal cord injured (incomplete lesions) and multiple sclerosis patients. Barriers for applying this therapy in neurogenic LUTD were mainly related to magnetic resonance imaging incompatibility, size of the implantable pulse generator (IPG), and battery depletion. Newer technological advances have been made to address these limitations and will be widely available in the near future. Conclusions SNM seems a promising therapy for neurogenic LUTD in carefully selected patients with incomplete lesions. Further studies are still needed to define which subgroups of neurological patients benefit the most from this minimally invasive technique.

Oxidative stress in the bladder of men with LUTS undergoing open prostatectomy: a pilot study

ABSTRACT Purpose: This study aims to evaluate the link between preoperative parameters and oxidative stress (OS) markers in the bladder wall of men undergoing open prostatectomy. Materials and Methods: From July 2014 to August 2016, men aged ≥ 50 years and presenting with LUTS were prospectively enrolled. Preoperative assessment included validated questionnaires (IPSS and OAB - V8), lower urinary tract ultrasound and urodynamics. Bladder biopsies were taken during open prostatectomy for determination of OS markers. Increased OS was defined by increased concentration of malondialdehyde (MDA) and / or decreased concentration of antioxidant enzymes (superoxide dismutase and / or catalase). P<0.05 was regarded as statistically significant. Results: Thirty - eight consecutive patients were included. Mean age was 66.36 ± 6.44 years, mean prostate volume was 77.7 ± 20.63 cm3, and mean IPSS was 11.05 ± 8.72 points. MDA concentration was increased in men with severe bladder outlet obstruction (BOO grade V - VI according to the Schaefer's nomogram) in comparison with BOO grade III - IV (p = 0.022). Patients with severe LUTS also had higher MDA concentration when compared to those with mild LUTS (p = 0.031). There was a statistically significant association between increased post - void residual urine (cut off ≥ 50 mL) and not only higher levels of MDA, but also reduced activity of SOD and catalase (p < 0.05). Conclusions: This pilot study showed that severity of LUTS and BOO were associated with increased MDA concentration in the bladder wall of men undergoing open prostatectomy. Further studies are still needed to assess the role of non - invasive biomarkers of OS in predicting bladder dysfunction in men with LUTS.

Overactive bladder - 18 years - Part II

ABSTRACT Traditionally, the treatment of overactive bladder syndrome has been based on the use of oral medications with the purpose of reestablishing the detrusor stability. The recent better understanding of the urothelial physiology fostered conceptual changes, and the oral anticholinergics – pillars of the overactive bladder pharmacotherapy – started to be not only recognized for their properties of inhibiting the detrusor contractile activity, but also their action on the bladder afference, and therefore, on the reduction of the symptoms that constitute the syndrome. Beta-adrenergic agonists, which were recently added to the list of drugs for the treatment of overactive bladder, still wait for a definitive positioning – as either a second-line therapy or an adjuvant to oral anticholinergics. Conservative treatment failure, whether due to unsatisfactory results or the presence of adverse side effects, define it as refractory overactive bladder. In this context, the intravesical injection of botulinum toxin type A emerged as an effective option for the existing gap between the primary measures and more complex procedures such as bladder augmentation. Sacral neuromodulation, described three decades ago, had its indication reinforced in this overactive bladder era. Likewise, the electric stimulation of the tibial nerve is now a minimally invasive alternative to treat those with refractory overactive bladder. The results of the systematic literature review on the oral pharmacological treatment and the treatment of refractory overactive bladder gave rise to this second part of the review article Overactive Bladder – 18 years, prepared during the 1st Latin-American Consultation on Overactive Bladder.

Initial experience with sacral neuromodulation for the treatment of lower urinary tract dysfunction in Brazil

ABSTRACT Objectives: We report on the short-term outcomes of sacral neuromodulation (SNM) for treatment of idiopathic lower urinary tract dysfunction in Brazil (procedures performed before 2014). Materials and Methods: Clinical data and surgical outcomes of patients who underwent SNM staged procedures were retrospective evaluated. Urological assessment included a focused medical history and physical examination, measurement of postvoid residual volumes, urodynamics, and bladder diaries. A successful test phase has been defined by improvement of at least 50% of the symptoms, based on bladder diaries. Results: From January 2011 to December 2013, eighteen consecutive patients underwent test phase for SNM due to refractory overactive bladder (15 patients), non-obstructive chronic urinary retention (2 patients), and bladder pain syndrome/interstitial cystitis (1 patient). All patients underwent staged procedures at four outpatient surgical centers. Mean age was 48.3±21.2 (range 10-84 years). There were 16 women and 2 men. Median follow-up was 3 months. Fifteen patients (83.3%) had a successful test phase and underwent implantation of the pulse generator (IPG). Median duration of the test phase was 7 days (range 5–24 days). Mean age was 45.6±18.19 years in responders versus 61.66±34.44 years in non-responders (p=0.242). Mean operative time (test phase) was 99±33.12 min in responders versus 95±35 min for non-responders (p=0.852). No severe complications were reported. Conclusion: SNM is a minimally invasive treatment option for patients with refractory idiopathic lower urinary tract dysfunction. Our initial experience with staged technique showed that tined-lead electrodes yielded a high rate of responders and favorable clinical results in the short-term follow-up.

Overactive bladder - 18 years - Part I

ABSTRACT Abstract: Overactive bladder syndrome is one of the lower urinary tract dysfunctions with the highest number of scientific publications over the past two decades. This shows the growing interest in better understanding this syndrome, which gathers symptoms of urinary urgency and increased daytime and nighttime voiding frequency, with or without urinary incontinence and results in a negative impact on the quality of life of approximately one out of six individuals – including both genders and almost all age groups. The possibility of establishing the diagnosis just from clinical data made patients' access to specialized care easier. Physiotherapy resources have been incorporated into the urological daily practice. A number of more selective antimuscarinic drugs with consequent lower adverse event rates were released. Recently, a new class of oral drugs, beta-adrenergic agonists has become part of the armamentarium for Overactive Bladder. Botulinum toxin injections in the bladder and sacral neuromodulation are routine modalities of treatment for refractory cases. During the 1st Latin-American Consultation on Overactive Bladder, a comprehensive review of the literature related to the evolution of the concept, epidemiology, diagnosis, and management was conducted. This text corresponds to the first part of the review Overactive Bladder 18-years.

Twenty-five milligrams of clomiphene citrate presents positive effect on treatment of male testosterone deficiency - a prospective study

INTRODUCTION: Male testosterone deficiency is associated with bad sexual function and quality of life (QoL). The aim of this study was to determine whether a daily dose of 25 mg clomiphene citrate (CC) is effective in stimulating the endogenous testosterone production pathway and to address the applicability of this medication as a therapeutic option for symptomatic hypogonadism. MATERIALS AND METHODS: This was a prospective study. Men with low sexual desire and testosterone levels (T) below 400 ng/dL were selected to receive CC. Blood samples were obtained to determine baseline measurements of serum T, estradiol, LH, lipid profile and fasting plasma glucose. Each patient was treated with a daily dose of 25 mg CC for at least 3 months. Patients were asked if they experienced any side effects related to the use of CC and if they experienced any improvement in their sexual profile. Paired samples T-test was utilized to analyze responses to therapy. RESULTS: Our cohort consisted of 125 men with hypogonadism and low libido. Mean age was 62 years (± 11.1 years). Serum T levels ranged from 309 ng/dL (baseline, mean value) to 642 ng/dL (3 months after CC initiation, mean value) (p < 0.001). Serum cholesterol levels ranged from 197 to 186 mg/dL (p = 0.003). There were no statistically significant differences when comparing pre and post-treatment HDL-Cholesterol, triglycerides, fasting plasma glucose and prolactin. All men reported improvements in the post-treatment QoL scores. No serious adverse events were recorded. CONCLUSIONS: The CC was effective in stimulating the endogenous production of testosterone. A lower level of total cholesterol was verified after three months of treatment. This medication should be considered as a therapeutic option for some patients with symptomatic male testosterone deficiency.

Long-term follow-up of penile curvature correction utilizing autologous albugineal crural graft

PURPOSE: Peyronie's disease is an acquired connective tissue disorder of the penile tunica albuginea with fibrosis and inflammation. The disease produces palpable plaques, penile curvature and pain during erections. Usually it results in impairment of the quality of life. Our objective is to review the long-term results of the albugineal grafting harvested from the penile crura for the treatment of severe penile curvature. MATERIALS AND METHODS: Thirty-three patients with Peyronie's disease were submitted to a grafting with tunica albuginea from the penile crura for the correction of penile curvature. The results were evaluated after 6 months of the procedure. Variables studied were overall satisfaction with the procedure, correction of the penile curvature, erectile capacity, penile shortening and the presence of surgical complications. RESULTS: Mean follow-up after surgery was 41 months. Complete correction of the curvature was achieved in 30 patients (90%). The mean preoperative curvature was 91.8 degrees and median plaque length was 2 cm (ranged from 1 to 5 cm). Three patients (9%) experienced recurrence of the penile curvature and required a new procedure. In 30 men (90%) the procedure fulfilled their expectations and in 31 patients (93.9%) their opinions were that sexual partners were satisfied with the penile correction. Penile shortening or augmentation was referred in 6 (18.1%) and 1 (3%) patient, respectively. CONCLUSION: Our series demonstrated that grafting the albugineal defect after incision of the tunica albuginea with tunica from the crus for the correction of penile curvature is safe and results in satisfactory straight erections duringa long-term follow-up.

Diagnóstico e tratamento da hiperplasia benigna da próstata / Diagnosis and treatment of benign prostatic hyperplasia

A hiperplasia benigna da próstata (HBP) é uma condição muito prevalente em homens a partir dos 40 anos, atingindo mais da metade da população masculina na sétima década e a quase totalidade na oitava década. Os sintomas a ela relacionados podem causar grande prejuízo à qualidade de vida desses pacientes. O objetivo da presente revisão é resumir a literatura atual sobre a patologia, focando na sua epidemiologia, diagnóstico e manejo. A avaliação inicial do paciente com HBP deve compreender a anamnese com aplicação do escore de sintomas prostáticos (IPSS), exame físico com toque retal, avaliação laboratorial (PSA sérico, exame de urina e função renal), além de métodos de imagem e urodinâmica para casos selecionados. O tratamento inicial para casos leves e moderados é medicamentoso, com o uso de alfa-bloqueadores ou inibidores da 5-alfaredutase, ou ainda a combinação desses. Pacientes que não respondem ao tratamento medicamentoso, com sintomas graves, ou que desenvolvem complicações da HBP devem ser considerados para tratamento cirúrgico. Este consiste em cirurgia aberta para próstatas de grande volume, ressecção transuretral para próstatas menores, além de outros tratamentos invasivos pouco disponíveis ou indisponíveis no nosso meio. O tratamento expectante para casos leves deve ser lembrado. Em conclusão, a HBP é doença com alta prevalência, cujo tratamento deve ser individualizado e instituído antes do surgimento de complicações maiores

Benign prostatic hyperplasia (BPH) is a very prevalent condition in men after 40 years of age, affecting more than half the male population in the seventh decade, and almost all in the eighth decade of life. The related symptoms can cause great damage to the quality of life of these patients. The purpose of this review is to summarize the current literature on the disease, focusing on epidemiology, diagnosis, and management. The initial evaluation of patients with BPH must include anamnesis with scoring of prostatic symptoms (IPSS), physical examination with digital rectal examination, laboratory evaluation (serum PSA, urinalysis and renal function), and imaging and urodynamics for selected cases. The initial treatment for mild to moderate cases is drug-based, using alpha blockers or 5-alpha-reductase inhibitors, or a combination of these. Patients who do respond to drug treatment, with severe symptoms, or who develop complications of BPH should be considered for surgical treatment. This consists in open surgery for large-volume prostates, transurethral resection for smaller prostates, and other invasive treatments little or unavailable in our community. The expectant treatment for mild cases should be considered. In conclusion, BPH is a highly prevalent disease whose treatment should be individualized and started before the onset of major complications