[Application and progress of neuromodulation in lower urinary tract dysfunction].

For those patients with refractory lower urinary tract dysfunction who are not well treated by traditional therapy such as behavior therapy and drug therapy, neuromodulation technologies have gradually become alternative treatments. Several neuromodulation technologies are also used in animal experimental and clinical scientific research by more and more scholars, in order to find more effective methods and mechanisms of treatment of lower urinary tract dysfunction. This article introduces the principle and advantages of common neuromodulation technologies, which focuses on the application in lower urinary tract dysfunction treatment, and analyzes the direction and the broad prospect of neuromodulation.

Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant manipulation of the urinary tract (UT). We aim to describe the urological events and their management in patients who underwent CRS-HIPEC. METHODS: Clinical records of patients who underwent treatment between 2007 and 2015 were reviewed. Urological events and their multidisciplinary management were analyzed. Descriptive statistics were calculated. RESULTS: A total of 103 patients were included. Mean age was 51 years (SD ± 11.8). Mean peritoneal cancer index (PCI) was 20.4 (SD ± 10.1). Primary tumors included appendicular (64%), gynecological (16%), colorectal (10%), and peritoneal mesotheliomas (9%). Ninety-three percent of patients had bilateral ureteral catheters inserted prior to surgery, without complications. Intraoperative UT injuries occurred in 7% of patients. In 5% of patients, tumor invasion of the bladder was evident at surgery and partial resection and primary repair of the bladder wall was performed. Urological complications included urinary tract infection (UTI) (21%) acute post-renal failure (4%), urinary fistulae (4%), and acute urinary retention (AUR) (1%). CONCLUSIONS: In our study, intraoperative UT events and postoperative complications, although not neglectable, were infrequent. Due to the high complexity of these cases, a multidisciplinary approach is mandatory. However, randomized clinical trials are necessary to clarify current data on the need and efficacy of prophylactic ureteral catheterization in patients undergoing CRS-HIPEC.

Evaluation of the axonics modulation technologies sacral neuromodulation system for the treatment of urinary and fecal dysfunction.

INTRODUCTION: Sacral neuromodulation (SNM) remains one of the few effective treatments for refractory bladder and bowel dysfunction. However, SNM is associated with frequent need for surgical intervention, in many cases because of a failed battery. A rechargeable SNM system, with a manufacturer-reported battery life of 15 years or more, has entered post-market clinical testing in Europe but has not yet been approved for clinical testing in the United States. Areas covered: We review existing neuromodulation technologies for the treatment of lower urinary tract and bowel dysfunction and explore the limitations of available technology. In addition, we discuss implantation technique and device specifications and programming of the rechargeable SNM system in detail. Lastly, we present existing evidence for the use of SNM in bladder and bowel dysfunction and evaluate the anticipated trajectory of neuromodulation technologies over the next five years. Expert commentary: A rechargeable system for SNM is a welcome technological advance. However surgical revision not related to battery changes is not uncommon. Therefore, while a rechargeable system would be expected to reduce costs, it will not eliminate the ongoing maintenance associated with neuromodulation. No matter the apparent benefits, all new technologies require extensive post-market monitoring to ensure safety and efficacy.

A Joint Mechanism of Action for Sacral Neuromodulation for Bladder and Bowel Dysfunction?

Sacral neuromodulation (SNM) is a clinically effective intervention for treatment of urinary and bowel disorders. The aim is to establish the hypothesis that there is a common mechanism of action for SNM in both systems. Current knowledge includes the following: (1) Therapeutic parameters may be different for the 2 efficacy measures. (2) SNM invokes neural circuits that can be observed as neurochemical changes in specific neuroanatomic structures downstream from the therapy delivery site. (3) There are important central nervous system effects for both therapies. (4) Clinical observations regarding normal continence sensations as well as physiological measures of continence are different for the 2 therapy areas.

How does neuromodulation work.

Although sacral neuromodulation (SNM) is approved and successfully used for different urological and proctologic functional diseases for the long-term treatment, less is known about the working mechanisms underlying SNM. This review highlights SNM clinical application, the current data of LUT neuroanatomy and neurophysiology, SNM techniques and its prospective working mechanisms. Functional imaging techniques have facilitated a more detailed insight into the neural network between the central nervous system (CNS) and the lower urinary tract (LUT). In addition to the well-known factors of the spinal micturition pathway, several pontine (e.g. pontine micturition centre) and suprapontine (e.g. cingulate cortex) regions and their interactions have been identified. An attribution of CNS activity levels to different LUT conditions is possible for the first time. Based on this information, different SNM actions could also have been allocated to different ascending/descending pathways and supraspinal regions, whereas acute SNM especially affects regions of learning activity, chronic SNM might result in CNS plasticity even though clinical effectiveness fades after SNM deactivation. Studies to treat fecal incontinence or to prevent detrusor overactivity in complete spinal cord injured patients support the importance of sympathetic pathways for the action of SNM. Despite increasing knowledge about SNM influence on the CNS, the complexity of its underlying working mechanisms is not understood at all. Further investigations with improved functional imaging techniques will enhance our SNM background.

[Local anesthesia with articain in operative interventions in urology].

The aim of the work was to improve the technique of local anesthesia with "ultrakain D-S" in surgical operations in urology. The research included 50 patients with penis diseases, 70 patients with diseases of the scrotum body, 40 patients with various prostate diseases complicated by acute urinary retention. Operative interventions in the patients were carried out with "ultrakain D-S". The control group consisted of patients with similar pathology and operations under local anesthesia, but with lidocain as anesthesia. The data obtained show that in more pronounced anesthetizing effect of "ultrakain D-S" the quantity of the injected drug was less as well as the time necessary for getting anesthesia was shorter than in the control group.

Sacral neuromodulation for neurogenic lower urinary tract dysfunction: systematic review and meta-analysis.

CONTEXT: Treatment of neurogenic lower urinary tract dysfunction (LUTD) is a challenge, because conventional therapies often fail. Sacral neuromodulation (SNM) has become a well-established therapy for refractory non-neurogenic LUTD, but its value in patients with a neurologic cause is unclear. OBJECTIVE: To assess the efficacy and safety of SNM for neurogenic LUTD. EVIDENCE ACQUISITION: Studies were identified by electronic search of PubMed, EMBASE, and ScienceDirect (on 15 April 2010) and hand search of reference lists and review articles. SNM articles were included if they reported on efficacy and/or safety of tested and/or permanently implanted patients suffering from neurogenic LUTD. Two reviewers independently selected studies and extracted data. Study estimates were pooled using Bayesian random-effects meta-analysis. EVIDENCE SYNTHESIS: Of the 26 independent studies (357 patients) included, the evidence level ranged from 2b to 4 according to the Oxford Centre for Evidence-Based Medicine. Half (n=13) of the included studies reported data on both test phase and permanent SNM; the remaining studies were confined to test phase (n=4) or permanent SNM (n=9). The pooled success rate was 68% for the test phase (95% credibility interval [CrI], 50-87) and 92% (95% CrI, 81-98%) for permanent SNM, with a mean follow-up of 26 mo. The pooled adverse event rate was 0% (95% CrI, 0-2%) for the test phase and 24% (95% CrI, 6-48%) for permanent SNM. CONCLUSIONS: There is evidence indicating that SNM may be effective and safe for the treatment of patients with neurogenic LUTD. However, the number of investigated patients is low with high between-study heterogeneity, and there is a lack of randomised, controlled trials. Thus, well-designed, adequately powered studies are urgently needed before more widespread use of SNM for neurogenic LUTD can be recommended.

Transurethral resection of the prostate syndrome: almost gone but not forgotten.

Transurethral resection of the prostate (TURP) syndrome is a rare but potentially fatal syndrome with multifactorial pathophysiology that is now better understood. Unfortunately, despite this improved understanding, it is not yet obsolete and still remains a risk. Many reviews of TURP syndrome have been presented from an anesthetic perspective; this review reflects more the urologic perspective with emphasis on the importance of multidisciplinary management of this complex syndrome. We present a review of TURP syndrome that specifically assesses advances in the understanding of risk factors, pathophysiology, and techniques used to prevent this syndrome. The databases Medline, Embase, Cochrane Controlled Trial Register, and Database of Abstracts of Reviews of Effects were systematically reviewed from inception to April 2009 for the keywords TUR (P), TUR (P) syndrome, and transurethral resection of prostate. There was no language restriction for our search. Randomized controlled trials, review articles and case series were included in our search. Our review showed a declining trend in the incidence of TURP syndrome despite TURP remaining the gold standard for the management of benign prostatic obstruction. Technologic advances using an array of laser techniques, the use of bipolar circuitry, together with advances in training techniques have helped minimize the risk of development of this syndrome. This review demonstrates the complexity of TURP syndrome. Even with a greater understanding of the pathophysiology, it highlights the unpredictability of the syndrome from presenting symptoms, preventative measures, and management. TURP syndrome cannot be protocol driven and the need for vigilance, a high index of suspicion, intensive monitoring, and a multidisciplinary approach is vital.

Traditional medicinal plants of cold desert Ladakh-used against kidney and urinary disorders.

AIM OF THE STUDY: Traditional medicine of clod desert Ladakh has large potential to treat various ailments among tribal communities inhabited in the remotest region of Indian subcontinent. This study was conducted to document the new ethno-medico-botanical information and traditional use of medicinal plants against kidney and urinary disorders, and thus to conserve the rapidly disappearing traditional knowledge system of Amchis of Ladakh. MATERIALS AND METHODS: The information was collected from 105 villages of Leh and Kargil districts of Ladakh region by involving 47 Amchis (the herbalists), village heads and old aged persons including women population through on spot interview and repeated queries among other interviewees over a period of 3 years from 2004-2006. RESULTS: The use of 68 medicinal plants belonging to 29 families and 58 genera of clod desert was documented against the treatment of kidney and urinary disorders in the tribal communities of Ladakh region in India. These species were used in combination of some exotic species such as Bergenia ligulata, Cinnamomum zeylanicum, Crocus sativus, Elettaria cardamomum, Emblica officinalis, Ficus religiosa, Mangifera indica, Punica granatum, Santalum album, Spondiax axillaris, Terminalia belerica, Terminalia chebula, Zingiber officinale and some medicinal stones, minerals and salts etc. Problem in urine discharge, burning sensation and painful urination, inflammation and bleeding in the kidney, irritable condition of bladder, haemorrhage of kidney and removal of blocked urine and kidney stone were the frequently reported disorders in the study area. CONCLUSION: The effectiveness of traditional system of medicine, role of Amchis in preparation of remedies according to age, sex and severity of ailment, method of preparation, doses and its administrations among tribal communities of Ladakh provides certain new information. Though the system is extensively used among the tribal communities in the remotest regions but still it has a great scope of proper phytochemical and pharmacological validation of the medicinal plants used in different remedies for conservation and development of traditional system of medicine according to modernization.

[Neuromodulation in the management of neurogenic lower urinary tract dysfunction]. / Neuromodulation dans la prise en charge des troubles vésico-sphinctériens neurologiques.

Various methods using electrical nerve stimulation for neuromodulation can be proposed to patients with neurogenic lower urinary tract dysfunction. However, few studies have reported the results in this specific patient population. In this article, the authors describe the various hypotheses to explain the efficacy of neuromodulation, and the results of the two main neuromodulation techniques currently used in France: sacral neuromodulation and posterior tibial neuromodulation.

Change in urinary symptoms and quality of life in men with benign prostatic hyperplasia after transurethral resection of prostate.

The aim of this study was to determine the improvement in symptoms and quality of life in men with Benign Prostatic Hyperplasia (BPH) after transurethral resection of prostate (TURP). Fifty consecutive patients fit for undergoing TURP for BPH were included in this study. All patients were assessed prior to definitive surgical treatment using standardized questionnaires of international prostate symptom score (IPSS) which includes single disease-specific quality of life (QOL) score. Follow up of these patients was done at three months with same questionnaires. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age and duration of symptom was 68.3 years and 26.7 months respectively. The average volume of prostate was 46.1 cm3. Preoperative IPSS and QOL score were 23.4 and 5.2 respectively; 56.6% of the score was contributed by obstructive symptoms. At three months follow up, the mean IPSS reduced down to 7.9 and QOL score improved to 1.5. The average change in IPSS and QOL score were 15.6 and 3.6; these changes were statistically significant and correlated with preoperative symptom severity. Most of the patients presented with severe symptom associated with decreased QOL. After TURP, there was significant improvement in IPSS and QOL scores. The improvement was graded as good out come and strongly related to preoperative symptom severity.

Acupuncture reflexotherapy in the treatment of sensory urgency that persists after transurethral resection of the prostate: a preliminary report.

AIMS: In this study, we wanted to evaluate whether acupuncture reflexotherapy is able to treat the sensory irritative components of LUTS (lower urinary tract symptoms) that persist after transurethral resection of the prostate. METHODS: We have evaluated 42 patients, randomly selected into three groups: 14 patients received placebo, 15 patients received oxybutynin, and 13 patient were treated with electrostimulation by acupuncture reflexotherapy. RESULTS: Before treatment, the mean maximum flow rate (Qmax) was 21.0 +/- 3.2 mL/sec, the mean International Prostate Symptom Score (I-PSS) score was 12.9 +/- 4.2, the mean I-PSS Quality of Life (IPSS QoL) score was 3.6 +/- 1.2. At the first check-up performed after 3 months, we could observe that the I-PSS and QoL scores were 12.6 +/- 4.3 and 3.8 +/- 1.3 in the group who received placebo; the scores decreased to 11.1 +/- 3.2 and to 3.1 +/- 1.0, respectively, in the 15 patients treated with oxybutynin and decreased to 6.1 +/- 2.6 and 1.3 +/- 1.1, respectively, in the 13 patients who underwent acupuncture reflexotherapy. At 1-year follow-up, these parameters were practically similar. The voiding diaries allowed us to deduce that the average number of daytime voidings decreased by 8% in patients who received oxybutynin and decreased by 20% in 13 patients who underwent reflexotherapy; the average number of nocturnal micturitions decreased by approximately 20% and 60%, respectively, in patients who received oxybutynin and reflexotherapy. CONCLUSIONS: This study has pointed out that acupuncture reflexotherapy has a real benefit in patients with sensory urgency that persists after transurethral resection of the prostate.

TUMT 2.0: results three months and three years after treatment.

OBJECTIVE: To examine the durability of the results following low-power transurethral microwave thermotherapy (TUMT). MATERIAL AND METHODS: 28 patients 55 to 83 years of age with lower urinary tract symptoms (LUTS) and marginal/moderate infravesical obstruction and 4 patients with LUTS, peak urinary flow (Qmax) less than than 15 ml/sec and prostate volume below 40 ml. We used a Prostatron version 2.0. RESULTS: transurethral resection of the prostate (TURP) was done shortly after treatment in one patient with acute obstruction caused by necrotic tissue. Three months after treatment 15 patients reported that they were cured from LUTS and 10 experienced improvement of symptoms. A significant reduction of the symptom scores was seen among the 31 patients not operated while Qmax was unchanged. Three years after treatment two patients were still cured from LUTS, 9 hadsome reduction of symptoms, and TURP had been done in further three patients. Symptom scores among the 24 patients still in the study were significantly lower than the baseline values but also significantly higher than the symptom scores three months after treatment. Residual urine was reduced while no changes were seen in Qmax. CONCLUSION: TUMT done by Prostatron version 2.0 causes mainly a reduction of symptoms. Most of the effect disappears after a few years.

Motor evoked potentials from the pelvic floor in patients with multiple sclerosis.

The use of motor evoked potentials (MEPs) to study the integrity of pelvic floor motor innervation is poorly described in the literature. This study evaluated the clinical use of pelvic floor MEPs in 16 women with multiple sclerosis. Lower urinary tract dysfunction was assessed with urodynamic investigations. Transcutaneous magnetic stimulation was applied over the motor cortex and spinal roots, and MEPs were recorded from the puborectalis, the external urethral sphincter, and the abductor hallucis muscles. In many patients, responses from the pelvic floor muscles could not be evoked, and central motor conduction times for the puborectalis motor pathways could only be calculated in 56%. There was a poor correlation of abnormal conduction to lower urinary tract dysfunction. It is concluded, that unevokable responses from pelvic floor muscles in a patient with multiple sclerosis should be interpreted with care, and that pelvic floor MEPs have a limited clinical value in the investigation of suspected demyelinating disease.

The 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy vs transurethral resection of the prostate.

OBJECTIVE: To assess the 2-year symptomatic and urodynamic results of a prospective randomized trial of interstitial radiofrequency therapy of the prostate (IRFT) vs transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Patients with lower urinary tract symptoms (LUTS) and urodynamic evidence of bladder outlet obstruction (BOO) were randomized to undergo IRFT or TURP and were followed up using the International Prostate Symptom Score (IPSS) and urodynamic assessment for 2 years. RESULTS: At 2 years there was a clinically relevant reduction in the IPSS in the IRFT (20 to 9) and TURP groups (22 to 4). There was also a statistically significant reduction in the detrusor pressure at maximum urinary flow in both groups, but the reduction in the IRFT group was probably not sufficient to explain the observed symptomatic improvements solely from a reduction in BOO. CONCLUSION: IRFT can produce a sustained improvement in LUTS for at least 2 years. However, such improvements are unlikely to be entirely the result of a reduction in BOO. The effects of radiofrequency energy may, at least partly, be independent of any thermal effect and depend instead on neuromodulation of lower urinary tract nerves.

Front and rear: the pelvic floor is an integrated functional structure.

The pelvic floor is a muscular structure, pierced by the urologic, genital and distal intestinal tract. This structure is not a frozen but a functional unit. Normal function can thus be replaced by dysfunctions of several kinds, overlapping voiding, sexual, genital and defecatory behaviour. For instance, vaginismus is akin to anismus and vesicourethral dyssynergia. Recent recognition of the medicosurgical consequences of sexual abuse has shown that many urologic, genital and digestive dysfunctions are sort of a body signature of the trauma, which must be dealt with if the symptom is to disappear. If the pelvic floor is integrated, unsuspected pathology will lie outside of the spectrum of activities of a given specialty, and thus urologists, gynecologists, gastroenterologists and colorectal surgeons should not only exchange, but should also be aware of the pathologies of neighbouring specialties. This paper elaborates on a more holistic vision of pelvic floor function including sexuality. Out of this, a number of different hypotheses are elaborated in the different spheres of activities, about different pathologies, their basic cause, and how they could be dealt with.

[Uro- and colodynamic studies in combined diseases of the pelvic organs in children]. / Uro- i kolodinamicheskoe issledovanie pri sochetannykh zabolevaniiakh tazovykh organov u detei.

A variety of examination techniques are widely used by the authors in uro- and colodynamic investigations of children with combined pelvic lesions. These are: rectotonometry, electroimpulse test of the urethra and anal canal, thermocontrast test of the bladder and distal colon, electrostimulation of the pudendal nerve, investigation of the bladder and rectosphincteral reflex, anal and bulbocavernous reflexes, etc. Such multimodality approach is helpful in detection of local pelvic dysfunction and in prediction of the treatment outcomes.

[Electroacupuncture and laser puncture in the early postoperative period of urological patients]. / Elektroakupunktura i lazeropunktura v rannem posleoperatsionnom periode u urologicheskikh bol'nykh.

To provide an objective assessment of the analgetic effect obtained at electric or laser acupuncture early after operative treatment of 117 uronephrological patients, the study was performed of a general vegetative and psychoneurological responses and blood levels of some hormones. There were positive effects on psychoemotional postoperative stress, pain impulses from the wound reflected by higher pain thresholds and lowered levels of contrainsular hormones against higher insulin and C-peptide concentrations. These changes were dependent on a nociception degree and agreed with the analgetic action of the reflex anesthesia modalities.