Induction Chemotherapy Reduces Patient-reported Toxicities During Neoadjuvant Chemoradiation with Intensity Modulated Radiotherapy for Rectal Cancer.

BACKGROUND: Initial treatment with either neoadjuvant chemoradiation (CRT) or induction FOLFOX (5-Fluorouracil, leucovorin, and oxaliplatin) chemotherapy followed by CRT is considered standard treatment for locally advanced rectal cancer. We compared patient-reported outcomes (PRO) during CRT in patients who had received induction chemotherapy versus those who did not. PATIENTS AND METHODS: We reviewed records of patients with locally advanced rectal cancer who were treated with CRT between September 2009 and October 2014, and who had completed ≥ 4 PRO assessments during treatment. Clinician- and patient-reported toxicities were collected each week during treatment. We fit binomial generalized linear models to maximum toxicity scores across all patients' visits. RESULTS: Of 123 patients with ≥ 4 PRO assessments, 87 (71%) patients reported a clinically meaningful PRO score of 3 or higher for diarrhea, and 91 (74%) patients reported a PRO score of ≥ 3 for urgency, during 1 or more weeks of treatment, corresponding to 'very frequent' or worse. Of 116 patients who had also completed ≥ 4 clinician-reported assessments for descriptive analysis, clinically significant diarrhea (Common Terminology Criteria for Adverse Events grade ≥ 2) was reported in 9% of patients, and grade 2 proctitis and cystitis were reported in 20% and 4%, respectively. Eighty-four (68%) patients had undergone induction chemotherapy prior to CRT. Patients who received induction chemotherapy had 68% lower odds of experiencing significant urgency (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.11-0.95; P = .04), 76% lower odds of bleeding (OR, 0.24; 95% CI, 0.1-0.62; P < .01), and 75% lower odds of tenesmus (OR, 0.25; 95% CI, 0.11-0.6; P < .01) versus those treated with upfront CRT. CONCLUSION: Based on PROs, a high proportion of patients experienced clinically significant symptoms during pelvic CRT, with diarrhea and urgency being most commonly reported. This appears to be under-reported on clinician-reported assessments. Delivery of induction chemotherapy was associated with lower odds of experiencing urgency, bleeding, and tenesmus on PROs during subsequent CRT, with no significant impact on diarrhea and rectal pain.

Results of Sacral Neuromodulation Therapy for Urinary Voiding Dysfunction: Five-Year Experience of a Retrospective, Multicenter Study in China.

PURPOSE: This five-year, retrospective, multicenter study evaluated the long-term safety and efficiency of sacral neuromodulation (SNM) in Chinese patients with urinary voiding dysfunction. PATIENTS AND METHODS: This is a Chinese national, multicenter, retrospective study that included 247 patients (51.2% female) who received an implantable pulse generator (IPG) (InterStim, Medtronic, Minneapolis, MN, USA) between 2012 and 2016. Success was considered if the initial ≥50% improvement in any of primary voiding diary variables persisted compared with baseline. The results were further stratified by identifying patients who showed >50% improvement and those although showed <50% improvement but still wanted to receive IPG; these data were collected and analyzed for general improvement. RESULTS: Following test stimulation, 187 patients (43%) declined implantation and 247 (57%) underwent implantation using InterStim®. Among 247 patients, 34 (13.7%) had overactive bladder (OAB), 59 (23.8%) had interstitial cystitis/bladder pain syndrome (IC/BPS), 47 (19%) had idiopathic urinary retention (IUR), and 107 (44.1%) had neurogenic bladder (NB). IPG efficiency rate for OAB, interstitial cystitis/bladder pain syndrome, idiopathic urinary retention, and neurogenic bladder were 42.5, 72.4, 51.6, and 58.8%, respectively. The mean duration of follow-up was 20.1 ± 12.8 months. CONCLUSIONS: SNM appears effective in the long term, with a total IPG implantation rate of approximately 57% (ranging between 42.5 and 72.4% depending on indication). Interstitial cystitis/bladder pain syndrome appear to be the best indication for stage I testing. Chinese neurogenic bladder patients are most inclined to choose SNM. SNM is relatively safe, with low postoperation adverse events of 16.1% and reoperation rate of 3.2% during the follow-up period.

Dysfunctional Voiding in Pediatrics: A Review of Pathophysiology and Current Treatment Modalities.

In Dysfunctional Voiding (DV), the external urethral sphincter or pelvic diaphragm (consisting of striated muscle) contracts during voiding, contrary to normal physiological mechanism. In Flowmetry plus pelvic Electromyography (EMG), the perineal surface electrodes will show a persistent activity during voiding. The cause is believed to be the persistence of an immature bladder control. The overall prevalence of DV is estimated between 7 and 11% of girls of school age. Symptoms of DV comprise a range of symptoms, deriving from outlet obstruction, incomplete voiding and elevated Post Micturition Residual (PMR): from daytime urine leaks, nocturnal enuresis, Urinary Tract Infections (UTI), or Vesicoureteral reflux (VUR), to the final decompensation of upper urinary tract in extreme cases. The literature reflects a high prevalence of constipation among these patients: between 33 and 56% of dysfunctional voiders are constipated. Initially, therapy of functional voiding disorders such as DV, comprises a series of fundamental principles called Urotherapy or voiding re-education. Currently, Urinary animated Biofeedback (Bfb) is the treatment modality of choice. This therapy discloses patients their own physiological and muscular mechanisms. Majority of the studies on Bfb efficacy reflect an improvement/ cure rate of around 70-80%. Initial flowmetric improvement followed by symptom relief or clinical improvement as the Bfb sessions continue, is likely to occur. It has been observed that there are two variables associated with clinical success of Bfb in DV syndrome: the absence of PMR at the end of treatment and an adequate or even aggressive constipation management.

Voiding Dysfunction in Multiple Sclerosis.

Voiding dysfunction is a common and debilitating consequence of multiple sclerosis (MS). The prevalence and severity of voiding dysfunction increases with the increasing severity of MS, but even the mildest forms of the disease are associated with urinary symptoms in 30% of patients. Every component of the central nervous system is involved in regulating voiding; as a result, MS can lead to a wide variety of urinary symptoms and urologic complications. The effect of MS on voiding can be classified according to the resulting function of the bladder and the urethral sphincter during storage and emptying of urine. Therapy is targeted to the specific bladder and sphincter abnormalities that occur. The primary goals of therapy are prevention of injury to the upper urinary tract (kidneys), reduction in urinary tract infections, and maintenance of urinary continence. These goals can be achieved by interventions ranging from behavioral modification to major reconstructive surgery.

Reflujo vaginal: no se puede diagnosticar lo que no se conoce / Vaginal reflux: what is not known cannot be diagnosed

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Late urinary side effects 10 years after low-dose-rate prostate brachytherapy: population-based results from a multiphysician practice treating with a standardized protocol and uniform dosimetric goals.

PURPOSE: To determine late urinary toxicity (>12 months) in a large cohort of uniformly treated low-dose-rate prostate brachytherapy patients. METHODS AND MATERIALS: From 1998 to 2009, 2709 patients with National Comprehensive Cancer Network-defined low-risk and low-tier intermediate-risk prostate cancer were treated with Iodine 125 ((125)I) low-dose-rate prostate brachytherapy; 2011 patients with a minimum of 25 months of follow-up were included in the study. Baseline patients, treatment, implant factors, and late urinary toxicity (Radiation Therapy Oncology Group [RTOG] grading system and International Prostate Symptom Score [IPSS]) were recorded prospectively. Time to IPSS resolution, late RTOG genitourinary toxicity was examined with Kaplan-Meier and log-rank tests. Cox proportional hazards regression was done for individual covariates and multivariable models. RESULTS: Median follow-up was 54.5 months (range, 2-13 years). Actuarial toxicity rates reached 27% and 10% (RTOG ≥2 and ≥3, respectively) at 9-13 years. Symptoms resolved quickly in the majority of patients (88% in 6-12 months). The prevalence of RTOG 0, 1, 2, 3, and 4 toxicity with a minimum of 7 years' follow-up was 70%, 21%, 6.4%, 2.3%, and 0.08%, respectively. Patients with a larger prostate volume, higher baseline IPSS, higher D90, acute toxicity, and age >70 years had more late RTOG ≥2 toxicity (all P≤.02). The IPSS resolved slower in patients with lower baseline IPSS and larger ultrasound prostate volume, those not receiving androgen deprivation therapy, and those with higher D90. The crude rate of RTOG 3 toxicity was 6%. Overall the rate of transurethral resection of the prostate was 1.9%; strictures, 2%; incontinence, 1.3%; severe symptoms, 1.8%; late catheterization, 1.3%; and hematuria, 0.8%. The majority (80%) resolved their symptoms in 6-12 months. CONCLUSION: Long-term urinary toxicity after brachytherapy is low. Although actuarial rates increase with longer follow-up (27% RTOG 2 and 10% RTOG 3 at 13 years), symptoms resolve relatively quickly; between 5 and 13 years' follow-up, >90% of patients have minimal urinary toxicity. Refining patient selection criteria, planning, and treatment delivery may further reduce toxicity.

Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review.

BACKGROUND: Percutaneous Tibial Nerve Stimulation (PTNS) has been proposed for the treatment of overactive bladder syndrome (OAB), non-obstructive urinary retention (NOUR), neurogenic bladder, paediatric voiding dysfunction and chronic pelvic pain/painful bladder syndrome (CPP/PBS). Despite a number of publications produced in the last ten years, the role of PTNS in urinary tract dysfunctions remains unclear. A systematic review of the papers on PTNS has been performed with the aim to better clarify potentialities and limits of this technique in the treatment of OAB syndrome and in other above mentioned urological conditions. METHODS: A literature search using MEDLINE and ISI web was performed. Search terms used were "tibial nerve" and each of the already mentioned conditions, with no time limits. An evaluation of level of evidence for each paper was performed. RESULTS: PTNS was found to be effective in 37-100% of patients with OAB, in 41-100% of patients with NOUR and in up to 100% of patients with CPP/PBS, children with OAB/dysfunctional voiding and patients with neurogenic pathologies. No major complications have been reported.Randomized controlled trials are available only for OAB (4 studies) and CPP/PBS (2 studies). Level 1 evidence of PTNS efficacy for OAB is available. Promising results, to be confirmed by randomized controlled studies, have been obtained in the remaining indications considered. CONCLUSIONS: PTNS is an effective and safe option to treat OAB patients. Further studies are needed to assess the role of PTNS in the remaining indications and to evaluate the long term durability of the treatment. Further research is needed to address several unanswered questions about PTNS.

[Effects of "attenuation and synergia" for Bushenhuoxue Granules on Parkinson's patients].

OBJECTIVE: To study the effects of "Attenuation and Synergia" for Bushenhuoxue Granules (BSHXG) on Parkinson's patients. METHODS: 120 patients were enrolled and divided into two groups randomly, the control group were treated with placebo and treatment group with BSHXG, both groups based on Madopar treatment. Double-blinded clinical trial was adopted in treatment period. Follow-up period for 6 months. Usage of Madopar and score of treatment complications were adopted to measure related motor complications before and after treatment. RESULTS: Usage of Madopar and score of treatment complications in treatment group were decreased (P < 0.05). No adverse effects were found in this trial. CONCLUSION: BSHXG can decrease the side-effects of Madopar and put off the development of PD. The effects of "Attenuation and Synergia" of BSHXG becomes clear with time.

Correlation of right frontal hypoperfusion and urinary dysfunction in iNPH: a SPECT study.

OBJECTIVES: To elucidate the pathophysiology of urinary dysfunction in idiopathic normal-pressure hydrocephalus (iNPH) by single-photon emission computed tomography (SPECT) and statistical brain mapping. METHODS: Urinary symptoms were observed and N-isopropyl-p-[(123)I]-iodoamphetamine (IMP)-SPECT imaging was performed in 97 patients with clinico-radiologically definite iNPH. The patients included 56 men and 41 women; mean age, 74 years. The statistical difference in normalized mean tracer counts was calculated and visualized between patients with urinary dysfunction of severer degrees (>grade 2/4) and milder degrees (

Effectiveness of biofeedback for dysfunctional elimination syndrome in pediatrics: a systematic review.

PURPOSE: Dysfunctional elimination syndrome is associated with an inability to effectively empty the bladder and may present with UTI, incontinence, intestinal constipation or other voiding symptoms. Biofeedback has emerged as one potentially effective and non-invasive treatment. We sought to analyze if biofeedback is an effective method to treat children less than 18 years of age. METHODS: A literature search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Database, AUA, CUA, AAP and ESPU abstracts. Copies of all relevant articles were retrieved for quality assessment and data abstraction by two independent reviewers. Primary outcomes were UTIs and daytime incontinence. RESULTS: 27 studies were included (1 RCT and 26 case-series). The pooled estimate showed 83% (95% CI: 79%-86%) and 80% (95% CI: 76%-85%) improvement in UTI and daytime incontinence respectively. I(2) statistic showed "Low" (7%) and "High" (77%) heterogeneity across studies results for UTI and daytime incontinence. The only included RCT favored biofeedback over standard therapy (RR 1.4, 95% CI: 0.98-2.00) but this was not statistically significant. On analysis of all included studies there was also improvement in constipation (18%-100%), frequency (67%-100%), urgency (71%-88%) and VUR (21%-100%). PVR improvement ranged from 26 ml to 99 ml and Q(max) improvement was from 3.1 ml/s-4.7 ml/s. CONCLUSION: Based on this review, biofeedback is an effective, non-invasive method of treating dysfunctional elimination syndrome, and approximately 80% of children benefited from this treatment. However, most reports were of low level of evidence and studies of more solid design such as RCT should be conducted.

The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding.

PURPOSE: The aim of the study was to compare the treatment outcome of two urotherapy programs in children with dysfunctional voiding (DV) through analyzing the clinical manifestations and uroflowmetry parameters. MATERIALS AND METHODS: Eighty-six children with DV were randomly divided into two groups (A and B). Children in both groups were educated about the importance of regular voiding and hydratation, and about the appropriate posture during voiding. Simple voiding instructions were provided. In group A diaphragmatic breathing and pelvic floor muscles (PFM) retraining were additionally assigned to children. Constipation and recurrent urinary tract infections (UTIs) were treated in both groups. Selected children from both groups received pharmacotherapy (anticholinergics or desmopressin). Uroflowmetry with pelvic floor electromyography and ultrasound residual urine volumes were obtained before and at the end of the 12-month treatment period. RESULTS: After one year of therapy, urinary incontinence and nocturnal enuresis were cured in a significantly larger number of children in group A than in group B (P < 0.001; P < 0.05). Although more children with UTIs were cured in group A, the difference was not statistically significant compared to group B. There was a significant recovery constipation-wise in both groups. Post-treatment uroflowmetry parameters and curve pattern were markedly improved only in group A. CONCLUSIONS: Carefully planned and regularly controlled abdominal and PFM retraining is beneficial in children with DV for curing urinary incontinence, nocturnal enuresis, UTIs and normalizing urinary function. Further trials are needed to define the most effective treatment program for achieving the best treatment outcome.

[Clinical outcome of intermediate risk prostate cancer treated with iodine 125 monotherapy: The Hotel-Dieu of Quebec experience]. / Evolution clinique des patients atteints d'un cancer prostatique de risque intermédiaire traités par implants permanents d'iode-125 : l'expérience de l'Hôtel-Dieu de Québec.

PURPOSE: To describe the biochemical failure-free survival (BFFS), GU toxicity and erectile dysfunction in intermediate risk prostate cancer treated with iodine 125 monotherapy (I125). PATIENTS AND METHODS: Between October 1994 and October 2007, 1282 patients were treated with I125 at the Hotel Dieu de Quebec. Two hundred patients were intermediate risk prostate cancer. One hundred and fifty-seven had enough follow-up to be evaluated in this study. Biochemical failure-free survival is reported using Phoenix definition. Acute and late GU toxicity was described using the International Prostate Symptoms Score (IPSS) as well as with the rate of bladder catheter. Erectile dysfunction was also reported. RESULTS: The mean age of the patients was 65.6 years (S.D.=6 years) and the mean pretreatment PSA was 8.7ng/ml. About half of the patients (51%) were T2b/T2c. About 44.6% had a PSA greater than 10 and 4.5% had Gleason score of 7/10. More than half of the patients received a short course of hormones of less than 6 months for cytoreduction (57.4%). The median follow-up was 60 months. Biochemical failure-free survival at 60-month and 96-month were 87.1% and 81% according to Phoenix definition. The mean IPSS rose from 5 immediately after the implant to 15 1 month after and then slowly decreased to 8 at 24 months. Acute urinary retention with bladder catheter occurred in 10.9% of patients. Only 4.3% presented erectile dysfunction at 5 months post-implant. CONCLUSION: I125 monotherapy for intermediate risk prostate implant gives biochemical failure-free survivals at 5 years and 8 years comparable to those obtained with high dose external beam radiotherapy. GU toxicity and erectile dysfunction were low and acceptable. Therefore, the use of I125 alone in this group of patients could be presented and discussed with the patient in the waiting of phase III validation.

Benign prostatic obstruction and parkinson's disease--should transurethral resection of the prostate be avoided?

PURPOSE: According to the literature transurethral resection of the prostate in patients with Parkinson's disease has an increased risk of postoperative urinary incontinence. However, this conclusion might have been reached because some patients with multiple system atrophy incorrectly diagnosed as Parkinson's disease were included in these reports. Therefore, we investigated the outcome of transurethral prostate resection in patients with a secure neurological diagnosis of Parkinson's disease. MATERIALS AND METHODS: A total of 23 patients with Parkinson's disease who underwent transurethral prostate resection for benign prostatic obstruction were evaluated retrospectively. Subsequent neurological developments in patients were followed, ensuring that those with multiple system atrophy had not been included in analysis. RESULTS: At transurethral prostate resection median patient age was 73 years, median duration of Parkinson's disease before the resection was 3 years, and median Hoehn and Yahr scale was 2. Of the 14 patients with a preoperative indwelling urinary catheter transurethral prostate resection restored voiding in 9 (64%) and only 5 (36%) required catheterization postoperatively. Of the 10 patients with preoperative urge urinary incontinence, continence was restored in 5 and improved in 3 following transurethral prostate resection. There were no cases of de novo urinary incontinence after transurethral prostate resection. At a median postoperative followup of 3 years transurethral prostate resection was successful in 16 of the 23 patients (70%). CONCLUSIONS: Transurethral prostate resection for benign prostatic obstruction in patients with Parkinson's disease may be successful in up to 70% and the risk of de novo urinary incontinence seems minimal. Thus, Parkinson's disease should no longer be considered a contraindication for transurethral prostate resection provided that preoperative investigations including urodynamic assessment indicate prostatic bladder outlet obstruction.

Pediatric voiding dysfunction: current evaluation and management.

Voiding dysfunction and urinary incontinence in children is common. Both are associated with significant effects on quality of life and comorbidities, including urinary tract infections (UTIs) and constipation. A thorough history, physical examination, and non-invasive evaluation are essential in determining the etiology. Interventions, such as behavioral therapy/biofeedback and pharmacologic therapies, are primary treatments. Prevalence rates, current evaluation, and management techniques are discussed in this article.

How to engage the Latino or African American patient with benign prostatic hyperplasia: crossing socioeconomic and cultural barriers.

Disparities based on race and ethnicity still exist in the US healthcare system. Such disparities are reflected in the diagnosis and treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) among African Americans and Latinos. The prevalence of risk factors for BPH and LUTS and symptom progression are higher in these populations, but treatment is less common. African American men and Latinos frequently have other serious comorbidities, such as cardiovascular disease, diabetes mellitus, and metabolic syndrome. Health plan constraints and variabilities, race/ethnicity, socioeconomic status, language, healthcare-seeking behaviors, and cultural beliefs and practices influence the treatment of BPH and LUTS, oftentimes resulting in unequal access to care or inferior quality of care. The provision of nondiscriminatory treatment poses a challenge to clinicians that can partially be addressed by improving the cultural competence of practitioners in minority communities. An awareness of the customs and healing traditions of African Americans and Latinos may also facilitate culturally appropriate care and improve outcomes, and the participation of clinicians in continuing education/professional development programs to increase knowledge about minority health issues is recommended. Conversely, improving the health literacy of African American and Latino patients with BPH and LUTS can help avoid ineffective nontraditional methods of treatment.

Urodynamic evaluation in diabetic patients with prostate enlargement and lower urinary tract symptoms.

INTRODUCTION: Lower urinary tract symptoms (LUTS) are common in men over 50 years of age due to prostate enlargement. Diabetes mellitus is also more prevalent in this group. LUTS may result from bladder outlet obstruction (BOO) secondary to prostate enlargement or bladder dysfunction secondary to diabetes or even from a combination of both. OBJECTIVES: The objective of this study was to determine the prevalence of BOO and other urodynamic abnormalities in diabetic patients with LUTS and enlarged prostate. A secondary objective was to assess the predictive value of non-invasive tests for BOO diagnosis in this group of patients. PATIENTS AND METHODS: 50 consecutive diabetic patients with enlarged prostate and LUTS were evaluated by the International Prostate Symptom Score (IPSS), ultrasonography and urodynamics. BOO diagnosis was based on pressure/flow measurements according to the International Continence Society's standards. RESULTS: Of the 50 patients in the study, 23 (46%) had BOO. There was no correlation between the IPSS, uroflowmetry, post-voiding residual urine or prostate volume and the presence of BOO (p > 0.05). CONCLUSIONS: There is a relatively low prevalence of BOO in diabetic patients with prostate enlargement and LUTS. Non-invasive tests did not allow the identification of these subjects. Only urodynamic evaluation is able to determine symptom etiology.

Long-term urinary sequelae following 125iodine prostate brachytherapy.

PURPOSE: We describe long-term urinary function in men treated with 125iodine brachytherapy without supplemental beam irradiation. MATERIALS AND METHODS: A total of 484 men with favorable risk prostate cancer received 125I prostate brachytherapy with a followup ranging from 12 to 93 months (median 41). Prior hormonal therapy (2 to 6 months) was used in 14% of patients to reduce prostate size. Urinary function was assessed before implant by the International Prostate Symptom Score and a voiding study, and in followup by International Prostate Symptom Score. Urinary retention and catheterization, urgency and urge incontinence, persistently increased International Prostate Symptom Score, stricture, and the need for surgical intervention are reported. RESULTS: Beyond 1 year 73.3% of men had no significant urinary sequelae. A flare in the International Prostate Symptom Score to greater than 15 and at least 5 points above baseline occurred in 23%, lasting a median of 3 months. Symptoms of retention requiring catheterization or surgical intervention were seen in 3.4% (1.7% stricture, 0.4% transurethral resection of the prostate, 2.7% catheter). Of the 13 men requiring catheterization at any time after 1 year, 5 (1% of total) remain dependent on clean intermittent catheterization. Median duration of catheter use for those with resolution is 4.5 months. Moderate to severe urinary urgency occurred in 6.4% of patients but it was unresponsive to anticholinergics in only 0.8%. CONCLUSIONS: In this group 27% of men experienced late urinary morbidity following 125I prostate brachytherapy. Rates may vary according to technique and selection factors. The majority responded well to medical or surgical intervention, with 0.8% persistent urgency, and 1% catheter dependence.

Is the current practice providing an integrated approach to the management of LUTS and ED in primary care? An audit and literature review.

INTRODUCTION: Lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are highly prevalent in aging men. A common pathophysiology is hypothesized to explain causal link. However, prevalence of ED in patients with LUTS remains underdiagnosed, as we believe general practitioners (GPs) do not inquire about ED in men presenting with LUTS. AIM: Our goal to find out if LUTS and ED were dealt with in an integrated fashion in primary care. METHODS: One hundred consecutive patients with LUTS attending the prostate assessment clinic anonymously completed a locally developed, qualitatively validated questionnaire and sexual health inventory for men. MAIN OUTCOME MEASURES: (i) Prevalence of concomitant ED in men presenting with LUTS; (ii) proportion of GPs enquiring about ED; (iii) patients with LUTS + ED who were offered treatment in primary care; and (iv) patients who sought treatment on review in secondary care. RESULTS: The age of patients was 39-86 years. Fifty-four percent admitted to ED: 66% >/=60 years, and 28%