A Prospective Observational Study of Posterior Tibial Nerve Stimulation in Multiple Sclerosis.

INTRODUCTION AND HYPOTHESIS: The objective was to examine the outcomes of posterior tibial nerve stimulation (PTNS) on bladder, bowel, and sexual health-related quality of life among a cohort of patients with multiple sclerosis (MS) with refractory lower urinary tract symptoms (LUTS). METHODS: Patients with MS and refractory LUTS were recruited for a prospective, observational study using PTNS to treat their symptoms. Patients underwent 12 weekly 30-min PTNS sessions and bladder, bowel, and sexual symptoms were evaluated at baseline, 3, 12, and 24 months with voiding diaries, visual analog scales (VAS), and validated patient-reported questionnaires, including the American Urological Association Symptom Score (AUA-SS), Neurogenic Bladder Symptom Score (NBSS), Michigan Incontinence Symptom Index (M-ISI), Health Status Questionnaire, Sexual Satisfaction Scale, and Bowel Control Scale. RESULTS: A total of 23 patients were recruited: 18 started PTNS and 14 completed 3 months of PTNS. Of the 18 who started PTNS, the mean age was 52 years (SD 12), 61% were female, 83% were white, and most patients had relapsing remitting (39%) MS. Baseline (n=18) and 3-month voiding (n=11) outcomes showed no significant change in number of voids or incontinence episodes. The median VAS symptom improvement was 49 (IQR 26.5, 26) and 9 (53%) patients elected for monthly maintenance PTNS. On paired analysis, there was a significant improvement in median change in NBSS, AUA-SS, and M-ISI. There was no significant change in bowel or sexual dysfunction. CONCLUSIONS: This prospective, observational study of PTNS in patients with MS with refractory LUTS shows improvement in patient-reported bladder outcomes, but not in number of voids per day or bowel or bladder function.

Factors impacting bowel symptoms in a contemporary spinal cord injury cohort: results from the Neurogenic Bladder Research Group Registry.

STUDY DESIGN: Cross sectional. OBJECTIVES: To identify variables associated with severe bowel symptoms in spinal cord injured people. SETTING: National cohort. METHODS: Adult spinal cord injured (SCI) people were recruited for an online registry and 1373 were included for analysis. Univariate analysis and logistic regression was used to evaluate associations between severity of bowel symptoms and variables. Bowel symptoms were assessed by the Neurogenic Bowel Dysfunction (NBD) score and patients scoring ≥14 were categorized as having severe bowel symptoms. Autonomic dysreflexia (AD) severity was measured using a six item questionnaire and reported as total AD score (0-24). Bladder management was categorized as: voiding, clean intermittent catheterization (CIC), surgery (augmentation/diversion) or indwelling catheter. RESULTS: Severe bowel symptoms were reported in 570 (42%) On multivariable logistic regression, every point increase of AD total score was associated with 5% increased odds of having more severe bowel symptoms [OR 1.05 95% CI 1.03-1.10]. Type of bladder management was also associated with more severe symptoms (p = 0.0001). SCI people with indwelling catheters (OR = 2.16, 95% CI 1.40-3.32) or reconstructive surgery (OR = 1.79, 95% CI 1.08-3.32) were almost twice as likely to report more severe bowel symptoms than those performing CIC.

A prospective observational cohort study of posterior tibial nerve stimulation in patients with multiple sclerosis: design and methods.

BACKGROUND: Posterior tibial nerve stimulation (PTNS) is a promising treatment for lower urinary tract symptoms (LUTS) in patients with MS. However, long term data focusing on PTNS impact on health-related quality of life (HRQOL), bowel and bladder symptoms are lacking. This paper describes a study protocol that examines the extended efficacy of PTNS on MS related bladder and bowel symptoms and resulting HRQOL. METHODS/DESIGN: This is a single-centered, prospective, longitudinal, observational cohort study of patients with MS who suffer from LUTS and are refractory to two prior treatment modalities. Participants who have elected to pursue PTNS therapy for LUTS will be eligible. The primary outcome is the median number of urinary frequency and incontinence episodes on a 3-day voiding diary at 3, 12 and 24 months compared to baseline. Secondary outcome measures will include change in total AUA-SS, M-ISI, NBSS, SF-12, SSS and BCS scores from baseline The Expanded Disability Status Scale and magnetic resonance imaging will be evaluated at baseline and annually throughout the study. DISCUSSION: This research protocol aims to expand on the existing literature regarding outcomes of PTNS in MS. Specifically, it will provide long term follow-up data on bladder, bowel, sexual and HRQOL outcomes. The completion of this study will provide longitudinal efficacy data of the impact of PTNS in MS patients. TRIAL REGISTRATION: NCT04063852.

Intermittent catheterization and urinary tract infection in multiple sclerosis patients.

INTRODUCTION: We sought to investigate whether starting clean intermittent catheterization (CIC) for multiple sclerosis (MS) patients with lower urinary tract symptoms (LUTS) and elevated post-void residual (PVR) would improve urinary quality of life (QoL) and decrease risk of urinary tract infection (UTI). MATERIALS AND METHODS: We retrospectively reviewed an institutional data base for MS patients with PVR > 100 mL and obstructive LUTS. Patients were categorized by subsequent choice of treatment: CIC versus medical treatment. Outcomes compared over 1-year follow up included incidence of UTI, urinary QoL, emergency room visits, and adherence to therapy. RESULTS: Between 2014 and 2017, 37 patients met inclusion criteria. Nineteen patients started daily CIC, while 18 patients had pharmacologic therapy. At 1-year follow up, the CIC group had less improvement in urinary symptoms (26% improvement from baseline versus 72%, p = 0.02) and 7 times greater odds of having minimum one UTI within 1 year (OR 6.8, p = 0.01). The CIC group was also more likely to start an additional treatment for LUTS, and to visit the ED (all p < 0.05). CONCLUSIONS: In this group of MS patients with LUTS and elevated PVR, initiation of CIC was associated with increased incidence of UTI and less improvement in urinary symptoms over the subsequent year compared to pharmacologic treatment.

Surveillance After Ureteroneocystostomy: Is it Necessary?

OBJECTIVE: To determine the utility of post-operative imaging after ureteroneocystostomy and whether long-term symptom or radiographic surveillance aided in the detection of recurrent obstruction. MATERIALS AND METHODS: Adult patients were identified who underwent a ureteroneocystostomy with or without psoas hitch or Boari flap between January 2012 and June 2021. Patients who underwent a bilateral procedure, had active malignancy or immediate failure, or did not have 6 months of follow-up with 2 imaging studies were excluded. Using the initial imaging study after stent removal, patients were categorized into normal and equivocal groups according to predefined radiologic criteria. Patients were followed longitudinally to determine whether they subsequently developed radiographic evidence of obstruction. Follow up visits were reviewed for patient symptoms suggestive of post-operative obstruction, defined as flank pain, hematuria, or pyelonephritis. RESULTS: One hundred and twelve patients met criteria. Normal and equivocal initial imaging was seen in 99 and 13 patients, respectively. At a mean radiologic follow-up of 32 months, stricture recurrence was identified in 3 patients with normal initial imaging. No patients with initial equivocal imaging demonstrated recurrent obstruction at mean radiologic follow-up of 29 months. All patients with recurrent stricture presented with symptoms of obstruction. Of patients who developed symptoms after ureteroneocystostomy, 13.6% had recurrent stricture. CONCLUSION: Asymptomatic patients after ureteroneocystostomy who had either normal or equivocal post-operative imaging did not benefit from additional radiologic testing in this cohort. All patients that demonstrated failure presented with symptomatic obstruction that warranted imaging. Surgeons may consider restricting surveillance imaging to symptomatic patients after the initial post-operative period.

Does Early Ureteroneocystostomy After Iatrogenic Ureteral Injury Jeopardize Outcome?

OBJECTIVE: To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days). METHODS: A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups. RESULTS: Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001). CONCLUSION: In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.

Robotic Versus Open Ureteroneocystostomy: Is There a Robotic Benefit?

Aim: We sought to compare the outcomes of patients who underwent an open vs robotic ureteroneocystostomy for ureteral obstruction. Methods: Retrospective review was performed on adult patients who underwent primary ureteroneocystostomy for obstruction from January 2012 to April 2018. Intraoperative outcomes of estimated blood loss (EBL) and operative time, as well as postoperative outcomes of catheter and stent duration, length of hospital stay, inpatient nurse-controlled opioid use, patient-controlled analgesia (PCA), and outpatient opioid prescription, complications, readmission, radiologic and clinical stricture recurrence, and follow-up, were compared. Among the open cohort, indications for an open approach were evaluated, identifying patients with prior complex open abdominal surgery that would make an open approach preferable. Results: Open ureteroneocystostomy was performed in 27 patients compared with 18 who underwent a robotic approach. The open and robotic cohorts were not significantly different in age, gender, Charlson comorbidity index, stricture location or side, abdominal surgery (laparoscopic or open), pelvic radiation, or preoperative urinary tract infection. The robotic group had a significantly lower rate of prior open abdominal surgery. The robotic cohort had significantly lower EBL, length of stay (LOS), catheter duration, prescribed morphine milliequivalents (MME) at discharge, and rate of PCA usage. Among the open cohort, 13 (48%) patients demonstrated indications making an open approach preferable. Comparing the robotic group with the remaining 14 open patients revealed a significantly lower rate of inpatient PCA use, prescribed MME at discharge, LOS, and catheter duration. Mean operative time was higher in the robotic group. EBL was not significantly different in this subanalysis. Conclusions: Robotic ureteroneocystostomy provides similar outcomes when compared with an open approach in well-selected patients when assessing for recurrent ureteral obstruction or adverse events. Robotic surgery is associated with lower postoperative narcotic pain prescriptions at discharge, lower PCA usage, and shorter LOS, which are important benefits when compared with open surgery.

Multi-institutional Outcomes for Simultaneous and Staged Urinary and Fecal Diversions in Patients Without Cancer.

OBJECTIVE: To compare the morbidity and postoperative recovery between patients treated with urinary diversion after colostomy with patients undergoing simultaneous double diversion (DD). METHODS: A multi-institutional retrospective review was performed in patients treated with urinary diversion after colostomy or simultaneous DD between 2007 and 2014 for noncancerous indications. The Clavien-Dindo system was used to classify complications occurring within 90 days of surgery, and high-grade adverse events (HGAE) were classified grade 3 or higher. RESULTS: A total of 46 patients were identified with fecal and urinary diversions (19 in the after colostomy (AC) group, 27 in the DD group). Common indications for urinary diversion were neurogenic bladder (54%) and urinary fistula (44%). Mean hospital stay and return of bowel function after surgery for entire cohort was 13 and 7 days, respectively, with no differences between AC and DD groups. Almost 50% of patients in the cohort experienced an HGAE but there was no difference in HGAE incidence (8/19 AC, 13/27 DD; P = .69) or complication type between the groups. Increased operative time (5% risk per every 15 minutes over 7 hours, P = .03) was the only independent variable associated with increased risk of HGAE. DD was not independently associated with increased risk of HGAE compared with staged urinary diversion. CONCLUSION: Morbidity and postoperative recovery appeared similar whether urinary diversion is performed after colostomy or during a DD.

Peripheral and Sacral Neuromodulation in the Treatment of Neurogenic Lower Urinary Tract Dysfunction.

Sacral and peripheral neuromodulation are minimally invasive surgical procedures that are third-line therapy options for the treatment of patients with idiopathic overactive bladder syndrome. There has been interest in their efficacy in the management of neurogenic lower urinary tract dysfunction (NLUTD). Contemporary data suggest promising outcomes for urinary and bowel symptoms in carefully selected patients with spinal cord injury and/or multiple sclerosis. This article reviews the current literature regarding urinary and bowel outcomes in patients with NLUTD and also discusses contemporary studies that suggest that treatment during particular stages of neurologic injury may prevent long-term urinary sequelae.

Comparative evaluation of physical characteristics of different inflatable penile prostheses.

OBJECTIVE: The aim of this study was to describe and evaluate existing inflatable penile prostheses (IPPs) in an independent laboratory setting. MATERIALS AND METHODS: New IPPs were obtained from two manufacturers: American Medical Systems (AMS) and Coloplast. The AMS 700™ LGX (18 cm), CX (18 cm) and CXR (14 cm), and the Coloplast Titan® Touch (18 cm) and Titan Narrow (14 cm) were investigated. Internal pressure, length and girth of the cylinders were measured at 2 ml increments. A urodynamic individual transducer connected to an analogue amplifier and recording system was used to measure pressure. Rigidity and axial loading of the different IPPs were evaluated with a compression system. RESULTS: Regular-size prostheses were inflated to 22 ml and narrow prostheses to 16 ml. The Titan Touch had a girth of 17.8 mm at 22 ml compared to 15.6 mm for the AMS 700 LGX and 16.5 mm for CX. The AMS 700 LGX increased in length by 13 mm from baseline, a feature that was unique among all the tested prostheses. Rigidity curves as assessed by compression showed significant variability, with both Titan prostheses and the AMS CXR exhibiting similar patterns and requiring a higher load to reach 50% compression. The buckling experiment showed different patterns of deformity. CONCLUSIONS: The results suggest that these prostheses exhibit significant physical differences. The clinical impact of these differences is poorly elucidated. These variations in behavior of the prostheses could be considered by physicians and patients when objectively assessing the choice of prosthesis. These findings could aid in objective patient counseling.