Affirming Long-Term Outcomes After Contemporary Urethroplasty: The Adverse Impact of Increasing Stricture Length, Lichen Sclerosus, Radiation, and Infectious Strictures.

PURPOSE: There is a paucity of reported long-term outcomes after contemporary urethroplasty. Our objective is to determine the long-term success of modern urethroplasty and identify factors associated with stricture recurrence in this context. MATERIALS AND METHODS: Patients undergoing urethroplasty from July 2003 to May 2013 with at least 100 months of follow-up were identified. Long-term outcomes including stricture recurrence and patient satisfaction were evaluated by review of regional/provincial electronic records and telephone interview. Urethroplasty failure was defined as a recurrent stricture (<16F) confirmed on cystoscopy. Cox regression was used to evaluate variables associated with long-term stricture recurrence. RESULTS: A total of 733 patients were identified with ≥ 100 months follow-up. Median patient age was 45 years, stricture length was 4.7 cm, and 85.8% failed prior endoscopic treatment. At a median follow-up of 12.3 years, 89 recurrences were observed. Cumulative incidence of stricture recurrence was 6%, 10%, and 12% after 1, 5, and 10 years, respectively. From a patient-reported perspective, 89% of patients reported being satisfied with the outcome of surgery. On multivariable analyses, increasing stricture length (HR 1.1, 95% CI 1.05-1.15; P < .001) and stricture etiology (P < .001), in particular lichen sclerosus (HR 4.46, 95% CI 2.25-9.53), radiation (HR 4.25, 95% CI 1.65-10.9), and infectious strictures (HR 5.27, 95% CI 2.03-13.7), were independently associated with stricture recurrence. CONCLUSIONS: This study affirms the widely held belief that modern urethroplasty provides high long-term patency and patient-reported satisfaction. Patients with longer strictures as well as those with lichen sclerosus, radiation, and infectious etiologies have a higher hazard of stricture recurrence in the long term.

Defining bladder outlet obstruction and detrusor underactivity in females with overactive bladder: Are we forgetting about the free uroflowmetry?

INTRODUCTION: Both detrusor underactivity (DU) and bladder outlet obstruction (BOO) can coexist in patients with overactive bladder. Definitions of both DU and BOO are based on pressure-flow study (PFS) data. However, invasive urodynamics study can differ from a natural micturition, in fact, discrepancies between free uroflowmetry (UFM) and PFS have been largely described. Our goal is to assess the correlation of free-flowmetry and PFS among patients with OAB and to evaluate how different definitions of DU/BOO are able to discriminate patients with different free UFMs. METHODS: A retrospective review of urodynamics performed at a single institution was conducted. Females with OAB who voided more than 150 mL in both UFM and PFS were included. Parameters from both voiding episodes were compared with nonparametric test. Two definitions of DU were applied; PIP1: Pdet@Qmax+Qmax < 30 and Gammie: Pdet@Qmax < 20 cmH2 O, Qmax < 15 mL/s, and BVE < 90% (Bladder voiding efficiency). Also, two definitions of obstruction were chosen; Defretias: Pdet@Qmax ≥25 cmH2 O and Qmax ≤ 12 mL/s and Solomon-Greenwell female BOO index ≥ 18. Patients who matched with each definition were compared to those who did not, to assess if any definitions were able to discriminate different noninvasive uroflowmetries. RESULTS: A total of 195 patients were included. Overall, mean age was 55 ± 12 years, 90.8% had mixed urinary incontinence, and 39% complained of at least one voiding symptom. Globally, Qmax and BVE correlated poorly between UFM and PFS, showing that most of the variation corresponded to a systematic error. Twenty-two individuals were found to have DU, they had a difference of 13 mL/s on both maximum flows. Fifty-four patients showed BOO, with a difference between their Qmax of 19 mL/s. Among the four definitions analyzed, only PIP1 and Defreitas were able to discriminate patients with actually a lower Qmax on the free UFM. CONCLUSIONS: Patients with overactive bladder seem to have a systematic discordance between the urine flow of the free and invasive studies. Current definitions of DU and BOO, which are based on the PFS parameters, are not consistently able to discriminate patients who actually void deficiently on the free UFM.

Dropped abdominal pressure at void in women.

INTRODUCTION AND HYPOTHESIS: "Dropped pabd at void" occurs when pabd decreases below the previous resting pressure during voiding time. We sought clinical factors associated with this phenomenon and evaluated whether its correction modifies the urodynamic diagnosis. METHODS: Retrospective cross-sectional study of non-neurological consecutive symptomatic women. The following definitions were used: "dropped pabd at void": decrease in pabd at Qmax ≥ 5 cmH2O; bladder outflow obstruction (BOO) (pdetQmax ≥ 25 cmH2O + Qmax ≤ 12 ml/s and female BOO index (pdetQmax - 2.2*Qmax) > 18; "low detrusor contraction strength": PIP1 (pdetQmax + Qmax) < 30. In patients with "dropped pabd at void", pdetQmax was corrected. RESULTS: A total of 360 women were analyzed. Ninety-five percent of the women had a variation in pabd at Qmax between -13 and 53 cmH2O. "Dropped pabd at void" was found in 100 women (27.8%). History of stress urinary incontinence (SUI) surgery was significantly higher (p = 0.016) and symptoms of mixed urinary incontinence were significantly lower (p = 0.030) in patients with "dropped pabd at void". On multivariate analysis only the history of SUI surgery maintained its significance (OR = 1.787 [95% CI: 1.058, 3.017], p = 0.030). When correcting pdetQmax in women with "dropped pabd at void", 2 or 5 patients lost BOO diagnosis (depending on how it was diagnosed) and 7 patients gained a "low detrusor contraction strength" diagnosis. CONCLUSIONS: Approximately one-quarter of women had "dropped pabd at void", which was associated with a history of SUI surgery. Correction of pdetQmax would lead to a 2.5% to 3.33% diagnostic modification.

Urodynamic and clinical features in women with overactive bladder: When to suspect concomitant voiding dysfunction?

AIM: The aim of this study is to describe the prevalence and type of female voiding dysfunction (FVD) in patients with overactive bladder (OAB) who were studied by urodynamics and its relationship with voiding symptoms. METHODS: This is a cross-sectional study of female adult patients with OAB syndrome who underwent UDS in a University Hospital in Chile between January 2015 and April 2020. FVD was defined either as bladder outlet obstruction (BOO) or detrusor underactivity (DU). BOO was established if the Solomon-Greenwell BOO index was higher than 18. DU was diagnosed when the invasive maximum flow rate (Qmax) was ≤15 ml/sec, detrusor pressure at Qmax (Pdet@Qmax) was ≤20 cmH2 O and postvoid residual (PVR) was greater than 10%. Urodynamic data and clinical features were compared between groups. RESULTS: Two hundred and ninety-nine UDS were selected and analyzed. Bladder outlet obstruction was diagnosed in 59 patients (19.7%), whereas DU was found in 10 patients (3.3%). In the multivariate analysis, the logistic regression to predict BOO demonstrated that night-time frequency, the presence of detrusor overactivity and a higher PVR were independent predictors of BOO. Instead, for DU, the only independent predictor was a smaller voided volume in the pressure-flow study. CONCLUSION: Female voiding dysfunction was found in 23% of patients with overactive bladder. BOO is more frequent than DU, and should be suspected in patients with higher night-time frequency, presence of detrusor overactivity and a high PVR. Instead, DU should be suspected in patients with a smaller voided volume.

Laparoendoscopic single-site simultaneous bilateral nephrectomy: first reported case series.

Bilateral renal tumors in patients on dialysis are usually managed with bilateral nephrectomy. With traditional laparoscopy, this procedure requires the insertion of multiple trocars. Laparoendoscopic single-site surgery (LESS) uses a single umbilical incision to insert multiple instruments and is also employed for extraction of specimens. This technique appears especially useful for bilateral nephrectomy, since many access ports can be spared. We describe 5 cases of simultaneous bilateral radical nephrectomies performed at a single academic institution. We had no intraoperative complications and a mean operating time of 155 minutes. Four patients could be resected using this approach; one case was converted to a traditional laparoscopy. One case had a postoperative complication. We believe this technique is feasible, and can be accomplished with acceptable morbidity and ade-quate operative time.