Guidelines of Guidelines: Conservative, Pharmacological, and Surgical Management for Neurogenic Lower Urinary Tract Dysfunction.

Neurogenic lower urinary tract dysfunction (NLUTD) encompasses a broad spectrum of neurological conditions affecting the lower urinary tract. Managing NLUTD requires a tailored approach focused on preserving kidney function and enhancing patients' quality of life. Clinical guidelines provide valuable guidance for healthcare professionals, but discrepancies in recommendations arise among other factors due to limited high-quality clinical evidence. Prominent guidelines from organisations like the International Consultation of Incontinence, the European Association of Urology, the American Urological Association, and the National Institute for Health and Care Excellence offer varying recommendations for NLUTD management. This study reviews and summarizes the recommendations for conservative, pharmacological, and surgical management options across these guidelines. Cite this article as: Ochoa DC, Mahoney AC. Fontaine C, Hashim H. Guidelines of guidelines: conservative, pharmacological, and surgical management for neurogenic lower urinary tract dysfunction (NLUTD). Urol Res Pract. Published online March 31, 2024. doi: 10.5152/tud.2024.23232.

Primary Definitive Treatment versus Ureteric Stenting in the Management of Acute Ureteric Colic: A Cost-Effectiveness Analysis.

Objectives: To analyze the differences in cost-effectiveness between primary ureteroscopy and ureteric stenting in patients with ureteric calculi in the emergency setting. Patients and Methods: Patients requiring emergency intervention for a ureteric calculus at a tertiary centre were analysed between January and December 2019. The total secondary care cost included the cost of the procedure, inpatient hospital bed days, emergency department (A&E) reattendances, ancillary procedures and any secondary definitive procedure. Results: A total of 244 patients were included. Patients underwent ureteric stenting (62.3%) or primary treatment (37.7%), including primary ureteroscopy (URS) (34%) and shock wave lithotripsy (SWL) (3.6%). The total secondary care cost was more significant in the ureteric stenting group (GBP 4485.42 vs. GBP 3536.83; p = 0.65), though not statistically significant. While mean procedural costs for primary treatment were significantly higher (GBP 2605.27 vs. GBP 1729.00; p < 0.001), costs in addition to the procedure itself were significantly lower (GBP 931.57 vs. GBP 2742.35; p < 0.001) for primary treatment compared to ureteric stenting. Those undergoing ureteric stenting had a significantly higher A&E reattendance rate compared with primary treatment (25.7% vs. 10.9%, p = 0.02) and a significantly greater cost per patient related to revisits to A&E (GBP 61.05 vs. GBP 20.87; p < 0.001). Conclusion: Primary definitive treatment for patients with acute ureteric colic, although associated with higher procedural costs than ureteric stenting, infers a significant reduction in additional expenses, notably related to fewer A&E attendances. This is particularly relevant in the COVID-19 era, where it is crucial to avoid unnecessary attendances to A&E and reduce the backlog of delayed definitive procedures. Primary treatment should be considered concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.

Emergency Primary Ureteroscopy for Acute Ureteric Colic-From Guidelines to Practice.

OBJECTIVE: To review the factors that may influence the ability to achieve the present guidelines' recommendations in a well-resourced tertiary centre. According to current National Institute for Health and Care Excellence (NICE) guidelines, definitive treatment (primary ureteroscopy (URS) or shock wave lithotripsy (ESWL)) should be offered to patients with symptomatic renal colic that are unlikely to pass the stone within 48 h of diagnosis. METHODS: Retrospective review of all patients presenting to the emergency department between January and December 2019 with a ureteric or renal stone diagnosis. The rate of emergency intervention, risk factors for intervention and outcomes were compared between patients who were treated by primary definitive surgery vs. primary symptom relief by urethral stenting alone. RESULTS: A total of 244 patients required surgical management for symptomatic ureteric colic without symptoms of urinary infection. Of those, 92 patients (37.7%) underwent definitive treatment by either primary URS (82 patients) or ESWL (9 patients). The mean time for the procedure was 25.5 h (range: 1-118). Patients who underwent primary definitive treatment were likelier to have smaller and distally located stones than the primary stenting group. Primary ureteroscopy was more likely to be performed in a supervised setting than emergency stenting. CONCLUSIONS: Although definitive treatment carries high success rates, in a high-volume tertiary referral centre, it may not be feasible to offer it to all patients, with emergency stenting providing a safe and quick interim measure. Factors determining the ability to provide definitive treatment are stone location, stone size and resident supervision in theatre.

Modern advancements in minimally invasive surgical treatments for benign prostatic obstruction.

A wide variety of minimally invasive surgical techniques are now being offered for treating voiding lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). These options offer an alternative to both medical therapy and traditional surgical options. Minimally invasive surgical treatments in LUTS/BPO boast both day case and local anaesthetic options, with a potentially reduced side effect profile compared to traditional surgical interventions matching the needs for a range of patients. We provide a narrative review of minimally invasive surgical treatments available for BPO in terms of the technology, efficacy, safety, institutional recommendations, cost and potential future developments.

Update on the management of overactive bladder.

Overactive bladder (OAB) syndrome is a common condition characterised by urinary urgency, with or without urgency incontinence, frequency and nocturia, in the absence of any other pathology. Clinical diagnosis is based upon patient self-reported symptomology. Currently there is a plethora of treatments available for the management of OAB. Clinical guidelines suggest treatment via a multidisciplinary pathway including behavioural therapy and pharmacotherapy, which can be commenced in primary care, with referral to specialist services in those patients refractory to these treatments. Intradetrusor botulinum A and sacral neuromodulation provide safe and efficacious management of refractory OAB. Percutaneous tibial nerve stimulation and augmentation cystoplasty remain available and efficacious in a select group of patients. Unfortunately, there remains a high rate of patient dissatisfaction and discontinuation in all treatments and thus there remains a need for emerging therapies in the management of OAB.

Patient treatment preferences for symptomatic refractory urodynamic idiopathic detrusor overactivity.

INTRODUCTION: There is a multiplicity of treatments currently available for patients with symptomatic refractory urodynamic idiopathic detrusor overactivity (SRU IDO). We have assessed patient treatment preferences and their outcomes over a 12-month period from January 1 2009 to December 31 2009. PATIENTS AND METHODS: A retrospective database of all patients with SRU IDO was reviewed for patient demographics, treatment preference, and outcome. All patients attending for treatment in the time period were offered: no further treatment, repeat bladder training ± antimuscarinic (BT ± AM), acupuncture, intravesical botulinum toxin injection, sacral neuromodulation (SNM), clam cystoplasty ± Mitrofanoff channel formation, and ileal conduit. STATISTICAL ANALYSIS USED: Statistical analysis of outcomes was done by Chi-square test, and statistical significance was determined as P < 0.05. RESULTS: A total of 217 patients with SRU IDO underwent primary treatment in this time period, with a median age of 56 years and follow-up for a minimum of 12 months' posttreatment to determine outcome. No patients opted for any further treatment or an ileal conduit. The majority of patients opted for intravesical botulinum toxin injections and SNM with similar success rates (approximately 70%). A small number of patients decided to have nonsurgical interventions (BT ± AM or acupuncture) and had a broadly similar success rate (50%). A minority opted for clam cystoplasty ± Mitrofanoff channel formation - this group reported the highest success rate at 86%. CONCLUSIONS: Treatment options in SRU IDO are diverse, with the majority of patients opting for minimally invasive surgery. Clinicians should be familiar with all treatment options for management of SRU IDO.