Lifelong LUTS: Understanding the bladder's role and implications across transition phases, a comprehensive review.

INTRODUCTION: Lower urinary tract symptoms (LUTSs) are a diverse array of urinary and pelvic dysfunctions that can emerge from childhood, extend through adulthood, and persist into older age. This narrative review aims to provide a comprehensive perspective on the continuum of LUTS and shed light on the underlying mechanisms and clinical implications that span across the lower urinary tract. METHODS: A panel of five experts from Belgium, the Netherlands, India, Denmark, and the United States participated in an intensive research to explore and pinpoint existing insights into the lifelong concept of LUTS, particularly at the pelvic level. The experts reviewed the existing literature and held a webinar to discuss their findings. RESULTS: Childhood LUTS can persist, resolve, or progress into bladder underactivity, dysfunctional voiding, or pain syndromes. The Lifelong character can be explained by pelvic organ cross-talk facilitated through complex neurological and nonneurological interactions. At the molecular level, the role of vasopressin receptors in the bladder's modulation and their potential relevance to therapeutic strategies for LUTS are explored. Frailty emerges as a parallel concept to lifelong LUTS, with a complex and synergistic relationship. Frailty, not solely an age-related condition, accentuates LUTS severity with insufficient evidence regarding the effectiveness and safety profile of the available therapeutic modalities. CONCLUSION: Understanding lifelong LUTSs offers insights into genetic, anatomical, neurological, and molecular mechanisms. Further research could identify predictive biomarkers, elucidate the role of clinically translatable elements in pelvic cross-talk, and uncover molecular signatures for personalized management.

Exploring lifelong overactive bladder: Transitions, evidence, and clinical implications; A modified Delphi process.

INTRODUCTION: Overactive bladder (OAB) is a prevalent urological condition characterized by urinary urgency, with or without urgency urinary incontinence, accompanied by increased daytime frequency and nocturia. However, the current definition of OAB lacks a specified time frame, hindering our understanding of the temporal aspects and transitions that occur within the OAB spectrum. METHODS: A modified Delphi study was conducted in three rounds, involving a panel of international experts in functional urology, urogynaecology, geriatrics, transitional medicine, and pediatric urology. The study took place between February 2023 and June 2023 and employed two sequential rounds of online surveys, followed by a final hybrid group discussion session in June 2023. RESULTS: The Delphi process resulted in a consensus definition of lifelong OAB as a persistent and continuous condition that may manifest differently from birth and evolve over time, with varying levels of clinical perception. The course of its progression is influenced by transition periods and modifying factors, mainly anatomical, hormonal, and psychosocial/stressors. Three main transition periods were identified: achievement of daytime continence, adulthood to elderly, and transition to frail elderly. The panel also considered the therapeutic and diagnostic implications of lifelong OAB, as well as future research prospects in terms of importance and feasibility. CONCLUSIONS: Future longitudinal research is needed to develop this concept and further identify transitions and temporal dynamics.

What should be next in lifelong posterior hypospadias: Conclusions from the 2023 ERN eUROGEN and EJP-RD networking meeting.

BACKGROUND: A congenital disease is for life. Posterior hypospadias, the severe form of hypospadias with a penoscrotal, scrotal, or perineal meatus, is a challenging condition with a major impact on lifelong quality of life. AIM: Our network meeting is aimed to identify what is currently missing in the lifelong treatment of posterior hypospadias, to improve care, quality of life, and awareness for these patients. METHODS: The network meeting "Lifelong Posterior Hypospadias" in Utrecht, The Netherlands was granted by the European Joint Programme on Rare Diseases-Networking Support Scheme. There was a combination of interactive sessions (hackathons) and lectures. This paper can be regarded as the last phase of the hackathon. RESULTS: Surgery for hypospadias remains challenging and complications may occur until adulthood. Posterior hypospadias affects sexual function, fertility, and hormonal status. Transitional care from childhood into adulthood is currently insufficiently established. Patients should be more involved in defining desired treatment approach and outcome measures. For optimal outcome evaluation standardization of data collection and registration at European level is necessary. Tissue engineering may provide a solution to the shortage of healthy tissue in posterior hypospadias. For optimal results, cooperation between basic researchers from different centers, as well as involving clinicians and patients is necessary. CONCLUSIONS: To improve outcomes for patients with posterior hypospadias, patient voices should be included and lifelong care by dedicated healthcare professionals guaranteed. Other requirements are joining forces at European level in uniform registration of outcome data and cooperation in basic research.

Very long-term follow-up of Indiana Pouches proves durability.

INTRODUCTION: An Indiana Pouch (IP) is a heterotopic, continent, urinary diversion from an ileocolonic segment. Numerous studies have investigated its long-term outcomes, albeit none extending beyond a 5-year follow-up period. IPs can be used as urinary diversion for benign indications and as such are constructed in typically young patients. As a consequence of their extended lifespan, there is a need for very long-term (>5 years) IP outcome data and comprehensive complication analysis. MATERIALS AND METHODS: In this retrospective cohort study, the data of all patients attending our academic functional urology tertiary referral center for surveillance between 2015 and 2022 after an earlier IP procedure without uro-oncological indication were analyzed. The primary objective was to identify the prevalence of complications associated with IP, including stomal stenosis, ureter-pouch stenosis, pouch calculi, stomal leakage, pouch perforation, and parastomal herniation, and to determine the time span between creation of the IP and occurrence of complications. RESULTS: A cohort of 33 patients (23 female) was analyzed. Median age at IP creation was 38 (range 5-62) years. Median follow-up was 258 (range 24-452) months. During follow-up, 22 (67%) patients underwent at least one surgical revision. In total, 45 revision procedures were performed. The estimated mean revision-free survival was 198 (95%-CI 144-242) months. CONCLUSION: Two-thirds of our IP patients required surgical revision during very long-term follow-up. However, the mean revision-free survival was 198 months. This establishes the IP as a durable and resilient option for urinary diversion, yet underlines the need for lifelong follow-up as some of these complications and indication were subclinical. These results contribute significantly to patient counseling when discussing different options for urinary diversion, especially at a younger age.

Continent catheterizable urinary channels: Lessons for lifelong urological care from a comparative analysis of very long-term complications and revision-free survival of three different types.

INTRODUCTION: Continent catheterizable channels (CCC) provide an alternative route to the bladder in both pediatric and adult patients. This study compared very long-term complications and revision-free survival of three different CCC techniques: appendicovesicostomy (AVS), ileum (Monti), and tubularized bladder flap (TBF). MATERIALS AND METHODS: A retrospective cohort study was performed. Data from adult patients with CCC under surveillance at our academic tertiary referral urological center in 2020 and 2021 were collected. Both patients who acquired the CCC as a child and as an adult were included. The primary outcome was revision-free survival of the three CCC types. The secondary outcome was the prevalence of complications requiring surgical revision. Revisions were categorized as major (open subfascial or complete revisions) and minor (open suprafascial or endoscopic). RESULTS: We included 173 CCCs (AVS 90, Monti 51, TBF 32). Median follow-up was 12.4 years (4.8-18). Mean revision-free survival was 162 ± 13 months, with no significant difference between the three types. Ninety-two individual CCCs (53%) required surgical revision and a total of 157 surgical revisions were performed. Seventy CCCs (40%) required major surgical revision: AVS (27/90%-30%), Monti (31/51%-61%), TBF (12/32%-38%). CONCLUSION: Complications of CCCs are common; in this study with very long-term follow-up, more than half of CCCs required surgical revision. Revisions were more common in Monti channels compared with AVS and TBF. The mean revision-free survival of >13 years illustrates the sustained long-term durability of CCCs which is important in the lifelong urological care of this population with high life expectancy.

Beyond the urothelium: Interplay between autonomic nervous system and bladder inflammation in urinary tract infection, bladder pain syndrome with interstitial cystitis and neurogenic lower urinary tract dysfunction in spinal cord injury-ICI-RS 2023.

INTRODUCTION: Inflammation and neuronal hypersensitivity are reactive protective mechanisms after urothelial injury. In lower urinary tract dysfunctions (LUTD), such as urinary tract infection (UTI), bladder pain syndrome with interstitial cystitis (BPS/IC) and neurogenic LUTD after spinal cord injury (SCI), chronic inflammation can develop. It is unclear how the protective reactionary inflammation escalates into chronic disease in some patients. METHODS: During its 2023 meeting in Bristol, the International Consultation on Incontinence-Research Society (ICI-RS) reviewed the urothelial and inflammatory changes after UTI, BPS/IC and SCI. Potential factors contributing to the evolution into chronic disease were explored in a think-tank. RESULTS: Five topics were discussed. (1) Visceral fat metabolism participates in the systemic pro-inflammatory effect of noradrenalin in BPS/IC and SCI. Sympathetic nervous system-adipocyte-bladder crosstalk needs further investigation. (2) Sympathetic hyperactivity also potentiates immune depression in SCI and needs to be investigated in BPS/IC. Gabapentin and tumor necrosis factor-α are promising research targets. (3) The exact peripheral neurons involved in the integrative protective unit formed by nervous and immune systems need to be further identified. (4) Neurotransmitter changes in SCI and BPS/IC: Neurotransmitter crosstalk needs to be considered in identifying new therapeutic targets. (5) The change from eubiosis to dysbiosis in SCI can contribute to UTI susceptibility and needs to be unraveled. CONCLUSIONS: The think-tank discussed whether visceral fat metabolism, immune depression through sympathetic hyperactivity, peripheral nerves and neurotransmitter crosstalk, and the change in microbiome could provide explanations in the heterogenic development of chronic inflammation in LUTD. High-priority research questions were identified.

Changes in bladder emptying during inpatient rehabilitation after spinal cord injury and predicting factors: data from the Dutch Spinal Cord Injury Database.

STUDY DESIGN: Secondary analysis of multicentre prospective observational data. OBJECTIVES: To describe methods of bladder emptying at admission and discharge in patients with recently acquired spinal cord injury (SCI) and to describe predictors of bladder emptying methods at discharge. SETTING: First inpatient rehabilitation in specialised rehabilitation centres in the Netherlands. METHODS: Data from the Dutch Spinal Cord Injury Database collected between 2015 and 2019 were used. McNemar-Bowker test was used to evaluate if bladder emptying methods differed over time; One-Way ANOVA and Chi-Square tests to see if bladder emptying methods differed by demographic and injury-related characteristics. Binary logistic regression was used to predict the type of bladder emptying at discharge with demographic and injury-related characteristics measured at admission. RESULTS: Of 1403 patients, 44.1% had cervical, 38.4% thoracic and 17.5% lumbosacral lesions at admission. AIS classification was mostly D (63.8%). The method of bladder emptying changed significantly (p < 0.001) from admission to discharge: decrease of clean intermittent assisted catheterisation (17.1% to 4.1%) and indwelling catheter (33.4% to 16.3%) and increase in clean intermittent self-catheterisation (CISC, 7.8% to 22.2%) and normal voiding (40.2% to 56.1%). Age, sex, SCI level, AIS classification and level of independence predicted the method of bladder emptying at discharge (all p < 0.001). CONCLUSIONS: During first inpatient rehabilitation, the method of bladder emptying changed resulting in more patients discharged with normal voiding and CISC. Age, sex, SCI level, AIS classification and level of independence in self-care were all confirmed as factors playing a role in this change.

What do X-ray images of the bladder during video urodynamics show us in patients with spinal cord injury?

STUDY DESIGN: Retrospective anonymized cohort study. OBJECTIVES: To study X-ray images of video urodynamics (VUD) in patients with spinal cord injury (SCI). SETTING: Single-center study. METHODS: X-ray images during VUD were categorized. Relation with the American Spinal Injury Association Impairment Scale (AIS), time since and level of SCI, cystometric data, method of bladder management, findings of flexible cystoscopy, and renal ultrasound were evaluated. Changes over time were studied. RESULTS: In 231 consecutive patients, VUD was done at a mean of 8.5 years after SCI. X3-ray bladder appearance was categorized as normal/standard, tonic, or flaccid. In 19 patients, specific findings were seen: diverticula, cystocele, vesicoureteral reflux. X-ray images differed by maximum cystometric capacity, presence of neurogenic detrusor overactivity, and maximum detrusor pressure during detrusor overactivity, but not by bladder compliance. There was no difference in the categories found in different levels and completeness of SCI. In the 23 patients able to void no pathology was seen on urethral images. Renal ultrasound was normal in >99%. In 86 patients, repeated testing after 72 ± 143 weeks showed changed findings in 30%. Cystoscopy showed significantly more local pathologies. CONCLUSION: Complications in the lower urinary tract were seen on imaging only in a limited number of our cohort. As our findings represent a real-life example of the actual yield of VUD in patients with neurogenic bladder due to SCI treated following the international guidelines, further multicentre evaluation is needed to determine when imaging should be used or not.

Combining different evaluations of sensation to assess the afferent innervation of the lower urinary tract after SCI.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To study a combination of three evaluations of sensation in the lower urinary tract (LUT) in patients with spinal cord injury (SCI). SETTING: University Antwerp Belgium, Unicenter study. METHODS: Evaluation of perineal sensation with light digital touch, reporting of filling sensation during a standardised urodynamic investigation and determination of the electrical perception threshold (EPT) were evaluated in patients with SCI. RESULTS: 150 individuals were included: 97 men and 53 women, mean age 46 ± 17 years. Patients had different levels and completeness of SCI, and different techniques for bladder emptying. Seventy-four patients (49%) reported sensation to touch in the perineal area. Sensation of bladder filling was reported in different patterns by 81 patients (54%). EPT was determined in 69 patients of which 50 (72%) reported sensation in different patterns. The outcome of absence/presence of sensation between the three tests differed greatly: with perineal sensation absent 53% had filling sensation (p = 0.040) and 58% positive EPT (p = 0.009). With filling sensation absent 59% had EPT sensation (not significant). Perineal sensation was strongly associated with level and completeness of SCI, while a significant association existed for filling sensations FSF, FDV, SDV and EPT in the distal urethra. CONCLUSIONS: Our study shows that different evaluations of sensation in the LUT of individuals with SCI complement each other. and we therefore propose combined use in the urological evaluation of patients with SCI to allow a more complete picture of the LUT sensations.

Is coexistent overactive-underactive bladder (with or without detrusor overactivity and underactivity) a real clinical syndrome? ICI-RS 2019.

AIMS: Lower urinary tract symptoms (LUTS) can be classified into symptom syndromes based on which symptoms are predominant. Overactive bladder (OAB) syndrome, a storage dysfunction, and underactive bladder (UAB) syndrome, a voiding dysfunction, are common syndromes, which urodynamic tests may show to be caused by detrusor overactivity (DO) and detrusor underactivity (DU), but can also be associated with other urethro-vesical dysfunctions. Sometimes OAB and UAB can coexist in the same patient and, if so, need a specific approach beyond treatment of the single and apparently opposing syndromes. METHODS: During its 2019 meeting in Bristol, the International Consultation on Incontinence Research Society held a literature review and expert consensus discussion focused on the emerging awareness of the coexisting overactive-underactive bladder (COUB). RESULTS: The consensus considered whether COUB is the combination of OAB and UAB syndromes, or a real unique clinical syndrome in the same patient, possibly with a common etiology. Definitions, pathophysiology, diagnosis, and treatment were discussed, and high-priority research questions were identified. CONCLUSIONS: COUB (with or without urodynamic evidence of DO and DU) may be considered a real clinical syndrome, because it differs from single OAB and UAB, and may not be the combination of both syndromes. Urodynamic tests may be necessary in unclear cases or in cases not responding to initial treatment of the most troublesome symptoms. It is pivotal to define the evolution of the syndrome and the characteristic population, and to recognize predictive or phenotyping factors to develop a specific approach and adequate outcome measures.

Bladder-bowel interactions: Do we understand pelvic organ cross-sensitization? International Consultation on Incontinence Research Society (ICI-RS) 2018.

AIMS: Mounting evidence from experimental animal and human studies suggests that cross-sensitization exists between different organs. Lower urinary tract (LUT) and bowel dysfunction commonly overlap, and the role of cross-sensitization between pelvic visceral organs is uncertain. METHODS: At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2018, a panel of clinicians participated in a discussion on bladder and bowel interactions in the context of pelvic organ cross-sensitization. RESULTS: Bladder and bowel problems commonly co-occur in adults and children across different disorders, and the mechanism responsible for overlapping dysfunction is uncertain in most instances. At a neuronal level, cross-sensitization occurs as a result of afferent signaling from the LUT and lower bowel through different central and peripheral mechanisms. Studies in animals and humans have demonstrated evidence for cross-organ sensitization following experimental inflammation or distension of the lower bowel, affecting the LUT. Nerve stimulation is an effective treatment for different functional LUT and bowel disorders, and whether this treatment may influence cross-organ sensitization remains uncertain. The role of physiologically dormant C-fibers, the bladder-gut-brain axis, and gut microbiome in cross-sensitization are speculative. CONCLUSION: Recommendations for research were made to explore the role of cross-organ sensitization in the pathogenesis of co-occurring LUT and bowel dysfunction in humans.

Basics of videourodynamics for adult patients with lower urinary tract dysfunction.

AIMS: Videourodynamics is the addition of imaging to invasive urodynamics and one of the methods to ensure objective diagnosis in persons with signs or symptoms of lower urinary tract dysfunction. This manuscript has the aim to outline the basics of the practice of videourodynamics and to elementary explain interpretation of the results. METHODS: Literature sources and expert opinion were arranged to provide the reader with an introductory overview of current knowledge. RESULTS: Videourodynamics was-like most diagnostics in health care-introduced on the basis of plausibility and expert conviction but has stood the test of time. Videourodynamics has, especially in patients with congenital or acquired neurogenic dysfunction of the lower urinary tract, undisputedly although not precisely quantifiable, added to (lower urinary tract) health care quality. CONCLUSION: The manuscript summarizes the basic elements of indication, practice, and interpretation of videourodynamics.

How can we develop a more clinically useful and robust algorithm for diagnosing and treating nocturia? ICI-RS 2017.

AIMS: Nocturia, or waking up at night to void, is a highly prevalent and bothersome symptom. Currently, there is a lack of clear and consistent recommendations regarding evaluation and management of nocturia. The aim of this report is to discuss how to fill the gaps in our knowledge in order to develop a practical patient-oriented diagnostic and therapeutic algorithm for nocturia. METHODS: This paper is a report of the presentations and subsequent discussion of a Think Tank session at the annual International Consultation on Incontinence Research Society (ICI-RS) in June 2017 in Bristol. RESULTS AND CONCLUSION: Further investigations are needed to better understand the pathophysiology of nocturia, to allow improvement in diagnosis, and to optimize treatment by increasing efficacy and reducing adverse events. Patient-oriented practical guidelines on nocturia are needed to help clinicians from different disciplines diagnose and treat nocturia.

Knowledge of the pelvic floor in nulliparous women.

[Purpose] Proper pelvic floor function is important to avoid serious dysfunctions including incontinence, prolapse, and sexual problems. The current study evaluated the knowledge of young nulliparous women about their pelvic floor and identified what additional information they wanted. [Subjects and Methods] In this cross-sectional survey, a validated, 36 item questionnaire was distributed to 212 nulliparous women. The questionnaire addressed demography, pelvic floor muscles, pelvic floor dysfunction, and possible information sources. Descriptive statistics were generated for all variables. Stability and validity testing were performed using Kappa statistics and intra class correlation coefficients to define agreement for each question. The study was approved by the ethics Committee (B300201318334). [Results] Using a VAS scale (0 to 10), the women rated their knowledge about the pelvic floor as a mean of 2.4 (SD 2.01). A total of 93% of the women were insufficiently informed and requested more information; 25% had concerns about developing urinary incontinence, and 14% about fecal incontinence. Many of the women were unaware what pelvic floor training meant. [Conclusion] There was a significant lack of knowledge about pelvic floor function among nulliparous women. The majority of nulliparous women expressed a need for education, which might offer a way to reduce dysfunction.

Knowledge of the pelvic floor in menopausal women and in peripartum women.

[Purpose] Pelvic floor dysfunction is an important health-care issue, with pregnancy, childbirth, and menopause as the most important risk factors. Insufficient knowledge about pelvic floor dysfunction is the largest barrier to seeking care. The aim of this study was to investigate the level of knowledge and information on pelvic floor dysfunction in peripartum and menopausal women. [Subjects and Methods] The present study was a cross-sectional survey. A valid and reliable questionnaire of 48 items was distributed to 402 women who were pregnant or had recently given birth and to 165 postmenopausal women. All answers were analyzed and interpreted. The study was approved by an ethics committee (B300201318334). [Results] On a VAS scale of 0 to 10, the mean ratings of the peripartum and postmenopausal women concerning their knowledge were 4.38 (SD 2.71) and 4.92 (SD 2.72). Peripartum women held significantly more pessimistic perceptions about the occurrence of postpartum pelvic floor dysfunction. The results showed that 75% of the peripartum women and 68% of the postmenopausal women felt insufficiently informed or want to get better informed. [Conclusion] The results reveal sparse knowledge about the pelvic floor among women of all ages and that a major proportion of them would be interested in more information. Amelioration of common knowledge could improve help-seeking behavior in women.

Exploring associations between lower urinary tract symptoms (LUTS) and gastrointestinal (GI) problems in women: a study in women with urological and GI problems vs a control population.

OBJECTIVES: To study the prevalence of self-reported lower urinary tract symptoms (LUTS) in women consulting a Gastroenterology clinic with complaints of functional constipation (FC), fecal incontinence (FI) or both, compared with a female control population. Also, to study the influence of FC, FI, or both on self-reported LUTS in women attending a Urology clinic. PATIENTS AND METHODS: We present a retrospective study of data collected through a validated self-administered bladder and bowel symptom questionnaire in a tertiary referral hospital from three different female populations: 104 controls, 159 gastroenterological patients and 410 urological patients. Based on the reported bowel symptoms, patients were classified as having FC, FI, a combination of both, or, no FC or FI. LUTS were compared between the control population and the gastroenterological patients, and between urological patients with and without concomitant gastroenterological complaints. Results were corrected for possible confounders through logistic regression analysis. RESULTS: The prevalence of LUTS in the control population was similar to large population-based studies. Nocturia was significantly more prevalent in gastroenterological patients with FI compared with the control population [odds ratio (OR) 9.1]. Female gastroenterological patients with FC more often reported straining to void (OR 10.3), intermittency (OR 5.5), need to immediately re-void (OR 3.7) and feeling of incomplete emptying (OR 10.5) compared with the control population. In urological patients, urgency (94%) and urgency urinary incontinence (UUI, 54% of UI) were reported more often by patients with FI than by patients without gastroenterological complaints (58% and 30% of UI respectively), whereas intermittency (OR 3.6), need to immediately re-void (OR 2.2) and feeling of incomplete emptying (OR 2.2) were reported more often by patients with FC than by patients without gastroenterological complaints. CONCLUSION: As LUTS are reported significantly more often by female gastroenterological patients than by a control population, and as there is a difference in self-reported LUTS between female urological patients with different concomitant gastroenterological complaints, we suggest that general practitioners, gastroenterologists and urologists should always include the assessment of symptoms of the other pelvic organ system in their patient evaluation. The clinical correlations between bowel symptoms and LUTS may be explained by underlying neurological mechanisms.

Mechanisms of pelvic organ cross-talk: impact of urethral ligation on the inhibitory rectovesical reflex.

PURPOSE: The existence of an inhibitory rectovesical reflex elicited by noxious colorectal afferent input was previously documented in an isovolumetric cystometry model with a ligated urethra. We compared the effect of noxious colorectal distension on bladder cystometry with an open and a ligated urethra. MATERIALS AND METHODS: We used female Sprague Dawley® rats anesthetized with urethane. The effect of noxious (60 mm Hg) colorectal distension on intermittent and continuous cystometry with an open urethra was studied and then compared to inhibiting isovolumetric bladder contractions in the same rat after ligating the urethra. We evaluated volume, the pressure micturition threshold, the intercontraction interval, bladder contraction frequency and amplitude of micturition contractions. RESULTS: Noxious colorectal distension at 60 mm Hg did not significantly influence volume or the pressure micturition threshold during intermittent cystometry. It also did not influence the pressure micturition threshold, the intercontraction interval or bladder contraction frequency during continuous cystometry. After urethral ligation 60 mm Hg colorectal distension inhibited isovolumetric bladder contraction frequency in the same rat (mean ± SEM 0.363 ± 0.207 vs 0.886 ± 0.106 contractions per minute, p <0.05). This inhibition persisted a mean of 289.08 ± 91.24 seconds after deflating the rectal balloon. CONCLUSIONS: The inhibitory rectovesical reflex elicited by noxious colorectal distension clearly occurred in an isovolumetric bladder model with a ligated urethra but only to a negligible extent in filling related voiding contractions. Our results suggest that the inhibitory rectovesical reflex, most likely at the level of the lumbosacral spinal cord, is the result of an additive noxious urethral and colonic afferent stimulus.

Tubularized Bladder Flap as a Continent Catheterizable Channel in Adults.

OBJECTIVE: To describe a modified, less invasive, surgical technique to create a continent catheterizable channel (CCC) in adults: the tubularized bladder flap (TBF). MATERIALS AND METHODS: We retrospectively reviewed records of patients in whom a TBF CCC was constructed at adult age between 2019 and 2023. We reported on demographics, operative outcomes, and 30-day and post-30-day complications. RESULTS: A total of 11 patients (10 female) were described. The median operative time was 96 (range 90-115) minutes in patients with only TBF creation. Estimated blood loss was <100 cc in all patients. Within 30 days postoperatively, 6/11 (55%) patients developed a complication, all grade 1 Clavien Dindo. No bowel complications occurred (paralytic ileus, mechanical obstruction, or leakage/perforation). Median follow-up was 25 (range 6-56) months. In 2/11 (18%) patients surgical revision for stenosis was done; 3/11 (27%) patients underwent surgical revision for stomal leakage. CONCLUSION: TBF as a means to create a CCC avoids intraperitoneal surgery, and bowel closure (appendicovesicostomy) or anastomosis (retubularized ileum). Postoperative bowel complications were not seen in any of our patients. Surgical revision rates for a TBF CCC appear to be comparable to other CCCs. Therefore, TBF could be considered in patients with sufficient bladder capacity as TBF is less invasive than other CCC techniques and avoids potential bowel complications.

Mechanisms of pelvic organ cross-talk: 2. Impact of colorectal distention on afferent nerve activity of the rat bladder.

PURPOSE: Pelvic organ neural cross-talk is mediated by central and peripheral pathways. We investigated the effects of colorectal distention at the peripheral level on mechanosensitive bladder single unit afferent activity. MATERIALS AND METHODS: We used 16 female Sprague-Dawley® rats in this study. The single unit afferent activity of nerves originating from the bladder were identified by electrical stimulation of the pelvic nerve and by bladder distention. They were classified by conduction velocity as C or Aδ fibers. After measuring single unit afferent activity during constant bladder filling without colorectal distention, measurements during bladder filling were repeated with colorectal distention at 20, 40 and 60 mm Hg. To evaluate the convergence of bladder and colorectal afferent fibers, rapid colorectal distention was performed with an empty bladder. Bladder afferent fibers with an increased response to rapid colorectal distention were defined as convergent fibers and the others were defined as nonconvergent fibers. RESULTS: A total of 30 single units (19 C and 11 Aδ fibers) were isolated. Continuous colorectal distention increased the bladder single unit afferent activity of C and Aδ fibers in a pressure dependent manner. C fibers could be divided into convergent (12) and nonconvergent (7) fibers but all Aδ fibers were nonconvergent. The facilitatory effect of continuous colorectal distention on bladder single unit afferent activity was absent in nonconvergent C fibers. CONCLUSIONS: In rats the convergence of bladder and colorectal peripheral nerves was electrophysiologically identified only in mechanosensitive C fibers and not in Aδ fibers. Continuous colorectal distention probably increased the bladder single unit afferent activity of C fibers through direct convergence at the peripheral level between the bladder and sensory ganglia. It probably increased the bladder single unit afferent activity of Aδ fibers through an alternative pathway.

Mechanisms of pelvic organ crosstalk: 1. Peripheral modulation of bladder inhibition by colorectal distention in rats.

PURPOSE: Bladder activity can be inhibited by afferent input from the colorectum (inhibitory rectovesical reflex). We evaluated the functional response of the rat bladder to nonnoxious and noxious colorectal distention, and investigated the mechanical and pharmacological peripheral modulation of this response. MATERIALS AND METHODS: In 70 female Sprague-Dawley® rats we evaluated the effect of nonnoxious (20 mm Hg) and noxious (40 and 60 mm Hg) colorectal distention on the micturition volume threshold and on bladder activity in a filled bladder. We also studied the effect of rectal balloon size (1.5 vs 3.5 cm long), and rectal administration of 2% lidocaine jelly or 1 mM allyl isothiocyanate solution on the inhibitory rectovesical reflex. RESULTS: Colorectal distention at 60 mm Hg increased the micturition volume threshold (mean ± SE 0.640 ± 0.056 vs 0.448 ± 0.035 ml in controls, p <0.001). Bladder contraction frequency was significantly decreased by 40 and 60 mm Hg colorectal distention vs controls (mean 0.62 ± 0.06 and 0.33 ± 0.05 per minute, respectively, vs 0.77 ± 0.03, each p <0.001). These effects were reversible and pressure dependent (p <0.001), and more pronounced using a large rectal balloon (mean 40 vs 60 mm Hg colorectal distention 0.35 ± 0.12 vs 0.07 ± 0.04 per minute, p = 0.004). We noted no significant graded inhibition of bladder contraction amplitude or duration. The inhibitory rectovesical reflex was reversibly abolished by intrarectal lidocaine administration. Intrarectal allyl isothiocyanate administration significantly increased the effect of noxious colorectal distention on bladder contraction frequency. CONCLUSIONS: Only noxious levels of colorectal distention initiated the inhibitory rectovesical reflex. The effect increased with rectal balloon size and with intrarectal administration of allyl isothiocyanate. It was reversibly abolished by lidocaine. Results suggest that spinal interneurons are the mechanism behind the inhibitory rectovesical reflex.