Management of the Devastated Bladder Outlet after Prostate CANCER Treatment.

PURPOSE OF REVIEW: Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion. RECENT FINDINGS: The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.

The effect of pelvic floor muscle training in women with functional bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: Female voiding dysfunction is often due to bladder outlet obstruction (BOO). We investigated pelvic floor muscle training (PFMT) effectiveness in women with functional BOO. METHODS: This is a prospective study recruiting 63 women functionally obstructed, over 18yo, maximum flow rate (Qmax) less than 12 ml/sec, naïve of voiding treatment. Exclusion criteria were anatomical BOO, neurological condition, pelvic intervention, psychiatric or anticholinergic medication, diabetes mellitus and affected upper urinary tract. At baseline, women underwent uroflow, post void residual (PVR) measurement, cystoscopy, cystogram and urodynamic study (UDS) with pelvic electromyography (EMG). Blaivas-Groutz nomogram has been used to define obstruction. After diagnosis, patients underwent six-month PFMT. Re-evaluation was offered four weeks after end of treatment. Data were analyzed with SPSSv22.0. RESULTS: 63 women were recruited and 48 finally included. At baseline, 20 reported 3 urinary tract infections (UTIs) during last year, and 12 had one episode of urine retention. Median Qmax was 7.5 ml/sec and median PVR 110 ml. 40 women were obstructed. 16 (40%) had mild, 16 (40%) moderate and 8 (20%) severe obstruction. All subjects had an overactive pelvic floor on EMG. Obstructed women were re-evaluated. Median Qmax was 8.5 ml/sec, close to baseline (p = 0.16). Median PVR was 65 ml, reduced to baseline (p = 0.02). 33 (82.5%) remained obstructed, 22 (66.67%) with mild, 8 (24.24%) moderate and 3 (9.09%) severe obstruction. 7 (17.5%) were non-obstructed. 4 patients reported one UTI episode with no cases of retention. CONCLUSIONS: A 6 month PFMT reduced UTIs and PVR in women with functional BOO. Additionally, most patients had a de-escalation to milder obstruction.

Partial inhibition of activin receptor-like kinase 4 alleviates bladder fibrosis caused by bladder outlet obstruction.

The bladder undergoes profound structural alterations after bladder outlet obstruction (BOO), characterized by hypertrophy of the bladder wall and accumulation of extracellular matrix (ECM). Transforming growth factor-ß (TGF-ß) has been found to promote fibrosis of the bladder induced by partial bladder outlet obstruction (pBOO). Activin receptor-like kinase 4 (ALK4) is a downstream receptor of the TGF-ß superfamily. However, the role of the ALK4-Smad2/3 pathway in the pathogenesis of bladder fibrosis caused by pBOO remains unknown. This study focused on learning the role of ALK4 in the process of bladder fibrosis caused by pBOO. The pBOO mice models showed that ALK4 expression was found to upregulate in the wild-type bladder 6 weeks after pBOO compared to control group. Then, mice with heterozygous knockout of the ALK4 gene (ALK4+/-) were generated. Histological analysis and Western blot (WB) results showed significant suppression of collagen expression in the bladders of ALK4+/- mice after pBOO compared with WT mice. WB also showed that ALK4+/- mice demonstrated significant suppression of phosphorylated Smad2/3 (p-Smad2/3) expression in the bladder 6 weeks after pBOO but not of phosphorylated extracellular signal-regulated kinase, c-Jun N-terminal kinase or protein 38 (p-ERK, p-JNK, p-P38) expression. This effect might have occurred through partial inactivation of the Smad2/3 signaling pathway. In vitro, ALK4 overexpression promoted collagen production in cultured BSMCs and activated the Smad2/3 signaling pathway. Taken together, our results demonstrated that ALK4 insufficiency alleviated bladder fibrosis in a mouse model of pBOO partly by suppressing Smad2/3 activity.

Role of human adipose-derived stem cells (hADSC) on TGF-ß1, type I collagen, and fibrosis degree in bladder obstruction model of Wistar rats.

INTRODUCTION: Bladder outlet obstruction (BOO) was caused by a series of histological and biochemical changes in the bladder wall, through the inflammation process in the bladder wall, hypertrophy and fibrosis. ADSC has an important role in bladder regeneration. METHODS AND MATERIALS: This study was an experimental randomized study using male Wistar rats which were monitored at 2 and 4 weeks to determine the effect of ADSC therapy on TGF-ß1 type I collagen, and degree of fibrosis. RESULT: Rats were divided into 5 groups. In the week 2 BOO group, 1 sample included in the category of moderate fibrosis, 1 sample that was given ADSC with mild fibrosis category, 3 samples included in severe fibrosis category, 3 samples that were given ADSC included in the category of moderate fibrosis. The concentration of TGF-ß1 in the hADSC therapy group was significantly lower than the control group at the 2nd and 4th week of monitoring (p2 = 0.048, p4 = 0.048), and also with more type I collagen on 2nd and the 4th week (p2 = 0.048, p4 = 0.048). CONCLUSION: ADSC therapy can reduce the concentration of TGF-ß1, type I collagen, and degree of fibrosis in the male Wistar BOO model.

Update on the Management of Urological Problems Following Kidney Transplantation.

Urological problems in kidney transplant recipients are not limited only to posttransplantation urological complications. These problems are a cause of significant patient mortality and morbidity that have wide-ranging effects on graft survival throughout the entire life of the graft. Ultimately, the transplant comprises a major portion of the urinary system; therefore, the transplant team should be prepared for foreseeable and unforeseeable urological problems in the short and long terms. These mainly include postoperative urological complications (urine leakage, ureteral stenosis, and vesicoureteral reflux), bladder outlet obstruction, and graft urolithiasis. In recent years, significant advances have been made in the management of urological complications, especially due to advances in endourologic interventions. The aim of this review is to summarize the management of urological problems after kidney transplantation in the context of the current literature.

[Female voiding dysfunction: Clean intermittent catheterization is not the only option]. / Troubles de la vidange vésicale chez la femme : l'autosondage n'est pas la seule solution.

Female voiding dysfunction exists but are largely underdiagnosed, especially in France. They can result from two different mechanisms: detrusor underactivity or bladder outlet obstruction, with very different pathophysiology and therapeutic management. There are many different therapeutic options, including surgical treatments, to offer as alternative to clean intermittent catheterization which are often burdensome for patients. Seeking voiding dysfunction in female patients with lower urinary tract symptoms and searching for their etiology to tackle it could lead to a paradigm change in these women: from standardized treatment to individualized treatment. In their practice, nurses can detect warning symptoms suspect of voiding dysfunction, and have thus a role to play in the improvement of patients' screening, education other healthcare providers, and management of female voiding dysfunction.

Intraperitoneal administration of mesenchymal stem cells is effective at mitigating detrusor deterioration after pBOO.

Partial bladder outlet obstruction (pBOO) results in bladder fibrosis that is initiated by an inflammatory cascade and the decompensation after smooth muscle hypertrophy. We have been using an animal model to develop the hypothesis that mesenchymal stem cells (MSCs) are able to mitigate this cytokine cascade and prevent bladder deterioration. We hypothesized that intraperitoneal administration of MSCs can produce the same effects as intravenously administered cells but may require higher dosing. Intraperitoneal treatment will provide insights into the mechanisms of action and may offer advantages over intravenous administration, as it will permit allow higher doses and potentially reduce systemic exposure. Rats underwent a surgical induction of pBOO and instillation of either 1 × 106 or 5 × 106 commercially acquired MSCs into the peritoneum. RT-PCR, immunohistochemistry, and urodynamics were used to compare treatment groups with controls. pBOO resulted in a marked, statistically significant, upregulation of inflammatory markers in the bladder, including transforming growth factor-ß, hypoxia-inducible factor-1α, hypoxia-inducible factor-3α, mammalian target of rapamycin, and collagen types I and III. Moderate but inconsistent levels of downregulation were seen with 1 × 106 MSCs, but excellent and reliable downregulation was seen with 5 × 106 MSCs (P < 0.05). Immunohistochemistry confirmed that protein levels were affected in accordance with mRNA upregulation. Urodynamics demonstrated MSC treatment resulted in whole organ physiological benefits, as they prevented elevations in detrusor pressure. In conclusion, intraperitoneal administration of MSCs resulted in a similar effect as intravenous administration; however, this required a higher dose. This has significant implications for determining the mechanism of action and potential clinical application for human therapy.

Phenotypic severity scoring system and categorisation for prune belly syndrome: application to a pilot cohort of 50 living patients.

OBJECTIVE: To design a novel system of scoring prune belly syndrome (PBS) phenotypic severity at any presenting age and apply it to a large pilot cohort. PATIENTS AND METHODS: From 2000 to 2017, patients with PBS were recruited to our prospective PBS study and medical records were cross-sectionally analysed, generating individualised RUBACE scores. We designed the pragmatic RUBACE-scoring system based on six sub-scores (R: renal, U: ureter, B: bladder/outlet, A: abdominal wall, C: cryptorchidism, E: extra-genitourinary, generating the acronym RUBACE), yielding a potential summed score of 0-31. The 'E' score was used to segregate syndromic PBS and PBS-plus variants. The cohort was scored per classic Woodard criteria and RUBACE scores compared to Woodard category. RESULTS: In all, 48 males and two females had a mean (range) RUBACE score of 13.8 (8-25) at a mean age of 7.3 years. Segregated by phenotypic categories, there were 39 isolated PBS (76%), six syndromic PBS (12%) and five PBS-plus (10%) cases. The mean RUBACE scores for Woodard categories 1, 2, and 3 were 20.5 (eight patients), 13.8 (25), and 10.6 (17), respectively (P < 0.001). CONCLUSIONS: RUBACE is a practical, organ/system level, phenotyping tool designed to grade PBS severity and categorise patients into isolated PBS, syndromic PBS, and PBS-plus groups. This standardised system will facilitate genotype-phenotype correlations and future prospective multicentre studies assessing medical and surgical treatment outcomes.

Do patients have to choose between ejaculation and miction? A systematic review about ejaculation preservation technics for benign prostatic obstruction surgical treatment.

PURPOSE: Ejaculatory dysfunction is the most common side effect related to surgical treatment of benign prostatic obstruction (BPO). Nowadays, modified surgical techniques and non-ablative techniques have emerged with the aim of preserving antegrade ejaculation. Our objective was to conduce a systematic review of the literature regarding efficacy on ejaculatory preservation of modified endoscopic surgical techniques, and mini-invasive non-ablatives techniques for BPO management. METHODS: A systematic review of the literature was carried out on the PubMed database using the following MESH terms: "Prostatic Hyperplasia/surgery" and "Ejaculation", in combination with the following keywords: "ejaculation preservation", "photoselective vaporization of the prostate", "photoselective vapo-enucleation of the prostate", "holmium laser enucleation of the prostate", "thulium laser", "prostatic artery embolization", "urolift", "rezum", and "aquablation". RESULTS: The ejaculation preservation rate of modified-TURP ranged from 66 to 91%. The ejaculation preservation rate of modified-prostate photo-vaporization ranged from 87 to 96%. The only high level of evidence studies available compared prostatic urethral lift (PUL) and aquablation versus regular TURP in prospective randomized-controlled trials. The ejaculation preservation rate of either PUL or aquablation compared to regular TURP was 100 and 90 versus 34%, respectively. CONCLUSIONS: Non-ablative therapies and modified endoscopic surgical techniques seemed to be reasonable options for patients eager to preserve their ejaculatory functions.

Stem cells and lower urinary tract dysfunction: Has its potential finally reached clinical maturity? ICI-RS2018.

AIMS: Efforts to engineer and repair genitourinary tissue to treat lower urinary tract dysfunction (LUTD) have recently increased thanks in part to advances in stem cell (SC) research. At the International Consultation on Incontinence-Research Society meeting in Bristol in 2018 a proposal was convened to address the question: has the potential of SCs in treating LUTD reached clinical maturity? METHODS: The proposal conducted a literature review and an expert consensus meeting focusing on available data from animal models and clinical trials involving the use of SCs for LUTD. RESULTS: To date, there are only small studies investigating bladder replacement using scaffolds with or without SC. Results have been conflicting because of the variability in cell numbers, biomaterials types, and graft surface differences. Similarly, preclinical results suggest a possible role of SC in bladder outlet obstruction (BOO); however, SC clinical trials for BOO are lacking. Research into the use of SC for female stress urinary incontinence (SUI) is close to reaching clinical maturity. In the Canadian phase 3 randomized controlled trial (RCT), a beneficial effect of adult muscle-derived cells (AMDC) over placebo was detected in reducing the frequency of incontinence episodes, especially after prior anti-incontinence surgery. Only two small studies have been published on male SUI. CONCLUSIONS: Questions remain regarding the mechanism of action of SC injected into the LUT and the viability of cells seeded onto grafts placed into the LUT. Also, the optimal time for intervention with SC therapy in the LUT remains to be elucidated.

Comparing Outcomes of Medical Management and Minimally Invasive Surgical Techniques for Lower Urinary Tract Symptoms due to BPH.

PURPOSE OF REVIEW: Compare outcomes of medical therapy as compared to minimally invasive surgical therapy (MIST) for treatment of bladder outlet obstruction RECENT FINDINGS: Treatment for lower urinary tract symptoms due to benign prostatic hyperplasia (LUTS/BPH) remains largely driven by patient symptomatology with medical therapy or watchful waiting as the first-line management strategies. However, most patients are not adherent to prescribed medical therapies and are hesitant to accept the risks associated with more invasive therapies. Minimally invasive surgical therapies are treatments providing short-term symptom relief superior to medical therapies without the sequela of more invasive procedures. Though there are few direct comparisons, MIST seems to relieve LUTS/BPH symptoms at least as well as medical therapy without the need for daily adherence.

[Etiology, Diagnosis, and Management of Female Bladder Outlet Obstruction]. / Blasenentleerungsstörungen bei der Frau ­ Ursachen, Diagnostik und Therapie.

Etiology, Diagnosis, and Management of Female Bladder Outlet Obstruction Abstract. Bladder outlet obstruction affects up to every fourth woman. This condition is causing difficulties to void. Patients complain about frequency, an urge to void, or they describe the feeling of post-void residual urine. Increased post-void residual urine or a pathological micturition pattern with increased pressure or pathological flow curves are suggestive for a bladder outlet obstruction. Common causes are genital organ prolapse, previous incontinence surgery, or dysfunctional voiding. Correspondingly, the underlying etiology is determining therapy: surgical correction of the pelvic organ prolapse usually eliminates the obstructive situation; a tightly placed incontinence sling should be loosened or incised, while dysfunctional disorders can be well addressed by pelvic floor rehabilitation.

Urologists' attitudes to sexual complications of LUTS/BPH treatments.

INTRODUCTION: Many LUTS/BPH treatments currently available may affect sexual function (SD). We wished to assess urologists' attitude and practice in this area. METHODS: Attendees of an international meeting were randomly selected, interviewed and stratified by professional status and LUTS/BPH cases seen per month. There were four questions: treatment options offered, frequency of discussing erectile dysfunction (ED) with each treatment, frequency of discussing ejaculatory dysfunction (EjD) with each treatment, and offering alternative treatment based on the risks of sexual dysfunction. RESULTS: 199 of the 245 interviewed (81%) were urologists. The most common treatments offered were α-blockers (99.5%), 5-ARI (95.0%) and TURP (92.5%). About 70% of the specialists discuss ED before α-blockers (not known to cause ED). Regarding EjD, 70% discuss this prior to prescribing α-blockers, 60% before 5-ARI therapy, while 80% before TURP. A significant minority fails to discuss this complication in all areas. Many respondents do not routinely discuss alternative therapies on the risk of SD. The higher the caseload, the less likely was a urologist to offer alternative therapies, with 37% of urologists seeing over 30 LUTS/BPH patients per month stating they would "Not at all often" offer alternative therapies for this reason. CONCLUSIONS: There is a significant discrepancy in attitudes to counselling patients on SD related to LUTS/BPH treatments. This may, in some cases, affect the validity of consent to the treatment. Most urologists do not discuss alternative treatments with patients based on the risks of different outcomes and complications, and this seems more marked in those with the busier practices. This may sit ill with the concept of personalised healthcare.

Do we understand voiding dysfunction in women? Current understanding and future perspectives: ICI-RS 2017.

AIMS: Urinary retention in women is poorly understood, compared to the equivalent condition in men, and was the subject of a dedicated session organized at the International Consultation on Incontinence Research Society (ICI-RS) in Bristol, United Kingdom, 2017. METHODS: The current understanding of the pathophysiological correlates of idiopathic voiding dysfunction in women, the role of urodynamics, neurophysiology, and non-invasive tests in characterizing functional bladder outlet obstruction due to a non-relaxing urethral sphincter, and poorly defined diagnosis of detrusor underactivity were reviewed. RESULTS: Putative factors underlying the pathogenesis of urinary retention following urinary tract infections were discussed. Further research is required to explore the association between bladder wall inflammation and alterations in detrusor contractile functions. The complex interrelationship between urinary retention and psychological co-morbidities and sexual trauma were explored, and the overlap between these and psychological co-morbidities and functional neurological problems with functional urological problems were recognized. Understanding the mechanism of action of sacral neuromodulation, often a successful treatment for urinary retention, would provide insight into the underlying factors that may be responsible for urinary retention. Specifically, there is a need to understand the role of the endogenous enkephalinergic system in the pathogenesis of urinary retention and to identify predictors of successful treatment with sacral neuromodulation. Based on current understanding and potential directions of research in the future, an algorithm for the evaluation of women with voiding dysfunction was proposed. CONCLUSIONS: In the future, recommendations for research should lead to a better understanding of urinary retention in women and its treatment.

Suprameatal urethrolysis with Martius flap for refractory bladder outflow obstruction following stress incontinence surgery in females.

AIMS: To present our technique of suprameatal urethrolysis with Martius flap (SMUM) and outcomes of this procedure for refractory female bladder outflow obstruction (BOO). METHODS: A retrospective chart review was performed to identify female patients who underwent SMUM between January 2010 and August 2016 after failed transvaginal urethrolysis (TVU) for BOO due to prior stress urinary incontinence (SUI) surgery. The primary outcome measure was surgical success defined as patient ability to void volitionally without need for catheterization or additional surgery for BOO. Secondary outcomes assessed included perioperative outcomes, intraoperative and 30-day complications, change in post-void residual volume (PVR), resolution of urge urinary incontinence (UUI), incidence of recurrent SUI, and treatment for any urinary incontinence. RESULTS: Eleven patients were identified. After a median follow-up of 10.8 months (range 3.1-20.1), the procedure was successful in nine patients (82%). Postoperative median PVR was 29 cc (range 0-425) and median change in PVR was a 280 cc (range 29-1050) decrease (P < 0.01). Among the seven patients who required catheterization preoperatively, five patients (71%) recovered volitional voiding. Two patients (18%) continued to require indwelling or intermittent catheterization and underwent additional surgery for BOO. SUI recurred in one patient (9%). UUI persisted in all four patients who reported this preoperatively. CONCLUSIONS: SMUM is successful in improving or relieving refractory BOO in this challenging patient population. After TVU, we believe that Martius flap interposition is critical to preventing recurrent fixation of the urethra to the pubic bones and thus achieving improved voiding.

A comparison of the treatment recommendations for neurogenic lower urinary tract dysfunction in the national institute for health and care excellence, European Association of Urology and international consultations on incontinence guidelines.

AIMS: Healthcare guidelines are an important vehicle in establishing up-to-date evidence based medicine (EBM) in clinical practice. Due to varying development processes, clinical guidelines created by different institutions can often contain contrasting recommendations. This can have implications for optimal and standardized patient care across management settings. METHODS: The similarities and differences of treatment recommendations made in the National Institute for Health and Care Excellence (NICE), The European Association of Urology (EAU), and the International Consultation on Continence (ICI) guidelines for neurogenic lower urinary tract dysfunction (NLUTD) were assessed. RESULTS: The guidelines generally agree on their approach to conservative management, including behavioral therapies, and catheterization techniques. There was discrepancy on the benefit of using an alpha blocker in NLUTD and bladder outlet obstruction (BOO) and administering Botulinum toxin A (Onabotulinum-A) in NLUTD. The highest degree of divergence was seen in recommendations for surgical treatments, where the EAU made gender-specific recommendations, and gave continent urinary diversion higher preference than given in the NICE and ICI guidelines. CONCLUSIONS: In the absence of high-quality clinical evidence, many of the recommendations made across all three guidelines are based on expert opinion. NICE, the EAU and ICI have similarities but they place differing emphasis on costs and expert opinion, which translated in notably different recommendations. It is evident that increased research efforts, possibly in the form of prospective registries, pragmatic trials, and resource utilization studies are necessary to improve the underlying evidence base for NLUTD, and subsequently the strength and concordance of recommendations across guidelines.

Management of Postoperative Lower Urinary Tract Symptoms (LUTS) After Pelvic Organ Prolapse (POP) Repair.

PURPOSE OF REVIEW: Pelvic organ prolapse (POP) is a common condition for which approximately 200,000 US women annually undergo surgical repair [Am J Obstet Gynecol 188:108-115, 2003]. After surgical correction, persistent or new lower urinary tract symptoms (LUTS) can be present. We provide guidance on the current tools to predict, counsel, and subsequently handle postoperative LUTS. The current literature is reviewed regarding LUTS diagnosis and management in the setting of prolapse surgery with an emphasis on newer developments in this area. RECENT FINDINGS: 1. More severe stages of prolapse are positively correlated with obstructive symptoms [Am J Obstet Gynecol 185:1332-1337, 2001], but not with other LUTS [Adv Urol 2013:5673753, 2013, Eur J Obstet Gynecol Reprod Biol 177:141-145, 2014, Am J Obstet Gynecol 199:683, 2008, Int Urogynecol J 21:1143-1149, 2010]. 2. One-week ambulatory pessary trial is an effective way to approximate postoperative results-one study correctly predicted persistent urgency and frequency in addition to occult stress urinary incontinence in 20% of study population [Obstet Gynecol Int 2012:392027, 2012]. 3. No preoperative overactive bladder (OAB) symptom was the best predictor for the absence of de novo OAB symptoms postoperatively [Int Urogynecol J 21:1143-1149, 2010]. 4. Urge incontinence patients respond favorably to sacral neuromodulation [Neurourol Urodyn 26: 29-35, 2007], botulinum toxin, and anticholinergic therapy [Res Rep Urol 8:113-122, 2016 , N Engl J Med, 367:1803-1813, 2012]. 5. Primary bladder outlet obstruction (BOO) can be treated effectively with alpha antagonists or anticholinergics, timed voiding, and pelvic physiotherapy as first-line therapy. Counseling regarding postoperative LUTS is key when planning POP surgery. A thorough understanding of patient history is crucial to successful repair. Patients with significant preoperative symptoms, history of neurologic disease, pelvic floor dysfunction, bladder neck obstruction, or higher stages of anterior wall prolapse may be higher risk for postoperative LUTS. UDS with or without reduction and an ambulatory pessary trial can help prognosticate. Patients will likely maintain a positive therapeutic relationship postoperatively for LUTS if counseled preoperatively.

[Management of the bladder outlet obstruction associated with BPH in patients with special circumstances and/or complications]. / Prise en charge de l'obstacle sous vésical lié à une HBP chez les patients à terrain particulier et/ou ayant une complication.

INTRODUCTION: Medical or surgical treatment of lower urinary tract symptoms associated with the bladder obstruction due to BPH must take into account patient's comorbidities and tBPH complication. The objective is to review the different situations in order to optimize the treatment. METHODS: A review of the literature was conducted in English on the Pubmed website using the following keywords: BPH; diabetes; anticoagulants; antiplatelet agents; renal insufficiency; indwelling catheter; bladder calculus; urinary tract infection; hematuria; chronic bladder retention or diverticulum. The bibliographical sources cited in the European recommendations have been used. RESULTS: Some co-morbidities and complications may affect surgical outcomes: age is associated with increased anesthetic and surgical risks, diabetes with detrusor hypoactivity or overactivity that will not always be improved by surgery, chronic bladder retention with detrusor underactivity risk and anticoagulants and antiaggregants with an additional bleeding risk. Bladder stone should be treated with, in the majority of cases, BPH surgery. Bladder diverticulum is an indication of BPH surgery but not systematically associated with diverticulectomy. Persistent hematuria despite treatment with 5 alpha reductase inhibitor and repeated urinary tract infection are indications for surgery. CONCLUSION: The presence of co-morbidities or complication related to BPH leads to specifics of care that should not be ignored urologists. LEVEL OF EVIDENCE: 5 consensus d'experts.

Prediction of sacral neuromodulation treatment success in men with impaired bladder emptying-time for a new diagnostic approach.

INTRODUCTION: Detrusor underactivity (DU) is currently a topic that receives major attention within functional urology. Urologists are often confronted with men who present with voiding dysfunction without bladder outlet obstruction (BOO) or after desobstructive or neuromodulation treatment. Their impaired bladder emptying is suspected to be related to failure of detrusor contractile function. Earlier research indicated that patients with non-obstructive urinary retention (NOR), for example, detrusor underactivity (DU), have a lower success rate after sacral neuromodulation (SNM) compared to patients treated with SNM for storage dysfunction. However, predicting factors for treatment success in the NOR group have not yet been defined. METHODS AND EVIDENCE: The aim of this study was to assess whether the use of the new BOO-contractility (Maastricht-Hannover) nomogram can identify and predict SNM non-responders. Our results in 18 men showed that only 20% of patients below the 10th percentile, but 86% of men between the 10 and 25th percentiles of the nomogram can be treated successfully with SNM. All successfully treated patients voided without needing self- catheterisation. CONCLUSIONS: This pilot study showed for the first time that SNM treatment response in male patients with impaired bladder emptying can be predicted with the BOO-contractility (Maastricht-Hannover) nomogram. Men below the 10th percentile are likely to be treatment non-responders, whereas the majority of men above the 10th percentile are responders. Neurourol. Urodynam. 36:808-810, 2017. © 2016 Wiley Periodicals, Inc.

Washout policies in long-term indwelling urinary catheterisation in adults.

BACKGROUND: People requiring long-term bladder draining with an indwelling catheter can experience catheter blockage. Regimens involving different solutions can be used to wash out catheters with the aim of preventing blockage. This is an update of a review published in 2010. OBJECTIVES: To determine if certain washout regimens are better than others in terms of effectiveness, acceptability, complications, quality of life and critically appraise and summarise economic evidence for the management of long-term indwelling urinary catheterisation in adults. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings to 23 May 2016. We also examined all reference lists of identified trials and contacted manufacturers and researchers in the field. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing catheter washout policies (e.g. washout versus no washout, different washout solutions, frequency, duration, volume, concentration, method of administration) in adults (aged 16 years and above) in any setting (i.e. hospital, nursing/residential home, community) with an indwelling urethral or suprapubic catheter for more than 28 days. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. Disagreements were resolved by discussion. Data were assessed and analysed as described in the Cochrane Handbook. If data in trials were not fully reported, clarification was sought from the study authors. For categorical outcomes, the numbers reporting an outcome were related to the numbers at risk in each group to derive a risk ratio (RR). For continuous outcomes, means and standard deviations were used to derive mean differences (MD). MAIN RESULTS: We included seven trials involving a total of 349 participants, 217 of whom completed the studies. Three were cross-over and four were parallel-group randomised controlled trials (RCTs). Of these, two trials were added for this update (one parallel-group RCT with 40 participants and one cross-over RCT with 67 participants). Analyses of three cross-over trials yielded suboptimal results because they were based on between-group differences rather than individual participants' differences for sequential interventions. Two parallel-group trials had limited clinical value: one combined results for suprapubic and urethral catheters and the other provided data for only four participants. Only one trial was free of significant methodological limitations, but there were difficulties with recruitment and maintaining participants in this study.The included studies reported data on six of the nine primary and secondary outcome measures. None of the trials addressed: number of catheters used, washout acceptability measures (including patient satisfaction, patient discomfort, pain and ease of use), or health status/measures of psychological health; very limited data were collected for health economic outcomes. Trials assessed only three of the eight intervention comparisons identified. Two trials reported in more than one comparison group.Four trials compared washout (either saline or acidic solution) with no washout. We are uncertain if washout solutions (saline or acidic), compared to no washout solutions, has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.Four trials compared different types of washout solution; saline versus acidic solutions (2 trials); saline versus acidic solution versus antibiotic solution (1 trial); saline versus antimicrobial solution (1 trial). We are uncertain if type of washout solution has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because the results are imprecise.One trial compared different compositions of acidic solution (stronger versus weaker solution). We are uncertain if different compositions of acidic solutions has an important effect on the rate of symptomatic urinary tract infection or length of time each catheter was in situ because only 14 participants (of 25 who were recruited) completed this 12 week, three arm trial.Four studies reported on possible harmful effects of washout use, such as blood in the washout solution, changes in blood pressure and bladder spasms.There were very few small trials that met the review inclusion criteria. The high risk of bias of the included studies resulted in the evidence being graded as low or very low quality. AUTHORS' CONCLUSIONS: Data from seven trials that compared different washout policies were limited, and generally, of poor methodological quality or were poorly reported. The evidence was not adequate to conclude if washouts were beneficial or harmful. Further rigorous, high quality trials that are adequately powered to detect benefits from washout being performed as opposed to no washout are needed. Trials comparing different washout solutions, washout volumes, and frequencies or timings are also needed.