Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT: The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE: To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION: PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS: Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS: Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY: In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

What Are the Short-term Benefits and Potential Harms of Therapeutic Modalities for the Management of Overactive Bladder Syndrome in Women? A Review of Evidence Under the Auspices of the European Association of Urology, Female Non-neurogenic Lower Urinary Tract Symptoms Guidelines Panel.

CONTEXT: Overactive bladder syndrome (OAB) is highly prevalent among women and has a negative impact on their quality of life. The current available treatments for OAB symptoms include conservative, pharmacological, or surgical modalities. OBJECTIVE: To provide an updated contemporary evidence document regarding OAB treatment options and determine the short-term effectiveness, safety, and potential harms of the available treatment modalities for women with OAB syndrome. EVIDENCE ACQUISITION: The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched for all relevant publications up to May 2022. The risk of bias assessment followed the recommended tool in the Cochrane Handbook for Systematic Reviews of Interventions, and quality of evidence was assessed using the modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. A meta-analysis was performed where appropriate. EVIDENCE SYNTHESIS: Antimuscarinics and beta-3 agonists were significantly more effective than placebo across most outcomes, with beta-3 agonists being more effective at reducing nocturia episodes and antimuscarinics causing significantly higher adverse events. Onabotulinumtoxin-A (Onabot-A) was more effective than placebo across most outcomes, but with significantly higher rates of acute urinary retention/clean intermittent self-catheterisation (six to eight times) and urinary tract infections (UTIs; two to three times). Onabot-A was also significantly better than antimuscarinics in the cure of urgency urinary incontinence (UUI) but not in the reduction of mean UUI episodes. Success rates of sacral nerve stimulation (SNS) were significantly higher than those of antimuscarinics (61% vs 42%, p = 0.02), with similar rates of adverse events. SNS and Onabot-A were not significantly different in efficacy outcomes. Satisfaction rates were higher with Onabot-A, but with a higher rate of recurrent UTIs (24% vs 10%). SNS was associated with 9% removal rate and 3% revision rate. CONCLUSIONS: Overactive bladder is a manageable condition, with first-line treatment options including antimuscarinics, beta-3 agonists, and posterior tibial nerve stimulation. Second-line options include Onabot-A bladder injections or SNS. The choice of therapies should be guided by individual patient factors. PATIENT SUMMARY: Overactive bladder is a manageable condition. All patients should be informed and advised on conservative treatment measures in the first instance. The first-line treatment options for its management include antimuscarinics or beta-3 agonists medication, and posterior tibial nerve stimulation procedures. The second-line options include onabotulinumtoxin-A bladder injections or sacral nerve stimulation procedure. The therapy should be chosen based on individual patient factors.

Sepsis rates after template prostate biopsy with single-dose prophylactic antibiotic.

Introduction: Urosepsis is a significant risk associated with prostate biopsy. Resistance of microorganisms to antibiotics is a challenging issue for clinicians in everyday practice. In the current study, we investigated the rates of sepsis and hospital admissions following transperineal (TP) prostate biopsies using a single dose of gentamicin. Material and methods: Data for consecutive patients who underwent TP prostate biopsies (March 2019-March 2020) were included. Patients received a single-dose of prophylactic gentamicin 120 mg IV and had skin preparation with antiseptic povidone-iodine or chlorhexidine solution prior to the procedure. Patient's electronic records were reviewed for rates of sepsis and readmission to hospital within 7 days following TP prostate biopsy. Results: A total of 365 consecutive patients were included in the study. After exclusion of non-eligible patients, 280 patients were included in final analysis. The median age was 67 years (32-83), the median prostate-specific antigen (PSA) level was 8.5 ng/ml (0.2-58), and the median prostate size was 44 cc (10-188). Approximately 58% of patients had one or more comorbidities in the form of diabetes mellitus (DM), hypertension, asthma, chronic kidney disease, or ischemic heart disease. Adenocarcinoma was found in 71.7% of patients. None of the 280 patients developed sepsis. Urinary tract infection (UTI) occurred in 2.8% of patients with E.coli, none of them required hospital readmission. Conclusions: Our single centre experience showed a 0% sepsis rate after TP prostate biopsy with single prophylactic dose of gentamicin. Future randomized controlled trials (RCTs) should explore the possibility of performing these procedures without antibiotic prophylaxis in order to reduce the unnecessary use of antibiotics.

How did the first year of the COVID-19 pandemic affect urology practice in Arab countries? A cross-sectional study by the Arab Association of Urology research group.

OBJECTIVE: The aim of this study was to assess of the effect of coronavirus disease 2019 (COVID-19) pandemic on urology practice in the Arab world during the first year of the crisis. METHODS: An Internet-based questionnaire was created and sent out via email to members of the Arab Association of Urology (AAU) using 'Google Forms'. The survey assessed participants' demographics in terms of age, gender, country of origin, type of practice and position. Impacts of COVID-19 on urological practice were assessed in terms of the changes in hospital policies regarding consultations, and elective and emergency surgical cases. Moreover, impacts of COVID-19 on urologists were assessed. RESULTS: A total of 255 AAU members across 14 Arab countries (Emirates, Egypt, Saudi Arabia, Iraq, Jordan, Algeria, Kuwait, Yemen, Qatar, Lebanon, Libya, Oman, Sudan and Syria) completed the survey; 4% were female urologists. Consultations at outpatient clinics were closed or restricted to emergency cases or replaced by telemedicine in almost 15%, 40% and 25% of hospitals, respectively. Elective surgeries were stopped or reduced to under 25% of surgical capacity in >10% and about 25% of hospitals, respectively. Almost 90% (228) reported changes in the policy for emergency theatres. Nearly 65% of hospitals offered preoperative COVID-19 testing to patients and 50% of hospitals provided personal protective equipment (PPE) to their urologists. Of 99% (253) who reported a change in urological education, 95% relied on online webinars. About 56% of respondents had their own private practice, of whom 91% continued private practice during the crisis. About 38% of participants reported exposure to intimidation (75% emotional, 20% verbal and 5% physical). CONCLUSION: The COVID-19 pandemic resulted in major changes in hospitals' policies regarding outpatient consultations, elective and emergency operative cases, and the shift to telemedicine. Arab urologists have been facing major challenges either in both the governmental or the private sectors, and some of them were exposed to emotional, verbal and even physical intimidation.

European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed Urinary Incontinence.

CONTEXT: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guideline expands the remit to include these symptoms and conditions. OBJECTIVE: To summarise the diagnostic section of the non-neurogenic female LUTS guideline and the management of female overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI). EVIDENCE ACQUISITION: New literature searches were carried out in September 2021 and evidence synthesis was conducted using the modified GRADE criteria as outlined for all EAU guidelines. A new systematic review (SR) on OAB was carried out by the panel for the purposes of this guideline. EVIDENCE SYNTHESIS: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations. CONCLUSIONS: Non-neurogenic female LUTS are an important cause of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion based on the best available evidence. This guideline serves to present this evidence to health care providers in an easily accessible and digestible format. PATIENT SUMMARY: This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to diagnosis of these conditions, as well as the treatment of overactive bladder, stress urinary incontinence, and mixed urinary incontinence.

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia.

CONTEXT: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions. OBJECTIVE: To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females. EVIDENCE ACQUISITION: The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline. EVIDENCE SYNTHESIS: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations. CONCLUSIONS: Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format. PATIENT SUMMARY: This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.

Diagnostic Tests for Female Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.

CONTEXT: Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain. OBJECTIVE: To identify and compare different tests to diagnose fBOO through a systematic review process. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). EVIDENCE SYNTHESIS: Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Qmax) and voiding detrusor pressure at Qmax. The sensitivity, specificity, and overall accuracy ranges were 54.6-92.5%, 64.6-93.9%, and 64.1-92.2%, respectively. CONCLUSIONS: The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO. PATIENT SUMMARY: Evidence on tests used to diagnose female bladder outlet obstruction was reviewed. The most common test used was pressure-flow studies ± fluoroscopy, which remains the current standard for diagnosing bladder outlet obstruction in women. TAKE HOME MESSAGE: The available evidence on diagnostic tests for female bladder outlet obstruction is limited and heterogeneous. The most common test used was video-urodynamics, which remains the current standard for diagnosing bladder outlet obstruction in women.

Benefits and Harms of Conservative, Pharmacological, and Surgical Management Options for Women with Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.

CONTEXT: While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female BOO. OBJECTIVE: The aim of this systematic review was to evaluate the benefits and harms of therapeutic interventions for the management of BOO in women. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The study protocol was registered with PROSPERO (CRD42020183839). A systematic literature search was performed and updated by a research librarian in May 2021. The study population consisted of adult female patients diagnosed with BOO, who underwent treatment. EVIDENCE SYNTHESIS: Out of 6344 records, we identified 33 studies enrolling 1222 participants, of which only six randomized controlled trials (RCTs) were found. One placebo-controlled crossover randomized trial assessed the role of baclofen in 60 female patients with dysfunctional voiding. The trial met its primary endpoint with a significantly greater decrease in the number of voids per day in the baclofen group (-5.53 vs -2.70; p = 0.001). The adverse events were mild and comparable in both groups (25% vs 20%). One placebo-controlled crossover randomized trial assessed the role of sildenafil in 20 women with Fowler's syndrome. There were significant improvements from baseline in maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and postvoid residual (PVR), but with no statistically significant difference when compared with placebo. In a large RCT including 197 female patients with functional BOO, the alpha-blocker alfuzosin significantly improved IPSS, Qmax, and PVR compared with baseline, but the differences were not statistically significant compared with the placebo group. Several small single-arm prospective series reported improvement of BOO-related symptoms and voiding parameters with urethroplasty, sling revision, urethral dilation, vaginal pessary, and pelvic organ prolapse repair. CONCLUSIONS: Evidence to support the use of conservative, pharmacological, and surgical treatments for BOO is scarce. PATIENT SUMMARY: According to the present systematic review of the literature, evidence to support the use of conservative, pharmacological, and surgical treatments for either anatomical or functional bladder outlet obstruction is scarce.

Is There Outcome Reporting Heterogeneity in Trials That Aim to Assess the Effectiveness of Surgical Treatments for Stress Urinary Incontinence in Women?

CONTEXT: Inconsistent reporting of effectiveness outcomes in surgical trials of stress urinary incontinence (SUI) has hindered direct comparisons of various surgical treatments for SUI. OBJECTIVE: To systematically review the verbatim outcome names, outcome definitions, and tools used to measure the outcomes in surgical trials of SUI in women. EVIDENCE ACQUISITION: Trials of women with SUI who have undergone surgical interventions were included. We conducted a systematic review (SR) on outcomes reported in randomized controlled trials of surgical management published in 2014-2019, covering the following databases: MEDLINE, EMBASE, CENTRAL, and CDSR. Verbatim outcome names extracted from the included studies were categorized and then grouped into domains using the Williamson-Clarke (W/C) outcome taxonomy. A matrix was also created to visualize and quantify the dimensions of outcome reporting heterogeneity in SUI trials. EVIDENCE SYNTHESIS: A total of 844 verbatim outcome names were extracted, of which, 514 varied terms were reduced to 71 standardized outcome names. They were further categorized into 11 domains from the W/C taxonomy. There were 7.24 different terms on average to describe each outcome, and the four outcomes with the most heterogeneity evident in terms used to describe them were "urinary retention", "reoperation", "subjective cure rate" and "quality of life". Each of them had ≥20 different terms. Only 28% of the outcome definitions were reported and a variety of measuring tools was noted, particularly in subjective outcomes. High heterogeneity was found in the outcome names, outcome definitions, choice and number of measuring instruments of the outcomes, and choice and number of outcomes reported across studies. CONCLUSIONS: This SR provides objective evidence of heterogeneity in outcome reporting in SUI surgical trials. Our categorization of outcomes highlights the difficulties in summarizing the current evidence base. A core outcome set, developed using the methods advocated by the Core Outcome Measures in Effectiveness Trials (COMET) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) initiatives, is required. PATIENT SUMMARY: In this research, we have highlighted the diversity in outcomes reporting in stress urinary incontinence (SUI) surgical trials and have categorized the outcomes. We support the development of a core outcome set for SUI, which will promote future clinical researchers to measure the same outcome in the same way in all trials. This will, in turn, help researchers summarize the evidence more effectively and aid decision making for patients and doctors.

Ciprofloxacin: single versus multiple doses in transrectal ultrasound guided prostate biopsy.

INTRODUCTION: There is rising concern regarding overuse of fluoroquinolones due to severe musculoskeletal and neurological side effects, and development of resistant microorganisms. In June 2019, the European Commission recommended fluoroquinolones should not be used routinely for prophylaxis in urological surgical procedures. Methods to reduce unnecessary exposure to fluroquinolones should be investigated.The aim of this article was to determine differences in hospital admission secondary to sepsis following transrectal ultrasound (TRUS) guided prostate biopsies between patients who received single vs. multiple doses of fluoroquinolones. MATERIAL AND METHODS: A retrospective analysis (June 2017-September 2018) of 200 consecutive TRUS biopsies at a single centre was undertaken. Group 1 (n = 100) received 750 mg ciprofloxacin 1-hr before their procedure followed by 3 days of ciprofloxacin 250 mg BD. Group 2 (n = 100) received a single dose of 750 mg ciprofloxacin 1-hr before the procedure. Midstream urine (MSU) culture results were examined pre-biopsy and 7 days post-biopsy. Data was also gathered on readmission rates to hospital as a result of urosepsis. RESULTS: A total of 1% of patients in each group required hospital admission secondary to Escherichia coli sepsis. A further 4% (n = 4) in Group 1 developed a urinary tract infection requiring antibiotic treatment post biopsy compared with 1% (n = 1) in Group 2. There was no statistically significant difference in development of infectious complications post-biopsy between the two groups (p >0.05). CONCLUSIONS: A single prophylactic dose of 750 mg of ciprofloxacin 1-hour pre-biopsy is as effective as multiple doses for TRUS guided prostate biopsy. Avoiding an unnecessary and prolonged course of fluoroquinolones has advantages in reducing potential side effects and development of resistant pathogens.

Female neurogenic stress urinary incontinence.

PURPOSE OF REVIEW: The aim of this article is to look into recent updates on the management of neurogenic stress urinary incontinence (NSUI) in adult females. RECENT FINDINGS: Recently, a small number of studies have investigated different surgical modalities in treatment of NSUI in adult females including artificial urinary sphincter (AUS), suburethral tapes (SUT) and adjustable slings and urethral bulking agents. Up to 70% of neurogenic patients who received AUS implants are continent and have not required surgical revision over a 20-year follow-up period. However, the risk for explantation of AUS may be twice as high in neurogenic patients compared with nonneurogenic patients. SUT have success and improvement in quality of life rates of up to 52 and 68%, respectively. However, complications may be as high as 24%. Early data on adjustable slings may suggest up to 80% continence with low complication rates. SUMMARY: AUS can provide satisfactory continence levels with acceptable rates of revision and explantation. SUT are effective but more than half of patients may require additional procedures. Adjustable slings could be a promising option. Further high-quality studies with careful attention to methodology and standardization of both definitions used and outcome reporting are required to help us reach safe conclusions.

Scrotal ultrasonographic findings in obese infertile patients and their correlations to semen and hormonal profile.

OBJECTIVE: The aim of this prospective study was to compare scrotal ultrasonographic findings in obese and normal weight infertile men and correlate these findings with semen parameters and hormonal profile. MATERIAL AND METHODS: A total of 188 men presented for infertility evaluation were included in this study. They were divided according to body mass indices into obese (n=96) and normal weight infertile patients (n=92). Basic infertility evaluation, semen analysis and scrotal duplex ultrasound examination in addition to measurement of serum levels of follicular stimulating hormone, testosterone and estradiol were done for all cases. The ratio between testicular size measured by scrotal ultrasound and body mass index were calculated. RESULTS: Any significant differences were not observed in semen parameters, serum levels of follicular stimulating hormone and testosterone between obese and normal weight infertile men (p>0.05). Serum estradiol level was significantly higher in obese than normal weight infertile men (p<0.001). There is significant increase in subclinical varicocele, hydrocele and testicular microlithiasis detected by scrotal ultrasound in obese infertile men than nonobese patients (p<0.05). Despite having comparable testicular size detected on scrotal ultrasound, infertile obese men had significantly lower total testicular volume to body mass index ratio and this ratio correlated positively with semen volume, sperm concentration, total sperm count and serum testosterone but negatively with serum follicular stimulating hormone and estradiol levels. CONCLUSION: We therefore conclude that the incidence of subclinical varicocele, hydrocele and testicular microlithiasis was higher in obese infertile patients and the ratio between testicular volume assessed by scrotal ultrasound and body mass index may be a new parameter that correlates with subfertility status in these men.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence.

CONTEXT: The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016. OBJECTIVE: We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination. EVIDENCE ACQUISITION: Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria. EVIDENCE SYNTHESIS: The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/. CONCLUSIONS: These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances. PATIENT SUMMARY: Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Complications of Urethral Bulking Agents for Stress Urinary Incontinence: An Extensive Review Including Case Reports.

OBJECTIVES: Stress urinary incontinence in women is a common problem that significantly impacts quality of life. Periurethral injection of urethral bulking agents (UBAs) is a simple, noninvasive, and cost-effective treatment. However, complications associated with UBA are often underappreciated. Objective of this review was to get a complete overview of all published complications of UBA. METHODS: An extensive search of the scientific literature was conducted to quantitatively summarize the complications and their treatments of 8 UBAs. A total of 117 articles (original articles and case reports) were included in the final analysis. Complication incidence, treatment incidence, and follow-up time were extracted when mentioned. Statistical analysis of complication incidence of each UBA was calculated if possible. RESULTS: A total of 2095 complications in 6462 treated patients were reported in 79 studies. Sixty-seven (3%) were considered serious implying operative correction (Clavien grade III); of these, 46 (69%) required incision and drainage, and 21 (31%) required a more invasive procedure. In 38 case reports and small case series, 49 patients were treated for 110 complications. Of these 110 complications, 41 (37%) can be classified as Clavien grade III. CONCLUSIONS: This extensive review shows that various UBAs have different complication rates, with certain UBAs being more prone to serious complications. Based on available publications, most UBAs have a good safety profile, with low complication rates. However, although the majority of UBA complications are transient and require no or noninvasive treatment, serious complications may require invasive intervention and treatment.

Impact of leukocytospermia on sperm dynamic motility parameters, DNA and chromosomal integrity.

INTRODUCTION: To characterize sperm dynamic motility patterns and chromatin integrity in infertile men with leukocytospermia. MATERIAL AND METHODS: Fifty patients with primary infertility and oligoasthenoteratozoospermia included in this prospective, controlled, blind study. All patients underwent clinical evaluation, semen peroxidase stain, computer aided semen analysis (CASA), sperm DNA integrity evaluation with acridine orange test (AOT) and fluorescence in situ hybridization (FISH) analysis of 18, X and Y chromosomes. Pregnancy outcomes were documented following antibiotic treatment of patients with leukocytospermia. RESULTS: Infertile men with leukocytospermia had significantly lower progressive and total sperm motility percentages compared to the control group. Sperm dynamic motility parameters by CASA including curvilinear, straight line and average pathway velocities, straightness and amplitude of lateral head displacement were significantly lower in leukocytospermia. Sperm DNA fragmentation index was significantly higher in leukocytospermia. Percentages of sperm with disomy XY and 18 were significantly higher. These changes in sperm motility parameters and DNA integrity correlated with the number of peroxidase positive leukocytes. Follow-up of 23 of the 25 patients with leukocytospermia after antibiotic treatment revealed significantly higher pregnancy rates in cured patients than in those with persistent leukocytospermia. CONCLUSIONS: Leukocytospermia has a significant impact on sperm dynamic motility patterns, DNA and chromosomal integrity in infertile men which can adversely affect the likelihood of a successful pregnancy.

A novel algorithm for the non-invasive detection of bladder outlet obstruction in men with lower urinary tract symptoms.

OBJECTIVE: To determine the ability of bladder wall thickness (BWT) in combination with non-invasive variables to distinguish patients with bladder outlet obstruction (BOO). PATIENTS AND METHODS: Patients completed the International Prostate Symptom Score (IPSS) questionnaire and prostate size was measured by transrectal ultrasonography (US). Pressure-flow studies were performed to determine the urodynamic diagnosis. BWT was measured at 250-mL bladder filling using transabdominal US. Recursive partition analysis (RPA) recursively partitions data for relating independent variable(s) to a dependent variable creating a tree of partitions. It finds a set of cuts of the dependent variable(s) that best predict the independent variable, by searching all possible cuts until the desired fit is reached. RPA was used to test the ability of the combined data of BWT, maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), IPSS, and prostate size to predict BOO. RESULTS: In all, 72 patients were included in the final analysis. The median BWT, voided volumes, PVR, mean Qmax, and IPSS were significantly higher in patients who had an Abrams/Griffiths (A/G) number of >40 (55 patients) compared to those with an A/G number of ≤40 (17 patients). RPA revealed that the combination of BWT and Qmax gave a correct classification in 61 of the 72 patients (85%), with 92% sensitivity and 65% specificity, 87% positive predictive value, and 76% negative predictive value (NPV) for BOO (area under the curve 0.85). The positive diagnostic likelihood ratio of this reclassification fit was 2.6. CONCLUSIONS: It was possible to combine BWT with Qmax to create a new algorithm that could be used as a screening tool for BOO in men with lower urinary tract symptoms.

Single session vs two sessions of flexible ureterosopy (FURS) for dusting of renal pelvic stones 2-3 cm in diameter: Does stone size or hardness play a role in number of sessions to be applied?"

OBJECTIVE: To evaluate the stone hardness in predicting the need for single or two sessions of retrograde intrarenal surgery (RIRS) for renal pelvis stones of 2-3 cm in size. MATERIAL AND METHODS: Ninety-six patients (64 male and 32 female) with only renal stones (2.5±0.3 cm) underwent RIRS using flexible 7.5 Fr ureteroscope (FURS). The stone hardness was evaluated by preoperative non-contrast computed tomography (NCCT). The patients were divided into two groups based on stone hardness: Group I (n=54) (hard stones - Hounsfield Unit (HU) >1000) and group II (n=42) (not hard stone - HU <1000). The stone-free rate, the operative time, any intra or postoperative complications and the need for second sessions of RIRS were evaluated. RESULTS: All stones were successfully accessed. Intraoperative complications were not reported. The initial stone-free rate was 40% in Group I and 95% in Group II after a single session (p=0.01). A second session FURS was needed in 32 cases of Group I (40%) where postoperative CT showed significant residual stone fragments of 6±2 mm, and stone-free rate up to 100 percent. On the contrary only 2 cases from Group II underwent second session FURS (p=0.01). The operative times were 75±15 minutes in Group I and 55±13 minutes in Group II (p<0.01). Six patients (4 in group I and 2 in group II) had postoperative high-grade fever (Clavien Grade II). CONCLUSION: Stone hardness had a significant impact on the decision of performing single versus two sessions of FURS for renal pelvic stones of 2-3 cm rather than the stone size alone.

Pathophysiology and Contributing Factors in Postprostatectomy Incontinence: A Review.

CONTEXT: The incidence and awareness of postprostatectomy incontinence (PPI) has increased during the past few years, probably because of an increase in prostate cancer surgery. Many theories have been postulated to explain the pathophysiology of PPI. OBJECTIVE: The current review scrutinizes various pathophysiologic mechanisms underlying the occurrence of PPI. EVIDENCE ACQUISITION: A search was conducted on PubMed and EMBASE for publications on PPI. The primary search returned 2518 publications. Animal and basic research studies, letters, publications on prostatectomy for benign reasons, pathology of prostatic carcinoma, radiotherapy and hormone therapy of prostatic carcinoma, and review articles were all used as criteria for exclusion from the study. A total of 128 publications were selected for final analysis. EVIDENCE SYNTHESIS: Neuromuscular anatomic elements and pelvic support are known to influence PPI as evidenced by multiple publications. A number of non-anatomic and surgical elements have been postulated as contributing factors to PPI. Biological factors and preoperative parameters include: functional bladder changes, age, body mass index (BMI), pre-existing lower urinary tract symptoms (LUTS), prostate size, and oncologic factors. Multiple studies reported the impact of specific anatomic/surgical factors, including fibrosis, shorter membranous urethral length (MUL), anastomotic stricture, damage to the neurovascular bundle, and extensive dissection, all of which have a negative impact on the continence status of patients following radical prostatectomy (RP). Investigation of the impact of techniques to spare the bladder neck and additional procedures to reconstruct the posterior or anterior support structures (eg, the Rocco stitch) on continence status is ongoing. CONCLUSIONS: Anatomic support and pelvic innervation appear to be important factors in the etiology of PPI. Biological/preoperative factors including greater age at time of surgery, pre-existing LUTS, high BMI, shorter MUL, and functional bladder changes have a negative impact on continence after RP. Extensive dissection during surgery, damage to the neurovascular bundle, and postoperative fibrosis also have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior fixation of the bladder-urethra anastomosis are associated with better continence rates. There is still debate about whether posterior pelvic reconstruction leads to better postoperative continence rates. PATIENT SUMMARY: Radical prostatectomy is an oncologic procedure and thus requires removal of the entire prostate gland and seminal vesicles, ideally with negative surgical margins. This sometimes results in urinary incontinence. The factors contributing to urinary incontinence are explained in this article.