Genitourinary Fistula: 5 Years' Experience of Five Referral Centers in Iran.

INTRODUCTION AND HYPOTHESIS: Genitourinary fistula is a devastating ailment that has an impact on women's physical health, mental health, emotional health, and financial security. The management of genitourinary fistula depends on the type, size, and duration of fistula formation. The purpose of this study is to report the features of genitourinary fistula in Iranian women and our experience in the management of fistula. METHODS: Retrospective chart reviews of 283 patients were performed to determine the cause of the fistula, prior repairs, tissue interposition, and the success rate. The operation was considered successful if the patient did not have any urine leakage during the observation time. RESULTS: The mean (SD) age of women was 49.51 (19.39; range: 21-70) years, Of these, 137 (52.9%) had a history of previous genitourinary fistula surgery. The average fistula was 1.53 (0.041) cm in size. The median (interquartile range) operation lasted 70 (15) min. The success rate after fistula repair was 91.5%. The typical follow-up period lasted 13.26 (range: 1-88) months. Forty-three (15.2%) patients had a big fistula (>2.5 cm) and 4 patients (1.4%) had a history of pelvic radiation therapy, among other reasons for failure. After a second repair, all patients' initial failures were resolved. There were no significant complications, as classified by Clavien-Dindo class 2 or greater. Additionally, there were no bowel, ureteral, or nerve injuries. CONCLUSIONS: Our patients with genitourinary fistula had a successful outcome following repair techniques, without any significant morbidity or mortality.

Long-term follow-up of intravesical abobotulinumtoxinA (Dysport®) injections in women with idiopathic detrusor overactivity.

Objective: Only a few numbers of studies have been published on the use of abobotulinumtoxinA (Dysport®) in idiopathic detrusor overactivity (IDO). This study reported the long-term follow-up of women with IDO who were treated with intravesical Dysport® injections. Methods: Two hundred and thirty-six patients with IDO who had failed first-line conservative and antimuscarinic therapy received 500-900 units of Dysport® between April 2014 and July 2015. All patients were followed up for 5 years after their initial injection and interviewed on the phone. Results: A total of 236 women with IDO aged from 18 years to 84 years (mean±standard deviation: 49.6±15.9 years) were included in our study. The median follow-up time for patients was 36.5 (range: 10-70) months, and the median recovery time after injection was 18.5 (range: 0-70) months. A total of 83 (35.2%) patients stated that they had subjective improvement of their symptoms whereas 84 (35.6%) patients did not report any improvement in symptoms. The initial International Consultation on Incontinence Questionnaire Overactive Bladder mean score was 6.9 (standard deviation 3.4). There was a positive association between the median recovery time and the components of the International Consultation on Incontinence Questionnaire Overactive Bladder questionnaire. Conclusion: In a sub-population of overactive bladder patients with IDO who have failed first-line therapy, a single intravesical Dysport® injection can resolve patient symptoms completely or reduce the symptoms to an acceptable level that can be controlled with antimuscarinics or re-injection on demands.

One-layer macroscopic verus two-layer microscopic vasovasostomy: Our experience in two referral hospitals.

OBJECTIVE: Vasovasostomy is the most common surgery to restore the fertility of vasectomized men. This study aimed to compare the outcomes of one-layer macroscopic VV (MOLVV) or two-layer microscopic VV (TLMVV). METHODS: This study was performed on the medical records of 100 patients who underwent VV surgery in two tertiary hospitals from 2014 to 2017. All patient information, including demographic and sperm analysis, was collected. The chi-square test, independent t-test, and survival analysis using Kaplan-Meyer test and Cox regression were performed to analyze the data using SPSS software version 25, and the significance level was considered 0.05. RESULTS: The fertility rate in patients of both groups was 15%. The findings showed a statistically significant difference between the mean percentage of normal sperm morphology according to the type of surgery (p = 0.045). There was no statistically significant difference between the mean sperm count, sperm motility percentage, and mean hospital costs according to the type of surgical procedure (p > 0.05). The incidence of spouse pregnancy in the TLMVV method after 15 and 24 months was 87.5% and 58.3%, respectively. In patients with unilateral anastomosis, the incidence of pregnancy at 13 and 15 months after surgery was 98.7% and 95.8%, respectively. The mean and median time of pregnancy in the spouses of patients with each surgical shower were 24 and 25 months. Other variables had no significant effect on spouse pregnancy. CONCLUSION: Vasovasostomy with the one and two-layer methods had equal results. The number, movement, and normal morphology of sperm after surgery were low. Therefore, these people will need assisted reproductive techniques.

Sacral neuromodulation in patients with detrusor underactivity: Is biological sex an indicator?

OBJECTIVES: This study aimed to report sacral neuromodulation (SNM) outcomes in detrusor underactivity (DU). METHODS: A multicentric, multinational, retrospective case series was conducted between March 2017 and June 2021 in three different referral centers. Initial test phase stimulation included either a percutaneous nerve evaluation (PNE) or an advanced lead evaluation test phase (ALTP) before permanent SNM implantation. The test phases were performed under local anesthesia, either in the outpatient (PNE) or operating room (ALTP), in the prone position, which was implanted in the third or fourth sacral foramina under fluoroscopic guidance. Patients with favorable response to the initial test phase during the first 2 weeks underwent the implantable pulse generator (IPG) implantation (Medtronic neurostimulation generator device InterStim™). Favorable response was defined as ≥ 50% improvement in symptoms, frequency of clean intermittent catheterization (CIC) and/or decrease in postvoid residual (PVR), increase in voided volume, or improvement in bladder voiding efficiency (BVE) based on the bladder diary. RESULTS: Fifty-eight patients were recruited with a mean age of 39.95 ± 15.28 years. Among the 58 cases, 36 (62.1%) patients responded to the initial stage. Of these, 12 patients (30.8%) with non-neurogenic etiology and nine patients (52.9%) with neurologic etiology did not respond to the initial test phase; thus, they did not undergo full implantation (p = 0.141). Voided volume, PVR, and the median maximum flow rate (Qmax) improved significantly (p < 0.001) in both sexes; however, there was no statistical difference between both genders. Most female cases (78.3%), and nearly half of the men (51.4%), responded to the test phase and were candidates for the IPG phase. Among the 35 cases who underwent IPG, 27 patients (72.2% of males, and 77.8% of females; p = 0.700) had a favorable response to IPG. 46.6% of patients had a successful outcome at the end of the study. CONCLUSION: This multicentric study showed that SNM effectively and safely provided symptom improvement in refractory DU in males similar to females which is an important finding as previously it has been suggested that SNM works better in nonobstructive urinary retention in women and not in women.

Efficacy of combination therapy of mid-urethral sling and low-dose Abobotulinumtoxin-A injection in mixed urinary incontinence.

OBJECTIVES: To determine the outcome of combined transobturator tape sling (TOT) and low dose intradetrusor injection of Abobotulinumtoxin-A (Abobot-A, Dysport®) in women with mixed urinary incontinence (MUI). METHODS: This randomized, active comparator-controlled, parallel-group, two-part clinical trial was conducted on women who had positive Valsalva leak point pressure (VLPP) + detrusor overactivity (DO), cough-associated DO. In Part 1, 20 women with MUI who had a failure of medical and behavioral therapies to cure MUI, randomized in two groups receiving TOT surgery alone, or in combination with Dysport® injection (n = 10 in each group), and then Part 2 was initiated as a prospective open-label on 40 more patients. We performed cystoscopy and injected 300 U of Dysport®in 20-30 intradetrusor injection sites in each patient. RESULTS: The patient's symptoms in both groups decreased significantly after treatment. The symptoms were improved significantly in the combination therapy group according to the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB) questionnaire (p < .001), and International Consultation on Incontinence Questionnaire-urinary Incontinence-short form (ICIQ-UI-SF) (p = .041) in comparing with the TOT group. In Part 2, the mean score was 17.10 (4.75) for ICIQ-UI-SF and 9.22 (2.89) for ICIQ-OAB before the treatment. Twelve weeks after the intervention, the median (interquartile range: IQR) of ICIQ-OAB symptoms (2.0 [3.0]; p < .001) and ICIQ-UI-SF decreased, too (1. 0 [2.0]; p < .001). Considering improvement using Patient Global Impression of Improvement scale, 46 (92.0%) stated that they had significant subjective improvement of their symptoms. CONCLUSIONS: Combination therapy was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.

Diagnostic value of nerve growth factor in detrusor overactivity: a study on women with mixed urinary incontinence.

OBJECTIVE: Urinary incontinence has a profound impact on women's quality of life. Studies have shown that changes in urinary protein levels could be a potential diagnostic biomarker in some urological diseases. The aim of present study is to determine the diagnostic value of nerve growth factor (NGF) in women with mixed urinary incontinence (MUI) as a diagnostic biomarkers of detrusor overactivity (DO). METHODS: Seventy women aged between 20 and 75 years with MUI were enrolled in this prospective study. All participants underwent urodynamic study. Urine NGF levels were measured using an ELISA method. NGF level was compared between groups using Mann-Whitney U test. Receiver Operator Characteristic (ROC) analysis was employed to evaluate the diagnostic performance of urinary NGF. RESULTS: The results showed that the median (min, max) of NGF in patients with DO was significantly higher in comparing to its level in women without DO [184.10 (31, 346.60) pg/ml vs. 151.80 (21, 210.70)], respectively (P = 0.035). Using receiver-operator characteristics analysis, the threshold urinary NGF value of 102.00 pg/ml provided a sensitivity of 88% and specificity of 40% in diagnosing DO, PPV of 39.1%, and NPV of 88.2%, positive likelihood ratio 2.18 and negative likelihood ratio of 0.45 (P = 0.02). CONCLUSION: Based on high sensitivity and low specificity, we can conclude that NGF can be a good tool for ruling out the OAB when the test is negative. However, the future investigations are needed to expand the observed correlation in larger groups of women with DO.

Percutaneous Drainage with Injection of Ethanol as the Sclerosing Agent for Treatment of Simple Kidney Cysts: A New Modification.

Introduction: The simple kidney cyst is the most common type of benign kidney tumor in adults and it is usually asymptomatic. Symptomatic cysts are treated with percutaneous aspiration with or without sclerosing agent injection, laparoscopic decortication, or open surgery in rare cases. Considering the probable complications of anesthesia in open surgery and laparoscopic methods, we used an innovative method of percutaneous aspiration, insertion of a single J draining catheter for 24 hours, and injection of sclerosing agents, leaving the agent inside the cyst, while the catheter was removed immediately. Long-term results of this method were evaluated using sonography. Materials and Methods: Twenty-eight patients with symptomatic kidney cysts underwent the process of insertion of the percutaneous catheter and aspiration of its contents in two steps and a one-time injection of 95% ethanol. After the first aspiration, patients stayed admitted for 24 hours. Then, the second aspiration was performed and the total fluid volume was measured. Patients were then followed for a mean follow-up period of 14 months. The procedure was considered effective with no signs of relapse (consistent with reduced size of cysts) in a sonographic evaluation of long-term results. Results: Among all the patients, 23 (82.14%) showed positive results in the sonographic evaluation after 14 months. Death occurred in one patient (3.6%), not attributable to the procedure, and recurrence was observed in five patients (17.9%). Conclusions: Our study showed that this method is safe, effective, and minimally invasive in treating simple kidney cysts and can be a proper substitute for the other current methods.

An adapted enhanced recovery protocol for adult augmentation cystoplasty in limited sources countries: A pilot clinical trial.

OBJECTIVE: To investigate an adapted enhanced recovery after surgery (ERAS) protocol in adult augmentation cystoplasty (AC). MATERIAL AND METHODS: A total of 33 consecutive cases with a history of refractory idiopathic detrusor overactivity (IDO) or neurogenic bladder (NGB) with low capacity, poor compliance, high sustained detrusor pressure, and whose previous therapeutic methods had failed were enrolled. The adapted ERAS fasting8 hours, high protein, low carbohydrate diet, antibiotics, did not use narcotics as much as possible during anesthesia, acetaminophen, early nasogastric tube removal, neostigmine injection postoperation, metoclopramide, early oral diet, and mobilization were applied, and morbidity and hospital stay duration were analyzed. RESULTS: Twenty-two patients had IDO, and the remained cases were NGB or had low bladder capacity or compliance. The mean age of patients in the IDO group was higher than in NGB cases (P » .020). Following the adapted ERAS protocol implementation, more than two-third of patients returned to a regular diet on the second day postoperation in both groups. The mean (SD) hospital stay duration was 7.7 (1.5) days. Postoperative fasting time was 8.8 6 3. 7 hours, and bowel function was returned 1 day postoperation in 82% of patients. Only 33.3% of adults need postprocedure acetaminophen for 2 days, and in 11 cases, it prescribed for 1 day. All subjects except paraplegic patients had early mobilization 1 day postoperation. CONCLUSION: Our findings revealed that adapted ERAS protocol could be safe and effective in adult AC. It accompanied by few complications, reduced intestinal motility problems, and a short length of hospital stay.

COVID-19 outbreak and the impact on renal disorders: A rapid review.

In this rapid review, we aimed to evaluate the effect of coronavirus disease 2019 (COVID-19) on renal functions and mortality of patients with kidney diseases. We searched MEDLINE, The Cochrane Library, Scopus, Embase, Web of Science, UpToDate, and TRIP databases using the following keywords: COVID-19, COVID19, 2019-nCoV, 2019-CoV, coronavirus, SARS-nCoV-2, urology, cancer, bladder, prostate, kidney, trauma, stone, neurogenic, and reconstructive. The initial search resulted in 495 records. After the primary screening of titles, abstracts, and full texts and removing duplicates, 10 articles were selected and included in this rapid review. Moreover, we performed meta-analysis of binary data for the outcomes with sufficient data. Owing to a high level of heterogeneity because of different study designs and contexts, we used a random model for the meta-analysis. Only 5 studies were eligible for the meta-analysis. In these studies, comprising 964 COVID-19 positive patients, the cumulative event rate of acute kidney injury (AKI) was 7.1% (95% confidence interval: 1.8%-24.5%, p<0.001, I2=92.4). Based on the qualitative synthesis of the 10 included studies, patients with COVID-19 and kidney diseases had higher risk of in-hospital mortality. If AKI occurs because of the novel coronavirus, the mortality rate will be very high. Therefore, we need further investigations and more studies to recognize the extent and the cause of renal involvement in COVID-19.