Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology.

BACKGROUND AND OBJECTIVE: Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology. METHODS: A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data. KEY FINDINGS AND LIMITATIONS: Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients. CONCLUSIONS AND CLINICAL IMPLICATIONS: The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients. PATIENT SUMMARY: Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Enhancing Kidney Transplant Outcomes: The Impact of Living Donor Programs.

INTRODUCTION: The protocol for deceased donor kidney transplants has been standardised. The procedure for a living donor has peculiarities derived from the differences in the graft. When a living kidney donor program is implemented, changes occur in both the profile of the kidney transplant candidate and in the postoperative treatments. AIMS: To discover whether a living donor program influences the functional outcomes of kidney grafts in a longstanding classical deceased donor kidney transplant program and to identify the factors associated with transplant outcomes. METHODS: Retrospective observational multicentre study. SAMPLE: Kidney transplant patients in two urology referral centres for renal transplant in Spain between 1994 and 2019. Groups: TV (living transplant): patients given kidney transplants from living donors (n = 150); TCpre11 (deceased transplant previous to 2011): patients given kidney transplants from deceased donors before the living donor program was implemented (n = 650); and TCpost11 (deceased transplant after 2011): patients given kidney transplants from deceased donors after the living donor program was implemented (n = 500). RESULTS: Mean age was 55.75 years (18-80 years), higher in TCpre11. There were 493 female patients (37.92%) and 1007 male patients (62.08%). Mean body mass index (BMI) was 26.69 kg/m2 (17.50-42.78 kg/m2), higher in TCpre11. Mean ischemia time was 17.97 h (6-29 h), higher in TCpost11. Median duration of urethral catheter: 8 days (6-98 days), higher in TCpost11. Median duration of double-J ureteral stent: 58 days (24-180 days), higher in TCpost11. Pretransplant UTIs: 17.77%, higher in TCpre11 (25.69%) than in TV (12%), higher in TV (12%) than TCpost11 (9.2%), and higher in TCpre11 (25.69%) than TCpost11 (9.2%). Acute renal rejection in 9.33% of TV, 14.77% of TCpre11, and 9.8% of TCpost11. Multivariate analysis: TCpost11 featured higher BMI, more smoking, and chronic renal failure progression time. Lower use of nonantibiotic prophylaxis to prevent recurrent urinary tract infections, increased duration of urethral catheters due to obstructive problems, and favoured deterioration of kidney function was observed in the deceased donor program. The living donor (LD) program had a strong influence on deceased donor transplants in the prelysis phase. Implementation of a LD program was associated with a decrease in the likelihood of acute rejection in TCpost11 and an increase in the tendency towards normal kidney function. CONCLUSIONS: Implementing living donor transplant programs affects functional outcomes in deceased donor transplants, reducing the probability of acute rejection and increasing the tendency towards normal kidney function. Preventing recurrent urinary tract infections with measures other than antibiotics, smoking cessation, delaying the removal of the double-J stent from the graft, and pre-emptive transplant (transplant prior to dialysis) are associated with improved renal function of the graft.

Recurrent Bacteriuria as a Prognosis Marker in the Adjuvant Treatment of Non-Muscle Invasive Bladder Cancer.

PURPOSE: Bacteriuria may affect the response to adjuvant therapy in non-muscle invasive bladder cancer (NMIBC). The main aim of this study was to examine the effect of recurrent bacteriuria (RB) on the prognosis of NMIBC in women receiving intravesical therapy. MATERIALS AND METHODS: We designed a prospective observational study from 2012 to 2019. We included women with bladder cancer treated with transurethral resection of the bladder (TURB) and adjuvant intravesical treatment. Significant bacteriuria was defined as a presence in urine cultures at or above 100,000 colony-forming units per millilitre. The recurrent bacteriuria group included patients with significant bacteriuria in at least two determinations in 6 months or in 3 or more determinations in a year. The institutional board approved the study. RESULTS: One hundred thirty-six patients diagnosed with NMIBC participate in the study, of whom 100 met the inclusion criteria. During follow-up, 48 were categorized in the RB group and 52 formed the non-bacteriuria group (NB). RB GROUP HAD A BETTER OUTCOME: Eight patients (16.67%) experiencing a recurrence of the same grade, with no progression to a higher-grade tumor or muscle-invasive tumor. In the NB group, 18 (34.6%) patients presented a recurrence (P = .001) and 22 (42.3%) progressed to a higher-grade tumor or muscular invasion (P = .001). The presence of RB was identified as a predictor of good response in multivariate regression with a relative risk of 0.13 (P = .018) CONCLUSIONS: Female patients with RB had a better response to adjuvant treatment for NMIBC. The RB group showed lower rates of tumor recurrences and progression.

Relationship between Mental Disorders, Smoking or Alcoholism and Benign Prostate Disease.

INTRODUCTION: Mental disorders, smoking, or alcoholism and benign prostate disease are highly prevalent in men. AIMS: To identify the relationship between mental disorders, smoking, or alcoholism and benign prostate disease. METHODOLOGY: A prospective multicenter study that evaluated prostate health status in 558 men from the community. Groups: GP-men who request a prostate health examination and whose medical history includes a mental disorder, smoking, or alcoholism prior to a diagnosis of benign prostate disease; GU-men who request a prostate health examination and whose medical history includes a benign prostate disease prior to a diagnosis of mental disorder, smoking, or alcoholism. VARIABLES: age, body mass index (BMI), prostate specific antigen (PSA), follow-up of the mental disorder, smoking or alcoholism, time elapsed between urological diagnosis and the mental disorder, smoking or alcoholism diagnosis, status of the urological disease (cured or not cured), concomitant diseases, surgical history, and concomitant treatments. Descriptive statistics, Student's t-test, Chi2, multivariate analysis. RESULTS: There were no mental disorders, smoking, or alcoholism in 51.97% of men. Anxiety, smoking, major depressive disorder, pathological insomnia, psychosis, and alcoholism were identified in 19.71%, 13.26%, 5.73%, 4.30%, 2.87%, and 2.15% of individuals, respectively. Nonbacterial prostatitis (31.54%), urinary tract infection (other than prostatitis, 24.37%), prostatic intraepithelial neoplasia (13.98%), and prostatodynia (1.43%) were prostate diseases. Unresolved symptomatic benign prostate disease was associated with anxiety, depression, and psychosis (p = 0.002). Smoking was the disorder that men managed to eliminate most frequently. The dominant disorder in patients with symptomatic benign prostatic disease was alcoholism (p = 0.006). CONCLUSIONS: Unresolved symptomatic benign prostatic disease is associated with anxiety, depression, and psychosis. Alcoholism is associated with a worse prognosis in the follow-up of symptomatic benign prostatic disease.

Can we define the optimal postvoid residual volume at which intermittent catheterization should be recommended, and are there other measures that could guide an intermittent catheterization protocol: ICI-RS 2023.

AIMS: The postvoid residual (PVR) volume of urine in the bladder is widely used in clinical practice as a guide to initiate treatment, including clean-intermittent self-catheterization (CISC). It is often believed that an elevated PVR causes complications such as recurrent urinary tract infections (UTI) and renal failure. However, evidence for this is limited and identifying alternative measures to guide treatment decisions may optimize patient care. At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2023 a Think Tank addressed the question of whether we can define the optimal PVR at which CISC should be recommended, and whether there are other measures that could guide a CISC protocol. METHODS: The Think Tank conducted a literature review and expert consensus meeting focusing on current limitations in defining and measuring PVR, and highlighting other measures that may optimize selection for, and persistence with, CISC. RESULTS: There is no consensus on the threshold value of PVR that is considered "elevated" or "significant." There is a lack of standardization on terminology, and the normal range of PVR in different populations of different ages remains to be well-studied. The measurement of PVR is influenced by several factors, including intraindividual variation, timing and method of measurement. Furthermore, the evidence linking an elevated PVR with complications such as UTI and renal failure is mixed. Other measures, such as bladder voiding efficiency or urodynamic parameters, may be better at predicting such complications, and therefore may be more relevant at guiding a CISC protocol. CONCLUSIONS: There is a lack of high quality evidence to support PVR as a predictor for complications of UTI or renal failure. Threshold values for normal PVR in different populations are unknow, and so threshold values for "elevated" or "significant" PVR cannot be determined. Other factors, such as urodynamic findings, may be better at predicting complications and therefore guiding management decisions, and this remains to be studied. Areas for further research are proposed.

Four vertex technique for correcting urethral prolapse: technique description and cohort study.

Introduction/Objectives: This study aims to describe the procedure and effectiveness of the four-vertex technique for correcting urethral prolapse in women. Methods and Materials: includes a retrospective case series of 17 patients who underwent surgery for urethral prolapse. Two study groups were distinguished based on the presence or absence of pelvic heaviness symptoms. The variables were analyzed, including age, BMI, concomitant diseases, obstetric and gynecological history, time from diagnosis to surgery, and outcomes of treatment. Results: All patients were postmenopausal, with a mean age at the time of the intervention of 70.41 years, with no differences between groups. Mean BMI was 23.67 kg/m2, higher in the group with a sensation of vaginal heaviness (p = 0.027). Mean time elapsed between diagnosis and operation was 231.58 days, with no differences between groups. Mean childbirth count was 2.29. The most frequent causes for consultation were urethrorrhagia (33.33%) and a bulging sensation (33.33%). After the intervention, 14 patients (82.35%) were asymptomatic, two (11.76%) had dysuria, and one (5.88%) had urinary urgency. Ten patients had pre-surgical urinary incontinence, which was resolved in nine patients. 17.46% subsequently presented pelvic organ prolapse. In three women there was secondary impairment of sexual activity. Conclusion: The four-vertex technique was effective in resolving symptoms in most patients. However, some patients experienced dysuria, urinary urgency, and pelvic organ prolapse after surgery. Urinary incontinence improved in most patients, but a few required additional treatments with suburethral tape. The study also identified associations between variables and the presence of cystocele, consultation for a bulging sensation, and bleeding from urethral prolapse. Overall, this study sheds light on the challenges and outcomes of surgical treatment for urethral prolapse and provides valuable insights for future research in this area.

Long-Term Functional Outcomes and Quality of Life after Male Transobturator-Retrourethral Sling Surgery.

INTRODUCTION: Post-prostatectomy urinary incontinence (PPUI) has an enormous impact in quality of life (QoL). Transobturator-rethrourethral sling (AdVanceTMXP sling) is a well-established treatment option although there is paucity of data on long-term outcomes. Our objective was to assess the long-term functional outcomes and QoL in a cohort of men undergoing AdVanceTMXP sling surgery. METHODS: Retrospective observational study of men undergoing AdVanceTMXP sling in a tertiary referral institution from August 2013 to July 2020. 55 patients met the inclusion criteria, with a minimum follow-up of 12 months. Main outcomes were pre- and post-operative daily pad use and scoring in the ICIQ-SF questionnaire. Post-operative complications were assessed following the Clavien-Dindo classification system. QoL and satisfaction with the procedure were assessed through direct interview. RESULTS: Mean number of pads prior to surgery was 3.1, and mean ICIQ-SF score was 13.5. After surgery, mean daily pads use went to 1.2, and mean ICIQ-SF dropped to 5. With a mean follow-up of 42.36 months, 21.8% patients did not use any pads/day and 76.4% achieved social continence (0-1 pad/day). We found no statistically significant differences in outcomes of patients with follow-up of <36 months, 36-48 months, and >48 months (p = 0.067). CONCLUSIONS: AdVanceTMXP sling implantation in men with PPUI improves urinary incontinence and QoL, and their results are sustained over time.

Validation of the Spanish Acute Cystitis Symptoms Score (ACSS) in native Spanish-speaking women of Europe and Latin America.

INTRODUCTION AND OBJECTIVES: The Acute Cystitis Symptom Score (ACSS) is a patient self-reporting questionnaire for clinical diagnostics and patient-reported outcome (PRO), which may assess the symptoms and the effect on the quality of life in women with acute cystitis (AC). The current study aimed to create a validated Spanish version of the ACSS questionnaire. MATERIAL AND METHODS: The process of linguistic validation of the Spanish version of the ACSS consisted of the independent forward and backward translations, revision and reconciliation, and cognitive assessment. Clinical evaluation of the study version of the ACSS was carried out in clinics in Spain and Latin America. Statistical tests included the calculation of Cronbach's α, split-half reliability, specificity, sensitivity, diagnostic odds ratio, positive and negative likelihood ratio, and area under the receiver-operating characteristic curve (AUC). RESULTS: The study was performed on 132 patients [age (mean;SD) 45.0;17.8 years] with AC and 55 controls (44.5;12.2 years). Cronbach's α of the ACSS was 0.86, and the split-half reliability was 0.82. The summary scores of the ACSS domains were significantly higher in patients than in controls, 16.0 and 2.0 (p < 0.001), respectively. The predefined cut-off point of ≥6 for a summary score of the "Typical" domain resulted in a specificity of 83.6% and a sensitivity of 99.2% for the Spanish version of the ACSS. AUC was 0.91 [0.85; 0.97]. CONCLUSIONS: The validated Spanish ACSS questionnaire evaluates the symptoms and clinical outcomes of patients with AC. It can be used as a patient's self-diagnosis of AC, as a PRO measure tool, and help to rule out other pathologies in patients with voiding syndrome.

Management of Acute Cystitis in the Era of COVID-19.

Purpose of Review: No specific guidelines have been developed for acute cystitis management during the COVID-19 pandemic. This review aims to provide up-to-date information about treatment and follow-up in patients with symptoms suggesting lower urinary tract infection. Recent Findings: Uncomplicated cystitis does not need microbiological confirmation; thus, clinical diagnosis via telephone interview or questionnaires may be done. When complicated infections are suspected, in-person evaluation or close follow-up is mandatory. Antibiotic treatment is still the gold standard for treatment, although non-pharmacological strategies have also been suggested and further investigations are warranted. Summary: Urinary tract infections are still a frequent reason for consultation that needs to be addressed in both primary care and specialized levels. Their management during the pandemic is similar than in precedent years, but telehealth options have emerged which can facilitate diagnosis and treatment.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa).

Introduction: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement. Results: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or ß 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance. Conclusions: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Artificial Urinary Sphincter in a High-Risk Urethra: Transcorporal Gullwing Modification Description of the Technique.

BACKGROUND: In this report, we describe a modification of transcorporal artificial urinary sphincter place ment known as Gullwing modification. DESCRIPTION OF TECHNIQUE: Using a penoscrotal approach, bilateral corpora cavernosa flaps are harvested and sutured in the midline covering the lateral and ventral surfaces of the urethra. Transcorporal cuff placement provides dorsal reinforcement, thus having extra tissue buttressing all the circumference in cases of a fragile urethra due to previous urethral cuff erosion, urethroplasty, or pelvic radiotherapy. PATIENT AND METHODS: After previous urethral cuff erosion, radiotherapy, and urethral reconstruction, our patient complained of severe stress urinary incontinence. Due to the high risk of urethral complications, we proceed to a transcorporal artificial sphincter placement with urethral reinforcement through a bilateral cavernosal flap. RESULTS: The surgery was successfully completed, and after 6 weeks, sphincter was activated with satisfac tory results. Two years after surgery, his continence status is stable without complications. CONCLUSION: Urethral complications associated with artificial urinary sphincter surgery remain a challenge for the reconstructive surgeon. Reinforcement of the ventral aspect of the urethra through corpora cavernosal flaps may reduce the likelihood of urethral erosion in high-risk cases.

Current role of neuromodulation in bladder pain syndrome/interstitial cystitis.

Neuromodulation is recommended by major international guidelines as a fourth-line treatment in bladder pain syndrome/interstitial cystitis (BPS/IC) patients after failure of behavioural, oral and intravesical pharmacological treatments, including hydrodistension. A non-systematic review of studies identified by electronic search of MEDLINE was performed with no time limitation. A narrative synthesis of the existing evidence regarding the results of sacral, tibial and pudendal nerve stimulation in the management of BPS/IC was developed. Neuromodulation in pelvic chronic pain disorders, including BPS/IC, is a useful tool for refractory patients to conventional treatments. Sacral neuromodulation may be effective in patients with BPS without Hunner's lesions, and the effect seems to be maintained in the mid- and long-term. Posterior tibial nerve stimulation can be offered to patients with BPS/IC in the context of a multidisciplinary approach. When pudendal neuralgia is suspected, selective pudendal nerve stimulation has a high response rate. The aetiology of the pain can influence the outcomes in the mid- and long-term of the different neuromodulation approaches, thus careful diagnosis is recommended.

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review.

CONTEXT: Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI). OBJECTIVE: To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management. EVIDENCE ACQUISITION: A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. EVIDENCE SYNTHESIS: A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively. CONCLUSIONS: The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques. PATIENT SUMMARY: Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.

Recurrent Urinary Tract Infections and Asymptomatic Bacteriuria in Adults.

Purpose of review: Our goal was to summarize recent evidence regarding recurrent urinary tract infections and asymptomatic bacteriuria in different adult populations. Recent findings: Several research groups are focused on the description of resident bacterial flora in the bladder and urinary dysbiosis in the microbiome era. Even the definitions might change in light of these discoveries. However, the role of urinary microbiome and bacterial interference has still to be determined. Summary: Systematic treatment of asymptomatic bacteriuria is not recommended and even classic indications such as asymptomatic bacteriuria in pregnant women are controversial. In fact, its treatment is associated with a higher probability of symptomatic UTI and a higher prevalence of antibiotic-resistant bacteria. Improving the diagnosis of asymptomatic bacteriuria and optimizing the management of recurrent urinary tract infections, especially through non-antibiotics measures, are needed in order to minimise antimicrobial resistance.

Female Urethroplasty: Anterior Vaginal Wall Flap (Blandy Flap) - Simpler Tends to Be Better.

Urethral stricture is a rare condition in women, representing a diagnostic challenge for the urologist. Its main etiology is traumatic or due to labor. Definitive treatment can be by means of dilations or urethroplasty using both local flaps and free grafts. In this study, we report the case of a patient with voiding symptoms during a period of 9 years after childbirth, despite an attempt of urethral dilation and chronic self-catheterization. The patient was finally diagnosed of a long distal urethral stricture, and she underwent urethroplasty with an anterior vaginal wall flap with satisfactory results. We take the opportunity to briefly review the diagnostic pathway in women with obstructive symptoms and the main female urethroplasty techniques.

Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review.

CONTEXT: Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group. OBJECTIVE: To present all used definitions of UTIs in neurourological patients. EVIDENCE ACQUISITION: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated. EVIDENCE SYNTHESIS: After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low. CONCLUSIONS: Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed. PATIENT SUMMARY: Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

Sublingual MV140 for Prevention of Recurrent Urinary Tract Infections.

BACKGROUND: Recurrent urinary tract infections (UTIs), which consist of three or more episodes in 1 year or two or more infections in 6 months, affect 5% to 10% of women. MV140, a sublingual preparation of whole-cell inactivated bacteria, has shown clinical benefit in observational studies. This trial examined treatment with MV140 to prevent recurrent UTI. METHODS: In this multicenter, randomized, double-blind, placebo-controlled, parallel-group 1-year trial, 240 women 18 to 75 years of age from Spain and the United Kingdom with recurrent UTI were allocated to receive MV140 for 3 or 6 months or placebo for 6 months in a 1:1:1 ratio. The primary end point was the number of UTIs in the 9-month study period after 3 months of intervention. Key secondary end points were the percentage of women who were UTI free over the above period, time to UTI onset, and health-related quality of life. RESULTS: The median (interquartile range) of UTI episodes was 3.0 (0.5 to 6.0) for placebo compared with 0.0 (0.0 to 1.0) in both groups receiving MV140 (P<0.001). Among women treated with placebo, 25% (95% confidence interval [CI], 15% to 35%) were free of UTIs compared with 56% (95% CI, 44% to 67%) and 58% (95% CI, 44% to 67%) of women who received 3 and 6 months of MV140 treatment, respectively. A total of 205 AEs in 101 participants were registered (81, 76, and 48 in the placebo, 3-month MV140, and 6-month MV140 groups, respectively). CONCLUSIONS: In this controlled trial of modest size and duration, MV140 showed promising clinical efficacy in reducing recurrent UTI in women suffering from this condition. Adverse effects were not clinically limiting. (Funded by Inmunotek S.L. and Syner-Med [Pharmaceutical Products] Ltd.; ClinicalTrials.gov number, NCT02543827.)

Same problem, different approaches: transvesical and extravesical laparoscopic vesicovaginal fistula repair-case report.

Vesicovaginal fistulas (VVaFs) are relatively uncommon in developed countries but with devastating consequences for the women suffering them. Conservative management has a low response rate. The surgical repair is a technically demanding procedure. Transvaginal, open transabdominal or laparoscopic (pure or robot-assisted) approaches have been described with similar post-operative results. We report two real-life cases of VVaF after surgery of benign gynaecological conditions, both presenting with continuous urinary incontinence and repaired with laparoscopic surgery. The first case had a simple tract above the trigone and was managed with an extravesical approach. The second is a complex case with multiple fistulous tracts that required a transabdominal-transvesical approach (modified O'Connor technique). Both patients have their fistula closed and are continent after surgery with a mean follow-up of 9 months. Given the lack on evidence for the selection of the best approach, it is important to report the outcomes with the different surgical techniques in both simple and complex fistulae. A pre-operative exhaustive study of the location and number of fistulous tracts is essential, as well as selecting the technique which best allows tissue dissection and tension-free suture to get a successful closure. Therefore, knowledge of several procedures and approaches is mandatory when dealing with this disorder.

Relationship between obstetric history and recurrent urinary infections.

Urinary tract infections affect more than 50% of women. 25% derive from recurrent UTI (RUTI). It is not known the relationship between obstetric history and RUTI occurrence. Investigate the relationship between obstetric events and RUTI. Multicenter observational retrospective study. Groups: G.RUTI (n = 294): women with RUTI; G.NON.RUTI (n = 126): women without RUTI (treated and cured of renal cancer). Descriptive statistics, ANOVA analysis of variance (with Scheffe's test for normal samples and Kruskal-Wallis for other distributions), Fisher's exact test, Pearson and Spearman correlation studies, and multivariate analysis multiple regression were used. Mean age 61.04 years (19-92), G.RUTI: 56.77 years SD 4.46 (19-85). G.NON.RUTI: 71 years SD 6.73 (25-92) (p = 0.0001). Obstetric history: Nulliparous G.RUTI: 20 (3.4%) G.NON.RUTI: 90 (71.42%) p 0.0001; Eutocic G.RUTI: 416 (70.74%) G.NON.RUTI: 30 (23.8%) p 0.0001. Dystocic G.RUTI: 58 (9.86%) G.NON.RUTI: 56 (44.44%) p 0.0001. G.RUTI abortion: 102 (17.34%) G.NON.RUTI: 30 (23.8%) p 0.1381. Hysterectomy without adnexectomy G.RUTI: 100 (17%) G.NON.RUTI: 18 (14.28%) p 0.5640. Hysterectomy with adnexectomy G.RUTI: 100 (17%) G.NON.RUTI: 66 (52.28%) p 0.0001. Nulliparity, dystocic delivery, and hysterectomy with adnexectomy are more frequent in women without RUTI, while eutocic births are more associated with RUTI. The most prevalent gynaecological-obstetric history in women with RUTI is eutocic delivery associated with a good health state.

Impact of whole-cell bacterial immunoprophylaxis in the management of recurrent urinary tract infections in the frail elderly.

PURPOSE: This study aimed to determine the effectiveness of whole-cell bacterial immunotherapy, i.e. MV140 and autovaccines, in reducing the number ofurinary tract infections (UTIs)in frail elderly patients with recurrent UTI (RUTI). METHOD: A prospective cohort observational study was performed including 200 frail elderly subjects suffering RUTI, both females and males, between 2016 and 2018. The effectiveness of autovaccines and the polybacterial formulation MV140 (Uromune®), consisting ofwhole-cell heat-inactivated Escherichia coli25%, Klebsiella pneumoniae25%, Proteus vulgaris25% andEnterococcus faecalis25% were evaluated. Subjects initiated a 3-month sublingually daily course with MV140 or autovaccine, either first treatment or a new course if they had been previously vaccinated prior to inclusion in the study. Number of UTIs and quality of life (QoL, SF-36 score) were measured in the different study groups. RESULTS: The mean age for participants was 82.67 (SD, 7.12) for female and 80.23 (SD, 11.12) for male subjects. In all groups, 12 months following bacterial immunotherapy, the number of UTIs significantly decreased compared to before the treatment with autovaccine or MV140: the rate of reduction ranged between 7- and 40-fold. An increase in QoL scoring was also observed in any study group. When comparing medical interventions, MV140 conferred significantly higher benefit than autovaccines. For previously vaccinated individuals, a new 3-month course with MV140 or autovaccines provided further clinical improvement. CONCLUSIONS: MV140 and autovaccines emerge as valuable immunoprophylaxis for the management of RUTI in the frail elderly, contributing to an improvement in patient's quality of life. Herein, MV140 has shown to confer a higher effectiveness compared to autovaccines, regardless sex or course of treatment.