Is Surgical Treatment for Obesity Able to Cure Urinary Incontinence in Women?-A Prospective Single-Center Study.

There is enough evidence to support weight loss in order to improve urinary incontinence. Nevertheless, weight loss and maintaining a lower weight are not easy to achieve in the general population. Our study aims to evaluate whether bariatric surgery has a positive effect on the symptoms of urinary incontinence in female patients. We performed a prospective study on obese female patients before and after bariatric surgery, over a period of 9 years. Patients with a BMI ≥ 33 kg/m2 were included if they described involuntary loss of urine and no previous surgery for urinary incontinence was performed. The patients underwent laparoscopic surgery, either gastric sleeve, bypass or banding, performed by four surgeons in our hospital. The type of incontinence was not assessed at the initial visit carried out by the surgeon. All patients who declared being incontinent were referred to the urologist where they received the ICIQ-UI-SF questionnaire before their bariatric surgery and during follow -up visits. The sum of points obtained at questions 3, 4 and 5 was used to evaluate the severity of incontinence, as well as the impact on the quality of life. Our evaluation collected data on age, time since onset of symptoms, pad usage, number and type of deliveries, concomitant conditions and medications. The type of incontinence was assessed by the urologist before bariatric surgery as urge, stress or mixed incontinence. At follow-up visits, the patients were also asked to fill out a 10-point VAS questionnaire evaluating their perception on the evolution of incontinence symptoms. Data were analyzed using t-test statistical analysis. Our objective defined changes in incontinence as cure, improved, no change and worse. We included 54 women from whom initial data and at least 18 months of follow-up were available. We observed that about 50% of all women undergoing bariatric surgery have some degree of urinary incontinence. The ICIQ score improved from 13.31 ± 5.18 before surgery to 8.30 ± 4.49 points after surgery (p < 0.0001). Before surgery, 38 patients (70%) described severe incontinence compared to only 20 patients (37%) after surgery. A total of 16 women (31%) reported complete cure of urinary incontinence after bariatric surgery. Data from the VAS questionnaire show improvement in 46 cases (85%). Pad usage improved from 7.04 ± 2.79 to 3.42 ± 2.77 (p < 0.001) per day. The number of patients using more than one pad per day decreased from 35 (65%) to 9 (17%). The type of incontinence did not seem to be relevant, but our sample size was too small to lead to statistically significant results. There was no impact on the outcome of incontinence of number/type of delivery, age or BMI. Our data show that bariatric surgery is able to cure urinary incontinence in one of three obese women. A significant improvement was obtained in more than two-thirds of the patients, regardless of the type of incontinence. For an obese female with urinary incontinence, treatment for obesity should prevail and incontinence should be treated only if symptoms remain.

First safety outcomes for rigicon conticlassic® artificial urinary sphincter.

The Rigicon ContiClassic® is a new sphincteric device designed to treat male stress urinary incontinence. This study evaluates the surgical outcomes and safety profile of the first 116 patients who received the implant between September 2021 and April 2022. Data were collected from patient information forms completed at the time of the implant and submitted by implanting surgeons, nursing staff in the Operating Room or company representatives present during the surgery. The study analyzed patient demographics, surgical details, and etiology of incontinence. The mean age of patients was 68.3 years +/- 9.65 yrs. Minimum age was 23 and maximum age was 83. The most common reason for implantation was urinary incontinence (58.6%) after radical prostatectomy. The results showed a revision rate of 6.90%, with three cases of fluid loss, four cases of iatrogenic mistaken sizing, and one case of patient dissatisfaction. There were no reported infections. Kaplan-Meier calculation showed survival rate of 93.2% at 12 months. This study shows the early safety outcomes for the Rigicon ContiClassic® sphincter device to be comparable to others presently on the market.

Management of Adrenal Cortical Adenomas: Assessment of Bone Status in Patients with (Non-Functioning) Adrenal Incidentalomas.

Our aim is to analyse the bone profile in adults with (non-functioning) adrenal incidentalomas (AIs), specifically addressing the impact of autonomous cortisol secretion (ACS). This narrative review, based on a PubMed search from inception to February 2023 (case reports, non-ACS, and other secondary causes of osteoporosis were excluded), included 40 original studies, a total of 3046 patients with female prevalence (female:male ratio of 1921:1125), aged between 20.5 and 95.5 years old. This three decade-based analysis showed that 37 studies provided dual-energy X-ray absorptiometry (DXA) information; another five studies reports results on bone micro-architecture, including trabecular bone score (TBS), spinal deformity index, and high-resolution peripheral quantitative computed tomography; 20 cohorts included data on bone turnover markers (BTMs), while four longitudinal studies followed subjects between 1 and 10.5 years old (surgical versus non-adrenalectomy arms). Post-dexamethasone suppression test (DST) cortisol was inversely associated with bone mineral density (BMD). TBS predicted incidental vertebral fractures (VFx) regardless of BMD, being associated with post-DST cortisol independently of age and BMD. Low BTMs were identified in ACS, but not all studies agreed. An increased prevalence of ACS-related osteoporosis was confirmed in most studies (highest prevalence of 87.5%), as well as of VFx, including in pre-menopause (42.5%), post-menopause (78.6%), and male patients (72.7%) depending on the study, with a 10-fold increased incidental VFx risk up to a 12-fold increased risk after a 2-year follow-up. No specific medication against osteoporosis is indicated in ACS, but adrenalectomy (according to four studies) should be part of the long-term strategy. This bone profile case sample-based study (to our knowledge, one of the largest of its kind) showed that AIs, including the subgroup designated as having ACS, embraces a large panel of osseous complications. The level of evidence remains far from generous; there are still no homogenous results defining ACS and identifying skeletal involvement, which might be a consequence of different investigation clusters underling adrenal and bone assessments over time. However, bone status evaluations and associated therapy decisions remain an essential element of the management of adults with AIs-ACS.

Single-Center Experience with Swiss LithoClast® Trilogy for Kidney Stones.

INTRODUCTION: PCNL remains the gold standard for larger kidney stones. Reducing the operating time of PCNL and its complication rate seems to be the next logical step in optimizing this classical technique. To achieve these objectives, some new methods of lithotripsy emerge. We present the data of a single, high-volume, academic center with combined ultrasonic and ballistic lithotripsy in PCNL using the Swiss LithoClast® Trilogy device. MATERIALS AND METHODS: We designed a prospective, randomized study including patients who underwent PCNL or miniPerc with lithotripsy using the new EMS Lithoclast Trilogy or EMS Lithoclast Master. The procedure was carried out with all patients in prone position, by the same surgeon. The working channel size was 24 Fr-15.9 Fr. We evaluated the stones' features, operative time, fragmentation time, complications, stone clearance rate and stone-free rate. RESULTS: Our study included 59 patients, 38 females and 31 males, of an average age of 54.5 years old. The Trilogy group included 28 patients and the comparator included 31 patients. Urine culture was positive in seven cases which required seven days of antibiotics. The mean stone diameter was 35.6 mm with a mean Hounsfield unit (HU) of 710.1. The average number of stones was 2.08 (6 complete staghorn stones and 12 partial staghorn stones). A total of 13 patients presented a JJ stent (46.4%). We found a very significant difference in all the parameters favoring the Trilogy device. The most important result in our opinion is the probe active time, which was almost six times shorter in the Trilogy group. The stone clearance rate was about double in the Trilogy group, leading to shorter overall and intra-renal operating times. The overall complication rate was 17.9% in the Trilogy group and 23% in the Lithoclast Master group. The mean hemoglobin drop was 2.1 g/dL with a mean creatinine rise of 0.26 mg/dL. CONCLUSIONS: Swiss LithoClast® Trilogy, a device combining ultrasonic and ballistic energy, is a safe and efficient method of lithotripsy for PCNL, proving statistically significant benefits over its predecesor. It can achieve the goal of reducing complication rates and operative times for PCNL.

A Novel Risk Calculator to Predict Erectile Dysfunction in HIV-Positive Men.

HIV infection is considered to be a lifelong medical condition, requiring follow-up and treatment for decades. HIV-positive men are reported to have erectile dysfunction more often than age-matched healthy controls, and improving sexuality is known to potentially improve overall health-related quality of life. The aim of this paper is to evaluate the presence of ED in HIV-positive men and the associated contributing factors and to create a statistical model to assess the risk to develop ED in this population. In a prospective study, we analyzed a group of HIV-positive men in a cross-sectional manner, looking at demographics, blood test results, and smoking habits. Data were statistically analyzed using the Kruskal-Wallis test. In our series, the overall incidence of ED was 48.5%, increasing with age. Our analysis showed no correlation with blood sugar level, but a very strong correlation with total serum lipids. We were able to develop and validate a risk calculator for ED in HIV-positive men.

Bladder Wall Structure Alterations in Patients Treated With Botulinum Toxin for Detrusor Overactivity - A Morphological Study.

BACKGROUND/AIM: The overactive bladder syndrome (OAB) is a bothersome condition that affects up to 33% of the population. In up to 69% of the cases, the underlying condition is an overactive detrusor (DO). Treatment options rely on behavioral changes, medical treatment, neuromodulation, and invasive treatment, such as injecting botulinum toxin (BoNT) in the detrusor or augmentation cystoplasty. The aim of this study was to evaluate, by morphological assessment on cold-cup biopsies of the bladder, the effect of botulinum toxin injections on the bladder wall, focusing on the histological structure and signs of inflammation and fibrosis. PATIENTS AND METHODS: We evaluated consecutive patients with DO that received BoNT intradetrusor injections. We analyzed inflammation and fibrosis in 36 patients, divided into two groups based on their history of BoNT treatment. Our patients underwent at least one round of injections and specimens were compared individually, before and after each injection. RESULTS: A decrease in inflammation was found in 26.3% of the cases, a reactive increase in 31.5%, and no change in 42.1%. No de novo or increase in preexisting fibrosis was found. In some cases, fibrosis diminished after a second round of BoNT. CONCLUSION: In most cases, BoNT intradetrusor injections in DO patients showed no effect on bladder wall inflammation and actually improved the inflammatory condition of the muscle in a significant number of samples.

Mini-Perc for Renal Stones-A Single Center Experience and Literature Review.

AIM: The aim of this study was to analyze the outcomes of miniaturized nephrolithotomy (mini-perc) in the management of renal stones with a diameter smaller than 20 mm. MATERIALS AND METHODS: We retrospectively reviewed the records of 102 patients who underwent mini-perc between March 2015 and March 2020 in our department. The primary objective was the stone-free rate, but we also analyzed the retreatment rate, complications, hospital stay, operative time and reduction in hemoglobin level. All these patients had this technique as their first-line treatment, in a prone position, using a 16 Fr sheath size. Data were compared to a series of patients from the literature, treated with conventional PCNL. RESULTS: The patients had calculus limited to either a single calyx or just extending to the renal pelvis, and stone size was less than 20 mm in its maximal dimension. The intrarenal stone location was in the upper calyx in 7 cases, middle calyx in 20 cases and lower calyx in 46 cases, and there were 29 patients with renal pelvis stone. The male to female ratio was 1.5:1, and the median age was 48.4 years. The average stone size was 17.4 mm in diameter (ranging between 9 and 20 mm) and all cases underwent Ho-YaG laser lithotripsy, ballistic energy and combined ultrasonic and ballistic lithotripsy. At the end of the procedure, an antegrade double J stent was placed under fluoroscopy for a maximum of 2 weeks in 42 cases, while 9 cases needed a nephrostomy tube 12-14 F. A total of 51 cases were totally tubeless. Our median operative time was 61 min (ranging from 35 to 75 min). The median hospitalization stay was 3.8 days. The stone free rate was 90.1% after one procedure, only nine (8.8%) cases needed a "second look" flexible ureteroscopy, and the final stone-free rate was 98% (absence of detectable calculi on ultrasound, KUB or non-contrast CT scan). The overall complication rate was 6.86% (Clavien classification I-57.14%; II-28.5%; III-14.2%), while no Clavien IV or V complications were reported. No patient required a blood transfusion, and mean hemoglobin loss was 0.81 mg/dL. Overall, our results are better than similar data for conventional PCNL in the literature. CONCLUSIONS: The "mini-perc" technique is an effective procedure for the treatment of the renal lithiasis that is less or equal to 2 cm. The results demonstrated that this minimally invasive technique is associated with a higher stone-free rate and minimal complications.

Doppler Ultrasonography - An Important Tool in Managing Patients With Varicocele and Secondary Infertility.

BACKGROUND/AIM: Doppler ultrasound was successfully implemented as part of the diagnostic plan of medical emergencies in scrotal pathology. This study aimed to investigate whether it could play an important role in managing not only varicocele, but patients with secondary infertility as well. PATIENTS AND METHODS: The current study included 135 patients with varicocele and infertility. Surgery was performed in 18 cases with painful varicocele, 15 cases with testicular hypotrophy, and 48 cases with infertility. RESULTS: Among cases with infertility who underwent surgery, aged between 19 and 36 years old, 80% showed a significant improvement in the spermogram after curing the varicocele. In patients over 36 years of age, only 42% had some improvement in the spermogram after surgery. In addition, after surgery, antispermatic antibodies showed a significant decrease in all patients. CONCLUSION: Varicocele and secondary infertility are a well-known pathology. While the role of Doppler ultrasonography is established in varicocele diagnosis, we found an important pool of patients with secondary infertility and asymptomatic varicocele that would not have been diagnosed in the absence of Doppler ultrasound investigations. Since the best results in fertility were observed in patients younger than 36 years of age, we reiterate the importance of Doppler ultrasonography in addressing infertility.

Solifenacin Treatment After Intradetrusor Injections With Botulinum Toxin in Patients With Neurogenic Detrusor Overactivity.

BACKGROUND: Neurogenic detrusor overactivity (NDO) is treated with antimuscarinics as first-line treatment. For patients with contraindications or unresponsive, intradetrusor injections with botulinum toxin (BoNT) are a safe and effective but expensive option. STUDY QUESTION: Our study evaluated whether adding solifenacin to the intradetrusor injection of BoNT A could boost the effect of BoNT in patients with NDO due to multiple sclerosis or spinal cord injury refractory to antimuscarinics alone and/or lead to less frequent injections. STUDY DESIGN: We performed a prospective study on 49 patients assigned alternatively to group A, undergoing BoNT injections, and group B, adding solifenacin. MEASURES AND OUTCOMES: We gathered data from urodynamic testing and questionnaire assessments before and 3 months after injections and reinjections. We analyzed 39 patients who achieved total continence and a minimum 24-month follow-up period. RESULTS: After treatment, both groups had statistically significant improvement of overactive bladder questionnaire (OABq) score, post void residue (PVR), and peak detrusor pressure (Pdet). Reinjection was needed after a mean 8.2 months for group A and 11.7 months for group B. We analyzed the improvement rate of parameters compared between the 2 groups-group B had greater OABq score improvement (A = 17.25 ± 5.07, B = 20.44 ± 4.51, P = 0.0485), as well as for maximum bladder capacity (A = 11.05 ± 7.04 mL, B = 19.39 ± 6.43 mL, P = 0.0005); differences in Pdet change (A = 51.72 ± 16.57 cmH 2 O, B = 50.80 ± 16.33 cmH 2 O, P = 0.7635) and PVR change (A = 17.67 ± 12.63 mL, B = 12.30 ± 8.32 mL, P = 0.126) were not statistically significant. CONCLUSIONS: Our study shows that adding solifenacin improves patient satisfaction, increases the interval between reinjections, thus lowering costs, and improves maximum bladder capacity. Pdet was kept in safe ranges, but no statistically significant conclusions could be drawn regarding Pdet and PVR decrease related to adding solifenacin. Although our study is limited by the small series of patients and lack of randomization and placebo control group, the BoNT-solifenacin combination could be considered in NDO in terms of cost-effectiveness. Further studies would be beneficial.

Magnetic resonance/ultrasound fusion targeted biopsy of the prostate can be improved by adding systematic biopsy.

AIM: Magnetic resonance/ ultrasound fusion targeted biopsy (Tbs) is widely used for diagnosing prostate cancer (PCa). The aim of our study was to compare the cancer detection rate (CDR) and the clinically significant prostate cancer detection rate (csPCa) of the magnetic resonance/ultrasound fusion targeted biopsy with those of the standard systematic biopsy (Sbs) and of the combination of both techniques. MATERIAL AND METHODS: A total of 182 patients underwent magnetic resonance/ultrasound fusion Tbs on the prostate for PCa suspicion based on multiparametric magnetic resonance imaging (mMRI) detection of lesions with PI-RADSv2 score ≥3. A total of 78 patients had prior negative biopsies. Tb was performed by taking 2-4 cores from each suspected lesion, followed by Sb with 12 cores. We evaluated the overall detection rate of PCa and clinically significant prostate cancer, defined as any PCa with Gleason score ≥3+4. RESULTS: Median prostate specific antigen (PSA) level pre-biopsy was 7.4 ng/ml and median free-PSA/PSA ratio was 10.2%. Patient median age was 62 years old. PIRADSv2 score was 3 in 54 cases, 4 in 96 cases and 5 in 32 cases. PI-RADS-dependent detection rate of Tbs for scores 3, 4 and 5 was 25.9%, 65.6% and 84.4%, respectively, with csPCa detection rates of 24.1%, 54.2%, and 71.9%. Overall detection rate was 57.1% for Tbs, which increased to 60.4% by adding Sbs results. Detection rate for clinically significant prostate cancer (csPCa) was 48.4% and increased to 51.1% by adding Sbs. Overall detection rate for repeated biopsy was 50% and 68.3% for biopsy in naïve patients. Sbs detection rate was 55.5%, 8 patients having a negative biopsy on Tbs. CONCLUSIONS: When Tbs is considered due to a PI-RADS ≥3 lesion on mMRI, combined Tbs + Sbs increases the overall CDR and csPCa detection rates.

Efficacy and safety of mirabegron in children and adolescents with neurogenic detrusor overactivity: An open-label, phase 3, dose-titration study.

AIMS: To evaluate the efficacy and safety of mirabegron in children and adolescents (aged 3 to <18 years) with neurogenic detrusor overactivity (NDO) using clean intermittent catheterization. METHODS: In this open-label, multicenter, baseline-controlled, Phase III study (NCT02751931), participants received once-daily mirabegron at an adult dose equivalent of 25 mg. Dose was increased to 50 mg equivalent unless there were safety/tolerability concerns. The primary efficacy endpoint was change from baseline to Week 24 in maximum cystometric capacity (MCC). Secondary urodynamic assessments, Pediatric Incontinence Questionnaire (PIN-Q), Patient Global Impression of Severity (PGI-S), Clinician Global Impression of Change (CGI-C), and Acceptability questionnaires were included. RESULTS: Overall, 86 participants (55 aged 3 to <12 years, 31 aged 12 to <18 years) received treatment; 68 were included in efficacy assessments. A statistically significant increase in MCC from baseline to Week 24 was observed (87.20 ml, 95% confidence interval: 66.07, 108.33; p < .001); this increase was apparent from Week 4. Significant increases in bladder compliance, bladder volume until first detrusor contraction, average volume per catheterization, maximum daytime catheterized volume and number of dry days per week. Significant decreases in detrusor pressure and number of leakage episodes per day were also observed. Significant improvement in PGI-S but not PIN-Q was observed. Most participants reported their condition had either much or very much improved using the CGI-C. Mirabegron was well tolerated in this population with a profile aligned with that in adults. CONCLUSIONS: Mirabegron was effective and well-tolerated in the treatment of pediatric patients with NDO.

Timing of radical cystectomy in Central Europe - multicenter study on factors influencing the time from diagnosis to radical treatment of bladder cancer patients.

INTRODUCTION: Time that passes between an unfavourable diagnosis to a radical cystectomy (RC) affects oncological outcomes in patients with bladder cancer. Unsatisfactory survival of patients after RC in Central Europe can potentially result from this factor. MATERIAL AND METHODS: The aim of this study was to assess the time interval between transurethral resection of the bladder tumor (TURBT) and RC in Central Europe and to identify clinical factors of possible delays. 941 consecutive patients who underwent RC in nine Central European urological centers were enrolled into the study. After the TURBT-RC time was calculated, selected clinical and pathological parameters were tested as potential factors influencing the timing of RC. RESULTS: On average, RCs were performed 73.8 days after TURBTs (median - 53, range 0-1587). In 238 patients (25.3%) the time exceeded 12 weeks. Patients with muscle-invasive cancer were operated earlier on than patients with nonmuscle-invasive cancer (67.6 vs.105.2 days, RR = 1.41, p = 0.00). In high volume centers (>30 RC per year) longer TURBT-RC intervals were observed (97.6 vs. 66.3 days, RR = 2.49, p = 0.00). Simultaneously, factors such as female sex (RR = 1.21), more advanced age of patient (>65 years, RR = 1.23), presence of concomitant CIS (RR = 2.43), grade of cancer cells (RR = 1.67) and final post-RC stage (RR = 1.51) had no statistically significant effect on the results (p >0.05). CONCLUSIONS: The mean time interval between the diagnosis and radical treatment of patients with bladder cancer in Central Europe is adequate. However, there are still a relatively high number of patients waiting for radical cystectomy longer than 8 weeks. A lower stage of disease as well as a higher case load within of a hospital may delay the surgery.

A review of prospective Clinical Trials for neurogenic bladder: Pharmaceuticals.

INTRODUCTION: The neurogenic urinary bladder is defined as a dysfunctional bladder associated with a known neurological injury. We review the data from good quality clinical trials looking at drug therapy for the neurogenic bladder. MATERIALS AND METHODS: IN ORDER TO IDENTIFY AS MANY PROSPECTIVE TRIALS AS POSSIBLE, WE PERFORMED INTERNET SEARCHES, USING THE SAME SEARCH STRING: Urinary Bladder, neurogenic (MESH). In each case, the search was limited to clinical trial, prospective trial, subjects were human and the language was English. There was no year limit for our search. The next step was duplicate removal, which led to a final number of 580 papers. We defined clear inclusion criteria for the papers. RESULTS: A total of 82 full text papers were reviewed and analyzed according to the previously mentioned algorithm. The oldest two prospective clinical trials date back to 1976, with an obvious increase in number of trials each year, reaching more than five trials per year after 2001, which demonstrates increased interest toward the subject. The total number of patients included in the trials is 3904, 888 of which are children. The male: female ratio is close to 1, although there were 9 studies where no information regarding the sex of the patients was available. CONCLUSIONS: Our analysis stresses the acute need for good quality trials looking at the drugs used for the management of the patients with neurogenic bladders, with adequate statistical power to support the data they present.

A review of prospective Clinical Trials for neurogenic bladder: The place of surgery, experimental techniques and devices.

INTRODUCTION: The neurogenic urinary bladder has been known for at least 30 years now and the concepts behind it are continuously evolving, but there is actually not much work that has been done to accumulate solid clinical evidence in this field. We review the surgical and experimental techniques used in the management of this condition. MATERIAL AND METHODS: TO ACHIEVE OUR GOAL, WE PERFORMED INTERNET SEARCHES USING THE SAME SEARCH STRING: Urinary bladder, neurogenic. In each case, the search was limited to clinical trial, subjects were human and the language was English. After duplicate removal, we obtained a final number of 580 papers. Data was extracted from each paper into a database file and was analyzed separately for adult and pediatric populations. RESULTS: A total of 70 full text papers were reviewed and analyzed according to the previously mentioned algorithm. The first prospective, randomized surgical trials were published less than 20 years ago, starting with 1994, and the number of papers published each year since then has remained in the range of 1-3. The oldest prospective clinical trial for this indication dates back to 1975. The total number of patients included in surgical trials is 3453, out of which 59% are males. The papers include a total of 369 children (21.2%), essentially looking at all the techniques that are also used in adults. CONCLUSIONS: There is still a lot of work to be done in order to obtain a significant level of evidence in the field of surgical procedures used in neurogenic bladder patients.

The Place of the Ice Water Test (IWT) in the Evaluation of the Patients with Traumatic Spinal Cord Injury.

In the last decades, functional Urology developed itself as a subspecialty, and, although is strongly linked to Urology, it has its own language, devices and dedicated people. The ice water test (IWT) was first described in 1957 and gained its place in the armamentarium of functional urologists for the coming years. Now, when urodynamic devices are more and more complex and sensitive, when neuromodulation and neurostimulation are gaining popularity and with the terminology changes of the last decade, one can wonder if a 50 years old test may still be of some use. We performed a prospective study using the ice water test in 150 consecutive patients referred to us for urodynamics in order to identify if there is any improvement in the diagnostic process. The patients were referred for varied indications, but a large number of them were neurogenic, given the special profile of our unit. We classified the patients in four different groups and analyzed the data for each group. The results showed that, while there is no use of the IWT as a routine procedure, the test might prove extremely useful in selected cases.