Antenatal staging of congenital lower urinary tract obstruction.

OBJECTIVE: To propose a staging system for congenital lower urinary tract obstruction (LUTO) capable of predicting the severity of the condition and its prognosis. METHODS: This was a national retrospective study carried out at the eight Academic Hospitals in The Netherlands. We collected prenatal and postnatal data of fetuses at high risk of isolated LUTO that were managed conservatively. Postnatal renal function was assessed by the estimated glomerular filtration rate (eGFR), calculated using the Schwartz formula, considering the length of the infant and the creatinine nadir in the first year after birth. Receiver-operating characteristics (ROC) curve analysis, univariate analysis and multivariate logistic regression analysis with stepwise backward elimination were performed in order to identify the best antenatal predictors of perinatal mortality and postnatal renal function. RESULTS: In total, 261 fetuses suspected of having LUTO and managed conservatively were included in the study. The pregnancy was terminated in 110 cases and perinatal death occurred in 35 cases. Gestational age at appearance of oligohydramnios showed excellent accuracy in predicting the risk of perinatal mortality with an area under the ROC curve of 0.95 (P < 0.001) and an optimal cut-off at 26 weeks' gestation. Fetuses with normal amniotic fluid (AF) volume at 26 weeks' gestation presented with low risk of poor outcome and were therefore defined as cases with mild LUTO. In fetuses referred before the 26th week of gestation, the urinary bladder volume (BV) was the best unique predictor of perinatal mortality. ROC curve analysis identified a BV of 5.4 cm3 and appearance of oligohydramnios at 20 weeks as the best threshold for predicting an adverse outcome. LUTO cases with a BV ≥ 5.4 cm3 or abnormal AF volume before 20 weeks' gestation were defined as severe and those with BV < 5.4 cm3 and normal AF volume at the 20 weeks' scan were defined as moderate. Risk of perinatal mortality significantly increased according to the stage of severity, from mild to moderate to severe stage, from 9% to 26% to 55%, respectively. Similarly, risk of severely impaired renal function increased from 11% to 31% to 44%, for mild, moderate and severe LUTO, respectively. CONCLUSIONS: Gestational age at appearance of oligo- or anhydramnios and BV at diagnosis can accurately predict mortality and morbidity in fetuses with LUTO. Our proposed staging system can triage reliably fetuses with LUTO and predict the severity of the condition and its prognosis. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The Endoscopic Morphological Features of Congenital Posterior Urethral Obstructions in Boys with Refractory Daytime Urinary Incontinence and Nocturnal Enuresis.

Purpose This study aims to evaluate the endoscopic morphological features of congenital posterior urethral obstructions in boys with refractory daytime urinary incontinence and/or nocturnal enuresis. Patients and Methods A total of 54 consecutive patients underwent endoscopy and were diagnosed with a posterior urethral valve (PUV) (types 1-4). PUV type 1 was classified as severe, moderate, or mild. A transurethral incision (TUI) was mainly performed for anterior wall lesions of the PUV. Voiding cystourethrography and pressure flow studies (PFS) were performed before and 3 to 4 months after TUI. Clinical symptoms were evaluated 6 months after TUI, and outcomes were assessed according to PFS waveform pattern groups (synergic pattern [SP] and dyssynergic pattern [DP]). Results All patients had PUV type 1 and/or 3 (i.e., n = 34 type 1, 7 type 3, and 13 types 1 and 3). There were severe (n = 1), moderate (n = 21), and mild (n = 25) cases of PUV type 1. According to PFS, SP and DP were present in 43 and 11 patients, respectively. TUI was effective in the SP group and symptoms improved in 77.4 and 69.3% of patients with daytime incontinence and nocturnal enuresis, respectively. Almost no effect was observed in the DP group. A significant decrease in the detrusor pressure was observed at maximum flow rate using PFS in the SP group. Conclusions PUV type 1 encompassed lesions with a spectrum of obstructions ranging from severe to mild, with mild types whose main obstructive lesion existed at the anterior wall of urethra occurring most frequently in boys with refractory daytime urinary incontinence and/or nocturnal enuresis.

The valuation of the International Prostate Symptom Score (IPSS) for use in economic evaluations.

OBJECTIVE: Lower Urinary Tract Symptoms (LUTS) suggestive of Benign Prostatic Obstruction (BPO) cause a reduction in quality of life, but the magnitude of that reduction cannot be estimated empirically. This is because survey instruments currently available merely sum the symptoms found, but do not value their impact on quality of life. It is therefore difficult to determine whether the effects of treatments for LUTS suggestive of BPO justify the costs. This complicates economic evaluations. METHODS: We valued the impact on quality of life of patients with LUTS suggestive of BPO, by valuing health states defined by the International Prostate Symptom Score (IPSS) using the time trade-off (TTO). TTO values ranged from 1.0 for perfect health to 0.0 for the value of death, and can be used to calculate Quality-Adjusted Life Years (QALYs), the preferred outcome measure in health economics. RESULTS: We reduced the number of health states defined by the IPSS using factor analysis. The resulting nine health states were valued by a representative sample of the general public (N=170) using TTO. The worst IPSS health state was valued at 0.87. CONCLUSION: The values for health states defined by the IPSS revealed that LUTS suggestive of BPO has a mild impact on quality of life. The valuation of the IPSS facilitates economic evaluations of treatments for LUTS suggestive of BPO, because QALYs (the preferred outcome measure in health economics) can be determined empirically.

Congenital urethral obstruction: Cobb's collar or prolapsed congenital obstructive posterior urethral membrane (COPUM).

OBJECTIVE: To determine whether there are two distinct types of congenital obstruction of the proximal urethra. PATIENTS AND METHODS: Three boys with a congenital bulbar urethral narrowing (Cobb's collar) were examined. Recent papers on congenital obstructive posterior urethral membrane (COPUM) were reviewed. RESULTS: The more proximal lesion is a membranous obstruction which is able to prolapse as far as the bulbar urethra, but has paramedian folds that attach along the posterior wall of the urethra to the verumontanum, and is due to persistence of an embryological attachment between the distal verumontanum and the anterior wall of the posterior urethra. The more distal narrowing is not always obstructive and is primarily a bulbar urethral membrane, is independent of the verumontanum and external sphincter, and may represent a persistence of part of the urogenital membrane. CONCLUSIONS: There are two distinct types of congenital obstruction of the proximal urethra, with the association to the verumontanum being the distinguishing feature.

[Combined urodynamic insufficiency in patients with an infravesical obstruction]. / Sochetannnaia urodinamicheskaia nedostatochnost' u bol'nykh s infravezikal'noi obstruktsiei.

Functional activity of the lower and upper urinary tract was examined in 169 patients with infravesical obstruction and in 20 controls. Combined investigation included: radioisotope uroflowmetry, retrograde cystomanometry, urethrosphincterometry, miction videocystourethrography, excretory urography, radioisotope renography, pharmacorenography, dynamic nephroscintigraphy and renal angiography. An analysis of lower urinary urodynamic findings has demonstrated stages as an important regularity in the development of functional lower urinary disturbances. As a result, a standard system has been evolved for the assessment and classification of stages in chronic lower-urinary urodynamic disorders. Four stages are identified in the classification. Evaluation of upper-urinary urodynamics in the same 169 patients with lower urinary tract disorders of varying severity demonstrated that upper urinary functional parameters become worse as lower urinary parameters deteriorate, but there is no strict correlation between those. A systematic study of the pattern of combined disorders of the lower and upper urinary tract has made it possible to develop a standard system for the assessment and classification of stages of combined urodynamic insufficiency, with 4 stages identified. The use of this system improves objective assessment of the severity of patient's condition and specifies indications for surgical treatment of infravesical obstructions.