Therapeutic efficacy of 180-W GreenLight laser photoselective vaporization of the prostate for storage symptoms concomitant with benign prostatic obstruction and a search for outcome predictors.

PURPOSE: Benign prostatic obstruction (BPO) is the most common cause of lower urinary tract symptoms among men. GreenLight photoselective vaporization of the prostate (GL-PVP) using a 180-W Xcelerated performance system (XPS) laser is a well-established method for treating BPO-induced voiding symptoms. However, its therapeutic effects on storage symptoms remain unclear. This study aimed to analyze the storage outcomes in patients who underwent 180-W XPS GL-PVP for BPO and to identify outcome predictors. MATERIALS AND METHODS: Patients who underwent 180-W XPS GL-PVP for BPO between May 2018 and May 2021 were retrospectively reviewed. Data on clinical characteristics, prostate volume, preoperative and postoperative International Prostate Symptom Scores (IPSS), and preoperative urodynamic parameters were collected. A favorable storage outcome was defined as ≥50% reduction in the IPSS storage subscore. RESULTS: Ninety-nine male patients were included, with a mean age of 69.4 ± 9.6 years and a baseline prostatic volume of 75.9 ± 33.1 mL. The IPSS total, storage, and voiding subscores significantly decreased after GL-PVP (all p < 0.001). Seventy-two patients achieved favorable storage outcome at 6 months. Multivariate analysis revealed that detrusor underactivity was predictive of unfavorable storage outcomes (p = 0.022), while IPSS voiding-to-storage subscore ratio >1.25 and the presence of detrusor overactivity were predictive of favorable storage outcomes (p = 0.008 and 0.033, respectively). CONCLUSION: 180-W XPS GL-PVP provided excellent outcomes in both voiding and storage lower urinary tract symptoms concomitant with BPO. Preoperative IPSS and multichannel urodynamic parameters including detrusor overactivity and underactivity are valuable predictors of postoperative storage outcomes.

Obstructing urethral membrane in a girl: a rare cause of female bladder outlet obstruction.

Bladder outlet obstruction is known to produce back pressure changes on the urinary tract with devastating sequelae more often than not. Among the causes, posterior urethral valve, which is the most common, is documented to occur exclusively in males. Female posterior urethral valves have been reported in the past in less than 25 cases in existing literature. We discuss the case of a female toddler who presented with symptoms of straining to void and recurrent urinary tract infections. On evaluation, she was found to have an obstructing urethral membrane causing bladder outlet obstruction, which was endoscopically ablated with success.

Occurrence of cardiovascular events in 168 cats with acute urinary tract obstruction.

Background: Cardiovascular dysfunction associated with acute kidney injury has been recently described in veterinary medicine, but limited information is available for cats with urinary tract obstruction (UTO). Objective: This retrospective study aimed to describe the type, frequency, timeline, and risk factors for cardiovascular events (CVEs) in cats treated for acute UTO. Animals and procedures: Medical records of cats admitted to the intensive care unit for either upper (ureteral: UUTO) or lower (urethral: LUTO) UTO from 2016 to 2021 were reviewed. Cardiovascular events were defined as development of arrhythmia, heart murmur or gallop sound, clinical signs consistent with fluid overload (CRFO), or decreased tissue perfusion (DTP). Results: One hundred and sixty-eight cats with UTO were recruited (56 with UUTO and 112 with LUTO). Cardiovascular events were reported in 61.9% of cases, including arrhythmia (33.6%), gallop rhythm (28.1%), heart murmur (15.3%), CRFO (14.4%), and DTP (8.6%). Potassium concentration, preexisting chronic kidney disease, and renal pelvic dilation at abdominal ultrasonography were associated with CVE occurrence in multivariate analysis. Conclusions: This study highlighted frequent CVEs in cats treated for UTO, with a potential strong impact on outcome. Therefore, cardiovascular parameters of cats with preexisting chronic kidney disease or those admitted with hyperkalemia or renal pelvic dilation should be closely monitored.

Survenue d'anomalies cardio-vasculaires chez 168 chats présentés pour obstruction du tractus urinaire. Contexte: Si des anomalies cardiovasculaires secondaires à une insuffisance rénale aigue ont été décrites récemment en médecine vétérinaire, ces données restent limitées concernant les obstructions du tractus urinaire (OTU) chez le chat. Objectif: Décrire le type, la fréquence, le délai d'apparition et les facteurs de risques d'anomalies cardio-vasculaires (ACV) chez des chats hospitalisés pour OTU aigue. Animaux et protocoles: Les dossiers médicaux des chats admis en unité de soins intensifs pour obstruction du tractus urinaire haut ( urétérales-OTUH) et bas (urétrales-OTUB) entre 2016 et 2021 ont été consultés. Les ACV retenus étaient des arythmies cardiaques, le développement de souffles cardiaques et de bruits de galop, les signes relatifs à une surcharge en fluide (SRSF) et de diminution de la perfusion tissulaire (SDPT). Résultats: Cent soixante-huit chats avec des OTU ont été recrutés (56 OTUH, 112 OTUB). Des ACV ont été observés dans 61,9 % des cas, incluant des arythmies (33,6 %), l'apparition de bruits de galop (28,1 %) et de souffles cardiaques (15,3 %), des SRSF (14,4 %) et des SDPT (8,6 %). La concentration plasmatique en potassium, la présence d'une MRC sous-jacente et d'une dilatation pyélique à l'échographie abdominale ont été associées à la présence d'ACV par l'analyse multivariée. Conclusions: Cette étude montre que les ACV surviennent fréquemment chez les chats présentés pour OTU, et suggère un impact sur la survie de ces animaux. Les animaux avec un historique de MRC, ceux présentés avec une hyperkaliémie et/ou avec une dilatation pyélique à l'échographie abdominale devraient être surveillés avec plus de précautions que les autres.(Traduit per les auteurs).

Kidney disease progression in pediatric and adult posterior urethral valves (PUV) patients.

BACKGROUND: Posterior urethral valves (PUV) is the most common cause of obstructive uropathy in boys; approximately 15% develop kidney failure by early adulthood. However, rates of kidney function decline are poorly defined in PUV children and adults, as is the impact of potentially modifiable chronic kidney disease (CKD) progression risk factors. METHODS: We conducted a retrospective review of all PUV patients followed at our institution from 1995 to 2018. Inclusion criteria were estimated glomerular filtration rate (eGFR) > 20 ml/min/1.73 m2 after 1 year of age, no dialysis or kidney transplant history, and ≥ 2 yearly serum creatinine values after age 1 year. eGFRs were calculated using creatinine-based estimating formulas for children (CKID U25) or adults (CKD-EPI). The primary outcome was annualized change in eGFR, assessed with linear mixed effects models. We also examined the association of acute kidney injury (AKI), proteinuria, hypertension (HTN), and recurrent febrile urinary tract infections (UTIs) with eGFR decline. RESULTS: Fifty-two PUV patients met the inclusion criteria. Median (interquartile range) eGFR decline was 2.6 (2.1, 3.1) ml/min/1.73 m2/year. Children (n = 35) and adults (n = 17) demonstrated progressive decline. Proteinuria and recurrent UTIs were significantly associated with faster progression; AKI and HTN were also associated but did not reach significance. CONCLUSION: PUV patients show progressive loss of kidney function well into adulthood. Proteinuria and recurrent UTIs are associated with faster progression, suggesting potential modifiable risk factors. This is the first study to report annualized eGFR decline rates in PUV patients, which could help inform the design of clinical trials of CKD therapies.

Congenital lower urinary tract obstruction with spontaneous fetal bladder rupture due to posterior urethral valves: a case report.

BACKGROUND: Congenital lower urinary tract obstruction (LUTO) is a rare but significant condition affecting fetal urinary tract development. LUTO has a range of etiologies, with posterior urethral valves (PUV) being the most common cause. The prenatal diagnosis of LUTO plays a crucial role in recognizing the condition and guiding management decisions. Prenatal ultrasound serves as the primary tool for identifying LUTO, with key findings including megacystis, bladder wall thickening, oligohydramnios, hydronephrosis, and the 'keyhole sign' indicating dilatation of the posterior urethra. We present a case of congenital LUTO with a rare complication of spontaneous fetal bladder rupture and urinary ascites, treated by peritoneo-amniotic shunt placement. CASE PRESENTATION: A 27-year-old pregnant Caucasian women was referred at 28 weeks of pregnancy due to the presence of megacystis and bilateral hydronephrosis on routine ultrasound and suspicion of LUTO. Repeat ultrasound at 29 weeks showed significant fetal ascites, oligohydramnios and resolution of megacystis and hydronephrosis, after which diagnosis of spontaneous bladder rupture was made. Despite ascites aspiration and amnio-infusion, there was persistent ascites and oligohydramnios. A peritoneo-amniotic shunt was placed with resolution of ascites and normalization of the amniotic fluid volume. At 35 weeks, relapse of the megacystis was observed with bilateral pyelectasis and oligohydramnios, possibly due to healing of the bladder rupture, after which elective cesarean section was planned. Cystography confirmed spontaneous healing of the bladder rupture and the presence of posterior urethral valves, which were resected in the neonatal period with cold knife incision. Total follow-up of 8 years continued to show positive ultrasonographic results and good renal function, but the child suffers from bladder dysfunction, manifesting as overactive bladder disease. CONCLUSIONS: LUTO might lead to important renal dysfunction and pulmonary hypoplasia in case of increasing disease severity. Spontaneous bladder rupture might improve renal prognosis, acting as a pop-off mechanism by decompression of the urinary tract. However, fetal bladder rupture is rare and only few cases have been reported. Prenatal intervention can be considered for moderate or severe LUTO, but the benefit for long-term outcome remains uncertain and further studies are needed.

[Surgical treatment options of lower urinary tract symptoms due to benign prostatic obstruction : The German S2e guideline 2023-part 3]. / Operative Therapie des benignen Prostatasyndroms ­ klassische Desobstruktion : Die deutsche S2e-Leitlinie 2023 ­ Teil 3.

BACKGROUND: Lower urinary tract symptoms (LUTS) due to benign prostatic obstruction (BPO) are one of the most common diagnoses in clinical practice. Bothersome LUTS impact considerably quality of life of men and may cause severe complications without treatment. According to the diagnostic assessment every patient should be treated with an adequate therapy. Management comprises a conservative approach, medication, novel minimally invasive options, and surgical procedures with the aim to remove the obstructing adenoma. The German guideline panel has updated the German guidelines on diagnostic evaluation and management of LUTS due to BPO. OBJECTIVES: Evidence-based recommendations of surgical treatment options of LUTS due to BPO are evaluated. MATERIALS AND METHODS: Chapters 11.1.1 and 11.2 of the updated German S2e guideline on the management of LUTS due to BPO are summarized as a review article. RESULTS: A treatment algorithm based on current evidence has been proposed. It is considered to provide guidance for the selection of the best procedure according to the needs of the patient. Anatomic features of the prostate, the patients' morbidity, and the preservation of ejaculatory function are taken into account for the choice of the best procedures. These surgical options can be divided into techniques with direct, delayed or no removal of the adenoma, procedures with suprapubic access, and embolizing approaches. CONCLUSIONS: The updated German S2e guideline on the management of LUTS due to BPO provides evidence-based recommendations for the selection of the best procedure according to the needs of the individual patient.

Hematological differentiation of bladder rupture and complete/partial urethral obstruction in castrated Hanwoo (Korean indigenous cattle) with urolithiasis.

This case report describes the hematological and radiological examination of urinary bladder rupture and complete urethral obstruction. associated with urolithiasis in Hanwoo. Hyponatremia, hypochloremia, azotemia, and hyperglycemia were observed in both urethral obstruction and urinary bladder rupture. However, cattle with urethral obstruction showed hyperkalemia and mild hyperglycemia, whereas cattle with bladder rupture showed marked hyperglycemia and normal potassium levels. In ultrasonography, the urethral obstruction showed a dilated bladder with a thick bladder wall. In contrast to previous literature, in this study, severe electrolyte changes such as severe hyponatremia, hypochloremia, and hyperkalemia occurred in a case of complete urethral obstruction.

A grading system for evaluation of bladder trabeculation.

PURPOSE: To establish a parameter-based grading system for evaluating bladder trabeculation (BT). MATERIALS AND METHODS: A retrospective analysis was conducted on children diagnosed with posterior urethral valve (PUV) or neurogenic bladder (NB) who underwent voiding cystourethrogram (VCUG), urodynamic testing, and urological ultrasonography between January 2016 and October 2022. Cases involving urologic surgery, secondary bladder pathology, and an interval of more than 12 months between examinations were excluded. A parameter named Bladder Dispersion (BD) was calculated through fluoroscopic images, and the grading system was developed as follows: BD < 40 (Grade 0), 40 ≤ BD < 60 (Grade 1), 60 ≤ BD < 90 (Grade 2), BD ≥ 90 (Grade 3). Grades 0-1 were classified as low-risk group, while grades 2-3 were classified as high-risk group. Analysis of variance, Kruskal-Wallis test, and Chi-square test were performed to compare urodynamic results and complications across different grades and groups. RESULTS: A total of 74 patients were eligible to participate, which included 46 boys (62.2%) and 28 girls (37.8%), the mean age was 75.18 ± 48.39 months. Among them, 11 (14.9%) were PUV, 50 (67.6%) were NB, and 13 (17.5%) were PUV and NB. Significant differences were observed in maximum detrusor pressure, post-void residual urine ratio, and compliance among grades 0-3. Severe hydronephrosis and histories of urinary tract infection were more prevalent in the high-risk group. CONCLUSION: A reliable grading system with objective standards was proposed which could aid in the assessment of BT severity.

Role of Bladder Functional Testing Prior to Surgeries for Benign Prostatic Obstruction.

PURPOSE OF REVIEW: There is no consensus on preoperative functional testing prior to surgeries for benign prostatic obstruction causing lower urinary tract symptoms (LUTS). RECENT FINDINGS: Surgical management offers definite benefits, but the results are not always satisfactory. The urodynamic study (UDS) is the gold standard for assessing bladder outlet obstruction (BOO) which is the best predictor of surgical success. Yet, it is not recommended by our urologic societies as standard testing prior to surgery. In this narrative review of the literature, we report recent findings and controversies regarding the benefits and downside of UDS, and the use of other less-invasive approaches to achieve this goal. The lack of strong evidence for or against performing UDS was surprising. Prospective UDS data may not predict surgical outcomes if there is no consensus on criteria that directs surgical intervention. However, confirming the presence of BOO and characterizing the bladder function to identify detrusor over- and underactivity may help counselling and setting patient's post-operative expectations. Urocuff, a non-invasive testing offers promising results to address this problem with a less-invasive assessment of BOO. We emphasize better pre-operative characterization of patients to confirm BOO and better define subgroups to improve surgical decision-making.

Posterior urethral valves, pressure pop-offs, and kidney function: systematic review and meta-analysis.

PURPOSE: To determine the role of pressure pop-off mechanisms, including vesicoureteral reflux and renal dysplasia (VURD) syndrome, in determining long-term kidney outcomes in boys with posterior urethral valves (PUV). METHODS: A systematic search was performed in December 2022. Descriptive and comparative studies with a defined pressure pop-off group were included. Assessed outcomes included end-stage renal disease (ESRD), kidney insufficiency (defined as chronic kidney disease [CKD] stage 3 + or SCr > 1.5 mg/dL), and kidney function. Pooled proportions and relative risks (RR) with 95% confidence intervals (CI) were extrapolated from available data for quantitative synthesis. Random-effects meta-analyses were performed according to the study design and techniques. The risk of bias was assessed with the QUIPS tool and GRADE quality of evidence. The systematic review was prospectively registered on PROSPERO (CRD42022372352). RESULTS: A total of 15 studies describing 185 patients with a median follow-up of 6.8 years were included. By the last follow-up, overall effect estimates demonstrate the prevalence of CKD and ESRD to be 15.2% and 4.1%, respectively. There was no significant difference in the risk of ESRD in patients with pop-off compared to no pop-off patients [RR 0.34, 95%CI 0.12, 1.10; p = 0.07]. There was a significantly reduced risk for kidney insufficiency in boys with pop-off [RR 0.57, 95%CI 0.34, 0.97; p = 0.04], but this protective effect was not re-demonstrated after excluding studies with inadequate reporting of CKD outcomes [RR 0.63, 95%CI 0.36, 1.10; p = 0.10]. Included study quality was low, with 6 studies having moderate risk and 9 having a high risk of bias. CONCLUSIONS: Pop-off mechanisms may be associated with reducing the risk of kidney insufficiency, but current certainty in the evidence is low. Further research is warranted to investigate sources of heterogeneity and long-term sequelae in pressure pop-offs.

Technical details and long-term outcomes of P.A.D.U.A. for congenital urethral narrowing; a case series and review of the literature.

INTRODUCTION: The P.A.D.U.A. technique is a method of addressing congenital urethral narrowing. It involves passive dilation with a series of progressively larger indwelling catheters. Utilization is limited by scant literature, particularly regarding technical details and long-term durability. Tools for achieving safe and reliable urinary drainage are critical in these patients, who require careful stewardship of their kidney and bladder function. OBJECTIVE: To describe long-term urethral patency and urinary function following P.A.D.U.A., and to provide sufficient technical detail to reproduce the technique. STUDY DESIGN: Patients with congenital urethral narrowing managed with P.A.D.U.A. were identified and chart review was performed. Details of catheter exchange sequences were compiled and described. The primary outcome was the attainment of adequate urethral caliber by successful completion of P.A.D.U.A., and the secondary outcome was voiding per urethra at most recent follow-up. RESULTS: P.A.D.U.A. achieved adequate urethral caliber in 9/11 (82%) of patients. This included seven patients with Prune Belly Syndrome, one with isolated urethral atresia, and one with a cloacal anomaly. P.A.D.U.A. failed to achieve urethral patency in one patient with urethral duplication, who was unable to progress through the catheter sequence, and one patient with Prune Belly Syndrome, who completed P.A.D.U.A. but developed recurrent narrowing one week later. There were no delayed failures of urethral patency. Patients who achieved patency underwent a median of seven catheter placements over 92 days. Median (range) initial and final catheter sizes were 3.5F (1.9-8F) and 14F (8-16F). While 82% achieved patency, only 3/11 (27%) were voiding spontaneously per native urethra at most recent follow-up. DISCUSSION: This series of patients undergoing P.A.D.U.A. for primary treatment of congenital urethral narrowing is the largest to date and provides granular technical details. It aligns with prior reports suggesting that P.A.D.U.A. achieves urethral patency in most patients with Prune Belly Syndrome or isolated urethral atresia, but has limited application in the hypoplastic duplicated urethra. Despite high rates of urethral patency in this select population, many patients will not achieve and maintain spontaneous voiding without catheterization. This is likely due to ongoing deterioration of bladder function caused by the prenatal developmental insult, paralleling the phenomenon seen in posterior urethral valves. CONCLUSION: P.A.D.U.A. is an effective and durable technique for achieving urethral patency. However, due to complicating factors such as the underlying bladder pathology present in many patients, urethral patency achieved with P.A.D.U.A. does not guarantee long-term safe and reliable spontaneous emptying per urethra.

A multicenter prospective cohort study of endoscopic urethral realignment versus suprapubic cystostomy after complete pelvic fracture urethral injury.

BACKGROUND: Pelvic fracture urethral injury (PFUI) occurs in up to 10% of pelvic fractures. There is mixed evidence supporting early endoscopic urethral realignment (EUR) over suprapubic tube (SPT) placement and delayed urethroplasty. Some studies show decreased urethral obstruction with EUR, while others show few differences. We hypothesized that EUR would reduce the rate of urethral obstruction after PFUI. METHODS: Twenty-six US medical centers contributed patients following either an EUR or SPT protocol from 2015 to 2020. If retrograde cystoscopic catheter placement failed, patients were included and underwent either EUR or SPT placement based on their institution's assigned treatment arm. Endoscopic urethral realignment involved simultaneous antegrade/retrograde cystoscopy to place a catheter across the urethral injury. The primary endpoint was development of urethral obstruction. Fisher's exact test was used to analyze the relationship between PFUI management and development of urethral obstruction. RESULTS: There were 106 patients with PFUI; 69 (65%) had complete urethral disruption and failure of catheter placement with retrograde cystoscopy. Of the 69 patients, there were 37 (54%) and 32 (46%) in the EUR and SPT arms, respectively. Mean age was 37.0 years (SD, 16.3 years) years, and mean follow-up was 463 days (SD, 280 days) from injury. In the EUR arm, 36 patients (97%) developed urethral obstruction compared with 30 patients (94%) in the SPT arm ( p = 0.471). Urethroplasty was performed in 31 (87%) and 29 patients (91%) in the EUR and SPT arms, respectively ( p = 0.784). CONCLUSION: In this prospective multi-institutional study of PFUI, EUR was not associated with a lower rate of urethral obstruction or need for urethroplasty when compared with SPT placement. Given the potential risk of EUR worsening injuries, clinicians should consider SPT placement as initial treatment for PFUI when simple retrograde cystoscopy is not successful in placement of a urethral catheter. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Outcomes of Pelvic Fracture Urethral Injuries Stratified by Urethral Injury Severity: A Prospective Multi-institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury. METHODS: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score. RESULTS: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001). CONCLUSION: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed.

Treatment of overactive bladder in men: Is it really different?

INTRODUCTION: Overactive bladder (OAB) in men is a topic that is gaining increasing attention as there is a wider understanding that OAB is not a female condition. There are several treatments; however, data in male populations are lacking compared to female cohorts. The high likelihood of concomitant benign prostatic hyperplasia (BPH) and benign prostatic obstruction (BPO) adds to the complexity of the treatment algorithm. The overlap in urinary storage symptoms also makes the interpretation of the literature challenging. METHODS: Articles that evaluated men with OAB and men with OAB and BPH/BPO were evaluated and assessed. RESULTS: Behavioral interventions can offer a significant benefit to male patients with OAB. Medical therapies that have been studied in men with OAB include anticholinergics, beta-3 agonists, and phosphodiesterase-5 inhibits. These agents can be offered in addition to alpha-blockers for men with coexisting BPH/BPO. The literature on Onabotulinumtoxin-A and neuromodulation modulation in the male population is growing and shows promising results. CONCLUSION: Male OAB is complex; however, there is a growing body of literature to help guide treatments. Many treatments are available and they have shown considerable success.

Vesico-amniotic shunt insertion prior to the completion of 16 weeks results in improved preservation of renal function in surviving fetuses with isolated severe lower urinary tract obstruction (LUTO).

PURPOSE: The purpose of this retrospective cohort study was to compare the outcome of human fetuses with isolated severe lower urinary tract obstructions (LUTO) that were first treated before the completion of 16 weeks of gestation to fetuses first treated later in gestation. PATIENTS AND METHODS: Vesicoamniotic shunt insertion (VAS) was performed in 63 subsequent fetuses with LUTO between 12 + 5 and 30 + 3 weeks. The fetuses were analyzed in three groups: Group-I-fetuses underwent their first intervention until the completion of 16 weeks, Group-II-fetuses were first treated between 16 + 1 and 24 + 0 weeks and Group-III-fetuses beyond 24 + 1 weeks. Renal and pulmonary outcome parameters and complicating factors were assessed. RESULTS: - All mothers tolerated the procedures well. Overall fetal survival was 47 of 63 (75%). The mean age at delivery of survivors was 35 weeks. 68% of Group-I-fetuses, 77% of group-II-fetuses, and 100% of group-III-fetuses survived beyond postnatal hospital discharge. Amongst the survivors the chance for normal renal function was higher for group I with 79% (15/19) compared to first fetal intervention after the completion of 16 weeks with 32% (9/28, p = 0.003, OR = 7.9 [2.0, 30.8] 95% CI). Clinically relevant pulmonary hypoplasia was observed in 11% of Group-I-, 27% of Group-II-, and 20% of Group-III-fetuses. CONCLUSIONS: Early intervention in fetal LUTO before the completion of 16 weeks may achieve a higher rate of normal renal and pulmonary function in survivors than treatment beyond that point in time. This observation is important for the future management of this challenging patient population.

Predicting childhood chronic kidney disease severity in infants with posterior urethral valve: a critical analysis of creatinine values in the first year of life.

BACKGROUND: Posterior urethral valve (PUV) is a leading cause of chronic kidney failure in children. Studies have shown that a creatinine nadir above historical cutoff values of 0.8 or 1.0 mg/dL correlates with worse kidney outcomes. The ability to use nadir creatinine more discriminately as a test of kidney outcomes is otherwise limited. METHODS: We performed a retrospective review of 102 infants treated with primary valve ablation prior to 1 year of age. Patient factors including creatinine at presentation (Cr-P), nadir within 6 weeks after ablation (Cr-6 W), and nadir within 1 year after ablation (Cr-1Y) were assessed as predictors of final chronic kidney disease (CKD) severity. An optimal threshold for four CKD levels was defined in incremental fashion using binary outcome with receiver operating characteristic (ROC). Multivariable logistic regression models compared Cr-P, Cr-6 W, and Cr-1Y while adjusting for patient factors. RESULTS: Boys were ablated at mean age of 36.3 days and followed for 6.6 years (± 3.7). When compared to other demographics, only creatinine remained independently predictive of CKD outcomes on multivariable analysis. ROC analysis demonstrated excellent diagnostic accuracy for Cr-6 W and Cr-1Y (p < 0.001) and acceptable accuracy for Cr-P (p < 0.005). Using the Cr-6 W and Cr-1Y models, high sensitivity and specificity creatinine nadir cutoffs were determined to predict each CKD outcome. CONCLUSIONS: The severity of childhood CKD can be predicted with high accuracy using the creatinine nadir within 6 weeks of ablation. The cutoff values described can be incorporated into a clinical setting for patient counseling and individual risk stratification.

Persistent use of medical therapy after surgery for lower urinary tract symptoms: a retrospective database analysis.

PURPOSE: To determine how many men are able to remain off of medical therapy for lower urinary tract symptoms (LUTS) following surgery for benign prostatic obstruction (BPO). METHODS: The TriNetX Analytics Network was used to identify men who were taking medical therapy for BPO (at least one of: alpha-1 blockers, anticholinergics, B3 agonists, or 5-alpha-reductase inhibitors) and subsequently underwent surgery for BPO. They were then placed into one of six cohorts, classified based on the type of surgery they received: transurethral resection of the prostate (TURP), Laser vaporization of prostate (PVP), transurethral incision of the prostate (TUIP), prostatic urethral lift (PUL), water-vapor thermal therapy (WV), or Laser enucleation of the prostate (LEP). Our primary outcome was persistent use of medical therapy at 6-months-2-years postoperatively. Secondary outcome was surgical retreatment by 2 years postoperatively. Propensity-score matching (PSM) was used to control for various risk factors for lower urinary tract symptoms (LUTS). RESULTS: A total of 21,475 men were identified who were on medical therapy and subsequently underwent surgery, which included 12,294 TURP, 5290 PVP, 397 WV, 1308 PUL, 346 TUIP, and 1840 LEP. Medication use between 6 months and 2 years after surgery was 38% for LEP, 50% for WV, 61% for TURP, 63% for PUL, 65% for TUIP and 66% for PVP. All surgical modalities had higher odds of using medications when compared to LEP (p < 0.001). This remained significant after PSM for 9 potentially confounding variables. CONCLUSION: A large percentage of men continue medical therapy after surgery for BPO. Amongst multiple surgical modalities available, LEP appears to have the highest rates of medication discontinuation after surgery. In men who wish to avoid medications or who have cardiac risk factors, a discussion with their urologist to select the best option to minimize medical therapy should occur.

Robotic Urethral Reconstruction Outcomes in Men With Posterior Urethral Stenosis.

OBJECTIVE: To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction. MATERIALS AND METHODS: A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed. RESULTS: Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included benign prostatic hypertrophy treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (benign prostatic hypertrophy), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (P = .52). Median length of stay after reconstruction was 2, 1, and 2 days (P = .45). Thirty-day complications occurred in 0%, 20%, 40% (P = .19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (P = .004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (P = .63), with functional success rates of 100%, 100%, 60% (P = .035). Median postoperative pad/day usage was 0,0, 10.5 (P <.001), and ultimately 0%, 30%, 80% (P = .013) underwent artificial urinary sphincter placement. CONCLUSION: Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence.

Mejora de las variaciones en la ecografía vesical Evaluación del volumen de orina residual posmiccional en obstrucción moderada de la salida de la vejiga / Improving Variations in Bladder Ultrasound Assessment of Post-Void Residual Urine Volume in Moderate Bladder Outlet Obstruction

Objectives: This study aimed to assess the accuracy of post-void residual (PVR) urine volume measurements in patients with moderate bladder outlet obstruction. Materials and Methods: This prospective observational study was conducted between January and December 2019. The inclusion criteria were male patients with symptoms of moderate bladder outlet obstruction. On the other hand, patients with a history of diabetes, symptoms of urinary tract infection, and positive urine for pyuria, as well as patients using medications, such as diuretics, alpha-blockers, and anticholinergic drugs, were excluded. The patients were asked to drink 1000 mL of water one to two hours before the initial ultrasound scan. Pre-void bladder capacity was measured, followed by a post-void ultrasound for residual urine volume measurement at three intervals: immediately after voiding, 15-20 minutes after the first void, and one week later with an empty bladder. Assessment of per-void capacity was carried out, based on the patient's subjective sensation of bladder fullness (a strong desire to void). Results: A total of 78 male patients, with the mean age of 60 years, were included in this study (27 cases in group I; 37 cases in group II; and 14 cases in group III). The mean PVR volume was 92 mL in the first measurement, 62 mL in the second measurement, and 60 mL in the third measurement. Significant differences were found between the first and second PVR measurements and between the first and third PVR measurements (P<0.05). However, no significant difference was found between the second and third PVR measurements (P=0.107). On the other hand, significant differences were found between groups I and II and between groups I and III (P<0.05) in the three PVR measurements. Nevertheless, there was no significant difference between groups II and III in the three PVR measurements (P=0.204, 0.56, and 0.487 for the first, second, and third PVR measurements, respectively). Conclusion: A bladder ultrasound must be performed and interpreted carefully to avoid further unnecessary medications, investigations, or procedures. We recommend a second PVR measurement in patients with bladder outlet obstruction. Also, it is suggested to conduct similar studies in different conditions to confirm our findings.

Inhibition of α1-adrenoceptor reduces TGF-ß1-induced epithelial-to-mesenchymal transition and attenuates UUO-induced renal fibrosis in mice.

Renal fibrosis is a common pathological hallmark of chronic kidney disease (CKD). Renal sympathetic nerve activity is elevated in patients and experimental animals with CKD and contributes to renal interstitial fibrosis in obstructive nephropathy. However, the mechanisms underlying sympathetic overactivation in renal fibrosis remain unknown. Norepinephrine (NE), the main sympathetic neurotransmitter, was found to promote TGF-ß1-induced epithelial-mesenchymal transition (EMT) and fibrotic gene expression in the human renal proximal epithelial cell line HK-2. Using both genetic and pharmacological approaches, we identified that NE binds Gαq-coupled α1-adrenoceptor (α1-AR) to enhance EMT of HK-2 cells by activating p38/Smad3 signaling. Inhibition of p38 diminished the NE-exaggerated EMT process and increased the fibrotic gene expression in TGF-ß1-treated HK-2 cells. Moreover, the pharmacological blockade of α1-AR reduced the kidney injury and renal fibrosis in a unilateral ureteral obstruction mouse model by suppressing EMT in the kidneys. Thus, sympathetic overactivation facilitates EMT of renal epithelial cells and fibrosis via the α1-AR/p38/Smad3 signaling pathway, and α1-AR inhibition may be a promising approach toward treating renal fibrosis.