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1.
Medicine (Baltimore) ; 99(14): e19338, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32243359

RESUMO

INTRODUCTION: A hiccup is myoclonus of a sudden involuntary contraction of the diaphragm. Hiccups have various causes, and brain stem stroke is one of the causes of central hiccups. Certain types of hiccups are caused by diseases that can be fatal. Therefore, it is beneficial for physicians to be familiar with the various cases of unusual hiccups. We report a case of hiccups triggered by urinary bladder filling in a brain stem stroke patient. To the best of our knowledge, previous reports have not described a similar case. PATIENT CONCERNS: We describe the case of a 54-year-old patient who had acute bilateral pontine hemorrhage. The patient had intermittent hiccups in the early stages of the stroke onset. The hiccups ceased by the administration of medication or stimulation of the pharyngeal or tracheal wall. Two months after the onset, the Foley catheter was removed to check if the patient could void the bladder voluntarily. Hiccups occurred whenever the bladder was filled with some amount of urine. DIAGNOSIS: Pontine hemorrhage, neurogenic bladder, and quadriplegia. INTERVENTIONS: When the hiccups occurred, the amount of urine in the bladder was checked using a transabdominal bladder ultrasonography scanner. After clean intermittent catheterization for bladder emptying, the hiccups subsided. OUTCOMES: The hiccups occurred 5 or 6 times a day, as often as the bladder was filling. He was unable to void the urine voluntarily for 5 days after the removal of the Foley catheter. Percutaneous suprapubic cystostomy was performed finally to remove the stimulation of bladder filling and the hiccups disappeared. CONCLUSION: Bladder filling is suspected to increase the sympathetic tone and cause a hiccup reflex. Bladder filling could be a factor triggering hiccups in pontine hemorrhage.


Assuntos
Infartos do Tronco Encefálico/complicações , Hemorragia Cerebral/complicações , Soluço/etiologia , Bexiga Urinaria Neurogênica/complicações , Cistostomia , Soluço/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Bexiga Urinaria Neurogênica/cirurgia , Cateterismo Urinário
2.
J Urol ; 203(3): 579-584, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31526261

RESUMO

PURPOSE: We investigated the prevalence of asymptomatic bacteriuria and the incidence of symptomatic urinary tract infections in patients with neurogenic lower urinary tract dysfunction undergoing urodynamics. We also assessed predictors of symptomatic urinary tract infections. MATERIALS AND METHODS: We evaluated a prospective consecutive series of 317 patients, including 106 women and 211 men, with neurogenic lower urinary tract dysfunction. Of the patients 111 (35%) voided spontaneously, 141 (44%) relied on intermittent self-catheterization and 65 (21%) relied on an indwelling catheter. Before urodynamics the urine samples were collected by sterile catheterization for dipstick testing and urine culture. We assessed the association of patient characteristics with symptomatic urinary tract infections after urodynamics in patients with asymptomatic bacteriuria and developed a prediction model based on the most important risk factors. RESULTS: Before urodynamics urine cultures were negative in 123 patients (39%) and positive in 194 (61%). Escherichia coli and Klebsiella pneumoniae were the most frequent bacteria, found in 32% and 18% of patients, respectively. Of 194 patients with a positive culture 35 (18%) had at least 1 symptomatic urinary tract infection. In patients with a history of previous urinary tract infections the overall estimated probability of a symptomatic urinary tract infection was 45% regardless of the underlying neurological disorder. CONCLUSIONS: A symptomatic urinary tract infection will develop in the followup year in about 1 of 5 patients with asymptomatic bacteriuria. This rather low overall probability precludes routine antibiotic prophylaxis or treatment in patients with neurogenic lower urinary tract dysfunction who have asymptomatic bacteriuria since 4 of 5 would be overtreated. However, in patients with a history of previous symptomatic urinary tract infections antibiotic prescription might be justified.


Assuntos
Bacteriúria/epidemiologia , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/epidemiologia , Bacteriúria/microbiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Fatores de Risco , Infecções Urinárias/microbiologia , Urodinâmica
3.
Urology ; 137: 206-207, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31790786

RESUMO

OBJECTIVE: Robot-assisted laparoscopic (RAL) techniques for the management of neurogenic bladder involves complex procedures using lower urinary tract and bowel. When medical therapy fails, surgery aims to preserve upper tract function and social continence.1 Traditionally, the procedure was performed in an open approach, but newer minimally-invasive techniques offer improved cosmesis, reduced pain and length of stay.2 A series of 38 cases showed the feasibility and safety of this approach.3 Here, we describe a RAL bladder neck reconstruction with appendicovesicostomy in a 7-year-old with neurogenic bladder (Fig. 1). METHODS: The patient was placed in a lithotomy position followed by double-J and Foley catheter placement. With an open Hasson technique, a 12-mm, two 8-mm, and a 5-mm port were positioned. The bladder is prefilled with saline (80 mL) and a cystotomy is performed. The tubularization is completed in 2 layers achieving a 3-cm tunnel (Figs. 2-3). The appendix is implanted in the posterior wall of the bladder with a submucosal tunnel. Ultimately, 2 suprapubic tubes are placed and the bladder is closed in a single layer. RESULTS: No complications reported, operative time was 5 hours and estimated blood loss was 50 mL. At 1-month follow-up, double-J stents were removed and the patient reported catheterizing well with good continence and well-healed incisions. CONCLUSION: Robotic continence procedures have demonstrated to be a safe and effective alternative. Here, we presented a satisfactory outcome using RAL bladder neck reconstruction with appendicovesicostomy in a 7 years old with persistent incontinence, despite untethering and maximal anticholinergic therapy.


Assuntos
Laparoscopia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Bexiga Urinaria Neurogênica , Derivação Urinária/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Criança , Humanos , Masculino , Duração da Cirurgia , Resultado do Tratamento , Bexiga Urinária/cirurgia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/cirurgia , Incontinência Urinária/etiologia , Incontinência Urinária/cirurgia
4.
Ren Fail ; 41(1): 937-945, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31599184

RESUMO

The aim of this work was to evaluate the efficacy and safety of botulinum toxin A (BTX-A) treatment in patients with neurogenic detrusor overactivity. PUBMED, EMBASE, and Cochrane Library were identified on 13 May 2017 to identify relevant randomized controlled trials. All data obtained were analyzed using Stata 12.0. Five randomized controlled trials were included in this study. Compared to placebo, the BTX-A groups had significantly fewer urinary incontinence (UI) episodes per day and per week (BTX-A with 300 U for frequency of UI per day at week 2, mean difference (MD): -1.13, 95% confidence interval (CI): -1.89 to -0.37; 200 U; BTX-A with 300 U for frequency of UI per week at week 6, MD: -11.42, 95% CI: -13.91 to -8.93; BTX-A with 200 U for frequency of UI per week at week 6, MD: -10.72, 95% CI: -13.40 to -8.04), increased in maximum cystometric capacity at week 6 (BTX-A with 300 U, MD: 154.88, 95% CI: 133.92-175.84; BTX-A with 200 U, MD: 141.30, 95% CI: 121.28-161.33), decreased maximum detrusor pressure at week 6 (BTX-A with 300 U, MD: -31.72, 95% CI: -37.69 to -25.75; BTX-A with 200 U, MD: -33.47, 95% CI: -39.20 to -27.73). For adverse effects, BTX-A was often associated with more complications and urinary tract infections (BTX-A with 300 U: relative risk (RR):1.42, 95% CI: 1.15-1.76; BTX-A with 200 U: RR: 1.42, 95% CI: 1.11-1.82). This meta-analysis suggests that treatment with BTX-A is effective and safe for neurogenic detrusor overactivity, and recommends using BTX-A with 300 U or with 200 U, as suitable dosage.


Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Bexiga Urinaria Neurogênica/tratamento farmacológico , Bexiga Urinária Hiperativa/tratamento farmacológico , Incontinência Urinária/tratamento farmacológico , Infecções Urinárias/epidemiologia , Administração Intravesical , Toxinas Botulínicas Tipo A/efeitos adversos , Relação Dose-Resposta a Droga , Humanos , Injeções , Placebos/administração & dosagem , Placebos/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Índice de Gravidade de Doença , Resultado do Tratamento , Bexiga Urinária/efeitos dos fármacos , Bexiga Urinária/inervação , Bexiga Urinária/fisiopatologia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Urinária Hiperativa/complicações , Bexiga Urinária Hiperativa/fisiopatologia , Incontinência Urinária/diagnóstico , Incontinência Urinária/etiologia , Infecções Urinárias/induzido quimicamente
5.
Urology ; 133: 199-203, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31454657

RESUMO

OBJECTIVE: To investigate the role of albuminuria as a clinical marker of early renal disease in children with neurogenic bladder (NGB) in association with commonly used predictors of renal risk. METHODS: Catheterized urine was obtained from 40 patients with NGB at a tertiary pediatric hospital. Albumin-to-creatinine ratio (ACR) was analyzed for associations with estimated glomerular filtration rate, vesicoureteral reflux, hydronephrosis, bladder dynamics, and renal scarring. RESULTS: About 32% (13/40) of NGB patients had elevated ACR (≥30 mg/g. Elevated ACR was associated with Caucasian race, clean intermittent catheterization, hydronephrosis, and vesicoureteral reflux on univariate analysis. In multivariable analysis, presence of vesicoureteral reflux and use of anticholinergic medication were significant predictors of ACR elevation. CONCLUSION: Albuminuria is an established clinical predictor of renal disease and risk for progression to renal failure. The presence of albuminuria in NGB patients with urinary tract abnormalities suggests these patients may be at increased risk for progressive renal disease. This supports the clinical utility of adding ACR to the evaluation of renal risk in pediatric NGB.


Assuntos
Albuminúria/etiologia , Nefropatias/diagnóstico , Nefropatias/etiologia , Bexiga Urinaria Neurogênica/complicações , Adolescente , Albuminúria/urina , Biomarcadores/urina , Criança , Pré-Escolar , Estudos Transversais , Diagnóstico Precoce , Feminino , Humanos , Nefropatias/urina , Masculino , Bexiga Urinaria Neurogênica/urina
6.
Urology ; 132: 210-211, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31299327

RESUMO

OBJECTIVE: Electromotive drug administration (EMDA) presents a minimally invasive method of intravesical instillation of therapeutic agents without the need for general anesthesia.1 It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between 2 electrodes.2 This video shows feasibility of botulinum toxin type A (BoNTA) EMDA in myelomeningocele children with urinary incontinence secondary to neuropathic detrusor overactivity. METHODS: In this technique (Video 1), catheterization was performed with a 10-Fr (CE-DAS, UROGENICS/Ag 9900 (pediatric), Mirandola, Italy) catheter electrode, after providing a local transurethral anesthesia with 2% lidocaine gel. The cuff of the catheter was filled by 2 cc saline solution. The bladder was then drained and irrigated with 0.9% saline solution until the catheter outflow became clear. The bladder was subsequently filled with sterile water to its maximal capacity. BoNTA (Dysport) at a dose of 10 IU/kg was added to the intravesical solution. Negative electrode as 2 dispersive electrodes was placed on the abdomen. Positive electrode was connected to the intravesical catheter. A pulsed current generator (Physionizer 30, Physion srl, Mirandola, Italy), delivered a current with frequency of 2,800 Hz, interval of 50 µs and amplitude of 10-20 mA for 20 minutes. At the end of the procedure, the bladder was emptied. RESULTS: For the first time, BoNTA/EMDA was performed on myelomeningocele patients with urinary incontinence in our center.3 According to our prior reports, urinary incontinence improved in 75% of the patients between 2 consecutive clean intermittent catheterizations at 1-year follow-up.4 Mean maximal cystometric capacity significantly increased from 148 ± 62 mL at baseline to 239 ± 73 mL 1 year after the treatment.4 CONCLUSION: This technique is a feasible, safe, reproducible, cost effective, long lasting, and pain free method, on an outpatient basis with long-term duration of effects and without anesthesia or cystoscopy procedure.


Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Incontinência Urinária/tratamento farmacológico , Administração Intravesical , Tratamento Farmacológico/métodos , Eletroforese , Eletroporação , Humanos , Iontoforese , Meningomielocele/complicações , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinária Hiperativa/complicações , Incontinência Urinária/etiologia
7.
Pediatr Infect Dis J ; 38(8): 804-807, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31261361

RESUMO

OBJECTIVE: The utility of the urinalysis as a potential marker to diagnose urinary tract infection (UTI) in patients with neurogenic bladder is controversial. We assessed the baseline urine characteristics and intraindividual variance of pyuria in a cohort of asymptomatic children with neurogenic bladder followed longitudinally. STUDY DESIGN: A cohort of 54 children with neurogenic bladder was followed from 2004 to 2015 at a single institution's multidisciplinary clinic. Urine data obtained from 529 routine urology visits were reviewed. Urine obtained within 2 weeks before or after treatment for UTI were excluded. Bladder surgery was defined as any operation that altered the bladder as a closed or sterile system. The effects of age, gender, catheterization, and bladder surgery on pyuria were evaluated using mixed-model regression analysis. RESULTS: Fifty patients with 305 urine samples had a mean length of follow-up of 3.2 years. Only 16/50 patients (32%) never had pyuria, and these patients had shorter follow-up compared with the group who ever had pyuria (≥5 white blood cells per high powered field) (1.7 vs. 3.8 years; P = 0.008). Catheterization was associated with a 15% increase in pyuria (P = 0.21). Surgery was associated with a 120% increase in pyuria (P < 0.001). The test-to-test variance of pyuria within an individual was consistently greater than between individuals (P < 0.001). CONCLUSIONS: Bladder surgery is associated with significant increases in pyuria among children with neurogenic bladder. The substantial test-to-test variation in pyuria in asymptomatic individuals indicates the low reliability of pyuria, when positive, as a marker for UTI in neurogenic bladder and the need to search for either methods to reduce this variability or alternative biomarkers of UTI in this population.


Assuntos
Piúria/diagnóstico , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/complicações , Infecções Urinárias/diagnóstico , Adolescente , Bacteriúria/diagnóstico , Biomarcadores , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Prognóstico , Reprodutibilidade dos Testes , Urinálise , Bexiga Urinaria Neurogênica/epidemiologia , Infecções Urinárias/epidemiologia , Wisconsin/epidemiologia
8.
Neurourol Urodyn ; 38(6): 1721-1727, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31165506

RESUMO

AIM: To evaluate the performance of the new device compared with clean intermittent catheterization (CIC). METHODS: From March 2015 to March 2018, patients who were admitted to the urologic outpatient clinic. A new intraurethral self-retaining device (ISRD) was made of medical grade silicone and it was inspired by similar catheters that use sliding disks to adjust or fix tubes used to drain the bladder. Patients were randomized into two groups (experimental group [GI]-ISRD vs control group [GII]-CIC). The evaluation was performed at the time of enrollment and 6 months after treatment. Intervention was initiated from the antisepsis of the perineal region and subsequent introduction of the device through the external urethral meatus. The primary outcome was quality of life (QOL). Urinary tract infections (UTIs) episodes, data on urodynamic parameters, adverse effects and number of diapers per day. RESULTS: A total of 177 subjects were analyzed. We found a significant improvement on QOL analysis in the ISRD group (P < .01). ISRD group presented an important reduction (two episodes after ISRD use) on number of UTIs (P < .01) and diaper use, and significant improvement on bladder capacity (80 mL of the average improvement) (P < .01) and compliance (P = .01). Among all registered serious adverse effects, ISRD presented with lower proportion. CONCLUSIONS: The new device has shown to be a safe and promising alternative for adequate emptying of the neurogenic bladder in female patients. Our study has a limitation that is related to a limited period of observation.


Assuntos
Equipamentos e Provisões , Bexiga Urinaria Neurogênica/reabilitação , Micção , Adolescente , Adulto , Anti-Infecciosos Locais/uso terapêutico , Criança , Feminino , Humanos , Tampões Absorventes para a Incontinência Urinária/estatística & dados numéricos , Cateterismo Uretral Intermitente , Pessoa de Meia-Idade , Cooperação do Paciente , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/psicologia , Cateterismo Urinário , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Urodinâmica
9.
Trials ; 20(1): 223, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30992071

RESUMO

BACKGROUND: Patients with lower neurogenic bladder dysfunction are at an increased risk of suffering from recurrent urinary tract infections. Recurrent symptomatic urinary tract infection is occasionally treated with antibiotics as a prophylactic prevention strategy. This risks increasing the frequency of antibiotic resistance. National healthcare policymakers have requested further research into alternative preventive measures for pathologies that require antibiotic treatment. METHODS: This study protocol describes a two-centre, randomised, double-blinded, placebo-controlled study to evaluate the prevention of recurrent urinary tract infections with the commercial immunotherapy agent Uro-Vaxom®, based on Escherichia coli pathogen-associated molecular patterns. Eligible participants are recruited by the direct healthcare team and randomised to receive Uro-Vaxom® in the form of an oral capsule, or a matching placebo. Participants will receive the study treatment daily for 3 months and followed up for an additional 3 months so that the number of symptomatic urinary tract infection episodes and individual signs and symptoms per episode can be recorded using participant study diaries. Primary outcome measures are: number of symptomatic urinary tract infections experienced over 3 months, number of symptomatic urinary tract infections experienced over 6 months, time from the start of treatment to the first urinary tract infection, and the presence of asymptomatic bacteriuria at 3 and 6 months. Secondary outcome measures are: individually recorded symptoms normally associated with recurrent urinary tract infection and consistency of reported symptoms during the symptomatic urinary tract infection experienced during the study, compliance with study protocol and study medication, and adverse events. DISCUSSION: Healthcare policymakers recommend that alternative preventative strategies are identified for symptomatic urinary tract infections that require antibiotic treatment. If Uro-Vaxom® is shown to be effective, this feasibility study would warrant a larger, statistically powered, multicentre study to investigate whether this immunotherapy strategy is an effective preventative measure for recurrent symptomatic urinary tract infection for people with spinal cord injuries and neurological pathologies. TRIAL REGISTRATION: ISRTCN. Registered on 30 October 2015. ClinicalTrials.gov, ID: NCT0251901 . Registered on 30 October 2015. URL of trial registry record: Ethics Ref: 15-LO-2069. IRAS Number: 185760. Sponsor Number: RXQ/648. NIHR Funding Reference: PB-PG-1013-32017.


Assuntos
Adjuvantes Imunológicos/uso terapêutico , Anti-Infecciosos Urinários/uso terapêutico , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/prevenção & controle , Adjuvantes Imunológicos/efeitos adversos , Doença Crônica , Interpretação Estatística de Dados , Método Duplo-Cego , Ética em Pesquisa , Estudos de Viabilidade , Humanos , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Recidiva
10.
Med Mal Infect ; 49(7): 495-504, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30885540

RESUMO

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.


Assuntos
Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/etiologia , Algoritmos , Humanos , Infecções Urinárias/diagnóstico , Infecções Urinárias/terapia
11.
J Pediatr Surg ; 54(4): 805-808, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30770128

RESUMO

INTRODUCTION AND AIM: Children with neuropathic lower urinary tract dysfunction usually suffer from associated bowel dysfunction, urinary tract infection and vesicoureteral reflux. This work aimed to highlight the impact of bowel management on bladder dynamics. PATIENTS AND METHODS: In the period from January 2011 to January 2013, 30 patients, 21 girls and 9 boys with neuropathic lower urinary tract dysfunction were studied. All suffered from urinary tract and bowel dysfunctions. All children were on urological treatment. They had their bowel managed by assurance and psychological support, dietary modification, retrograde or antegrade enemas and maintenance therapy. They were evaluated initially and on follow up by history, physical examination, ultrasound, urodynamics, Wexener score and bowel control chart. RESULTS: Mean age was 8.3 ±â€¯3.47 years (range from 4 to 18). There was a significant decrease in bowel dysfunction (Wexener score decreased from 12.67 ±â€¯1.54 to 10.17 ±â€¯1.76, p = 0.00), rectal diameter (decreased from 34.83 ±â€¯5.91 to 27.90 ±â€¯5.32 mm, p = 0.00), and frequency of UTI (p = 0.00). Detrusor leak point pressure decreased from 37.33 ±â€¯24.95 to 30 ±â€¯17.35 cmH2O, (p = 0.42). The cystometric capacity increased from 136.63 ±â€¯45.69 to 155.17 ±â€¯39.29 ml. (p = 0.001). Reflux and kidney function improved but was not statistically significant (p = 0.25 and p = 0.066 respectively). CONCLUSION: Management of bowel dysfunction is of utmost importance in the treatment of children with neuropathic bladder dysfunction. It has a positive effect on lower urinary tract function and decreasing the incidence of complications. This is a LEVEL III prospective study.


Assuntos
Enteropatias/terapia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinária/fisiopatologia , Urodinâmica/fisiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Enteropatias/complicações , Masculino , Estudos Prospectivos , Bexiga Urinaria Neurogênica/fisiopatologia
12.
J Pediatr Urol ; 15(2): 178.e1-178.e7, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30611650

RESUMO

INTRODUCTION: Recurrent urinary tract infections (UTIs) are common in patients with neurogenic bladder (NGB) performing clean intermittent catheterization (CIC) treated with or without oral antibiotic prophylaxis. OBJECTIVE: The authors aim to determine if daily neomycin-polymyxin or gentamicin bladder instillations reduce the rate of symptomatic UTIs, the need for oral antibiotic prophylaxis, emergency department (ED) visits for UTI, and inpatient hospitalizations for UTI in patients with NGB on CIC. The authors also aim to investigate resistance patterns in urine microorganisms in patients treated with antibiotic bladder instillations. STUDY DESIGN: The authors retrospectively reviewed the records of all-age patients cared for in the pediatric urology clinic with NGB on CIC having symptomatic UTIs and on daily intravesical instillations of neomycin-polymyxin or gentamicin between 2013 and 2017. Symptomatic UTIs were defined as a positive urine culture with greater than 10,000 colony forming units/mL associated with one or more of the following patient complaints: cloudy/foul-smelling urine, fevers, chills, increase in bladder spasms, pain, urinary leakage, or physician decision for antibiotic treatment. Multidrug-resistant organisms were resistant to two or more classes of antibiotics. RESULTS: Fifty-two patients with a median age of 14.5 years and 192 distinct urine cultures were identified. 90.4% and 9.6% of patients received neomycin-polymyxin and gentamicin instillations, respectively. After initiation of intravesical antibiotics, the rate of symptomatic UTIs was reduced by 58% (incidence rate ratio [IRR]: 0.42, 95% confidence interval [CI]: 0.31-0.56; P < 0.001), the rate of ED visits was reduced by 54% (IRR: 0.46, 95% CI: 0.30-0.71; P < 0.001), and the rate of inpatient hospitalizations for UTI was reduced by 39% (IRR: 0.61, 95% CI: 0.37-0.98; P = 0.043). Fewer patients received oral antibiotic prophylaxis after initiation of antibiotic instillations (odds ratio: 0.12, 95% CI: 0.02-0.067; P = 0.016). There was a trend toward a decrease in multidrug resistance and no change in gentamicin resistance in urine microorganisms. DISCUSSION: This study describes a feasible alternative treatment for patients with NGB on CIC who have persistent UTIs despite oral antibiotic prophylaxis, and for some patients, it may suggest a possibility of discontinuing oral prophylaxis. Limitations include a retrospective design with a small cohort of patients and varying dosages of neomycin-polymyxin. CONCLUSIONS: Antibiotic bladder instillations appear to decrease frequency of symptomatic UTIs, ED visits for UTI, inpatient hospitalizations for UTI, and the need for oral antibiotic prophylaxis in patients with NGB on CIC. There was no increase in multidrug resistance or gentamicin resistance in UTI organisms with use of intravesical antibiotic instillation.


Assuntos
Antibacterianos/administração & dosagem , Gentamicinas/administração & dosagem , Neomicina/administração & dosagem , Polimixinas/administração & dosagem , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/etiologia , Infecções Urinárias/prevenção & controle , Administração Intravesical , Adolescente , Criança , Combinação de Medicamentos , Farmacorresistência Bacteriana , Feminino , Humanos , Cateterismo Uretral Intermitente , Masculino , Estudos Retrospectivos , Bexiga Urinaria Neurogênica/terapia , Infecções Urinárias/microbiologia , Adulto Jovem
13.
Urology ; 124: 271-275, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30366042

RESUMO

OBJECTIVE: To identify nonclinical factors affecting postoperative complication rates in patients with neurogenic bladder undergoing benign genitourinary (GU) reconstruction. METHODS: Adult patients with neurogenic bladder undergoing benign GU reconstruction between October 2010 and November 2015 were included. Patients were excluded if a diversion was performed for malignancy, if patients had a history of radiation or if a new bowel segment was not utilized at the time of the operation. Clinical and nonclinical factors were abstracted from the patients' electronic medical records. Health literacy was assessed via the Brief Health Literacy Screen (BHLS), a validated 3-question assessment. Education, marital status, and distance from the medical center were also queried. RESULTS: Forty-nine patients with a neurogenic bladder undergoing complex GU reconstruction met inclusion and exclusion criteria. On average, patients lived 111 miles (standard deviation 89) from the hospital. Overall, mean BHLS score was 10.4 (standard deviation 4.6) with 35% of patients scoring a BHLS of ≤9. Mean years of educational attainment was 9.7, and only 31% of patients completed high school education. In the first month after surgery, 37 patients (76%) experienced a complication, and 22% were readmitted; however, analysis of complication data did not identify an association between any nonclinical variables and complication rates. CONCLUSION: Nonclinical factors including unmarried status, poor health literacy, and marked distance from quaternary care are prevalent in patients with neurogenic bladder undergoing complex GU reconstruction. To mitigate these potential risk factors, the authors recommend acknowledgment of these factors and multidisciplinary support perioperatively to counteract them.


Assuntos
Doenças Urogenitais Femininas/cirurgia , Doenças Urogenitais Masculinas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Feminino , Doenças Urogenitais Femininas/complicações , Acesso aos Serviços de Saúde , Humanos , Masculino , Doenças Urogenitais Masculinas/complicações , Estudos Retrospectivos , Fatores Socioeconômicos , Bexiga Urinaria Neurogênica/complicações , Procedimentos Cirúrgicos Urológicos/métodos
14.
Aktuelle Urol ; 50(3): 280-291, 2019 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-29843184

RESUMO

INTRODUCTION AND OBJECTIVES: Life expectancy for people with spinal cord injury/disease (SCI/D) is increasing, due to modern advances in treatment methods and in neuro-urology. However, with the increased life expectancy the risk of developing urinary bladder cancer is gaining importance. How is this patient group different from the general population? METHODS: Single-centre retrospective evaluation of consecutive patient data with spinal cord injury and proven urinary bladder cancer. RESULTS: Between January 1st 1998 and March 31st 2017, 32 (3 female, 29 male) out of a total of 6432 patients with SCI/D were diagnosed with bladder cancer.The average age at bladder cancer diagnosis was 54.5 years, which is well below the average for bladder cancer cases in the general population (male: 74, female: 75).Twenty-seven patients suffered from urodynamically confirmed neurogenic detrusor overactivity, while five patients (all male) had detrusor acontractility.The median latency period between the onset of SCI/D and tumor diagnosis was 29.5 years. Temporary indwelling catheterisation was found in four patients for only 1.61 % of the overall latency period of all patients.The majority of the patients (n = 27) had transitional cell carcinoma, while five had squamous cell carcinoma. Of the 32 patients, 25 (78 %) had muscle invasive bladder cancer at ≥ T2 at the time of diagnosis. Regarding tumour grading, 23 out of 32 patients showed a histologically poorly differentiated G3 carcinoma; two patients each had G2 and G1 tumours repectively (no information on tumour grading was available in five patients).The median survival for all patients was 11.5 months. The prognosis of patients with squamous cell carcinoma was even worse; 4 out of 5 died within 7 months (median 4 months). CONCLUSIONS: The significantly younger age at onset and the frequency of invasive, poorly differentiated tumour at diagnosis indicate that SCI/D influences both bladder cancer risk and prognosis significantly. The latency period between paralysis and tumour disease seems to be a decisive risk parameter.The type of neurogenic bladder dysfunction and the form of bladder drainage do not appear to influence the risk. Long-term indwelling catheter drainage played only a minor role in the investigated patients.Early detection of bladder cancer in patients with spinal cord injury remains a challenge.


Assuntos
Carcinoma de Células Escamosas/etiologia , Carcinoma de Células de Transição/etiologia , Traumatismos da Medula Espinal/complicações , Neoplasias da Bexiga Urinária/etiologia , Bexiga Urinaria Neurogênica/complicações , Fatores Etários , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células de Transição/patologia , Cateteres de Demora , Feminino , Humanos , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Estudos Retrospectivos , Fatores de Risco , Neoplasias da Bexiga Urinária/patologia
15.
Ther Apher Dial ; 23(1): 80-85, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30209889

RESUMO

Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been widely used for severe sepsis and septic shock. However, data are limited regarding the clinical experience and efficacy of PMX-DHP for septic shock resulting from urinary tract infection (UTI). At our institution, 15 patients with septic shock resulting from a UTI received PMX-DHP from January 2013 to July 2017. The cause of the urosepsis was mainly obstructive pyelonephritis secondary to ureterolithiasis or neurogenic bladder. Average Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores were 25.9 ± 4.3 and 10.5 ± 2.2, respectively. If patients were still hypotensive after initial resuscitation, we began PMX-DHP. Mean arterial pressure increased significantly from 58.3 ± 9.6 mm Hg to 93.6 ± 14.8 mm Hg just after PMX-DHP and to 94.7 ± 16.9 mm Hg (P < 0.0001) 24 h after the treatment. Catecholamine index decreased significantly from 20.7 ± 11.3 to 9.3 ± 13.5 (P = 0.0001) 24 h after the treatment. Of 15 patients, 14 (93.3%) had survived 28 days after admission. Our results suggest a possible role for PMX-DHP in the rapid stabilization of hemodynamics in patients with septic shock with an underlying UTI. These patients may be good candidates for PMX-DHP.


Assuntos
Hemodinâmica/efeitos dos fármacos , Hemoperfusão/métodos , Polimixina B/farmacologia , Choque Séptico , Infecções Urinárias , APACHE , Idoso , Antibacterianos/farmacologia , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Pielonefrite/complicações , Choque Séptico/diagnóstico , Choque Séptico/etiologia , Choque Séptico/terapia , Resultado do Tratamento , Ureterolitíase/complicações , Bexiga Urinaria Neurogênica/complicações , Infecções Urinárias/diagnóstico , Infecções Urinárias/etiologia , Infecções Urinárias/fisiopatologia , Infecções Urinárias/terapia
16.
World J Urol ; 37(5): 899-906, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30155727

RESUMO

PURPOSE: To examine the functional survival of the artificial urinary sphincter (AUS) AMS800 in a changing patient population. Because of increasing experience and dexterity of the operating team, we hypothesize that patients with known risk factors nowadays have a better survival of their prosthesis. However, due to a change to a more complex case mix, overall results appear to be worse. MATERIALS AND METHODS: All men who underwent implantation of an AUS between 2001 and 2016 because of urethral sphincter deficiency were retrospectively analyzed. Patients were divided in groups based on date of surgery and number of patients: 2001-2009 (G1), 2010-2013 (G2), 2014-2016 (G3). Baseline characteristics and additional therapies prior to implantation were analyzed in all groups. Risk factors for failure only in G1 and G2. Revision or explantation of the AUS was used as endpoint. Kaplan-Meier analysis was used to calculate survival of the device. RESULTS: A total of 129 patients (mean age 72 ± 9 years) underwent 129 primary implants, and 11 secondary implants. Median follow-up was 5.74 years in G1, 3.26 years G2 and 1.54 years G3. Approximately 25% of the patients in G1 had received adjuvant therapy for prostate cancer and 14% underwent previous surgery for incontinence. In G2, 51 and 55% underwent adjuvant therapy for prostate cancer and previous surgery for incontinence, respectively, G3 was comparable. The overall 50% survival improved in patients with radiotherapy and previous incontinence surgery in G2 as compared to G1. CONCLUSIONS: Despite the more complex patient population, the survival of the AUS did not decrease. In some patient categories, the AUS functional survival is even still improving over the past few years.


Assuntos
Complicações Pós-Operatórias/cirurgia , Falha de Prótese , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante , Diabetes Mellitus/epidemiologia , Humanos , Masculino , Prostatectomia , Radioterapia Adjuvante , Estudos Retrospectivos , Fatores de Risco , Slings Suburetrais , Estreitamento Uretral/epidemiologia , Estreitamento Uretral/cirurgia , Bexiga Urinaria Neurogênica/complicações , Incontinência Urinária por Estresse/etiologia , Procedimentos Cirúrgicos Urológicos Masculinos
17.
Neurourol Urodyn ; 38(1): 269-277, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30311685

RESUMO

AIMS: To assess the relative risks of pelvic organ prolapse (POP) and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor voiding with Valsalva versus those using clean-intermittent catheterization (CIC). METHODS: We conducted a retrospective analysis including all spina bifida patients with neurogenic acontractile detrusor with a minimum follow-up of 12 months. Patients were then divided in two groups according to their bladder management: voiding with Valsalva versus CIC. The primary endpoint was any de novo or worsened rectal and/or pelvic organ prolapse (POP) diagnosed during follow-up. The secondary outcome was urinary complications defined as febrile urinary tract infections (UTI) and/or urolithiasis and/or renal failure. RESULTS: Fifty-five patients (50.9% were males) met the inclusion/exclusion criteria: 28 voiding with Valsalva and 27 performing CIC. At baseline, the rates of vaginal prolapse (44.4% vs 50%; P = 0.99), and rectal prolapse/intussusception (25.9% vs 21.4%; P = 0.76) were similar in both groups. After a median follow-up of 80.6 and 65.6 months, respectively (P = 0.29), the rate of de novo or worsened rectal prolapse/intussusception was higher in the Valsalva voiding group than in the CIC group (32.1% vs 3.7%; P = 0.01). De novo or worsened vaginal prolapses were also more common in the Valsalva voiding group, but it did not reach statistical significance (33.3% vs 11.1%; P = 0.29). CONCLUSIONS: Valsalva voiding might be harmful in adult spina bifida patients with neurogenic acontractile detrusor as it may increase the risk of rectal prolapse/intussusception. Overall, the prevalence of POP and rectal prolapse was high in both groups.


Assuntos
Cateterismo Uretral Intermitente/efeitos adversos , Disrafismo Espinal/complicações , Bexiga Urinaria Neurogênica/terapia , Bexiga Inativa/terapia , Infecções Urinárias/etiologia , Prolapso Uterino/etiologia , Adulto , Feminino , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Disrafismo Espinal/fisiopatologia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Inativa/complicações , Bexiga Inativa/fisiopatologia , Prolapso Uterino/complicações
18.
J Pediatr Urol ; 15(1): 35.e1-35.e8, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30314731

RESUMO

INTRODUCTION: Achieving continence in children with neurogenic sphincteric incompetence is a challenge. Awareness of the long-term outcome in this young patient population is important. In the past 25 years, the study institution has built experience in bladder outlet procedures such as bladder neck sling and bladder neck reconstructions. OBJECTIVE: The objective of this study was to evaluate the long-term outcome on continence and re-intervention rate of bladder outlet procedures in children with neurogenic urinary incontinence at the study institution. DESIGN: All children who underwent a bladder neck procedure between 1992 and 2017 at the study institution were retrospectively reviewed. Continence at the end of follow-up was the primary endpoint, defined as 'dry' when there was an interval of a minimum of 4 h without urinary leakage. Non-parametric tests were used for statistical analysis. RESULTS: During this 25-year period, a total of 60 children underwent a bladder outlet procedure, either a bladder neck sling (n = 43) or a bladder neck reconstruction (n = 17). The median age at surgery was 11.6 years (interquartile range [IQR] 7.8-13.9). Concomitant surgery consisted of bladder augmentation in 80% and continent catheterizable urinary channel in 97% of children. Dry rate within 1 year was 38%. After a median follow-up of 10.4 years (IQR 6.5-15.5), 77% of all children were dry. Twenty-five children (42%) needed one or more re-interventions, including redo of the bladder outlet procedure, other type of outlet procedure, bulking agents, bladder augmentation, and bladder neck closure. DISCUSSION: This study confirms that achieving continence is a challenge. The inconsistent use of the definition of urinary continence creates confusion in the literature and makes comparison of outcome with other studies difficult. Openness of (long-term) results in achieving urinary continence is important and helpful for future patients. CONCLUSION: On the long term, the majority of children with neurogenic urinary incontinence were dry after a bladder outlet procedure, but a considerable number of patients had a re-intervention. The initial outcome on continence was slightly disappointing. Reporting long-term results is essential and helpful for patient counseling.


Assuntos
Bexiga Urinaria Neurogênica/cirurgia , Bexiga Urinária/cirurgia , Incontinência Urinária/cirurgia , Adolescente , Criança , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Fatores de Tempo , Bexiga Urinaria Neurogênica/complicações , Incontinência Urinária/etiologia
19.
Low Urin Tract Symptoms ; 11(1): 66-71, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29024564

RESUMO

OBJECTIVE: The aim of the present study was to analyze treatment outcomes and identify videourodynamic factors predictive of successful urethral onabotulinumtoxinA treatment of neurogenic and non-neurogenic detrusor underactivity (DU). METHODS: Patients with DU refractory to medical treatment were treated with injections totaling 100 U onabotulinumtoxinA into the urethral sphincter. Treatment outcomes were assessed 1 month after treatment using the Global Response Assessment. The videourodynamic parameters evaluated included bladder neck status during voiding, bladder sensation, detrusor pressure, maximum flow rate, and post-void residual volume. Treatment outcome was analyzed by patient and baseline videourodynamic characteristics. RESULTS: In all, 60 patients (27 with non-neurogenic and 33 with neurogenic DU) were included in the study and received urethral sphincter injections of 100 U onabotulinumtoxinA in total. Good outcomes were reported in 36 (60%) patients (20 [74.1%] with non-neurogenic and 16 [48.5%] with neurogenic DU). Treatment outcome was significantly better in patients with non-neurogenic than neurogenic DU (P = .039). However, good treatment outcome was not related to age, gender, or any videourodynamic variables, except for an open bladder neck during voiding vs non-opening bladder neck (94.3% vs. 12.0%; P < .0001). The duration of the therapeutic effect was similar between patients with non-neurogenic and neurogenic DU (mean [± SD] 7.37 ± 3.69 vs. 7.69 ± 3.18 months, respectively; P = .788). In all, 12 patients reported de novo urinary incontinence after urethral onabotulinumtoxinA injection, 4 of whom developed stress urinary incontinence and 8 who had exacerbated urgency urinary incontinence. CONCLUSION: Urethral sphincter injection of onabotulinumtoxinA is effective in 60% of patients with DU. Careful videourodynamic interpretation of bladder neck opening enables urologists to select appropriate candidates for onabotulinumtoxinA treatment.


Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Bexiga Urinaria Neurogênica/tratamento farmacológico , Bexiga Inativa/tratamento farmacológico , Retenção Urinária/tratamento farmacológico , Agentes Urológicos/administração & dosagem , Idoso , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade , Uso Off-Label , Estudos Retrospectivos , Resultado do Tratamento , Uretra , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/fisiopatologia , Bexiga Inativa/complicações , Bexiga Inativa/fisiopatologia , Retenção Urinária/etiologia , Retenção Urinária/fisiopatologia , Urodinâmica/fisiologia , Gravação em Vídeo
20.
J Spinal Cord Med ; 42(4): 453-459, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-29485355

RESUMO

Context/Objective: to investigate the usefulness of classical homeopathy for the prevention of recurrent urinary tract infections (UTI) in patients with spinal cord injury (SCI). Design: prospective study. Setting: rehabilitation center in Switzerland. Participants: patients with chronic SCI and ≥3 UTI/year. Interventions: Participants were treated either with a standardized prophylaxis alone or in combination with homeopathy. Outcome measures: The number of UTI, general and specific quality of life (QoL), and satisfaction with homeopathic treatment were assessed prospectively for one year. Results: Ten patients were in the control group; 25 patients received adjunctive homeopathic treatment. The median number of self-reported UTI in the homeopathy group decreased significantly, whereas it remained unchanged in the control group. The domain incontinence impact of the KHQ improved significantly (P = 0.035), whereas the general QoL did not change. The satisfaction with homeopathic care was high. Conclusions: Adjunctive homeopathic treatment lead to a significant decrease of UTI in SCI patients. Therefore, classical homeopathy could be considered in SCI patients with recurrent UTI. Trial registration: ClinicalTrials.gov. (NCT01477502).


Assuntos
Homeopatia/métodos , Profilaxia Pré-Exposição/métodos , Traumatismos da Medula Espinal/terapia , Bexiga Urinaria Neurogênica/terapia , Infecções Urinárias/prevenção & controle , Adulto , Idoso , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/epidemiologia , Suíça/epidemiologia , Bexiga Urinaria Neurogênica/complicações , Bexiga Urinaria Neurogênica/epidemiologia , Infecções Urinárias/epidemiologia , Infecções Urinárias/etiologia , Adulto Jovem
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