ABSTRACT
Objective Sacral root neuromodulation is becoming one of the standard options for the treatment of intractable voiding dysfunction. The current report presents the urodynamic changes supporting the subjective improvement achieved by sacral root neuromodulation in patients with both voiding and storage problems. Patients and Methods Out of 50 patients being candidates for peripheral nerve evaluation (PNE) for various voiding and storage problems; 38 patients agreed to be subjected to urodynamics before; during and after subchronic PNE. Seventeen patients presented with an urgency-frequency syndrome; 9 with urge incontinence and 12 with chronic idiopathic urinary retention. All patients had failed to respond to various previous oral and intravesical treatments. The protocol included a four-day voiding diary and urodynamics before; during and after subchronic PNE. Results Significant changes in the urodynamic results of the patients during PNE were noted. Urodynamics of the urge incontinence and urgency-frequency patients showed an increased volume compared to the first urge cystometric bladder capacity after sacral root neuromodulation. The cystometrograms of patients with chronic idiopathic urinary retention did not show any difference during PNE when compared to the pre-PNE tests. Pressure-flow studies that were not possible before PNE became normalized during PNE. The urodynamics of all patients one week after PNE showed variable degrees of deterioration. The urodynamic findings of 7 patients who had an implantation of permanent programmers still showed the same results as after PNE testing. Conclusion There is a definite correlation between both subjective and objective improvement of patients on neuromodulation proved by urodynamic studies. However; this needs to be further evaluated as a predictor for success
Subject(s)
Urine , UrodynamicsABSTRACT
Objective To evaluate the impact of preoperative accelerated hyperfractionated radiotherapy in the management of bladder carcinoma in Egyptian patients. Patients and Methods Between December 1996 and February 2000; 104 Egyptian patients with pathologically proven infiltrative bladder carcinoma were enrolled in this prospective study. Patients with all pathological subtypes; non-metastatic disease; clinical stage T2-T4; and medically operable were eligible for this study. A total preoperative dose of 45 Gy was given in an overall time of 3 weeks; 1.5 Gy/fraction; 2 fractions/day with an interval of 6 hours in between; 5 days/week. Three weeks later; this was followed by radical cystectomy with pelvic node dissection. The clinical radiation response of the tumor was evaluated by C.T. scan done before irradiation and just before surgery. Only 56 patients completed this treatment program. The median follow-up was 26 months; ranging from 9 to 32 months. Results The actuarial 2-year disease-free survival (DFS) of the 56 patients was 63.9; with 50of failures due to pelvic recurrences. The univariate analysis revealed that only lymph node infiltration and pathological staging correlated significantly with DFS. There was a marginal insignificant improvement of DFS among patients who showed an increased tumor regression after radiotherapy. The multivariate analysis using the Cox model showed that lymph node affection is the only significant predictor for DFS. Other factors including age; sex; cell type; bilharzial infestation and clinical radiation response did not show a significant importance regarding the DFS. Minimal acute radiation toxicity with no late tissue reaction was observed among the whole group of patients. No increased operative difficulty related to irradiation nor an increased postoperative morbidity was found. Conclusion The potential biological advantage of this preoperative radiation schedule (in terms of a shorter overall duration of treatment; a shorter preoperative treatment period; a lower dose per fraction and an overall dose equivalent to conventional fractionation); aiming at an increased tumor regression and a decrease of late normal tissue reaction with its impact on DFS; remains to be further investigated with a larger number of patients and a longer follow-up