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1.
Chinese Journal of Urology ; (12): 414-422, 2021.
Article in Chinese | WPRIM | ID: wpr-911043

ABSTRACT

Objective:To assess the efficacy and safety of 100 units of botulinum toxin A (BTX-A) intradetrusor injection in patients with overactive bladder.Methods:From April 2016 to December 2018, 17 tertiary hospitals were selected to participate in this prospective, multicenter, randomized, double-blind, placebo-controlled study. Two phases of study were conducted: the primary phase and the extended phase. This study enrolled patients aged 18 to 75 years who had been inadequately managed by anticholinergic therapy (insufficient efficacy or intolerable side effects) and had spontaneous voiding with overactive bladder. Exclusion criteria included patients with severe cardiac, renal and hepatic disorders, patients with previous botulinum toxin treatment for 6 months or allergic to BTX-A, patients with urinary tract infections, patients with urinary stones, urinary tract tumors, diabetes mellitus, and bleeding tendency. Eligible patients were randomly assigned to BTX-A group and placebo control group in a ratio of 2∶1. Two groups of patients received 20 intradetrusor injections of BTX-A 100U or placebo at the depth of the submucosal muscle layer respectively under cystoscope, including 5 injections at the base of the bladder, 3 injections to the bladder triangle, 5 injections each to the left and right walls and 2 injections to the top, sparing the bladder neck. As a placebo control group, patients received same volume of placebo containing no BTX-A and only adjuvant freeze-dried preparations for injection with the same method. A combination of gelatin, sucrose, and dextran served as adjuvants. Average micturition times per 24 hours, urinary incontinence (UI) episodes per day, average micturition volume per day, OAB symptom score(OABSS), and quality of life (QOL) score were recorded at baseline and the 2nd, 6th and 12th week after treatment. The primary efficacy endpoint was the change from baseline in the average micturition times per 24 hours at the 6th week after treatment. The secondary efficacy endpoints included the change from baseline in the average micturition times per 24 hours at 2nd and 12th week, as well as the change from baseline in the OABSS, QOL score, average frequency of urgency and UI episodes per day, urgency score, average micturition volume per day at 2nd, 6th and 12th week after treatment. Patients were followed for 12 weeks to assess adverse events (AEs). After assessed at week 12, if the micturition times has decreased less than 50% compared to baseline and the patient is willing to receive retreatment, then patients could enter the extended trial phase. In that phase, patients in both groups were injected with 100 units BTX-A from 12th week onwards and then followed up the same indicators for 12 weeks.Results:216 patients were enrolled in this trial (144 cases in the BTX-A group and 72 cases in the placebo control group). Baseline characteristics such as age (47.75±14.20 in the BTX-A group and 46.39±15.55 in the control group), sex (25 male/117 female in the BTX-A group and 10/61 in the control group), and disease duration (0.51 years in the BTX-A group and 0.60 years in the control group) were balanced between the two groups( P>0.05). A marked reduction from baseline in average micturition times per 24 hours was observed in all treatment groups at the 6th week and the reduction of the two groups was statistically different ( P<0.001 and P=0.008 respectively). Compared with the baseline, the average micturition times per 24 hours at the 6th week decreased from baseline by 2.40(0.70, 4.60)times for the BTX-A group and 0.70(-1.00, 3.30) times for the placebo control group respectively, and the difference between the two groups was considered to be statistically significant ( P=0.003). The change rates of average micturition times per 24 hours from baseline at the 6th week of the two groups were (16±22)% and (8±25)% respectively, and the difference between the two groups was statistically significant ( P=0.014). Compared with the baseline, the average micturition times per 24 hours at 2nd and 12th week decreased by 2.00(0.00, 4.00)and 3.30(0.60, 5.03)for the BTX-A group, 1.00(-1.00, 3.00)and 1.70(-1.45, 3.85)for the placebo control group respectively. The difference between two groups was considered to be statistically significant ( P=0.038 and P=0.012); the changes of average urgency times per day for the BTX-A group and the control group at the 2nd, 6th and 12th week were 2.00(0.00, 4.30)and 2.40(0.30, 5.00), 3.00(0.30, 5.70)and 0.70(-1.30, 2.70), 0.70(-1.30, 3.00) and 1.35(-1.15, 3.50), respectively. There were significant differences between two groups at the 2nd, 6th and 12th week, ( P=0.010, P=0.003 and P=0.025, respectively). The OABSS of the BTX-A group and the control group at the 6th week decreased by 1.00(0.00, 4.00)and 0.50(-1.00, 2.00) compared with the baseline, and the difference between the two groups was statistically significant ( P=0.003). 47 cases of BTX-A group and 34 cases of placebo control group entered the extended trial phase, and 40 and 28 cases completed the extended trial phase, respectively. The average micturition volume per 24 hours changed by -16.60(-41.60, -0.60)ml and -6.40(-22.40, 13.30)ml, (-35.67±54.41)ml and(-1.76±48.69)ml, (-36.14±41.51)ml and (-9.28±44.59)ml, (-35.85±43.35)ml and(-10.41±40.29)ml for two groups at the 12th, 14th, 18th and 24th week, and the difference between two groups was statistically significant at each follow-up time ( P=0.01, 0.006, 0.012 and 0.016, respectively). There was no significant difference in other parameters( P>0.05). However, adverse reactions after intradetrusor injection included increased residual urine volume (27 in the BTX-A group and 3 in the control group), dysuria (21 in the BTX-A group and 6 in the control group), urinary infection (19 in the BTX-A group and 6 in the control group), bladder neck obstruction (3 in the BTX-A group and 0 in the control group), hematuria (3 in the BTX-A group and 1 in the control group), elevated alanine aminotransferase (3 in the BTX-A group and 0 in the control group), etc. During the follow-up period, there was no significant difference in the other adverse events between two groups except the increase of residual urine volume( P<0.05). In the primary trial phase, among the 27 cases with increased residual urine volume in BTA group, only 1 case (3.70%) with PVR more than 300 ml; the PVR of 3 patients in the placebo group was less than 100 ml. The increase of residual urine volume caused by the injection could be improved or disappeared with the passage of time. Conclusions:Intradetrusor injection of Chinese BTX-A improved the average micturition times per 24 hours, the average daily urgent micturition times, OABSS, and average micturition volume per time, and reduced the adverse effects in patients with overactive bladder.Chinese BTX-A at dose of 100U demonstrated durable efficacy and safety in the management of overactive bladder.

2.
Chinese Journal of Urology ; (12): 226-228, 2021.
Article in Chinese | WPRIM | ID: wpr-884993

ABSTRACT

It is important to investigate the mechanical effects of morphology of prostatic urethra (PU) for benign prostatic hyperplasia (BPH). PU and bladder neck transverse diameter ratio (RPU-1), which related to vortex, and their influence on urine flow were observed by CFD. The results showed that vortexes appeared and expanded with increasing RPU on both sides of PU when RPU-1>0.79, and velocity of external urethral orifice decreased gradually. CFD is an available method for urodynamics research. The quantitative simulation of the relationship between RPU-1 and vortex was proposed for the first time, providing a new idea for advancing theory of PU lumen repair in BPH.

3.
Chinese Journal of Urology ; (12): 724-730, 2020.
Article in Chinese | WPRIM | ID: wpr-869749

ABSTRACT

Objective:To investigate the 2 years’ efficacy of intravesical instillation of domestic BCG versus epirubicin in the prevention of recurrence of intermediate-risk or high-risk non-muscular invasive bladder cancer and predictive factors of BCG instillation.Methods:From July 2015 to June 2020, 18-75 years old patients with moderate to high-risk non muscle invasive bladder cancer (NMIBC) confirmed by pathological examination were involved. The ECOG score was 0-2. Exclusion criteria included ①immune deficiency or impairment (such as AIDS), using immunosuppressive drugs or radiotherapy, suspected allergic to BCG or epirubicin or excipients of the two drugs, fever or acute infectious diseases including active tuberculosis or receiving anti tuberculosis treatment, with severe chronic cardiovascular and cerebrovascular diseases or chronic kidney disease; ②combined with other urogenital system tumors or other organ tumors; ③combined with muscle invasive bladder urothelial carcinoma (≥T 2); ④undergoing chemotherapy, radiotherapy or immunotherapy within 4 weeks (immediate instillation after surgery not included); ⑤ pregnant or lactating women; ⑥ comfirmed or suspected bladder perforation; ⑦gross hematuria; ⑧cystitis with severe bladder irritation that may affect the evaluation; ⑨participat in other clinical trials within 3 months; ⑩alcohol or drug addiction; ?any risk factors that may increasing the risk of patients. Epirubicin 50 mg was irrigated immediately after the operation(TURBT or laser resection). The patients were randomly divided into BCG15 group, BCG19 group and epirubicin group by the ratio of 2∶2∶1, and the patients were maintained intravescical instillation for 1 year. The recurrence and adverse events of the three groups were compared. Univariate and multivariate analysis was performed to predict the risk factors of BCG irrigated therapy failure. Result:By June 15, 2020, the median follow-up duration was 22.1 months(12.1, 32.3), and there was no statistical difference between the groups ( P=0.9024). There were 274 patients enrolled in BCG19 group, 277 patients enrolled in BCG15 group and 130 patients enrolled in the epirubicin group. The drop-off rate was 16.6%(113 cases)and made no difference between groups( P=0.6222). There were no significant difference in age, gender, BMI, or ECOG score( P>0.05). During the follow-up, 116 cases was detected recurrence or progression. The recurrence rate of the three groups was 14.2% and 14.8% in BCG19 group and BCG15 group, and 27.7% in the epirubicin group. There was no difference in recurrence rate between BCG19 and BCG15 group( P=0.9464). The recurrence rate of BCG19 group was lower than that of the epirubicin group ( P=0.0017). The recurrence rate of BCG15 group was lower than that of the epirubicin group ( P=0.0020). There was no difference in the cumulative recurrence free survival rate between BCG19 and BCG15 group (95% CI0.57-1.46, P=0.7173). The cumulative recurrence free survival rate of BCG 19 group was better than that of the epirubicin group( HR=0.439, 95% CI0.26-0.74, P=0.0006), and the cumulative recurrence free survival rate of BCG15 group was better than that of the epirubicin group ( HR=0.448, 95% CI0.29-0.80, P=0.0021). The total incidence of adverse events in 19 BCG19, BCG15 and epirubicin group were 74.5%, 72.6% and 69.8% respectively. There was no difference in the incidence of adverse events between BCG19 and BCG15 group( P=0.6153). The incidence of adverse events in epirubicin group was lower than that of BCG19( P=0.0051) and BCG15( P=0.0167) groups.There was no significant difference in the incidence of serious adverse events (SAE) among the three groups ( P=0.5064). Log rank test univariate analysis and Cox risk regression model multivariate analysis showed that the history of bladder cancer recurrence( HR=6.397, 95% CI1.95-20.94, P=0.0001)was independent risk factor for BCG irrigation failure. Conclusions:The 2 years’ efficacy of intravesical instillation of domestic BCG is better than than of epirubicin with good tolerance and safety. There is no difference between BCG19 and BCG15 group. BCG doesn’t increase SAE compared with epirubicin. Recurrence status was an independent prognostic factor regarding recurrence-free survival.

4.
Chinese Journal of Geriatrics ; (12): 1024-1027, 2019.
Article in Chinese | WPRIM | ID: wpr-797884

ABSTRACT

Objective@#To assess the clinical effects of percutaneous electrical stimulation on refractory lower urinary tract symptoms in elderly female patients.@*Methods@#Elderly female patients with refractory lower urinary tract symptoms from July 2016 to December 2017 were recruited.According to cystoscopy results, patients were divided into an interstitial cystitis group, a suspected interstitial cystitis group and an overactive bladder group.All patients received 3 courses of transcutaneous low-frequency electrical stimulation treatment in the suprapubic bladder area, with 40 min per time, 4 times per day, 7 days per course.Bladder diaries, pain scores and overactive bladder symptom scores were recorded before and after treatment.@*Results@#A total of 27 patients with a mean age of 74.3 years were enrolled.Under the cystoscope with water dilatation, 9 cases were found to have mucosal bleeding, with mast cells detected in mucosal specimens examined via electron microscopy(in the interstitial cystitis group), 5 cases had superficial mucosal congestion(in the suspected interstitial cystitis group)and 13 cases showed normal imaging(in the overactive bladder group). In the interstitial cystitis group, the 24-h urinary frequency improved from 15.4±2.5 times before treatment to 11.9±2.0 times after treatment(P<0.05), but pain scores had no significant difference before and after treatment[(8.3±2.0) and (8.2±1.6), P>0.05]. In the suspected interstitial cystitis group, the 24-h urinary frequency improved from (11.8±1.5) times before treatment to (8.4±1.1) times after treatment, and pain scores decreased from (6.4±1.1) to (4.2±1.1)(P<0.05). In the overactive bladder group, the 24-h urinary frequency improved from (19.2±2.0) times before treatment to (15.9±1.3) times after treatment(P<0.05), and the overactive bladder symptom score(OABSS)decreased from (8.9±1.6) to (5.9±1.6)(P<0.05).@*Conclusions@#Percutaneous electrical stimulation is an easy, safe and effective treatment in elderly females with refractory lower urinary tract symptoms, and should be encouraged in clinical practice.

5.
Chinese Journal of Urology ; (12): 726-731, 2019.
Article in Chinese | WPRIM | ID: wpr-796743

ABSTRACT

Objective@#To explore the clinical feasibility and effectiveness of novel preoperative evaluating tool to achieve accurate and quantitative evaluation of renal vascular anatomy for retroperitoneoscopic radical nephrectomy (RLRN).@*Methods@#Two-hundred and fifty one consecutive patients who underwent RLRN for renal tumours from September 2016 to March 2018 were enrolled prospectively, including 154 males (61.4%) and 97 females (38.6%), aged 26 to 84 years with the mean age of 58.7 and mean BMI of 25.8 kg/m2. The tumors were all isolated with the mean size of 5.4 cm. According to presence or absence of vascular correlation events (VCE) and nephrectomy times under endoscope (NTE), all the cases were divided into two groups: the common group (VCE, NTE <60 min) and the difficult group (no VCE, NTE ≥60 min). With the help of preoperative three-dimensional reconstruction, the specific and crucial arteriovenous anatomical features were recorded, which consist of side, count, spatial configuration and density of the vessel to be processed. After univariable analysis, multivariable analysis with logistic regression was performed for the selected risk factors. Individualized reno-vasculature evaluation for nephrectomy were established, when the value of risk factors were assigned separately according to its correlation and clinical practice.@*Results@#There was no statistical significance between common group and difficult group in the aspects of gender, age, BMI, maximum diameter of the tumor, R. E.N.A.L. score and PADUA score. There were statistical significance between common group and difficult group in the aspects of N (number of total vessels), D (vascular anomalies density), C (3D conformation), S (sides) of pending renal vessels (χ2=125.700, 102.014, 97.090, 12.603, P<0.05). The correlation of N, D, C were closely related (standardized regression coefficient were 0.742, 0.664, 0.324, P<0.05), but S was not significant (P>0.05). SIREN was preliminarily established as a preoperative evaluating tool to achieve accurate and quantitative evaluation of renal vascular anatomy. Of the 5 components of SIREN, N, D were scored on 1 to 3 points, C was scored on 0 to 3 points, E was scored on 0 to 1 point, and S was not scored but showed in terms of L or R. All of these constitute the assessment content with a full score of 10 points except S suffixed by L or R instead of scores. There was a statistically significant difference during low (2-3 points), middle (4-6 points), and high (7-10 points) groups (χ2=126.927, P<0.05) according to the comparisons between low and middle, low and high, as well as middle and high (χ2=90.997, 7.195, 91.679, P<0.05).@*Conclusions@#In virtue of the renal vascular scoring system named after SIREN by 3d reconstructing, the spatial structure information of the renal vascular system can be obtained accurately and expressed directly before operation, the difficulty of vascular treatment can be predicted, the preoperative planning can be optimized, and the accurate quantitative evaluation of renal vascular anatomical structure can be achieved to further improve the surgical safety and efficiency.

6.
Chinese Journal of Urology ; (12): 485-491, 2019.
Article in Chinese | WPRIM | ID: wpr-755476

ABSTRACT

Objective To investigate the efficacy and safety of intravesical instillation of BCG vaccine in the prevention of early recurrence of middle and high risk non-muscle invasive bladder cancer.Methods From July 2015,patients with non-muscle invasive bladder cancer aged 18-75 years with informed consent were screened and underwent transurethral resection of bladder tumor (TURBT).Immediately intravesical instillation of epirubicin 50 mg was given postoperatively.After pathology was comfirmed,patients was enrolled in group 1 (BCG15) or group 2 (BCG 19) or the control group (epirubicin 18) randomly with SAS 9.3 software.Data of follow-up and Adverse event was collected and analyzed.Results By May 31,2019,531 patients were enrolled in the study.The drop-off rate was 20.1%.167 patients (143 males and 24 females)in group 1,172 patients (141 males and 31 females)in group2 and 84(75 males and 9 females) in the control group with follow-up data were analyzed.There were no significant differences in age,gender,BMI,ECOG score,risk stratification between the three groups (P =0.8641,P =0.2906,P =0.9384,P =0.6126).The median follow-up time makes no statistical difference between the groups (P =0.9251),12.0 (6.0,22.5) months,13.0 (6.0,22.3) months,and 13.0 (7.0,22.3) months.The median recurrence time of the three groups was 4.0 (3.0,6.0) months,4.5 (3.0,9.8) months,4.5 (3.0,8.8) months.There was no statistical difference between the three groups (P =0.2852).Risk stratification in the patients got no significant difference between the three groups (P > 0.05).The 1-year recurrence-free survival rates were 80.0% in the group 1 and 88.3% in the group 2 and 73.7% in the control group.The group 2 was superior to the group 1 and the control group (P =0.0281,P =0.0031).There was no significant difference between group 1 and control group (P =0.2951).There was no significant difference in the cumulative recurrence-free survival between the experimental group 1 and the experimental group 2,(95% CI 0.80-2.43,P =0.2433).The cumulative recurrence-free survival in the group 1 and the group 2 was better than the control group (95 % CI 0.31-0.92,P =0.0266;95 % CI 0.20-0.65,P =0.0008).All the cases underwent instillation were analyzed for adverse events.The incidence of overall AE(adverse events) in group 1 was 68.5% (152/222),the incidence of grade Ⅰ-Ⅱ AE was 53.2% (118/222),the incidence of grade Ⅲ-Ⅳ AE was 15.3% (32/222).The incidence of overall AE in the group 2 was 71.8% (160/223),the incidence of grade Ⅰ-Ⅱ AE was 60.1% (134/223),and the incidence of grade Ⅲ-Ⅳ AE was 11.7% (26/223).The overall AE rate in the control group was 53.2% (59/111),of which the incidence of grade Ⅰ-Ⅱ AE was 42.4% (47/111),and the incidence of grade Ⅲ-Ⅳ AE was 10.8% (12/111).There was no difference in the incidence of overall AE between the group 1 and the group 2 (P =0.4497).The incidence of AE in the two experimental groups was higher than that in the control group (P =0.0062,P =0.0008).There was no difference in the incidence of grade Ⅲ-Ⅳ AE between the three groups (P =0.3902).Conclusions BCG(19 instillation schedule) has a better effect on preventing recurrence after 1 year of bladder surgery,which is superior to epirubicin group.The long-term efficacy of BCG in preventing recurrence and the efficacy of different schedules need to be further followed up.The lower urinary tract symptoms,which are mainly urinary frequency,are one of the causes of case fallout and should be fouced in future.Compared with epirubicin,BCG perfusion does not increase the incidence of grade Ⅲ-Ⅳ adverse reactions,and is safe to use.

7.
Chinese Journal of Urology ; (12): 726-731, 2019.
Article in Chinese | WPRIM | ID: wpr-791675

ABSTRACT

Objective To explore the clinical feasibility and effectiveness of novel preoperative evaluating tool to achieve accurate and quantitative evaluation of renal vascular anatomy for retroperitoneoscopic radical nephrectomy (RLRN).Methods Two-hundred and fifty one consecutive patients who underwent RLRN for renal tumours from September 2016 to March 2018 were enrolled prospectively,including 154 males (61.4%) and 97 females (38.6%),aged 26 to 84 years with the mean age of 58.7 and mean BMI of 25.8 kg/m2.The tumors were all isolated with the mean size of 5.4 cm.According to presence or absence of vascular correlation events (VCE) and nephrectomy times under endoscope (NTE),all the cases were divided into two groups:the common group (VCE,NTE < 60 min)and the difficult group (no VCE,NTE ≥ 60 min).With the help of preoperative three-dimensional reconstruction,the specific and crucial arteriovenous anatomical features were recorded,which consist of side,count,spatial configuration and density of the vessel to be processed.After univariable analysis,muhivariable analysis with logistic regression was performed for the selected risk factors.Individualized renovasculature evaluation for nephrectomy were established,when the value of risk factors were assigned separately according to its correlation and clinical practice.Results There was no statistical significance between common group and difficult group in the aspects of gender,age,BMI,maximum diameter of the tumor,R.E.N.A.L.score and PADUA score.There were statistical significance between common group and difficult group in the aspects of N (number of total vessels),D (vascular anomalies density),C (3Dconformation),S (sides) of pending renal vessels (x2 =125.700,102.014,97.090,12.603,P <0.05).The correlation of N,D,C were closely related (standardized regression coefficient were 0.742,0.664,0.324,P < 0.05),but S was not significant (P > 0.05).SIREN was preliminarily established as a preoperative evaluating tool to achieve accurate and quantitative evaluation of renal vascular anatomy.Of the 5 components of SIREN,N,D were scored on 1 to 3 points,C was scored on 0 to 3 points,E was scored on 0 to 1 point,and S was not scored but showed in terms of L or R.All of these constitute the assessment content with a full score of 10 points except S suffixed by L or R instead of scores.There was a statistically significant difference during low (2-3 points),middle (4-6 points),and high (7-10 points) groups (x2 =126.927,P < 0.05) according to the comparisons between low and middle,low and high,as well as middle and high (x2 =90.997,7.195,91.679,P < 0.05).Conclusions In virtue of the renal vascular scoring system named after SIREN by 3d reconstructing,the spatial structure information of the renal vascular system can be obtained accurately and expressed directly before operation,the difficulty of vascular treatment can be predicted,the preoperative planning can be optimized,and the accurate quantitative evaluation of renal vascular anatomical structure can be achieved to further improve the surgical safety and efficiency.

8.
Chinese Journal of Geriatrics ; (12): 1024-1027, 2019.
Article in Chinese | WPRIM | ID: wpr-791620

ABSTRACT

Objective To assess the clinical effects of percutaneous electrical stimulation on refractory lower urinary tract symptoms in elderly female patients.Methods Elderly female patients with refractory lower urinary tract symptoms from July 2016 to December 2017 were recruited.According to cystoscopy results,patients were divided into an interstitial cystitis group,a suspected interstitial cystitis group and an overactive bladder group.All patients received 3 courses of transcutaneous low-frequency electrical stimulation treatment in the suprapubic bladder area,with 40 min per time,4 times per day,7 days per course.Bladder diaries,pain scores and overactive bladder symptom scores were recorded before and after treatment.Results A total of 27 patients with a mean age of 74.3 years were enrolled.Under the cystoscope with water dilatation,9 cases were found to have mucosal bleeding,with mast cells detected in mucosal specimens examined via electron microscopy(in the interstitial cystitis group),5 cases had superficial mucosal congestion (in the suspected interstitial cystitis group)and 13 cases showed normal imaging(in the overactive bladder group).In the interstitial cystitis group,the 24-h urinary frequency improved from 15.4 ± 2.5 times before treatment to 11.9 ± 2.0 times after treatment (P <0.05),but pain scores had no significant difference before and after treatment[(8.3±2.0) and (8.2±1.6),P>0.05].In the suspected interstitial cystitis group,the 24-h urinary frequency improved from (11.8 ± 1.5) times before treatment to (8.4±1.1) times after treatment,and pain scores decreased from (6.4±1.1) to (4.2±1.1) (P<0.05).In the overactive bladder group,the 24-h urinary frequency improved from (19.2±2.0) times before treatment to (15.9 ± 1.3) times after treatment(P <0.05),and the overactive bladder symptom score(OABSS)decreased from (8.9±1.6) to (5.9±1.6)(P<0.05).Conclusions Percutaneous electrical stimulation is an easy,safe and effective treatment in elderly females with refractory lower urinary tract symptoms,and should be encouraged in clinical practice.

9.
Article in Chinese | WPRIM | ID: wpr-700337

ABSTRACT

Objective To evaluate the feasibility and safety of simultaneous flexible ureteroscopic in the treatment of bilateral upper urinary tract stones from systemic stress response and immune function changes. Methods Sixty bilateral upper urinary tract stones patients who had underwent flexible ureteroscopic lithotripsy (FURL) from December 2015 to December 2017 were selected. The patients were divided into simultaneous FURL treated bilateral upper urinary tract stones (group A, 29 cases) and FURL treated unilateral upper urinary tract stones (group B, 31 cases) according to the treatment method. The perioperative period indexes were recorded. The serum epinephrine (E), norepinephrine (NE), cortisol and peripheral blood T lymphocyte subsets 1 d before operation and 1, 3, 5 d after operation were detected. Results There were no statistical differences in length of stay in hospital, incidence of postoperative complications and stone clearance rate between 2 group (P>0.05). The operating time in group A was significantly longer than that in group B: (108.3 ± 11.5) min vs. (86.9 ± 13.3) min, and there was statistical difference (P<0.05). There was no statistical differences in serum E, NE, cortisol and peripheral blood CD3+, CD4+, CD8+, CD4+/CD8+ during perioperative period between 2 groups (P>0.05). The E, NE and cortisol levels only 1 d after operation in 2 groups were significantly higher than those before operation, and there were statistical differences (P<0.05); there were no statistical difference between 3 d after operation and before operation (P>0.05). Compared with those before operation, the peripheral blood CD3+, CD4+and CD4+/CD8+levels 1 and 3 d after operation in 2 groups were significantly lower, the CD8+ was significantly higher, and there were statistical differences (P<0.05); compared with those 1 d after operation, the peripheral blood CD3+, CD4+and CD4+/CD8+levels 3 d after operation in 2 groups were significantly higher, the CD8+was significantly lower, and there were statistical differences (P<0.05); There were no statistical differences in peripheral blood CD3+, CD4+, CD8+and CD4+/CD8+ levels in 2 groups between 5 d after operation and before operation (P>0.05). Conclusions It is feasible, safe and effective to perform simultaneously flexible ureteroscopic for bilateral upper urinary tract calculi patients. And this treatment will not increase the risks of transient adrenal dysfunction and immunosuppression.

10.
Cancer Research and Clinic ; (6): 312-314,323, 2018.
Article in Chinese | WPRIM | ID: wpr-712819

ABSTRACT

Objective To compare the safety, efficacy, intraoperative and postoperative outcomes between retro-laparoscopic partial nephrectomy with robotic-assisted laparoscopic (RA-RLPN) and three-dimensional laparoscopic systems(3D-RLPN).Methods Between May 2017 and November 2017,53 patients with cT1-staged renal mass underwent RLPN with two different systems in the First Hospital of Shanxi Medical University. Twenty-eight patients underwent RA-RLPN and twenty-five patients underwent 3D-RLPN. The safety, efficacy, intraoperative and postoperative outcomes were retrospectively analyzed between the two groups. Results All the operations were technically successful. Mean operating room time [(82±18) min vs. (105±5)min,t=4.958,P <0.001)],mean renal artery clamping time[(14.6±2.9)min vs. (18.4±3.5) min,t =5.616, P < 0.001] and postoperative hospitalization [(6.6±1.4) d vs. (7.2±1.5) d, t=2.647, P = 0.021] in RA-RLPN group were shorter than those in 3D-RLPN group. The estimated blood loss was reduced in RA-RLPN group compared with 3D-RLPN group [(60±20) ml vs. (76±24) ml, t= 2.958, P = 0.012]. The postoperative hospital stay in RA-RLPN group was shorter than that in 3D-RLPN group[(6.6±1.4) d vs. (7.2± 1.5) d, t= 2.647, P = 0.021)]. There were no significant differences in the postoperative complications and positive pathological margin incidence between the two groups(both P >0.05).Conclusions RA-RLPN, as a promising surgical technique, is a feasible and safe procedure associated with better intraoperative parameters and short-term effect.It is worthy of clinical application.

11.
Chinese Journal of Urology ; (12): 930-934, 2018.
Article in Chinese | WPRIM | ID: wpr-734559

ABSTRACT

Objective To explore the method and clinical value of sentinel lymph node biopsy for penile carcinoma guided by multispectral separate-merge guided surgery device (MGS).Methods The clinical data of 7 patients with sentinel lymph node biopsy of penile cancer guided by MGS from April 2017 to April 2018 were analyzed retrospectively at First Hospital of Shanxi Medical University.They were 62-78 years old,with an average age of 65 years.All of carcinoma was located in the glans or coronal sulcus,which diameter was 1.0-3.5 cm,with an average of 2.5 cm.Three cases of inguinal lymph nodes could be non-palpable and the others palpable.All patients were injected 0.25 ml (2.5 mg/ml) of indocyanine greensolution with 1 ml syringe at 12,4,6 and 9 points in the proximal normal skin of penile tumors.Immediately,the imaging probe was aligned with the injection point to observe the dynamic changes of fluorescence image on MGS display.Results There were 14 sides of groin in 7 patients,except for 1 side without images,other 13 sides developed well.The images displayed by MGS include visible image,fluorescent image and merged image,and the merged image was green pseudo color.According to the dynamic changes of the image,it could be divided into five parts:injection point,penile body,pubic symphysis,inguinal region and sentinel lymph node.In 13 well-developed sides,fluorescence gradually disappeared in other parts about 15 minutes after injection,and the location of sentinel lymph nodes was determined in vitro by gradually consolidating and fixing the fluorescence images in the inguinal region.The lymph node-like tissue with strong fluorescence intensity was observed immediately after the skin incision.There was a clear boundary between the lymph node-like tissue and the surrounding tissue.Along this boundary,lymph nodes were separated,ligated,excised.No lymph nodes were found on the undetected side.Postoperative pathology confirmed that lymph nodes were located by fluorescence imaging in vitro and traced by fluorescence imaging in vivo,the coincidence rate was 100%.There were residual fluorescent tissues on three sides and lymphatic vessels were removed.Conclusions MGS-assisted intraoperative fluorescence imaging could improve the doctor's visual depth so that physicians can real-time,dynamic,accurate in vitro location and in vivo tracking of sentinel lymph nodes of penile cancer.

12.
Chinese Journal of Urology ; (12): 900-904, 2018.
Article in Chinese | WPRIM | ID: wpr-734553

ABSTRACT

Objective To investigate the significance of mast cells activation,and IL-6,IL-10,sialic acid-binding immunoglobulin-like lectins 8 (Siglec-8) expression in interstitial cystitis/bladder pain syndrome.Methods Bladder mucosal biopsy tissues of 21 patients with IC/BPS admitted to our hospital from March 2016 to October 2017 were taken as the IC/BPS group,and normal bladder mucosa biopsy tissues of 9 patients who underwent ureteroscopy were taken as the control group.In the IC/BPS group,there were 3 males and 18 females aged (56.2 ± 3.4) years,and the patients'pain symptom score (PUF) was (24.6 ± 3.6).Four males and five females in the control group were aged (63 ± 5.1) years.The infiltration of bladder mucosa mast cells and plasma cells in IC/BPS group and control group was observed by transmission electron microscopy.The expression of IL-6,IL-10 and Siglec-8 were detected by immunohistochemical staining.The relationship between the expression level of the immune index and the PUF score was analyzed.Results In the IC/BPS group,mast cells and plasma cells was observed in 18 of the 21 cases,but no mast cells or plasma cells were observed in the control group.Expression of IL-6 in IC/BPS group 1 case (-),11 cases(+) and 9 cases (+ +).IL-6 expression in the control group 9 cases were all (-).The difference of IL-6 expression between the IC/BPS group and the control group was statistically significant (P =0.001).Expression of IL-10 were 3 cases (-),7 cases (+ +),11 cases (+ +) in IC/BPS group,while 7 cases (-),2 cases (+ +),and 0 cases (+ +)in the control group,and there was significant difference between the two group (P =0.001).In the IC/BPS group,expression of Siglee-8 were 12 cases (-),5 (+),4 (+ +),while in control group 7 cases (-),2 (+),and 0 (+ +),no statistically significant difference was found between the two group (P =0.214).The PUF score of the patients with IL-10 expression (-) was 19.7 ± 2.1,lower than those with IL-10 (+ +) (27.1 + 2.5,P < 0.001).PUF of patients with IL-10 (+) was 22.7 ± 1.8,lower than those with (+ +) (P =0.001).The PUF score of IL-6 expression (-) was 21.The PUF score of IL-6 expression (+) was (23.2 + 3.2),lower than (+ +) (26.7 + 3.1,P =0.025).The PUF score of (+ +) IC/BPS patients was (26.6 ± 2.4),higher than that of (+) IC/BPS patients (21.5 ± 2.1,P < 0.0 l).The PUF score of Siglec-8 expression (+ +) and (+) in IC/BPS group was (21.3 ± 2.0),lower than that of Siglec-8 (-) (27.0 ± 2.3,P < 0.0l).Conclusions Mast cells and plasma cells were expressed in IC/BPS tissues.The expression of IL-6 and IL-10 was positively correlated with clinical symptoms,while the expression of Siglec-8 was negatively correlated with clinical symptoms.

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Chinese Journal of Urology ; (12): 57-60, 2017.
Article in Chinese | WPRIM | ID: wpr-667267

ABSTRACT

Objective To study the expression and significance of CD68 and TGF-β2 in benign prostatic hyperplasia(BPH).Methods The immunohistochemistry PV two step method was used to detect the expression level of CD68 and TGF-β2 in 90 cases of benign prostatic hyperplasia and combined with clinical data were analyzed.Results Positive rate of CD68 as macrophages marker was 86%(77/90) in the epithelial cells,positive rate of TGF-β2 as transforming growth factor marker was 79%(71/90) in epithelial cells and stromal cells. Immune inlfammation mediated by macrophages,with coloring degree deepening,the degree of immune inlfammation increased,larger prostate volume(P<0.01),IPSS score higher (P<0.01),maximum urinary lfow rate lower(P<0.01),the dffierences between groups were statistically significant.Conclusions This point may indicate immune inlfammation play an important role in the development process of BPH and help to complete the pathogenisis theory.

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Chinese Journal of Urology ; (12): 782-785, 2017.
Article in Chinese | WPRIM | ID: wpr-662112

ABSTRACT

Objective To analyze the overactive bladder symptom score (OABSS) in evaluating bladder dysfunction in the different stages among type 2 diabetes mellitus patients,and to explore the value of bladder hyperactivity symptom score in screening early diabetic bladder dysfunction.Methods A total of 1 157 patients with type 2 diabetes mellitus,aged 40-88 yearswith mean age of 60.2 years,were enrolled from October 2013 to October 2016.The survey included the patients' characteristics,past history,current history,OABSS and quality of life (QOL) index scores.T test,single factor analysis of variance and multiple regression analysis are used to analyze the results.Results As many as 1 157 were qualified for final statistical analysis.OABSS is 1.94 ± 1.23 in group with diabetes duration < 10 years,3.24 ± 1.45in group with diabetes duration 10-20 years,and 4.00 ± 1.72 in group with diabetes duration > 20 years.The differences of OABSS in the different duration of diabetes was statistically significant.As diabetic duration increased,OABSS value increased (F =48.419,P < 0.001).The difference of OABSS in the different HbA1c level,age and concurrent peripheral neuropathy was statistically significant.There was no significant difference of OABSS in the different BMI and distinct therapies.There was no significant difference of OABSS in diabetes with hypertension and without hypertension,with cardiopathy and without cardiopathy,with cerebrovascular disease (CVD) and without CVD,with hyperhpemia and without hyperlipemia.The significant factors were used to make multivariate analysis.The results showed that the duration of diabetes,HbA1 c level,age,peripheral neuropathy were still statistically significant.Standardized partial regression coefficient of diabetic duration was 0.366.OABSS was positively correlated with QOL score (r =0.434,P < 0.001).Conclusions The related symptoms in OABSS with diabetic bladder dysfunction is correlated with the duration of diabetes,HbA1c level,age,concurrent peripheral neuropathy among type 2 diabetes.The duration of diabetes was the most significant factor.OABSS is likely to be one of the tools to assess the early symptoms of diabetic bladder dysfunction.

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Chinese Journal of Urology ; (12): 782-785, 2017.
Article in Chinese | WPRIM | ID: wpr-659419

ABSTRACT

Objective To analyze the overactive bladder symptom score (OABSS) in evaluating bladder dysfunction in the different stages among type 2 diabetes mellitus patients,and to explore the value of bladder hyperactivity symptom score in screening early diabetic bladder dysfunction.Methods A total of 1 157 patients with type 2 diabetes mellitus,aged 40-88 yearswith mean age of 60.2 years,were enrolled from October 2013 to October 2016.The survey included the patients' characteristics,past history,current history,OABSS and quality of life (QOL) index scores.T test,single factor analysis of variance and multiple regression analysis are used to analyze the results.Results As many as 1 157 were qualified for final statistical analysis.OABSS is 1.94 ± 1.23 in group with diabetes duration < 10 years,3.24 ± 1.45in group with diabetes duration 10-20 years,and 4.00 ± 1.72 in group with diabetes duration > 20 years.The differences of OABSS in the different duration of diabetes was statistically significant.As diabetic duration increased,OABSS value increased (F =48.419,P < 0.001).The difference of OABSS in the different HbA1c level,age and concurrent peripheral neuropathy was statistically significant.There was no significant difference of OABSS in the different BMI and distinct therapies.There was no significant difference of OABSS in diabetes with hypertension and without hypertension,with cardiopathy and without cardiopathy,with cerebrovascular disease (CVD) and without CVD,with hyperhpemia and without hyperlipemia.The significant factors were used to make multivariate analysis.The results showed that the duration of diabetes,HbA1 c level,age,peripheral neuropathy were still statistically significant.Standardized partial regression coefficient of diabetic duration was 0.366.OABSS was positively correlated with QOL score (r =0.434,P < 0.001).Conclusions The related symptoms in OABSS with diabetic bladder dysfunction is correlated with the duration of diabetes,HbA1c level,age,concurrent peripheral neuropathy among type 2 diabetes.The duration of diabetes was the most significant factor.OABSS is likely to be one of the tools to assess the early symptoms of diabetic bladder dysfunction.

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Chinese Journal of Urology ; (12): 127-130, 2017.
Article in Chinese | WPRIM | ID: wpr-505249

ABSTRACT

Objective To evaluate the feasibility and effectiveness of full-size three-dimensional individual printed model (3D-IPM) for improving the patient's understanding of laparoscopic partial nephrectomy (LPN) preoperatively.Methods Between June 2015 and June 2016,37 patients with cT1 renal tumors underwent retroperitoneal LPN.The 3D individual digital models (3D-IDMs) were created using 3D medical image reconstructing and guiding system (3D-MIRGS) and the full-size 3D-IPMs were fabricated correspondingly.For each patient and his/her closest accompanying immediate family member (CAIFM),two preoperative conversations with a single surgeon were held by using patient's CT films,the entity of 3D-IPM combined with 3D-IDM demonstration separately.The preoperative levels of comprehension to the renal anatomy,mass characteristics,the upcoming PN procedure,potential complication risks and postoperative prognosis were evaluated using a self-made scoring questionnaire in the patient and CAIFM groups.Results All the fabrications of full-size 3D-IPMs were technically successful.Both in patient and CAIFM groups,the total preoperative comprehending score (total-PCS) elevated significantly by presenting 3D-IPM combined with 3D-IDM demonstration than CT films (42.7 vs.31.5 in patient group,P < 0.05;44.6 vs.33.1 in CAIFM group,P < 0.05).Sub-PCSs in all 5 aspects also showed a uniformed climbing pattern with the assistance of 3D-IPM combined with 3D-IDM demonstration rather than CT films.Conclusion The application of 3D-IPM combined with 3D-IDM demonstration can improve the preoperative comprehension of the patient and CAIFM to LPN with more intuitionistic and verisimilar presentation.

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Article in Chinese | WPRIM | ID: wpr-480780

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Objective To investigate the clinical efficacy of pancreaticoduodenectomy (PD) and duodenumpreserving pancreatic head resection (DPPHR,including Beger,Frey and Berne procedures)for the treatment of chronic pancreatitis (CP) with mass in the head of the pancreas.Methods The clinical data of 48 patients with CP who were admitted to the Armed Police Corps Hospital of Hunan province(13) and the Third Xiangya Hospital of Central South University (35) between January 2007 and December 2013 were retrospectively analyzed.The operation methods were selected according to clinical symptoms,imaging findings and intraoperative pathological examinations.Twenty-three patients receiving PD (Whipple procedure or pylorus-preserving PD) were allocated into PD group and 25 receiving DPPHR (Beger,Frey and Berne procedures) were allocated into DPPHR group.The operation time,volume of intraoperative blood loss,rate of postoperative pain relief,changes of pancreatic endocrine and exocrine function,complications,duration of hospital stay and hospital expenses in the 2 groups were analyzed.Patients were followed up by telephone interview and outpatient examination up to September 2014.Measurement data with normal distribution were presented as (x) ± s.Comparison between groups was analyzed using the t test.Count data were analyzed using chi-square test or Fisher exact probability.Results Of the 23 patients in the PD group,15 patients received Whipple procedure and 8 patients received pylorus preserving PD.Of 25 patients in the DPPHR group,8 patients received Beger procedure,13 patients received Frey procedure and 4 patients received Berne procedure.The operation time and volume of intraoperative blood loss were (5.5 ± 0.4) hours,(372 ± 174) mL in the PD group,and (4.2 ± 0.6) hours,(272 ± 114) mL in the DPPHR group,showing significant differences between the 2 groups (t =8.712,2.375,P < 0.05).Three patients had massive hemorrhage in the PD group and 2 patients receiving Beger procedure had massive hemorrhage due to portal vein injury,with no significant difference (x2=0.010,P > 0.05).The intraoperative pathologic examinations of frozen section showed chronic inflammation in all pancreatic tissue samples with fibrous tissue proliferations.Overall pain relief rate was 95.7% (22/23) in the PD group,including 20 complete remissions and 2 partial remissions,and overall pain relief rate was 92.0% (23/25) in the PD group,including 18 complete remissions and 5 partial remissions,which were no different in overall pain relief rate (x2 =0.000,P > 0.05).The morbidity of postoperative diabetes mellitus and dyspepsia with fatty diarrhea were 38.9% (7/18) and 35.7% (5/14) in the PD group,which were no different from 9.5% (2/21) and 20.0% (3/15) in the DPPHR group (x2=3.200,0.281,P >0.05).The incidence of postoperative complication was 30.4% (7/23) in the PD group,including 1 case of intra-abdominal hemorrhage,pancreatic fistula and localized peritonitis,1 case of pancreatic fistula,2 cases of biliary fistula,3 cases of delayed gastric emptying.Patients with pancreatic fistula and biliary fistula recovered after 1-week sufficient drainage.The incidence of postoperative complication was 4.0% (1/25) in the DPPHR group,including 1 case of pancreatic fistula,showing significant difference in incidence of postoperative complication (x2=4.274,P < 0.05).The duration of postoperative stay and hospital expense were (12.4 ± 2.5) days and (57 751 ± 6 772) yuan in the PD group,which were significantly different from (8.2 ± 1.8) days and (49 109 ± 6 168)yuan in the DPPHR group (t =6.576,4.645,P < 0.05).Forty-eight patients were followed up with a median time of 51.6 months (9.0-92.0 months).Of the 2 patients died,1 patient who underwent Frey procedure died 3 months after diagnosis of pancreatic cancer due to epigastric pain at postoperative month 6,the other died 2 years later due to cardiovascular disease.Among 48 patients with follow-up,1 received biliary-intestine drainage 6 months later and other patients had no recurrence or canceration.Conclusions DPPHR is safe and effective for chronic pancreatitis with mass in the head of the pancreas,having advantages such as shorter duration of operation,less intraoperative hemorrhage,faster postoperative recover,shorter duration of hospital stay and delayed hypofunction of pancreatic endocrine and exocrine function.But DPPHR cannot completely replace PD,It is necessary to master indications for all kinds of operations and choose proper operative approaches based on lesion characteristics.

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Chinese Journal of Urology ; (12): 819-823, 2014.
Article in Chinese | WPRIM | ID: wpr-469861

ABSTRACT

Objective To explore the imaging characteristics and clinical value of multispectral cystoscopy.Methods From May 2011 to May 2013,31 male and 4 female patients were included in this study,including benign prostatic hyperplasia in 14 patients,bladder tumor in 16 patients,upper urinary tract disease alone in 5 patients.The mean age in this group was 56 years (range 43 to 84 years).All patients accepted the bladder CT scan for diagnosis.TURBT procedure and pathological examination were performed in those patients with bladder tumor.Under the epidural anesthesia,the 27 F resectoscope was inserted to bladder through the urethra.Then,the conventional light source was replaced by multispectral endoscope light source.The white light,UV-light (401.0 nm),blue light (467.6 nm),green light (534.2nm),red light (660.6 nm),and near-infrared light (763.8 nm) were used,subseqently.Meanwhile,the following data were recorded,such as the visibility of bladder cavity,the color of bladder tumors and bladder mucosa,the density of blood vessels,three-dimensional structure of blood vessels,the mobility between mucosa and submucosa.Results When UV-light and near-infrared light irradiated bladders,there were not any imaging on monitor.However,the bladder mucosa and submucosa blood vessels were showed clearly and constituted the three-dimensional blood vessel network when using green light.The density of blood vessels in mucosal and submucosal layer was increased but less clarity when using blue light.The mucosal surface was covered in red when using red light,which vascular and mucosal can not able to be distinguished.Among 16 patients who were accepted the TURBT procedure,seven cases with T1 stage tumors were resected to the submucosa by TURBT.The superficial muscle layer with integrity structure could be observed under white light.While,blood vessels were not appeared when using green light.In six cases with Ta stage tumors,the clear connection of blood spots between mucous blood vessels and the blood vessel from the tumor could be observed under the green-light conditions.In three patients with Tis stage tumors,the mucosal blood vessels were normal under the white-light after tumor resection.However,structural disorder could be found under the green-light,which should be highly suspected as Tis stage tumors.Conclusions Without any photosensitizer or fluorescent dye,tumor blood vessels and bladder mucosal vascular can be showed under the green light.This technique is useful for identify the minimal tumor and evaluate the carcinoma infiltrated depth.

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Chinese Journal of Urology ; (12): 771-773, 2014.
Article in Chinese | WPRIM | ID: wpr-469854

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Objective To compare the diagnostic accuracy of conventional urodynamic (CUD) and ambulatory urodynamic monitoring (AUM) in diagnosis of female stress urinary incontinence (SUI).Methods Forty women with SUI were prospectively enrolled and performed urodynamic studies after the ICI-Q-SF questionnaire.According to clinical symptoms,patients were divided into three groups:mild,moderate and severe group.Half patients in each groups performed CUD exam,and the other half of patients performed AUM exam.And two micturition cycles were recorded during AUM.Results There were no significant differrences in age,pregnant production times and ICI-Q-SF score between two groups.Three patients with SUI symptoms had negative findings in AUM group and 15 patients in CUD group (P<0.05).Among women with SUI,1 1 patients had positive findings in AUM group and 2 patients in CUD group (P< 0.05).Conclusion AUM can provide objective evidence for the majority of patients with SUI than CUD.

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Chinese Medical Journal ; (24): 261-265, 2014.
Article in English | WPRIM | ID: wpr-318003

ABSTRACT

<p><b>BACKGROUND</b>Overactive bladder (OAB) is a series of symptoms with high prevalence in elderly people. This study was conducted using the overactive bladder symptom score (OABSS) to evaluate the efficacy of solifenacin succinate for the treatment of OAB.</p><p><b>METHODS</b>This was a prospective, multicenter, single-arm, 12-week study that enrolled 241 OAB patients. The patients received 5-10 mg/day solifenacin. Changes in OABSS, symptoms from voiding diary, perception of bladder condition (PPBC) score, international prostate symptom score (IPSS) and quality of life (QOL) were evaluated at weeks 0, 4, and 12. The relationship between OABSS and PPBC score or parameters of voiding diary was also evaluated.</p><p><b>RESULTS</b>At baseline, the mean OABSS for all patients was 9.41 ± 2.40, and was reduced significantly at week 12 (-3.76 points; 61.21%, P < 0.0001). The OABSS subscore, PPBC score, IPSS, and QOL were also significantly reduced during the study (P < 0.0001). The overall incidence of adverse events was 19.91% (44 cases). The gastrointestinal system was the most commonly affected (11.31%). Around 5.88% of the cases had adverse events related to the genitourinary system. There was a strong correlation between OABSS and urinary symptoms that was recorded in the 3-day voiding dairy.</p><p><b>CONCLUSIONS</b>We showed that solifenacin was clinically effective for relieving OAB symptoms, considering the balance between efficacy, patients' well-being, and tolerability. OABSS integrates four OAB symptoms into a single score and can be a useful tool for research and clinical practice.</p>


Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Muscarinic Antagonists , Therapeutic Uses , Prospective Studies , Quality of Life , Quinuclidines , Therapeutic Uses , Solifenacin Succinate , Tetrahydroisoquinolines , Therapeutic Uses , Treatment Outcome , Urinary Bladder, Overactive , Drug Therapy
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