Application of data mining techniques to explore predictors of upper urinary tract damage in patients with neurogenic bladder

This study proposed a decision tree model to screen upper urinary tract damage (UUTD) for patients with neurogenic bladder (NGB). Thirty-four NGB patients with UUTD were recruited in the case group, while 78 without UUTD were included in the control group. A decision tree method, classification and regression tree (CART), was then applied to develop the model in which UUTD was used as a dependent variable and history of urinary tract infections, bladder management, conservative treatment, and urodynamic findings were used as independent variables. The urethra function factor was found to be the primary screening information of patients and treated as the root node of the tree; Pabd max (maximum abdominal pressure, >14 cmH2O), Pves max (maximum intravesical pressure, ≤89 cmH2O), and gender (female) were also variables associated with UUTD. The accuracy of the proposed model was 84.8%, and the area under curve was 0.901 (95%CI=0.844-0.958), suggesting that the decision tree model might provide a new and convenient way to screen UUTD for NGB patients in both undeveloped and developing areas.

The Ochoa urofacial syndrome: recognize the peculiar smile and avoid severe urological and renal complications / Síndrome urofacial de Ochoa: reconheça o sorriso peculiar e evite complicações urológicas e renais graves

Ochoa syndrome is rare and its major clinical problems frequently unrecognized. We describe facial characteristics of six patients to help health professional recognize the inverted smile that these patients present and refer them to proper treatment. Patients’ medical records were reviewed and patients’ urological status clinically reassessed. At last evaluation patients’ mean age was 15.5 years, and age ranged from 12 to 32 years. Mean follow-up was 35 months (12 to 60). Initial symptoms were urinary tract infections in four patients (67%) associated with enuresis and incontinence in three of them (50%). One patient had only urinary tract infection and two lower urinary tract symptoms without infections. Initial treatment consisted of clean intermittent catheterization with anticholinergics for all patients. Four patients (67%) were submitted to bladder augmentation. Two patients had end-stage renal disease during follow-up, one received kidney transplantation and one patient remained on the waiting list for a renal transplantation. Familial consanguinity was present in only one case. This significant condition is rare, but it must be recognized by pediatricians, nephrologists and urologists in order to institute early aggressive urological treatment.

A síndrome de Ochoa é rara, e seus principais problemas clínicos são frequentemente não reconhecidos. Descrevem-se aqui características faciais de seis pacientes para auxiliar profissionais de saúde a reconhecer o sorriso invertido que eles apresentam e encaminhá-los para o tratamento adequado. Os prontuários médicos foram revisados e a condição urológica dos pacientes foi reavaliada clinicamente. A média de idade na última avaliação foi de 15,5 anos, variando de 12 a 32 anos. O seguimento médio foi de 35 meses (12 a 60). Os sintomas iniciais foram infecções do trato urinário em quatro pacientes (67%) associadas com enurese e incontinência urinária em três deles (50%). Um paciente apresentou infecções do trato urinário isoladamente e dois apresentaram sintomas do trato urinário inferior, porém sem infecções. O tratamento inicial consistiu em cateterismo intermitente limpo, com anticolinérgicos em todos os pacientes. Reconstrução urinária foi realizada em quatro pacientes (67%) por meio de ampliação vesical. Dois pacientes apresentaram doença renal em estágio terminal no seguimento, um recebeu transplante renal e outro manteve-se em lista de espera para transplante renal. Consanguinidade familiar esteve presente em apenas um caso. Essa condição significativa é rara, porém deve ser reconhecida por pediatras, nefrologistas e urologistas, a fim de instituir tratamento urológico agressivo precoce.

[One-year follow-up of radiologic and clinical findings in children with prenatal and neonatal hydronephrosis]

Hydronephrosis is a common problem in prenatal and newborn infants diagnosed by ultrasonography. Bladder to ureter reflux, the upper or lower urinary tract obstruction, and neurogenic bladder are the most common causes of hydronephrosis in newborns and infants. In this study, 100 neonates and infants with hydronephrosis were observed clinically and laboratorically for one year. Patients were allocated to two groups of fetal and newborn infants by the time of detection of hydronephrosis. Classification of the severity of hydronephrosis was based on the anteriorposterior diameter of renal pelvis including: mild hydronephrosis [5-9 mm], moderate [10-15 mm], and severe [more than 15 mm]. Fifty four patients were boy and 46 were girl. Mean age of patients in first visit of fetal and newborn infants hydronephrosis were respectively 2.5 [79% asymptomatic] and 5 month [100% symptomatic]. Causes of fetal hydronephrosis were: bladder to ureter reflux [45%], idiopathic hydronephrosis [41%], ureteropelvic junction obstruction [UPJO] [3.11%], physiological hydronephrosis [7.5%], and posterior urethral valve [8.3%]. Bladder to ureter reflux was the most common cause of hydronephrosis in all of the patients [57%]. The most common causes of mild and severe hydronephrosis were bladder to ureter reflux and ureteropelvic junction obstruction, respectively. In patients with fetal hydronephrosis, 100%, 30% and 6% of cases of severe, moderate, and mild hydronephrosis need surgery, respectively. Using ultrasonography in pregnancy led to the discovery of most asymptomatic fetal hydronephrosis more than infant hydronephrosis

Percutaneous intervention of large bladder calculi in neuropathic voiding dysfunction

PURPOSE: To report our results and rationale for treating large bladder calculi in patients with neuropathic voiding dysfunction (NVD) using percutaneous cystolithalopaxy. MATERIALS AND METHODS: Ten patients with a previously diagnosed NVD presenting with a large stone burden were identified from our department database and a retrospective review of case notes and imaging was performed. RESULTS: Percutaneous access to remove bladder stones (range 8x7 to 3x2 cm) had a mean surgery length of 150 min and blood loss of 23 mL. Six of the seven patients treated percutaneously were discharged on the day of surgery and suffered no complications, while one patient experienced poor suprapubic tube drainage and required overnight admission with discharge the following day. Transurethral removal of stone burden (range 4x4 to 4x3 cm) had a mean surgery length of 111 min and blood loss of 8 mL. Each of these three patients were under our care for less than 23 hours, and one patient required a second attempt to remove 1x0.5 cm of stone fragments. There was no statistical difference between mean operative times and estimated blood loss, p = 0.5064 and p = 0.0944 respectively, for the two treatment methods. CONCLUSION: In this small series, percutaneous cystolithalopaxy was a safe, effective, and often preferred minimally invasive option for removal of large calculi in patients with NVD. We suggest possible guidelines for best endoscopic approach in this population, although a larger and prospectively randomized series will be ideal for definitive conclusions.

Botulinum toxin A for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients

PURPOSE: Neurogenic detrusor overactivity (NDO) is common in patients who suffer from multiple sclerosis (MS). When the usual pharmacological treatment fails, botulinum toxin type A (BTX-A) injections can be proposed. The safety and efficacy of this treatment are already well known, but only a few studies focus on its use in patients with MS. MATERIALS AND METHODS: Seventy-one patients with MS underwent their first BTX-A injection for refractory NDO. They had clinical and urodynamic cystometry assessment before and three months after injection. The patients were divided in three groups according to treatment efficacy: full success (total urinary continence, no overactive detrusor), improvement, or total failure (urge incontinence and overactive detrusor). RESULTS: 77 percent of the patients had clinical improvement or full success of the treatment with a reduction of their urgency and incontinence. Significant urodynamic improvement after treatment was shown on different parameters: volume at first involuntary bladder contraction (p = 0.0000001), maximum cystometric capacity (p = 0.0035), maximum detrusor pressure (p = 0.0000001). 46 percent of the patients were in the "full success" group. 31 percent of the patients had a partial improvement. 23 percent of the patients had no efficacy of the treatment. Duration of MS was a predictive factor of treatment failure (p = 0.015). CONCLUSIONS: Despite that a full success was obtained in 46 percent of the cases, BTX-A injection therapy failed to treat refractory NDO in 23 percent of patients suffering from MS. Duration of the disease was a predictive factor for an inefficient treatment. The injection therapy should be considered as soon as oral anticholinergic drugs fail to reduce NDO.

Vejiga neurogénica en pacientes con lesiones medulares / In patients with espinal cord injuries neurogenic bladder

Los pacientes que sufren lesiones medulares son proclives a padecer, entre otros problemas, trastornos urinarios. El sistema urinario regulado por los centros nerviosos puede encontrarse alterado cuando se produce una lesión medular. En la vejiga neurogénica, los nervios que llevan estos mensajes no funcionan adecuadamente. El tratamiento puede consistir en una cirugía o en maniobras específicas basadas en la educación del paciente para promover el autocuidado. Este trabajo presenta una muestra de las opciones que tiene el paciente para mitigar estos problemas con las alternativas de cuidados de enfermería. El presente artículo consta de dos partes. La Primera intenta reflejar algunas posibilidades técnicas con las que cuenta la ciencia hoy para aliviar y tratar este trastorno que puede significar un cambio radical en la vida del paciente.

Sling sub-uretral de fascia autóloga como tratamiento de la incontinencia urinaria por falla esfinteriana: experiencia del Instituto de Rehabilitación Infantil Teletón de Santiago / Suburethral autologous fascia swing for the management of urinary incontinence secondary to sphincter deficience

Se presenta nuestra serie clínica constituida por 14 pacientes de sexo masculino, portadores de Incontinencia Urinaria (IU) debido a vejiga neurogénica con falla esfinteriana, quienes luego de fracaso de tratamiento médico, fueron sometidos a tratamiento quirúrgico para mejorar su continencia, entre los años 1998 y 2006. La cirugía realizada consistió en elevar el cuello vesical con una cinta (Sling) de Fascia de músculo Recto Anterior, pasada por debajo del Cuello Vesical o Uretra Prostática y fijada a la aponeurosis del mismo músculo. En la mayoría de los casos, se realizó una Entero-Cistoplastía de ampliación(ECP) en el mismo acto quirúrgico. La complicación más frecuente, derivada del Sling, fue la estenosis uretral (2 casos). Se obtuvo un alto grado de satisfacción en cuanto a continencia: el 57 por ciento de los pacientes está completamente continente y el 21,5 por ciento se moja a grandes esfuerzos.

We report our experience in 14 consecutive male patients with urinary incontinence secondary to neurogenic bladder with sphincter deficiency. All patients underwent surgical management between 1998 and 2006. Surgery was indicated only after medical treatment failure. Anterior rectus fascia was used as a hammock to suspend the bladder neck by anchoring the fascia to the muscle’s aponeurosis. In most cases simultaneous augmentation cystoplasty was performed. Urethral stenosis was observed in 2 cases. Patient satisfaction was achieved in most cases with a 57 percent ofcomplete continence and 21.5 percent of minor stress incontinence.

Técnica de cierre de cuello vesical en pacientes neurogénicos / Bladder neck closure in neurogenic patients

Los pacientes con vejiga neurogénica e incompetencia esfinteriana requieren usar pañales permanentes con consecuencias sociales y psicológicas que afectan su calidad de vida. Estos pacientes, dentro de su manejo quirúrgico si son de difícil manejo, podrían requerir un cierre de cuello vesical. Esta cirugía, con un abordaje extravesical ha tenido resultados poco satisfactorios. El objetivo de este trabajo es evaluar los resultados de la técnica intravesical para el cierre de cuello en términos de continencia. Métodos: Desde el año 2004, y en forma prospectiva, ingresaron al estudio aquellos pacientes con indicación de cierre de cuello. Todos fueron sometidos a una técnica intravesical para el cierre de cuello y se evaluó su resultado en términos de continencia urinaria. Resultados: se realizó el cierre de cuello vesical con técnica intravesical en 4 pacientes con vejiga neurogénica (2 niños y 2 niñas), sin complicaciones perioperatorias. Tras un período de seguimiento de 6 a 24 meses, todos se cateterizan a través de un Mitrofanoff cada 3 ó 4 hrs y todos son continentes urinarios. Conclusiones: la técnica de abordaje intravesical, respecto a la extravesical, mejora la exposición de la anatomía del cuello vesical, resultando técnicamente más segura, facilitando la separación entre ambos cabos. Debido al éxito relativo de la cirugía de cuello en la literatura, y pese al corto periodo de seguimiento de nuestros pacientes, proponemos esta técnica como una alternativa cuando se plantea el cierre de cuello vesical.

The patients with neurogenic bladder and sphincteric incompetence require to use permanent diapers with social and psychological consequences that affect their quality of life. These patients, if they have a intractable incontinence, could require a bladder neck closure. This surgery, with a extrabladder approach has had little satisfactory results. The objective of this work is to evaluate the results of the intrabladder technique for bladder neck closure in continence terms. Methods: from 2004 we enrolled in a prospective study the patients with indication of bladder neck clousure. All were underwent a intrabladder technique for the bladder neck closureand the outcomes was evaluated in terms of urinary continence. Results: 4 patients with neurogenic bladder (2 males and 2 females), were underwent a this bladder neck closure technique, without postoperative complications. After 6 to 24 months, all the patients use their catheterizable continent conduit (Mitrofanoff) and all are urinary continent. Conclusions: The intrabladder approach, with respect to the extrabladder approach, improves the exhibition of the anatomy of the bladder neck, is a safe technique, and it facilitates the separation between both ends. Although the follow up is limited, we recommended this technique as a option for the bladder neck closure.

Neuropathic bladder as a cause of chronic renal failure in children

A retrospective study of all paediatric cases diagnosed as neurogenic bladder and presented with chronic renal failure [CRF] [GFR <50 ml/minute/1.73 m2] from December 2000 to December 2004. Fifteen patients were diagnosed as neuropathic bladder. Group A included nine spina bifida and one sacral agenesis cases and group B included four non-neurogenic neurogenic bladder [NNNB] cases. The mean age +/- SD at presentation was 6.2 +/- 3.8 years, GFR level was 24.2 +/- 12.4 ml/minute/1.73 m2 and creatinine level was 289.9 +/- 253.2 mumol/l. There was no difference in the age of presentation to paediatric nephrologist or the degree of renal failure at presentation between the two groups. All children with NNNB in group B presented with recurrent urinary tract infection [UTI] and the two older children were also reported as wet during the day. Clean intermittent catheterization [CIC] was not started in all patients before presentation to KAUH, except in two children, in whom it was started by urologists. Five children required dialysis, as they were in end stage renal failure [ESRF]; four in group A and one in group B. All cases, except one, received peritoneal dialysis [PD]. Their mean age at the start of dialysis was 10.8 +/- 1.7 years. Two children with shunted hydrocephalus were dialyzed peritoneally; one of them had peritonitis and complicated with a Staph. epidermis shunt infection; therefore this case was shifted to haemodialysis and required externalization of the V-P shunt for few weeks. Only one patient was started on haemodialysis from the start due to social reasons

The use and rationale of selective alpha blockade in children with non-neurogenic neurogenic bladder dysfunction

INTRODUCTION: We present here a long-term observation of 2 children with a rare syndrome with a non-neurogenic neurogenic bladder dysfunction (Hinman's syndrome), and we investigated the safety and efficacy of long-term use of terazosine in association with prophylactic antibiotics, timed voiding and a bowel regimen. MATERIALS AND METHODS: Two children, 7 years-old (22 kg) and 11 years-old (36 kg) presented in 1997 to our pediatric urology clinic with symptoms of urgency, frequency, urge incontinence and nocturnal enuresis. Both children were placed in a regimen of terazosine (starting with 0.5 mg increasing until 2 mg). RESULTS: There were no significant side effects throughout the entire treatment. The first 7-year old boy however developed some dizziness when the dose of terazosine was increased to 2 mg (after 4 weeks of administrating 1 mg), and this disappeared immediately when the dosage was reduced back to 1 mg daily. The urgency symptoms improved in both boys after 3 weeks of 1 mg terazosine. The secondary enuresis in the 11 year-old boy resolved after 2 months of 2 mg terazosine. CONCLUSION: It is possible to say that the alpha-blocker medication, terazosine can be administered safely to children with a non-neurogenic bladder dysfunction, also known as the Hinman's syndrome. These results have shown that dysfunctional voiding, postvoiding residual and upper tract involvement can disappear over time when long term terazosine is given in combination with timed voiding, prophylactic antibiotic therapy and treatment of the associated constipation. Our observations also suggest a permanent effect after discontinuing the medication.

Derivações urinárias continentes na criança / Continent urinary diversion in children

O tratamento da incontinência urinária na criança, particularmente da bexiga neurogênica, representa um grande desafio para o cirurgião ou urologista pediátrico. Antigamente, dispunha-se apenas de derivações cutâneas incontinentes para se preservar a função renal dessas crianças. Aos poucos, foram surgindo inovações, como o cateterismo limpo intermitente, em 1971, a cistostomia continente transapendicular ou principio de Mitrofanoff, em 1980, o enema anterógrado continente ou procedimento de Malone, em 1990, a técnica de Monti, em 1997. Todo esse arsenal terapêutico contribuiu muito para a melhoria do tratamento das crianças com bexiga neurogênica, tanto do ponto de vista social, mantendo-as continentes, quanto do ponto de vista renal, com preservação do trato urinário superior. Este trabalho pretende revisar as derivações continentes existentes na criança, discutindo aspectos ligados às suas indicações, à técnica cirúrgica e às suas complicações.

Treatment of urinary incontinence caused by spina bifida in children represents an enormous challenge to the pediatric urologist. In the past, cutaneous diversion was the only option to treat these children. Starting in 1971 with clean intermittent catheterization, new therapeutical modalities appeared, such as the Mitrofanoff principle (1980), the Malone procedure (1990) and the Monti principie (1997). These advances have changed dramatically the treatment of children with neurogenic bladder by achieving dryness and preservation of upper urinary, tract. This study intended to review the techniques of cominem diversion in children, with special attention to its indications, surgical aspects and complications.

Antibioticoterapia profilática e auto-cateterismo intermitente limpo em pacientes com bexiga neurogênica por traumatismo raqui-medular / Prophylactic antibiotics and clean intermittent self-catheterization in patients with neurogenic bladder due to spinal cord injury

Introduçäo: O cateterismo intermitente revolucionou o tratamento de pacientes com bexiga neurogênica. Foi realizado um estudo sobre a profilaxia da infecçäo urinária em pacientes com bexiga neurogênica que realizavam cateterismo intermitente. Material e Métodos: 141 pacientes portadores de bexiga neurogênica hiperreflexa por lesäo medular traumática, realizando auto-cateterismo intermitente limpo, foram acompanhados durante o período de 1 ano, com o objetivo de observar a incidência de infecçäo urinária sintomática, sem (durante os primeiros 6 meses) e com (durante os 6 meses consecutivos) o emprego de antibiótico-profilaxia em baixas doses (AP) e desta forma estabelecer critérios para o tratamento de infecçäo urinária neste tipo de doente. Resultados: Durante o período em que foram mantidos sem AP, 90,1 porcento dos pacientes apresentaram urinocultura positiva, com a presença de sintomas em 90,1 porcento dos casos. Após o início da AP, 90,1 porcento dos pacientes apresentaram urinoculturas positivas, porém destes apenas 59 (46,45 porcento) apresentaram sintomas, necessitando de antibioticoterapia em dose plena. Sessenta e oito pacientes permaneceram assintomáticos (53,55 porcento), mesmo com urinocultura positiva. Conclusäo: Pacientes com cateterismo intermitente devido a bexiga neurogênica por traumatismo raqui-medular, quando mantidos em AP apresentaram incidência diminuída de infecçöes urinárias sintomáticas

Trasplante renal en pacientes con vejiga neurogénica / Renal transplantation in patients with neurogenic bladder

Renal transplantation can be done in patients with neurogenic bladder and clean intermittent sel catheterization maintains renal function. To retrospective assess the results of renal transplantation in patients with neurogenic bladder. The medical records of seven patients aged 10 to 22 years old (3 female) followed during 7 to 32 months were reviewed. All patients had urinary tract infection prior to transplantation, were instructed to self catheterization and received tri-associated immunosupression. Grafts came from alive related donors in 5 patients and from cadavers in 2. Prior to transplantation, 3 patients were subjected to nephrectomy and 3 to bladder enlargement, leaving a pigtail catheter. After transplantation, one lymphocele was drained, one uretherostomy due to an impacted lithiasis and one nephrectomy plus vesical enlargement due to intravesical pressures over 40 cm H2O, were done. One uretheral stricture was treated with dilatation. Seven episodes of pyelonephritis, 19 urinary tract infections and 77 asymptomatic bacteriurias were documented. Serum creatinine at the end of follow up ranged from 0.7 to 2.1 mg/dl. There were 0.7 acute rejection episodes per patient and all grafts survived. Renal transplantation in patients with neurogenic bladder is feasible, performing a vesical enlargement. There is however a high frequency of infectious episodes

Bexiga de choque / Bladder injury

O tratamento urológico dos pacientes vítimas de traumatismo raquimedular nem sempre é bem conduzido. Esquece-se que as complicaçöes urinárias säo as de maior morbidade nesse grupo de doentes. O presente artigo salienta a importância da abordagem urológica precoce, apresentando as diretrizes básicas apra o atendimento urológico desses pacientes ainda na fase aguda, de choque medular

Algunas características clínicas de la vejica neurogénica en el diabético, con especial referencia a sus manifestaciones urinarias / Some clinical characteristics of the neurogenic bladder in the diabetic, with special reference to its urinary manifestations

Se estudiaron 62 pacientes con vejiga neurogénica, de un total de 72 pacientes diabéticos en quienes se sospechó su existencia. Los elementos de sospecha fueron: trastornos en la esfera sexual, trastornos en la esfera urinaria, o ambos, y diabéticos de difícil control sin las manifestaciones anteriores. La vejica neurogénica predominó en diabéticos de comienzo precoz y larga duración. Se señala la frecuencia de síntomas tales como: chorro de la orina débil, sensación de vaciamiento vesical incompleto, micción prolongada, disminución de la frecuencia de la micción en el día y volumen de la diuresis matutina aumentado. Se considera que una diuresis matutina mayor de 400 ml es un signo de gran valor para el diagnóstico clínico de vejiga neurogénica, y constituye la primera investigación que se debe realizar en pacientes con sospecha de esta neuropatía

Preservaçäo do trato urinário superior em pacientes com bexiga neurogênica e refluxo vésico-ureteral / Upper urinary tract preservation, in patients with neurogenic bladder and vesico-ureteral reflux

Analisam-se 14 pacientes portadores de refluxo vésico-ureteral secundário à disfunçäo neurogênica da bexiga e submetidos à esfincterotomia por via endoscópica. A avaliaçäo radiológica e urodinâmica realizada no pré e pós-operatório revelou que a esfincterotomia produziu 92,8% de bons resultados, com o desaparecimento do refluxo em 71,4% dos casos. Os resultados obtidos demonstram que o procedimento é altamente eficaz na preservaçäo do trato urinário superior de paraplégicos com refluxo vésico-ureteral secundário