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Purpose@#We investigated the effectiveness of intravesical botulinum toxin-A (BTX-A) injection therapy in patients with lower urinary tract dysfunction (LUTD) and upper urinary tract (UUT) deterioration and evaluated whether BTX-A injection therapy could substitute for augmentation uretero-enterocystoplasty (AUEC). @*Methods@#Data from a prospective, single-center cohort from 2017–2021 were analyzed. Patients were divided into 2 treatment groups: AUEC and BTX-A (i.e., patients who declined AUEC). Bladder and UUT functions were assessed by comparing clinical information, urodynamic data, laboratory results, and imaging records. @*Results@#In total, 121 patients were enrolled (BTX-A group: 41 patients; AUEC group: 80 patients). The BTX-A group showed a reduced maximum detrusor pressure and increases in the maximum bladder volume and bladder compliance (P0.05). Both VUR and UUTD improved significantly in the AUEC group, and the Scr and eGFR levels significantly improved after AUEC relative to baseline levels (P<0.05). The reduction in the Scr level was significantly lower in the BTX-A group than in the AUEC group during 0–15 months of follow-up (Scr reduction differences, -1.36; P<0.01). @*Conclusions@#Although BTX-A injection therapy was effective for improving bladder function, BTX-A injections did not alleviate UUT deterioration in this study, particularly in patients with advanced-stage LUTD. Conversely, AUEC for LUTD has a well-established role in improving UUT function. Hence, BTX-A injection therapy should not replace AUEC to ameliorate UUT impairment and protect UUT function.
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As a conservative treatment, intravesical electrical stimulation can not only restore bladder sensation, but also improve bladder contraction. Studies in recent decades have shown that intravesical electrical stimulation has a two-way regulating effect on bladder function, and there were few adverse reactions. At present, there was no uniform treatment standard yet, The mechanism of action and curative effect was not clear, so the choice of this treatment method is full of challenges for urologists. This article reviews the research progress in the treatment of lower urinary tract dysfunction by intravesical electrical stimulation.
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In recent years, the research on upper urinary tract urodynamics has been developing toward digitalization, simulation and noninvasive.This article reviews the physiological mechanism, clinical application and new research progress of upper urinary tract urodynamics. Pacemaker cells are considered to be the basis of upper urinary peristalsis, but the specific mechanism remains to be further studied. The dynamic technique of upper urinary tract is widely used in clinical practice to measure the perfusion rate-pressure relationship. Whitaker test can be used as an auxiliary examination in the diagnosis of suspicious cases. Artificial intelligence, three-dimensional reconstruction and other multidisciplinary integration may be the important means for the research in the future.
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Objective:To investigate the effects of sacral neuromodulation (SNM)using the new six-contact electrode vs. the four-contact electrode in patients with refractory overactive bladder.Methods:The clinical data of 29 patients underwent SNM testing therapy from January 2018 to January 2020 in China Rehabilitation Research Center were reviewed. In six-contact points electrode group 16 patients accepted SNM with new six-contact points electrode, while 13 patients in four-contact points electrode group accepted SNM with four-contact points electrode. There were no significant differences between the two group in age [(51.63±4.67) vs. (51.85±7.18) years], gender (male/female, 4/12 and 5/8), urination frequency [(22.10±9.05) vs. (21.79±8.05) times/24h], mean voided volume [(135.68±56.98) vs. (131.00±53.05) ml], and urgency score [(2.78±0.97) vs. (3.02±0.91)] (all P>0.05). The number of sensitive contact points, the ratio of reaction contact points, operation time of stage I and the success rate of two groups were calculated. Results:The mean number of sensitive points of six-contact points electrode group (3.31± 0.95) was significantly higher than that of the four-contact points electrode group (1.85± 0.38), ( P<0.05). There was no significant difference in the ratio of reaction contact points [ (96.87±6.71)% vs. (96.15± 9.39)%] and operation time of stage I [(71.25± 18.21)min vs.(68.85± 10.83)min]between six-contact points electrode group and four-contact points electrode group ( P<0.05). The contact E4 and E5 of six-contact electrodes had similar reaction voltage ( P>0.05). The implant rate of six-contact points electrode group was (14/16, 87.5%), which was higher than that of four-contact points electrode group (10/13, 76.9%), but there was no statistical difference ( P>0.05). Conclusions:This study showed that six-contact electrodes has more sensitive points compared with four-contact electrodes. Application of six contact electrodes, patients might get a higher implant rate.
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Objective:To investigate the long term outcome of artificial urinary sphincter implantation for patients with stress urinary incontinence.Methods:The data of 46 patients who underwent artificial urethral sphincter implantation in China Rehabilitation Research Center from April 2002 to April 2022 were retrospectively analyzed.The patients’ age ranged from 19-80 years old (median 45.6 years). There were 45 males and 1 female. The history of illness was 8 months to 33 years. The patients category were urethral injuries associated urinary incontinence ( n=24), neurogenic urinary incontinence ( n=9) and post-prostatectomy incontinence ( n=13). Preoperative daily pad usage was 3.5±1.0. The impact of incontinence on the quality of life (QOL)measured by the visual analogue scale (VAS)was 7.1±1.2. All 46 patients underwent artificial urethral sphincter implantation, of which 20 patients were treated with anticholinergic drugs (5 cases) or urinary tract related surgery (urethral stenosis incision in 2 cases, sphincterectomy in 3 cases, urethral dilation in 5 cases, urethral calculus lithotripsy in 1 case, and augmentation cystoplasty in 4 cases) before artificial urethral sphincter implantation. Of the 45 male patients, 25 patients had the transperineal approach and 20 had the trans-scrotal approach. The female case had a trans-retropubic approach. Different cuffs size was used based on individual circumference of bulbar urethra (45 male cases: 4.5cm in 16 cases, 4.0cm in 29 cases; one female case: 8.0cm). Long-term surgical efficacy was evaluated. Assessments included postoperative urinary continence (socially continent: one pad per day or less; complete dry: wearing no pads), artificial urinary sphincter status and complications. The influences of patients of different etiologies, surgical approaches and cuff size on surgical results were compared. Results:The mean follow-up time was 7.1 years ranged from 6 months to 19 years. At the latest visit, 32 patients (69.6%) maintained the primary functional artificial urinary sphincter. Three patients (6.5%) had artificial urinary sphincter revisions and maintained continence with the new device. 11 patients (23.9%) removed the artificial urinary sphincter because of post-complications. Thirty-five patients were socially continent, of which 16 patients were totally dry, leading to the overall social continent rate as 76.1%(35/46). There was a significant reduction in pad usage to 1.2±0.6 diapers per day ( P<0.001). The impact of incontinence on the QOL measured by the VAS dropped to 2.6±1.9 ( P<0.001). The complication rate was 32.6%(15/46), including infections ( n=4), erosions ( n=5), mechanical failure ( n=3), dysurie ( n=2) and urethral atrophy ( n=1). There were no significant differences in social continent rate between patients with different etiologies[75.0%(18/24)vs. 66.7%(6/9) vs. 84.6%(11/13)], perioperative complications [37.5%(9/24)vs. 33.3%(3/9) vs. 23.1%(3/13)] and device re-intervention rate[37.5%(9/24) vs. 33.3%(3/9)vs. 15.4%(2/13)]. There were no statistically significant differences in postoperative complete dry rate [32%(8/25)vs. 40%(8/20), P=0.76] and postoperative device failure free rate [60%(15/25)vs. 80%(16/20), P=0.20] between trans-perineal group and trans-scrotal group. There was no statistically significant difference in postoperative social continent rate between 4.5cm cuff and 4.0 cuff[75%(12/16) vs. 65.5%(19/29), P=0.74]. Conclusions:Artificial urethral sphincter implantation is an effective treatment for stress urinary incontinence due to intrinsic sphincter deficiency. There was no difference in the continent rate and complication rate between patients of different etiologies, different surgical approaches and cuff size selection.
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Objective:To investigate the long-term efficacy and complications of augmentation uretero-enterocystoplasty (AUEC).Methods:The clinical data of 262 patients with lower urinary tract dysfunction who underwent AUEC at our center from January 2003 to June 2022 were analyzed retrospectively. There were 193 males and 69 females, the median age was 24 (4, 67) years, the median disease duration was 12.0 (0.2, 56.0) years and the preoperative creatinine was 91.5 (68.1, 140.0) μmol/L. 320 ureters had high-grade UUTD, 216 ureters had VUR, 14 of which had low-pressure reflux.The number of low-grade VUR ureter was 22 (10.2%) and the number of high-grade VUR ureter was 194 (89.8%). Video-urodynamics showed that the maximum bladder capacity was 102 (47, 209) ml, the maximum detrusor pressure was 33.0 (15.5, 50.5) cmH 2O, and the bladder compliance was 6.4 (3.0, 12.3) ml/cmH 2O. All patients underwent AUEC. The surgical method is to cut a segment of sigmoid colon, open the sigmoid colon along the mesenteric margin, fold and suture it into " U" or " S" shaped intestinal mesh according to the principle of " detubulization" . At the same time, perform ureteroplasty and replanting, and then anastomosis the intestinal mesh with the opened bladder flap to form an expanded new bladder. Follow-up was performed via outpatient clinic or telephone. The creatinine, maximum bladder capacity, maximum detrusor pressure, bladder compliance, ureteral reflux and upper urinary tract dilatation were compared preoperatively and postoperatively. The postoperative complications were also evaluated. Results:The median follow-up time was 57.4 (4, 151) months after surgery. At 1-3 months after surgery, the maximum bladder capacity and bladder compliance increased to 303.9% and 189.9% of the preoperative level, and the maximum detrusor pressure decreased to 63.6% of the preoperative level. At 6-10 years after surgery, the maximum bladder capacity and bladder compliance increased to 490.2% and 627.9% and the maximum detrusor pressure decreased to 25.8% of the preoperative level. The UUTD of the patients was significantly reduced after surgery. The number of the high grade UUTD decreased to 116 (116/398, 29.2%) at 1-3 months and 51 (51/274, 18.6%) at 4-6 months. At 6-10 years, the number of the high-grade UUTD decreased to 4 (4/76, 5.3%) ( P<0.001), which was significantly lower than that before operation. The VUR was significantly relieved after operation, and 393 ureters had no VUR at 1-3 months, accounting for 97.8% (393/402) of the total ureters. Sustained remission of VUR was observed during follow-up. 73 ureters had no VUR at 6-10 years, accounting for 96.1% (73/76) of total ureters ( P<0.001). Patients' creatinine decreased to 79.0 (65.0-128.2) μmol/L at 1-3 months postoperatively, with a downward trend but no statistical difference, and creatinine levels were not significantly elevated at any postoperative time point compared with preoperative levels ( P>0.05). Postoperative complications included metabolic acidosis in 26 cases (9.9%), vesicoureteral anastomosis stenosis in 15 cases (5.7%), recurrent urinary tract infection in 16 cases (6.1%), and urinary calculi in 20 cases (7.6%), and intestinal obstruction requiring laparotomy in 8 cases (3.1%), all of them could be improved after treatments. Conclusions:AUEC is a safe and effective method for treating high-grade VUR or VUR with impaired anti-reflux mechanism, high-grade UUTD or UUTD with ureteral or vesicoureteral junction obstruction, and all of the complications can be improved after treatment. This technique can increase the bladder capacity and compliance, reconstruct the anti-reflux mechanism, and release upper urinary tract obstruction. It may play an important role in stabilizing and protecting the residual renal function from further deterioration.
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There’s a lack of understanding on the urinary incontinence after radical prostectomy (RP) among urologists domextically. The standard of the prevention, diagnosis, and treatment is urgently needed. Considering the current condition of the uncertainty of the definition, evaluation criteria, etiology, and risk factors, and the need of further exploration of current surgical techniques and prevention measures, this work reviewed the latest research progression and expert advices, to fulfill more precise prevention, diagnosis, and treatment of urinary incontinence after RP, and to eventually improve the precaution treatment of the disease and the quality of life of the patients in China.
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Purpose@#To explore the effect of intravesical electrical stimulation (IVES) on urinary adenosine triphosphate (ATP) and nitric oxide (NO) in rats with detrusor underactivity (DU) induced by bilateral pelvic nerve crush (bPNC), and to determine the underlying peripheral mechanism. @*Methods@#Twenty-four female Sprague-Dawley rats were equally divided into 3 groups: sham; bPNC; and IVES. Rats in the IVES group began to receive IVES treatment 10 days after bPNC (20 minutes per day for 14 consecutive days). After the 14th IVES, rat urine was collected and cystometry was performed. The serum creatinine, blood urea nitrogen, and urinary ATP and NO levels were measured, and a routine urinalysis was performed. @*Results@#The maximum cystometric capacity (MCC), maximum changes in bladder pressure during filling (∆FP), and postvoid residual urine (PVR) in the IVES group were significantly lower than the bPNC group, and the maximum changes in bladder pressure during voiding (∆VP) was significantly higher than the bPNC group. Compared with the sham group, the MCC, ∆FP and PVR were significantly increased, and the maximum voiding pressure (MVP) and ∆VP were significantly decreased in the bPNC group. After bPNC, urinary ATP was significantly decreased, and urinary NO was significantly increased. In IVES-treated rats, urinary ATP was significantly higher than the bPNC group, and NO was significantly lower than the bPNC group. In addition, the ATP-to-NO ratio of the rats in the bPNC group was significantly lower than the sham and IVES groups. Correlation analysis showed that the ATP and NO were not correlated with the MCC, ∆FP, MVP, ∆VP, and PVR. @*Conclusions@#Promoting the release of urothelial ATP and inhibiting the release of urothelial NO may be one of the peripheral mechanisms underlying IVES in the treatment of DU. Specifically, IVES may shift the balance between excitation and inhibition toward excitation.
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ObjectiveTo observe the inhibitory effects of a novel wearable transcutaneous tibial nerve stimulator on bladder reflex in cats under different stimulation parameters. MethodsA total of 18 cats were divided into intensities, frequencies and waveforms groups, which wore the stimulator on the ankles and stimulated in different threshold (T) intensities (1/2 T, 1 T, 3/2 T and 2 T), frequencies (5 Hz, 10 Hz, 15 Hz and 30 Hz) and waveforms (A and B). The cats were anesthetized and infused normal saline to induce bladder reflex, while the bladder capacity was measured. Cystometrograms were compared among stimulation parameters. ResultsThe bladder capacity was not significantly different among the intensities (F = 1.997, P = 0.126), while the bladder capacity was more after TNS of 3/2 T and 2 T than baseline (P < 0.05). The bladder capacity was significantly different among the frequencies (F = 3.894, P = 0.014), while the bladder capacity was more after 5 Hz, 10 Hz and 15 Hz of TNS (P < 0.05). The bladder capacity was significantly different between the waveforms (F = 5.184, P = 0.019), while the bladder capacity was more after waveform A of TNS than baseline (P < 0.05). ConclusionThe novel wearable transcutaneous tibial nerve stimulator can effectively inhibit the physiological bladder reflex in cats, which associates to the intensity, frequency and waveform of stimulation.
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Botulinum neurotoxin subtype A (BoNT-A) has been part of the urology treatment arsenal since it was first used in the treatment of detrusor-sphincter dyssynergia more than 30 years ago. BoNT-A has been recommended as an effective treatment for neurogenic detrusor overactivity and overactive bladder. However, direct intradetrusor injection of BoNT-A using cystoscopy after anesthesia may cause hematuria, pain, and infection; these adverse events have motivated urologists to find less invasive and more convenient ways to administer BoNT-A. The development of nanotechnology has led to the advancement of intravesical drug delivery. Using versatile nanocarriers to transport BoNT-A across the impermeable urothelium is a promising therapeutic option. In this review, we discuss the effectiveness and feasibility of liposomes, thermosensitive polymeric hydrogels, and hyaluronan-phosphatidylethanolamine as carriers of BoNT-A for intravesical instillation. To date, these carriers have not reached a similar efficacy as intradetrusor injections in long-term observations. Hopefully, researchers will make a breakthrough with new nanomaterials to develop clinical applications in the future.
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Purpose@#To determine the risk factors predicting upper urinary tract (UUT) damage using a grading system for upper urinary tract dilation (UUTD) and a descriptive system for all urinary tract dysfunction (AUTD) in patients with myelodysplasia. @*Methods@#Six hundred thirty-seven patients with myelodysplasia were evaluated at our center from January 2008 to November 2019. Clinical data, ultrasonography, magnetic resonance urography, and video-urodynamics (VUDS) parameters were collected. Univariate and multivariate analyses were used to determine the risk factors predicting UUT damage. @*Results@#Three hundred eighty-three males and 254 females were included. The average course of lower urinary tract symptoms (LUTS) was 14.08±7.07 years (range, 3–31 years). The urodynamic diagnoses of all patients were as follows: detrusor overactivity, 26.8%; detrusor underactivity, 6.44%; and acontractile detrusor, 66.72%. UUT damage was determined in 66.56% of the patients. Of the patients, 28.73 % had vesicoureteral reflux (VUR) during filling (bilateral, n=50; unilateral, n=133) on fluoroscopy during VUDS testing. Two hundred thirty-four patients had UUTD (bilateral, n=203; unilateral, n=31). The occurrence of hydronephrosis based on ultrasonography was closely related to ipsilateral VUR (P<0.05). Absent of bladder sensation, long-term course of LUTS, decreased maximum cystometric capacity (MCC) and bladder compliance (BC), and increased postvoid residual urine (PVR) were shown to be independent risk factors in logistic regression analysis. @*Conclusions@#This retrospective study using UUTD and AUTD systems indicated that patients with myelodysplasia have a high incidence of UUT damage. Absence of bladder sensation, long-term course of LUTS, decreased MCC and BC, and increased PVR were independent risk factors predicting UUT damage.
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@#Objective To observe the clinical effect of Mirabegron combined with Silodosin on detrusor hyperactivity with impaired contractile (DHIC).Methods From September, 2019 to December, 2021, 40 patients with DHIC in the Department of Urology of Beijing Bo'ai Hospital were selected and randomly divided into control group and experimental group, with 20 cases in each group. The control group took Silodosin only, and the experimental group took Mirabegron in addition, for four weeks. The urinary diary, residual urine volume, Overactive Bladder Symptom Score (OABSS) and quality of life (QOL) score were compared before and after treatment.Results A total of 18 patients in the control group and 19 in the experimental group finished the trial. After treatment, the number of night urination per day, the residual urine volume and QOL score improved in the control group (P<0.01); the number of urination per 24 hours, the number of night urination per day, the volume per urination, the residual urine volume, the daily urgency score, the OABSS score and QOL score improved in the experimental group (P<0.01). The number decrease of urination per 24 hours, the volume decrease of per urination, the daily urgency score decrease, the OABSS score decrease and QOL score decrease were more in the experimental group than in the control group (P<0.01). The adverse reactions included palpitations, increased heart rate, dyspareunia, increased blood pressure, gastric discomfort, postural hypotension, and retrograde ejaculation, and there was no significant difference between two groups (P > 0.05).Conclusion The efficacy of Mirabellone combined with Silodosin on DHIC is better than Silodosin only, and there was no significant increase in drug-related adverse effects.
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Purpose@#The present study determined the effects of saphenous nerve stimulation (SNS) at different stimulation frequencies on bladder reflex and explored a possible action mechanism of tibial nerve stimulation (TNS) on bladder activity in cats. @*Methods@#Two bipolar nerve cuff electrodes were implanted on the saphenous nerve and the contralateral tibial nerve in 13 cats, respectively. Multiple cystometrograms were obtained to determine the effects of single SNS at different frequencies and that of combined SNS and TNS on the micturition reflex by infusing normal saline. @*Results@#SNS at 1 Hz significantly reduced the bladder capacity (BC) to 59.8%±7.7% and 59.3%±5.8% of the control level at the intensity threshold (T) and 2T, respectively (P0.05), while combined stimulation at 1T significantly increased the BC to 122.7%±1.9% of the control level and induced an inhibitory effect which was similar to that TNS at 2T. @*Conclusions@#The current study revealed that SNS reduced and increased BC depending on different stimulation frequencies. The combined SNS and TNS maximized the clinical efficacy at a low intensity. Also, SNS may be a potential therapeutic mechanism of TNS.
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Objective:To explore the efficacy of sacral neuromodulation (SNM) in the treatment of neurogenic bladder (NB), and to analyze the predictive factors.Methods:The clinical data of 91 patients underwent SNM testing therapy from January 2012 to January 2020 in China Rehabilitation Research Center were reviewed. There were 53 males and 48 females with the average age of 36.5(28.0-52.5)years. Urinary diary, residual urine, neurogenic bowel dysfunction score (NBDS), video-urodynamic and pelvic floor electrophysiological examination before treatment were recorded. Among the 91 patients, 60 patients had symptoms of urinary storage period, including urgency, frequency and / or incontinence.The average number of voids/24 h was 13 (11, 18), the average volume per void was (123.0±45.9) ml, the average degree of urgency was (3.5±1.0), and the average 24-hour urine leakage was 100.0(50.0, 231.5) ml. 78 patients had chronic urinary retention symptoms, and the average post-void residual volume (PVR) was 200.0 (132.3, 300.0) ml. The neurogenic bowel dysfunction score (NBDs) of 91 patients was 11 (6.25, 13). The mean maximum cystometric capacity (MCC), maximum detrusor pressure (P detmax) and bladder compliance were 250 (117, 369) ml, 33 (17, 72) cmH 2O and 8.275 (4.540, 20.307) ml / cmH 2O, respectively. Pelvic floor electrophysiological examination showed that somatosensory evoked potential (SEP) was normal in 39 cases, abnormal in 19 cases and undetected in 33 cases. Bulbocavernosus reflex (BCR) was normal in 39 patients, abnormal in 23 patients and undetected in 29 patients. At the end of the test phase, the patient was re-evaluated. If " effective" or the patient willing to implant, permanent implantation of pulse generator was done. " Effective" was defined as improvement of more than 50% in at least one of the following conditions, including the number of voids in 24 hours, volume per void, degree of urgency, leakage volume in 24 hours, PVR. Quantitative values were compared using the t-test or non-parametric test. The potential risk factors were considered by logistic regression analysis. Results:The average test time was (18.7±6.7) days. 43/60 patients (71.7%) had improvement of more than 50% in at least one symptom of the storage period, and 21/78 patients (26.9%) had more than 50% improvement in urination symptoms. NBDS decreased from 11(6.25, 13) to 3(0, 8)( P < 0.05). During the filling period, MCC increased from 173.0(98.0, 326.0) ml to 300.0(201.0, 386.0) ml ( P<0.05), P detmax decreased from 40.0(27.0, 84.0) cmH 2O to 22.0(15.0, 60.0) cmH 2O ( P < 0.05), and bladder compliance increased from 6.84(3.75, 11.79) ml/cm H 2O to 19.23(4.95, 32) ml/cm H 2O ( P < 0.05). At the end of the test phase, 54 (59.3%) patients underwent permanent implantation. The median follow-up was 25.5 (11.5, 60.5) months. Four patients lost their curative effect, two patients developed grade 2 vesicoureteral reflux, and one patient underwent cystoplasty. Risk factors analysis showed that chronic urinary retention was a statistically significant variable ( P<0.05). Conclusions:SNM can not only improve the lower urinary tract symptoms of patients with neurogenic bladder, but also improve the urodynamic parameters and bowel function. Patients with chronic urinary retention symptoms before treatment experienced low efficiency at the end of the test phase.
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Objective:To explore the efficacy and safety of intravesical electrical stimulation (IVES) combined with a training for bladder motor and sensory dysfunction in the treatment of neurogenic underactive bladder(UAB).Methods:A prospective, single-blind, randomized controlled trial was used to study neurogenic UAB patients admitted to the China Rehabilitation Research Center from October 2019 to May 2021. Inclusive criteria included age≥18 years old, the patients who have been diagnosed as neurogenic UAB and the course of disease being more than 3 months; patients who have been undergone intermittent catheterization to empty the bladder or patients indicated for intermittent catheterization (post-void residual urine accounts for more than 40% of the functional bladder volume), voluntary signing of written informed consent, able to communicate well with researchers and comply with the requirements of the whole trial, and the patient not undergoing any treatment other than oral medication before IVES. Exclusion criteria included patients with low bladder compliance by urodynamic examination(<20 ml/cmH 2O), patients with mechanical outflow obstruction, patients with complete spinal cord injury, the patients with symptomatic urinary tract infection which was not cured, patients with hydronephrosis or bladder-ureteral reflux, patients with renal insufficiency(serum creatinine greater than 1.5 times of the upper limit of normality), patients with malignant tumors of the bladder or prostate, overactive bladder, Alzheimer's disease, brain atrophy, acute cerebrovascular disease, or cognitive impairment, patients who were pregnant or planning to be pregnant, bladder mucosa injury, patients with pacemakers or defibrillators, those who participated in other clinical trials 3 months before the study, and other circumstances that the researcher consider it is not suitable to be involved in this study. The patients were randomly divided into experimental group and control group according to the ratio of 1∶1. The experimental group used conventional transurethral insertion of bipolar catheter electrodes for IVES combined with bladder motor and sensory dysfunction training, and the control group underwent IVES with open circuit combined with bladder motor and sensory dysfunction training. The stimulation parameters of the two groups were two-way square wave, 1-30 mA intensity, 10-20 Hz frequency, 200 μs pulse width, once a day, lasting 30 minutes for each treatment, and for continuous 20 working days. The post-void residual urine, voiding efficiency, 24-hour intermittent catheterization times, first sensation of bladder filling volume and American Urological Association Symptom Index Quality of Life(AUA-SI-QOL) scores were recorded before and at the end of treatment. The adverse events during the treatment were recorded. Results:Fifty-two patients were selected and 50 patients completed the trial, including 26 patients in the experimental group and 24 patients in the control group. Before treatment, there were no significant differences in gender[16(male)/10(female)vs.13(male)/11(female), P=0.598], age [(40.7±13.5)years vs.(38.5±12.3)years, P=0.543], course of disease[0.71(0.42, 1.63)years vs.0.79(0.42, 1.50)years, P=0.695], post-void residual urine[300(193, 400)ml vs.325(178, 380)ml, P=0.724], voiding efficiency[17%(0, 47.8)% vs.21%(0, 38.0)%, P=0.960], 24-hour intermittent catheterization times[4(2, 4)vs.3(2, 4), P=0.692], first sensation volume during bladder filling[(325.8±74.3)ml vs.(307.5±75.0)ml, P=0.391] or AUA-SI-QOL scores[5(4, 5)vs.4(4, 5), P=0.313] between the experimental group and the control group. At the end of treatment, the post-void residual urine, first sensation volume during bladder filling and AUA-SI-QOL scores of the experimental group were significantly lower than those of the control group [250(40, 350)ml vs.300(200, 390)ml, P=0.034; (276.5±68.8)ml vs.(315.4±67.3)ml, P=0.049; 4(2, 4)vs.4(3, 5), P=0.024], and the voiding efficiency was significantly higher than that of the control group[33%(14.5, 84.5)% vs.18%(0, 35.8)%, P=0.041], but there was no significant difference in the number of 24-hour intermittent catheterization between the two groups [3(1, 4)vs.3(2, 4), P=0.174]. In the control group, there were no significant changes in post-void residual urine, voiding efficiency, 24-hour intermittent catheterization times, first sensation volume during bladder filling and AUA-SI-QOL scores before and after treatment [325(178, 380)ml vs.300(200, 390)ml, P=0.832; 21%(0, 38.0)% vs.18%(0, 35.8)%, P=0.943; 3(2, 4)vs.3(2, 4), P=0.239; (307.5±75.0)ml vs.(315.4±67.3)ml, P=0.257; 4(4, 5)vs.4(3, 5), P=0.157]. In the experimental group, there were significant improvements in post-void residual urine, voiding efficiency, 24-hour intermittent catheterization times, first sensation volume during bladder filling and AUA-SI-QOL scores before and after treatment [300(193, 400)ml vs.250(40, 350)ml, P<0.001; 17%(0, 47.8)% vs.33%(14.5, 84.5)%, P<0.001; 4(2, 4)vs.3(1, 4), P=0.011; (325.8±74.3)ml vs.(276.5±68.8)ml, P<0.001; 5(4, 5)vs.4(2, 4), P<0.001]. During the treatment period, 1 case of abdominal discomfort occurred in the experimental group and 1 case of urethral discomfort in the control group. After adjusting the stimulation intensity and catheter position, the discomfort disappeared without other serious adverse events. Conclusions:IVES combined with bladder motor sensory dysfunction training can not only effectively improve the bladder emptying efficiency and bladder sensation in patients with neurogenic UAB, but also be safe and easy to operate.
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Objective:To analyze the predictive factors of postpartum SUI, and establish and validate nomogram model.Methods:A total of 272 patient from Affiliated Jinhua Hospital, Zhejiang University School of Medicine were reviewed, and the general clinical data and ultrasound parameters were analyzed. The median age (range) was 32 (28-38) years. Vaginal delivery was recorded in 191(70.0%), while cesarean section was performed in 81(30.0%) cases. The average body mass index (BMI) was (23.0±2.9) kg/m 2. The median bladder neck mobility was 2.5cm and rate of bladder neck funnel was 25%. Patients were divided into two groups: Group SUI(n=98) and Group NSUI (without SUI, n=174). The independent predicting SUI were analyzed by univariate and multivariate logistic regression analysis. Two predictive models were constructed with the important general clinical data and ultrasound parameters, then receiver operating characteristic (ROC) curve analyses were conducted to evaluate the predictive power of two models. At last, the nomogram was established for the better model. Results:The results of multivariate analysis showed that age( OR=1.08, P=0.011), delivery method( OR=9.26, P<0.01), body mass index( OR=1.15, P=0.023), bladder neck distance ( OR=1.73, P=0.047) and bladder neck funneling( OR=18.44, P<0.01) were independent predictors for SUI. Two predictive models were used with independent predictors of SUI. The area under the receiver operating characteristic(ROC)curve of validation group was 0.88. The area under the ROC curve of general clinic factors was 0.77. The difference between the two model and other indicators was statistically significant( P<0.001). The nomogram model was well calibrated, with the mean absolute error of 1.9%. Conclusions:Age, delivery method, BMI, bladder neck mobility and bladder neck funneling were independent predictors for SUI. The nomogram model for predicting SUI has a good statistical significance.
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Objective:Evaluate the influence of different pressure transmission media of urodynamic water filled catheter(WFC) and air charged catheter(ACC) on the pressure measurement results to determine whether they can be used interchangeably.Methods:The results of 2 147 patients who underwent urodynamic examination in our hospital from January 2014 to December 2020 were retrospectively analyzed. A total of 2 538 times of bladder manometry data were obtained, including 1 299 times in WFC group, 856 times in male and 443 times in female, aged 37(24, 50)years, course of disease 1.2(0.4, 5.0) years, 1 130 times in neurogenic bladder(NB)and 169 times in non-neurogenic bladder(N-NB); In ACC group, there were 1 239 times, 773 times for male and 466 times for female, with age of 37(24, 55)years, course of disease of 1.5(0.5, 6.0)years, 1 040 times for Nb and 199 times for N-NB. There was no significant difference in baseline data of general clinical data between the two groups. The intravesical pressure(Pves), intra-abdominal pressure(Pabd)and detrusor pressure(Pdet) of WFC and ACC patients during filling and urination were analyzed. For traumatic spinal cord injury(SCI) and idiopathic patients, the two sets of pressure measurement data were analyzed separately. Nonparametric test and Chi-square test were used to compare the Pves, Pabd, and Pdet recorded by the two manometry catheters before, at the end and after urination, the maximum detrusor pressure at DO(Pdet.max-DO), and the maximum detrusor pressure during spontaneous urination (Pdet. max) and the detrusor pressure (Pdet.Qmax) corresponding to the maximum urine flow rate, the maximum urethral pressure (MUP) and the maximum urethral closure pressure (MUCP) during resting urethral pressure profile, and the initial cough Pdet signal pattern (typeⅠ, typeⅡand typeⅢ).Results:Regardless of the cause, the Pabd values measured by ACC were significantly higher than WFC before filling, end filling and after voiding[18(10, 26)cmH 2O vs.15(11, 21)cmH 2O; 23(16, 31)cmH 2O vs. 20(14, 26)cmH 2O; 23(15, 31)cmH 2O vs.18(12, 24)cmH 2O], and Pdet were significantly lower than WFC[0(0, 0) cmH 2O vs. 0(0, 1)cmH 2O; 5(1, 13)cmH 2O vs. 9(4, 17)cmH 2O; 6(1, 12)cmH 2O vs. 7(3, 14)cmH 2O]. In the initial cough state, Pves and Pabd increase value were also significantly lower than that of WFC [22(12, 36)cmH 2O vs. 23(14, 38)cmH 2O; 20(10, 33)cmH 2O vs. 21(12, 36)cmH 2O]. The Pves measured by ACC was also significantly higher than WFC before filling and after voiding[18(10, 27)cmH 2O vs. 16(11, 21)cmH 2O; 30(22, 39)cmH 2O vs. 26(20, 36)cmH 2O]. Maximum urethral pressure (MUP) and maximum urethral closure pressure (MUCP) measured by ACC were significantly higher than WFC [91(69, 118)cmH 2O vs.81(64, 106)cmH 2O; 77(55, 103)cmH 2O vs. 68(48, 91)cmH 2O], and there were no significant differences in Pdet.max-DO、Pdet.max和Pdet.Qmax. For patients with traumatic SCI, the Pves measured by ACC was significantly higher than WFC before filling[15(10, 24)cmH 2O vs. 14(10, 20)cmH 2O], and only MUP was significantly higher than WFC in the measurement of urethral pressure[95(71, 119)cmH 2O vs. 85(65, 112)cmH 2O], and there were no significant differences in Pdet.max-DO, Pdet.max, Pdet.Qmax and MUCP. For idiopathic patients, Pves measured by ACC before filling and after urination were significantly higher than WFC[25(20, 29)cmH 2O vs. 18(11, 23)cmH 2O; 35(29, 44)cmH 2O vs. 28(20, 38)cmH 2O], while Pdet.max-DO, Pdet.max, Pdet.Q max, MUP and MUCP were not significantly different in different pressure measurement systems. For the comparison of the initial cough Pdet signal pattern, ACC is easier to detect type Ⅰ, and WFC is easier to detect type Ⅱ and type Ⅲ. Conclusions:Compared with WFC, ACC measured higher Pves and Pabd and lower Pdet in resting state, and lower Pves and Pabd in initial cough state. The pressure values and signal pattern measured by WFC and ACC are not completely consistent, so they cannot be used interchangeably.
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Objective:To observe central responses and functional connectivity (FC) during urinary bladder storage in neurogenic overactive bladder (NOAB).Methods:Twenty patients with NOAB were recruited. Resting state functional magnetic resonance imaging (rs-fMRI)were performed in all subjects under the following two conditions: empty bladder state and full bladder (strong desire to void)state. Software MATLAB, SPM8 and DPABI were adopted to analyze the difference of brain imaging between the two conditions. Voxel-based analysis of the REHO was performed to analyze rs-fMRI data including the main excitatory regions and inhibitory areas, peak value(X-axis, Y-axis, Z-axis), clusters size (active volume unit: number of voxel), T value(the excitatory and inhibitory extent of brain active regions). Voxel-based analysis of the REHO maps and FC between empty and full bladder were performed.Results:Increased activity during strong desire to void with NOAB patients was observed in the left orbital part of superior frontal, right middle frontal gyrus, and right superior frontal. Decreased activity was observed in right precentral. FC analysis found that these activated or deactivated brain regions were widely connected with other brain areas, include: frontal lobe, parietal lobe, temporal lobe, cingulate gyrus, lenticular nucleus, insular lobe, angular gyrus, parahippocampal gyrus and anterior and posterior central gyrus.Conclusions:Our results suggested that the right frontal robe may play a role in the control of bladder with NOAB during strong desire to void, and inhibitory areas located in right precentral. In NOAB patients, excitatory and inhibitory connections were increased in frontal lobe and central gyrus, decreased in insular lobe and parhippocampal gyrus.
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Objective:To detect the abnormalities within the functional connectivity (FC) of the prefrontal cortex (PFC) in patients with overactive bladder (OAB) and to explore its central pathogenesis.Methods:Seven OAB patients (OAB group, 6 females, mean age 47.6±16.0 years) and 13 healthy controls [HC] (HC group, 10 females, mean age 49.9±9.2 years) were prospectively enrolled from August to December 2020. All subjects underwent rs-fNIRS scanning synchronized with urodynamic monitoring, and two rs-fNIRS scans were performed when the bladder was empty and when the desire to void was strong/urodynamic monitoring indicated detrusor hyperactivity (DO). The Pearson's correlation coefficients (r value, i. e., FC value) between time series of the 22 channels were calculated, and a 22×22 FC matrix for each subject was obtained. A paired-sample t-test ( P<0.05, FDR corrected) was used to compare the difference in FC values between the HC group and the OAB group when the bladder was empty and the desire to void was strong. A two-sample t-test ( P<0.05, FDR corrected) was used to compare the group differences in FC values between OAB and HC groups. Results:In this study, 7 patients were included in the OAB group, including 1 male and 6 female. The mean age was (47.6±16.0) years old. In HC group, 13 healthy subjects were included, including 3 males and 10 females. The mean age was (49.9±9.2) years. There was no significant difference in baseline data between the two groups, including age, sex composition, years of education, handedness and urgency score at the second scan ( P>0.05). Residual urine volume in both groups was less than 10 ml. The OABSS score, 3-day urine diary parameters (frequency of urination/24 h, frequency of urinary incontinence/24 h, frequency of urgency/24 h) and maximum detrusor pressure during urine storage in OAB group were significantly higher than those in HC group, with statistical significance ( P<0.01). The average urination volume/time, bladder capacity at first sensation and maximum bladder capacity in OAB group were significantly lower than those in HC group, and the differences were statistically significant ( P<0.01). In the process of bladder filling to strong desire to void, the detrusor pressure in HC group was stable without DO, and 6 cases in OAB group had DO. Compared to empty bladder state, healthy subjects with strong desire to void showed significantly increased FC within PFC in 5 Brodmann area (BA9, BA10, BA44, BA45, BA46)and 13 edges, such as the BA9(left dorsolateral prefrontal cortex [DLPFC]: ch 4, 5, 7 and right DLPFC: ch 3), BA10(left frontopolar area: ch 12, 21 and right frontopolar area: ch 10, 18), BA44(left pars opercularis Broca's area: ch 15), BA45(left pars triangularis: ch 22), BA46(left DLPFC: ch 6, 14); significantly decreased FC in 3 brain regions (BA9, BA10 and BA46) and 2 edges, such as the BA9(left DLPFC: ch 7), BA10(left frontopolar area: ch21 and right frontopolar area: ch 17), BA46(right DLPFC: ch 9). There was no significant difference in FC within PFC between OAB and HC groups with empty bladder. However, during the strong desire to void state, the FC within PFC in OAB patients was significantly abnormal when compared with HC. OAB patients showed significantly increased FC within PFC in 4 brain regions (BA9, BA10, BA45 and BA46) and 4 edges, such as the BA9(right DLPFC: ch 1 and left DLPFC: ch 7), BA10(right frontopolar area: ch 17), BA45(left pars triangularis: ch 22), BA46(right DLPFC: ch 9, 16); significantly decreased FC in 3 brain regions (BA9, BA10 and BA46) and 4 edges, such as the BA9 (right DLPFC: ch 3 and left DLPFC: ch 4), BA10(left frontopolar area: ch 12, 21), BA46(left DLPFC: ch 14) Conclusion:Compared with HC group, the PFC in OAB group showed significant abnormalities, which may lead to "dyssynergia" of PFC internal functions, result in frontal lobe dysfunction, involving sensory integration, motivation drive, emotional control and decision whether to urinate or not, etc., leading to urinary control dysfunction, which manifested as typical clinical symptoms of OAB. Our findings contribute to the understanding of the central pathogenesis of OAB and may provide a theoretical basis for the emergence of targeted brain therapy in the future.
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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.