[Long-term safety and efficacy of trospium chloride for the treatment of neurogenic overactive bladder due to Parkinson's disease is there an effect on cognitive status?]

AIM: To evaluate the efficiency of long-term use of trospium chloride (Spazmex) for the treatment of patients with neurogenic overactive bladder due to Parkinson's disease (PD) and to determine the influence of therapy on the cognitive status of patients. MATERIALS AND METHODS: 60 patients with PD and neurogenic overactive bladder with stages 2.5, 3 and 4 according to Hoehn-Yahr scale were included in the main group. The mean age was 58.2+/-5.7 years. All patients were prescribed trospium chloride at entry into the study, with doses titrated gradually according to clinical efficacy (30 to 90 mg). The comparison group included 15 patients with PD and neurogenic overactive bladder at stages 2,5 and 3, who received tibial neuromodulation according to the standard technique with skin electrodes. The mean age of patients was 56.4+/-4.6 years. At baseline, both groups were comparable in terms of gender, age and cognitive status (p=0.801). All patients received treatment for 52 weeks. The efficiency of therapy was assessed according to bladder diaries, while safety outcomes included postvoid residual, side effects, cognitive status according to the MoCA scale and quality of life according to the SF-Qualiveen questionnaire. RESULTS: clinical efficacy and satisfaction were achieved in all patients who completed the study (47 patients in the main group and 15 patients in the comparison group). Good clinical efficacy was demonstrated in both groups, since there was a decrease in the number of urinations, episodes of urgency and urinary incontinence. In addition, there was an improvement in the quality of life according to the SF-Qualiveen scale. The cognitive status during the entire follow-up period remained without significant changes in both groups. CONCLUSION: Trospium chloride is an effective drug in patients with PD. It does not affect cognitive functions during long-term use. Trospium chloride should be considered as first-line drug in those with urologic manifestations of PD.

[Neurogenic overactive bladder: focus on cognitive function].

BACKGROUND: An overactive bladder and cognitive impairment are two medical and social problems, which have an outmost importance, affecting the quality of life. Both disorders are common in the practice of a urologist, neurologist, internist, and other physicians. Parkinsons disease and multiple sclerosis are the most common neurological diseases, which often manifest by pelvic dysfunction and cognitive dysfunction. The clinician needs to understand the pathogenesis of the underlying disease and the pharmacologic properties of drugs, which can be used both in neurology and urology, as well as in other related specialties. AIM: To evaluate cognitive functions in patients with neurogenic overactive bladder treated with trospium chloride. MATERIALS AND METHODS: A total of 45 patients with neurological disease (28 with Parkinsons disease [group 1] and 17 with multiple sclerosis [group 2]) were included in the study. All patients had symptoms of an overactive bladder. Trospium chloride was administered in an individually adjusted dose for 12 weeks. Cognitive functions were assessed using the international Montreal Cognitive Assessment (MoCA) before and after the therapy. A change of total scores over time was assessed using the paired Wilcoxon test. The level of significance of <0.05 was used (confidence level of 95%). RESULTS: A significant decrease in all studied parameters of an overactive bladder in both groups was seen. The baseline evaluation of the total score on the MoCA scale prior to the start of taking trospium chloride revealed the presence of moderate cognitive impairment (21.3+/-2.9 points) in patients of the group 1. After 12 weeks of therapy, no significant change in cognitive functions was observed (21.7+/-3.1 points; p>0.05). In group 2, moderate cognitive impairment (MoCA 22.5+/-3.7 points) was found at baseline. After taking trospium chloride, no significant changes were noted (MoCA 22.9+/-4.1 points) (p>0.05). No central nervous system side effects were reported in any group. CONCLUSION: Trospium chloride is an effective drug, which does not affect cognitive functions in patients with neurogenic overactive bladder. This drug is safe to use in both Parkinsons disease and multiple sclerosis, considering the low risk of cognitive impairment in polypharmacy.

[The role of male factor in pregnancy loss].

Currently fertility specialists pay close attention to miscarriage. Spontaneous abortion and recurrent pregnancy loss in an early period of gestation are a frequent complication of pregnancy. Etiology of miscarriage includes genetic abnormalities, immunological disorders, endocrine abnormalities, infections and lifestyle factors. About 40% of cases of pregnancy losses remain unexplained. The role of male factor in miscarriages is considered in the review. The influence of advanced paternal ages, sperm DNA fragmentation, chromosomal abnormalities on pregnancy loss in natural conception or by assisted reproductive technique are described.

[Radical cystectomy: therapeutic aspects of preoperative and early postoperative management].

AIM: to improve the results of radical cystectomy by optimization of patient preparation for surgery and early postoperative care. MATERIALS AND METHODS: A total of 136 patients who underwent radical cystectomy and either orthotopic ileal neobladder or ileal conduit formation were included in the study. Brikkers operation was performed in 92 patients (76% men and 24% women) aged from 39 to 83 years, while in 44 patients (97.7% men, 2.3% women) aged from 32 to 75 years the Studer ileal neobladder was created. All patients underwent preoperative comprehensive examinations in order to determine type and extent of surgical treatment. RESULTS: A complication rate after radical cystectomy with urine derivation using bowel segment was 49.2%. Mortality rate in early postoperative period was 3.9%. CONCLUSION: An algorithm of postoperative care after radical cystectomy with formation of either orthotopic neobladder or ileal conduit and consideration of comorbid status and preparation which we have used in clinical practice was developed. According to the results, after implementation of algorithm of management in preoperative and early postoperative period a decrease in complications and mortality rate has been found.

[Current trends in the method used for urine derivation after radical cystectomy for muscle-invasive bladder cancer].

Bladder cancer ranks 7th in the world among all malignant tumors in men and 11th in both sexes. Radical cystectomy is the gold standard of muscle-invasive bladder cancer treatment in most countries of the world. A large number of fundamentally different options for urine derivation is developed. Therefore the choice of the method of urine derivation is one of the most important and difficult in the treatment of such patients. This review covers current international articles on this topic for 2015-2018.

[The incidence of malignant transformation of renal cysts of category 1, 2, and 2F by the BOSNIAK classification into multilocular cystic renal cell carcinoma].

RELEVANCE: Renal cysts remain the most common of benign renal lesions, but current literature is lacking large observational studies on the incidence of their malignant transformation. AIM: To assess the incidence of malignant transformation of renal cysts of category 1, 2, and 2F by the Bosniak classification into multilocular cystic renal cell carcinoma. MATERIALS AND METHODS: From January 2009 to December 2017, 177 patients with renal cysts of category 1 (n=50), 2 (n=74), and 2F (n=53) underwent laparoscopic decortication. In 10 cases, post-operative histological and immunohistochemical studies revealed foci of grade 1 (pT1a) multilocular cystic renal cell carcinoma. RESULTS: Foci of grade 1 (pT1a) multilocular cystic renal cell carcinoma were detected in 10 (5.65%) patients (five men, five women, mean age 58.9 years). The incidence of malignant transformation of renal cysts of categories 1, 2, and 2F was 0%, 2.7% (2 of 74 patients), and 15.1% (8 of 53 patients), respectively. Subsequently, all ten patients were submitted to surgical treatment: eight of them underwent a partial nephrectomy, and two received a nephrectomy. During a median of 49.3 (31-72) months follow-up, no metastasis, and recurrence of multilocular cystic RCC were observed. CONCLUSION: A more modern algorithm for managing patients with Bosniak category 1, 2 and 2F cysts need to be developed to establish early surveillance of patients starting with category 1 cysts. Given the low malignant potential of these tumors, they should be treated with organ-sparing surgery.

[Importance of surgery of quick recovery program for surgical treatment of bladder tumors].

The article presents an analytical review of literature outlining the prospects for the use of the program "Surgery of quick recovery" in the surgical treatment of the bladder malignant tumors. The multi-modal program "Surgery of quick recovery" was found to reduce the number of postoperative complications and shorten recovery of patients with bladder cancer.

[Treatment of exstrophy of bladder in adults].

Exstrophy of bladder in adults is extremely rare, since such anomalies are usually underwent surgery in early childhood. Difficulties in the treatment of adult patients are associated with severe long-term changes of the mucosa and surrounding tissues, chronic urinary infection, as well as a large diastasis between pubic bones and inefficiency of osteotomy. The article describes the methodology and results of the surgery in a patient 33 years old with exstrophy-epispadias after failed previous interventions. During the follow-up period of more than 5 years, there were no complications related to continent reservoir, reconstruction of the anterior abdominal wall, and urinary infection. Decrease in renal function was not observed. Thus, the cystectomy with formation of continent reservoir from the ileum is accompanied by a good functional and cosmetic results. Resection of vesical plate is justified due to severe long-term changes of the mucosa and the surrounding skin, as well as a high risk of malignancy. The use of polypropylene ? allows to reconstruct the anterior abdominal wall without osteotomy and provides a sufficient degree of its strengthening.

[Results of three-year clinical study of prostamol uno efficacy and safety in patients with initial symptoms of prostatic adenoma and risk of its progression].

Prostamol Uno (PU) efficacy and safety were studied in a multicenter, open-population, randomized and comparative trial. PU was given in a single daily dose 320 mg for 36 months to 50 patients with initial symptoms of prostatic adenoma (PA) in comparison with 50 matched controls. The trial evaluated PU action on the symptoms progression and quality of life with application of questionnaires IPSS and QoL (BS). It was found that PU treatment relieved PA symptoms by IPSS, while these symptoms progressed in the controls. QoL improved in the study group and deteriorated in the control one. Administration of PU significantly increased urinary flow rate though in the controls urinary flow rate decreased, size of the prostate diminished and increased, respectively. Changes in the PSA were not seen and were insignificant, respectively. The results of the study say that prostamol Uno in a dose 320 mg/day can prevent PA progression without side effects.

[Overcontinence in females after orthotopic replacement of the urinary bladder].

Treatment results were analysed for 27 patients (mean age 53 +/- 7 years) after orthotopic urinary diversion (by the method of Studer, Hautmann) following radical cystectomy. Radical cystectomy was performed without nerve preservation in all the patients. Overcontinence was detected in 4 (26.6%) of 15 patients who had undergone urinary diversion by a conventional method. At the average, residual urine was 220 ml. The modified operation for prevention of urine retention was made in 12 subsequent cystectomies. Neobladder topography was studied with MR imaging (MRI) of the pelvic organs and videoroentgenoreservoiroscopy, urodynamic examination was combined with electromyography of the pelvic base muscles. MRI has found that in patients without retention the reservoir was above linea pubbo-coccigeus both at rest and voiding. In patients with overcontinence at rest topographic details by MRI did not differ from those in patients without retention but in stress reservoir changed position. The modification proposed allows one to avoid change in reservoir position and to prevent formation of acute urethra-reservoir angle. Thus, the cause of retention (overcontinence) of the continent orthotopic intestinal neobladder is eliminated.

[Determination of optimal length of extramural tunnels for their adequate anticurrent properties in intestinal urine derivation].

An acute experiment on adult dogs with conduction of manometry in outlets and inlets in reservoir filling and with Valsalva's test has established that reliable continent properties of the anti-current mechanisms are provided in creation of the tunnel with functional length 5 cm minimum leading to proportional rise in pressure in reservoir and in outlet. Pressure in the outlet was approximately 2 times higher than in the reservoir. In tunnel length 4 cm Valsalva's test registered leaking. The results obtained contributed to effective clinical use of the method.

[Forming of straight urointestinal anastomosis at enteric replacement of urinary bladder].

Problem of decreasing the complications rate of intestinal urine derivation is very relevant. One of the most important problem is the stricture of urointestinal anastomosis. The problem of the choice of antireflux or direct method of ureters implantanion is not solved. Results of forming of 186 renoureteral units (RUU) according to direct method and 70 RUU according to antireflux method were analyzed by the authors. Straight anastomosis was applied according to Wallace 1 and 2 technique, antireflux--according to Abol-Enein technique or by means of transverse duplicating. Age of the patients ranged from 16 to 76 years (56 years on average); men prevailed in groups. Terms of supervision ranged from 6 to 108 months (54.6 months on average). Strictures and failure of ureteroreservoir anastomosis using Wallace method were not revealed (0%), then using antireflux methods (transverse duplicating or extramural Abol-Enein tunnel) the frequency of complication amounted 2.8% on average. Strictures after antireflux mode in case of their early exposure were successfully corrected using endoscopic methods. In other cases open revision of anastomoses with their repeated apply was carried out. Reno-reservoir reflux was not observed in any cases after antireflux methods. Clinical manifestation of reflux was revealed at 2 RUU. Basing on the data renal radionuclide of image renal function didn't significantly change after direct or antireflux methods of ureters implantation. Wallace method is remarkable for its technical usability. This method ensures low level of complications after as incontinent and continent urine derivation.

[Heterotopic urine derivation in females with urinary bladder extrophy].

Fifteen females aged from 17 to 31 years with bladder extrophy (the condition after ureterosygmostomy) have undergone heterotopic urine derivation with creation of a cutaneous urine-retention catheter mechanism. Surgery was indicated in progressive decline of renal function in the presence of renal reflux, total urine incontinence in the failure of pelvic floor muscles and rectal sphyncter apparatus. Creation of cutaneous urine-retention catheter mechanism was made by the following techniques: heterotopic plastic repair from the ileocecal angle by Mainz pouch I (11 patients, 73.4%); heterotopic W ileocystoplasty by Abol-Enein (4 patients, 26.8%). Implantation of both ureters was conducted by Wallace technique in 4 (26.7%) cases. In 7 (46.6%) patients ureteral implantation was performed with antireflux defense by the method of cross dublicate creation. Four (26.7%) patients with small intestinal derivation have undergone extramural implantation of the ureters according to Abol-Enein. The results show that conversion of ureterosygmostomy in heterotopic urine derivation with one-stage genital reconstructive interventions decreases the number of potential complications, improves surgical outcomes and provides much better medico-social rehabilitation. Heterotopic intestinal continent derivation of urine is an operation of choice in women with urinary malformations. In such patients orthotopic urine derivation is impossible.

[A comparative analysis of antireflux and direct methods of ureteral implantation in intestinal continent urinary derivation].

Intestinal continent urinary derivation was made from 1997 to 2006 in three groups of patients. The following kinds of derivation were performed: ureterosygmostomy according to Maintz-Pouch and Abol-Enein modification (group 1, n=32); heterotopic replacement of the urinary bladder in various modifications (group 2, 50 patients); orthotopic replacement according to Hautmann, Studer, Abol-Enein, sygmocystoplasty, n=51). In group 1 ureterosygmoanastomosis was created only by antireflux methods: Goodwin and Hohenfellner submucous technique and Abol-Enein extramural implantation. In groups 2 and 3 uretero-intestinal anastomosis was created by Wallace direct implantation and antireflux--Abol-Enein extramural implantation. The patients were followed up from 6 months to 9 years. The results show that both methods are effective. The antireflux methods are preferable in detubulizing ureterosygmostomy, in extended atonic ureters in case of creation of continent heterotopic and orthotopic reservoirs. The problem of antireflux mechanisms in creation of neobladder needs further investigation.

[Intestinal replacement of the urinary bladder with creation of continent cutaneostomy].

Continent urine derivation with creation of cutaneous urine-retaining catheter mechanism was conducted in 28 patients. Indications for surgery were the following: contracted urinary bladder in combination with long obliteration of the urethra, urinary bladder extrophy (the condition after ureterosygmostomy), urinary bladder cancer, arteriosclerotic urinary bladder. Creation of cutaneous urine-retaining cather mechanism was performed according to the following methods: urine derivation by Minez pouch I (with creation of appendistoma) was made in 14 patients; extending intestinoplasty by Minez pouch (creation of intestinal reservoir from ileocecal angle with catheter appendicostoma) was made in 8 patients; extending ileoplasty with catheter ileostoma by Huder--2 patients; creation of a reservoir of the ileum with catheter ileocutaneostoma by extramural technique of Ald-Enein--2 patients; extending intestinoplasty with catheter ileostoma--2 patients. Implantation of the ureters was made using principles of antireflux defense.

[Analysis of efficacy of extensive systematic transperineal TRUS-guided cor biopsy of the prostate].

The paper presents the technique of extensive systemic transperineal TRUS-guided cor biopsy of the prostate. Some aspects of the patients' safety and quality of biopsy cores are considered. The analysis of TNM stages of the detected cancers (55 cases out of 142 patients who have undergone systemic biopsy) showed 65.4% of local cancer (T1-2). The quality of cores was adequate for histological examination in 92.8% cases. None serious complications was reported. Only in two of ten patients subjected to radical prostatectomy stage T2 was changed to stage T3 in the absence of metastases to regional lymph nodes and distant metastases.

[Oncology and urology: relations between specialities].

The article presents the analysis of present-day medical care for patients with urogenital cancer (UGC) in the Russian Federation (RF). In 2004 cancer treatment service in the RF has 8 Research Cancer and Radiological Institutes, 110 inpatient and 7 outpatient cancer clinics. According to the statistics for 1998, UGC patients are treated in 32 specialized departments in 24 regions. The rest regions provide such care in urological departments and clinics. In view of the importance of oncourology nowadays, we propose to set up an oncourological section at All-Russia Urology Society as a center of integration of efforts of specialists in oncourology.