Angular Power Spectrum of Gravitational-Wave Transient Sources as a Probe of the Large-Scale Structure.

We present a new, simulation-based inference method to compute the angular power spectrum of the distribution of foreground gravitational-wave transient events. As a first application of this method, we use the binary black hole mergers observed during the LIGO, Virgo, and KAGRA third observation run to test the spatial distribution of these sources. We find no evidence for anisotropy in their angular distribution. We discuss further applications of this method to investigate other gravitational-wave source populations and their correlations to the cosmological large-scale structure.

[POSITION STATEMENT ON OVERACTIVE BLADDER].

INTRODUCTION: Bothersome urinary symptoms during the storage phase are common among women and men. These symptoms described as urinary urgency, frequency and nocturia with or without urge urinary incontinence may be caused by various pathologies including bladder overactivity. Diagnosis of an overactive bladder is based on the patient's clinical presentation after exclusion of other disorders that may cause these symptoms. The minimal requirements for a urological evaluation include medical history, physical examination and urinalysis. Behavioral therapies and medical therapy are the mainstay of treatment for an overactive bladder. While the use of minimally invasive procedures are reserved for patients not interested in medications or for those patients in whom symptoms were not improved by other therapies. Treatment outcome is evaluated by documentation of changes in symptoms, signs and quality of life. This position statement paper represents the approach of the Israeli Urological Association regarding the evaluation and treatment of overactive bladder syndrome.

Correlation between MRI and double-balloon urethrography findings in the diagnosis of female periurethral lesions.

This study aims to evaluate the correlation of MRI findings with double-balloon urethrography (DBU) in diagnosing female urethral diverticula and other periurethral lesions. In this retrospective study, females with clinically suspected periurethral lesions who underwent both MRI and DBU between 2008 and 2012 were evaluated. MRI was performed on a 1.5 Tesla unit using a pelvic phased array coil. Protocol included small FOV pelvic images, multiplanar T2-w, T1-w with and without contrast injection. DBU was performed by a dedicated catheter. Images were evaluated in consensus by two readers. Diverticula were evaluated by, size, number, complexity, location and connection to urethra, and other periurethral lesions were evaluated by size, location and connection. Supplement clinical and surgical data were retrieved from medical records and telephone interviews. Seventeen females (mean age 44 years, range 20-69) were included in the study. Diverticula were diagnosed by both modalities (9 cases), by neither (6 cases, 88% correlation) by MRI alone (1 case) and by DBU alone (1 case). Among diverticula, correlation of number, complexity, location and demonstration of connection to urethra was 89%, 67%, 67%, and 56%, respectively. Alternative diagnosis solely by MRI included vaginal wall cysts (3 cases), endometriosis (1 case) and ectopic ureter (1 case). No periurethral lesion was found by either modality in 2 cases. The correlation between MRI and DBU in diagnosing female periurethral lesions is very good for anatomical delineation of diverticula. MRI, which does not involve radiation, may also indicate alternative diagnoses that can contribute to proper patient management.

Depressive symptoms and treatment of women with urgency urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Depression is more common in patients with urinary incontinence (UI). Drug or rehabilitation therapy have been shown to be effective in reducing urgency UI (UUI) symptoms, but whether these treatments can ameliorate the negative impact of UUI on the psychological aspects of quality of life is unclear. METHODS: A secondary analysis of an assessor-blinded randomized controlled trial was performed. The number of depressive symptoms was the primary outcome as measured by the Center for Epidemiologic Studies Depression scale (CES-D). RESULTS: Thirty-six (22%) subjects had a CES-D score >16 at baseline, the cutoff for having depressive symptoms. A significant association was found between having a CES-D score >16 and lower quality of life related to UI at baseline. The mean CES-D score among those with depressive symptoms at baseline was significantly reduced throughout the study, with a mean of 23.7 at baseline, to 18.3 and 15.2 at the 3-month and 1-year follow-up (p < 0.001), respectively. The number of participants who had depressive symptoms decreased during the study period only in the physical therapy groups, from 31 at baseline to 28 and 25, at 3 and 12 months, respectively, while there was no such change in the drug group. CONCLUSIONS: Patients with UUI who had depressive symptoms showed significant improvement in their depressive symptoms with treatment over 1 year. This improvement occurred regardless of the type of treatment. This study emphasizes the increasingly recognized problem of undiagnosed depression among middle-aged women with UUI.

Long-term urinary bladder function following unilateral refluxing low loop cutaneous ureterostomy.

PURPOSE: Unilateral low loop cutaneous ureterostomy (LLCU) has been offered as the preferred method of temporary urinary diversion in cases of massively dilated and refluxing ureters. We sought to explore whether LLCU is effective in preserving urinary bladder function in the long term. MATERIALS AND METHODS: The charts of all patients who had undergone temporary unilateral LLCU as newborns in the presence of massive vesico-ureteric reflux were retrospectively reviewed. Demographic data, follow-up length, and presence of incontinence were recorded. Patients were interviewed regarding lower urinary tract symptoms (LUTS), and their urination patterns were recorded by using uroflow and post-void residual (PVR) measurements. RESULTS: Between 1972 and 2003, a total of 24 patients underwent unilateral LLCU in the presence of massively refluxing ureters. Eight patients were included in the final analysis. The median age at diversion was 12 days, the median time to closure was 22.5 months, and the median follow-up was 12.5 years. Urinary bladders showed normal contour, normal capacities, and minimal PVRs in most cases. None of the patients required augmentation cystoplasty. One patient suffered from urinary leakage and few demonstrated minimal LUTS. CONCLUSIONS: Unilateral refluxing LLCU is an effective method of urinary diversion that preserves urinary bladder function for the long term. Larger studies are required to confirm this finding.

Self-report function and disability: a comparison between women with and without urgency urinary incontinence.

PURPOSE: To compare self-reported function and disability between women with urgency urinary incontinence (UUI) and healthy controls. METHOD: Self-reported function and disability were evaluated using the Late Life Function and Disability Instrument (LLFDI) in 66 women with UUI (mean age 61.9 ± 5.6) and 66 age-matched control women without UUI in a cross-sectional study. The function component evaluates difficulty in performing physical activities in upper and lower extremities and the disability component evaluates limitations in life activities and frequency in taking part in life tasks. Body Mass Index (BMI), self-report incontinence quality of life questionnaire (I-QoL) and Visual Analog Scale (VAS) that indicate the degree to which the bladder problems limited the subject's daily life activity were also evaluated. RESULTS: The LLFDI scores in overall function, basic and advanced lower limb function, were significantly lower in women with UUI compared with continent women, while the upper extremity function and disability components were not. There was significant negative correlation between BMI and function scores in women with UUI. CONCLUSION: Our results support the assumptions that the women with UUI are likely to show poorer lower extremity physical functioning and that disability is a multifactorial combination of behavioral, psychological and environmental factors, and not functional limitations per se.

Reproducibility of ultrasonic measurements of pelvic floor structures in women suffering from urinary incontinence.

The aim of this study was to examine the reproducibility of ultrasound (US) findings relating to pelvic floor muscle in women with urinary incontinence (UI). Eighteen women with UI were examined twice by the same examiners over an interval of 1 month. The US findings comprised of (1) distance between bladder neck and symphysis pubis (BN/SP) at rest, during contraction, and while performing the Valsalva maneuver and (2) distance between anorectal angle and symphysis pubis (AR-SP) during the same conditions. Statistical analysis included test-retest correlations (ICC(3,K)), and the assessment of measurement error and smallest real difference (SRD) for change. BN-SP and AR-SP exhibited high ICCs. The lowest SRD values related to the AR-SP variables (10-19%). US-based measures of the bladder neck and the anorectal angle, distance, and displacement seem to offer reasonable clinical reproducibility.

Renal artery occlusion during nephron-sparing surgery: retrospective review of 301 cases.

OBJECTIVES: Temporary occlusion of the renal artery during nephron-sparing surgery may facilitate complete tumor resection and reduce operative bleeding. However, it may also entail a greater risk of ischemic kidney damage. In contrast, when vascular occlusion is not applied, the risk of bleeding, as well as the risk of positive margins, may be increased. To study these issues, we retrospectively evaluated our results with nephron-sparing surgery for kidney masses using renal artery occlusion compared with patients in whom vascular occlusion was not applied. METHODS: From 1988 to 2003, 301 consecutive patients underwent nephron-sparing surgery for a kidney mass at our institutions. At the surgeons' discretion, the renal artery was temporarily occluded in 181 patients (60%) and was not in 120 (40%). RESULTS: No statistically significant differences were found between the two groups regarding blood loss, transfusion rates, and overall complication rates. The loss of the renal unit because of ischemia was noted in 2 patients (1.2%) after renal artery occlusion and in none of the nonoccluded group. Positive tumor margins were found in 5 patients (4.2%) in the nonoccluded group and in 1 patient (0.6%) in the vascular occlusion group. CONCLUSIONS: Our results suggest that although vascular occlusion during nephron-sparing surgery may increase the risk of permanent kidney damage, patients with no vascular occlusion may have a greater risk of positive tumor margins after surgery. These two factors should be taken into consideration and could be discussed with the patient when attaining informed consent.

Fascial patch technique for repair of complicated urethrovaginal fistula.

INTRODUCTION: The operative repair of urethrovaginal fistula due to tension-free vaginal tape (TVT) erosion is a challenging task, and coexisting stress urinary incontinence may complicate the situation even further. We present our technique for the repair of recurrent urethrovaginal fistula combined with stress urinary incontinence, occurring after previous removal of an eroded TVT and failed repair of the fistula. TECHNICAL CONSIDERATIONS: With the patient in the dorsal lithotomy position, an inverted U-shaped incision was cut in the anterior vaginal wall, and a vaginal flap was developed. The Martius flap from the previous repair was identified and separated from the urethra, thereby disclosing a large fistula hole on the left side of the mid-urethra. Because the periurethral tissues were very friable and attenuated, only one-layer closure of the fistula hole with these tissues was feasible. Therefore, we opted to combine a pubovaginal fascial sling with a fascial patch graft, used to reinforce the fistula site. Through a low transverse abdominal incision, a 15 x 2-cm strip of rectus fascia was harvested. A 2 x 2-cm patch of fascia was excised from the strip and transfixed to the periurethral tissues, covering the sutured fistula site. The Martius flap was repositioned over the flap, and a pubovaginal sling procedure was done. The postoperative course was uneventful, the fistula has healed, and the patient regained full continence. CONCLUSIONS: This technique can be used in complicated urethrovaginal fistula repair when the surrounding periurethral tissues have been devastated and can be combined with pubovaginal fascial sling placement.

Spontaneous reduction of bladder base prolapse with gradual filling: a video-urodynamic observation.

OBJECTIVE: To report video-urodynamic observations on the effect of gradual bladder filling on the degree of bladder base prolapse while erect, as the effect of bladder fullness on the degree of bladder base descent in patients with a cystocele has rarely been addressed. PATIENTS AND METHODS: Thirty-six consecutive patients with complaints of a protruding vaginal mass due to bladder prolapse underwent video-urodynamic studies, comprised of filling and voiding cystometry with contrast material, while standing. RESULTS: During filling cystometry, in 16 of 36 patients (44%) the prolapse gradually and spontaneously reduced with increasing bladder volumes, so that at cystometric capacity the bladder base was completely reduced. Straining at cystometric capacity did not affect the bladder base position and, during voiding cystometry, the bladder base remained completely reduced. In the remaining 20 patients there was only partial reduction of the cystocele during bladder filling, i.e. the cystocele was reduced by half or less. Seven of the 16 patients with a full reduction of cystocele had concurrent uterine prolapse, compared with 15 of 20 (80%) who had only partial or no spontaneous reduction; the difference was statistically significant (P = 0.02). CONCLUSION: These video-urodynamic results suggest that when erect the degree of bladder base descent is volume-dependent, and that concomitant uterine prolapse might hinder spontaneous reduction of the cystocele.

Laparoscopic partial nephrectomy: is it advantageous and safe to clamp the renal artery?

OBJECTIVES: To compare the outcomes of laparoscopic partial nephrectomy (LPN) performed with and without vascular clamping and to evaluate the impact of clamping on postoperative renal function. METHODS: A total of 45 patients underwent LPN, 29 with and 16 without vascular occlusion. The two groups were compared regarding complication rates, blood loss, conversion rates, operative time, mean tumor size, and incidence of positive margins. Renal function was evaluated by postoperative dimethyl mercaptosuccinic acid scans. RESULTS: The mean blood loss was lower when vascular clamping was applied (320 versus 510 mL, P <0.05) than when it was not. The conversion rates were similar (10.3% versus 12.5%), and the mean operative time was shorter in the nonclamped group (115 versus 126 minutes). Urinary leakage occurred in 2 patients, 1 from each group. The mean tumor diameter was 3.2 cm in the clamped and 1.9 cm in the nonclamped group (P <0.05). In 2 patients (12.5%) in the nonclamped and 1 patient (3.4%) in the clamped group, the surgical margins were focally positive for tumor. The mean warm ischemia time was 28 minutes, and dimercaptosuccinic acid scans performed in 18 patients showed normal ipsilateral renal function (mean relative function 48%). CONCLUSIONS: LPN without vascular clamping is feasible in selected cases. However, clamping of the artery seems to be associated with reduced blood loss and a lower incidence of positive margins. Moreover, according to the postoperative dimercaptosuccinic acid scan findings, limited warm ischemia does not seem to result in permanent renal damage. We suggest that clamping of the renal artery should be considered during LPN, even for very small, superficial tumors.

[May children and adolescents with a solitary kidney participate in sports activities?].

The presence of a solitary kidney in children and adolescents is not a rare condition, and flank injury in this context may result in renal impairment, with subsequent nephrectomy, dialysis or kidney transplantation. Participation in sports activities commonly results in pediatric injuries, and the kidneys are the most frequently affected organs during blunt abdominal trauma. Nonetheless, the incidence of major renal trauma during sports activities, according to pediatric trauma registries in the United States, is still relatively low. Subsequently, there is an ongoing debate in the literature regarding the safety of participation of children with a solitary kidney in sports activities. The literature review presented reveals that the general recommendation has shifted from a formerly restrictive attitude towards a more permissive one, based upon pooled data and calculated risks.

Laparoscopic nephrectomy: initial experience in Israel with 110 cases.

BACKGROUND: Data during the last decade show that laparoscopic nephrectomy is becoming an accepted and advantageous minimally invasive alternative to the open procedure. OBJECTIVE: To evaluate the efficacy, safety and reproducibility of laparoscopic nephrectomy in a series of 110 consecutive procedures. METHODS: A total of 110 patients underwent laparoscopic nephrectomy in our institution during the last 3 years. Their data were entered into a database and analyzed, including age, gender, indications for surgery, operative time, blood loss, intraoperative complications, conversion rates, and postoperative complications (defined as complications occurring up to 1 month after surgery). Histologic results and outpatient follow-up were also recorded. RESULTS: Mean age at surgery was 63 years (range 21-89 years). The indications for surgery included solid renal masses in 64 cases, non-functioning kidneys in 35, and collecting system or ureteral tumors in 11; and the procedures performed were radical nephrectomy, simple nephrectomy, or nephroureterectomy, respectively. The mean operative time was 125 minutes (range 70-310 minutes). Intraoperative complications were recorded in eight cases (7.3%), including vascular injuries of the renal artery in two, and of the renal vein, inferior vena cava and right adrenal vein in one case each. Injury of the large bowel and splenic hylus was recorded in one case and malfunction of the vascular endoGIA stapler leading to severe bleeding in one case. Nine cases were converted to open surgery (8.2%), four of them urgently due to intraoperative complications, while in another five cases conversions were elective following poor progression of the laparoscopic procedure. Comparison of the complication rate at follow-up between the initial 50 and the last 60 patients revealed no change. The conversion rate dropped significantly along the learning curve with 7 cases converted among the initial 50 patients, versus 2 in the last 60. There was no perioperative mortality. In two cases we recorded major postoperative complications, including pneumothorax treated by insertion of a thoracic drain and incarcerated inguinal hernia treated by surgery, while minor complications were seen in five patients. Histologic examination showed renal cell carcinoma pT1-T3a in 62 patients, oncocytoma in 5, transitional cell carcinoma T1G2-T3G3N1 in 10, renal sarcoma in 1, metastasis from lung tumor in 1, and end-stage kidney in the remainder. Negative margins were obtained in all cases. CONCLUSIONS: Laparoscopic nephrectomy may be currently considered a routine, safe and effective procedure associated with minimal morbidity. The conversion rate seemed to drop significantly after 50 cases. In view of the inherent benefits for patients, in terms of reduced pain level, faster recovery and improved cosmetic results, the laparoscopic approach has become the standard approach for nephrectomy in our institution.

[Lower urinary tract reconstruction by augmentation cystoplasty and insertion of artificial urinary sphincter cuff only: long term follow-up]. / Reconstruction du bas appareil urinaire par entérocystoplastie d'agrandissement et mise en place isolée d'une manchette de sphincter artificiel.

OBJECTIVES: To review retrospectively our long-term experience with augmentation cystoplasty and simultaneously insertion of artificial urinary sphincter cuff only for lower urinary tract reconstruction in cases of mixed bladder and sphincteric dysfunction. We tried to assess the postoperative continence status, as well as the associated morbidity, focusing upon infections, urethral erosion and revision rates. PATIENTS AND METHODS: Eleven patients with urinary incontinence due to a small capacity and low compliant bladder, combined with incompetent outlet, underwent lower urinary tract reconstruction by augmentation cystoplasty and simultaneous insertion of a bladder neck sphincter cuff only (AMS, model AS-800). Mean age was 29 years (range 18-45). The etiology of voiding dysfunction was a seminal cord injury in 6 patients, myelomeningocele in 2 and spinal cord surgery in 1, bladder exstrophy (1) and pelvic trauma combined with spinal cord injury (1). RESULTS: With mean follow-up period of 115 months (range 45-141), 8 patients (73%) achieved continence on clean intermittent catheterization without any further interventions. Two patients required insertion of sphincter pump and reservoir at a second stage to achieve full continence and subsequently one was removed due to erosion (overall continence rate of 82%). In another patient, the cuff located at the level of the bladder neck has eroded and was removed. None of the patients has experienced an infection of the device in the immediate postoperative period, neither thereafter. CONCLUSIONS: Insertion of sphincter cuff only during augmentation cystoplasty may be sufficient to achieve continence in many incontinent patients who may not be cured by bladder augmentation alone. The procedure is technically easy and is not associated with increased risk of injury to the augmented bladder, neither with subsequent infectious complications.

Comparison of voiding cystourethrography and double-balloon urethrography in the diagnosis of complex female urethral diverticula.

The preoperative work-up of female urethral diverticula should provide the surgeon with maximum data regarding the anatomy and structure of the diverticulum. Preoperatively, the number of diverticula, as well as the location, size, configuration, and communication to the urethra need to be clearly depicted. The objective of this study was to compare the information gained by voiding cystourethrography (VCUG) and positive-pressure double-balloon urethrography (DBU), and to verify which imaging modality can better delineate the features of the diverticula. Twelve women with a presumptive clinical diagnosis of a urethral diverticulum underwent VCUG followed by DBU, and the radiological data from each modality were compared. In 4 of 12 patients (33.3%) VCUG completely failed in demonstrating the diverticulum, whereas DBU showed a large complex diverticulum in 2 patients and a distinct mid-urethral diverticulum in 2 patients. In the remaining 8 women (66.7%) VCUG delineated only the lower part of the diverticulum, whereas DBU depicted a large diverticulum extending beneath the bladder neck in 3 patients and multiple diverticula in 5 patients. The sensitivity of DBU and VCUG, in our series, was therefore 100 and 66.7%, respectively. The DBU supplied excellent documentation regarding the location, size, configuration, and communication of the diverticula to the urethra in every case, which markedly facilitated surgical excision of the diverticula in 9 of 12 patients. Three patients refused surgery and elected conservative treatment. In our experience, VCUG had a low sensitivity as a screening test for the diagnosis of female urethral diverticula, and failed to demonstrate properly the major structural characteristics of the diverticula, whereas DBU was highly sensitive as a diagnostic tool and supplied excellent anatomical delineation of the diverticula.

The efficacy and safety of perioperative low molecular weight heparin substitution in patients on chronic oral anticoagulant therapy undergoing transurethral prostatectomy for bladder outlet obstruction.

PURPOSE: Candidates for prostatectomy who require chronic anticoagulant therapy present a major perioperative management problem due to the threat of significant hemorrhage associated with surgery and the risk of thromboembolism associated with discontinuation of the anticoagulants. We evaluated prospectively a perioperative routine using low molecular weight heparin substitution to allow safe discontinuation of prophylactic oral anticoagulants in patients undergoing transurethral resection of the prostate. MATERIALS AND METHODS: We treated 20 patients on chronic oral anticoagulant therapy who required prostatectomy for bladder outlet obstruction according to a prospective protocol based on exchange of the oral anticoagulants with perioperative injections of low molecular weight heparin and resumption of oral anticoagulants early postoperatively. The safety and efficacy of this regimen were assessed in comparison to a control group comprised of 20 randomly selected nonwarfarin treated patients who underwent prostatectomy during the same period. RESULTS: The need for blood transfusions and mean number of units transfused did not significantly differ between the 2 groups. Due to persistent hematuria routine removal of the catheter was possible only in 9 of 20 patients (45%) in the heparin group compared to 18 of 20 (90%) in the control group. Average catheterization and hospitalization period in the heparin group was 3.2 days and 4.2 days respectively, compared to 2.1 and 2.1 days in the control group, respectively (p <0.01). No long-term hemorrhagic or thromboembolic complications were noted at 3 months postoperatively. CONCLUSIONS: Despite longer hospitalization in the heparin treated group, our substitution protocol is safe and effective.

Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue.

Postoperative chylous ascites is a rare complication of retroperitoneal surgery. The treatment of postoperative chylous ascites is primarily conservative, consisting of repeated paraceteses, medium chain triglyceride (MCT) diet, salt restriction, diuretics and bowel rest with total parenteral nutrition. Occasionally, chylous ascites may take a protracted course which may necessitate insertion of peritoneo-venous shunts or direct surgical lymphostasis. Recently, Somatostatin was shown to be highly effective in closure of refractory lymphatic fistulas. We present a case of refractory chylous ascites following radical nephrectomy with inferior vena caval thrombectomy that failed to respond to conventional conservative measures and resolved rapidly following the administration of Somatostatin.