Influence of bladder lithiasis on lower urinary tract dynamics in patients with spinal cord injury.

STUDY DESIGN: A prospective and a case-matched control study. OBJECTIVES: To study the lower urinary tract dysfunction associated with bladder lithiasis in patients with spinal cord injury (SCI). SETTING: Toledo (Spain). METHODS: We have carried out a urodynamic study in 30 patients with SCI with lithiasis in their bladder before and 3 months after bladder endoscopic lithotripsy. This second study was compared with the urodynamic findings of a different group of 30 patients with SCI, without a history of bladder lithiasis, paired with cases by gender and date of urodynamic study. RESULTS: We have found that the prevalence of neurogenic detrusor overactivity (NDO) was significantly different after bladder lithotripsy, although the cystomanometric capacity was significantly increased. A group of patients with lithiasis showed a maximum flow rate, a voiding maximum detrusor pressure and the detrusor contractility parameter Wmax lower than that in controls. On the other hand, a voiding abdominal straining was found to be significantly greater than that in controls. CONCLUSIONS: Bladder lithiasis affects the presence of NDO in patients with SCI. Patients with SCI who develop bladder lithiasis present a lower detrusor contractility power compared with those who do not.

Role of 18F-Choline PET/CT in guiding biopsy in patients with risen PSA levels and previous negative biopsy for prostate cancer.

OBJECTIVES: To study 18F-Choline PET/CT in the diagnosis and biopsy guide of prostate cancer (pCa) in patients with persistently high prostate-specific antigen (PSA) and previous negative prostate biopsy. To compare the clinical risk factors and metabolic variables as predictors of malignancy. METHODS: Patients with persistently elevated PSA in serum (total PSA >4ng/mL) and at least a previous negative or inconclusive biopsy were consecutively referred for a whole body 18F-Choline PET/CT. Patient age, PSA level, PSA doubling time (PSAdt) and PSA velocity (PSAvel) were obtained. PET images were visually (positive or negative) and semiquantitatively (SUVmax) reviewed. 18F-Choline uptake prostate patterns were defined as focal, multifocal, homogeneous or heterogeneous. Histology on biopsy using transrectal ultrasound-guided approach was the gold standard. Sensitivity (Se), specificity (Sp) and accuracy (Ac) of PET/CT for diagnosis of pCa were evaluated using per-patient and per-prostate lobe analysis. Receiver-operating-characteristic (ROC) curve analysis was used to assess the value of SUVmax to diagnose pCa. Correlation between PET/CT and biopsy results per-prostate lobe was assessed using the Chi-square test. Univariate and multivariate logistic regression analysis were applied to compare clinical risk factors and metabolic variables as predictors of malignancy. RESULTS: Thirty-six out of 43 patients with histologic confirmation were included. In 11 (30.5%) patients, pCa was diagnosed (Gleason score from 4 to 9). The mean values of patient age, PSA level, PSAdt and PSAvel were: 65.5 years, 15.6ng/ml, 28.1 months and 8.5ng/mL per year, respectively. Thirty-three patients had a positive PET/CT; 18 had a focal pattern, 7 multifocal, 4 homogeneous and 4 heterogeneous. Se, Sp and Ac of PET/CT were of 100%, 12% and 38% in the patient based analysis, and 87%, 29% and 14% in the prostate lobe based analysis, respectively. The ROC curve analysis of SUVmax showed an AUC of 0.568 (p=0.52). On a lobe analysis, poor agreement was observed between PET/CT findings and biopsy results (p=0.097). In the univariate/multivariate analysis, none of clinical and metabolic variables were statistically significant as predictor of pCa. CONCLUSION: Choline PET/CT is a suitable procedure for the detection of pCa in highly selected patients, however, a high rate of false positive should be expected.

Other radiological lesions of the Lower Urinary Tract in patients after isolated pelvic radiotherapy and combined with surgery. / Otras lesiones radiológicas del tracto urinario inferior (TUI) en pacientes sometidos a radioterapia pélvica en monoterapia y combinada con cirugía.

INTRODUCTION: The cystographic study of patients who have undergone radiotherapy (RT) and pelvic surgeries is uncommon in the literature, not described in patients without complications, and mostly related to urinary fistulae. OBJECTIVE: The study of the lower urinary tract (LUT) by cystography in these patients, with a description of some other types of radiation lesions. METHODS: 127 cystographies have been performed (88 men and 39 women) in consecutive patients undergoing radiotherapy (RT) (48 monotherapy and 79 cases combined with surgery), with a mean age of 69.6 years, and a mean time from radiation of 215 months (17 years). A General Electric X ray equipment has been used. We studied: behavior of the bladder neck at rest and during micturition, assessment of vesicoureteral reflux (VUR), bladder morphology (BM), urethral strictures (UE) and fistulas (F). RESULTS: We observed: Filling phase bladder neck incompetence (BNI) (37.8%), bladder smooth morphology (60.6%), coughing urinary incontinence (UI) (26.4%), basal cystocele (64.7%) and Valsalva cystocele (96.6%), a normal opening bladder neck (96,1%), reduction of the urethral diameter during voiding (41.3%), and vesicoureteral reflux (VUR) (13.2%). Five cases of filling BNI, were all related to prostate cancer (PC) (one of them with colon cancer as well). There were six cases of fistulae (4.14%), five of them women. Forty two patients (28.96%) had reduced urethral lumen, thirty five of them affecting the posterior urethra (83%), five (11.9%) the anterior and, finally, two cases of mixed lesion (5%). 95% were patients with PC without concurrent interventions (67%). Significant differences were found regarding the gender and the background of pelvic surgery. The filling BNI (p=0.007), the irregular bladder morphology (p=0.004) and the reduction of the urethral lumen (p<0.001) have been found to be more common in male patients, while the coughing UI was more common in women (p=0.007). The study shows that BNI (p=0.046), VUR (p=0.02) and the IU due to cough (p=0.03) were more frequent in operated patients, while reduced urethral lumen was less common (p<0.01). Patients with VUR present more time from radiotherapy, but not in other cystography variables. There was a relationship between RT and the BNI, stress urinary incontinence, anterior urethral stricture and VUR. The risk factor was increased by surgery. CONCLUSIONS: Bladder neck incompetence, stress UI, anterior urethral stricture and VUR have been related to radiotherapy. Surgery increased the risk factor in operated patients.

Utilidad de la procalcitonina y proteína C reactiva para predecir bacteriemia en las infecciones del tracto urinario en el servicio de urgencias / Usefulness of procalcitonin and C-reactive protein for predicting bacteremia in urinary tract infections in the emergency department

Introducción: El objetivo del estudio fue analizar y comparar la capacidad de la procalcitonina (PCT), proteína C reactiva (PCR), lactato y leucocitos para predecir la existencia de bacteriemia en los pacientes con infección del tracto urinario (ITU). Métodos: Estudio observacional, retroprospectivo y analítico de pacientes adultos (≥ 15 años) diagnosticados de ITU en un servicio de urgencias desde agosto de 2012 hasta enero de 2013. Resultados: Se incluyeron 328 casos diagnosticados de ITU con una edad media de 52 ± 22 años, el 74% mujeres. De ellos 43 (13,1%) con bacteriemia. Para predecir bacteriemia la PCT obtiene la mayor área bajo la curva ROC (ABC-ROC), de 0,993 (IC 95%: 0,987-1, p < 0,001) y con un punto de corte ≥ 1,16 ng/ml se consigue una sensibilidad del 100%, especificidad del 97%, un valor predictivo positivo de 84% y un valor predictivo negativo del 100%. El lactato consigue un ABC-ROC de 0,844 y la PCR solo de 0,534. Los valores medios al comparar la PCT en pacientes con ITU con/sin bacteriemia fueron 8,08 ± 16,37 vs 0,34 ± 0,37 ng/ml, p < 0,001. Conclusiones: En los pacientes con ITU en el servicio de urgencias la PCT consigue un gran rendimiento diagnóstico para sospechar bacteriemia, mayor que el lactato, la PCR y los leucocitos

Introduction: The aim of this study was to analyze and compare the capacity of procalcitonin (PCT), C-reactive protein (CRP), lactate and leukocytes to predict the presence of bacteremia in patients with urinary tract infections (UTIs). Methods: Observational, retro-prospective analytical study of adult patients (≥15 years) diagnosed with UTI in an emergency department from August 2012 to January 2013. Results: The study included 328 patients diagnosed with UTI, with a mean age of 52 ± 22 years, 74% of whom were women. Of these, 43 (13.1%) had bacteremia. For predicting bacteremia, PCT achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at .993 (95% CI .987-1; P < .001). A cutoff ≥ 1.16 ng/mL achieves a sensitivity of 100%, a specificity of 97%, a positive predictive value of 84% and a negative predictive value of 100%. Lactate achieved an ROC-AUC of .844, and CRP achieved only .534. The mean values when comparing PCT levels in patients with UTIs with and without bacteremia were 8.08 ± 16.37 and .34 ± .37 ng/mL, respectively (P < .001). Conclusions: For patients with UTIs in the emergency department, PCT achieves considerable diagnostic performance for suspecting bacteremia, a performance greater than that of lactate, CRP and leukocytes

Risk factors of urethral diverticula in male patients with spinal cord injury.

STUDY DESIGN: A case-control study in a series of 55 males with urethral diverticula (UD) and their correspondent control, matched by age and time of radiological assessments. OBJECTIVES: To evaluate the risk factors to develop UD in males with spinal cord injury (SCI) and the place in the urethra where they are, most commonly, allocated. SETTING: Toledo, Spain. METHODS: Clinical histories and urodynamic studies, of all patients, were reviewed. The study was completed with a telephone survey according to an established protocol. RESULTS: The univariate analysis study showed the following risk factors: the age of onset of the spinal injury, the sphincterotomy procedure, personal history of lower urinary tract infections (LUTIs) and the chronic need of either indwelling catheter (IC) or the external condom drainage (ECD). Regarding the location of the UD, we have found the stress urinary incontinence as the only risk factor to develop UD in the prostatic urethra.On the other hand, we can conclude that the sphincterotomy, the ECD, the personal history of LUTIs and the detrusor external sphincter dyssynergia seem to be risk factors to develop diverticula in the bulbo-membranous urethra. Finally, we could point out the IC as the only risk factor for penile UD. Multivariate analysis showed that all of these risk factors were independent among them except the age of the onset of the injury and the ECD for UD in the bulbo-membranous urethra. CONCLUSION: According to our study, there is evidence of some specific risk factors for the development of UD in male patients with SCI, and therefore we should adopt the appropriate preventive measures to prevent them.

Usefulness of procalcitonin and C-reactive protein for predicting bacteremia in urinary tract infections in the emergency department.

INTRODUCTION: The aim of this study was to analyze and compare the capacity of procalcitonin (PCT), C-reactive protein (CRP), lactate and leukocytes to predict the presence of bacteremia in patients with urinary tract infections (UTIs). METHODS: Observational, retro-prospective analytical study of adult patients (≥15 years) diagnosed with UTI in an emergency department from August 2012 to January 2013. RESULTS: The study included 328 patients diagnosed with UTI, with a mean age of 52±22 years, 74% of whom were women. Of these, 43 (13.1%) had bacteremia. For predicting bacteremia, PCT achieved the largest area under the receiver operating characteristic curve (ROC-AUC) at .993 (95% CI .987-1; P<.001). A cutoff≥1.16ng/mL achieves a sensitivity of 100%, a specificity of 97%, a positive predictive value of 84% and a negative predictive value of 100%. Lactate achieved an ROC-AUC of .844, and CRP achieved only .534. The mean values when comparing PCT levels in patients with UTIs with and without bacteremia were 8.08±16.37 and .34±.37ng/mL, respectively (P<.001). CONCLUSIONS: For patients with UTIs in the emergency department, PCT achieves considerable diagnostic performance for suspecting bacteremia, a performance greater than that of lactate, CRP and leukocytes.

Factores que influyen en los resultados urodinámicos de la toxina botulínica en el tratamiento de la hiperactividad neurógena / Factors that influence the urodynamic results of botulinum toxin in the treatment of neurogenic hyperactivity

Objetivos: Determinar la eficacia urodinámica y los factores que influyen en los resultados urodinámicos del tratamiento de la hiperactividad neurógena del detrusor con inyección intradetrusoriana de toxina botulínica tipo A (TXB-A) en pacientes con lesión medular (LM). Material y métodos: Se realizó un estudio retrospectivo en una cohorte de 70 pacientes formada por 40 varones y 30 mujeres con LM estable de 39 ± 13,3 años de edad (media ± desviación típica), sometidos a inyección intradetrusoriana de 300 UI de TXB-A. Se realizó un estudio urodinámico previo y otro a los 6 ± 4,3 meses del tratamiento. Posteriormente se realizaron nuevos estudios urodinámicos hasta un intervalo de 16 ± 12,2 meses. Resultados: La TXB-A aumentó significativamene (p < 0,05) la capacidad vesical cistomanométrica, el volumen vesical de la primera contracción involuntaria del detrusor y el residuo posmiccional. Se observó una disminución con tendencia hacia la significación estadística (p < 0,1) de la presión máxima miccional del detrusor y el flujo miccional máximo. No varió significativamente la acomodación vesical ni el índice de resistencia uretral (BOOI). El aumento de la capacidad vesical se mantuvo en el 50% de la muestra más de 32 meses. La edad, el sexo, el tratamiento anticolinérgico y la antigüedad de la lesión no mostraron influencia respecto del aumento de la capacidad vesical. La sonda a permanencia (SVP) fue el único factor negativo estadísticamente significativo. Conclusiones: El efecto urodinámico de la TXB-A se mantiene durante un considerable intervalo de tiempo. La SVP influye negativamente en el resultado del tratamiento

Objectives: To determine the urodynamic efficacy and factors that influence the urodynamic results of treatment of neurogenic detrusor hyperactivity with intradetrusor injection of botulinum toxin type A (BTX-A) in patients with spinal cord injury (SCI). Material and methods: A retrospective study was conducted with a cohort of 70 patients composed of 40 men and 30 women with stable SCI (mean age, 39 ± 13.3 years) who underwent an intradetrusor injection of 300 IUs of BTX-A. A urodynamic study was conducted prior to the injection and 6 ± 4.3 months after the treatment. New urodynamic studies were subsequently performed up to an interval of 16 ± 12.2 months. Results: The BTX-A significantly increased (p < .05) the cystomanometric bladder capacity, the bladder volume of the first involuntary contraction of the detrusor and the postvoid residue. We observed a decrease that tended towards statistical significance (p < .1) of the maximum detrusor pressure and the maximum urine flow. Neither the bladder accommodation nor the urethral resistance index (bladder outlet obstruction index) varied significantly. The increase in vesical capacity was maintained in 50% of the sample for more than 32 months. Age, sex, anticholinergic treatment and lesion age showed no influence in terms of the increase in bladder capacity. The indwelling urinary catheter (IUC) was the only statistically significant negative factor. Conclusions: The urodynamic effect of BTX-A is maintained for a considerable time interval. The IUC negatively influences the result of the treatment

Factors that influence the urodynamic results of botulinum toxin in the treatment of neurogenic hyperactivity.

OBJECTIVES: To determine the urodynamic efficacy and factors that influence the urodynamic results of treatment of neurogenic detrusor hyperactivity with intradetrusor injection of botulinum toxin type A (BTX-A) in patients with spinal cord injury (SCI). MATERIAL AND METHODS: A retrospective study was conducted with a cohort of 70 patients composed of 40 men and 30 women with stable SCI (mean age, 39 ± 13.3 years) who underwent an intradetrusor injection of 300 IUs of BTX-A. A urodynamic study was conducted prior to the injection and 6 ± 4.3 months after the treatment. New urodynamic studies were subsequently performed up to an interval of 16 ± 12.2 months. RESULTS: The BTX-A significantly increased (p < .05) the cystomanometric bladder capacity, the bladder volume of the first involuntary contraction of the detrusor and the postvoid residue. We observed a decrease that tended towards statistical significance (p < .1) of the maximum detrusor pressure and the maximum urine flow. Neither the bladder accommodation nor the urethral resistance index (bladder outlet obstruction index) varied significantly. The increase in vesical capacity was maintained in 50% of the sample for more than 32 months. Age, sex, anticholinergic treatment and lesion age showed no influence in terms of the increase in bladder capacity. The indwelling urinary catheter (IUC) was the only statistically significant negative factor. CONCLUSIONS: The urodynamic effect of BTX-A is maintained for a considerable time interval. The IUC negatively influences the result of the treatment.

[Information given to patients and their participation in clinical decision-making]. / La información al paciente y su participación en la toma de decisiones clínicas.

OBJECTIVES: To evaluate the information provided by physicians during consultations, the information requested by patients, and patients' participation in decision-making. DESIGN: Descriptive, cross-sectional study based on observations of visits to the doctor's office and subsequent telephone interview. SETTING: Primary care centers in Toledo, Spain.Participants. 152 clinical interviews.Interventions. Questionnaire with items on age, sex, types of information provided by the physician, information requested by the patient, and evaluation of the patient's participation in decision-making and degree of satisfaction. MAIN MEASURES AND RESULTS: Mean age of the patients was 41.1 years, and 55.9% were women. The type of information given most frequently to patients was related to treatment (88.3%). Of the 152 patients whose visits were observed, 55 (36.2%) did not request additional information. The information requested most frequently when not provided spontaneously by the physician concerned treatment (35.3%) and cause of the symptoms (29.7%). Almost all patients (94.0%) considered the information received to be sufficient. However, 22.7% stated that when they left the doctor's office there was something they wished they had asked about, and 18.6% said they understood the doctor's explanations "in part." According to the observers, 69.4% of the patients did not take part in the decision about their treatment. CONCLUSIONS: The information provided by the physician was not as complete as it might have been. Patients usually ask few questions, and a large percentage of patients had something they wished they had asked about, or did not fully understand the information. Patients' participation in decision-making was low.