Neurogenic lower urinary tract dysfunction: Clinical management recommendations of the Neurologic Incontinence committee of the fifth International Consultation on Incontinence 2013.

BACKGROUND: Evidence-based guidelines for the management of neurological disease and lower urinary tract dysfunction have been produced by the International Consultations on Incontinence (ICI). These are comprehensive guidelines, and were developed to have world-wide relevance. AIMS: To update clinical management of neurogenic bladder dysfunction from the recommendations of the fourth ICI, 2009. MATERIALS AND METHODS: A series of evidence reviews and updates were performed by members of the working group. The resulting guidelines were presented at the 2012 meeting of the European Association of Urology for consultation, and consequently amended to deliver evidence-based conclusions and recommendations in 2013. RESULTS: The current review is a synthesis of the conclusions and recommendations, including the algorithms for initial and specialized management of neurogenic lower urinary tract dysfunction. The pathophysiology is categorized according to the nature of onset of neurological disease and the part(s) of the nervous system affected. Assessment requires clinical evaluation, general investigations, and specialized testing. Treatment primarily focuses on ensuring safety of the patient and optimizing quality of life. Symptom management covers conservative and interventional measures to aid urine storage and bladder emptying, along with containment of incontinence. A multidisciplinary approach to management is essential. DISCUSSION: The review offers a pragmatic review of management in the context of complex pathophysiology and varied evidence base. Neurourol. Urodynam. 35:657-665, 2016. © 2016 Wiley Periodicals, Inc.

Iatrogenic splenectomy during left nephrectomy: a single-institution experience of eight years.

INTRODUCTION: Iatrogenic injury to the spleen is not an uncommon complication. Left nephrectomy has been reported as the second commonest cause of iatrogenic splenectomy with a reported incidence between 1.3 and 24%. Iatrogenic splenectomy is associated with significant morbidity and mortality. AIMS: We reviewed the occurrence of iatrogenic splenectomy during left nephrectomy at our centre. Our aims were to determine the incidence of iatrogenic splenectomy within the Mid Yorkshire Hospitals NHS Trust in order to understand the nature of the splenic injury and the morbidity and mortality associated with it. METHODS: All splenectomy and nephrectomy histology reports from January 2000 to December 2007 were reviewed retrospectively. Indications for splenectomy and nephrectomy were identified. Patients' demographic data, tumour characteristics, operative details, length of hospital stay and any reported morbidity or mortality were collected. RESULTS: A total of 447 nephrectomies were identified which included 234 left nephrectomies. Within the same period 136 cases of splenectomy were performed. Thirty-four cases were iatrogenic splenectomies and 12 were caused by left nephrectomy. The incidence was 5.13%. The male to female ratio was 1:1 with an average age of 66 years. Grade 2 and stage pT2 renal cancer were the commonest tumour characteristics. All iatrogenic injuries occurred during mobilisation of the colon or division of adhesion. The average operative time was 4.7 h. Average length of hospital stay was 14 days. Five patients had postoperative complications and 1 died of respiratory failure and sepsis. CONCLUSION: Splenic injury during left nephrectomy is a morbid complication. A good understanding of anatomy and surgical approach may reduce the incidence, morbidity and mortality of iatrogenic splenectomy during left nephrectomy.

British Association of Urological Surgeons' suprapubic catheter practice guidelines.

UNLABELLED: What's known on the subject? and What does the study add? The suprapubic catheter (SPC) is a useful and widely used tool in urological practice. However, complications can arise from its insertion or ongoing care. Currently there are no guidelines relating to SPC usage. This study has reviewed the available clinical evidence relating to SPC usage. Where this is lacking, expert opinion has been sought. Guidelines are suggested to help maximise safety and ensure best practice in relation to SPC usage. OBJECTIVE: To report the British Association of Urological Surgeons' guidelines on the indications for, safe insertion of, and subsequent care for suprapubic catheters. METHODS: A comprehensive literature search was conducted to identify the evidence base. This was reviewed by a guideline development group (GDG), who then drew up the recommendations. Where there was no supporting evidence expert opinion of the GDG and a wider body of consultees was used. RESULTS: Suprapubic catheterisation is widely used, and generally considered a safe procedure. There is however a small risk of serious complications. Whilst the evidence base is small, the GDG has produced a consensus statement on SPC use with the aim of minimising risks and establishing best practice (Table 1). It should be of relevance to all those involved in the insertion and care of suprapubic catheters. Given the paucity of evidence, areas for future research and development are also highlighted. This review has been commissioned and approved by BAUS and the Section of Female, Neurological and Urodynamic Urology. [Table: see text] CONCLUSIONS: It is hoped that these guidelines will assist in minimising morbidity associated with SPC usage.

Managing the urinary tract in spinal cord injury.

This review sets out to provide an overview of the author's approach to the management of the urinary tract in the patient who has suffered from an injury to their spinal cord. Emphasis is given to the need to understand the fundamental pathophysiological patterns that are seen with injuries that involve the sacral segments of the cord (the conus) and those that spare the conus but interrupt communication between the sacral parasympathetic and somatic centers and the brain (supraconal lesions). The importance of patient participation in management decisions is highlighted by considering the different ways in which the urinary tract can be managed and how the clinician needs to try to meet patient expectations and requirements while establishing safe urological management. Finally, consideration is given to the importance of establishing an appropriate follow up regime and managing urinary tract complications effectively.

A 10-year retrospective review of a nonrandomized cohort of 458 patients undergoing radical radiotherapy or cystectomy in Yorkshire, UK.

PURPOSE: We have previously reported on the mortality, morbidity, and 5-year survival of 458 patients who underwent radical radiotherapy or surgery for invasive bladder cancer in Yorkshire from 1993 to 1996. We aim to present the 10-year outcomes of these patients and to reassess factors predicting survival. METHODS AND MATERIALS: The Northern and Yorkshire Cancer Registry identified 458 patients whose cases were subjected to Kaplan-Meier all-cause survival analyses, and a retrospective casenote analysis was undertaken on 398 (87%) for univariate and multivariate Cox proportional hazards modeling. Additional proportional hazards regression modeling was used to assess the statistical significance of variables on overall survival. RESULTS: The ratio of radiotherapy to cystectomy was 3:1. There was no significant difference in overall 10-year survival between those who underwent radiotherapy (22%) and radical cystectomy (24%). Univariate analyses suggested that female sex, performance status, hydronephrosis and clinical T stage, were associated with an inferior outcome at 10 years. Patient age, tumor grade, treatment delay, and caseload factors were not significant. Multivariate analysis models were created for 0-2 and 2-10 years after treatment. There were no significant differences in treatment for 0-2 years; however, after 2 years follow-up there was some evidence of increased survival for patients receiving surgery compared with radiotherapy (hazard ratio 0.66, 95% confidence interval: 0.44-1.01, p = 0.06). CONCLUSIONS: a 10-year minimum follow-up has rarely been reported after radical treatment for invasive bladder cancer. At 10 years, there was no statistical difference in all-cause survival between surgery and radiotherapy treatment modalities.

Neuromodulation 10 years on: how widely should we use this technique in bladder dysfunction?

PURPOSE OF REVIEW: There has been growing interest in sacral nerve stimulation in the management of both overactivity syndromes and nonobstructive voiding dysfunction. Its increased use has led to a growth in experience with this treatment and where and when it is best used. At this point, some technical aspects of the use of neuromodulation have become more standardized and the next stages of research will hopefully shed light on how to maximize the efficacy of the technique. RECENT FINDINGS: Over the past year, there has been considerable interest and development of the use of neuromodulation in colorectal surgery and much of the literature has been in this field. Recent urological developments focus on modification of technique and attempts to identify which patients are more likely to find benefit. SUMMARY: Neuromodulation has a role in the treatment of nonobstructed urinary retention and overactive bladder syndrome, especially when accompanied by urgency incontinence. There are a number of unanswered questions remaining, however, which will need to be addressed to maximize its benefit.

Fulguration of the lumen does not improve vasectomy sterilization rates.

OBJECTIVES: To assess the effect of adding lumen diathermy fulguration to our standard technique of vas ligation with polyglactin 910 (Vicryl(TM), Ethicon, Sommerville, NJ, USA) excision and fascial interposition, in an attempt to improve our sterilization rates. We previously reported the effect of changing suture material on vasectomy success rates; 3005 post-vasectomy semen analyses (PVSA) revealed a decrease in sterilization rates after surgery on changing from chromic catgut to polyglactin 910. PATIENTS AND METHODS: We retrospectively reviewed PVSA undertaken for vasectomies performed by urological surgeons at the Mid-Yorkshire NHS Trust for 18 months from September 2005 to February 2007. RESULTS: There were 592 vasectomies in all; the age distribution of patients between the groups treated with the standard and new method was similar. Overall, 166 patients (28%) failed to provide two semen samples as instructed, and so were excluded from further analyses. Sterility was achieved in 367 patients (86%); a further 28 (7%) have indeterminate analyses to date, with one of the last two PVSAs showing sperm, with the PVSA of 32 (7%) patients showing persisting sperm. For the eight surgeons reviewed the sterility rates were broadly similar. CONCLUSIONS: The introduction of diathermy fulguration of the lumen has not improved vasectomy sterilization rates, with up to 14% having sperm on PVSA.

The continent, catheterizable abdominal conduit in adult urological practice.

OBJECTIVE: To report a large, single-centre experience with a continent, catheterizable abdominal conduit in adult patients. PATIENTS AND METHODS: We retrospectively reviewed the case notes of all 65 patients who had surgery to create a continent catheterizable conduit based on the Mitrofanoff principle. Operations were carried out over a 13-year period. Data on surgical procedure, complications and final outcome were collected and analysed. RESULTS: The mean age of the patients was 38.4 years and mean follow-up interval was 75.2 months. Patients with neuropathic lower urinary tracts accounted for the largest single indication for reconstruction (36 patients). The appendix was the conduit of choice and was available and suitable for use in 37 patients. There were 57 patients who continued to use their native bladder or had undergone an augmentation or substitution cystoplasty; 24.5% of these 57 individuals had also undergone closure of the bladder neck or urethra. There were postoperative complications requiring laparotomy in five (8%) patients. In all, 30 patients (46%) had catheterization problems, but most of these were easy to treat. Five patients (8%) had an incontinent conduit which was a more difficult problem to deal with. Two patients have died of unrelated cause and five patients have been converted to an ileal conduit. In all, 58 patients (92%) now have a Mitrofanoff conduit, of which 97% are catheterizable and 95% are continent. CONCLUSIONS: Continent urinary diversion, based on the Mitrofanoff principle, has similar outcomes in adult urological practice to those described in published paediatric case series. There is good evidence to suggest that Mitrofanoff conduits are durable. However, patients should be aware of complications and the need for long-term follow-up.

Neuromodulation for lower urinary tract dysfunction--an update.

The aim of this review is to provide an update on the use of neuromodulation using sacral nerve stimulation for the treatment of disorders of the lower urinary tract. Neuromodulation using the InterStim system (Medtronic Inc.) is now accepted as an established therapeutic option for patients with detrusor overactivity, and for women with retention or severe voiding difficulties. However, the use of nerve stimulation in modulating lower urinary tract function has to be regarded as a technique that is in its infancy. Much has yet to be learned about the mechanism by which neuromodulation exerts its effects and there is a need to better define the clinical indications for the treatment. There is also work to be done in terms of optimising stimulation delivery, both in anatomical and electronic terms.

The pattern and progression of lower urinary tract symptoms after transurethral prostatectomy compared with those seen in the general population.

OBJECTIVES: Men undergoing transurethral prostatectomy (TURP) often have some level of residual symptoms after this operation. Reliance on symptom scores to assess outcomes means there is relatively little information on the exact pattern of such symptoms. The aim of this study was to describe the pattern, progression, and associated bother of lower urinary tract symptoms after TURP. METHODS: Detailed information on urinary symptoms, prostatectomy status, and associated bother was obtained from a randomly selected sample of community-dwelling men by using a postal questionnaire. Rates of individual urinary symptoms in the postprostatectomy population were calculated, and compared with those in the background population and those in secondary care. RESULTS: Of 7640 men who responded, 422 had undergone prostatectomy. Symptom levels remained significantly higher in the postoperative group than the background population, with 19.4% experiencing four or more symptoms on a weekly basis. The pattern of symptoms was similar to that seen in the general population. Men in the post-TURP group experienced greater levels of bother when symptom level (odds ratio: 2.69; 95%CI, 1.80-4.01) was controlled. Both symptom and bother, however, were significantly lower than those in people referred for secondary care treatment of their symptoms. CONCLUSIONS: Men with a previous prostatectomy still report high levels of urinary symptoms and appear to experience greater levels of bother from these symptoms than men in the general population.

Stress urinary incontinence after male to female gender reassignment surgery: Successful use of a pubo-vaginal sling.

The case of a 50-year-old patient who had undergone male to female gender reassignment surgery is presented. She presented with mixed incontinence with symptoms of stress incontinence predominating. Initial conservative treatment was unsuccessful and subsequent videourodynamic assessment demonstrated urodynamic stress incontinence in association with a partially open bladder neck at rest. Also noted during the study was cough-induced detrusor overactivity. The option of inserting a pubo-vaginal sling using autologous rectus sheath was chosen. The procedure proved to be straightforward to perform and was uncomplicated. Subsequent follow-up demonstrated a resolution of her stress incontinence.

Lower urinary tract symptoms and related help-seeking behaviour in South Asian men living in the UK.

OBJECTIVE: To describe the pattern and prevalence of lower urinary tract symptoms (LUTS) and related help-seeking behaviour in men of South Asian origin living in the UK, and to compare this to the white population. SUBJECTS AND METHODS: Data were obtained as part of the Leicestershire MRC Incontinence Study. Community-dwelling men aged >40 years were sent a postal questionnaire addressing urinary symptoms, bother and help-seeking. Prevalence rates of self-reported LUTS were compared on the basis of the Office of Population Censuses and Surveys ethnic classifications. Logistic regression was used to estimate the relative risk of symptoms between groups. Data from 7810 men were included in the analysis. RESULTS: In all, 409 (5.3%) of the population sample described themselves as Asian; 36.5% of these men described at least one significant LUTS, vs 29.0% of white men. The overall prevalence rates for all storage symptoms were significantly higher in Asian men. Straining to void was the only voiding symptom to show a difference in prevalence between the groups. However, when controlling for age, Asian men were at greater risk for all symptoms except a weak urinary stream. Reported levels of bother and felt need were the same in both population groups, but actual help-seeking was significantly less in the Asian group. Only 25.0% of Asian men had actively sought help, compared to 53.1% of white men. CONCLUSION: South Asian men in the UK have a higher risk of experiencing LUTS than white men from the same population. This increase in risk is greatest for storage symptoms. Although levels of bother are the same, South Asian men are less likely to seek help for their symptoms.

The Mitrofanoff procedure in the management of intractable incontinence: a critical appraisal.

PURPOSE OF REVIEW: The term intractable urinary incontinence can be applied to urinary incontinence that cannot be managed using conventional treatments like drug therapy for detrusor overactivity or sling procedures for female stress incontinence. This review considers the role of the Mitrofanoff procedure in extending the range of options for the patient who might otherwise consider using an indwelling catheter or an ileal conduit diversion to overcome incontinence. Clinicians use the label 'Mitrofanoff procedure' quite loosely to describe any continent catheterizable abdominal stoma. For the purposes of this review, we will use the term in this generic sense while acknowledging our imprecision. RECENT FINDINGS: Reviews confirm that the Mitrofanoff procedure has stood the test of time. Quality-of-life benefits, however, need a conclusive demonstration in scientific terms. Enthusiasts of laparoscopic surgery show that this type of lower urinary tract reconstruction can be carried out using minimally invasive methods. SUMMARY: Reconstructive options using a catheterizable abdominal stoma should be discussed with patients with intractable urinary incontinence. Reliable surgical techniques are established; though complications are frequent, most can be dealt without recourse to major surgical intervention. Unfortunately, authoritative data on the impact of the Mitrofanoff procedure on patients' qualities of life are still lacking.