Ultrasound prostate parameters as predictors of successful trial without catheter after acute urinary retention in patients ongoing medical treatment for benign prostatic hyperplasia: a prospective multicenter study.

BACKGROUND: Alpha-blockers (ABs) are considered the standard treatment after initial management of acute urinary retention (AUR). However, no data are available on the predictors of a successful trial without catheter (TWOC) in patients previously on treatment with ABs and 5alpha reductase inhibitors (5ARI). The aim of our study was to investigate prostate ultrasound parameters as predictors of TWOC outcome. METHODS: A consecutive series of patients, on treatment with ABs alone or in combination with 5ARI, experiencing AUR were prospectively enrolled. Clinical data (i.e., age, body mass index (BMI) and IPSS), urinary ultrasound features including hydronephrosis, prostate volume-TRUS, bladder wall thickness (BWT), intravesical prostatic protrusion more than 10mm (IPP≥10) were related to TWOC outcome performed seven days after AUR. A binary logistic regression analysis was computed to detect predictors of successful TWOC. RESULTS: Overall,143 patients with a median age of 72 years (IQR 64-77) were enrolled. Seventy-mine patients (54%) with smaller prostate volume (59 [IQR 52-74] vs. 99 [IQR 74-125] mL, P=0.008) and a thinner BWT (5[IQR 4.8-5.2] vs. 5.2 [4.7-5.5] mm P=0.001) recovered voiding at TWOC. IPP≥10 was less common in patients with successful TWOC 11 (14%) vs. 33 (52%), P=0.001. On multivariate analysis, IPP<10mm (OR 6.10 [95%CI 2.61-14.20], P=0.001), lower IPSS (OR 0.95 [95% CI 0.89-0.99], P=0.045), smaller TRUS (OR 0.96 [95% CI 0.95-0.97], P=0.001), thinner BWT OR 1.23 (95%CI 0.73-0,92) P=0.001were the independent predictors of voiding recovery. CONCLUSIONS: Patients receiving medical treatment for BPH and experiencing AUR still present a 54% probability of a successful TWOC. Ultrasound may help to identify patients with successful TWOC.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 1 - Female population.

Although, until a few years ago, the diagnostic power of urodynamic testing had never been questioned, recent studies in the literature have raised some doubts on the routine use of this tool. The benefits of the urodynamic studies (UDS) should be weighted against costs, time-consumption and patient discomfort. These recommendations are intended to guide clinicians in the right selection of the female patients to submit to a urodynamic evaluation. We reviewed the literature, regarding the use of UDS in female adults with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction. Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and uro-gynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in female population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with lower urinary tract symptoms and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population.

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Transvaginal mesh surgery for pelvic organ prolapse does not affect sexual function at long term follow up.

OBJECTIVE: Pelvic Organ Prolapse (POP) may impair sexual health. Though sexual dysfunction in women with POP is associated with reduced sexual arousal and dyspareunia, sexual outcomes have not been fully investigated. Transvaginal mesh repair (TVMR) is a POP therapeutic option, but is debated as a possible cause of worsening in sexual function. Aim of this study is to evaluate pre- and post-operative sexual outcomes in women undergone to TVMR. STUDY DESIGN: Data coming from sexually active women submitted to TVMR for POP with commercial mesh kits (device whose production has been suspended) were prospectively collected from 2012 to 2016 in a tertiary referral center. POP was measured according to the POP-Q classification. Patients' characteristics, operative and post-operative data were collected. Follow-up was carried out at month 1, 6, 12 and then yearly. Sexual function was measured through FSFI (Female Sexual Function Index) questionnaire. Minimum follow up was 12 months. FSFI score was assessed in these women before and after TVMR. A sub-analysis according to mesh kit used was made. RESULTS: From 2012 to 2016, 155 women underwent TVMR active for stage III or higher POP and 56 (36.6%) were sexually active, while 52 (92.9%) had adequate follow-up. Median age was 62 years (IQR 56-66), median BMI was 24,7 kg/m2 (IQR 22,3-28,9) and median parity was 2 (IQR 1-2). All patients presented anterior compartment POP and 14 (269%) had previous POP surgery. Urodynamic SUI was present in 13 (250%) patients. Commercial mesh kits used were Prolift© in 19 patients (36.5%) and Elevate© in 33 (63.5%). Median follow up was 42 months (IQR 22-59). Globally, FSFI was unaltered from TVMR at 12 months and at last follow up (p = 0.856). In detail, even if dyspareunia was reported in 1 patient, pain sub score was stable at long term follow up after TVMR (p = 0.124). Globally, there were 8 (15.4%) perioperative complications, none exceeding Clavien 2. At late follow up here was 1 (1.9%) mesh vaginal erosion occurred and there were 4 (7.7%) de novo stress urinary incontinence. Preoperative characteristics, surgical complications and outcomes were similar between mesh kits (p > 0.05). CONCLUSION: In our experience, global sexual function doesn't seem to be affected by TVMR when performed by expert surgeons. Despite being a confounding factor, lost at follow up rate was low, thus affecting only in a mild way surgical outcomes. Also ageing might be a confounding factor during follow up to establish real mesh impact on sexual function. Dyspareunia was a rare complication in patients during follow-up and pain was not a major complaint.

Long-term experience with a novel uterine-sparing transvaginal mesh procedure for uterovaginal prolapse.

OBJECTIVES: To evaluate outcomes and quality of life in patients operated transvaginally with an original mesh shape for uterus-sparing prolapse surgery and to demonstrate the safety and efficacy of the technique. STUDY DESIGN: We prospectively evaluated 66 postmenopausal patients (POP-Q Stage III: 32, IV: 34) operated between May 2008 and December 2013. We used wide weave polypropylene monofilament mesh that functions as a hammock anchored posteriorly to sacrospinous ligaments, its anterior wings exit the pelvis through the obturatory membrane. Follow-up was scheduled at 3-, 12- months and in May 2016. Prolapse-Quality of Life Questionnaire (P-QoL) was administered preoperatively, at 12 months and in May 2016. The chi square and Wilcoxon test were used for statistical analysis. RESULTS: Mean follow-up was 5.6 (SD: 1.6, Range: 1.1-8.1) years. The overall success rate (POP-Q ≤ 2) was 92.5% at 12 months and 84.4% at May 2016, these data remained stable over time (p > 0.05). Early complications occurred in 2 (3%) patients, late in 5 (7.8%) of which mesh extrusion in 4 (6.3%). Data from P-QoL showed significant improvement between preoperative and postoperative data (P < 0.01 for all domains) and they remained stable with time (p > 0.05). De-novo dyspareunia was 17.6% at 12 months and 10.3% at May 2016. CONCLUSIONS: The low rate and grade of complications demonstrates the safety of the procedure, which offers stable anatomical correction with significant improvement in QoL.

Florence robotic intracorporeal neobladder (FloRIN): a new reconfiguration strategy developed following the IDEAL guidelines.

OBJECTIVE: To describe our step-by-step technique for robotic intracorporeal neobladder configuration, including the stages of conception, development and exploration of this surgical innovation, according to the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Collaboration guidelines. PATIENTS AND METHODS: The Florence robotic intracorporeal neobladder (FloRIN) was performed employing the following main surgical steps: isolation of 50 cm of ileum; bowel anastomosis; urethro-ileal anastomosis creating an asymmetrical 'U'-shape (30 cm distally and 20 cm proximally to anastomosis), ileum detubularisation; posterior wall reconfiguration as an 'L'; bladder neck reconstruction; anterior folding of the posterior plate to reach the 12 o'clock position; uretero-enteral 'orthotopic' bilateral anastomosis. The conception and development of the FloRIN followed the IDEAL guidelines recommended stages: Phase 1 (simulation) involved the neobladder robotic configuration using silicone models. Phase 2a (development) aimed to reproduce the configuration in an open fashion in one patient, and then in the first three robotic procedures. Phase 2b (exploration) consisted of the technique standardisation in 15 consecutive robotic approaches. Phase 2a and 2b included urodynamics and imaging assessment of the patients treated. RESULTS: From February 2016 to September 2017 FloRIN was performed in 18 patients. Comparing the first three (Phase 2a) with the subsequent 15 patients (Phase 2b), the median (interquartile range [IQR]) reconstruction operating time was 260 (220-340) vs 160 (150-210) min, respectively. Postoperative surgical complications occurred in four of the 18 patients (22.1%), including one surgical Clavien-Dindo Grade III and three Grade I, postoperative medical Clavien-Dindo Grade II complications occurred in three (16.7%) patients. On urodynamic examination (available in nine [50%] patients) the median (IQR) reservoir cystometric capacity, compliance, and post-void residual were 240 (220-267) mL, 18 (12.5-19.8) mL/cmH2 O, and 0 (0-50) mL, respectively. Ultrasonography showed no Grade ≥2 vesico-ureteric reflux. CONCLUSION: We describe the FloRIN configuration, showing its technical feasibility with acceptable time efficiency. The first cases studied had good reservoir capacity, low pressure with no reflux, and complete voiding.

Impact of Preoperative Patient Characteristics and Flow Rate on Failure, Early Complications, and Voiding Dysfunction After a Transobturator Tape Procedure: A Multicentre Study.

PURPOSE: To evaluate the impact of preoperative patient characteristics and flow rate on failure, early postoperative complications, and voiding in patients who underwent transvaginal tension-free vaginal tape-obturator (TVT-O) treatment for uncomplicated stress urinary incontinence (SUI). METHODS: We retrospectively reviewed patients who underwent TVT-O for SUI at 3 Italian centres. The exclusion criteria were predominant voiding and storage symptoms suggestive of detrusor overactivity, the presence of grade >1 urogenital prolapse, previous pelvic radiotherapy or other clinical contraindications for surgical procedures, neurogenic bladder dysfunction, and collagen diseases. Multivariate logistic regression models were constructed to identify predictors of early voiding dysfunction after TVT-O. RESULTS: A total of 219 patients underwent TVT-O between January 2010 and December 2015. All patients received follow-up at 3, 6, and 12 months, and underwent a stress test, uroflowmetry, and bladder ultrasound to evaluate the postvoid residual volume. They also responded to the Urogenital Distress Inventory (UDI-6) questionnaire. The rates of persistent incontinence after TVT-O, postoperative complications, and satisfaction were 16.4% (36 of 219), 24.2% (53 of 219), and 86.3% (189 of 219), respectively. Nineteen patients (9.5%) experienced early voiding dysfunction. Based on an analysis of baseline characteristics, we determined that a cutoff value of 9.0 on the UDI-6 predicted postoperative SUI with 62% specificity, 72% sensitivity, and 66% accuracy. In the multivariate logistic regression analysis, a preoperative UDI-6≥9.0 was an independent predictor of postoperative SUI. The predictors of complications were menopause (P = 0.04) and the preoperative UDI-6 score (P = 0.01). CONCLUSIONS: Menopause and UDI-6 scores could be prognostic factors for persistent SUI after TVT-O. Well-designed prospective studies with a suitable number of patients are needed to corroborate our findings.

The Diagnosis of Benign Prostatic Obstruction: Validation of the Young Academic Urologist Clinical Nomogram.

OBJECTIVE: To externally validate the Young Academic Urologist (YAU) nomogram for the prediction of benign prostatic obstruction (BPO) in patients with lower urinary tract symptoms and benign prostatic enlargement. MATERIALS AND METHODS: Between January 2013 and September 2014, a consecutive series of patients with lower urinary tract symptoms and benign prostatic enlargement underwent standardized pressure flow studies (PFSs) in 2 tertiary Italian centers. Variables assessed were International Prostatic Symptom Score, Prostate Specific Antigen (PSA), prostate size, transitional zone volume, maximal urinary flow rate (Qmax), postvoid residual urine. BPO was defined as a Schäfer grade ≥ 3 at PFSs. Qmax and transitional zone volume were plotted on the YAU nomogram to predict the presence of BPO. Receiver operating characteristic curve analysis was used to evaluate predictive properties of the nomogram for the final diagnosis of BPO. RESULTS: A total of 449 patients were consecutively enrolled. In those, 310 patients (69%) presented a BPO (Schäfer ≥ 3) at PFSs. The novel YAU nomogram presented an area under the curve of 0.76; 95% confidence interval: 0.72-0.82 for the diagnosis of BPO. At the best cutoff value of 80% (nomogram probability), the sensitivity was 74% and specificity was 79%, the positive predictive value was 89%, and the negative predictive value was 56%. CONCLUSION: Although further studies are needed to confirm our results, the YAU nomogram was, in our experience, an excellent tool to predict the presence of BPO.

The Female Sexual Function Index (FSFI): linguistic validation of the Italian version.

INTRODUCTION: Although several new measurements for female sexual dysfunction (FSD) have recently been developed, the Female Sexual Function Index (FSFI) remains the gold standard for screening and one of the most widely used questionnaires. The Italian translation of the FSFI has been used in several studies conducted in Italy, but a linguistic validation of the Italian version does not exist. AIM: The aim of this study was to perform a linguistic validation of the Italian version of the FSFI. METHODS: A multicenter cross-sectional study conducted in 14 urological and gynecological clinics, uniformly distributed over Italian territory. We performed all steps necessary to determine the reliability and the test-retest reliability of the Italian version of the FSFI. The study population was a convenience sample of 409 Italian women. MAIN OUTCOME MEASURES: The reliability of the questionnaire was calculated using Cronbach's alpha, which was considered weak, moderate, or high if its value was found less than 0.6, between 0.6 and 0.8, or equal to or greater than 0.8, respectively. The test-retest reliability was assessed for all women in the sample by calculating Pearson's concordance correlation coefficient for each domain and for the total score, both at baseline and after 15 days (r range between -1.00 to +1.00, where +1.00 indicates the strongest positive association). RESULTS: Cronbach's alpha coefficients for total and domain score were sufficiently high, ranging from 0.92 to 0.97 for the total sample. The test-retest procedure revealed that the concordance correlation coefficient was very high both for FSFI-I total score (Pearson's P = 0.93) and for each domain (Pearson's P always >0.92). CONCLUSION: For the first time in the literature, our study has produced a validated and reliable Italian version of the FSFI questionnaire. Consequently, the Italian FSFI can be used as a reliable tool for preliminary screening for female sexual dysfunction for Italian women.