Early serum sodium changes in elderly patients with nocturia receiving desmopressin.

Purpose: The purpose of the study is to identify early serum sodium changes that could happen in elderly patients with nocturia receiving desmopressin. Materials and Methods: This study was conducted on 28 patients complaining of nocturia and receiving desmopressin. Inclusion criteria were patients diagnosed as having nocturia (at least one or more voids per night) aging ≥55 years with normal baseline serum sodium (135-150 mEq/L). All patients received desmopressin in the form of 60 µg at bedtime. Close follow-up was done for any adverse effects that may have occurred related to hyponatremia and serum sodium was reevaluated for all patients at 3, 7, 14, and 30 days from the start of the treatment. Results: Desmopressin resulted in a significant decrease in nocturnal urine volume, a decrease in nocturnal polyuria index, number of night voids and the time to first void was delayed. Furthermore, statistically insignificant sodium drop in males and statistically significant sodium drop in females were noted with infrequent side effects, for example, headache (10.7%) and hyponatremia (7.14%) that started after treatment by 1 week. Conclusion: Hyponatremia can be avoided using the minimal effective dose of desmopressin. To receive desmopressin in elderly patients sodium baseline level must be ≥135 mmol/L. Close sodium monitoring has to be done at 7, 14, and 30 days from start of treatment for high-risk patients (especially elderly) or patients receiving other medication causing hyponatremia.

The restoration and erection of the world's first elevated obelisk.

Obelisks presented an important element in the architecture of ancient Egypt. This research is concerned with the re-erection of an obelisk that belongs to the famous Pharoah Ramses II. It was found broken and was transported to the Grand Egyptian Museum for restoration and display. An observation of Ramses II Cartouche at the bottom side of the obelisk base inspired the authorities to provide an innovative architectural design to display the obelisk elevated. The supporting structure was designed to allow the visitors to walk underneath the obelisk and observe Ramses II's signature. The idea of elevating the obelisk presented several challenges including evaluating the obelisk's current condition, restoration and fixation methodology, structural stability, and uncertainties of material characteristics, amongst others. To control the obelisk deformations under lateral loading, state-of-the-art base isolators were introduced. For the task to be achieved, a multidisciplinary team including historians, conservators, archaeologists, architects, and engineers with different specialties was appointed. The team performed the task successfully and currently, the obelisk stands at the entrance piazza of the Grand Egyptian Museum representing the world's first elevated obelisk.

Innovative training modality for sacral neuromodulation (SNM): Patient-specific computerized tomography (CT) reconstructed 3D-printed training system: ICS School of Modern Technology novel training modality.

INTRODUCTION: Sacral neuromodulation (SNM) is an effective treatment of urinary and bowel dysfunction, including secondary to neurological disorders. The learning curve for the optimal electrode placement for SNM is steep, expensive, and limited by patient factors such as obesity and previous injuries. We aim to create a patient specific 3-dimensional (3D) model for successful SNM training. MATERIALS AND METHODS: A total of 26 urology residents who had different level of knowledge and experience were enrolled to the 3D SNM training program. The creation of 3D sacrum model has been started with evaluation of real patient computerized tomography images and creation of Digital Imaging and Communications in Medicine files. The segmented anatomic structures from the files then edited and stereolithographic files were generated for 3D-model prints via Mimics© software. The 3D-printed models were used for training and evaluation of participants during the SNM intervention was performed. The evaluation of 3D SNM model training was led by one mentor who is expert on SNM. RESULTS: On the preprinted 3D sacrum model all 26 participants were requested to perform the essential steps to complete a SNM procedure and individual procedure time was recorded. The mean and median scores were 18.8 and 19, respectively according to Likert scores (min 11 max 28). CONCLUSIONS: SNM is increasing in popularity as a treatment option with physicians and patients with refractory symptoms. Few experienced specialists exist, and more effective training methods are needed to tackle the increasing demand, and individual patient anatomy.

An International Continence Society (ICS) report on the terminology for female pelvic floor fistulas.

INTRODUCTION: The terminology for female pelvic floor fistulas (PFF) needs to be defined and organized in a clinically based consensus Report. METHODS: This Report combines the input of members of the International Continence Society (ICS) assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of 19 rounds of internal and external review was involved to examine each definition, with decision-making by collective opinion (consensus). RESULTS: A terminology report for female PFF, encompassing 416 (188 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in different specialty groups involved in female pelvic floor dysfunction and PFF. Female-specific imaging (ultrasound, radiology, and magnetic resonance imaging) and conservative and surgical PFF managements as well as appropriate figures have been included to supplement and clarify the text. Interval (5-10 years) review is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based terminology report for female PFF has been produced to aid clinical practice and research.

A comparative study of robot-assisted laparoscopic intracorporeal versus open urinary diversion.

AIMS: Robot-assisted laparoscopic intracorporeal urinary diversion (ICUD) has several potential benefits of a smaller incision and reduced pain over extracorporeal urinary diversion (ECUD). We compared the perioperative outcomes of patients who have undergone these procedures with or without cystectomy. SUBJECTS AND METHODS: This study is a retrospective chart review of patients who underwent ICUD and ECUD in a single tertiary referral hospital. Patient demographics, perioperative outcomes, and the 90-day postoperative complications were collected. STATISTICAL ANALYSIS USED: The statistical analyses were performed using the Chi-square test for categorical variables which are specified as frequency (percentage). RESULTS: Thirty-five patients who underwent urinary diversion procedure were identified for inclusion in the study. Of these patients, 14 underwent ICUD and 21 underwent ECUD. The mean operative time was longer in the ICUD group compared to that of the ECUD (457.14 ± 103.91 and 388.29 ± 110.17, respectively, P = 0.07). The median blood loss was statistically significantly lower in the ICUD group (250 ml) than in the ECUD group (450 ml, P = 0.05). The mean hospital stay was marginally longer for the ECUD group (8.1 days) as compared to the ICUD group (6.3 days, P = 0.17). There was no difference in the readmission or reoperation rates after 30 days. The 90-day complication rate was not statistically significantly different between the two groups, but a trend favoring ICUD (64%) over ECUD (71%, P = 0.656) was noted. CONCLUSIONS: Robot-assisted ICUD is associated with decreased blood loss, and there is a trend toward fewer postoperative complications and shorter hospital stays.

Impact of food and drinks on urine production: A systematic review.

CONTEXT: The impact of food and drinks on body fluid metabolism is of direct clinical relevance but current evidence remains fragmented. AIM: Synthesise current evidence on the role of food and drinks in urine production. METHODS: Systematic review as per PRISMA guidelines using MEDLINE and EMBASE databases (completed October 2019). Studies reporting on the effect of food, food constituents, and drinks on urine production were included. Two authors performed an independent extraction of relevant articles using predetermined data sets and completed quality-of-study indicators. RESULTS: A total of 49 studies were included, of which 21 enroled human subjects, and 28 were clinically relevant animal studies (all of which utilised rodent models). The included studies were determined to be of variable quality. High dietary sodium, as well as wine, spirits, high-caffeine coffee, and caffeinated energy drinks, increased urine production in human studies. Decreased urine production was associated with low dietary sodium and consumption of milk, orange juice, and high-salt/high-sugar drinks. In animal models, a variety of fruits, vegetables, herbs, spices, and honey were associated with increased urine production. CONCLUSION: Current evidence suggests that although several types of food and drinks may impact body fluid metabolism, the quality of the data is variable. Urine production appears to be influenced by multiple factors including composition (ie, moisture, macronutrients, and electrolytes), metabolite load, and the presence of specific diuresis-promoting substances (eg, caffeine, alcohol) and other bioactive phytochemicals. Future research is needed to support current evidence and the physiologic mechanisms underlying these findings.

Complications of urethral bulking therapy for female stress urinary incontinence.

AIMS: To review, report, and discuss the complications associated with urethral bulking therapy in female stress urinary incontinence. METHODS: An extensive nonsystematic literature review on complications associated with injectable bulking agents used in the clinical practice was conducted. We reviewed articles published in English and indexed in the PubMed, Embase, and Google Scholar databases. Original articles, case reports, and case series were taken into consideration. Data regarding the safety of injectable bulking agents and the complications associated with their utility within the context of urethral bulking therapy for female stress urinary incontinence were extracted and discussed. RESULTS: Approximately, 1/3 of the patients experience some type of a complication after urethral bulking therapy. The majority of these complications are of low grade, transient, do not necessitate additional surgical intervention, and amenable to treatment with conservative measures such as clean intermittent catheterization and antibiotics. However, more serious complications such as abscess formation, delayed hypersensitivity reactions, and vaginal erosion have been reported. Some of the injectable bulking agents have been withdrawn from the market because of their unfavorable adverse effect profile. CONCLUSIONS: Urethral bulking therapy can be considered as a low-risk procedure. However, it is not without complications which can be severe in rare instances. The search for the ideal urethral bulking agent is ongoing and future comparative studies assessing the safety and efficacy of these compounds in randomized controlled settings are warranted.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document.

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

International Continence Society consensus on the diagnosis and treatment of nocturia.

INTRODUCTION: Patients with nocturia have to face many hurdles before being diagnosed and treated properly. The aim of this paper is to: summarize the nocturia patient pathway, explore how nocturia is diagnosed and treated in the real world and use the Delphi method to develop a practical algorithm with a focus on what steps need to be taken before prescribing desmopressin. METHODS: Evidence comes from existing guidelines (Google, PubMed), International Consultation on Incontinence-Research Society (ICI-RS) 2017, prescribing information and a Delphi panel (3 rounds). The International Continence Society initiated this study, the authors represent the ICI-RS, European Association of Urology, and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU). RESULTS: Diagnostic packages: consensus on, history taking for all causalities, intake diary (fluid, food) and bladder diary, not for its duration. Pelvic (women) or rectal (men) examination, prostate-specific antigen, serum sodium check (SSC), renal function, endocrine screening: when judged necessary. Timing or empty stomach when SSC is not important. Therapeutic packages: the safe candidates for desmopressin can be phenotyped as no polydipsia, heart/kidney failure, severe leg edema or obstructive sleep apnea syndrome. Lifestyle interventions may be useful. Initiating desmopressin: risk management consensus on three clinical pictures. Follow-up of desmopressin therapy: there was consensus on SSC day 3 to 7, and at 1 month. Stop therapy if SSC is <130 mmol/L regardless of symptoms. Stop if SSC is 130 to 135 mmol/L with symptoms of hyponatremia. CONCLUSION: A summary of the nocturia patient pathway across different medical specialists is useful in the visualization and phenotyping of patients for diagnosis and therapy. By summarizing basic knowledge of desmopressin, we aim to ease its initiation and shorten the patient journey for nocturia.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document.

BACKGROUND: The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial. AIMS: In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. MATERIALS & METHODS: This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures. RESULTS: Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. DISCUSSION: The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. CONCLUSION: At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The energy based devices for vaginal "rejuvenation," urinary incontinence, vaginal cosmetic procedures, and other vulvo-vaginal disorders: An international multidisciplinary expert panel opinion.

AIMS: Energy-based devices using radiofrequency and laser technologies have gained popularity as therapies for vaginal atrophy, urinary incontinence, and vaginal prolapse. They have been promoted by cosmetic and aesthetic industries for vaginal "laxity" and vaginal "rejuvenation," both of which are undefined conditions and terms. This article aims to review the current available literature and its quality on this emerging technology. METHODS: An international panel of gynaecologists, urogynaecologists, and urologists undertook a review of the available published literature, identifying articles, guidance, and society statements on the use vaginal energy-based devices. RESULTS: There is currently no formal guidance for the use of vaginal energy based therapies. No randomized controlled trials have been published. No comparative studies to existing treatment has been carried out. Studies suggest that vaginal laser can be used in the treatment of vaginal prolapse or "vaginal laxity" and stress urinary incontinence with no quality evidence supporting the use of the therapy for vaginal atrophy or lichen sclerosis. CONCLUSIONS: This international group propose that whilst there remains a paucity of good quality data describing the safety, benefits, and appropriate use of vaginal radiofrequency or laser treatments in gynaecology and urogynaecology, a consensus best practice document by an established scientific community needs to be developed.

Burch colposuspension.

AIMS: To evaluate the historic and pathophysiologic issues which led to the development of Burch colposuspension, to describe anatomic and technical aspects of the operation and to provide an update on current evidence. METHODS: We have performed a focused literature review and have searched the current available literature about historic dimension, technical descriptions, and efficacy of Burch colposuspension. RESULTS: Burch colposuspension, performed either by an open or a laparoscopic approach, is an effective surgical treatment for stress urinary incontinence. CONCLUSIONS: In current recommendations, Burch colposuspension remains an option for secondary treatment. Because midurethral slings have recently become under scrutiny, it may return as a first-line treatment procedure. Both open and laparoscopic Burch colposuspension should therefore nowadays be provided in fellowship programs worldwide.

Safety and effectiveness of laparoscopic sacrocolpopexy as the treatment of choice for pelvic organ prolapse.

Objective: To evaluate the safety and effectiveness of laparoscopic sacrocolpopexy (LSC)/laparoscopic sacrohysteropexy (LSH) at 1-year follow-up for female pelvic-organ prolapse (POP). Patients and methods: In all, 52 patients were included and underwent LSC/LSH in the Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. All patients with POP, with Grade ≥II of any anatomical site (anterior, posterior or combined) who were medically fit for general anaesthesia, were included in the study. Patients with previous major abdominal surgery, a body mass index (BMI) of >40 kg/m2 or un-correctable bleeding diatheses, were excluded. Preoperative data, peri- and postoperative functional and anatomical outcomes were assessed. The patients were followed-up at 3, 6 and 12 months postoperatively. Results: Pre- and postoperative data were available for the 52 patients operated on for POP. The subjective cure rate was 92.3% and the objective cure rate was 98.1%. Failure was defined as recurrence of Grade ≥II POP. Conclusion: LSC/LSH is a safe and effective procedure for the treatment of female POP due to its durable results and low rates of complications with high objective and subjective cure rates. Abbreviations: BMI: body mass index; (RA)LSC: (robot-assisted) laparoscopic sacrocolpopexy; LSH: laparoscopic sacrohysteropexy; PFDI-20: Pelvic Floor Distress Inventory; PFIQ-7: Pelvic Floor Impact Questionnaire; POP: pelvic-organ prolapse; QoL: quality of life; SUI: stress urinary incontinence; TVM: total transvaginal mesh; VVP: vaginal vault prolapse.

Prevalence and impact of lower urinary tract symptoms: Results of the epic survey in Egypt.

AIMS: To estimate the prevalence of lower urinary tract symptoms (LUTS), including overactive bladder (OAB), and urinary incontinence (UI), in Egypt and the impact on patients' quality of life. METHODS: A population-based, cross-sectional survey (EPIC) was conducted with a random sample of adults aged ≥18 years. Prevalence estimates were based on 2002 International Continence Society definitions. RESULTS: A total of 3600 adult men and women participated in the survey; 86% of them experienced ≥1 LUTS: storage symptoms were more frequently reported (75%) than voiding (52%) or postmicturition (42%) symptoms. The most prevalent storage symptom was nocturia (defined as ≥1 time per night) in 70% of the population. UI was reported by 21% (mixed UI [MUI]: 9%; stress UI [SUI]: 4%; urgency UI [UUI]: 5%; other UI: 3%), and 30% met criteria for OAB. Despite the high prevalence of LUTS, few individuals with UUI, MUI, SUI, or OAB took prescription medicine (12%) or consulted a healthcare professional about their symptoms (23%). CONCLUSION: High prevalence rates of LUTS and OAB were found in adult men and women in Egypt, although low healthcare utilization and low prescription medication use for symptoms were observed.

Autologous versus synthetic slings in female stress urinary incontinence: A retrospective study.

OBJECTIVE: To evaluate and compare the clinical (patient's morbidity, quality of life [QoL]) and economic impact of autologous vs synthetic slings in female stress urinary incontinence (SUI), as over the last decade, the introduction of synthetic vaginal tapes for managing SUI has gained wide acceptance being quicker with low morbidity. Synthetic vaginal tapes have been progressively replacing the use of autologous rectus fascia. However, the high cost of these synthetic tapes is almost always an obstacle for most patients of limited socio-economic resources in the Egyptian community. PATIENTS AND METHODS: This retrospective study included 126 women with SUI. Data for patients that matched the study inclusion criteria were collected from the Urology Department of Ain-Shams University Hospitals from March 2011 to May 2013. Patients were categorised into two groups: Group I included 62 patients who underwent an autologous sling procedure using rectus sheath; and Group II included 64 patients that had a synthetic sling, using transobturator tape (TOT). The following variables were compared: operative time, postoperative pain scores, duration of indwelling urethral catheter, hospital stay, cost including the price of the synthetic tape when used, return to normal activity, and QoL assessment (International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form [ICIQ-UI-SF]) before and after discharge from hospital. RESULTS: Patients amongst the two groups were normally distributed with no statistically significant differences in patient's demographic data and comorbidities. The mean hospital stay was longer and the return to normal activity was delayed in Group I compared to Group II. The highest mean postoperative pain score was recorded in Group I. The overall morbidity was 12.9% and 4.68% in groups I and II, respectively. The mean (SD) overall cost was 2571.65 (254.8) and 3502.34 (196.9) Egyptian pounds (local currency) in groups I and II, respectively, being insignificantly lower in Group I when compared to Group II (P > 0.05). There were statistically significant differences between groups I and II for operative time, hospital stay, and postoperative pain scores. However, the differences in hospital cost amongst Group I and Group II were in favour of Group I. Post-surgical outcome was categorised into either complete cure (dry) or improved or failed with no significant differences in success rate and QoL amongst the study groups. The mean (SD) change in the QoL score was 10.95 (4.19) and 12.32 (4.1) in groups I and II, respectively. The higher success rate (complete cure) was in Group II, at 93.75%. Also, a statistically significant improvement of >70% of mean ICIQ-UI-SF score was shown in all groups when compared to baseline on both the 1- and 6-month follow-up visits. CONCLUSION: Autologous grafts should be considered as a repair option in females with SUI in countries were health insurance policies do not cover the cost of synthetic materials in many instances. The cost-effectiveness of synthetic TOT slings, as a minimally invasive procedure with lower overall morbidity, has yet to be confirmed in larger scale studies with longer periods of follow-up, to confirm the durability of its successful outcomes and be considered as the primary treatment of choice in female SUI.

Evaluation and surgery for stress urinary incontinence: A FIGO working group report.

AIMS: To review available evidence regarding evaluation and treatment of stress urinary incontinence (SUI) and provide recommendations for management of urinary incontinence under specific conditions determined by the International Federation of Gynecology and Obstetrics (FIGO) Working Group. METHODS: The FIGO Working Group discussed the management of SUI during meetings and assessed the evidence. The search of evidence was performed using MEDLINE® and Cochrane databases as well as additional searches from societies and major organizations for additional guidelines and recommendations and hand searches from bibliographies. Initial searches from 1985 to December 31, 2012 extended until July 15, 2015. After review, recommendations are made based on levels of evidence according to the recommendations from Oxford EBM Center. RESULTS: Initial evaluation of SUI consists of history and physical examination; cough stress test, evaluation for urinary tract infections (UTI), assessment of urethral mobility, and post-void residual volumes (LOE 5). Urodynamic studies are not necessary to evaluate patients with uncomplicated SUI (LOE 1a). Conservative treatment should be tried prior to surgery and more importantly in areas of low resources (LOE 5). Midurethral slings (MUS), pubovaginal (traditional suburethral) slings (PVS), and Burch colposuspension are effective in treating SUI (LOE 1a). Patients with SUI with ISD or UUI appear to have lower cure rates than patients without (LOE 2-4). There are limited data on surgical outcomes under limited resources (LOE 5). CONCLUSIONS: MUS, PVS, and Burch colposuspension are effective treatments for SUI. Evidence for recommendations to treat patients in underserved low resource areas is lacking. Neurourol. Urodynam. 36:518-528, 2017. © 2016 Wiley Periodicals, Inc.

Stiffening of short small-size circular composite steel-concrete columns with shear connectors.

An experimental program was conducted to investigate the effect of shear connectors' distribution and method of load application on load-displacement relationship and behavior of thin-walled short concrete-filled steel tube (CFT) columns when subjected to axial load. The study focused on the compressive strength of the CFT columns and the efficiency of the shear stud in distribution of the load between the concrete core and steel tube. The study showed that the use of shear connectors enhanced slightly the axial capacity of CFT columns. It is also shown that shear connectors have a great effect on load distribution between the concrete and steel tubes.