Urodynamic autonomic bladder dysfunction in women with complex chronic pelvic pain is associated with small fiber polyneuropathy.

AIMS: Small fiber neuropathy/polyneuropathy (SFN) has been found to be present in 64% of complex (refractory or multisystem) chronic pelvic pain (CPP) patients. The small fiber dysfunction seen in SFN can negatively impact autonomic control of micturition in addition to pain. This study investigated the clinical association of autonomic dysfunction (detrusor underactivity and primary bladder neck obstruction [BNO]) on video urodynamics (VUDS) with SFN in patients with CPP. METHODS: This was a retrospective observational study, querying data from patients with complex CPP. Inclusion criteria were: the presence of complex (refractory or multisystem) CPP, and completion of both (1) subspecialty autonomic neurology evaluation for SFN and (2) high-quality VUDS performed according to ICS standards. Autonomic bladder dysfunction (BNO or detrusor underactivity) on VUDS was compared to the presence of SFN. RESULTS: Thirty-two female patients with complex CPP met criteria. Of the 32, 23 (72%) were found to have SFN. Patient with autonomic bladder dysfunction (BNO or detrusor underactivity) were more likely to have SFN (OR = 9.5 [95% CI: 1.641, 55.00], p = 0.007). Post-void residual volume was higher in the SFN group (p = 0.011 [95% CI: 13.12, 94.0]) and symptoms of urge urinary incontinence were more likely to be present (p = 0.000 [95% CI: -3.4, -1.25]). CONCLUSIONS: Patients with complex CPP with autonomic bladder dysfunction are more likely to have SFN. This suggests patients with complex CPP should be considered for diagnosis and treatment of SFN, particularly if BNO or detrusor underactivity is noted on VUDS evaluation.

Robotic assisted proximal dorsal urethral diverticulectomy.

INTRODUCTION AND HYPOTHESIS: Urethral diverticula are rare but clinically significant entities among female patients. Ventrally located, mid-to distal, simple or horseshoe diverticula are most commonly observed and are usually repaired via a transvaginal approach with varying levels of difficulty but high success rates. Dorsally (anteriorly) located urethral diverticula are more challenging to repair secondary to the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter. Unique proximal anatomy in the case presented led to careful consideration of the surgical options. METHODS: We present a review of techniques reported in the literature and a video demonstrating our technique for transabdominal robot-assisted laparoscopic excision of a large, dorsal, very proximally located, crescenteric urethral diverticulum in a patient who initially presented with urosepsis. RESULTS: Robotic-assisted excision of the urethral diverticulum was accomplished in 3:27 h with an estimated blood loss of 50 cc. Vaginal counter-incision was not necessary. The patient's postoperative course was uneventful. Postoperative voiding cystourethrogram prior to suprapubic catheter removal revealed a well-healed repair without extravasation. At 6-month follow-up, she denied any de novo lower urinary tract symptoms such as urinary incontinence, post-void dribbling, urinary tract infection or urinary hesitancy. CONCLUSIONS: Dorsal urethral diverticulum in women, particularly when very proximal, can present a diagnostic and surgical challenge for reconstructive pelvic surgeons. The robotic approach to urethral diverticulectomy is feasible for a proximal dorsal urethral diverticulum which lies cephalad to the pubic symphysis. This or other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for complex urethral diverticuli with a proximal dorsal component.

Clinical and molecular assessment of 13 Iranian families with Wolfram syndrome.

PURPOSE: Wolfram syndrome (WS) is a rare genetic disorder described by a pattern of clinical manifestations such as diabetes mellitus, diabetes insipidus, optic nerve atrophy, sensorineural hearing loss, urinary tract abnormalities, and psychiatric disorders. WFS1 and WFS2 loci are the main genetic loci associated with this disorder. METHODS: In the current study, we investigated associations between these loci and WS via STR markers and homozygosity mapping in 13 Iranian families with WS. All families were linked to WFS1 locus. RESULTS: Mutation analysis revealed four novel mutations (Q215X, E89X, S168Del, and E391Sfs*51) in the assessed families. Bioinformatics tools confirmed the pathogenicity of the novel mutations. Other identified mutations were previously reported in other populations for their pathogenicity. CONCLUSIONS: The current study adds to the mutation repository of WS and shows a panel of mutations in Iranian population. Such panel would facilitate genetic counseling and prenatal diagnosis in families with WS cases.

Use of the Quick Sequential Organ Failure Assessment Score for Prediction of Intensive Care Unit Admission Due to Septic Shock after Percutaneous Nephrolithotomy: A Multicenter Study.

PURPOSE: Recent studies have demonstrated that quick sequential organ failure assessment criteria may be more accurate than systemic inflammatory response syndrome criteria to predict postoperative sepsis. In this study we evaluated the ability of these 2 criteria to predict septic shock after percutaneous nephrolithotomy. MATERIALS AND METHODS: We performed a retrospective multicenter study in 320 patients who underwent percutaneous nephrolithotomy at a total of 8 institutions. The criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome were collected 24 hours postoperatively. The study primary outcome was postoperative septic shock. Secondary outcomes included 30 and 90-day emergency department visits, and the hospital readmission rate. RESULTS: Three of the 320 patients (0.9%) met the criteria for postoperative septic shock. These 3 patients had positive criteria for quick sequential organ failure assessment and systemic inflammatory response syndrome. Of the entire cohort 23 patients (7%) met quick sequential organ failure assessment criteria and 103 (32%) met systemic inflammatory response syndrome criteria. Specificity for postoperative sepsis was significantly higher for quick sequential organ failure assessment than for systemic inflammatory response syndrome (93.3% vs 68.4%, McNemar test p <0.001). The positive predictive value was 13% for quick sequential organ failure assessment criteria and 2.9% for systemic inflammatory response syndrome criteria. On multivariate logistic regression systemic inflammatory response syndrome criteria significantly predicted an increased probability of the patient receiving a transfusion (ß = 1.234, p <0.001). Positive quick sequential organ failure assessment criteria significantly predicted an increased probability of an emergency department visit within 30 days (ß = 1.495, p <0.05), operative complications (ß = 1.811, p <0.001) and transfusions (p <0.001). The main limitation of the study is that it was retrospective. CONCLUSIONS: Quick sequential organ failure assessment criteria were superior to systemic inflammatory response syndrome criteria to predict infectious complications after percutaneous nephrolithotomy.

Assessment of readability, quality and popularity of online information on ureteral stents.

OBJECTIVE: To evaluate the quality and readability of online information on ureteral stents. METHODS: Google.com was queried using the search terms "ureteric stent", "ureteral stent", "double J stent" and, "Kidney stent" derived from Google AdWords. Website popularity was determined using Google Rank and the Alexa tool. Website quality assessment was performed using the following criteria: Journal of the American Medical Association (JAMA) benchmarks, Health on the Net (HON) criteria, and a customized DISCERN questionnaire. The customized DISCERN questionnaire was developed by combining the short validated DISCERN questionnaire with additional stent-specific items including definition, placement, complications, limitations, removal and "when to seek help". Scores related to stent items were considered as the "stent score" (SS). Readability was evaluated using five readability tests. RESULTS: Thirty-two websites were included. The mean customized DISCERN score and "stent score" were 27.1 ± 7.1 (maximum possible score = 59) and 14.6 ± 3.8 (maximum possible score = 24), respectively. A minority of websites adequately addressed "stent removal" and "when to seek medical attention". Only two websites (6.3%) had HON certification (drugs.com, radiologyinfo.org) and only one website (3.3%) met all JAMA criteria (bradyurology.blogspot.com). Readability level was higher than the American Medical Association recommendation of sixth-grade level for more than 75% of the websites. There was no correlation between Google rank, Alexa rank, and the quality scores (P > 0.05). DISCUSSION: Among the 32 most popular websites on the topic of ureteral stents, online information was highly variable. The readability of many of the websites was far higher than standard recommendations and the online information was questionable in many cases. These findings suggest a need for improved online resources in order to better educate patients about ureteral stents and also should inform physicians that popular websites may have incomplete information.

Three-Dimensional Virtual Sonographic Cystoscopy for Detection of Ureterocele in Duplicated Collecting Systems in Children.

OBJECTIVES: Ureterocele is a sac-like dilatation of terminal ureter. Precise anatomic delineation is of utmost importance to proceed with the surgical plan, particularly in the ectopic subtype. However, the level of ureterocele extension is not always elucidated by the existing imaging modalities and even by conventional cystoscopy, which is considered as the gold standard for evaluation of ureterocele. This study aims to evaluate the accuracy of three-dimensional virtual sonographic cystoscopy (VSC) in the characterization of ureterocele in duplex collecting systems. METHODS: Sixteen children with a mean age of 5.1 (standard deviation 1.96) years with transabdominal ultrasonography-proven duplex system and ureterocele were included. They underwent VSC by a single pediatric radiologist. All of them subsequently had conventional cystoscopy, and the results were compared in terms of ureterocele features including anatomy, number, size, location, and extension. RESULTS: Three-dimensional VSC was well tolerated in all cases without any complication. Image quality was suboptimal in 2 of 16 patients. Out of the remaining 14 cases, VSC had a high accuracy in characterization of the ureterocele features (93%). Only the extension of one ureterocele was not precisely detected by VSC. CONCLUSIONS: The results of this study suggest three-dimensional sonography as a promising noninvasive diagnostic modality in the evaluation of ectopic ureterocele in children.

Cessation of Ureteral Colic Does Not Necessarily Mean that a Ureteral Stone Has Been Expelled.

PURPOSE: We evaluated whether cessation of renal colic is consistent with an expelled ureteral stone or whether imaging may be indicated even in the absence of symptoms. MATERIALS AND METHODS: We performed a retrospective study of patients who presented to our institution with acute renal colic and ureteral stone, and were subsequently evaluated at a followup visit where they reported complete cessation of pain for at least 72 hours. RESULTS: Study inclusion criteria were met by 52 patients, who reported no pain for at least 72 hours at the time of the followup visit. A persistent ureteral stone was demonstrated in 14 of the 52 patients (26%) although they denied any associated symptoms. Multivariate logistic regression did not show an association between stone size or location and the likelihood of passage in this cohort. CONCLUSIONS: Cessation of pain was associated with ureteral stone passage in almost 75% of this study cohort but 26% of patients still had persistent ureteral stones. We recommend routine followup imaging in all patients with ureteral stones to document stone passage and avoid the risks of silent ureteral obstruction.

Ointment Fistulography: Introducing a Novel Technique for Single or Multiple Urethrocutaneous Fistula Diagnosis After Hypospadias Surgery.

INTRODUCTION AND OBJECTIVE: Hypospadias is a common congenital malformation of the male genital tract. The most frequent complication after hypospadias repair is urethrocutaneous fistula.1 Its incidence has been reported up to 35% worldwide.2 The diagnosis of these fistulas is sometimes challenging particularly with tiny and multiple fistulas. Usually, parents complain of urinary spraying, sprinkling, or passing a single stream of urine from the undersurface of the penis after the surgery. Urethrocutaneous fistulas are not always visible on physical examination. Locating the fistula and status of the surrounding skin is very important in order to choose the surgical repair technique.3 The patency and anatomy of the distal urethra should also be determined before the repair surgery.4 That is why urologists usually use retrograde urethrography or cystoscopy to find the location of fistula. However, these modalities have their own risk for children and are not always helpful. Sometimes the contrast media inserted can clog some fistulas especially near the glans and preclude the diagnosis. We present an easy technique to screen for urethrocutaneous fistulas after hypospadias surgery. TECHNIQUE: In this technique (Video 1), an antibiotic ointment is inserted through the meatus while the base of the penis is held; the ointment is then gently pushed through the meatus. As shown in the video, the ointment will protrude through the fistulas anywhere along the shaft. This technique can also be performed reversely as the ointment inserted from the fistulas will protrude from the meatus. For younger children under the age of 3, we exclusively perform this technique under anesthesia on the repair surgery day, whereas in toddlers we perform this technique in the office and once again under anesthesia right before the repair surgery. RESULT: This technique shows even tiny and multiple fistulas not detectable on physical examinations. We have used this technique in our clinic and have not missed any fistulas. The diameter of the protruded ointment in reverse fistulography is an indicator of the distal urethral diameter. Therefore, in case of narrow ointment diameter, distal urethral strictures should be suspected as correction of distal obstruction is an important determinant in the success rate of fistula repair surgery.5 CONCLUSION: We suggest this diagnostic technique as a safe, inexpensive, easy, office-based, feasible, and reproducible method. Negative urine culture is not required for this examination. Also, there is no need to insert contrast media as in retrograde urethrography or induce anesthesia as in cystoscopy. We believe this simple technique help urologists around the world to diagnose this common complication of hypospadias surgery without the need for special equipment.

The mobile technology era: Potential benefits in pediatric urology.

Mobile technology has been increasingly used in the world of medicine. We describe an application of mobile phones in the evaluation of urinary symptoms in infants, neonates, and toddlers. We believe this is a cheap, accessible and easy-to-use solution in pediatric urology for physicians and nurses around the world. In this video, we demonstrate some unique features of various anatomic and functional pediatric urology conditions, which are detectable in voiding clips taken by a cellphone camera.

Outcomes of ureteroscopy.

Over the past 2 decades, ureteroscopy has changed from a procedure considered second-line to shockwave lithotripsy to a commonly performed procedure for renal and ureteral stones. The increase in the use of ureteroscopy is due largely to improvements in technique and technology during this time period. Herein we review outcomes of ureteroscopy in terms of success rates, complications, and unique patient populations. This work will synthesize the data as it pertains to the practice of ureteroscopy for all endourological indications, including stone disease and management of upper tract urothelial carcinoma, as well as review state-of-the-art techniques.

A Novel Method of Urinary Sphincter Deficiency: Serial Histopathology Evaluation in a Rat Model of Urinary Incontinence.

In this study, a novel technique of irreversible sphincter deficiency by pudendal nerve transection (PNT) using 40 female rats for studying the pathophysiology of stress urinary incontinence associated with childbirth was developed. Of the 40 rats, 10 served as controls and the remaining underwent bilateral PNT at the anastomotic lumbosacral trunk level. Urethral morphological changes following bilateral PNT were assessed with serial hematoxylin and eosin (H&E) and immunohistochemistry (IHC) staining methods at 50, 90, and 130 days post-intervention. Leak point pressure (LPP) measurement was used to determine the effect of pudendal injury on urethral outlet resistance after the transection. H&E and IHC staining showed irreversible loss of striated muscle mass of the sphincter region and increase in collagen deposition compatible with muscle atrophy. LPP measurements also significantly decreased following bilateral PNT. In conclusion, a novel method of irreversible sphincter insufficiency was developed. This model effectively decreased urethral outlet resistance and caused irreversible striated muscle atrophy. It was suggested that this technique can be used to develop a permanent sphincter deficiency model for the preclinical testing of treatment modalities exclusively triggering the pudendal nerve.

Transcutaneous interferential electrical stimulation for the management of non-neuropathic underactive bladder in children: a randomised clinical trial.

OBJECTIVES: To assess the efficacy of transcutaneous interferential electrical stimulation (IFES) and urotherapy in the management of non-neuropathic underactive bladder (UAB) in children with voiding dysfunction. PATIENTS AND METHODS: In all, 36 children with UAB without neuropathic disease [15 boys, 21 girls; mean (sd) age 8.9 (2.6) years] were enrolled and then randomly allocated to two equal treatment groups comprising IFES and control groups. The control group underwent only standard urotherapy comprising diet, hydration, scheduled voiding, toilet training, and pelvic floor and abdominal muscles relaxation. Children in the IFES group likewise underwent standard urotherapy and also received IFES. Children in both groups underwent a 15-session treatment programme twice a week. A complete voiding and bowel habit diary was completed by parents before, after treatment, and 1 year later. Bladder ultrasound and uroflowmetry/electromyography were performed before, at the end of treatment course, and at the 1-year follow-up. RESULTS: The mean (sd) number of voiding episodes before treatment was 2.6 (1) and 2.7 (0.76) times/day in the IFES and control groups, respectively, which significantly increased after IFES therapy in IFES group, compared with only standard urotherapy in the control group [6.3 (1.4) vs 4.7 (1.3) times/day, P < 0.002). The mean (sd) bladder capacity before treatment was 424 (123) and 463 (121) mL in the control and IFES groups, respectively, which decreased significantly at 1 year after treatment in the IFES group compared with the controls, at 227 (86) vs 344 (127) mL (P < 0.01). Maximum urine flow increased and voiding time decreased significantly in the IFES group compared with controls at the end of treatment sessions and 1 year later (P < 0.05). All the children had abnormal flow curves at the beginning of the study. The flow curve became normal in 14/18 (77%) of the children in the IFES group and six of 18 (33%) in the control group by the end of follow-up (P < 0.007). At the end of the treatment course, night-time wetting was improved in all children who had this symptom before the treatment in the IFES group (P < 0.01). CONCLUSION: Combining IFES and urotherapy is a safe and effective therapy in the management of children with UAB.

Decellularized dermal strip as a suburethral sling in a rat model of stress urinary incontinence.

INTRODUCTION: To report the feasibility, efficacy and safety of decellularized dermal strip as a sling material in the pudendal denervated stress urinary incontinence (SUI) in an animal model. METHODS: Thirty female Sprague-Dawley rats were randomly allocated into three equal groups (n = 10). In group 1, rats underwent bilateral pudendal nerve transection (BPNT) with no vaginal sling placement. Group 2 underwent BPNT with homologous decellularized dermal strip placement as vaginal sling 12 weeks later. Group 3 was considered as controls to evaluate baseline leak point pressure (LPP). Leak point pressure was measured 18 weeks after BPNT in group 1 and 6 weeks after sling implantation in group 2. Sling and sphincter samples were prepared for histological and immunohistochemistry (IHC) staining. RESULTS: H&E staining of external urethral sphincter showed decrease in striated muscle layer in group 1 (BPNT) compared to control confirmed by desmin staining (45 % decrease in desmin staining). Sling implantation caused significant increase in mean LPP from 11.6 ± 2.8 cm H2O in group 1 (BPNT) to 27.2 ± 5.4 cm H2O in group 2 (BPNT/sling). There was no significant difference between LPP after the sling placement in group 2 and LPP in group 3 (27.2 ± 5.4 cm H2O vs. 27.6 ± 5.9, P = 0.832). IHC staining was positive for α-SMA and CD34. CONCLUSIONS: Based on present results, this dermal strip could be considered as a potential sling material for treatment of SUI in this animal model. This study provides the basis for further investigation of the efficacy of biological decellularized scaffold as suburethral sling material.

Management of bladder dysfunction in Wolfram syndrome with Mitrofanoff appendicovesicostomy: long-term follow-up.

PURPOSE: To present the long-term outcomes of appendicovesicostomy using the Mitrofanoff principle for end-stage Wolfram bladder dysfunction as an alternative to clean intermittent self-catheterization (CIC) per urethra mainly following blindness. METHODS: Twelve Wolfram patients presenting with bilateral hydroureteronephrosis and advanced bladder dysfunction were included in this study. All patients were managed initially by CIC per urethra. All of these patients became blind during follow-up and were unable to perform urethral CIC independently. Out of these patients, six patients agreed to proceed to appendicovesicostomy. Appendicovesicostomy urinary diversion using the Mitrofanoff principle was performed in these six blind patients. The rest of the patients stopped CIC or performed CIC irregularly. RESULTS: Severe hydroureteronephrosis and large bladders were found in all patients prior to intervention. All patients were able to conduct CIC independently through the stoma and maintained overnight bladder free drainage. In all patients with urinary diversion and CIC, the hydroureteronephrosis was reduced and renal function returned to normal. However, the non-intervention group ended with different degrees of progressive renal failure with three mortalities during the follow-up. CONCLUSIONS: We suggest appendicovesicostomy as a safe and lifesaving procedure for long-term management of bladder dysfunction in Wolfram syndrome particularly after progression to blindness.

Efficacy of transcutaneous interferential electrical stimulation in treatment of children with primary nocturnal enuresis: a randomized clinical trial.

BACKGROUND: Electrical stimulation has been used as an alternative therapy for adult urinary syndromes and for children with constipation. We have evaluated the safety and efficacy of interferential (IF) electrical stimulation in children with nocturnal enuresis (NE). METHODS: This was a randomized clinical trial in which 54 children (23 girls, 31 boys) aged 6-14 years with primary NE were recruited and randomly divided into two groups. Children in the control group underwent standard urotherapy only (hydration, scheduled voiding, toilet training, diet), whereas children in the IF group (cases) were treated with standard urotherapy + 15 sessions of IF electrical stimulation for 20 min twice per week. An improvement score was calculated to identify relative decrease in wet nights after the treatment for each child. All children were followed for 1 year. RESULTS: Overall, 15/27 (55.5%) and 6/27 (22%) of children in the IF and control groups responded to treatment at the 1-year follow-up (P = 0.01). The mean number of wet nights per week in the control and IF groups decreased from 5.4 ± 2 and 5.7 ± 2 to 3.3 ± 3 and 1.1 ± 2, respectively, at first evaluation (P = 0.003). The mean improvement score in the IF group was significantly higher than that of the control group after 1 year (78 vs. 46%, respectively; P = 0.004). CONCLUSION: Interferential therapy can be applied as a safe, effective and well-tolerable alternative therapy in the treatment of children with NE.

Does percutaneous nephrolithotomy cause elevated cardiac troponins?

BACKGROUND: Percutaneous nephrolithotomy is the treatment of choice in large and staghorn renal stones, and myocardial infarction is one the possible complications during and after the surgery. We investigated if renal and skeletal muscle injury, caused by percutaneous nephrolithotomy, can cause elevation in cardiac troponins (cTn). METHODS: This study was conducted on otherwise healthy patients with renal stone undergoing percutaneous nephrolithotomy. A baseline 12-lead electrocardiogram, echocardiography, and cTn assessment confirmed no cardiac pathology in any patients. Cardiac troponins T (cTnT) and I (cTnI), and also creatine kinase (CK) were assessed before and after surgery. RESULTS: A total of 55 patients (69.1% males, mean age: 40.5 ± 13.8 year) were included. Serum creatinine level ranged from 0.7 to 1.3 mg/dl (mean = 1.03 ± 0.17). The level of CK was significantly increased by 469.5 ± 201.4 U/l (P < 0.001), and no positive cTnT or cTnI was observed after surgery. CONCLUSION: The results of the present study showed that renal cell injury, caused by percutaneous nephrolithotomy, is not associated with elevated cardiac troponins. These findings show that increasing troponins in patients undergoing percutaneous nephrolithotomy indicate a cardiovascular pathology.

Neurovascular sparing vas clipping: last option for recurrent epididymo-orchitis in urethrovasal reflux due to urethral injury.

Acute scrotum is a critical clinical entity in children. This report presents a 12-year-old boy presented with recurrent epididymo-orchitis (EO) with a history of pelvic trauma and urethral disruption 10 years ago. Antegrade and retrograde studies confirmed urethrovasal reflux. The patient did not respond to prophylactic antibiotics, clean intermittent catheterization and endoscopic injection of bulking agent at the junction of the ejaculatory duct and posterior urethra. As the last option, neurovascular sparing vas clipping was performed and the patient made a full recovery. This is the first report of this technique in the treatment for recurrent EO caused by traumatic injury.