British Association of Urological Surgeons (BAUS) consensus document: Management of female voiding dysfunction.

OBJECTIVES: To report the British Association of Urological Surgeon's (BAUS) guidance on the assessment and management of female voiding dysfunction. METHODS: A contemporary literature search was conducted to identify the evidence base. The BAUS Section of Female, Neurological and Urodynamic Urology (FNUU) Executive Committee formed a guideline development group to draw up and review the recommendations. Where there was no supporting evidence, expert opinion of the BAUS FNUU executive committee, FNUU Section and BAUS members, including urology consultants working in units throughout the UK, was used. RESULTS: Female patients with voiding dysfunction can present with mixed urinary symptoms or urinary retention in both elective and emergency settings. Voiding dysfunction is caused by a wide range of conditions which can be categorized into bladder outlet obstruction (attributable to functional or anatomical causes) or detrusor underactivity. Guidance on the assessment, investigation and treatment of women with voiding dysfunction and urinary retention, in the absence of a known underlying neurological condition, is provided. CONCLUSION: Wa have produced a BAUS approved consensus on the management pathway for female voiding dysfunction with the aim to optimize assessment and treatment pathways for patients.

British Association of Urological Surgeons (BAUS) consensus document: management of bladder and ureteric injury.

Injuries to the bladder and ureter are uncommon but usually require prompt urological management. Due to their infrequent nature, Urologists maybe unfamiliar with managing these acute problems and may not work in specialist centres with readily available expertise in open and abdominal surgery. We aim to provide advice in the form of a consensus statement led by the Female, Neurological and Urodynamic Urology (FNUU) Section of the British Association of Urological Surgeons (BAUS), in consultation with BAUS members and consultants working in units throughout the UK, to create a comprehensive management pathway and a series of statements to aid clinicians.

British Association of Urological Surgeons (BAUS) and Nurses (BAUN) consensus document: management of the complications of long-term indwelling catheters.

OBJECTIVE: To look at best evidence and expert opinion to provide advice in the form of a consensus statement lead by Female, Neurological and Urodynamic Urology (FNUU) section of the British Association of Urological Surgeons (BAUS) in conjunction with the British Association of Urological Nurses (BAUN). METHODS: Initially a literature search was performed with incorporation of aspects of the existing guidance and further informed by UK best practice by core members of the group. The document then underwent reviews by the FNUU Executive Committee members, the BAUN executive committee, a separate experienced urologist and presented at the BAUS annual meeting 2020 to ensure wider feedback was incorporated in the document. RESULTS: Complications of long-term indwelling catheters include catheter-associated urinary tract infections (CAUTI), purple urine bag syndrome, catheter blockages, bladder spasms (causing pain and urinary leakage), loss of bladder capacity, urethral erosion ("catheter hypospadias")/dilatation of bladder outlet and chronic inflammation (metaplasia and cancer risk). CONCLUSIONS: We have provided a list of recommendations and a troubleshooting table to help with the management of the complications of long term catheters.

British Association of Urological Surgeons suprapubic catheter practice guidelines - revised.

AIMS: To report the updated and revised British Association of Urological Surgeons (BAUS) guideline on indications, safe insertion and subsequent care of suprapubic catheters (SPCs). METHODS: The existing BAUS guideline on the insertion of SPCs was reviewed and has been updated in light of both activity and outcome data published since the original guideline was written. A systematic review of all new data from 2010 onwards was carried out. This updated guideline is largely evidence-based but, where evidence was lacking, is based on the consensus of expert opinion from members of the BAUS Section of Female, Neurological and Urodynamic Urology. RESULTS: Suprapubic catheterization is widely used and generally considered a safe procedure. There is, however, a small risk of serious complications including bowel injury. The BAUS has produced an updated consensus statement on SPC use with the aim of minimizing risks and establishing best practice. Areas for future research and development are also highlighted. This review has been commissioned and approved by the BAUS and the Section of Female, Neurological and Urodynamic Urology. CONCLUSIONS: While SPC insertion is generally regarded as a safe procedure, the risk of serious morbidity and death must always be considered and outlined to patients. These revised guidelines should assist in minimizing the morbidity associated with SPC usage.

Another Therapeutic Role for Intravesical Botulinum Toxin: Patients with Long-stay Catheters and Refractory Bladder Pain and Catheter Bypass Leakage.

BACKGROUND: Botulinum neurotoxin (BotN) is used to treat detrusor overactivity (DO) refractory to medical treatment. Catheterised patients with symptoms of bladder spasm and catheter bypass leakage are challenging to manage and the efficacy of BotN is not established. OBJECTIVE: To review our experience using intravesical BotN to treat refractory bladder pain and catheter bypass leakage in patients with long-term indwelling catheters. DESIGN, SETTING, AND PARTICIPANTS: We carried out a review of data prospectively collected for patients with indwelling urethral or suprapubic catheters receiving BotN for the treatment of bladder spasms and catheter bypass leakage in a UK tertiary centre. An unvalidated structured questionnaire was used to ascertain quality of life (QoL) outcomes. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Qualitative data were collected for patient-reported symptoms and QoL. Paired Student t tests were applied for statistical analysis. RESULTS AND LIMITATIONS: Of the 54 catheterised patients who received BotN, 14 (26%) were male and 40 (74%) were female. The mean follow-up was 38mo. Of the patients, 34 (63%) had a neurological aetiology and 94% had experienced failure of medical therapy before BotN administration. The BotN starting dose was 100 or 200U and 17 patients (31%) required dose escalation. All 34 neurogenic and six non-neurogenic patients started on 200U. After treatment, 63% of patients managed their catheter with intermittent drainage and 37% managed on free drainage; 51 patients (94%) reported that their symptoms were controlled and 38% reported being treated for a urinary tract infection following BotN. Patients reported a mean improvement in QoL of 7.7/10 following BotN, while 83% reported a significant reduction in urine leakage (p=0.0001). CONCLUSIONS: Outpatient intravesical BotN is safe and efficacious for patients with long-term catheters suffering from bladder pain and catheter bypass leakage. PATIENT SUMMARY: Outpatient administration of intravesical botulinum toxin is a safe and effective treatment for patients with a long-term indwelling catheter with bothersome urine storage symptoms. Attention should be paid to urine microbiology results before treatment to ensure appropriate prophylactic antibiotic treatment to reduce the incidence of urinary tract infections.

Augmentation cystoplasty in neuropathic bladder.

Objectives: To look at the changing role of cystoplasty in the neuropathic population.Design: Retrospective case series.Setting: Single center over a 10-year period from 2004 to 2014.Participants and intervention: In 1995, the Princess Royal spinal injuries unit published the outcomes of 78 neuropathic patients who had undergone cystoplasty in the 10-year period from 1982 to 1992. [Singh G, Thomas DG. Enterocystoplasty in the neuropathic bladder. Neurourol Urodyn 1995; 14(1): 5-10.]. In this series, we review 51 consecutive patients undergoing the same operation over a 10-year period from 2004 to 2014 in the same single unit.Outcome measures: Demographic data were collected to include patient age, condition, and previous treatments. Pre- and post-operative details included sphincter insertions, renal function, continence rates, and complications.Results: Despite an increase in the number of patients seen at the unit, there were considerably fewer cystoplasty procedures performed in the current series (51 vs. 78 in the 1982-1992 series). There were also significantly fewer patients with spina bifida and fewer concomitant sphincter insertions in the latter series (eight patients vs. 52 in the 82/92 series). Nevertheless, similar outcomes are observed between the current and 1982-1992 series, with continence rates of 93.7 and 93.6%, respectively and low numbers of reported adverse events for both retrospective cohorts.Conclusions: Cystoplasty remains a safe and effective option for the management of neuropathic bladder in a carefully selected group of patients.

Penile Paraffinoma.

Penile paraffinoma is a rare cause of penile mass that can occur following injection of liquid paraffin, performed illicitly for penile augmentation. Over the past 2 yr, we have observed an increasing number of cases presenting with the complications of penile paraffinoma; three patients of central European origin have required inpatient treatment at our institution and posed a significant management dilemma. This mini-review aims to review the literature on the aetiopathogenesis, clinical features, diagnosis, and management of penile paraffinoma. A systematic search of PubMed and Scopus was performed with 10 case series and 26 case reports identified between 1956 and 2017. A total of 124 cases, with a mean age of 36.29 yr, were identified. The majority originated in Korea, and the most common injected material was liquid paraffin (80.6%). Patients presented with pain/swelling, ulceration/fistulae, and penile deformity. The majority required surgical excision of paraffinoma followed by reconstruction with a variety of procedures including split skin grafting, scrotal skin flap reconstruction, and prepuce grafting. Mean duration of follow-up was 15.8 mo. Penile paraffinoma remains a rare presentation; however, it can present management difficulties. We have had an increase in cases, with three patients presenting with complications following injection of paraffin in our unit in the past 2 yr. Definitive management includes surgical excision and reconstruction as required with early involvement of plastic surgeons. There may be a role for conservative management; however, long-term outcomes are unclear. There may be a need for targeted preventative measures through public health agencies in communities where the practice is more prevalent. PATIENT SUMMARY: Penile paraffinoma can occur following injection of liquid paraffin or similar substances, generally used by non-healthcare personnel for the purpose of penile augmentations, and can cause significant pain, ulceration, and penile deformity. Definitive management includes surgical excision with reconstruction as required. Prevention of its use through awareness and education may be required in communities where the practice is more common.

Surveillance and management of urologic complications after spinal cord injury.

PURPOSE: Neurogenic bladder due to spinal cord injury has significant consequences for patients' health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management. METHODS: This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs). RESULTS: At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population. CONCLUSIONS: There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

What is the feasibility of switching to 200IU OnabotulinumtoxinA in patients with detrusor overactivity who have previously received 300IU?

INTRODUCTION: To assess the feasibility of converting from 300IU to 200IU OnabotulinumtoxinA in patients diagnosed with either idiopathic detrusor overactivity (IDO) or neurogenic detrusor overactivity (NDO). MATERIAL AND METHODS: Retrospective case-notes review of patients who were converted from 300IU to 200IU OnabotulinumtoxinA. Subjective patient reported improvements at interview and bladder diary reported parameters of urgency, urgency incontinence, frequency and nocturia. RESULTS: Forty-four patients had received 300IU OnabotulinumtoxinA and were switched to 200IU after July 2008, 28 for IDO and 16 for NDO. Thirty-seven patients reported ongoing improvement with 200IU OnabotulinumtoxinA, six patients had worsening in their symptoms since down-titrating to 200IU and one patient did not attend follow-up. Improvement in urgency and urgency incontinence episodes per day were 82% and 72%, respectively, in patients who received 200IU. Of the 44 patients, 39 continued to receive 200IU, four requested up-titration to 300IU (due to decreased effect) and one did not attend after the 1st treatment. After converting from 300IU to 200IU, additional three patients were started on CISC for de novo voiding difficulty. CONCLUSIONS: Seventy-nine percent of patients were satisfied with their symptoms after switching from 300IU to 200IU OnabotulinumtoxinA. Only 9% of patients (all with NDO) reverted back to receiving 300IU. This study showed similar efficacy and longevity in the majority of patients (90%) using 200IU in both NDO and IDO.

A proposed guideline for the urological management of patients with spinal cord injury.

OBJECTIVE: To develop a guideline for the urological management of patients with spinal cord injury (SCI). METHODS: The existing practice in the UK was evaluated by a series of expert meetings. Previous publications on the subject were evaluated, and the information synthesized to produce a proposed guideline. RESULTS: The literature review showed limited good-quality data. As a result of the process a series of research questions was produced, the answers to which would allow a guideline to be established based on good-quality evidence. In the absence of high-quality evidence, the guideline was constructed using expert opinion. Urological care is described in the immediate, intermediate and long-term phases after SCI. CONCLUSION: The urological consequences of SCI can be devastating. Urological care is an important part of the holistic care of these patients, and should be delivered from SCI centres through a network of qualified clinicians.

Opposing actions of TGFbeta1 and FGF2 on growth, differentiation and extracellular matrix accumulation in prostatic stromal cells.

TGFbeta 1 and FGF2 are autocrine growth factors in prostatic stroma and are elevated in benign prostatic hyperplasia (BPH), a disease characterized by enlargement of the stromal compartment of the prostate. TGFbeta1 has a biphasic effect on proliferation of prostatic stromal cells, inducing proliferation at low doses (< 1 ng/ml), but inhibiting growth above 1 ng/ml. This study investigated the role of TGFP 1 and FGF2 on growth factor bioavailability and extracellular matrix (ECM) accumulation synthesis in cultured prostatic stromal cells. Real-Time-PCR showed that TGFbeta1 expression is auto-inductive, whereas FGF2 is auto-repressive. FGF2 also induced TGFbeta1 secretion in the absence of increased TGFbeta1 mRNA expression. TGFbeta1 and FGF2 have opposing actions on Type 1 collagen expression, a finding confirmed by Western blotting. The bioavailability of TGFbeta1 regulated by FGF2 may represent part of a negative feedback mechanism controlling stromal growth, differentiation and ECM. Dysregulation of this pathway in favour of TGFbeta1 bioactivity may exacerbate BPH.

Long-term 5-year followup of the results of the vesica procedure.

PURPOSE: We evaluated the long-term results of Vesica (Boston Scientific Corp., Watertown, Massachusetts) percutaneous bladder neck suspension for stress urinary incontinence. MATERIALS AND METHODS: A total of 40 women with urodynamically proven stress urinary incontinence (SUI) underwent Vesica percutaneous bladder neck suspension between 1994 and 1997. Patients were assessed at 6 months, 12 months and 5 years with a simple questionnaire to elicit whether they had experienced any adverse effects, whether they were dry and whether further investigation or a surgical incontinence procedure was offered. RESULTS: Only 1 of the 40 women was lost to long-term followup. Initial results were excellent with 85% of women reporting complete dryness at 6 months. However, wound infections developed in 16% of patients secondary to hematomas in the suprapubic incisions and 10% required a period of intermittent self-catheterization. By 12 months only 46% of women remained dry, although most only reported occasional leakage. At 5 years 69% of patients had recurrent SUI and more than two-thirds of this group (70%) had symptoms severe enough to be offered a further surgical procedure. Patients undergoing subsequent secondary procedures were found to have fraying of the suspensory sutures at the bone anchor. CONCLUSIONS: Initial results of this minimally invasive procedure were excellent and despite the lack of long-term data the technique rapidly came into widespread use. The 5-year outcome shows a 31% continence rate. We no longer advocate this particular form of bladder neck suspension for SUI.