Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis.

AIMS: We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms. METHODS: Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention. RESULTS: There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high. CONCLUSIONS: BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

A new option for the management of urethral trauma: primary reconstruction of posterior urethral disruption with a buccal mucosa transplant.

Up to now, the management of traumatic posterior urethral disruption ranges from primary realignment to delayed urethroplasty. However, we reconstructed the membranous part of the urethra with an onlay graft of buccal mucosa after traumatic complete disruption as a first line therapy. After 7 months followup, the clinical outcome is very good. Because primary reconstruction of the urethra with a buccal mucosa graft after traumatic disruption has not yet been reported, the question arises whether this technique should be routinely included as an option for primary urethral reconstruction after trauma of the posterior urethra.

[Subjective patient satisfaction after injection of botulinum-a toxin in detrusor overactivity]. / Subjektive Patientenzufriedenheit nach Botulinumtoxin-A-Injektionen bei Detrusorhyperaktivität.

PURPOSE: The established treatment for overactive detrusor function consists of anticholinergic drugs. But this treatment can fail or produce intolerable side effects. We therefore investigated the effect of botulinum-A toxin in treating overactive detrusor function in patients with neurogenic and nonneurogenic bladder dysfunction. We were particularly interested in patient satisfaction with this therapy. MATERIAL AND METHODS: The subjects were 38 patients who had overactive detrusor function of different origins and in whom therapy with anticholinergic drugs had failed. To measure results, we used urodynamic studies and a questionnaire that consisted of 27 validated questions ("Urogenital Distress Inventory UDI-6", "Symptom Severity Index" and "Symptom Impact Index") as well as a satisfaction questionnaire. We injected 200 - 300 U of botulinum-A toxin (Botox) cystoscopically. RESULTS: At least 4 weeks after injection, 90 % of the patients reported clear improvement of their voiding situation and 93 % stated that they would undergo this procedure again. The frequency of micturition decreased by 29 % in average, and the increased postvoid residual volume was clinically irrelevant. Patients reported side effects or complications in 6.7 % of cases. The satisfaction scale (0 - 10) averaged 6.9. Urodynamically, reflex volume increased by 85 %, maximal bladder capacity increased by 47 %, and bladder pressure decreased by 33 %. CONCLUSIONS: Botulinum-A toxin injection into the overactive detrusor muscle seems to be very effective. The effect is not only reflected in urodynamic studies but also in the subjective patient satisfaction.

Pubovaginal bone anchor fixation with polyethylene versus fascia lata slings in the treatment of female stress incontinence: sling material and processing are predominant factors in success.

OBJECTIVE: The opponents of the In-Taca bone anchor system note the risk of a high rate of wound infection and osteitis pubis. We evaluated whether there is a difference in the outcome of the use of two different sling materials--polyethylene and fascia lata--with regard to wound infection, and analyzed the incidence of osteitis pubis further in a larger series. MATERIAL AND METHODS: A total of 61 women (mean age = 65.4 years) were treated for stress urinary incontinence (SUI) type II and III using the In-Taca bone anchor system. In 15 of 61 patients, we used a synthetic sling of polyethylene, and in 46, a fascia lata sling. The subjective success rate was determined with validated questionnaires (Urinary Distress Inventory-6, Symptom Severity Index and Symptom Impact Index). The objective assessment included a pad test according to the ICS- standard and a urogynecologic evaluation. Mean follow-up was 10.2 months. RESULTS: Wound inflammation of only very mild degree occurred in 15% in the fascia lata group, whereas 33% in the polyethylene group developed serious sling infection; in three patients explantation of the sling was necessary. Accordingly, satisfaction with the procedure was low in the polyethylene group. In both groups, there were no hints of osteitis pubis. The sling material used did not affect continence rate. CONCLUSION: Using the bone anchor system, the infection rate depends primarily on the sling material used and its processing: polyethylene is well tolerated in other reconstructive procedures (such as TVT, where a netlike mesh is used), so the processing of synthetic sling material plays an extremely important role in infection rate: platelike, dense synthetic material tends to cause wound infection.

Laparoscopic management of hydronephrosis in a woman with rare genitourinary anomalies: unicornous uterus, contralateral agenesis of the kidney, and contralateral ectopic ovary in the groin.

A 40-year-old woman had infected right-sided hydronephrosis and rare genitourinary anomalies-a dextroposed unicornous uterus-as the cause of the hydronephrosis, which had to be mobilized laparoscopically by dissecting the scar tissue. Furthermore, the patient had left-sided agenesis of the kidney and a left-sided ectopic ovary with a rudimentary tube in the inner inguinal canal.

Botulinum-a toxin detrusor injection as a novel approach in the treatment of bladder spasticity in children with neurogenic bladder.

OBJECTIVES: Children with neurogenic hyper-reflexive bladder in whom classical therapy with anticholinergic drugs and intermittent catheterization fails are threatened by high intravesical pressure, vesicoureteral reflux, and impairment of kidney function. Surgery, such as bladder augmentation, is often necessary in such cases. To obviate surgery in these high-risk children, we investigated the use of detrusor injection of botulinum-A toxin (Botox). METHODS: Our subjects were 20 children with hyper-reflexive detrusor muscle and high bladder pressure, over 40 cmH(2)O despite anticholinergic therapy. After baseline urodynamic measurements, we injected botulinum-A toxin into the detrusor muscle at 30-50 sites at 12 U/kg of body weight up to a maximum of 300 U. Follow-up cystometric measurements were taken two to four weeks and three and six months after injection. RESULTS: From basic measurements to follow-up cystometry, mean reflex volume changed from 97.1 ml before injection to 178.6 ml after four weeks (p<0.01) and to 162.8 ml after three months (p<0.01). After six months mean reflex volume returned to 119.3 ml (n.s.). Maximal bladder capacity changed from 163.1 ml to 219.9 ml (p<0.01), to 200.6 ml (p<0.01) and to 222.4 ml (p<0.01), respectively, and maximal detrusor pressure changed from 59.6 cmH(2)O to 34.9 cmH(2)O (p<0.01), to 46.7 cmH(2)O (n.s.) and to 61.8 cmH(2)O (n.s.), respectively. CONCLUSION: Botulinum-A toxin (Botox) is effective when injected into the hyper-reflexive detrusor muscle. It is a valuable treatment option in the management of neurogenic bladder. The effect lasts about six months, and then reinjection is necessary.

[Primary retroperitoneal fibrosis with renal involvement]. / Primäre Retroperitonealfibrose mit renaler Beteiligung.

We report on a patient suffering from primary retroperitoneal fibrosis with histologically proven involvement of the right kidney. The problems in making the correct diagnosis, for which in this case a laparotomy and histological examination were also necessary, are discussed.

Evidence that desensitization of the negative feedback of oestrogen and priming for the positive feedback of oestrogen depend upon a common mechanism of oestrogen action in rats.

Oestrogen priming of the central nervous system is required for the positive feedback of oestrogen, and the sensitivity of the negative feedback of oestrogen can be reduced by oestrogen itself. Using adult female and male rats we examined the possibility that these effects depend upon a common mechanism of oestrogen action that is mediated by the medial preoptic area (MPOA). Guide cannulae were implanted in the MPOA of 4-day cyclic rats which were ovariectomized during the evening of day 1 of dioestrus. Glass capillary tubes containing different substances were placed in the cannulae between 09.00 and 12.00 h on the presumptive day 2 of dioestrus. The effectiveness of oestrogen priming was evaluated by examining whether an s.c. implant of oestradiol-17 beta (OE2) induced an LH surge, and the inhibitory effect of oestrogen on tonic LH secretion was investigated by injecting the rats with 3 micrograms oestradiol benzoate (OB)/100 g body weight. The priming effect of an s.c. implant of OE2 could be imitated by the bilateral implantation in the MPOA of a mixture of OB and cholesterol at a ratio of 1:360 for 3 h only. Similar medial preoptic oestrogen implantation also significantly reduced the LH-inhibiting effect of OB. In accord with findings obtained in former studies on desensitization of the negative oestrogen feedback, oestrogen priming resulting from the s.c. administration of OE2 could be suppressed by short-term medial preoptic implantation of clomiphene citrate or apomorphine; bilateral electrical stimulation of the medial amygdaloid nucleus induced an increase in the serum concentration of LH in ovariectomized females implanted with OB in the MPOA, but not in castrated males pretreated and implanted with OB.(ABSTRACT TRUNCATED AT 250 WORDS)

Oestrogen priming for the positive oestrogen feedback: site of action.

The significance of oestrogen priming for efficacy of the positive, ovulation-inducing oestrogen feedback has been known for more than 15 years, but the site and mechanism of oestrogen action in the priming effect have not yet been elucidated. Long-term ovariectomized adult female rats were injected once or twice with 20 micrograms oestradiol benzoate (OB), and the serum LH concentration was estimated. Whereas a single injection of OB induced significant inhibition of LH secretion, high circulating LH levels were recorded in rats injected twice with the hormone at an interval of 48 h. This increase was prevented in ovariectomized females fitted with guide cannulae, if the antioestrogen clomiphene citrate was implanted into the medial preoptic area (MPOA) before the first injection of oestrogen and removed prior to the second. On the other hand, replacement of the first oestrogen administration by the implantation of a very low dose of OB into the MPOA resulted in stimulation of LH secretion. OB implants placed into the hypothalamic ventromedial-arcuate region were ineffective in this regard. Taken together, the findings suggest that the priming effect of oestrogen is mediated in rats, at least in part, by the MPOA.