Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment.

BACKGROUND: Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI. METHODS: A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions. DISCUSSION: There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

A national UK audit of suprapubic catheter insertion practice and rate of bowel injury with comparison to a systematic review and meta-analysis of available research.

OBJECTIVES: Limited data exist on the risks of complications associated with a suprapubic catheter (SPC) insertion. Bowel injury (BI) is a well-recognized albeit uncommon complication. Guidelines on the insertion of SPC have been developed by the British Association of Urological Surgeons, but there remains little evidence regarding the incidence of this complication. This study uses contemporary UK data to assess the incidence of SPC insertion and the rate of BI and compares to a meta-analysis of available papers. METHODS: National Hospital Episodes Statistics data were searched on all SPC insertions over an 18-month period for operating procedure codes, Code M38.2 (cystostomy and insertion of a suprapubic tube into bladder). Patients age, 30-day readmission rates, 30-day mortality rate, and catheter specific complication rate were collected. To estimate the BI rate, we searched patients who had undergone any laparotomy or bowel operation within 30 days of SPC insertion. Trusts were contacted directly and directed to ascertain whether there was SPC-related BI. PubMed search to identify papers reporting on SPC related BI was performed for meta-analysis RESULTS: 11 473 SPC insertions took place in the UK in this time period. One hundred forty-one cases had laparotomy within 30 days. Responses from 114 of these cases reported one BI related to SPC insertion. Meta-analysis showed an overall BI rate of 11/1490 (0.7%). CONCLUSIONS: This is the largest dataset reported on SPC insertions showing a lower than previously reported rate of BI. We recommend clinicians use a risk of BI of less than 0.25% when counseling low-risk patients.

Patient reported outcome measures in male incontinence surgery.

INTRODUCTION: Patient reported outcome measures (PROMs) were used to evaluate outcomes of the artificial urinary sphincter (AUS) and the AdVance™ (American Medical Systems, Minnetonka, MN, US) male sling system (AVMS) for the symptomatic management of male stress urinary incontinence. METHODS: All male patients with stress urinary incontinence referred to our specialist clinic over a two-year period completed the ICIQ-UI SF (International Consultation on Incontinence Questionnaire on Urinary Incontinence Short Form) and the ICIQ-MLUTS LF (International Consultation on Incontinence Questionnaire on Male Lower Urinary Tract Symptoms Long Form) at consultation as well as at subsequent follow-up appointments. The Wilcoxon signed-rank test for non-parametric paired data was used for pre and postoperative comparisons. The chi-squared test was used for categorical variables. RESULTS: Thirty-seven patients (forty surgical cases) completed a preoperative and at least one follow-up questionnaire. There was a statistically significant improvement in PROMs postoperatively, regardless of mode of surgery (p<0.01). Analysis of the ICIQ-MLUTS LF showed that patients with higher preoperative scores (>25) had greater improvement with an AUS than with the AVMS (p<0.01). CONCLUSIONS: This prospective study shows that completion and collection of PROMs as part of routine clinical practice is achievable and useful in the assessment of male stress incontinence surgery. PROMs are important instruments to assess effectiveness of healthcare intervention and they are useful adjuncts in surgical studies.

Modeling the urinary tract-computational, physical, and biological methods.

Models of the lower urinary tract are used to understand better the physiological and pathological functions of the tract and to gain insight into the relative importance of different components. The key requirement of a model is described, namely: to involve a continuous iteration with experiment; whereby experiments provide parameters and validation for components of the model, which is then used to generate hypotheses, which are tested experimentally. Different types of models are described: computational models that describe mathematically the whole urinary tract or components; physical models useful especially in testing medical devices; and tissue-engineered models. The purpose of modeling is first described in terms of the ability of models to predict the properties of the system of interest, using components that have a physiological interpretation, and to gain insight into the relative importance of different components. Examples are used to illustrate the use of modeling the urinary tract with reference to the different categories listed above.

Whose side are you on? The diagnostic conundrum of solitary crossed renal ectopia.

A 56-year-old man presents with haematuria and through extensive investigation is found to have solitary crossed renal ectopia. This congenital abnormality occurs as a result of a combination of unilateral renal agenesis and renal ectopia. With only 34 cases reported in the worldwide literature, the rarity of solitary crossed renal ectopia makes its diagnosis a challenge. We review the embryological theories behind this congenital anomaly and highlight some of the typical features demonstrated in our case that would lead one to consider a diagnosis of solitary crossed renal ectopia. We also describe features which have not previously been noted in case reports.

The double wire technique: an improved method for treating challenging ureteroileal anastomotic strictures and occlusions.

Up to 10% of patients who undergo ileal conduit urinary diversion may go on to develop ureteroileal anastomotic stenosis (UIAS); this can lead to recurrent urinary tract infections and deterioration in renal function. Classical management has been open revision of the anastomosis. We describe a novel technique that allows balloon dilatation and ureteral stent placement in a retrograde fashion. All patients in this study had undergone radical cystectomy and ileal conduit formation with Wallace type end-to-end refluxing uretero-intestinal anastomosis. After initial retrograde loopogram, a 6F MPA-1 catheter and an 0.035 inch extra stiff guide was passed to the distal ostium. Subsequently, a customised 8F bright tip MPA-1 guiding catheter was advanced over the guide wire which allowed effective splinting of the equipment to facilitate greater control of a second catheter and guide wire combination to access the stenotic or occluded anastomosis. Results show that a total of ten anastomoses were treated; nine anastomoses were successfully treated with a primary retrograde approach with no intra or post-procedural complications. After a mean follow-up of 19 months (5-33 months), as assessed by ascending loopograms, all anastomoses remained open. In conclusion, morbidity of open surgery has resulted in the popularization of endourological techniques in treating anastomotic stenoses. However, key to these endourological techniques is access to the anastomosis; typically, this has been via a percutaneously placed nephrostomy. The ideal route to the anastomosis is via a retrograde approach; we have illustrated a safe and successful novel technique that utilized two guidewires and a guiding catheter, allowing retrograde ureteral access.

Ca2+ regulation in detrusor smooth muscle from ovine fetal bladder after in utero bladder outflow obstruction.

PURPOSE: We characterized intracellular Ca(2+) regulation in fetal bladders following outflow obstruction by examining the Ca(2+) response to agonists in smooth muscle cells. MATERIALS AND METHODS: Severe bladder outflow obstruction was induced in male fetal sheep by placing a urethral ring and urachal ligation midway through gestation at 75 days. Fetuses were examined 30 days after surgery. Intracellular Ca(2+) in single smooth muscle cells isolated from the bladder wall was measured with epifluorescence microscopy using fura-2(AM) during exposure to agonists, such as carbachol and adenosine triphosphate, and to other activators, such as caffeine and KCl. RESULTS: Detrusor smooth muscle cells from obstructed bladders had resting intracellular Ca(2+) similar to that in sham operated controls. The maximal response to carbachol was decreased following obstruction (p <0.05). Construction of dose-response curves also demonstrated higher EC(50) (p <0.05). However, these changes were not mirrored by caffeine evoked Ca(2+) release, which was not significantly different between the obstruction group and sham operated controls. Kinetic analysis of carbachol transients further revealed an attenuated maximal rate of increase in obstructed bladders (p <0.01). The magnitude of intracellular Ca(2+) to purinergic neurotransmitter adenosine triphosphate was also found to be smaller in cells from obstructed bladders (p <0.05), although transmembrane influx by high K depolarization was not significantly affected. CONCLUSIONS: Muscarinic and purinergic pathways were down-regulated in fetal detrusor muscle following outflow obstruction. These major functional receptors appeared to be more susceptible to obstruction than other Ca(2+) regulators. Their impairment may contribute to the compromised contractile function seen in in utero bladder outflow obstruction.

The management of hydronephrosis in patients undergoing TURBT.

OBJECTIVE: Previous studies have shown the negative prognostic correlation of hydronephrosis in bladder cancer; however, practical uncertainties remain regarding the management of these patients. METHODS: We retrospectively reviewed the notes of patients undergoing TURBT over a three year period and recorded the management and outcome of patients with hydronephrosis. RESULTS: Six percent with bladder cancer had hydronephrosis. Nearly all the cases had muscle invasive disease. At TURBT, the ureteric orifice was seen in 41%; in the remaining 59% of patients, the ureteric orifice was involved and resected. This resolved the hydronephrosis in only one patient (who had superficial disease). CONCLUSIONS: Hydronephrosis in bladder cancer is associated with a poor prognosis. The hydronephrosis does not resolve with resection alone. As awaiting it's resolution may delay definitive treatment, we suggest aggressive management of hydronephrosis from the time of initial diagnosis with ureteric stenting in order to protect renal units and optimize renal function prior to further definitive treatment of bladder cancer.

Ca2+ regulation in detrusor smooth muscle from developing fetal sheep bladders.

Sheep fetus is a useful model to study in utero bladder outflow obstruction but little is known about cell physiology of fetal bladders. To remedy this defect we have characterised intracellular Ca(2+) regulation in fetal sheep myocytes of different developmental ages. Fetal detrusor myocytes had a similar resting [Ca(2+)](i) to adult cells and exhibited transient [Ca(2+)](i) increases in response to carbachol, ATP, high-K, caffeine and low-Na. The carbachol transients were abolished by atropine and caffeine; the ATP response was blocked by alpha,beta-methylene ATP; high-K-evoked [Ca(2+)](i) rises were antagonised by verapamil. The maximal responses to carbachol, high-K, caffeine and low-Na in fetal cells were similar to those of adult counterparts, whilst the ATP response was smaller (p < 0.05). These variables were largely similar between the three gestational groups with the exception of ATP-induced response between early fetal and adult bladders (p < 0.05). Dose-response curves to carbachol demonstrated an increase of potency between mid-gestation and early adulthood (p < 0.05). These data show that muscarinic receptors coupled to intracellular Ca(2+) release, P2X receptor-linked Ca(2+) entry, depolarisation-induced Ca(2+) rise via L-type Ca(2+) channels, Na(+)/Ca(2+) exchange and functional intracellular Ca(2+) stores are all operational in fetal bladder myocytes. Whilst most of Ca(2+) regulators are substantially developed and occur at an early fetal age, a further functional maturation for cholinergic sensitivity and purinergic efficacy continues throughout to adulthood.

A key cause of paraphimosis.

A 90-year-old man on hormonal treatment for invasive (T4) adenocarcinoma of the prostate presented as an emergency with a paraphimosis secondary to placement of four circumferential key rings around his penis. He had experienced referred penile pain from his prostate cancer, and to overcome this, had attempted to 'gate out' his pain by constricting his penis and thus stimulating the pudendal nerve. His treatment in our unit consisted of a penile local anaesthetic block, removal of the key rings with a ring cutter and manual reduction of the paraphimosis.

Do patients with frank haematuria referred under the two-week rule have a higher incidence of bladder cancer?

INTRODUCTION: The new NHS guaranteed that everyone with suspected cancer would be able to see a specialist within 2 weeks of their GP deciding that they need to be seen urgently. We investigated whether referrals under the two-week rule for frank haematuria results in a clinically significant advantage over normal referral pathways in patients with suspected bladder cancer. PATIENTS AND METHODS: Patients referred for frank haematuria specifically under the two-week cancer rule were prospectively recorded over a 2-year period. Results of haematuria investigations were compared to a control group of routine frank haematuria referrals. RESULTS: Of the 32 patients in each group, four bladder cancers were found in the 2-week rule group and five bladder cancers were found in the control group (P > 0.05). The number of other demonstrable urological causes of frank haematuria was also the same in the two groups. CONCLUSIONS: The incidence of bladder cancer and other urological pathologies is the same irrespective of referral pattern. It is not clear whether seeing such patients within 2 weeks confers any clinically significant advantage over conventional referral pathways. Not all patients with macroscopic haematuria are referred or seen under the two-week rule, this has considerable clinical governance implications for all departments of urology.

Extraperitoneal laparoscopic pyeloplasty for primary and secondary ureteropelvic junction obstruction.

PURPOSE: Greater experience with urological laparoscopy has lead to increasing interest in its use for reconstructive surgery, such as pyeloplasty. MATERIALS AND METHODS: A total of 124 cases of laparoscopic pyeloplasty were performed, of which 11 followed failed primary treatment done elsewhere, namely balloon dilation (3), endopyelotomy (3); open pyeloplasty (3), endopyelotomy plus balloon dilation (1) and open pyeloplasty plus balloon dilation (1). Nine patients had renal calculi. A 4 port, balloon dissecting, extraperitoneal laparoscopic approach was used in all except 1 patient, who had a horseshoe kidney, necessitating a transperitoneal approach. RESULTS: Operative time was 29 minutes longer in the secondary pyeloplasty group compared to primary cases (173.3 vs 144.0 minutes) but the conversion rate (0% vs 1.6%) and duration of postoperative hospitalization (2.8 nights each) were no greater. The complication rate was 3.6% and 9.1%, respectively. The success rate was 98.2% and 90.9% (p = 0.63) at a mean followup of 20.2 and 19.7 months, respectively. In the 9 patients with renal calculi a total of 18 calculi (94.7%) were successfully removed and the ureter was transposed medial to a crossing vessel in 50.0%. Trainee operating did not significantly prolong the procedure vs no training (162.0 vs 143.9 minutes, p = 0.06). CONCLUSIONS: Extraperitoneal laparoscopic dismembered pyeloplasty is capable of addressing all causes of ureteropelvic junction obstruction with excellent functional results and low morbidity, and with an operative time similar to that of open pyeloplasty. Secondary laparoscopic pyeloplasty does not increase hospitalization, conversion or complication rates.

A preliminary study of natural-fill radiotelemetered ovine fetal cystometry.

OBJECTIVE: To determine whether fetal cystometric studies by radiotelemetry are feasible in the fetal lamb, and potentially suitable for chronically monitoring fetal bladder pressures in an experimental fetal model of bladder outlet obstruction (BOO), as in utero BOO (e.g. caused by posterior urethral valves) results in significant postnatal bladder dysfunction but the pathophysiological progression of fetal bladder maldevelopment remains poorly understood. MATERIALS AND METHODS: The procedure required fetal sheep surgery and anaesthesia. Radiotelemetry implants comprised catheters that transmitted pressure fluctuations to an implant body; data were then transmitted using radio frequency to a receiver that passed this information to a computer. Four fetuses were used with different methods of catheter placement to optimize the technique. RESULTS: Recordings were possible in three of the four sheep; during observation there were: (i) quiet periods with no abdominal or bladder pressure rises; (ii) synchronous activity in the bladder and abdomen; and (iii) discriminate activity, associated with intravesical activity only. Four patterns of discriminate bladder activity were observed, defined as void, immature void, staccato activity and 'unstable' type activity. CONCLUSIONS: Radiotelemetry cystometry for long-term monitoring is feasible in the experimental fetus without causing death or morbidity, or inhibiting growth. The method can discriminate reproducible patterns of detrusor activity. Recorded 'voiding' types were consistent between experiments and as reported in other fetal animal studies.

Neurotransmission and viscoelasticity in the ovine fetal bladder after in utero bladder outflow obstruction.

Fetal bladder outflow obstruction, predominantly caused by posterior urethral valves, results in significant urinary tract pathology; these lesions are the commonest cause of end-stage renal failure in children, and up to 50% continue to suffer from persistent postnatal bladder dysfunction. To investigate the physiological development of the fetal bladder and the response to urinary flow impairment, we performed partial urethral obstruction and complete urachal ligation in the midgestation fetal sheep for 30 days. By electrical and pharmacological stimulation of bladder strips, we found that muscarinic, purinergic, and nitrergic mechanisms exist in the developing fetal bladder at this gestation. After bladder outflow obstruction, the fetal bladder became hypocontractile, producing less force after nerve-mediated and muscarinic stimulation with suggested denervation, and also exhibited greater atropine resistance. Furthermore, fetal bladder urothelium exerted a negative inotropic effect, partly nitric oxide mediated, that was not present after obstruction. Increased compliance, reduced elasticity, and viscoelasticity were observed in the obstructed fetal bladder, but the proportion of work performed by the elastic component (a physical parameter of extracellular matrix) remained the same. In addition to denervation, hypocontractility may result from a reduction in the elastic modulus that may prevent any extramuscular components from sustaining force produced by detrusor smooth muscle.