EAU guidelines on surgical treatment of urinary incontinence.

CONTEXT: The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology. OBJECTIVE: We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience. EVIDENCE ACQUISITION: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system. EVIDENCE SUMMARY: The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report. CONCLUSIONS: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]. / Guía clínica de la Asociación Europea de Urología sobre la evaluación y el tratamiento no quirúrgico de la incontinencia urinaria.

CONTEXT: The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology. OBJECTIVE: We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination. EVIDENCE ACQUISITION: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system. EVIDENCE SUMMARY: The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice. CONCLUSIONS: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

The utility of CT angiography in planning perineal flap reconstruction following radical pelvic surgery.

INTRODUCTION: Closure of the perineum following radical excision of pelvic tumours can prove to be a complex surgical problem. A number of pedicled flaps have been used for perineal reconstruction in order to reduce post-operative complications such as infection and abscess formation. The aim of this case series was to analyse the use of pre-operative computer tomography (CT) angiography to guide flap selection for perineal reconstruction following radical excision of pelvic tumours. METHODS: We conducted a retrospective review to identify all patients who underwent CT angiography prior to radical excision of pelvic tumours and planned flap reconstruction over an 18 month period. Six patients were identified and are presented in this case series. Patients' medical records, histology reports, pre-operative investigations and CT angiograms, complications and follow-up were reviewed. RESULTS: The mean patient age was 58.3 years, with a male to female ratio of 1:2. Four out of six patients (66.6%) underwent pre-operative radiotherapy. The deep inferior epigastric arteries (DIEA) were visualised in all six cases (100%) and the pre-operative CT angiography helped guide flap choice in all cases (100%). In one case, narrowing of the DIEA vessels was noted precluding the use of a DIEA-based flap. One patient had a minor superficial wound dehiscence. CONCLUSION: Pre-operative CT angiography allows accurate visualisation of the DIEA system including perforator vessels. CT angiography is a useful tool, providing the surgical team with significant additional information to aid pre-operative planning and optimise reconstructive choice and outcome.

P2X and P2X receptor expression in human bladder urothelium and changes in interstitial cystitis.

OBJECTIVE: To investigate whether the expression of P2X(3) receptors (implicated in the pathophysiology of pain) is altered in human bladder urothelium from patients with interstitial cystitis (IC, a major symptom of which is pain), and as P2X(2) receptors can be co-expressed with P2X(3) receptors, to assess their expression also. PATIENTS AND METHODS: Bladder tissue samples were collected from patients undergoing cystectomy or radical prostatectomy. Patients with IC were diagnosed using the international criteria. RNA protein expression levels of both receptors were evaluated using reverse transcription-polymerase chain reaction (PCR), real-time quantitative PCR and Western blot analysis. RESULTS: P2X(2) was expressed in the human urothelium, in a glycosylated form. There was less gene expression of P2X(3) in IC urothelium, whereas P2X(2) gene expression was unchanged. This contrasted with the protein expression, which was increased for both P2X(2) and P2X(3). CONCLUSION: This is the first report of the expression of the P2X(2) receptor in human bladder urothelium. There was greater protein expression of both P2X(2) and P2X(3) in IC bladder urothelium which did not directly correlate with the gene expression. Changes in expression of P2X(2) and P2X(3) receptors may contribute to the pain that patients with IC have, and might provide novel drug targets.

Presumptive coding. A preliminary study of the aggregation of input diagnoses to determine their relevance to clinical governance and urological resourcing.

OBJECTIVE: To determine the validity of a system for coding the reason for urological referral from primary care, using ICD10, and thus enable benchmarking of urological outpatient activity. PATIENTS AND METHODS: Four studies were conducted: (i) A pilot study to aggregate information into a few input diagnosis codes (925 patients); (ii) Validation of the aggregated codes using input diagnoses from a second centre (928 patients); (iii) A prospective study by three urologists to determine the system's generic utility (918 patients); (iv) A study to aggregate the presumptive codes for 2771 patients to gain an insight into the case-mix of patients referred to a general urological service via the outpatient department. RESULTS: The aggregation of input diagnoses from general practice referrals into 36 'presumptive codes' was possible and could be validated. Prospective coding, for 96% of eligible patients, was possible with < 1% of referral diagnoses not being codable. Further aggregation of the data for 2771 patients showed that 31% were referred with urological malignancy whilst 69% had symptoms suggesting benign urological disease. CONCLUSIONS: This preliminary study of presumptive coding suggests that it is a feasible and valid method of recording the input diagnoses for patients presented to a urological service. The information it provides has relevance for the structuring, benchmarking, resourcing and manpower requirements of that service, essential components for clinical governance. It also has relevance to the prospective collection of patient data for research and audit.

Pelvic lymph node metastases from bladder cancer: outcome in 83 patients after radical cystectomy and pelvic lymphadenectomy.

PURPOSE: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy. MATERIALS AND METHODS: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study. RESULTS: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer. CONCLUSIONS: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.

The effect of nerve sparing cystectomy technique on postoperative continence after orthotopic bladder substitution.

PURPOSE: Continence after orthotopic bladder substitution may be influenced by characteristics of the reservoir and of the sphincter mechanism. Autonomic innervation probably contributes to pressure generation by the sphincter mechanism at rest. We therefore examined the effect of nerve sparing cystectomy technique on continence in 165 consecutive men who underwent cystectomy and construction of an ileal low pressure reservoir and were followed regarding continence for at least 3 months postoperatively. MATERIALS AND METHODS: Nerve sparing was attempted bilaterally in 20 men, unilaterally in 96 and not at all in 49. Patients were followed prospectively and completed regular voiding diaries, including details of continence. Postoperative sexual potency was ascertained by questionnaire. The effects of attempted nerve sparing and of age on continence were examined in Kaplan-Meier models and in Cox's proportional hazards models. RESULTS: Median times to continence during the day and at night for all men were 3 and 9 months, respectively. Continence differed significantly between patients with attempted nerve sparing and no attempt at nerve sparing (day, p = 0.003 and night, p = 0.001, log rank test) and between men less than 65 years old and those older than 65 (day, p = 0.037 and night, p = 0.005, log rank test). In the multivariate analysis, attempted nerve sparing was significantly associated with improved continence by day (t = 1.96) and by night (t = 1.98). CONCLUSIONS: These data suggest that attempted nerve sparing is associated with improved urinary continence after orthotopic bladder substitution.

Cystectomy and urinary diversion.

New insights into bladder cancer mechanisms have not yet produced clinical benefit. Without novel treatments, cystectomy remains the most effective local treatment, albeit the most aggressive. Uncertainty about the natural history of bladder cancer, the progression rate after other treatments, the risks of cystectomy and subsequent quality of life, foster debate about the indications for cystectomy. There are numerous urinary diversions and bladder substitutes. Differences in tumour extent, patient age, performance status, renal and mental function, and acceptance make different diversion techniques necessary. Urologists need not know every technique, but should know at least one technique of each class: an incontinent diversion (such as the ileal conduit), ureterosigmoidostomy, continent reservoir, and orthotopic bladder substitute. The common principles, advantages, and contraindications of these techniques are discussed.

Smooth muscle of the bladder in the normal and the diseased state: pathophysiology, diagnosis and treatment.

The smooth muscle of the normal bladder wall must have some specific properties. It must be very compliant and able to reorganise itself during filling and emptying to accommodate the change in volume without generating any intravesical pressure, but whilst maintaining the normal shape of the bladder. It must be capable of synchronous activation to generate intravesical pressure at any length to allow voiding. The cells achieve this through spontaneous electrical activity combined with poor electrical coupling between cells, and a dense excitatory innervation. In the diseased state, alterations of the smooth muscle may lead to failure to store or failure to empty properly. The diseased states discussed are bladder instability and diabetic neuropathy. Bladder instability is characterised urodynamically by uninhibitable rises in pressure during filling, and is seen idiopathically and in association with bladder outflow obstruction and neuropathy. In diabetic neuropathy, many of the smooth muscle changes are a consequence of diuresis, but there is evidence for alterations in the sensory arm of the micturition reflex. In the unstable bladder, additional alterations of the smooth muscle are seen, which are probably caused by the patchy denervation that occurs. The causes of this denervation are not fully established. Nonsurgical treatment of instability is not yet satisfactory; neuromodulation has some promise, but is expensive, and the mechanisms poorly understood. Pharmacological treatment is largely through muscarinic receptor blockade. Drugs to reduce the excitability of the smooth muscle are being sought, since they may represent a better pharmacological option.

Antireflux nipples or afferent tubular segments in 70 patients with ileal low pressure bladder substitutes: long-term results of a prospective randomized trial.

PURPOSE: Intestinal low pressure orthotopic bladder substitutes have no major coordinated contractions during micturition. Therefore, the importance and type of reflux prevention were assessed in a prospective randomized study. MATERIALS AND METHODS: A total of 70 patients with an ileal low pressure bladder substitute was randomized to receive a nipple valve or an isoperistaltic afferent ileal tubular segment for reflux prevention. RESULTS: After median observation times of 57 and 45 months, respectively, the results regarding functional reservoir capacity, incidence of infected urine, urinary continence, voiding habits and serum electrolytes, urea and creatinine were similar in both groups. Severe upper tract dilatation due to ureteroileal or nipple stenosis occurred in 9 of 67 evaluable reno-ureteral units (13.5%) in patients with antireflux nipples and in 2 of 69 (3%) in patients with an afferent tubular segment. This difference in favor of the latter cases is significant (Fisher's exact test p < 0.03). Video urodynamics did not show reflux of contrast medium during voiding in either group. A simultaneous intravesical, intra-abdominal and intrapelvic pressure increase was noted during the Valsalva maneuver. CONCLUSIONS: While long-term upper tract preservation by an afferent tubular ileal segment must be confirmed in larger patient series with longer followup, our results indicate that reflux prevention in patients with orthotopic low pressure bladder substitutes is not a major concern and does not justify the use of antireflux mechanisms with a high complication rate.

Summary of 10 years' experience with an ileal low-pressure bladder substitute combined with an afferent tubular isoperistaltic segment.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

Haemodynamic effects of transurethral prostatectomy.

Thoracic bio-impedance cardiography was used to study the haemodynamic changes in 28 patients undergoing transurethral prostatectomy (TURP) under either general or spinal anaesthesia. Cardiac output and mean arterial pressure fell with induction of general anaesthesia, whilst mean arterial pressure and systemic vascular resistance fell with induction of spinal anaesthesia. The transthoracic fluid index fell during resection under general anaesthesia, but no significant haemodynamic changes were seen during resection under either anaesthetic. This study suggests that resection has no specific adverse haemodynamic consequences. Spinal anaesthesia may produce less haemodynamic disturbance than general anaesthesia in patients undergoing TURP and formal comparison of the 2 techniques seems necessary.