Consensus update on the therapeutic approach to patients with neurogenic detrusor overactivity.

INTRODUCTION AND OBJECTIVES: A Consensus document on the management of patients with neurogenic detrusor overactivity (NDO) was published in 2018. The present document aims to update its recommendations regarding treatment considering the new evidence available, and to contribute to the standardization of the management of this disorder. METHODS: The methodology used was based on a systematic review and the Nominal Group Technique. The clinical coordinator (CC) and the Consensus update group (CUG) defined the questions to be updated and carried out a systematic review to identify the new available evidence. After being evaluated by the expert panel, the relevant recommendations were updated and agreed in a consensus meeting. RESULTS: A total of 3210 publications were identified and 26 publications that met the inclusion criteria were included. The CUG updated 18 recommendations on the therapeutic approach to NDO. Unanimous consensus was reached on all of them. CONCLUSIONS: Previous recommendations need to be revised due to the availability of new drugs, the increasing evidence on the use of botulinum toxin or neuromodulation procedures, and new surgical options.

Factores pronósticos del tratamiento endoscópico del reflujo vesicoureteral en pacientes con lesión medular / Prognostic Factors of Endoscopic Treatment of Vesicoureteral Reflux in Spinal Cord Injured Patients

Introducción: El reflujo vesicoureteral (RVU) constituye una complicación importante en pacientes con lesión medular por su frecuencia y morbilidad. Una de las opciones terapéuticas más extendidas es la inyección endoscópica de sustancias obliterantes en el meato ureteral. Objetivo: Analizar los factores pronósticos del tratamiento del RVU mediante sustancias obliterantes en pacientes con lesión medular. Material y métodos: Se realizó un estudio prospectivo en una cohorte de 76 pacientes (edad 48,9 ± 14,4 años), de ambos sexos, con lesión medular sometidos a tratamiento endoscópico del RVU, durante los años 2008 a 2011. A todos los pacientes se les realizó una historia clínica y un estudio videourodinámico preoperatorio y a los 7,32 meses (desviación típica: 6,28 meses) de la intervención. El tratamiento consistió en la inyección endoscópica de copolímero de ácido hialurónico (62 casos) y polidimetilsiloxano (14). Las pruebas estadísticas aplicadas fueron el test exacto de Fisher y la prueba de comparación de medias de la «t» de Student. El nivel de significación se fijó en el 95% bilateral. Resultados: La resolución del RVU se consiguió en 46 casos (61%). Los factores pronósticos estadísticamente significativos fueron la edad (menor edad en los pacientes curados), la bilateralidad y el grado del reflujo (mayor grado y bilateralidad los casos de persistencia del reflujo) y la presencia de hiperactividad neurógena del detrusor (mayor porcentaje en el caso de persistencia del reflujo), la incontinencia urinaria de esfuerzo (mayor porcentaje en pacientes curados), la potencia contráctil (menor en pacientes curados) y la resistencia uretral (mayor en pacientes curados). Conclusiones: Entre los factores pronósticos que influyen en el resultado del tratamiento endoscópico del RVU en pacientes con disfunción neurógena del tracto urinario inferior (DNTUI) se encuentran tanto factores anatómicos como funcionales (AU)

Introduction: Vesicoureteral reflux (VUR) is an important complication in patients with spinal cord injury due to its frequency and morbidity. One of the most extended therapeutic options is endoscopic injection of obliteration substances in the urethral meatus. Objective: To analyze the prognostic factors of VUR treatment using obliterative substances in patients with spinal cord injury. Material and methods: A prospective study was performed in a cohort of 76 patients (age 48.9 ± 14.4 years), of both genders, with spinal cord injuries, who underwent endoscopic treatment of the VUR during the years 2008 to 2011. In all the patients, a clinical history was obtained and a pre-operative videourodynamic study was performed. Another study was carried out at 7.32 months (standard deviation: 6.28 months) of the intervention. Treatment consisted in endoscopic injection of dextranomer/hyaluronic acid copolymer (62 cases) and polydimethylsiloxane (14). The statistical tests applied were the Fisher's exact test and the Student's T test comparing the means. Bilateral significance level was established at 95%. Results: Resolution of VUR was achieved in 46 cases (61%). The statistically significant prognostic factors were age (younger aging cured patients), bilaterality and reflects great (greater grade in bilaterality in the cases with persistence of reflux) and presence of neurogenic detrusor overactivity (greater percentage in the cases of reflux persistence). Stress urinary incontinence (greater percentage in cured patients), contractile potency (lower percentage in cured patients) and urethral resistance (greater percentage in cured patients) were also statistically significant prognostic factors. Conclusions: Among the prognostic factors that affected the endoscopic treatment results of the VUR in patients with neurogenic lower urinary tract dysfunction (NLUTD), anatomical as well as functional factors were found (AU)

Prognostic factors of endoscopic treatment of vesicoureteral reflux in spinal cord injured patients.

INTRODUCTION: Vesicoureteral reflux (VUR) is an important complication in patients with spinal cord injury due to its frequency and morbidity. One of the most extended therapeutic options is endoscopic injection of obliteration substances in the urethral meatus. OBJECTIVE: To analyze the prognostic factors of VUR treatment using obliterative substances in patients with spinal cord injury. MATERIAL AND METHODS: A prospective study was performed in a cohort of 76 patients (age 48.9±14.4 years), of both genders, with spinal cord injuries, who underwent endoscopic treatment of the VUR during the years 2008 to 2011. In all the patients, a clinical history was obtained and a pre-operative videourodynamic study was performed. Another study was carried out at 7.32 months (standard deviation: 6.28 months) of the intervention. Treatment consisted in endoscopic injection of dextranomer/hyaluronic acid copolymer (62 cases) and polydimethylsiloxane (14). The statistical tests applied were the Fisher's exact test and the Student's T test comparing the means. Bilateral significance level was established at 95%. RESULTS: Resolution of VUR was achieved in 46 cases (61%). The statistically significant prognostic factors were age (younger aging cured patients), bilaterality and reflects great (greater grade in bilaterality in the cases with persistence of reflux) and presence of neurogenic detrusor overactivity (greater percentage in the cases of reflux persistence). Stress urinary incontinence (greater percentage in cured patients), contractile potency (lower percentage in cured patients) and urethral resistance (greater percentage in cured patients) were also statistically significant prognostic factors. CONCLUSIONS: Among the prognostic factors that affected the endoscopic treatment results of the VUR in patients with neurogenic lower urinary tract dysfunction (NLUTD), anatomical as well as functional factors were found.

Aspectos urodinámicos de la incontinencia urinaria femenina tratada con cabestrillos / Urodynamic Aspects of Feminine Urinary Incontinence Treated with Slings

Objetivos: El tratamiento de la incontinencia urinaria de esfuerzo (IUE) femenina con cabestrillos pretende suplir la función de los ligamentos dañados, favoreciendo la transmisión correcta de las tensiones. Nuestro objetivo es determinar qué variables preoperatorias pueden predecir el resultado del tratamiento quirúrgico de la IUE y estudiar los cambios urodinámicos que produce la cirugía. Material y métodos: 139 mujeres (edad =61,7; σ =10,88) intervenidas por IUE fueron estudiadas retrospectivamente. En 118 casos (84,8%) se utilizaron técnicas de cabestrillo (TVT, TOT, TVT-Safyre, REEMEX). Se realizó evaluación clínica y vídeo-urodinámica completa preoperatoria y a los tres meses de cirugía. Se realizó tratamiento estadístico (test de Fisher, Wilcoxon, Friedman, «t» de Student y χ2 Pearson) y análisis de regresión logística multivariante mediante método de eliminación por pasos. Resultados: Postoperatoriamente disminuyó la IUE (p=0,000) y el síndrome de hiperactividad vesical (p=0,001). Los porcentajes de éxito (ausencia urodinámica de IUE) para cada técnica fueron: TVT-Safyre (75%), TOT (73%), TVT (60%) y REEMEX (57%), sin diferencias significativas. La edad (punto de corte ROC 61 años) fue factor pronóstico de éxito (p=0,024). El flujo máximo (Qmáx) preoperatorio (16ml/s) constituyó el único parámetro urodinámico con valor predictivo (p=0,026) para éxito. Un cuello vesical abierto fue factor de riesgo para la persistencia de IUE postoperatoria (RR=2,78). Se comprobó disminución significativa de Qmáx postquirúrgico (p=0,017), sin aumento del residuo posmiccional ni de Wmáx. También se observó aumento de resistencia uretral (URA) poscirugía (p=0,004). Conclusiones: El Qmáx preoperatorio es el parámetro urodinámico pronóstico más importante en la cirugía de la IUE femenina, asociándose su normalidad a una mayor posibilidad de cura de la incontinencia. En los casos de flujo preoperatorio disminuido se desaconsejan los cabestrillos que más incrementan la resistencia uretral (REEMEX). La hiperactividad del detrusor preoperatoria no modifica significativamente los resultados de la cirugía de la IUE (AU)

Objectives: Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery. Material and methods: 139 women (age =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ2) and analysis of multivariant logistic regression analysis by step elimination method were performed. Results: Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004). Conclusions: The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI (AU)

[Urodynamic aspects of feminine urinary incontinence treated with slings]. / Aspectos urodinámicos de la incontinencia urinaria femenina tratada con cabestrillos.

OBJECTIVES: Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery. MATERIAL AND METHODS: 139 women (age X =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ(2)) and analysis of multivariant logistic regression analysis by step elimination method were performed. RESULTS: Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16 ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004). CONCLUSIONS: The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI.

[Results of prostatectomy in the treatment of obstructive benign prostatic hypertrophy]. / Resultados de la prostatectomía en el tratamiento de la hipertrofia prostática benigna obstructiva.

Aimed to evaluate the results of surgery in patients with obstructive prostatic hypertrophy, we studied the clinical and flow measure results from 51 patients undergoing prostatectomy (31 TUR, and 20 retropubic prostatectomies). It was shown that prostatectomy significantly improved the irritation (63% of patients), and most importantly, the obstructive (89%) symptoms. Peak flow increased in 100% of patients while maximum flow percentile in 92% of patients. Post-operative results showed no correlation to the patients' age, duration of evolution or severity of urinary symptoms, weight of prostate removed or histology of the prostate. Our results were compared with those obtained with other therapeutical options, and it was demonstrated that prostatectomy (both retropubic and RUT) are, clinically and urodynamically, the most effective procedure in the treatment of obstructive prostate hypertrophy.

A study on the viscoelastic properties of the urinary bladder in dogs.

This experimental study was designed and carried out in order to investigate the participation of the collagen and muscular tissues on the viscoelastic properties of the bladder wall. Sixty-five adult male mongrel dogs were utilized. These animals were divided into 5 groups: control group (n = 10); dogs (n = 10) receiving 2.5 mg/kg atropine (cholinergic antagonist); dogs (n = 10) receiving 0.7 mg/kg verapamil (calcium extracellular inflow blocker); dogs (n = 10) receiving 0.1 mg/kg/min nitroprusside (intracellular calcium blocker), and dogs (n = 25) receiving EGTA (a calcium-chelating agent) at increasing doses from 90 to 450 mg/kg. Based on a mathematical model, we have demonstrated that: (1) the collagen component is responsible for the elastic properties; (2) the muscle component is responsible for the viscoelastic properties; (3) the viscoelastic properties have an active element which is affected by calcium total depletion, and (4) such viscoelastic properties are not dependent on cholinergic stimulation.

Importance of the active component of the detrusor muscle in bladder compliance.

An appropriate experimental study was designed and carried out in mongrel dogs, in order to evaluate the active muscle and cholinergic participation on bladder compliance. The filling bladder pressure was measured at 100 ml of bladder volume, in 50 dogs distributed into five groups of 10 dogs each: (1) control group, (2) group which received atropine (cholinergic antagonist), (3) group which received verapamil (extracellular Ca2+ blocker), (4) group which received nitroprusside (intracellular Ca2+ antagonist), and (5) group which received EGTA (Ca(2+)-chelating agent). Furthermore, the following was demonstrated. (1) The greatest decrease of the bladder filling pressure was observed in the group which was treated with EGTA. (2) A significant decrease of the bladder filling pressure was also seen in the group which was given nitroprusside. (3) The decrease of bladder filling pressure in the verapamil group tended towards statistical significance. (4) There was no decrease in the atropine group. Thus, it was concluded that the active muscle component has an important role in the bladder compliance (through the intracellular calcium fraction), and the cholinergic component does not participate in the bladder compliance.

[Urinary incontinence in the elderly: clinical and urodynamic review of 195 cases]. / Incontinencia urinaria en el anciano: revisión clínica y urodinámica de 195 casos.

One hundred ninety-five male and female patients over 65 years old presenting with urinary incontinence were evaluated by clinical and urodynamics. Urinary incontinence was in the form of urgency-incontinence in 68% of the cases, incontinence at cough in 26%, and urinary incontinence which the patient referred to no specific situation in 6%. Among the different urodynamics data, bladder instability was the most common (73%). Urinary stress incontinence was observed in 35% of the cases. Bladder instability was demonstrated in 77% of the cases with urgency-incontinence and in 69% of the cases with incontinence not referred to a specific situation. All the male patients with lower urinary tract obstruction had urgency-incontinence. Stress incontinence was demonstrated in 60% of the cases with incontinence at cough. Stress incontinence was not observed in male patients without associated diseases. The associated neurological disorder was accompanied by bladder hyperreflexia in 90% of the cases. A prior adenomectomy or hysterectomy was associated with a greater number of cases with stress urinary incontinence, accounting for 62% in both males and females.

[Rapidly growing leiomyosarcoma of the kidney]. / Leiomiosarcoma renal de rápido crecimiento.

One case of renal leiomyosarcoma in an adult man with fast growth is presented. Clinical and iconographic features of the cases are compared with other cases reported and their diagnostic and therapeutic orientation discussed.

[Clinical and urodynamic study of enuresis in a juvenile male population]. / Estudio clínico y urodinámico de la enuresis en una población juvenil masculina.

We carried out a clinical and urodynamic assay of 100 cases of enuresis of a male population of ages ranging from 17 to 25. 64% displayed urodynamic alterations and these were significantly greater (p less than 0.005) amongst those suffering from nocturnal enuresis with diurnal symptoms (90%) than amongst those suffering from nocturnal enuresis only (59%). 36% of the patients did not display any urodynamic alteration. The urodynamic dysfunction most commonly displayed was vesical instability (46%). The other urodynamic dysfunctions found were 18% of the total, and detrusor contraction alteration constituted 10% of these (2 of the cases corresponded to vesical-urethral neurogenic dysfunction). The presence of minimum latent rachichisis was accompanied by urodynamic alterations in a significantly larger proportion (p less than 0.005) than in individuals not displaying this. The three case of wide-scale rachischisis were accompanied by urodynamic alterations corresponding to vesico-urethral neurogenic dysfunction. The case of secondary enuresis displayed neither urodynamic nor radiological alterations. Juvenile age enuresis displayed similar characteristics to infantile enuresis, although the percentage of vesical instability was lower. However, detrusor contraction alterations increased and the presence of previously non diagnosed vesico-urethral neurogenic dysfunctions was displayed.