Application of the ERAS guidelines in pediatric urological surgery: a systematic review.

INTRODUCTION: Consensus for Enhanced Recovery After Surgery (ERAS) in pediatrics has been achieved in neonatal intestinal surgery, yet it is not widely utilized in pediatric urology. We investigated the application of ERAS guidelines in pediatric urology, and determined its effects given the available level of evidence supporting the ERAS protocol in children. EVIDENCE ACQUISITION: A systematic literature review including series providing adoption of fast-track recovery protocols for pediatric urology procedures was carried out. Main outcome measures were study characteristics, adherence to the 19 ERAS items, complication rates and length of hospital stay. Sub-group analysis by surgery type (hypospadias versus major surgery) was performed. EVIDENCE SYNTHESIS: Nine series with data from 1272 surgical pediatric cases were included. An enhanced recovery pathway was applied in 67.3% of the reports. Two series included patients undergoing hypospadias repair and ERAS items were insufficiently reported. Studies including children undergoing major procedures mentioned a median of 15 ERAS items, yet applied a median of 11 items. Median compliance rate was 88.9% (range 50-100). More ERAS guideline items were reported (applied or mentioned) in the most recently published studies. CONCLUSIONS: There is limited reporting and use of the ERAS guidelines in urologic surgery particularly in hypospadias repair; whilst in major surgery in children, adherence and compliance rates vary widely. In more recent series there was an increase in ERAS items that have been mentioned and applied. Future research is needed to identify barriers and to overcome them in order to fully adopt and benefit from the ERAS pathway.

Mobility and Sporting Activity After Renal Trauma: A Survey Regarding Best Clinical Practice During the Recovery Stage.

OBJECTIVE: To evaluate strategies that are followed after pediatric renal trauma during the recovery stage, with an emphasis on mobility and involvement in subsequent sporting activities. Renal trauma is the most common urogenital trauma in children. The American Association for the Surgery of Trauma (AAST) scale is most commonly used to stratify the severity of injury. There is no consensus in the existing literature with respect to the recovery stage following renal trauma. METHODS: A survey was constructed by the European Association of Urology (EAU) - Young Academic Urologists (YAU) Pediatric Urology Working Group and then made digitally available on SurveyMonkey. The survey consists of 15 questions exploring relevant factors and timing to start again with mobility and activity. RESULTS: In total 153 people responded, of whom 107 completed the entire survey. The presence of pain and severity of trauma were acknowledged as most important factors to commence mobilization, whereas presence of hematuria was identified as an additional factor for sporting activity. Regardless of severity of trauma a minimum of 90% of respondents recommend return to noncontact sports within 12weeks. For contact sports, a minimum of 33% of respondents advised >12weeks minimum before starting again. A small number of respondents would never allow sporting activities again. CONCLUSION: The time to allow sporting activity shows high variation among the respondents, some even restricting sporting activities completely. This survey highlights the need for a standardized protocol based on multicenter follow-up data.

Undescended testis: A roundtable discussion based on clinical scenarios - Part 1.

Undescended testis (UDT, cryptorchidism) is the most common congenital anomaly of the genital tract. Despite its high incidence, the management of UDT varies between specialties (urology, pediatric surgery, pediatric urology, pediatric endocrinology). Therefore, as the European Association of Urology - Young Academic Urologists Pediatric Urology Working Group, we requested experts around the world to express their own personal approaches against various case scenarios of UDT in order to explore their individual reasoning. We intended to broaden the perspectives of our colleagues who deal with the treatment of this frequent genital malformation.

Long-term beneficial effects of mirabegron in pediatric patients with therapy-refractory neurogenic lower urinary tract dysfunction.

INTRODUCTION: Neurogenic lower urinary tract dysfunction (NLUTD) in children can cause renal failure and urinary incontinence if not treated sufficiently. Antimuscarinics (AM) and intradetrusor botulinum toxin injections (BoNT-A) with clean intermittent catheterization (CIC) are widely used treatment options for children with NLUTD. However, a considerable number will become refractory to these treatment options. This study aimed to evaluate the efficacy and long-term outcomes of mirabegron in children with NLUTD as an add-on and as a stand-alone treatment. MATERIAL AND METHODS: Patients under 18 years of age with NLUTD who were refractory to AM and/or BoNT-A and were treated with mirabegron 50 mg were retrospectively studied. Mirabegron was either used as monotherapy or in addition to AM and/or BoNT-A. Video-urodynamic studies (VUDSs) were performed before and after treatment with mirabegron. Changes in video-urodynamic parameters, the need for other NLUTD therapy during follow-up, patient-reported side effects, and urinary incontinence were outcomes of interest. RESULTS: A total of 34 patients with NLUTD were included. All patients were on CIC and the median age was 13.1 years (IQR 15.9-10.3). Median follow-up was 31.4 months (IQR 57.4-11.4). Bladder compliance improved by 89.9%, from 14.9 to 28.3 ml/cm H2O (p-value<0.001). Maximum cystometric capacity, end-filling detrusor pressure, volume at first detrusor overactivity, vesicoureteral reflux, and urinary incontinence significantly improved after mirabegron. The add-on therapy group showed more significant improvements in video-urodynamic outcomes compared to the monotherapy group. The median time of requiring other NLUTD therapy was 25.5 months (IQR 39.8-14.8). None of the included patients reported side effects. CONCLUSIONS: Mirabegron is an effective treatment for children with therapy-refractory NLUTD with an average efficacy of 2 years after which additional therapy is required. Despite the retrospective character of this study, our results confirm the beneficial effect of mirabegron in children with therapy-refractory NLUTD, in particular when mirabegron is used as add-on therapy in those with low-compliance bladders.

Real-world management of testicular torsion: Level of adherence to the EAU Pediatric Urology guidelines.

BACKGROUND: Testicular torsion is the most frequent cause of irreversible ischemia to the testis. Despite guidelines being available, challenges remain in both diagnosis and management of the disease. OBJECTIVE: This study aims to determine the adherence of urologists and residents in urology to the European Association of Urology (EAU) Pediatric Guideline on Testicular torsion. STUDY DESIGN: Both Dutch and European urologists, and residents in urology filled in a survey on testicular torsion. Information on demographics, diagnostics, and treatment modalities was retrieved from the questionnaire based on the EAU Guideline on Paediatric Urology. RESULTS: A total of 303 responders participated, of which 214 (71%) were from The Netherlands. Most (61%) responders treated three or more cases of testicular torsion in 2020. Ultrasound was used by 64%, followed by an attempt of manual detorsion by 38% (Summary Fig.). Importantly, 23% preferred not to perform emergency surgery after successful manual detorsion. A Winkelmann procedure was performed by 23%, without fixation of the test is using suture material. A large group of responders (30%) only fixed the contralateral testis by a proven testicular torsion. DISCUSSION: A feasible adherence to the EAU Guideline on Paediatric Urology in treating testicular torsion was reported using this survey, although not all recommendations are implemented as proposed. The fact that outcomes of the different diagnostic and treatment modalities are lacking might be a limitation in interpreting the results of this survey. CONCLUSION: Majority of the responders followed the EAU Guideline on Paediatric Urology in the diagnosis and treatment of testicular torsion. Ultrasound might contribute to diagnosing testicular torsion as long as this does not cause any delay for surgical exploration. Surprisingly, many urologists do not perform a surgical fixation of the testis after detorsion. Since a wide range of techniques and materials is used in case of surgical fixation, the guideline may provide in preferences for a unified policy among urologists.

Development of a prediction model in female pure or predominant urge urinary incontinence: a retrospective cohort study.

Background: Urinary incontinence is a prevalent form of pelvic floor dysfunction, with a non-negligible impact on a patient's quality of life. There are several treatment options, varying from conservative to invasive. The aim of this study is to predict treatment outcomes of pure or predominant urge urinary incontinence (UUI) in women to support shared decision-making and manage patient expectations. Methods: Data on patient characteristics, disease history, and investigations of 512 consecutive women treated for UUI in three hospitals in the Netherlands were retrospectively collected. The predicted outcome was the short-term subjective continence outcome, defined as patient-reported continence 3 months after treatment categorized as cure (no urinary leakage), improvement (any degree of improvement of urinary leakage), and failure (no improvement or worsening of urinary leakage). Multivariable ordinal regression with backward stepwise selection was performed to analyze association between outcome and patient's characteristics. Interactions between patient characteristics and treatment were added to estimate individual treatment benefit. Discriminative ability was assessed with the ordinal c-statistic. Results: Conservative treatment was applied in 12% of the patients, pharmacological in 62%, and invasive in 26%. Subjective continence outcome was cure, improvement, and failure in 20%, 49%, and 31%, respectively. Number of incontinence episodes per day, voiding frequency during the day, subjective quantity of UI, coexistence of stress urinary incontinence (SUI), night incontinence, and bladder capacity and the interactions between these variables were included in the model. After internal validation, the ordinal c-statistic was 0.699. Conclusions: Six variables were of value to predict pure or predominant UUI treatment outcome in women. Further development into a comprehensive set of models for the use in various pelvic floor disorders and treatments is recommended to optimize individualized care. This model requires external validation before implementation in clinical practice.

The prognostic value of testicular microlithiasis as an incidental finding for the risk of testicular malignancy in children and the adult population: A systematic review. On behalf of the EAU pediatric urology guidelines panel.

INTRODUCTION: The exact correlation of testicular microlithiasis (TM) with benign and malignant conditions remains unknown, especially in the paediatric population. The potential association of TM with testicular malignancy in adulthood has led to controversy regarding management and follow-up. OBJECTIVE: To determine the prognostic importance of TM in children in correlation to the risk of testicular malignancy or infertility and compare the differences between the paediatric and adult population. STUDY DESIGN: We performed a literature review of the Medline, Embase and Cochrane controlled trials databases until November 2020 according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) Statement. Twenty-six publications were included in the analysis. RESULTS: During the follow-up of 595 children with TM only one patient with TM developed a testicular malignancy during puberty. In the other 594 no testicular malignancy was found, even in the presence of risk factors. In the adult population, an increased risk for testicular malignancy in the presence of TM was found in patients with history of cryptorchidism (6% vs 0%), testicular malignancy (22% vs 2%) or sub/infertility (11-23% vs 1.7%) compared to TM-free. The difference between paediatric and adult population might be explained by the short duration of follow-up, varying between six months and three years. With an average age at inclusion of 10 years and testicular malignancies are expected to develop from puberty on, testicular malignancies might not yet have developed. CONCLUSION: TM is a common incidental finding that does not seem to be associated with testicular malignancy during childhood, but in the presence of risk factors is associated with testicular malignancy in the adult population. Routine monthly self-examination of the testes is recommended in children with contributing risk factors from puberty onwards. When TM is still present during transition to adulthood a more intensive follow-up could be considered.

EAU-ESPU pediatric urology guidelines on testicular tumors in prepubertal boys.

BACKGROUND: Testicular tumors in prepubertal boys account for 1-2% of all solid pediatric tumors. They have a lower incidence, a different histologic distribution and are more often benign compared to testicular tumors in the adolescent and adult group. This fundamental difference should also lead to a different approach and treatment. OBJECTIVE: To provide a guideline for diagnosis and treatment options in prepubertal boys with a testicular mass. METHOD: A structured literature search and review for testicular tumors in prepubertal boys was performed. All English abstracts up to the end of 2019 were screened, and relevant papers were obtained to create the guideline. RESULTS: A painless scrotal mass is the most common clinical presentation. For evaluation, high resolution ultrasound has a detection rate of almost 100%, alpha-fetoprotein is a tumor marker, however, is age dependent. Human chorionic gonadotropin (HCG) was not a tumor marker for testis tumors in prepubertal boys. CONCLUSION: Based on a summary of the literature on prepubertal testis tumors, the 2021 EAU guidelines on Pediatric Urology recommend a partial orchiectomy as the primary approach in tumors with a favorable preoperative ultrasound diagnosis.

Update of the EAU/ESPU guidelines on urinary tract infections in children.

INTRODUCTION/BACKGROUND: Urinary tract infections (UTIs) are common in children and require appropriate diagnostic evaluation, management and follow-up. OBJECTIVE: To provide a summary of the updated European Association of Urology (EAU) guidelines on Pediatric Urology, which were first published in 2015 in European Urology. STUDY DESIGN: A structured literature review was performed of new publications between 2015 and 2020 for UTIs in children. The guideline was updated accordingly with relevant new literature. RESULTS: The occurrence of a UTI can be the first indication of anatomical abnormalities in the urinary tract, especially in patients with a febrile UTI. The basic diagnostic evaluation should include sufficient investigations to exclude urinary tract abnormalities, but should also be as minimally invasive as possible. In recent years, more risk factors have been identified to predict the presence of these anatomical anomalies, such as a non-E. Coli infection, high grade fever and ultrasound abnormalities. When these risk factors are factored into the diagnostic work-up, some invasive investigations can be omitted in a larger group of children. In addition to the treatment of active UTIs, it is also essential to prevent recurrent UTIs and consequent renal scarring. With the increase of antimicrobial resistance good antibiotic stewardship is needed. In addition, alternative preventative measures such as dietary supplements, bladder and bowel management and antibiotic prophylaxis could decrease the incidence of recurrent UTI. CONCLUSION: This paper is a summary of the updated 2021 EAU guidelines on Pediatric Urology. It provides practical considerations and flowcharts for the management and diagnostic evaluation of UTIs in children.

Are EAU/ESPU pediatric urology guideline recommendations on neurogenic bladder well received by the patients? Results of a survey on awareness in spina bifida patients and caregivers.

AIMS: The Paediatric Urology Guidelines Panel reports initial experience with patient involvement in spina bifida patient groups to gather information on their awareness of the guidelines and reflection of guideline recommendations. METHODS: The survey was delivered to spina bifida patients/parents via the national society groups in Turkey, Germany, and The Netherlands. Questions included demographic features, medical status, awareness, and agreement on the recommendations given in the guidelines and future expectations. RESULTS: A total of 291 patients from 3 countries responded to the survey. Mean age was 13.9 ± 12.2 years, male/female ratio 138/151, 75% of all surveys were completed by the caregivers. The medication was taken by 78% of patients (64% anticholinergics). Complete dryness rates for urine and stool were 24% and 47%, respectively. The agreement rates on the recommendations regarding urodynamics, intermittent catheterization, anticholinergics drug use, bowel management, and life-long follow-up were 97%, 82%, 91%, 77%, and 98%, respectively. Only 8% of responders were aware of the European Association of Urology/European Society for Pediatric Urology guidelines. The priorities of patients for future expectations were as the following: quality of life (QoL), surgical techniques, development of new medications and sexuality/fertility issues. Male spina bifida patients preferred new medications and sex/fertility issues more, whereas females favored QoL issues improvement more. CONCLUSIONS: Although the native language of the involved patients was different from English, awareness of guidelines was 8%. The general approval of the recommendations given in the guidelines is quite high. The national society groups showed a great interest to get involved in the creation of the guidelines to improve health care for spina bifida patients.

The Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-15): Validation of the Dutch version in patients with multiple sclerosis and spinal cord injury.

AIMS: The Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-15) evaluates symptoms of sexual dysfunction in patients with multiple sclerosis (MS). The objective of this study was to provide and validate a Dutch version of the MSISQ-15 in patients with neurological disease such as MS and spinal cord injury (SCI). METHODS: The linguistic validation process of the original English MSISQ-15 into Dutch was performed according to standardized guidelines. Sexually active patients with MS or spinal cord disorders, including SCI and cauda equine syndrome, who visited a tertiary urology center or a rehabilitation center completed the MSISQ-15, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) in women, or International Index of Erection Function (IIEF-15) in men at baseline (test) and 2 weeks later (retest). A reference group recruited from a general medical practice completed the questionnaires once. Data were analyzed for measurement properties. RESULTS: Fifty-three patients with MS, 49 patients with spinal cord disorder, and 50 references were included. Content validity was adequate. Internal consistency (Cronbach's alpha >0.8) and reproducibility (intraclass correlation coefficient >0.8) of the MSISQ-15 were excellent. Patients' MSISQ-15 scores were correlated with severity of symptoms of sexual dysfunction measured by PISQ-12 or IIEF-15 and confirmed positive rating for criterion validity. MSISQ-15 scores in patients were higher than in references (on a scale of 15-75: 38.9 ± 11.4 vs 21.1 ± 5.4; P < 0.001), indicating good construct validity. CONCLUSIONS: The Dutch MSISQ-15 is a reliable and valid measure to evaluate symptoms of sexual dysfunction in patients with MS or with SCI.

Urotherapy in children with dysfunctional voiding and the responsiveness of two condition-specific questionnaires.

AIMS: We sought to establish the responsiveness of the Dutch Vancouver Symptom Score for Dysfunctional Elimination Syndrome (VSSDES) and Pediatric urinary incontinence Quality of life (PinQ) questionnaires. Secondary, we evaluated the outcome of urotherapy extended for children with dysfunctional voiding (DV). METHODS: This cross-sectional multicenter study was done in one tertiary and two community hospitals. Children with DV were included, also when refractory to previous urotherapeutic treatment. The questionnaires were completed before and after urotherapy. The primary outcome measure was the responsiveness of the Dutch VSDESS and PinQ. Secondary outcome was the initial success (defined by the International Children's Continence Society) of extended urotherapy. RESULTS: Between June 2014 and May 2016, 64 children (median age 7 years, IQR 6-10) received urotherapy (median 18 weeks, IQR 11-28). In contrast to the VSSDES, the PinQ showed good responsiveness. For children and parents, respectively, the area under the ROC-curve was 0.79 (P = 0.01) and 0.72 (P = 0.03) for the PinQ and 0.50 (P = 0.98) and 0.55 (P = 0.62) for the VSSDES. Fifty children received extended urotherapy, 27 had complete, and 14 had partial response. Sixteen children had been refractory to previous treatment; four showed complete, and six showed partial response. CONCLUSION: The PinQ is able to detect clinically important changes in continence-specific quality of life after treatment. We support the use of the VSSDES questionnaire in addition to the current diagnostics for the diagnosis of DV. Extended urotherapy showed to be a successful treatment for children with DV, also for those who had received previous unsuccessful treatment.

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review.

AIMS: To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients. METHODS: This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017. RESULTS: A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found. CONCLUSIONS: We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.

The validation of the Dutch SF-Qualiveen, a questionnaire on urinary-specific quality of life, in spinal cord injury patients.

BACKGROUND: Optimizing the patients' quality of life is one of the main goals in the urological management of spinal cord injury (SCI) patients. In this study we validated the Dutch SF-Qualiveen, a short questionnaire that measures the urinary-specific quality of life, in SCI patients. No such measure is yet available for this patient group. METHODS: In 2015-2016 SCI patients with urinary symptomatology who visited the outpatient clinics of Urology at the Erasmus Medical Centre and Rehabilitation at Rijndam Revalidation completed the SF-Qualiveen and UDI-6 during the visit and 1-2 weeks later. The UDI-6, a urinary tract symptom inventory, served as gold standard. Controls, recruited from the Otolaryngology outpatient clinic, completed the questionnaires once. Content-, construct-, and criterion validity and reliability (internal consistency and reproducibility) of the SF-Qualiveen were determined. RESULTS: Fifty seven SCI patients and 50 controls were included. 12 SCI patients asserted that the SF-Qualiveen covered their bladder problems (good content validity). Patients' SF-Qualiveen scores being positively associated with severity of urinary symptoms and patients' scores being higher than those of controls indicated good construct validity. The positive association that was found between SF-Qualiveen and UDI-6 in patients (r = 0.66-0.67, P < 0.001) and controls (r = 0.63, P < 0.001) confirmed good criterion validity. Internal consistency (Cronbach's alpha 0.89-0.92) and reproducibility (intraclass correlation coefficient 0.94) of the SF-Qualiveen were good. CONCLUSIONS: The Dutch SF-Qualiveen is a valid and reliable tool to measure the urinary-specific quality of life in SCI patients.

A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review.

CONTEXT: Impaired sexual function has a significant effect on quality of life. Various patient-reported outcome measures (PROMs) are available to evaluate sexual function. The quality of the PROMs to be used for neurologic patients remains unknown. OBJECTIVE: To systematically review which validated PROMs are available to evaluate sexual function in neurologic patients and to critically assess the quality of the validation studies and measurement properties for each identified PROM. EVIDENCE ACQUISITION: A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The included publications were assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist. EVIDENCE SYNTHESIS: Twenty-one studies for PROMs regarding sexual function were identified for the following patient groups: spinal cord injury (11 studies), multiple sclerosis (MS; 6 studies), Parkinson's disease (2 studies), traumatic brain injury (1 study), and epilepsy (1 study). The evidence for the quality of PROMs was found to be variable, and overall evaluation of measurement properties was lacking in 71% of the studies. The measurement error and responsiveness were not studied in any of the publications. CONCLUSIONS: Several PROMs have been identified to evaluate sexual function in neurologic patients. Strong evidence was found only for the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 for patients with MS, although evidence was lacking for certain measurement properties as well. Future research should focus on identifying relevant PROMs and establishing adequate quality for all measurement properties in studies with high methodological quality. PATIENT SUMMARY: A quality assessment of patient-reported outcome measures (PROMs) for sexual function in neurologic patients was made. The evidence found for good PROMs was limited. Studies with high methodological quality are needed to improve the quality of PROMs to evaluate sexual function in neurologic patients.

The fecal incontinence quality of life scale (FIQL) and fecal incontinence severity index (FISI): Validation of the Dutch versions.

AIMS: Fecal incontinence (FI) is known to have a major impact on quality of life. The Fecal Incontinence Quality of Life scale (FIQL) and Fecal Incontinence Severity Index (FISI) have been developed to assess this impact. The aim of this study was to validate the FIQL and FISI in the Dutch language. METHODS: The study population consisted of women and men experiencing FI and a reference group. The FIQL (four domains) and FISI questionnaires were validated by testing standardized measurement properties: discriminative ability, internal consistency, reproducibility, construct validity, and responsiveness. RESULTS: A total of 55 patients and 277 reference participants were included. Patients had significant lower and higher scores at the FIQL and FISI, respectively, than references (FIQL: 2.58 ± 0.70 and 3.92 ± 0.36, FISI: 38.57 ± 10.73 and 23.17 ± 15.01; P < 0.001), indicating worse functioning in patients and with this the discriminative abilities of the measures. The FIQL demonstrated adequate internal consistency on all domains (0.72-0.96), except for the embarrassment domain (0.55). The reproducibility was good for both measures. A negative correlation was found between the FIQL and FISI. Furthermore, the FIQL showed a positive (0.77) and the FISI a negative correlation (-0.31) with the Mental Component Summary scale of the SF-12. Responsiveness analysis showed a minimal important change of 0.40 points for the FIQL. CONCLUSIONS: Validity and reliability were good in the Dutch FIQL, but inconclusive in the FISI. The Dutch FIQL can support physicians in determining the impact of FI on patient's quality of life. Neurourol. Urodynam. 36:710-715, 2017. © 2016 Wiley Periodicals, Inc.