Should simultaneous ureteral reimplantation be performed during sigmoid bladder augmentation to reduce vesicoureteral reflux in neurogenic bladder cases?

PURPOSE: To assess the necessity of performing simultaneous collateral reimplantation during sigmoid bladder augmentation (SBA) to reduce vesicoureteral reflux (VUR) in low-compliance neuropathic bladder with associated VUR. METHODS: We retrospectively identified 31 patients who underwent SBA alone or with simultaneous ureteral reimplantation at our hospital. The video urodynamics data, VUR status, renal function, and clinical symptoms were studied during follow-up. RESULTS: The mean follow-up time was 57 months (range 12-117). All patients displayed significantly increased safe cystometric capacity (P < 0.001) and bladder compliance (P < 0.001) and decreased creatinine (P < 0.01) and urea nitrogen (P < 0.05) compared with preoperative levels. High-grade VUR was resolved in only 7 of 15 patients (47%) in Group A (simultaneous ureteral reimplantation), whereas low-grade VUR was resolved in 13 of 16 patients (81%) in Group B (SBA alone). The other 11 patients still displaying VUR after SBA had larger safe bladder volumes due to augmentation. The patients' improving renal function benefited most from the enlarged bladder and partly from increased antireflux resistance of vesico-ureter anastomosis. Twelve (38.7%) had recurrent febrile urinary tract infection after SBA, and one (3.2%) suffered from vesico-ureter anastomosis contracture after ureteral reimplantation. CONCLUSIONS: A preoperative intravesical VUR pressure of 20 cmH2O is not an effective cutoff point for whether ureteral reimplantation should be simultaneously performed during SBA. Augmentation appears to be more important than reimplantation for protecting kidney from damage due to febrile urinary tract infection after SBA. Simultaneous reimplantation may be not necessary during SBA in neurogenic bladder.

Long-term follow-up of sigmoid bladder augmentation for low-compliance neurogenic bladder.

OBJECTIVE: To assess the clinical and urodynamic outcomes of patients with low-compliance neurogenic bladder who were treated with sigmoid bladder augmentation (SBA) over a long-term follow-up. MATERIALS AND METHODS: We retrospectively reviewed 52 patients with low-compliance neurogenic bladder who underwent SBA alone or with antireflux techniques in our hospital from 2006 to 2014. Clinical outcomes regarding bladder function, incontinence, medications, catheterization schedules, subsequent interventions, bowel function, and patient satisfaction were addressed. RESULTS: The mean follow-up was 49 months. All patients experienced significant increases in safe cystometric capacity from 113.8 ± 65.9 mL to 373.1 ± 66.7 mL (P <.001), bladder compliance from 2.96 ± 1.55 mL/cm H2O to 14.07 ± 5.45 mL/cm H2O (P <.001), and decreases in creatinine from 88.1 ± 38.6 µmol/L to 77.1 ± 30.4 µmol/L (P <.001) compared with those before surgery. Six patients (11.5%) required anticholinergic medicine to control neurogenic detrusor overactivity, and 11 (21.1%) had recurrent febrile urinary tract infections after SBA. Among 47 prehydronephrosis patients (grade I-II in 10 and III-V in 37), 16 still had minor hydronephrosis after SBA, but the hydronephrosis had been improved significantly (all posthydronephroses were grade I-II instead). All patients reported significant improvements in constipation, and no patient had obvious metabolic acidosis or bladder perforation after SBA. All patients expressed extreme satisfaction with the operation. CONCLUSION: SBA provided durable clinical and urodynamic improvement for patients with low-compliance neurogenic bladder and constipation. SBA alone, without ureteral reimplantation, seemed sufficient for neurogenic bladder. Furthermore, there was a high level of patient satisfaction with SBA.

[Genotypes and serotypes of avian infectious bronchitis viruses isolated during 2009-2011 in Guangxi, China].

In order to investigate the prevalence and track genetic and antigenic evolutions of infectious bronchitis virus (IBV) and their prevalence in Guangxi, China since 1985, gene amplification and sequencing and virus neutralization (VN) test on chicken embryo tracheal organ cultures were used in genotyping and serotyping of 28 IBV isolates during 2009-2011 in Guangxi. The results of N gene sequencing and comparison showed that the 28 isolates and reference strains were classified into three groups, and most isolates belonged to group Ill, while the isolates in 1985-2008 belonged to groups IV and II. The data of VN test indicated that the 28 isolates belonged to 6 serotypes; among them, 71. 4% belonged to serotypes 1, 2, and 3, and 11 (39.3%) shared the same serotype with the current vaccine strains. Given the data of our previous study, it is found that prevalent serotypes and their proportions varied in different areas of Guangxi and during different periods. These data lay a good foundation for developing an oil-emulsified inactivated polyvalent vaccine containing local dominant serotypes for the effective prevention and control of infectious bronchitis.

Bladder neck incision for female bladder neck obstruction: long-term outcomes.

OBJECTIVE: To evaluate the long-term outcomes of bladder neck incision (BNI) for primary bladder neck obstruction in women. METHODS: Eighty-four women were diagnosed on the basis of videourodynamic study. BNI was performed for each patient, with incisions made at 2 different sites on the bladder neck. RESULTS: Follow-up data were available for 6-78 months (average, 27.4), postoperatively. Successful recovery after BNI without serious complications was achieved in 71 of 84 (84.5%) patients. During follow-up, the mean International Prostate Symptom Score decreased from 22.9 to 7.9 (P <.01). Quality of life decreased from 4.1 to 2.4 (P <.01). The maximum uroflow rate increased from 9.75 to 18.79 mL/s (P <.01). The postvoid residual decreased from 115.11 to 23.29 mL (P <.01). The maximal detrusor pressure at the maximum uroflow rate decreased from 69.61 to 20.48 cm H2O (P <.01). Several complications were identified after surgery, including hemorrhage, re-BNI, vesicovaginal fistula (VVF), stress urinary incontinence (SUI), and urethral stricture. All these complications were grade IIIa in the Clavien Classification of Surgical Complications. Three patients (3.6%) developed a VVF after BNI; these VVFs were repaired successfully. Four (4.7%) patients experienced SUI and recovered after transvaginal tension-free vaginal tape-obturator. Postoperative bleeding was identified in 3 patients (3.6%), and 1 received a blood transfusion. Three (3.6%) patients experienced urethral stricture after BNI and recovered after receiving intermittent urethral dilation. CONCLUSION: Primary bladder neck obstruction is uncommon and easily treatable when properly diagnosed by videourodynamic study, and BNI has a high success rate. Careful, sufficiently deep incisions at the 2- and 10-o'clock positions can ensure its success. Complications such as postoperative VVF or SUI can occur and must be actively managed.

Diagnosis of bladder outlet obstruction in men using a near-infrared spectroscopy instrument as the noninvasive monitor for bladder function.

OBJECTIVE: To investigate the feasibility and accuracy of the diagnosis of bladder outlet obstruction (BOO) in men using near-infrared spectroscopy (NIRS) as a noninvasive monitor. MATERIALS AND METHODS: The study included 94 patients with lower urinary tract symptoms owing to benign prostatic hyperplasia. All patients underwent uroflow rate and post-void residual (PVR) followed by NIRS assessment of BOO and pressure-flow study for diagnosis. The results of the NIRS were compared with that of the pressure-flow study. RESULTS: The data of 87 patients were finally enrolled in this study. According to the BOO judged by the NIRS, the 87 patients were divided into an obstruction group (52 cases) and a nonobstruction group (35 cases). The differences in the Abrams-Griffiths number, the linear passive urethral resistance relation value, and urethral resistance factor value between the 2 groups were significant (P ≤.001), indicating the practical significance of the NIRS method in the diagnosis of BOO. Further analysis showed the following: (1) the NIRS has a sensitivity of approximately 68.3%, specificity of 62.5%, and average diagnosis coincidence rate of 66.7% compared with the "gold standards"-Abrams-Griffiths number, and (2) the sensitivity (68.3%) and the coincidence rate (66.7%) of the NIRS diagnosis for BOO were significantly higher than the sensitivity (33.3%) and the coincidence rate (48.3%) of the examination method of free uroflow rate + PVR. CONCLUSION: Compared with the "maximum uroflow rate (Qmax) + PVR", NIRS can be more accurate and noninvasive for the diagnosis of BOO in men; this approach provides a new noninvasive method of high clinical value.

[Efficiency of O'Leary-Sant symptom index and problem index in the diagnosis of interstitial cystitis].

OBJECTIVE: To evaluate the efficiency of O'Leary-Sant problem index and symptom index (OPSI) in the diagnosis of interstitial cystitis (IC). METHODS: A total of 82 patients, initially diagnosed as IC, with urinary frequency, urgency and pain on pubic area during bladder filling phase from January 2008 to March 2013 were enrolled.OPSI was used to evaluate their symptoms. They were eventually divided into IC and non-IC groups according to the clinical diagnosis. The scores of OPSI, interstitial cystitis problem index (ICPI) and interstitial cystitis symptom index (ICSI) were compared between two groups. And the ROC curve was plotted to screen the diagnostic specificity and sensitivity. RESULTS: Among them, 58 were diagnosed with IC and the rest with non-IC. The average score of OPSI for groups IC and non-IC were 24.7 ± 6.9 and 23.2 ± 7.8 respectively (P = 0.403). And the ICPI score for two groups were 11.7 ± 3.2 and 10.2 ± 3.7 (P = 0.070) and the ICSI score 13.0 ± 4.0 and 13.1 ± 4.3 (P = 0.975) respectively.No significant differences existed between two groups. If an OPSI score of 12 or greater for diagnosing IC, the sensitivity was 98% and specificity 8%. Because of a high sensitivity, OPSI was a useful indicator for screening IC patients from others.In the ROC curve, acreage under curve for OPSI, ICPI, ICSI were 0.548 ± 0.071, 0.622 ± 0.069 and 0.492 ± 0.070 respectively. These three indices were not good indicators for diagnosing IC. CONCLUSIONS: The O'Leary-Sant symptom index and problem index has a high sensitivity but a low specificity in the diagnosis of IC. Therefore it should not be used to differentiate interstitial cystitis. A cutoff OPSI value of 12 may be used for differentiation.

[Identification of lower urinary tract voiding dysfunction in females by using video-urodynamic study].

OBJECTIVE: To assess the value of video-urodynamic study (VUD) in the identification of lower urinary tract voiding dysfunction in female. METHODS: A total of 126 female patients with sign and symptoms of lower urinary tract voiding dysfunction underwent VUD from December 2008 to January 2011 in Beijing Chaoyang Hospital. The causes of voiding dysfunction were analyzed based on VUD findings. RESULTS: Neurogenic voiding dysfunction was found in 30 patients (23.8%), non-neurogenic voiding dysfunction was found in 96 patients (76.2%). The 72 patients suffered from recurrent urinary tract infection (57.1%) and 23 patients suffered from hydronephrosis (18.3%). Based on special characteristics of video-urodynamic study, a total of 126 patients were classified as: (1) Bladder outlet obstruction (BOO) was found in 65 patients. Of them, bladder neck obstruction in 40 patients (61.5%), their VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck did not open in a funnel shape and no contrast was found in urethra. Distal urethral stricture in 22 patients (33.8%), VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck open in a funnel shape, proximal urethra dilated and no contrast was found in distal urethral. Urethral sphincter obstruction in 3 patients (including detrusor-sphincter dyssynergia in 1 and sphincterismus in 2 patients), VUD showed "high pressure-low flow" obstructive curve and synchronic image showed bladder neck open in a funnel shape, sphincteric urethra did not open, proximal urethra dilated and no contrast was found in distal urethral. (2) Detrusor areflexia (DA) was found in 39 patients (2 patients with hydronephrosis), the VUD finding was: no voluntary detrusor contraction in voiding phase, and abdominal pressure voiding pattern. (3) OAB was found in 3 patients, which VUD findings was frequent involuntary detrusor contraction at storage period with or without urine leakage. (4) Low compliance bladder was found in 17 patients (13.5%), 16 patients with hydronephrosis, the VUD showed that increased bladder storage pressure with significantly decreased bladder safe capacity and compliance, appearance of the bladder as "Christmas tree", with or without ureteral reflux. (5) And stress urinary incontinence (SUI) was in 2. CONCLUSIONS: The main causes of female BOO may be non-neurogenic conditions or organic obstruction. VUD would offer valuable information for confirmed diagnosis of voiding dysfunction in female patients.

Video-urodynamics study on female patients with bladder neck obstruction.

BACKGROUND: Pressure-flow study combined with cystourethroscopy were used as the major method to define female bladder neck obstruction in China. However, the definition of urodynamics for female bladder outlet obstruction (BOO) is not clear so far. Video-urodynamic study (VUDS) would provide more information to define the female BOO, but it is not used commonly due to the limitation of video-urodynamic equipment in China. We attempted to find a better way for diagnosis of female BOO by performing VUDS. METHODS: VUDS and cystourethroscopy were performed in 38 women with signs and symptoms of difficult voiding from March 2008 to April 2010 in Beijing Chao-Yang Hospital. Bladder neck obstruction was defined by radiological evidence of narrowing bladder neck, voiding pressure greater than 20 cmH2O and maximum flow rate (Q(max)) less than 12 ml/s. Transurethral incision of bladder neck was then performed on those patients. Follow-up examination (Q(max) and residual urine) was recorded 3 months after operation. RESULTS: The mean time from its onset to diagnosis was (18.1 ± 9.1) months in 38 patients. Average patient age was 36.1 years (range from 19 to 79 years). The mean Q(max) was (10.6 ± 4.7) ml/s and residual urine was (81.5 ± 42.4) ml. Three out of 38 patients had obvious distal urethral stricture, eight of them suffered from definitely bladder neck contracture and the remaining 27 patients did not show obvious abnormalities measured by cystourethroscopy examination. For the 35 patients without urethral stricture, the most frequent findings of VUDS were high-voiding pressure plus low-flow rate and narrow bladder neck during voiding on simultaneous fluoroscopy examination. With video-urodynamics definition, 32 patients were diagnosed as bladder neck obstruction with mean Q(max) of (10.8 ± 3.7) ml/s, residual urine of (76.9 ± 32.7) ml and detrusor pressure at maximum flow (P(det Q(max))) of (50.7 ± 19.1) cmH2O. Other three patients were suffered from detrusor hypocontractility. All 32 patients including eight with definitely bladder neck contracture and 24 with primary bladder neck obstruction received transurethral bladder neck incision. The symptom of difficult voiding was relieved. The postoperative follow-up showed that Q(max) was (21.7 ± 7.6) ml/s (P < 0.01) and the residual urine was (23.2 ± 17.6) ml (P < 0.01). CONCLUSIONS: The real cause of the obstruction for female patient with difficult voiding might be various. A full VUDS would give us valuable information for correct diagnosis in female patients with bladder neck obstruction.

[Clinical efficacy of a short-term regimen of Cardura XL on lower urinary tract symptoms and international prognostic scoring system in the treatment of benign prostatic hyperplasia].

OBJECTIVE: To evaluate the clinical efficacy of Cardura XL (doxazosin mesylate controlled release tablets) on lower urinary tract symptoms, IPSS (international prognostic scoring system) and short-term QOL (quality of life) (3 months) in the treatment of benign prostatic hyperplasia (BPH). METHODS: From July 2008 to February 2009, 80 male BPH patients with a mean age of 70.5 years old (range: 62-82) were prospectively recruited to receive a daily dose of Cardura XL 4 mg for 3 months. Clinical parameters of IPSS QOL, Qmax (maximum flow rate), residual urine, blood pressure and heart rate were recorded before and 3 months after treatment. Paired t test was performed on the corresponding data. And therapeutic efficacy and side effects were analyzed according to the statistical results. RESULTS: All 80 patients finished a 3-month medical regimen. Between pre-treatment and 3 months after medication, paired t test was performed on the corresponding data of maximum flow rate (Qmax), residual urine, IPSS, QOL, blood pressure and heart rate. Significant differences were observed in all corresponding data (P < 0.001) except heart rate (P = 0.685). Furthermore analyses were performed on the corresponding IPSS and QOL between one month and 3 months after treatment. Significant improvement was also observed in IPSS and QOL after a longer medication (P < 0.001). Transient side effects were observed in 16 patients (20%): headache (n = 8, 10%), fatigue (n = 4, 5%) and dizziness (n = 4, 5%). No patient withdrew from the study. CONCLUSION: Cardura XL, at a daily dose of 4 mg daily for 3 months, is a safe and effective regimen in BPH patients. Significant improvement is observed for lower urinary tract symptoms, IPSS and QOL. A longer medication may lead to further improvement of IPSS and QOL. After dosing, both systolic and diastolic blood pressures fall down significantly. No significant effect on heart rate is found. And most patients have an excellent tolerance.

[Diagnosis of lower urinary tract voiding dysfunction with video-urodynamic studies].

OBJECTIVE: To evaluate the role of video-urodynamics (VUD) in the diagnosis of lower urinary tract voiding dysfunction. METHODS: From December 2008 to March 2010, 115 patients with lower urinary tract voiding dysfunction were included in our study. All patients underwent VUD studies. RESULTS: Neurogenic bladder was found in 37 patients, including 25 male patients and 12 female patients. Among these patients, 18 patients were detrusor areflexia (DA), 2 patients were overactive bladder (OAB), 10 patients were low compliance bladder with hydronephrosis and 7 patients were detrusor-external sphincter dyssynergia. Non-neurogenic voiding dysfunction was found in 59 patients, including 34 male patients and 25 female patients. Among these patients, bladder outlet obstruction was found in 33 patients, OAB in 4 patients, urethra stricture in 4 patients and sphincterismus in 3 patients. Seven patients receiving augmentation of bladder took second VUD examination, including 4 male patients and 3 female patients. One patient receiving Indiana pouch and one patient receiving ureter reimplantation all took VUD examination. Ten patients had basic normal bladder urethra function from VUD examination, including 6 male patients and 4 female patients. CONCLUSION: From combination of pressure-flow figure and real time image, VUD examination provides precise evidence of diagnosis and treatment for lower urinary tract voiding dysfunction.

[Orthotopic T pouch ileal neobladder: evaluations of urodynamics and upper urinary tract functions].

OBJECTIVE: To evaluate the urodynamics and functions of upper urinary tract in a substitute of orthotopic T pouch ileal bladder. METHODS: From June 2004 through September 2009, 90 patients underwent the construction of an orthotopic T pouch ileal neobladder after radical cystectomy for muscle-invasive bladder cancer. The radiographic or ultrasound evaluation of upper urinary tract, determination of renal functions and urodynamic evaluation of T pouch ileal neobladder were performed by data analysis. RESULTS: Renal function as determined by serum creatinine remained in a normal range in all patients. Temporary dilation of renal pelvic and ureter was observed in 18 patients (20.0%) at Day 45 post-operation and then disappeared spontaneously in the late follow-up. A slight dilation of collecting system was found in other 4 patients (4.4%), but there was no negative impact on renal function. Reflux into afferent limb of neobladder was observed in 4 patients (4.4%) by cystography. Excellent daytime and nighttime continence was reported in 100% and 82.2% of evaluated patients respectively. The urodynamic assessment showed a mean capacity of (316 ± 96) ml with a mean intra-bladder pressure of (16 ± 10) cm H2O. These evaluated patients voided with a mean maximum intra-bladder pressure of (87 ± 25) cm H2O, a mean maximum flow rate of (17 ± 10) ml/s and a mean residual urine of (33 ± 29) ml. CONCLUSION: With an intermediate follow-up, the functional results of T pouch ileal neobladder are encouraging with an excellent capacity and compliance, successful daytime and nighttime continence and anti-reflux mechanism.

[Applying bladder outlet obstruction number to predict bladder outlet obstruction of benign prostatic hyperplasia].

OBJECTIVE: Applying bladder outlet obstruction number (BOON) to predict bladder outlet obstruction (BOO) of benign prostatic hyperplasia (BPH). METHODS: Seventy-six male who were suspected to suffer from BOO due to BPH with lower urinary tract symptoms were evaluated. The data included prostate volume (by transrectal prostate ultrasound), maximum urine flow rate (Qmax) and mean voided volume to calculate the BOON by simple algorithm: prostate volume (cm(3))-3 x Qmax (ml/s)-0.2 x mean voided volume (ml). Pressure-flow study was also performed on each patient to get AG number and Schäfer obstruction grade. Correlation between traditional parameters, BOON and AG number was calculated to evaluate the price of using BOON to predict BOO. RESULTS: Parameters such as age, prostate volume, maximum urine flow rate, residual urine and BOON were used as independent and AG was used as dependent to calculated the multiple linear regression. Data expressed the entire regression equation's R = 0.542 (P = 0.000), and result showed BOON had the strongest relationship with AG (P = 0.000). Eighteen patients' BOON number were greater than -10, by AG number and Schäfer obstruction grade proving, all these patients were suffered from BOO, the sensitivity and the specificity of judging BOO by BOON were 31% and 100% respectively. While take BOON as -20, the sensitivity and the specificity were 42.4% and 88.2%, when take BOON as -30, the sensitivity and the specificity were 66.1% and 82.4%, respectively. Fifty-two persons' BOON were greater than -40, 46 patients suffered from BOO, the sensitivity and the specificity were 77.9% and 64.7%, the specificity and the opportunity of having BOO decreased significantly. The data showed that: taking BOON = -30 as critical point can predict BOO with higher sensitivity and specificity, greater BOON means greater possibility of BOO. CONCLUSIONS: Using BOON which is deduced from prostate volume, maximum urine flow rate and mean voided volume, the point -30 as critical point, can predict the probability of BOO with higher sensitivity and specificity.

[Length and volume of intravesical prostatic protrusion closely correlated with bladder outflow obstruction in BPH patients].

OBJECTIVE: To analyze the correlation of the length and volume of intravesical prostatic protrusion (IPP) with bladder outflow obstruction (BOO) in patients with BPH and to find a simple method for the diagnosis of the disease. METHOD: The length and volume IPP were measured by transrectal ultrasound for 87 patients with BPH, the diagnosis of BOO was made by urodynamic tests and the correlation of the length and volume of IPP with BOO was analyzed, and reanalyzed 3 months after oral medication of a-blocker. The length and volume of IPP were measured again during the operation in 54 of the cases to confirm the ultrasound findings. RESULTS: BOO was diagnosed in 51 of the patients. The coefficient of correlation between the length of IPP and BOO and that between the volume of IPP and BOO were 0.53 and 0.47 (P < 0.01). Not considering the dynamic factors, they were 0.69 and 0.62 (P < 0.01), respectively. BOO was confirmed in patients with the length of IPP > 1.0 cm or the volume > 1.5 ml. There was no significant difference between the results of transrectal ultrasound and the findings during the operation concerning the length and volume of IPP (P > 0.05). CONCLUSION: There is a close correlation between the length and volume of IPP and BOO, which can be conveniently applied to the diagnosis of BOO in BPH patients.

[Non-improvement after different procedures of prostatectomy].

OBJECTIVE: To analyze the causes of non-improvement after different procedures of prostatectomy. METHODS: Using the urodynamics and other techniques, we examined 84 non-improved patients who had undergone different procedures of prostatectomy. RESULTS: In the TURP group, the main causes of non-improvement included bladder outlet obstruction (84.9%), weak contractility of the detrusor (30.4%), and detrusor instability (DI) (18.2%). In the open group, however, the main causes of non-improvement included detrusor weak contractility (52.9%), DI (35.2%), and bladder outlet obstruction (33.3%). There was significant difference between the two groups according to the Pearson Chi-square test (P = 0.000). The re-obstruction rate in the TURP group was much higher than that in the open group, suggesting that the level of the TURP should be improved. CONCLUSIONS: Different operative procedures yield different non-improvement after prostatectomy gradually. When BPH patients are diagnosed with detrusor weak contractility and DI, prostatectomy should be carefully considered.