Neurourology and Urodynamics最新文献

Background: Following the severe complications widely reported in some women following polypropylene suburethral mesh implantation for the treatment of stress urinary incontinence, it has become clear that careful preclinical study in an appropriate animal model is essential. The preclinical model described here allows the postoperative clinical and histochemical assessment of material implanted in the sheep vagina and represents a model that allows prediction of the potential vaginal tissue responses to suburethral mesh implantation before implantation into humans.

Objectives: To develop and evaluate a relevant preclinical animal model to mimic suburethral implantation of support materials for stress urinary incontinence.

Material: Fourteen parous ewes of 30-40 kg were used. Under general anesthetic, animals were placed in the lithotomy position. A 12-French Foley catheter was inserted. The ventral vaginal wall was longitudinally incised. The space between the vaginal wall and the urethra was developed, with lateral retropubic dissection. Either a standard transvaginal polypropylene tape (seven animals) or a fascia mimetic microfibre spun polyurethane tape (seven animals) were inserted using an introducer either via a suprapubic (seven animals) or a transvaginal approach (seven animals) into the suburethral and retropubic space. The incisions were closed, and the catheter was removed. A betadine vaginal pack was placed and removed after 24 h. Postoperatively, the animals were observed carefully for pain and complications and allowed access to water and food under continuous veterinary supervision adhering to USA-approved protocols.

Results: On the second postoperative day, all the animals passed urine freely and had regular bowel motions. No procedure related complications were observed.

Conclusion: This is the first large animal model which has been designed for suburethral implantation. and which can be effectively used for the preoperative evaluation of novel materials designed for suburethral implantation. We believe that this technique in this large animal model accurately reproduces the surgical technique used to treat stress urinary incontinence in women. It provides a new and effective in vivo model for the objective evaluation of new materials to treat female stress incontinence.

Background: Nocturia is among the most common and bothersome urinary tract symptoms in older adults. While sleep quality is key to nocturia management, there is little information on the impact of nocturia itself on sleep quality. We investigated the impacts of nocturia on sleep quality and quality of life and explored factors contributing to reduced sleep quality.

Methods: A total of 186 men, aged 42-88 years (patients with nocturia and a control group), were evaluated using the Pittsburgh Sleep Quality Index, the Nocturia Quality-of-Life questionnaire, a visual analog scale measurement of dry mouth, and the Overactive Bladder Symptom Score, among other tools. Patients were graded into four categories of nocturia severity based on 3-day frequency volume charts. Factors associated with reduced subjective and comprehensive sleep quality were investigated using multiple regression analysis.

Results: Initial undisturbed sleep duration was negatively associated with nocturia frequency. Subjective and comprehensive sleep quality, overactive bladder scores, sleep efficiency and oral dryness were significantly associated with nocturia-related quality of life, when controlled for both age and nocturia severity. Sleep efficiency was a major predictor of reduced subjective and comprehensive sleep quality; overactive bladder scores and oral dryness were also independently significantly associated with reduced subjective and comprehensive sleep quality on multiple regression analysis, although nocturia frequency and initial undisturbed sleep duration were not.

Conclusions: It may be beneficial to conduct a comprehensive assessment for overactive bladder and dry mouth when managing nocturia in older adults with poor sleep quality.

Introduction: Primary bladder neck obstruction (BNO) occurs when the bladder neck fails to open during voiding, causing urinary symptoms despite no anatomic obstruction. The cause of BNO is unclear but may involve neurogenic dysregulation related to the sympathic nervous system such as upper motor neuron lesion or peripheral autonomic neuropathy (small fiber neuropathy (SFN)). Another etiology can incuded increased sympathetic tone secondary to anxiety or stress conditons. Botulinum toxin A (BoNT-A) to the bladder neck has been used in our practice to treat women with BNO who failed conventional therapies (alpha blockers, relaxation strategies). This is the first report of patient-reported outcomes after BoNT-A treatment in women with pelvic pain and BNO.

Materials and methods: We included female patients with pelvic pain and BNO who received BoNT-A to the bladder neck between January 2022 and March 2023, and mailed self-reported outcome questionnaires. The primary outcome was the Global Response Assessment (GRA); secondary outcomes included pain scores on the Visual Analogue Scale (VAS) and symptom checklists. BNO was diagnosed using Nitti Criteria (high bladder pressure, low flow in bladder neck on video urodynamics), supplemented by additional criteria (e.g., high voiding pressure, prolonged attempts, Valsalva effort, and cystoscopic evidence or symptoms related to BNO). Urodynamic studies followed International Continence Society standards. Additionally, due to BNO's association with SFN, patient history of biopsy-confirmed SFN was recorded.

Results: Our inclusion criteria was satisfied among 18 patietns, with 17 completing the questionnaire. Out of those, 14 patients (77%) reported improvement on the GRA, with an average VAS of 8.3 ("Very Helpful"). The most commonly improved symptoms were feeling of incomplete emptying, difficulty starting stream, urethral burning, pain with urination, and pelvic pain. Postoperative symptom flares were reported in six patients for an average of 16 days. All six patients with biopsy-confirmed SFN showed significant improvement (VAS 8.7). Total of 14 patients (77%) indicated they would repeat the procedure.

Conclusions: BoNT-A to the bladder neck significantly improved pelvic pain and refractory hesitancy in women with bladder neck obstruction, especially in those with small fiber neuropathy. Symptom flares are common, but did not reduce interest in repeated treatments, and scheduling injections before symptom recurrence may mitigate these flares.

Introduction: Robot-assisted (RA) surgery has many advantages for urinary tract and pelvic floor reconstruction (UTPFR) but its application is only slowly increasing. Studies are limited in number, patients and follow-up duration. The low-volume high-complexity nature of UTPFR warrants specific research to evaluate the potential role of the RA approach.

Methods: During its 2024 meeting in Bristol, the International Consultation on Incontinence-Research Society (ICI-RS) reviewed the current literature on RA UTPFR. Priority research questions and strategies were explored in a proposal.

Results: Four different topics were discussed. (1) Large multicentre prospective studies on RA UTPFR are needed to evaluate clinical effectiveness and safety. The RA approach needs to be prioritized in specific procedures and patients, to first improve patient care where gains are highest. (2) Models for cost-utility analysis for RA UTPFR are needed to (re)direct limited resources as efficiently as possible in a quickly changing technological field. (3) A modular curriculum for training UTPFR surgeons to become RA certified needs to be developed, to allow valid interpretation and comparison of outcomes. (4) Technological improvements to address tissue handling, accessibility, efficiency and sustainability are needed. Digitalization can be a gamechanger for RA UTPFR through telesurgery (training and expertize coverage), augmented reality and artificial intelligence providing intra-operative assistance, assessment and feedback.

Conclusions: The proposal discussed the need for studies on clinical and cost effectiveness, safety, and training curriculum development for RA UTPFR. Recent technological developments hold great promise for RA UTPFR. High-priority research questions were identified.

Aims: To provide a brief anatomical pathogenesis of the Working Group SUI publication recommendations.

Methods and results: The anatomical science and surgical practice presented here formed the original basis for the MUS and other bladder dysfunctions, updated to 2024 with videos: https://atm.amegroups.org/issue/view/1400. Bladder control is binary, from outside the bladder, with ONLY two modes, EITHER closed (continence) OR open (micturition). The key concept for surgical repair of stress (SUI) and other types of urinary dysfunctions, is the role of three balanced oppositely-acting muscle forces which contract against PUL (pubourethral ligament) and USL (uterosacral ligaments) to close urethra, open it before evacuation and stretch vagina to prevent premature activation of micturition, perceived as "urge to go." Collagen-induced weakness in PUL or USL may cause dysfunction in all three of these activities, which can be improved or cured by collagen-creating ligament repair techniques (e.g., slings). It is important to diagnose Tethered Vagina Syndrome (TVS), iatrogenic scarring at bladder neck, much more frequent since large vaginal mesh implantation. TVS is often confused with SUI, as its cardinal symptom is massive urine loss with the "effort" of getting out of bed. Sling surgery worsens TVS as it adds more scar. Vaginal skin graft is required to restore elasticity and continence.

Conclusions: "Anatomical defects in binary control may cause SUI, retention or urge," and are potentially repairable. With regard to SUI, "a normal PUL does not lengthen during effort."

Aims: This study aimed to investigate the role of N-methyl-D-aspartate receptors (NMDARs) in bladder smooth muscle (BSM) function and their potential as therapeutic targets for overactive bladder conditions.

Methods: We employed a multi-faceted approach to assess NMDAR activity in BSM. Myography was used to evaluate the effects of NMDAR antagonists and agonists on BSM contraction. Calcium imaging was conducted to determine changes in intracellular calcium ions. We also analyzed single-cell RNA sequencing data to examine NMDAR subunit expression in bladder cell subpopulations from both human and mouse tissues. Immunofluorescence staining was performed to localize the obligate NMDAR subunit, GluN1, in mouse BSM.

Results: NMDAR agonists did not modulate BSM contractile force. NMDAR antagonists had varied effects: D-AP5 showed no impact, CGS-19755 significantly inhibited contraction at the highest concentration, and MK-801 enhanced contractile force in a concentration-dependent manner at EFS frequencies of 1, 2, and 5 Hz. Neither agonists nor antagonists, including MK-801, induced calcium ion shifts in BSM cells. Single-cell RNA sequencing revealed no NMDAR subunit expression in BSM cells from human or mouse tissues. Immunofluorescence confirmed GluN1 expression in pulmonary artery smooth muscle but not in BSM.

Conclusions: Our findings indicate the absence of functional active NMDARs in BSM, suggesting that the therapeutic benefits of NMDAR inhibition observed in vivo for treating overactive bladder are unlikely to be directly mediated through effects on the BSM itself. This highlights the need to explore alternative mechanisms or targets for therapeutic interventions in overactive bladder conditions.

Background and objective: This study aimed to assess the prevalence of urinary incontinence (UI) and lower urinary tract symptoms (LUTS) in five selected low and middle-income countries to provide appropriate evidence for other related studies.

Materials and methods: In this multinational population-based cross-sectional survey between August 2019 and April 2021, validated questionnaires were used to assess LUTS in adults over 18 years from Iran, Egypt, Bangladesh, Brazil, and Cameroon.

Results: A total of 1477 participants from five countries completed the questionnaires. The mean age of participants was 43.5 ± 15.7 years. 37.1% reported at least one episode of UI per week. UUI prevalence in different countries analysis showed that the commonest prevalence was reported in Cameron (40.0%; n = 30), while the lowest was 15.0% (n = 31) in Brazil. Stress UI was common in Iran (38.7%; n = 338), and Bangladesh had the lowest rate (7.8%; n = 16). Urinary urgency was the common LUTS among participants (59.9%, n = 818 out of 1477 participants). Nocturia was the other prevalent symptom among cases (50.6%; 748 out of 1477 cases), and this symptom had a higher rate in elderly populations. Men reported voiding and postmicturition symptoms more frequently than women. Storage symptoms except for nocturia, including frequency, urgency, and UI were common in women while voiding symptoms, including straining, and intermittency were reported more frequently in men than women.

Conclusion: A high prevalence of urinary symptoms was reported in low to middle-income countries.

Purpose: The International Continence Society and the International Urogynecological Association have not yet standardized the definition of de novo stress urinary incontinence. Recent studies define the development of stress urinary incontinence as occurring after surgical repair of pelvic organ prolapse in previously continent women. The mechanisms that cause de novo stress urinary incontinence are not yet clear. Knowledge of the predictive factors for this outcome after surgical correction of pelvic organ prolapse would be useful for assessing whether a concomitant anti-incontinence procedure should be performed.

Materials and methods: The aim of this systematic review and meta-analysis was to identify some of the risk factors for de novo stress urinary incontinence: high body mass index, pelvic organ prolapse stage before surgery, presence of occult urinary incontinence, type of surgery, and the presence of diabetes mellitus. The present study was registered in the PROSPERO database under number CRD42021293764, and the systematic review was carried out according to the MOOSE recommendations and with the PRISMA 2020 guidelines.

Results: A total of 2429 articles were identified. Nine cohort studies were included in the systematic review and seven in the meta-analysis. The risk of bias was assessed via the Newcastle-Ottawa scale and the certainty of evidence was assessed using the GRADE approach for each outcome. In the meta-analysis, associations were identified between de novo stress urinary incontinence and occult urinary incontinence (n: 422; OR: 2.01; 95% CI: 1.26-3.22; p = 0.004), diabetes (n: 1213; OR: 2.35; 95% CI: 1.30-4.26; p = 0.005), and advanced pelvic organ prolapse (n: 1003; OR: 1.94; 95% CI: 1.14-3.30; p = 0.01). Consulting a meta-analysis for the type of surgery was deemed impossible. A previous study comparing abdominal sacrocolpopexy with minimally invasive sacrocolpopexy revealed that women who underwent abdominal sacrocolpopexy were more likely to develop de novo stress urinary incontinence (n: 77; OR: 4.73; 95% CI: 1.56-14.34; p = 0.005). Another study found that pelvic organ prolapse repair using a transvaginal mesh was associated with higher levels of de novo stress urinary incontinence compared to robot-assisted sacrocolpopexy (n: 76; OR: 6.74; 95% CI: 1.35-33.75; p = 0.02). A meta-analysis of overweight or obesity was not possible due to the different assessment methods used in the studies.

Conclusions: This meta-analysis revealed that occult incontinence, diabetes, and advanced pelvic organ prolapse before repair were associated with de novo stress urinary incontinence and these groups may therefore benefit from for anti-incontinence procedures concomitant with pelvic organ prolapse repair.