Neurourology and Urodynamics最新文献

Introduction: Lower urinary tract symptoms (LUTS) are prevalent among older adults, a population that faces multiple medical challenges, with frailty being a major concern. Despite the high prevalence of LUTS, current treatment strategies for older adults are often inadequate. This paper aims to address these issues by defining daytime and/or nighttime LUTS and examining the impact of comorbid conditions on these symptoms. We will identify the priorities of older patients regarding LUTS management and propose treatment strategies to improve outcomes in this vulnerable population.

Methods: This review is based on discussions at the ICI-RS 2024 meeting in Bristol, UK, alongside an extensive literature review examining LUTS in older adults. The review explores distinctions between daytime and nighttime symptoms, the impact of frailty, patient priorities, treatment strategies and the role of comorbidities.

Results: LUTS in older adults present a complex and multifaceted challenge, with notable differences between daytime and nighttime manifestations, which may coexist. Clear definitions are needed. There is a lack of evidence that treating associated comorbidities will improve LUTS or urinary incontinence. Personalized care approaches, integrated into broader geriatric health strategies, are essential for addressing these symptoms. An ideal treatment strategy is proposed, focusing on daytime, nighttime or combined day- and nighttime LUTS. Further research is needed to refine treatment pathways and optimize outcomes for this population.

Conclusions: A comprehensive, individualized approach is necessary to address LUTS in older adults. Future research should focus on refining diagnostic definitions, exploring the interplay between comorbidities and LUTS, and developing patient-centered treatment strategies that account for both daytime and nighttime (or combined) symptoms.

Introduction: Ketamine, a versatile anesthetic, has seen increased recreational use, leading to significant health issues, including ketamine-induced uropathy (KIU). KIU manifests with lower urinary tract symptoms (LUTS) and can involve the upper urinary tract. This study aims to provide a comprehensive overview of KIU, addressing its pathophysiology, diagnostic strategies, and treatment options; and to define/identify future research priorities.

Methods: During the 2024 meeting of the International Consultation on Incontinence Research Society (ICI-RS) in Bristol, a dedicated Proposal (P) convened to explore KIU. This initiative involved a thorough review of existing literature, expert presentations, and consensus-driven discussions. The methodology ensured a comprehensive exploration of KIU from both clinical and pre-clinical perspectives, leading to actionable research recommendations.

Results: Understanding the mechanisms of KIU is crucial for developing effective treatment options targeting specific pathophysiological pathways. Key findings include bladder fibrosis driven by transforming growth factor-β1 (TGF-β1), elevated purinergic responses and upregulated P2X1 purinoceptor expression, decreased barrier function due to increased expression of antiproliferative factor (APF), and functional loss of the bladder through Cav1.2 channel blockade. Research indicates that fibrosis, typically considered irreversible, may be mitigated. However, the exact timing and extent of fibrosis initiation and its impact on long-term outcomes require further research. LUTS typically improve after ketamine cessation but relapse upon resumption, indicating a hypersensitivity mechanism involving elevated serum IgE levels. Advanced stages of KIU do not always correlate with LUTS severity, shedding light on potential systemic effects and the need for evaluating liver enzymes. Furthermore, psychological dependency on ketamine, due to its positive perceptive and mood-altering effects, complicates cessation efforts. Long-term management requires a holistic approach, integrating medical treatments and supportive measures to help patients navigate life with potentially irreversible complications.

Conclusion: This comprehensive review spans from fundamental pathology to practical clinical management, addressing both urological and systemic complications, and bridging insights from animal models to human applications. Developing effective treatment strategies necessitates addressing both the physical and psychological aspects of ketamine dependency.

Introduction: Bladder outflow obstruction (BOO) is a urethral resistance (UR) at a level above a clinically relevant threshold. UR is currently graded in terms of the existence and severity of the BOO based on maximum flowrate and associated detrusor pressure only. However, the pressure-flow relation throughout the course of voiding includes additional information that may be relevant to identify the type of BOO. This study introduces a new method for the distinction between the provisionally called compressive and constrictive types of BOO and relates this classification to underlying patient and urodynamic differences between those BOO types.

Methods: In total, 593 high-quality urodynamic pressure-flow studies in men were included in this study. Constrictive BOO was identified if the difference Δp between the actual minimal urethral opening pressure (p_muo) and the expected p_muo according to the linearized passive urethral resistance relation (linPURR) nomogram was >25 cmH₂O. Compressive BOO is identified in the complementary case where the pressure difference Δp ≤ 25 cmH₂O. Differences in urodynamic parameters, patient age, and prostate size were explored.

Results: In 81 (13.7%) of the cases, constrictive BOO was found. In these patients, the prostate size was significantly smaller when compared to patients diagnosed with compressive BOO, while displaying a significantly lower maximum flowrate, higher detrusor pressure at maximal flowrate and more postvoid residual (PVR).

Conclusion: This study is an initial step in the validation of additional subtyping of BOO. We found significant differences in prostate size, severity of BOO, and PVR, between patients with compressive and constrictive BOO. Subtyping of voiding-outflow dynamics may lead to more individualized management in patients with BOO.

Aims: Existing questionnaires provide limited information on the nature, severity and context surrounding lower urinary tract symptoms (LUTS) experienced during running, jogging and brisk walking. The aims of this study were to develop a theoretical model of the experience of LUTS by females participating in gait-based exercise activities and to use this model to generate a questionnaire to evaluate the presence, symptoms and bother associated with LUTS experienced by females during gait-based activities.

Methods: A theoretical model was developed through a review of the literature and refined through a focus group consultation including pelvic health physiotherapists, females who experienced leakage during exercise and academic researchers who studied female LUTS. A draft questionnaire was developed using key constructs identified in the model by the focus group. A new expert panel was recruited, which included physiotherapists, women with self-reported gait-induced LUTS and urogynecologists. This panel followed a DELPHI process to evaluate the relevance and completeness of the constructs within the questionnaire.

Results: Two rounds of consultation were required to reach consensus on the completeness of included constructs as well as the inclusion and wording of questions. The resulting questionnaire contains questions related to five key constructs: physical activity characteristics, symptoms of urgency, urgency urinary incontinence, stress urinary incontinence experienced during exercise and management/mitigation strategies adopted by respondents.

Conclusions: The content validity of the brisk walking- and running-induced lower urinary tracts symptoms questionnaire has been established. The next steps are to ensure that the questionnaire has adequate comprehensibility, followed by adequate measurement properties.

Aims: To discuss the role of autocrine/paracrine signaling of urothelial arginine vasopressin (AVP) on mammalian bladder capacities and micturition thresholds, impact of distension on water/urea reabsorption from the bladder, review of the literature to better characterize the central/peripheral effects of AVP, desmopressin (dAVP) toxicity, and urine biomarkers of nocturia.

Methods: This review summarizes discussions during an International Consultation on Incontinence-Research Society 2024 think tank with respect to the role of urothelial AVP in aged individuals with nocturnal polyuria, impact of solute and water reabsorption by the bladder on uninterrupted sleep, central effects of AVP, pharmacological basis of dAVP toxicity, and biomarkers in nocturia/lower urinary tract dysfunction (LUTD) with neurological diseases.

Results: Consensus recognized AVP function and pathways in the central nervous system (CNS), pre-proAVP localized using immunohistochemistry in bladder sections from adult/aged noncancerous human punch biopsies and rodent bladder sections is likely to accelerate the systemic uptake of water and urea from the bladder of anesthetized mice instilled with ³H-water and ¹⁴C-urea. Mechanisms for charged and uncharged solutes and water transport across the bladder, mechanism of dAVP toxicity, and utility of urine biomarkers in those with neurological diseases/nocturia were determined from literature reviews.

Conclusion: Pre-proAVP is present in human/rodent bladders and may be involved in water reabsorption from bladder that prevents the sensation of fullness for uninterrupted sleep in healthy adults. The mechanism of action of AVP in the CNS was discussed, as was electrolyte/water transport across the bladder, the basis for dAVP toxicity, and feasibility of urine biomarkers to identify nocturia/LUTD with neurological diseases.

Aims: Urogynecology and Reconstructive Pelvic Surgery (URPS) fellowship can be pursued after completion of either a urology (URO) or obstetrics and gynecology (GYN) residency. Our aim is to determine differences in graduating fellow cohort (GFC) case logs between URO- and GYN-based URPS programs.

Methods: Accreditation Council for Graduate Medical Education case logs for URPS GFCs in both GYN- and URO-based programs were analyzed for the 2019-2023 academic years (AY). Unpaired t-tests with Welch's correction were used to compare annual mean logged cases between URO- versus GYN-based GFCs for select surgical categories and the top 11 most logged index cases.

Results: GYN-based GFCs logged more cases for all pelvic organ prolapse (POP) categories including surgery on apical POP, anterior wall POP, and posterior wall POP (all p < 0.01), while URO-based GFCs logged more cases for surgery on the urinary system (p = 0.03). For the top 11 logged procedures, URO-based GFCs logged more sacral neuromodulation cases (p = 0.02), whereas GYN-based GFCs logged more slings, vaginal hysterectomies, minimally-invasive hysterectomies, vaginal apical POP, vaginal posterior POP, vaginal anterior POP, and minimally-invasive apical POP cases (all p < 0.01). There was no difference between URO- and GYN-based GFCs for complex urodynamics, cystoscopy with botox injection, or periurethral injection cases.

Conclusions: URO-based URPS fellows tend to graduate with more surgery on the urinary system and sacral neuromodulation cases, while GYN-based fellows perform more slings, hysterectomies, and POP surgery. These findings may help fellowships better understand potential differences in training among graduates from URO- and GYN-based programs and encourage collaboration to lessen these discrepancies.

Introduction: We aim to compare the clinical and urodynamic profile of lower urinary tract symptoms (LUTS) in patients undergoing laparoscopic, open transabdominal, and laparoscopic transabdominal vesicovaginal fistulae (VVF) repair at 3 months of repair, that is, in early postoperative period.

Materials and methods: Fifty-one consecutive patients with endoscopically confirmed VVF were enrolled in our study over 2 years. Malignant fistulae, radiation-induced, and complex fistulae were excluded after cross-sectional imaging. All patients underwent a postoperative assessment for the success of the repair. Then at 3 months, they completed the American Urological Association Symptom Score questionnaire and underwent a dual channel pressure-flow urodynamic study. The results of transvaginal, laparoscopic, and open transabdominal repairs were compared.

Results: All patients belonged to the Indian Caucasian race. The mean age was 35.43 ± 6.63 years. Thirty-two patients had supratrigonal and 19 had trigonal fistulae. Laparoscopic transabdominal repair was done in 15 patients, open transabdominal repair in 22 patients, and transvaginal repair in 14 patients. Forty-six patients reported some LUTS at a median follow-up of 5.83 ± 2.37 months postoperatively. Only 18 (35.2%) of these patients had moderate to severe symptoms The postoperative bladder dysfunction rates in open transabdominal, transvaginal and laparoscopic transabdominal groups were 36.4%, 28.6%, and 20%, respectively. Twenty-seven patients (52.9%) had some urodynamic abnormality, that is, small capacity (5), high voiding pressures (14), genuine stress incontinence (3), and poor compliance (3). Bladder capacity was a significant predictor of bladder dysfunction in our patients.

Conclusions: In our study, all three surgical approaches were associated with bladder dysfunction, however, it was the least in the laparoscopic transabdominal approach. Postoperative bladder capacity is a significant predictor of bladder dysfunction.

Importance: Many women report inadequate symptom control after sacral neuromodulation (SNM), despite 50% reduction in urgency incontinence episodes (UUIE) after test stimulation.

Objective: To determine the ideal percent UUIE reduction after test stimulation that predicts 24-month success.

Study design: Using data from a multicenter SNM trial, we constructed receiver operating characteristic curves to identify an ideal threshold of percent UUIE reduction after test stimulation. We defined 24-month success as Patient Global Impression of Improvement of "very much better" to "better." We compared predictive accuracy of two models predicting success: (1) percent UUIE reduction alone and (2) with baseline characteristics.

Results: Of 149 women (median [IQR] baseline daily UUIE 4.7 [3.7, 6.0]), the ideal threshold for 24-month success was 72% (95% confidence interval 64,76%) UUIE reduction with accuracy 0.54 (0.42, 0.66), sensitivity 0.71 (0.56, 0.86) and specificity 0.27 (0.05, 0.55). The accuracy of the 50% reduction threshold was 0.60 (0.49, 0.71), sensitivity 0.95 (0.88, 1.0) and specificity 0.04 (0.0, 0.12). Percent reduction in UUIE was not better than chance in predicting 24-month success (concordance index [c-index] 0.47 [0.46, 0.62]); adding age, body mass index, diabetes mellitus and visual or hearing impairment the c-index was 0.68 (0.61, 0.78).

Conclusions: Among women who received an internal pulse generator (IPG) due to ≥50% UUIE reduction after test stimulation, we found no ideal threshold that better predicted 24-month success. Percent reduction in UUIE after test stimulation poorly predicts 24-month success with or without clinical factors. Given this, re-evaluating how we determine who should receive an IPG is needed.