Neurourology and Urodynamics最新文献

Aims: Patients coming for urodynamics expect those delivering the service to be fully trained, with assurance of competence and quality. This document proposes a single UKCS Certification and Re-certification process for all health care professionals who perform or interpret urodynamics.

Methods: The Working Group of the United Kingdom Continence Society engaged with stakeholders in relevant professional societies and institutions, recirculating drafts until consensus was reached.

Results: A process of Certification has been designed to ensure that patients attending urodynamics undergo high quality investigations, the results of which are accurately interpreted, in order to guide both the patient and their clinicians in the patient's future management.

Conclusions: The United Kingdom Continence Society strongly recommends that all urodynamic investigations are carried out by, or under the supervision of, certified individuals. This document presents such a process of Certification and Re-certification that aims to ensure that quality standards are maintained and that patients have high quality urodynamics.

Objective: Sacral neuromodulation (SNM) is an established treatment for detrusor underactivity (DU) and nonobstructive urinary retention. The mechanism of action for SNM in DU, however, remains poorly understood. The objective of this study was to investigate the urodynamic study (UDS) changes in DU patients during the trial period following first stage tined-lead placement (FSTLP).

Materials and methods: Retrospective chart review was performed to identify patients diagnosed with DU on initial UDS, who had repeat UDS during the 2-week trial period following FSTLP by a single clinician. Urodynamic parameters including maximum flow rate (Qmax), detrusor pressure at maximum flow (PdetQmax), post-void residual (PVR), voiding efficiency (VE), and detrusor contractility index (DCI) were collected. Using the definition of improvement in baseline VE of ≥ 50% post-FSTLP or improvement in DCI of ≥ 50% in complete voiders, patients were divided into "responders" and "nonresponders." Pre- and post-FSTLP urodynamic findings were compared using Wilcoxon signed-rank tests.

Results: A total of 17 patients were identified who met the inclusion criteria. Repeat UDS were done on account of inability or unwillingness to perform clean intermittent catheterization and thus inability to chart an accurate bladder diary. There were 9 female and 8 male patients. Four patients (23.5%) had pure DU while the other 13 (76.5%) had concurrent detrusor overactivity (DO-DU). Among all patients, there was a statistically significant improvement in PdetQmax (14 vs. 29 cmH₂O, p < 0.01) and DCI (62 vs. 92, p < 0.01). Six patients (35.3%) responded to the trial of SNM for DU. Among responders, statistically significant improvements in Qmax (5 vs. 15.5 mL/s, p = 0.03), PVR (215 vs. 80 mLs, p = 0.04), VE (22.9% vs. 82.5%, p = 0.04), and DCI (29 vs. 97.5, p = 0.03) were observed. Nonresponders had improvement in PdetQmax (14 vs. 29 cmH₂O, p = 0.02), but not in Qmax (9 vs. 10 mL/s, p = 0.89).

Conclusions: Among all patients, an improvement in PdetQmax and DCI was observed. Responders exhibited improvement in Qmax, PVR, VE, and DCI without statistically significant improvement in PdetQmax. Nonresponders had statistically significant improvement in PdetQmax, but not in Qmax. Possible mechanisms of action of SNM in DU patients based on our data are inhibition of the guarding reflex/relaxation of the urethra (shown by improvement in Qmax in responders only) and direct strengthening of bladder contractility (shown by improvement in PdetQmax in all patients). Improvement in Qmax was observed exclusively in responders suggesting the former mechanism is the predominant one. Further larger prospective studies are required to confirm these findings.

Introduction: The reoperation rate for artificial urinary sphincters (AUS) in men is about 25%, with poorer survival rates when reimplantation occurs after urethral erosion or infection. Data on the outcomes of second AUS implants are rare, and no data exist for third AUS implants. We aimed to evaluate the functional and survival outcomes of a third AUS after two previous explantations.

Methods: The records of all patients implanted with a third AUS between 2006 and 2023 in seven French university hospitals were reviewed retrospectively. Only AUS implants following two previous AUS cuff explantations or revisions were included. The primary endpoint was the reoperation-free survival of the third AUS. Secondary endpoints included functional outcomes at 6 months and at the last follow-up, and overall functional outcomes after possible subsequent AUS implants, as well as reoperations.

Results: A total of 75 patients were included. Early complications occurred in 16.7% of patients. Median follow-up was 11 months (1-122), 28 explantations were required (37.3%). The 5-year reoperation-free survival rate was 34.8%. The only significant predictive factor for explantation was smoking. At 6 months, 66.2% of patients were socially continent (0-1 protection per day), 10.8% were improved, and 23% were unchanged or worsened. At the last follow-up of the third AUS, these results were 40%, 5.3%, and 54.7%, respectively. However, at the last overall follow-up (median 12 months, 1-183), social continence was 54.8%, improvement 9.6%, and failure 35.6%, with 23 patients (30.7%) receiving a fourth or fifth AUS.

Conclusion: Early functional outcomes of a third AUS are similar to primary AUS, but survival rates and late functional outcomes are inferior. Predictive factors for outcomes were related to patients, not the surgery itself. A third AUS may be suitable for motivated patients with limited therapeutic options. Further studies are needed to refine patient selection and assess the impact of reimplantation techniques on outcomes.

Context: Water intake in drinks and food is essential for life. Multiple guidelines exist to help give recommendations for healthy water intake and urine output, but few of these are specific to patients with lower urinary tract symptoms.

Methods: A debate held at the International Consultation on Incontinence-Research Society meeting, held in Bristol in June 2024, considered ways to improve this situation.

Results and conclusion: There are challenges in measuring both total water intake and also urine output, but we suggest that urine output may be the most helpful measure to focus on for future guidelines for patients.

Introduction: Defining "high-risk bladder" or "high-pressure bladder" involves recognizing the potential for an unsafe lower urinary tract, where dysfunction in storage and micturition can threaten upper urinary tract health, leading to unfavorable outcomes like dialysis, recurrent infections, systemic impact, or mortality.

Methods: ICI-RS was held in Bristol in June 2024, and Think Tank 2 aimed to define research priorities including identifying clinical predictors and developing prevention and monitoring strategies.

Results: Risk factors encompass both congenital and neurogenic lower urinary tract dysfunction, bladder outlet obstruction, vascular diseases, and inflammatory disorders, but a validated stratification risk is lacking. Reduced compliance and detrusor overactivity lead to high filling pressures and raised detrusor leak point pressure, playing urodynamic studies a crucial role in risk assessment, though further research is needed for different neurogenic populations. Congenital conditions such as spina bifida, posterior urethral valves, and bladder exstrophy also contribute to a high-risk bladder through fibrosis and reduced compliance. Inflammation and ischemia are key factors, with inflammation leading to fibrosis and impaired bladder storage and voiding function. Novel treatments, including sGC activators, PDE5 inhibitors, and regenerative therapies like stem cell injections and extracorporeal shock wave treatment, show promise in mitigating fibrosis and improving bladder compliance.

Conclusions: Identifying and validating clinical risk stratification models, precise biomarkers and therapeutic windows remains essential for effective management and reversal of bladder fibrosis and dysfunction.

Context: Lower Urinary Tract Symptoms (LUTS) are defined by their distressing effect on patients' day-to-day life. Given the pressures on secondary care resources, LUTS may be overlooked or inadequately assessed and therefore patients may be burdened for an extended period before treatment.

Methods: In a debate held at the International Consultation on Incontinence Research Society (ICI-RS) meeting in Bristol in June 2024, we considered how new technologies might contribute to an expedited, dignified and effective investigation of LUTS.

Results: We describe three broad areas where technology has a role to play: streamlining of existing investigations through mobile and miniaturized technology; entirely new investigations made possible by the technology; and advanced analytics to provide better insights from the data available.

Conclusion: We describe key research questions that will signpost us toward answering the question raised in the title.