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Ralf Böthig,1 Burkhard Domurath,2 Johannes Kutzenberger,3 Jörn Bremer,4 Ines Kurze,5 Albert Kaufmann,6 Jana Pretzer,7 Jens-Peter Klask,8 Birgitt Kowald,9 Christian Tiburtius,1 Klaus Golka,10 Sven Hirschfeld,11 Roland Thietje11 1Department of Neuro-Urology, Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Hamburg, Germany; 2Centre for Neuro-Urology, Kliniken Beelitz, Neurologische Rehabilitationsklinik, Beelitz-Heilstätten, Germany; 3Department of Neuro-Urology, Kliniken Hartenstein UKR, Bad Wildungen, Germany; 4Centre for Spinal Cord Injuries, BDH-Klinik Greifswald, Greifswald, Germany; 5Centre for Spinal Cord Injuries, Department of Paraplegiology and Neuro-Urology, Zentralklinik Bad Berka, Bad Berka, Germany; 6Department of Neuro-Urology, Kliniken Maria Hilf GmbH, Mönchengladbach, Germany; 7Department of Urology and Neuro-Urology, BG Trauma Hospital Berlin, Berlin, Germany; 8BG Trauma Hospital Duisburg, Duisburg, Germany; 9Biomechanical Laboratory, BG Klinikum Hamburg, Hamburg, Germany; 10Leibniz Research Centre for Working Environment and Human Factors at TU Dortmund(IfADo), Dortmund, Germany; 11Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Hamburg, GermanyCorrespondence: Ralf BöthigDepartment of Neuro-Urology, Centre for Spinal Cord Injuries, BG Klinikum Hamburg, Bergedorfer Str. 10, Hamburg 21033, GermanyTel +49 40 7306 2608Fax +49 40 7306 2621Email r.boethig@bgk-hamburg.dePurpose: For successful long-term rehabilitation of patients with neurogenic lower urinary tract dysfunction (NLUTD), it is necessary to define the objective requirement for urological aids based on a scientifically validated basis.Methods: This was a cross-sectional multicenter study, based on a questionnaire. Data concerning bladder management and daily consumption of urological appliances for patients with NLUTD in a community setting were collected through a standardized survey.Results: Seven hundred and sixty-seven records were analyzed: 543 males, 221 females (N/A = 3). Patients using intermittent catheterization (n= 608) required 5.06 (mean) single-use catheters per day. Out of them, 94 (15.5%) required additional pads (mean: 2.29 per day), 34 patients (5.6%) additionally used pants (mean: 2.55 per day) and 46 patients (7.6%) utilized condom catheters (mean: 3.81 per day) between catheterizations. Among all, 126 patients (16.4%) used pads (mean: 5.03 per day), and 51 patients (6.6%) used pants (mean: 3.03 per day). Women needed both pads (p

Background: In Germany about one million patients suffer from neurogenic lower urinary tract dysfunction (NLUTD). If left untreated, various forms of NLUTD can lead to secondary damage of the lower and upper urinary tract. Thus, the guideline was developed for the drug therapy of patients with NLUTD, who frequently require lifelong care and aftercare., Methods: The guideline was developed in a consensus process with several meetings and online reviews, and final recommendations were decided on in online consensus meetings. Ballots were sent to elected officials of the contributing professional societies. Level of consensus was given for each coordinated recommendation ( https://www.awmf.org/leitlinien/detail/ll/043-053.html ). RESULTS/MOST IMPORTANT RECOMMENDATIONS: (Video)urodynamic classification of the NLUTD should be conducted before the use of antimuscarinic drugs (84.2%). Approved oral antimuscarinics should be used as first choice. Contraindications must be respected (100%). If oral treatment is ineffective or in the case of adverse drug reaction (ADRs) alternatively instillation of oxybutynin solution intravesically (83%) or onabotulinumneurotoxine (OBoNT) injection should be offered (89.5%). In case of failure or ADRs of antimuscarinics, β3 sympathomimetic mirabegron can be used to treat neurogenic detrusor overactivity (NDO) (off-label use) (100%). In case of paraplegia below C8 or multiple sclerosis with an expanded disability status scale (EDSS) of ≤ 6.5, OBoNT injection can be offered as an alternative (89.5%). Drug therapy for NDO should be started early in newborns/young children (84.2%). Conservative, nondrug therapy should be considered in frail elderly (94.7%). No parasympathomimetic therapy should be used to treat neurogenic detrusor underactivity (94.7%)., Conclusion: Precise knowledge of the neurological underlying disease/sequence of trauma and the exact classification of the NLUTD are required for development of individualized therapy., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Multiple sclerosis patients often develop neurogenic lower urinary tract dysfunction with a potential risk of upper urinary tract damage. Diagnostic tools are urodynamics, bladder diary, uroflowmetry, and post-void residual, but recommendations for their use are controversial., Objective: We aimed to identify clinical parameters indicative of neurogenic lower urinary tract dysfunction in multiple sclerosis patients., Methods: 207 patients were prospectively assessed independent of the presence of lower urinary tract symptoms. We analyzed Expanded Disability Status Scale scores, uroflowmetry, post-void residual, rate of urinary tract infections, standardized voiding frequency, and voided volume in correlation with urodynamic findings., Results: We found a significant correlation between post-void residual (odds ratio (OR) 4.17, confidence interval (CI) 1.20-22.46), urinary tract infection rate (OR 3.91, CI 1.13-21.0), voided volume (OR 4.53, CI 1.85-11.99), increased standardized voiding frequency (OR 7.40, CI 2.15-39.66), and urodynamic findings indicative of neurogenic lower urinary tract dysfunction. Expanded Disability Status Scale shows no correlation. Those parameters (except post-void residual) are also associated with reduced bladder compliance, as potential risk for kidney damage., Conclusion: Therefore, bladder diary and urinary tract infection rate should be routinely assessed to identify patients who require urodynamics.

Background: In the clinical management of patients with multiple sclerosis (MS), the challenge is to make an early diagnosis and initiate adequate treatment of neurogenic disorders of the lower urinary tract (NLUTD). Various national guidelines provide practical recommendations which are sometimes discordant., Objective: To develop a simple evidence-based algorithm for detecting NLUTD in patients with MS that could be taken as a principle for deriving therapeutic consequences., Material and Methods: A prospective multicenter study was initiated as a direct result of two multidisciplinary conferences. The aim was to identify statistically and clinically relevant parameters for the routine diagnosis of NLUTD in patients with MS. Urodynamic abnormalities served as the gold standard. At three subsequent consensus conferences, the results of the study were discussed, a diagnostic algorithm was developed and consensus was reached on a first-line treatment., Results and Discussion: The proposed algorithm enables the detection of NLUTD in patients with MS with the help of four statistically significant predictors: 1) the residual urine volume, 2) the number of urinary tract infections (UTI) within the last 6 months, 3) the standardized micturition frequency and 4) the presence/absence of urinary incontinence. The newly developed algorithm has proved to be efficient with the following results: approximately 75% of the patients do not need a urodynamic examination for a first-line treatment decision. In 25% of cases, urodynamic examinations are essential for an adequate treatment decision. Routine assessments include the patient medical history, residual urine volume measurement, a micturition diary and a uroflowmetry (optional).

Background: Neurogenic lower urinary tract dysfunction (NULTD) is common in patients with multiple sclerosis (MS); nevertheless, it is often underestimated, underdiagnosed, and undertreated due to patients' sense of shame, variability of symptoms, as well as lack of communication between neurologists and urologists, despite the availability of several guidelines based on scientific evidence and expert opinion., Objective: This study was conducted to develop an easy-to-perform algorithm for diagnosing neurogenic lower urinary tract disease in patients with MS for daily neurological and urological routine, including the identification of red flags., Methods: In consensus group meetings, interprofessional experts (neurologists, urologists, neurourologists, nurses, nurse practitioners, occupational therapists, physical therapists as well as representatives of national MS centers, self-care groups, social care, residential care, and health-aid-providers) developed a diagnostic algorithm to detect NULTD in patients with MS. Subsequently, the group evaluated the algorithm in 121 patients with MS using micturition diary, post-void residual volume, uroflowmetry, and urodynamic studies. Statistical analysis was conducted on the basis of logistic regression models to compare patients with normal and abnormal urodynamic examinations. Differentiation was performed using selected diagnostic parameters as well as standard performance measures for binary classifiers to assess prognostic quality., Results: The following four parameters allowed to diagnose NLUTD in patients with MS: post-void residual urine volume, rate of urinary tract infections during the past 6 months, micturition frequency, and incontinence. According to statistical analysis, the following thresholds could be defined: post-void residual volume (PVR) ≥70 mL (Odds Ratio (OR) = 1.24; 95% CI:[1.07,1.62]), urinary tract infection (UTI) rate - none in 6 months (OR = 2.03; 95% CI:[1.04,6.68]), and micturition frequency >13/day, standardized on 2000 mL urine excretion (OR = 1.24; 95% CI:[1.07,1.49]). Uroflowmetry served as a further predictor of urodynamically measurable urinary bladder dysfunction (OR = 4.80; 95% CI: [1.41, 19.21]). Interestingly, patients without any complaints of NLUTD had an abnormal urodynamic examination in >50% of the cases. The entire algorithm has a sensitivity of 95%., Conclusions: All patients with MS should undergo a basic examination to detect NLUTDs. Within the algorithm developed in this study, four easy-to-collect parameters may reveal NLUTD in patients with MS., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Spinal cord injury (SCI) is a highly devastating injury with a variety of complications; among them are neurogenic bladder, bowel, and sexual dysfunction. We aimed to evaluate the effect of sacral anterior root stimulation with sacral deafferentation (SARS-SDAF) on neurogenic bladder and sexual dysfunction in a large well-defined spinal cord injury cohort., Methods: In the manner of cross-sectional study, subjects undergone SARS-SDAF between September 1986 and July 2011 answered a questionnaire concerning conditions before and after surgery in the department of Neuro-Urology, Bad Wildungen, Germany., Results: In total 287 of 587 subjects were analyzed. Median age was 49 years (range 19-80), median time from SCI to surgery was 10 years (range 0-49), and from surgery to follow-up 13 years (range 1-25). Of the analyzed subjects, 100% of both gender used SARS for bladder emptying. On the visual analogue scale (VAS) ranging from 0 to 10 (best), satisfaction with SARS-SDAF was 10 concerning bladder emptying, however 5 and 8 regarding sexual performance, for female and male users, respectively. Baseline and follow-up comparison showed a decline in self-intermittent catheterization (p < 0.0001), partial catheterization by attendant (p = 0.0125), complete catheterization and suprapubic catheterization (p < 0.0001), transurethral catheterization (p < 0.0011), and fewer cases of involuntary urine leakage (p < 0.0001)., Conclusions: The SARS-SDAF is a beneficial multi-potential treatment method with simultaneous positive effect on multi-organ dysfunction among SCI subjects.

Purpose: Intermittent catheterization is the recommended standard treatment for neurogenic bladder dysfunction. However, standard intermittent catheters can be unwieldy, difficult to use and carry discreetly. This can influence patient ability to perform catheterization efficiently, discreetly and privately, therefore, affecting patient quality of life. We evaluated whether the discreet design of the compact catheter would improve quality of life in intermittent catheterization users compared with standard catheters., Materials and Methods: We performed a nonblinded, randomized, multicenter, 2-way crossover study with 2 treatment periods of 6 weeks ± 3 days. A total of 125 patients with neurogenic bladder dysfunction were included in the study from 17 study sites, including 7 in France, 3 each in Germany, Denmark and Sweden, and 1 in Norway. Quality of life was evaluated by the intermittent self-catheterization questionnaire. The difference in questionnaire scores between the compact catheter and standard hydrophilic coated catheters was analyzed using a mixed linear normal model., Results: The intermittent catheterization questionnaire score increased significantly due to compact catheter use. We noted an estimated mean difference of 17.0 between the compact and standard intermittent catheters (p <0.001), corresponding to a 28% increase. The primary study results were further supported by the positive results of the secondary objective of preference, that is 63% of patients preferred the compact catheter., Conclusions: The discreet design of the compact catheter significantly improved patient quality of life related to intermittent self-catheterization., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate treatment outcomes and resource consumption of patients with neurogenic detrusor overactivity (NDO) before and after botulinum toxin A (Botox) therapy in Germany., Methods: In a multi-center, cross-sectional, retrospective cohort study, data of patients with NDO 12 months before and after the first Botox therapy were analyzed., Results: 214 patients (mean age 38 +/- 14.8 years, 145 male, 69 female) with NDO due to spinal cord injury (81%); myelomeningocele (14%), or Multiple Sclerosis (5%) from seven hospitals were included. Mean interval between treatments was 8 months. Following treatment, mean maximum detrusor pressure, maximum cystometric capacity and detrusor compliance improved significantly. Prior to Botox therapy, 68% reported urinary tract infections (UTI), 63% had incontinence episodes, and 58% used incontinence aids. These numbers decreased significantly (p < 0.05) after treatment to 28, 33, and 28%, respectively. In patients using incontinence aids, mean costs per patient decreased from 2euro to 1euro per day, whereas the mean cost of drugs to treat UTIs per patient decreased from 163euro to 80euro per year, respectively., Conclusion: This is the first study demonstrating the clinical usefulness of Botox therapy in clinical practice. Successful treatment resulted in lower costs for NDO associated morbidity due to less need for incontinence aids and UTI medication.

Objective: To compare, in a retrospective observational cohort study, the efficacy, tolerability, safety and clinical effectiveness of propiverine and oxybutynin in children and adolescents with neurogenic detrusor overactivity (NDO)., Patients and Methods: In all, 255 children and adolescents (aged 1-18 years) with NDO (199 myelomeningocele, 46 spinal cord injury, 10 other diagnoses) were enrolled at 14 study centres. To evaluate the efficacy of propiverine and oxybutynin, urodynamic and clinical variables were assessed before and after at least 12 month of the antimuscarinic agents administered at variable doses., Results: In all, 127 patients given propiverine and 128 given oxybutynin were enrolled. The primary efficacy outcome, i.e. reductions in urodynamically assessed individual maximum detrusor pressure (P(detmax)), was assumed to indicate success in 74.2% of those on propiverine vs 49.6% on oxybutynin. The mean P(detmax) was significantly reduced during treatment, from 59.8 to 36.7 cmH(2)O in the propiverine and from 65.2 to 54.9 cmH(2)O in the oxybutynin groups. The mean maximum cystometric bladder capacity increased from 146 to 242 mL in the propiverine and from 222 to 310 mL in the oxybutynin group. Propiverine was better tolerated than oxybutynin, having fewer adverse drug reactions (9.4% vs 17.2%, odds ratio 2.04), and for its severity grades and premature treatment termination (none vs 11 cases)., Conclusion: In this non-interventional study, reflecting 'real-life' clinical practice, comparing the efficacy, tolerability and safety of propiverine and oxybutynin in children and adolescents with NDO, propiverine was at least as effective as oxybutynin, but better tolerated, resulting in superior clinical effectiveness than for oxybutynin.

Introduction: Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The hyperreflexia of the detrusor and the external sphincter causes incontinence and threatens those patients with recurrent urinary tract infections (UTI), renal failure, and autonomic dysreflexia. All of these severe disturbances may be well managed by sacral deafferentation (SDAF) and implantation of an anterior root stimulator., Material and Method: Between September 1986 to December 2002, 464 paraplegic patients (220 female, 244 male) received a SDAF-SARS. Almost exclusively the SDAF was done intradurally, which means with one operation field there can be done two steps (SDAF and SARS)., Results: 440 patients have a follow-up with 6.6 years (at least > 6 months-17 years). The complete deafferentation was successful in 94.1%. A total of 420 paraplegics may use the SARS for voiding (frequency 4.7 per day) and 401 use it for defecation (frequency 4.9 per week). Continence was achieved in 364 patients (83%). UTI declined from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function presented stable. Early complications were 6 CSF leaks, 5 implant infections. Late complications with receiver or cable failures made us do surgical repairs in 34 paraplegics. A step-by-step program for trouble-shooting differentiates implant failure and myogenic or neurogenic failure., Conclusion: SDAF is able to restore the reservoir function of the urinary bladder and to achieve continence. Autonomic dysreflexia disappeared in most of the cases. By means of an accurate adjustment of stimulation parameters it is possible to accomplish low resistance micturition. The microsurgical technique requires an intensive education. One has to be able to manage late implant complications.

The clinical application of laser in urology has become possible after intensive experimental work. Because of necessary facilities and high costs connected with, the use of laser can be recommended for high specialised medical institutions. At the present time only Neodym-YAG- and Argon-laser meet all the urologic requirements. The CO2-laser is restricted for broad application. Actually tumours of the bladder, urethra, and penis are the fields for laser-application. Treatment of urethral strictures with laser-irradiation seems to be successful too. The photosensitization could being break-through in treatment of superficial tumours.

The importance of kidneys from newborn donors in transplantation has not been clearly defined. The purpose of this study was to investigate the degree of morphological and functional adaptation of the newborn kidney in an adult recipient. 7 MLS-matched kidneys from LEWE minipig puppies (age 3-4 weeks) had been transplanted en bloc to their mothers with immediately bilateral nephrectomy. Preliminary results suggested that arterial vasculature and blood supply are limiting factors in adaption of newborn donor kidneys in adult recipient.