Search

Background Failure after open ureteral reimplantation has been reported to occur in 2 to 7% of cases. While a second open reconstructive surgery is appropriate in most cases, there are data suggesting similar outcomes utilizing the laparoscopic approach. The objective of this study is to describe a modification and report our experience with laparoscopic ureteral reimplantation after failed open reimplantation reinforced with a psoas hitch. Materials and Methods A retrospective review of pediatric patients who underwent laparoscopic ureteral reimplantation after failed open surgery between September 2012 and April 2018 at three different academic centers was performed. Patient demographics, surgical indications, complications, and outcomes were reviewed. Either ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches or a cross-trigonal extravesical approach was utilized, depending on the length of the ureter. In all cases, a psoas hitch was performed to gain a longer submucosal tunnel and relieve tension, thus facilitating an efficient antireflux mechanism. Results Seventeen patients underwent a laparoscopic ureteral reimplantation after failed open surgery. Median age at second surgery was 106 months (interquartile range [IQR]: 53–122.5). Ipsilateral ureteral reimplantation with a combined intravesical and extravesical approaches was performed in 11 cases and cross-trigonal extravesical approach in 6 cases. Median ureteral diameter before the redo surgery was 16 mm (IQR: 14.5–18.5) and after surgery was 6 mm (IQR: 3.5–8.5) (p Conclusion Laparoscopic ureteral reimplantation with incorporation of a psoas hitch after failed open reimplantation is safe and effective.

Introduction Minimally invasive pyeloplasty (MIP), namely, laparoscopic and robot-assisted interventions, has gained popularity in recent years. Double-J ureteral stents are frequently inserted during surgery. Foreign bodies in the urinary tract are considered as risk factor for developing urinary tract infection (UTI). This study aimed to specify the bacteria cultured from urine and stents responsible for UTI in children with indwelling ureteral stents undergoing MIP. Patients and Methods We retrospectively reviewed medical records of 30 children (22 boys and 8 girls) who had undergone MIP between 2014 and 2017. Median age at surgery was 2.7 years (interquartile range [IQR]: 0.5–7.9). Urine cultures were obtained before surgery, before stent removal, 1 month after stent removal, and if UTI was suspected. Stents were removed 4 to 8 weeks after surgery and cultured. Patients' demographics, types of stents, and surgical details were recorded. Results Median stent indwelling time was 5.09 weeks (IQR: 4–6). Postoperative febrile UTI developed in 4/30 (13%) patients. Afebrile UTI occurred in another 4/30 (13%) patients. Stent cultures were positive in 19/30 (63%) patients. Stent and urinary cultures were identical in only one patient. Three of four patients with preoperative asymptomatic bacteriuria developed postoperative UTI. There was no association between UTI, gender, stent diameter, and duration of indwelling catheter. Conclusion After MIP, febrile UTI and afebrile UTI occurred in about one quarter of patients. Pathogens isolated postsurgically from urinary cultures were unrelated to those colonizing the stents. Therefore, routine stent culturing is of low clinical significance. Moreover, small-caliber stents and longer indwelling periods were not risk factors for UTI. Optimizing antibiotic treatment for children with preoperative UTI may potentially prevent morbidity after surgery.

Bladder outlet obstruction (BOO) in women might be associated with significant lower urinary tract storage symptoms such as increased frequency, urgency, and incontinence. This prospective study was designed to assess whether there is an objective association between BOO and abnormal parameters during filling cystometry in women. A total of 169 consecutive women (mean age 56 ± 14 years) who were referred for urodynamic investigation were prospectively recruited. Comprehensive medical, obstetric, and gynecological histories were recorded. All patients underwent physical examination, renal and bladder ultrasound, and filled out the International Prostate Symptoms Score (IPSS) questionnaire. The cohort was divided into obstructed and un-obstructed groups based on pressure flow results (Obstruction: Qmax 25 cmH2O). There was no significant difference in the frequency of detrusor overactivity between the obstructed and non-obstructed group (37% vs 32%, p = 0.71). All bladder sensation volumes were significantly lower in obstructed women than non-obstructed women in univariate and multivariate logistic regression analyses. Of the sensation parameters, first desire to void (FDV) had the highest area under the curve (AUC = 0.75, 95% CI = 0.672–0.837, p

Objective Higher serum alkaline phosphatase (sALP) levels associate with a poor prognosis in maintenance hemodialysis patients. However, little is known about the meaning of lower sALP in this population. We hypothesized that lower sALP concentrations may express nutritional status and survival accordingly. Methods A retrospective, longitudinal cohort study of a clinical database containing the medical records of 554 patients (367 men and 187 women, mean age 67.6 ± 14.2 years) receiving maintenance hemodialysis from November 2007 to July 2018 in a single center was conducted. sALP, nutritional, bone turnover, and inflammatory marker levels were recorded at 0, 6, 12, 18, 24, 30,and 36 months followed by 58 additional months of clinical observations. Results The median sALP level was 90.0 (71.0-125.8) U/L. In a linear mixed effects model adjusted for baseline demographics and clinical parameters, each 1.0 U/L increase above the mean sALP at baseline was associated with 0.7% slower rate of decline in geriatric nutritional risk index per 3 years (P = .02 for sALP × time interaction). sALP remained associated with the rate of change in geriatric nutritional risk index, even after controlling for C-reactive protein and intact parathyroid hormone levels. For each 1.0 U/L increase in sALP over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 0.996 (95% confidence interval 0.993-1.000, P = .04). Conclusions Increasing longitudinal levels of sALP associate with improved nutritional status and lower mortality rates. sALP can be used as an integrated marker, combining the properties of the nutritional marker, the marker of mineral-bone disease and inflammation, according to its levels.

Objective: The aim of this study was to assess whether there is an objective association between bladder outlet obstruction (BOO) and abnormal sensation parameters during filling cystometry in men. Methods: This was a prospective study. Consecutive patients referred for urodynamic examination were assessed for eligibility. Patients with permanent catheters, BPH related surgery, neurologic disease, or inability to complete the urodynamic study were excluded. All patients underwent full physical examination, as well as renal and bladder ultrasound including prostate size estimation, post void residual volume, and PSA, and they completed the International Prostate Symptoms Score (IPSS) questionnaire. The cohort was divided into obstructed and un-obstructed groups according to the Bladder Outlet Obstruction Index. Results: Ninety of the 115 patients recruited were obstructed (78%). Obstructed patients had significantly higher PSA, larger prostate volume, and higher IPSS. Detrusor overactivity did not differ between the two groups (45.6% vs. 48.1%, p = 0.83). First, normal, strong, and urgent desires to void were significantly lower in obstructed men: median (IQR) 118 (57–128) vs. 180 (80–200), 171 (85–257) vs. 227 (125–350), 221 (150–383) vs. 307 (180–477), and 276 (197–480) vs. 344 (280–535), respectively. First desire to void (FDV) had the highest area under the curve (AUC = 0.83, 95% CI = 0.76–0.90, p < 0.001) for predicting BOO with a Youden index of 0.78 at 140 mL. Conclusions: Our results suggest that there is a strong association between bladder oversensitivity and BOO in men. Men with FDV

Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure.Seven group prospective, randomized controlled study: groups 1-3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4-6 as in 1-3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0-10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation.Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared.Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.

Objective: To review and compare robotic ipsilateral uretero-ureterostomy (RIUU) and laparoscopic ipsilateral uretero-ureterostomy (LIUU) in terms of safety, efficacy, and outcomes. Materials and methods: A retrospective chart review, including all pediatric patients who underwent RIUU and LIUU at 5 different medical centers, between 2015 and 2019, was performed. Patient's demographics, perioperative data, surgical techniques, complications, and results were compared. Results: The study included 66 pediatric patients, 22 RIUU and 44 LIUU. Median age at surgery was 12 month (IQR 7–52) and median weight was 12 kg (IQR 9–16). Upper to lower IUU was performed in 55 cases and lower to upper IUU in 11 cases. Median operative times for RIUU and LIUU were 90 min (IQR 75–97.5) and 112.5 min (IQR 81.5–121.25), respectively (p = 0.034). Clavien-Dindo grade 3 postoperative complications occurred in two LIUU patients. One patient underwent an ancillary procedure with laparoscopic distal ureteral stump removal. All patients had resolution of symptoms and improvement in hydronephrosis or a non-obstructed curve on MAG3 diuretic renal scan. Conclusion: RIUU and LIUU are both safe and effective minimally invasive approaches for duplex upper urinary tract anomalies in the pediatric population. RIUU demonstrated shorter operating times .

Purpose: We present a multi-institution experience of laparoscopic and robotic-assisted reconstruction approach of lower-pole UPJO (ureteropelvic junction obstruction) in duplicated collecting systems. Methods: Retrospective review of patients who underwent laparoscopic or robotic pyeloplasty for lower pole UPJO between 2011 and 2020. Patient demographics, perioperative surgical data, complications and outcomes are described. Surgical approach was adjusted to the anatomic variant. Success was defined as improved hydronephrosis, indicated by improved Society of Fetal Urology classification at 9 months follow up. Results: Forty-one patients underwent MIS reconstruction surgery of lower pole UPJO (38- laparoscopy, 3- robot assisted). Median age at surgery was 13 months (IQR, 5–32). Mean operative time was 80 min (IQR, 70–110). There were no intraoperative complications, no conversions and estimated blood loss was negligible. Lower pole dismembered pyeloplasty was performed in 19 (46%) patients, uretero-pyelostomy (lower pole pelvis to upper pole ureter) in 15 (36.5%), concomitant obstruction of the upper pole moiety was encountered in 4 (10%) patients; lower pole dismembered pyeloplasty and upper pole ureter to lower pole pelvis (end-to-side uretero-pyelostomy) was performed and concomitant ipsilateral upper pole partial nephrectomy was carried out in 3 (7%) patients. Overall, 3 patients had grade 1 or 2 Clavien-Dindo postoperative complications and one patient developed a grade 3 complication. Surgical success was achieved in 38/41 (93%), 3 patients required an additional procedure. Conclusions: UPJO of lower pole of duplication anomaly is highly variable anatomically; therefore, an individualized surgical approach is mandatory. The minimal invasive approach is feasible and safe with good outcomes.

To compare 2 minimally invasive surgical options for the treatment of obstructed megaureter: robot assisted dismembered extravesical cross-trigonal ureteral reimplantation (RADECUR) and laparoscopic dismembered extravesical cross-trigonal ureteral reimplantation (LDECUR).A 2 arm retrospective comparative study, including all pediatric patients who underwent ureteral reimplantation of unilateral obstructed megaureter, either by RADECUR or LDECUR. Patient demographics, perioperative surgical data, complications, and results are described. The surgical technique in both arms was similar: dismembering of the ureter, performing an extravesical cross-trigonal detrusorotomy, and intracorporeal tailoring of the ureter when indicated, were the pivotal maneuvers utilized.The study included 95 patients (48 and 47 in the RADECUR and LDECUR arms, respectively) operated between the years 2016 and 2019. Overall, median age at surgery was 24 months (IQR 12-48) and median weight was 14 kg (IQR 11-21). Median operative time was 93 minutes (IQR 90-120) for RADECUR and 130 minutes (IQR 105-160) for LDECUR (P0.001). Intracorporeal excisional tapering was performed in 11 of the RADECUR patients and 19 LDECUR patients. Grade 1-2 Clavien-Dindo complications occurred in 7 patients, and grade 3 complication in 1 patient in the RADECUR arm. In the LDECUR arm, grade 1-2 complications occurred in 2 patients, and 2 had a grade 3 complications. Surgical success was achieved in 97% and 94% in the RADECUR and LDECUR groups, respectively.Unilateral robotic extravesical cross-trigonal ureteral re-implantation for treatment of obstructed megaureter in the pediatric population is safe and effective both for RADECUR and LDECUR. Operative time is significantly shorter for RADECUR.

The aims of this study were to describe a novel technique for transvaginal repair of large (> 4 cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up. The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4 cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture. All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4 years yielded no recurrence and no other late complications. Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

Objective To evaluate whether anesthesia of the meatal orifice reduces pain during cystoscopy in women, known to cause significant pain, discomfort and anxiety in women. Secondary end-point was to compare pain between rigid and flexible cystoscopy. Methods A total of 120 women, median age 66 (interquartile range 57-69), referred for office cystoscopy were prospectively randomized into 2 groups according to meatal orifice exposure: (1) 5-minute meatus exposure with 2% lidocaine gel; (2) 5-minute meatal exposure with water soluble gel. In each group a pad soaked by the gel was externally placed on the meatal orifice. Each group was further divided to flexible or rigid cystoscopy. Exclusion criteria included urethral stricture, urinary tract infection, chronic pain disease (e.g., IC/PBS), neurogenic disorder, allergy to lubricant, and concurrent pain medication. In all patients, a water-based lubricant applied on the cystoscope, was used for lubrication. A 0-10 visual analogue scale was performed at 4 checkpoints: before examination, immediately following urethral penetration, immediately at end of procedure and 15 minutes after completion Results Study groups did not significantly differ in clinical or demographic parameters. Pain level prior to procedure was 0 in all patients. Mean visual analogue scale immediately after urethral penetration was 4.2 ± 2.3 in both groups 1 and 2 (P= 1). No significant differences in other checkpoints was reported. Further subanalysis by cystoscope type did not demonstrate significance. Conclusion Meatal analgesia does not increase tolerance to cystoscopy in females. Pain level is not reduced by the use of flexible cystoscope in the female population.

Background/Aims: Residual kidney function (RKF) is a pivotal predictor of better clinical outcomes in maintenance hemodialysis (MHD) patients. So far there has been no attempt to use bioimpedance analysis (BIA) measurements to calculate residual glomerular filtration rate (GFR) in dialysis population. We hypothesized that performing of multi-frequency BIA at the beginning and end of hemodialysis session can enable us to predict the measured residual GFR in MHD patients. Thus our aim was to develop and validate a new RKF prediction equation using multi-frequency BIA in MHD patients. Methods: It was diagnostic test evaluation study in a prospective cohort. Participants (n=88; mean age, 66.3±13.2 years, 59.1% males) were recruited from a single hemodialysis center. A new equation (eGFRBIA) to predict RKF, utilizing BIA measurements performed pre- and post-dialysis, was generated and cross-validated by the leave-one-out procedure. GFR estimated as the mean of urea and creatinine clearance (mGFR) using urine collections during entire interdialytic period. Results: A prediction equation for mGFR that includes both pre- and post-dialysis BIA measurements provided a better estimate than either pre- or post-dialysis measurements alone. Mean bias between predicted and measured GFR was -0.12 ml/min. Passing and Bablok regression showed no bias and no significant deviation in linearity. Concordance correlation coefficient indicated good agreement between the eGFRBIA and mGFR (0.75, P2 ml/min/1.73 m2 yielded an area under curve of 0.96, sensitivity 85%, and specificity 89% in predicting mGFR. The κ scores for intraobserver reproducibility were consistent with substantial agreement between first and second estimation of RKF according to eGFRBIA (weighted κ was 0.60 [0.37-0.83]). Conclusion: We present a valid and clinically obtainable method to predict RKF in MHD patients. This method, which uses BIA, may prove as accurate, convenient and easily reproducible while it is operator independent.

Background: Recent experimental studies have suggested that obestatin, a proposed anorexigenic gut hormone and a physiological opponent of acyl-ghrelin, has protective cardiovascular effects. We tested the hypothesis that obestatin is independent of inflammatory mediators and/or acyl-ghrelin in predicting outcomes of the maintenance hemodialysis (MHD) population. Methods: It was a 6-year cohort study on 261 MHD patients. Obestatin, acyl-ghrelin, adipokines (leptin and adiponectin), markers of inflammation and nutrition, prospective all-cause and cardiovascular mortality were studied. Results: During the follow-up, 160 patients died in total, with 74 deaths due to cardiovascular causes. For each ng/mL increase in baseline obestatin level in fully adjusted models (including malnutrition-inflammation score, Interleukin-6 [IL-6], adipokines and acyl-ghrelin), the hazard for death from all causes was 0.90 (95% CI 0.81–0.99) and for cardiovascular death 0.85 (95% CI 0.73–0.99). However, these associations were more robust in the subgroup of patients aged above 71 years: 0.85 (95% CI 0.73–0.98) for all-cause death and 0.66 (95% CI 0.52–0.85) for cardiovascular death. An interaction between high IL-6 (above median) and low obestatin (below median) levels for increased risk of all-cause mortality (synergy index [SI] 5.14, p = 0.001) and cardiovascular mortality (SI 4.81, p = 0.02) emerged in the development of multivariable adjusted models. Interactions were also observed between obestatin, Tumor necrosis factor-alpha, adipokines and acyl-ghrelin, which were associated with mortality risk. Conclusion: Serum obestatin behaves as a biomarker for cardiovascular and all-cause mortality in MHD patients. The prognostic ability of obestatin in this regard is independent of inflammation, nutritional status, acyl-ghrelin’s and adipokines’ activity and is modified by age being very prominent in patients older than 71 years.

Introduction The significance of asymptomatic bacteriuria in maintenance hemodialysis (MHD) patients remains controversial. We hypothesized that the presence of asymptomatic bacteriuria as a sole clinical manifestation of urinary tract infection (UTI) in asymptomatic MHD patient may contribute to the chronic inflammatory response. Our aim was to explore the relationship between asymptomatic bacteriuria and elevated levels of inflammatory markers in MHD patients. Methods A randomized open-label single center study of 114 MHD patients was conducted. Forty-six patients presented negative urine culture and 41 subjects were excluded due to different reasons. The remaining 27 patients (mean age of 71.5 ± 12.2 years, 63% men), fulfilling the criteria for having asymptomatic bacteriuria, were randomly assigned to either the treatment group (13 patients) or the observational group (14 subjects). The treatment group received 7 days of antibiotic treatment given according to bacteriogram sensitivity. After 3 months of follow-up all measurements of the study were repeated. The primary end point was change in inflammatory biomarkers from baseline by the end of the study. Findings There were no statistically significant differences in white blood cell changes (P = 0.27), ferritin (P = 0.09), C-reactive protein (P = 0.90), and interleukin-6 (P = 0.14) levels between the groups from baseline to the end of study or at the end of the study. Analyzing cross-sectional data, asymptomatic bacteriuria was found to not be a predictor of higher levels of inflammatory parameters at baseline. Discussion Asymptomatic bacteriuria is not a modifiable risk factor for chronic inflammation in the MHD population.

To assess whether urethral pain during male catheterization can be reduced if the patient is instructed to void during the insertion of the catheter.Ninety-six males (age 66 ± 13) who were referred for multichannel urodynamic study were prospectively randomized to 2 groups according to the catheter insertion technique: (1) patients who were instructed to void during catheterization, and (2) patients who had no guidance prior or during catheterization. Exclusion criteria were the following: use of analgesics within the previous 24 hours, active urinary tract infection, indwelling urethral catheter, pre-existing urethral pain, and known urethral stricture or inability to cooperate with pain assessment due to mental disorders. A 0 to 10 visual analog pain scale was filled in different time points: prior and immediately after instillation of the lubricant gel into the urethra, immediately after the insertion of the catheter, and 15 minutes after the test.Study groups did not differ in terms of demographic, clinical, and urodynamic parameters. The median visual analog pain scale during catheterization was 2 (interquartile range 1-3) and 4 (interquartile range 3-5) in groups 1 and 2, respectively (P .001). There were no differences in the reported scores in the other checkpoints.Pain level during urethral cauterization in males can be significantly reduced when the patient is instructed to void during the insertion of the catheter into the urethra.

The neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios have been proposed as emerging markers of inflammation and prognosis in maintenance hemodialysis (MHD) patients. However, to date, no longitudinal performance of these indices is known. The study’s purpose was to examine the longitudinal relationship between NLR, PLR, inflammatory and nutritional parameters in MHD patients and how their changes over time associate with adverse clinical outcomes. A historical longitudinal cohort study was conducted using a clinical database which included 554 patients (mean age, 67.6 ± 14.2 years; 34% women) from a single center receiving MHD from November 2007 to July 2018. NLR, PLR, C-reactive protein (CRP) and nutritional parameters were recorded at 0, 6, 12, 18, 24, 30 and 36 months, followed by 58 additional months of clinical observations. In a linear mixed-effects model adjusted for baseline demographics and clinical parameters, including white blood cell count, NLR and PLR were both associated with CRP levels at any given time point observation (linear estimates (95% CI): 1.53, (0.11–2.95) and 1.55 (0.15–2.93), respectively). For each 1.0-unit increase in NLR over time, the fully adjusted all-cause mortality hazard ratio using Cox models with the time-varying risk effect was 1.04 (95% CI 1.01–1.07, P = 0.006). However, when CRP was included in this model, the relationship was no longer significant. PLR’s performance did not match the prognostic marker. Longitudinal changes in NLR mimic CRP changes and predict all-cause mortality risk in MHD patients.

Summary Background Obestatin, a physiological opponent of acylated ghrelin, is linked to appetite suppression regulation in mice but its anorexigenic properties in humans are controversial. We aimed to investigate obestatin's potential role in dietary intake regulation by examining response to a meal in maintenance hemodialysis (MHD) patients. Methods In this prospective observational case series study, we investigated the response of obestatin to a fixed calorie meal (500 kcal) in 21 MHD patients (age 69.2 ± 13.1 years, 10 women, with a body mass index 27.2 ± 5.5 kg/m2). Parallel changes in serum obestatin and insulin levels and subjective scores of appetite (visual analogue scales for hunger, satiety, fullness and prospective food consumption) were recorded on fasting and 30, 60 and 120 min after the meal. Results In a linear mixed effects model controlling for baseline demographics and clinical parameters including serum insulin concentrations, postprandial levels of obestatin did not change significantly from baseline in response to the meal. The response was the same in MHD patients treated with high- or low-flux dialyzers. However, postprandial obestatin levels were associated with the rate of change in sensation of fullness (linear estimate: 11.60 (95% confidence interval 0.17 to 23.04, P Conclusions Obestatin levels do not change acutely with food administration in MHD patients, but associate with the changes in sensation of fullness. This supports the possible role of obestatin in the long-term regulation of appetite in MHD patients.

The geriatric nutritional risk index (GNRI) has been reported as a useful predictor of prognosis in maintenance hemodialysis (MHD) patients, demonstrating GNRI less than 90 as a marker of a poorer nutritional status and significantly increased mortality. We tested whether GNRI as a whole associated stronger with clinical and laboratory surrogates of nutrition and inflammation, muscle function, health-related quality of life (QoL), and predicts all-cause and cardiovascular (CV) morbidity and mortality in this population better than its individual components (albumin and body weight to ideal body weight ratio).A prospective observational study with a median follow-up of 30 months (interquartile range - 19-41 months) was performed on 352 MHD outpatients (38.0% women) with a mean age of 67.4 ± 13.2 years. All-cause and cardiovascular hospitalization and mortality, GNRI, handgrip strength (HGS), body composition parameters (anthropometry and bioimpedance) and short form 36 (SF-36) quality-of-life scores were measured. Multivariate linear regression analyses were performed to obtain adjusted correlations. Receiver operating characteristic (ROC) curves were generated and multivariate Cox proportional hazards models were applied to identify the predictive value of GNRI and its components separately.GNRI positively correlated with total score (r = 0.15, P 0.05), the physical health dimension (r = 0.14, P 0.05), the general health (r = 0.18, P 0.01) and some other scales of the SF-36. A significant correlation of GNRI with HGS in male patients didn't stand up to multivariable adjustments. For each one unit increase in baseline GNRI levels, the first hospitalization hazard ratio (HR) after adjustments for confounders was 0.98 (95% confidence interval (CI), 0.97 to 0.99) and the first CV event HR was 0.98 (95% CI, 0.97 to 0.99); all-cause death HR was 0.97 (95% CI, 0.96 to 0.99) and CV death HR was 0.97 (95% CI, 0.95-0.99). Albumin was related to QoL and clinical outcomes with higher strength and magnitude than GNRI.Despite the significant relationship with clinical outcomes and QOL, GNRI is not better and is even slightly worse than albumin's performance. This raises doubts as to the clinical utility of GNRI as a prognostic tool in the MHD population.

Aims We investigated the 4-year outcomes of three protocols of pelvic floor physical therapy and anticholinergic drug in women with wet over-active bladder (OAB). Methods One hundred and sixty-four women were randomly allocated to one of four interventions: drug therapy (DT), bladder training (BT), pelvic floor muscle training (PFMT), or combined pelvic floor rehabilitation (CPFR) that includes BT, PFMT, and behavioral advice. The active treatment in each group lasted 3 months. Of the 132 women who completed a 1-year follow-up, 120 women (90%) responded to our questionnaires and therefore were included in this study. Outcome measures were the number of voids per day, number of urgency urinary incontinence (UUI) episodes per week, completely dry rate and Incontinence Quality of Life questionnaire (I-QOL) at 4 years. Results After 4 years of follow-up, the outcome measures improved significantly and equally in all four groups. The median number of UUI episodes/week dropped by 3, 1, 2, and 2 in the DT, BT, PFMT, and CPFR groups, respectively (P = ns). The dry rates were 25%, 31%, 44%, 34% in the DT, BT, PFMT, and CPFR groups, respectively (P = ns). I-QOL scores improved significantly in all four groups. Conclusions Women who suffer from wet-OAB may experience the same degree of long-term improvement following various pelvic floor physical therapy protocols as they would from drug therapy. Neurourol. Urodynam. © 2016 Wiley Periodicals, Inc.

The potential side effects of common phosphate binders are gastrointestinal in practice. We hypothesized that regular use of phosphate binders may be associated with decreased appetite, dietary intake and consequently, poor nutritional status.This was cross-sectional study of 78 patients (mean age 67.5±13.0, 34.6% women) undergoing maintenance hemodialysis (MHD) treatment. Participants were divided into three equal groups - sevelamer (n=25), lanthanum (n=24) and the control group (n=29). Eating motivation was assessed using visual analogue scales (VAS) and by a self-reported appetite assessment which was graded on a 5-point Likert scale. Main outcome measure was differences in VAS scores for appetite, dietary intake and nutritional status (malnutrition-inflammation score [MIS]) in the study groups.Appetite, dietary intake, biochemical nutritional markers, anthropometric measures and MIS were similar in the three groups. A statistically significant difference was observed in sensation of fullness between the groups: multivariable adjusted ORs in the sevelamer carbonate group was 4.90 (95% CI: 1.12 to 21.43), p=0.04 and in the lanthanum carbonate group was 5.18 (95% CI: 1.15 to 23.30), p=0.03 versus the control group. However, no linear association was observed between MIS scores and VAS scores for appetite in any study group.Regular use of these phosphate binders was not associated with anorexia, decreased dietary intake and nutritional status in the study population. Therefore, there is no preference in the choice of phosphate binders in MHD patients with hyperphosphatemia, even those who are at nutritional risk.

The biological basis of abdominal obesity leading to more severe outcomes in patients with normal body mass index (BMI) on maintenance hemodialysis (MHD) is unclear. The aim of this study was to compare the properties of abdominal obesity in different BMI categories of patients on MHD.We performed a cross-sectional study of 188 MHD patients (52.7% women; mean age, 69.4 ± 11.5 y) with abdominal obesity in different BMI groups using criteria from the World Health Organization. Appetite and dietary intake, body composition, handgrip strength, malnutrition inflammation score (MIS), inflammatory biomarkers, adipokines, and health-related quality-of-life (QoL) questionnaires were studied.According to multivariable analyses, abdominally obese patients with normal BMIs consumed less protein per day (P = 0.04); had lower measurements of surrogates of lean (P0.001) and fat mass (P0.001); and had higher total cholesterol, tumor necrosis factor-α (P0.05), and ratios of adiponectin to leptin (P = 0.003) than overweight and obese patients with abdominal obesity. Multivariable analyses showed no differences in handgrip strength among the study groups.The abdominally obese study participants with normal weight had significantly lower scores in role physical (P = 0.003) and pain (P = 0.04) scales after multivariable adjustments.Normal-weight MHD patients with abdominal obesity exhibited a more proatherogenic profile in terms of inflammatory markers and adipokine expression, lower body composition reserves, and lower physical ability than patients with abdominal obesity with overweight and obesity. This at least partially explains the abdominal obesity paradox in the MHD population in which worse clinical outcomes are seen in abdominally obese patients with normal BMIs, as opposed to overweight and obese patients who are also abdominally obese.

A position paper presents the standpoint of the Israeli Urological Association on clean intermittent catheterization (CIC) for all physicians and nurses. The position paper is based on international guidelines and professional literature and is adapted to medical activities in Israel. CIC is indicated for the treatment of temporary/permanent disability in the emptying of the bladder, which is expressed by large post-voided urine/urine retention and related complications. There are a few contra-indications for CIC (low bladder volume or compliance, pressure sores/external infection of the urethra, anatomical, functional or cognitive disorder that does not allow to perform CIC, recurrent macrohematuria or urethrorrhagia, urethral pain that does not allow frequent catheterization, patient unwillingness to perform CIC by himself or by another person). There are alternatives to performing CIC permanent urethral or suprapubic catheter, urinary tract diversion, sphincterotomy. Before starting to perform CIC, the patient should be verified as being able to perform CIC and adhere to a predetermined schedule. It is recommended to perform the CIC at regular intervals during the day. During training and early stages of the CIC, it is recommended to catheter every 4-6 hours to assess bladder volume at these time intervals (urinary volume per catheterization). It is recommended to record drinking volumes, voiding volumes, and catheterization volumes for adjusting and timing the CIC. In order to determine the right number of catheterizations, several factors should be taken into account, such as the patient's ability to void, bladder capacity, and various urodynamic variables. In some cases additional therapy might be administered to reduce bladder pressure. If a patient cannot perform CIC on his own, a caregiver or a family member may be instructed to perform the procedure. The Committee described the methods and techniques to perform CIC and described possible complications (although rare) such as urinary tract infections (UTI), urethral and/or bladder damage, and the difference between a condition of asymptomatic bacteriuria and UTI. The Committee recommends that preventive antibiotic treatment should not be given to CIC patients. Antibiotic treatment should be given only in the case of UTI. The Committee recommends active participation of medical, nursing, social workers, family members and direct caregivers to improve the quality of life of CIC patients. Long-term follow-up is needed to diagnose and prevent complications of CIC/underlying disease leading to CIC. Different follow-up tests should be performed based on underlying disease, complications or changes in patient symptoms. The Committee described different types of catheters and recommends that the use of single-use catheters is preferable. Pre-shielding should be used before using the catheters without external coating.

Urethral lubrication during catheterization can be performed by instilling the gel directly in the urethra or by pouring the gel on the catheter tip. In this study we compared the pain level associated with each technique during female urethral catheterization in the setup of a multichannel urodynamic study.A total of 94 women with a mean ± SD age of 55 ± 14 years who were referred for a multichannel urodynamic study were prospectively randomized into 2 groups according to lubrication technique, including 1) instillation of 5 ml 2% lidocaine gel in the urethra 5 minutes before catheterization or 2) lubrication of the distal part of the catheter with 5 ml 2% lidocaine gel. A visual analog pain scale of 0 to 10 was completed at different time points, including prior to gel instillation (baseline), during gel instillation (group 1), during catheterization, and 5 and 30 minutes after the procedure ended.The study groups did not differ in demographic, clinical or urodynamic parameters. The mean visual analog scale score during catheterization was 2.3 ± 1.4 and 2.4 ± 1.6 in groups 1 and 2, respectively (p = 0.71). There was no difference in the reported visual analog scale score at the other checkpoints. The mean recorded visual analog scale score during instillation of the lubricant in the urethra in group 1 was 1.9 ± 0.9.The actual act of lubricant instillation in the urethra during catheterization in women causes additional and unnecessary pain. Therefore, it is not recommended. Other than that there is no difference in the urethral pain level between the 2 lubrication techniques.

Aims To find out if information leaflets reduce anxiety levels before urodynamic studies (UDS). Methods One hundred and four patients (age 60 ± 15 years) who were referred for multichannel UDS were prospectively recruited and randomized into 2 groups: (1) received a leaflet containing detailed information regarding the examination; (2) did not receive a leaflet. Patients who were unable to complete the questionnaire due to mental disorders and patients who had previously undergone UDS were excluded. The leaflets were mailed to the patients in group 1 one month before the examination. This leaflet included information on how the examination would be performed, its purpose, recommended preparation, potential complications, and common events that might occur in association with the examination, such as incontinence. Emotional distress was measured by the State Anxiety Inventory (SAI)—a validated questionnaire composed of 20 items measuring anxiety. These measures are divided into two psychological domains: (1) positive well being; (2) psychological distress. Patients filled out the SAI immediately before entering the examination room. Results Demographics and clinical and psychological co-morbidities were similar between the groups. The “psychological distress“ score was significantly lower in group 1 (13.1 ± 2.9 vs. 24.8 ± 5.8, P

Pelvic organ prolapse (POP) among young women is a relatively rare disorder with a unique clinical background. The objective of our study was to investigate the relative risk factors for POP and the relationship between family history and POP development in young women.In a retrospective longitudinal study we investigated 26 young patients (age45 years) who underwent POP surgery and compared them to a control group of 26 patients (age55 years) who underwent similar surgery and were matched with regard to parity. All women were interviewed for family history of POP, POP surgery among first-degree relatives, and hernia repair.Family history of POP was five times more prevalent among women in the study group than in the control group (46 % vs. 8 %, P 0.01). Moreover, POP surgery among the first-degree relatives was significantly more prevalent in the study group (23.1 % vs. 3.8 %, p 0.05). The prevalence of a family history of POP in more than one first-degree relative (11.5 % vs. 3.84 %, p = 0.3) and the family history of hernia repair among first-degree relatives (11.5 % vs. 15.4 %) did not differ between the groups.A family history of POP is significantly more common in younger affected women than in older affected women. We suggest that future genetic studies should concentrate on this specific population.

Objective To assess the feasibility and the safety of a mixture instillation of TC-3 gel, a novel reverse-thermal gelation hydrogel, and botulinum toxin-A (BTX-A) for the treatment of interstitial cystitis-bladder pain syndrome (IC/BPS). TC-3 gel-BTX-A mix is instilled into the bladder as liquid, solidifies because of body heat, and gradually dissolves to release BTX-A for several hours. Methods A single intravesical instillation of 200 U BTX-A premixed with 40 mL TC-3 gel was delivered to the bladder. Adverse events and preliminary efficacy outcome measures were assessed: bladder diary, visual analog scale (VAS) for pain, and Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ICPI) at baseline and at 2, 6, and 12 weeks. Results A total of 15 severely symptomatic patients with IC/BPS (ICSI and ICPI score ranges 12-19 and 12-16, respectively; median VAS = 7) were enrolled (male and female = 4 and 11, ages 24-76). In terms of safety, no increase in VAS score was noted at instillation. All adverse events were transient and mild, the most common being temporary mild constipation (n = 4, 26%). The mean VAS at baseline vs week 12 was 6.6 ± 2.7 vs 5.3 ± 2.8 (P = .044). The mean ICSI and ICPI scores were reduced at week 12 compared with baseline (15.4 ± 2.4 vs 12.9 ± 4.3, P = .004, and 14.8 ± 1.4 vs 11.9 ± 4.0, P = .004, respectively). The mean number of voids per night at baseline decreased for 6 weeks (3.3 ± 2.1 vs 1.8 ± 0.9, P = .046) and then returned to baseline level at week 12. Conclusion Intravesical instillation of a TC-3 gel-BTX-A mixture is safe and tolerable. Preliminary results suggest temporary efficacy lasting for a few weeks.

Bothersome urinary symptoms during the storage phase are common among women and men. These symptoms described as urinary urgency, frequency and nocturia with or without urge urinary incontinence may be caused by various pathologies including bladder overactivity. Diagnosis of an overactive bladder is based on the patient's clinical presentation after exclusion of other disorders that may cause these symptoms. The minimal requirements for a urological evaluation include medical history, physical examination and urinalysis. Behavioral therapies and medical therapy are the mainstay of treatment for an overactive bladder. While the use of minimally invasive procedures are reserved for patients not interested in medications or for those patients in whom symptoms were not improved by other therapies. Treatment outcome is evaluated by documentation of changes in symptoms, signs and quality of life. This position statement paper represents the approach of the Israeli Urological Association regarding the evaluation and treatment of overactive bladder syndrome.

The significance of asymptomatic bacteriuria in maintenance hemodialysis (MHD) patients remains controversial. We hypothesized that the presence of asymptomatic bacteriuria as a sole clinical manifestation of urinary tract infection (UTI) in asymptomatic MHD patient may contribute to the chronic inflammatory response. Our aim was to explore the relationship between asymptomatic bacteriuria and elevated levels of inflammatory markers in MHD patients.A randomized open-label single center study of 114 MHD patients was conducted. Forty-six patients presented negative urine culture and 41 subjects were excluded due to different reasons. The remaining 27 patients (mean age of 71.5 ± 12.2 years, 63% men), fulfilling the criteria for having asymptomatic bacteriuria, were randomly assigned to either the treatment group (13 patients) or the observational group (14 subjects). The treatment group received 7 days of antibiotic treatment given according to bacteriogram sensitivity. After 3 months of follow-up all measurements of the study were repeated. The primary end point was change in inflammatory biomarkers from baseline by the end of the study.There were no statistically significant differences in white blood cell changes (P = 0.27), ferritin (P = 0.09), C-reactive protein (P = 0.90), and interleukin-6 (P = 0.14) levels between the groups from baseline to the end of study or at the end of the study. Analyzing cross-sectional data, asymptomatic bacteriuria was found to not be a predictor of higher levels of inflammatory parameters at baseline.Asymptomatic bacteriuria is not a modifiable risk factor for chronic inflammation in the MHD population.

Aims To compare the pain perception between intraurethral instillation of 2% lidocaine gel and liquid paraffin during Urodynamic study in men. Methods A randomized, single-blind comparison trial was conducted. Forty men scheduled to undergo multichannel Urodynamic study were randomized to receive either 10 ml of 2% lidocaine gel (group 1, n = 20) or 10 ml of liquid paraffin (group 2, n = 20). Patients recorded their pain on a 0–10 visual analog scale prior to lubricant instillation, immediately after lubricant instillation, after the introduction of the Urodynamic catheter, 5 and 30 min after the catheter was taken out. Results pain scores were significantly higher in group 1 compared to group 2 immediately after the instillation of the lubricants (4.2 ± 1.5 vs. 2.6 ± 0.9, P

Aims To estimate the effect of plantar-flexion on the wave amplitude of involuntary detrusor contraction and the severity of urinary urgency during filling cystometry in patients with detrusor overactivity (DO). Methods Twenty-two consecutive patients with DO were enrolled. During urodynamics, the mean peak detrusor pressures of each contraction were documented and compared. At the beginning of the 2nd or 3rd wave, patients were asked to perform continuous plantar-flexion by pushing their tiptoes against the floor. Following each wave, patients were asked to grade the severity of the urgency by a visual analogue scale (VAS). Results The mean peak detrusor pressure without plantar-flexion was 58 cmH2O (95% CI: 46.3–69.7) compared to 31 cmH2O (95% CI: 23.1–38.9) with plantar-flexion (P

We compared symptoms in women with detrusor overactivity with impaired contractility and women with detrusor overactivity who had preserved contractility.The study included 359 consecutive women with detrusor overactivity who underwent multichannel urodynamics at our department between 2009 and 2011. The women were divided into 2 groups, including 151 (42%) with detrusor overactivity and impaired contractility, and 208 (58%) with detrusor overactivity and preserved contractility. We compared the 2 groups.Women with detrusor overactivity and impaired contractility were older (mean ± SD age 73.2 ± 17.3 vs 54.1 ± 20.7 years) with a higher frequency of diabetes mellitus (49% vs 31%, each p0.001). The prevalence of previous urinary retention and recurrent cystitis was significantly higher in women with impaired contractility (7% vs 1%, p0.01 and 22% vs 7%, p0.001, respectively). Mean post-void residual urine was greater in the group with impaired contractility (89 ± 42 vs 21 ± 18 ml) and the mean maximal flow rate was lower (11 ± 6 vs 23 ± 5 ml per second, each p0.001). The frequency of storage symptoms was similar in the 2 groups. However, voiding symptoms were more common in women with impaired contractility, including a slow stream in 69% vs 42%, an intermittent stream in 72% vs 26%, hesitancy in 35% vs 22%, straining in 84% vs 26%, terminal dribbling in 73% vs 42% and incomplete emptying in 71% vs 49% (p0.001).Women with detrusor overactivity and impaired contractility are older than women with detrusor overactivity and preserved detrusor contractility. Urinary retention and recurrent cystitis are more frequent in women with detrusor overactivity and impaired contractility, and voiding symptoms are significantly more common.

Background Ghrelin, a gastric orexigenic peptide, and body mass index (BMI) are known as inversely associated to each other and are both linked to cardiovascular (CV) risk and mortality in maintenance hemodialysis (MHD) patients. However, it is unclear whether the interaction between ghrelin and BMI is associated with a risk of all-cause and CV death in this population. Methods A prospective observational study was performed on 261 MHD outpatients (39% women, mean age 68.6 ± 13.6 years) recruited from October 2010 through April 2012, and were followed until November 2014 (median follow-up-28 months, interquartile range-19–34 months). We measured acyl-ghrelin (AG) levels, appetite, nutritional and inflammatory markers, prospective all-cause and cardiovascular (CV) mortality. Results During follow-up, 109 patients died, 51 due to CV causes. A significant interaction effect of high BMI and high AG (defined as levels higher than median) on all-cause mortality was found. Crude Cox HR for the product termed BMI x AG was 0.52, with a 95% confidence interval (CI): 0.29 to 0.95 (P = 0.03). Evaluating the interaction on an additive scale revealed that the combined predictive value of BMI and AG is larger than the sum of their individual predictive values (synergy index was 1.1). Across the four BMI-AG categories, the group with high BMI and high AG exhibited better all-cause and cardiovascular mortality irrespective of appetite and nutritional status (multivariable adjusted hazard ratios were 0.31, 95% CI 0.16 to 0.62, P = 0.001, and 0.35, 95% CI 0.13 to 0.91, P = 0.03, respectively). Data analyses made by dividing patients according to fat mass-AG, but not to lean body mass-AG categories, provided similar results. Conclusions Higher AG levels enhance the favourable association between high BMI and survival in MHD patients irrespective of appetite, nutritional status and inflammation.

Purpose The objective of this study was to review the history, epidemiology, diagnosis, and current management techniques for bladder stones (BS) in women. Methods A MEDLINE search for articles published from 1950 to 2011 was done using a list of terms related to BS including calculi, cystolithiasis, stones, urinary bladder, and women. Results Approximately 5% of all BS occur in women and are usually associated with foreign bodies (sutures, synthetic tapes, or meshes) or urinary stasis. Bladder stones can be asymptomatic but may result in hematuria, recurrent infections, and irritable symptoms. Stones can be detected by x-ray, ultrasound, or computed tomography scan and frequently at the time of routine cystourethroscopy performed during pelvic surgery. Because BS is a sign of an underlying problem, definite treatment of the underlying abnormality is nearly always indicated. The preferred treatment for BS is endoscopic transurethral fragmentation of the stone (cystolithotripsy). Any associated suture or synthetic mesh can be removed or cut flush with the bladder mucosa. Partial resection of the mesh with cystotomy should be considered whenever transurethral treatment failed. When stone burden is large, percutaneous endoscopic disintegration or open suprapubic cystolithotomy is preferable. Extracorporeal shockwave lithotripsy has been demonstrated to be simple, effective, and well tolerated. However, ancillary procedures are required in a significant number of patients. Conclusions The increased usage of synthetic material in reconstructive pelvic floor surgery in women will probably increase the incidence of BS on intravesical foreign bodies. Bladder stones should be ruled out in women investigated for irritable bladder symptoms or recurrent urinary infection.

To identify predictors of treatment failure of dimethyl sulfoxide (DMSO) "cocktail" for patients with interstitial cystitis (IC).Fifty-one IC patients received weekly intravesical instillations of "cocktail" composed of 50% DMSO (50 mL), 100 mg of hydrocortisone (5 mL), 10,000 U of heparin sulfate (10 mL), and 0.5% bupivacaine (10 mL) for 12 weeks. A reduction from baseline in the O'Leary-Sant questionnaire score of ≥ 30% was considered as a response. Patients were evaluated every 3 weeks during the treatment course and at 1, 3, 6, 9, and 12 months thereafter. In addition, patients filled in a 3-day bladder diary and a 0-10 visual analogue scale (VAS) for pain. Responders and nonresponders were compared and predictors of treatment failure were identified using univariate analysis and multiple logistic regression.Thirty-one patients (61%) were responders. A significant decrease from baseline in the mean questionnaire's score (27.2 ± 2.8 vs 18.8 ± 2.0, P = .0001) was noted in the responders group. Improvements in the mean daily number of micturitions (16.7 ± 3.6 vs 14.8 ± 2.8, P = .003) and in the mean VAS (7.6 ± 1.6 vs 3.6 ± 1.0, P = .0001) were noted as well. In the nonresponders group, none of these variables improved significantly. Patient age, menopausal state, body mass index, diabetes mellitus, and cystometric and anesthetic capacities were all associated with response. However, only an anesthetic bladder capacity675 mL independently predicted treatment failure (odds ratio 83, 95% CI 9-714, P.0001).Intravesical cocktail for IC patients is associated with a 61% response rate. A small anesthetic bladder capacity predicts treatment failure.

Please cite this paper as: Lee J, Dwyer P, Rosamilia A, Lim Y, Polyakov A, Stav K. Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis. BJOG 2011;118:798–805. Objective To determine risk factors for persistence of urgency or urge urinary incontinence following midurethral sling surgery. Design Prospective cohort study. Setting Tertiary referral Urogynaecology Unit. Sample A total of 754 consecutive women with stress urinary incontinence (SUI) and urgency; and 514 women with SUI and urge urinary incontinence (UUI) who underwent midurethral sling with a mean follow up of 50 months. Methods Women with persistent urgency or UUI at long-term follow up were compared with those whose symptoms had resolved, using multivariate analysis to determine the risk factors for persistent symptoms. Main outcomes measures Odd ratios (OR) of independent risk factors for persistent urgency or UUI. Results Persistent urgency (304/754, 40%) and UUI (166/514, 32%) were common. Coexistent detrusor overactivity (OR 2.04, 95% CI 1.39–3.01), baseline symptom severity (OR 1.41, 95% CI 1.10–1.78) and age (OR 1.03, 95% CI 1.02–1.04) increased the risk of persistent urgency, while transobturator sling surgery (OR 0.61, 95% CI 0.39–094) and concomitant prolapse surgery (OR 0.54, 95% CI 0.38–0.75) decreased the risk. For UUI detrusor overactivity (OR 1.86, 95% CI 1.18–2.93), baseline symptom severity (OR 1.88, 95% CI 1.38–2.56), previous incontinence surgery (OR 2.18, 95% CI 1.28–3.70) increased the risk of persistence, whereas apical prolapse surgery (OR 0.33, 95% CI 0.15–0.70) decreased the risk. Women were more likely not to recommend surgery when they experienced persistent urgency (15.8% versus 2.7%, P

We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence.A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling.The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p0.001) and de novo urge urinary incontinence (22% vs 5%, p0.001) were more frequent in the repeat group compared with the primary group.A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Purpose. To review the condition of pudendal neuralgia (PN) and its role in chronic pelvic pain in women. Methods. A Medline search for articles published before April, 2008 was done using a list of terms related to PN including: pudendal nerve, neuralgia, chronic pelvic pain syndromes, and entrapment neuropathies. Results. The prevalence of PN is unknown and it seems to be a rare event. The main feature is neuralgic pain in the distribution of the pudendal nerve. The most common patient’s profile is a patient who had seen multiple physicians, with no evidence of organ disease, normal urogynecological and colorectal evaluations, and failed multiple pharmacologic treatments. The cause of the PN is not always clear, but it is believed that neuronal insult caused by stretching or compression is the primary etiology. PN is said to be a diagnosis of exclusion and requires a high index of suspicion. Although there are no pathognomonic signs and symptoms, clinical diagnostic criteria were recently discussed and published by a multidisciplinary working party in Nantes (France 2006). Clinical neurophysiology tests have quite low diagnostic efficacy and must therefore be considered to be complementary investigations. Optional treatments include behavioral modifications, physical therapy, analgesics, pudendal nerve block, and surgical nerve decompression. Conclusions. PN does seem to exist as a clinical syndrome rather than a specific diagnosis. It is important to note that it does not have definite etiological implications, and there is no evidence to support equating the presence of this syndrome with a diagnosis of pudendal nerve entrapment although that may be 1 etiological condition. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader should be able to use established criteria for the diagnosis of pudendal neuraligia, recall the pathophysiologic basis of pudendal neuralgia, and prepare a rational treatment plan for women with pudendal neuralgia.

This study aims to highlight pelvic organ prolapse (POP) in females following radical cystectomy and to describe our experiences with their management. This is a retrospective case series of five women who had symptomatic POP following radical cystectomy and ileal conduit urinary diversion. All patients presented with a midline anterior enterocele with atrophic ulcerated vaginal skin. One patient presented with small bowel evisceration and required an emergency surgical repair. The average time for presentation was 10.6 +/- 6.5 months after cystectomy. In all cases, repair was done via a transvaginal approach. Three patients underwent fascial repair, one colpocleisis, and one bilateral iliococcygeal repair. In three cases, we had to use mesh for reinforcement. Two patients underwent ancillary procedures because of POP recurrence. Surgical repair of POP in women following radical cystectomy is challenging especially if vaginal length is to be maintained. Transvaginal repair is feasible and using synthetic mesh may be necessary.

It has been suggested that oxidative stress is a potential mechanism for vancomycin-induced nephrotoxicity and hyperbaric oxygen therapy (HBO) has been shown to be effective in treating renal toxicity that has been pharmacologically induced in animal models. The aim of this study was to investigate the effect of HBO therapy on vancomycin-induced nephrotoxicity in rats. The study group comprised 36 Sprague Dawley male rats. We treated 30 with 500 mg/kg of intraperitoneal vancomycin once a day for 7 days. Half of these rats received a daily 1-hour treatment with HBO at 2 Atmospheres (ATM) on the same 7 days and formed the HBO+ group. The other 15 subjects received no HBO treatment (HBO- group). The remaining six rats served as the control group, three received HBO treatments alone and no treatment was administered to the other three rats. Laboratory results were obtained on day 8 and the intervention and control groups were compared. Rats in the HBO+ group gained less weight than the HBO- group (11.6 grams vs 22.6 grams; P = 0,008) and had significantly higher serum blood urea nitrogen (99.6 vs 52.6 mg/dL; P