Annette Schröder

EAU guidelines on urinary incontinence

CONTEXTnThe first European Association of Urology (EAU) guidelines on incontinence were published in 2001. These guidelines were periodically updated in past years.nnnOBJECTIVEnThe aim of this paper is to present a summary of the 2009 update of the EAU guidelines on urinary incontinence (UI).nnnEVIDENCE ACQUISITIONnThe EAU working panel was part of the 4th International Consultation on Incontinence (ICI) and, with permission of the ICI, extracted the relevant data. The methodology of the 4th ICI was a comprehensive literature review by international experts and consensus formation. In addition, level of evidence was rated according to a modified Oxford system and grades of recommendation were given accordingly.nnnEVIDENCE SUMMARYnA full version of the EAU guidelines on urinary incontinence is available as a printed document (extended and short form) and as a CD-ROM from the EAU office or online from the EAU Web site (http://www.uroweb.org/guidelines/online-guidelines/). The extent and invasiveness of assessment of UI depends on severity and/or complexity of symptoms and clinical signs and is different for men, women, frail older persons, children, and patients with neuropathy. At the level of initial management, basic diagnostic tests are applied to exclude an underlying disease or condition such as urinary tract infection. Treatment is mostly conservative (lifestyle interventions, physiotherapy, physical therapy, pharmacotherapy) and is of an empirical nature. At the level of specialised management (when primary therapy failed, diagnosis is unclear, or symptoms and/or signs are complex/severe), more elaborate assessment is generally required, including imaging, endoscopy, and urodynamics. Treatment options include invasive interventions and surgery.nnnCONCLUSIONSnTreatment options for UI are rapidly expanding. These EAU guidelines provide ratings of the evidence (guided by evidence-based medicine) and graded recommendations for the appropriate assessment and according treatment options and put them into clinical perspective.

EFFECT OF CHRONIC BLADDER OUTLET OBSTRUCTION ON BLOOD FLOW OF THE RABBIT BLADDER

PURPOSEnPrevious studies have shown that the initial reaction of the rabbit bladder to partial bladder outlet obstruction is increased blood flow at day 1 and a return to baseline blood flow at 1 week. Mucosal and muscle blood flow followed this pattern but mucosal blood flow was always 4 to 5-fold greater. In this study we examined the effect of 4 weeks of outlet obstruction on bladder blood flow and correlated it with the severity of bladder contractile dysfunction.nnnMATERIALS AND METHODSnA total of 14 male New Zealand White rabbits underwent partial outlet obstruction creation by standard methods. After 4 weeks the rabbits were anesthetized, and blood flow to the muscle and mucosa was determined by standard fluorescent microsphere technique. A section of each detrusor was used for in vitro contractility studies. Contractile responses to field stimulation, carbachol and potassium chloride were determined. A section of each detrusor tissue was fixed in formalin and used to determine the smooth muscle volume fraction.nnnRESULTSnFour weeks of partial bladder outlet obstruction caused a significant and variable increase in bladder weight and a decrease in blood flow to bladder muscle without changes in the blood flow to mucosa. There was a clear correlation between the severity of contractile dysfunction, bladder weight and the magnitude of the decrease in blood flow in muscle. The smooth muscle volume fraction remained stable at approximately 40%.nnnCONCLUSIONSnBladder decompensation was associated with decreased blood flow to bladder smooth muscle. Because compensated obstructed bladders with relatively normal contractile function are also hypertrophied but have normal blood flow, decreased blood flow in decompensated bladders is not simply a response to bladder hypertrophy. From this study we hypothesize that decreased blood flow to bladder smooth muscle is an etiological factor in bladder contractile dysfunction (bladder decompensation) secondary to partial outlet obstruction.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: Non-surgical considerations

Segments from almost all parts of the bowel have been used for urinary diversion. As a result, the available absorptive surface area of the bowel is reduced, and the incorporation of bowel segments into the urinary tract may have metabolic consequences. This is an area somewhat neglected in the literature. Metabolic complications are rare, but sub-clinical metabolic disturbances are quite common. Several studies have demonstrated that some of the absorbent and secreting properties of the bowel tissue are preserved after incorporation into the urinary tract. Hyperchloraemic metabolic acidosis can occur if ileal and/or colon segments are used, as well as malabsorption of vitamin B(12) and bile acid after the use of ileal segments. These metabolic effects are not as severe as may be suspected and can be prevented by prophylactic substitution. Secondary malignancies can develop as a long-term consequence of bladder augmentation. Using colonic segments, tumours are most likely to occur at the ureteral implantation site. To prevent metabolic complications, careful patient selection and meticulous and lifelong follow up, as well as prophylactic treatment, are mandatory. Endoscopy for early detection has been recommended, starting 10 years postoperatively for patients who underwent surgery for a benign condition.

Microduplications at 22q11.21 are associated with non-syndromic classic bladder exstrophy

The exstrophy-epispadias complex (EEC) comprises a spectrum of urogenital anomalies in which part or all of the distal urinary tract fails to close. The present study aimed to identify microaberrations characterized by loss or gain of genomic material that contribute to the EEC at a genome-wide level. Molecular karyotyping, utilizing 549,839 single nucleotide polymorphisms (SNPs) with an average spacing of 5.7 kilobases, was performed to screen an initial cohort of 16 patients with non-syndromic EEC. A de novo microduplication involving chromosomal region 22q11.21 was identified in one patient with classic exstrophy of the bladder (CBE). Subsequent multiplex ligation-dependent probe amplification (MLPA) analysis was performed with an MLPA 22q11 kit in a further 50 non-syndromic EEC cases. We identified one CBE patient with an overlapping 22q11.21 duplication in whom the duplication had been transmitted from the unaffected mother. Chromosomal region 22q11 is well known for its susceptibility to genomic rearrangements, and these are associated with various syndromes including the velo-cardio-facial/DiGeorge syndrome (VCFS/DGS), the der(22) syndrome, and the cat-eye syndrome. Duplications in this region result in a wide and variable spectrum of clinical presentations that include features of the VCFS/DGS, while some carriers present with a completely normal phenotype. Our findings extend the phenotypic spectrum of the 22q11.2 duplication syndrome, and indicate that this aberration predisposes to CBE with incomplete penetrance.

The effect of urine volume and nitric oxide on basal bladder blood flow: response to catheterization and drainage.

Preliminary studies demonstrated that catheterization and drainage of the urinary bladder resulted in a significant increase in blood flow to the bladder. The objectives of this study were to determine 1) the relationship between urine volume and basal blood flow to the bladder smooth muscle and mucosa, 2) the effect of acute catheterization and drainage on bladder mucosal and smooth muscle blood flow, and 3) whether nitric oxide was involved in regulation of basal blood flow or the increase in blood flow observed after catheterization and bladder drainage. Twenty‐four rabbits were separated into two groups: group 1(14 rabbits) and group 2 (10 rabbits) treated with L‐NAME (NOS inhibitor) 30 minutes before blood flow measurement. Blood flow was measured in all animals using a fluorescent microsphere technique before and immediately after catheterization and drainage of the bladder. The results demonstrated that 1) blood flow to the muscle and mucosa were independent of urine volume at the time of catheterization and drainage; 2) catheterization and drainage significantly increased blood flow to both the bladder smooth muscle and bladder mucosa, but not to the kidney; 3) L‐NAME significantly reduced basal blood flow to the kidney, but not to the bladder smooth muscle or mucosa; and 4) L‐NAME completely prevented the catheterization‐ and drainage‐induced increases in blood flow to the bladder body mucosa and muscle. This study demonstrates that basal blood flow to the bladder smooth muscle and mucosa during filling is independent of NO control; although bladder blood flow may be increased significantly by NO synthesis and release during bladder emptying, and thus may be an important regulator of blood flow during and immediately following micturition. Neurourol. Urodynam. 20:115–124, 2001.

Phenotype severity in the bladder exstrophy-epispadias complex: Analysis of genetic and nongenetic contributing factors in 441 families from North America and Europe

OBJECTIVEnTo identify genetic and nongenetic risk factors that contribute to the severity of the bladder exstrophy-epispadias complex (BEEC).nnnSTUDY DESIGNnPatients with BEEC from North America (n = 167) and Europe (n = 274) were included. The following data were collected: associated anomalies, parental age at conception, mode of conception, periconceptional folic acid supplementation, maternal risk factors during pregnancy, and environmental risk factors. The patients were divided into 3 subgroups according to phenotype severity: (i) mild, epispadias (n = 43); (ii) intermediate, classic bladder exstrophy (n = 366); and (iii) severe, cloacal exstrophy (n = 31). These subgroups then were compared with identify factors that contribute to phenotype severity.nnnRESULTSnMales were overrepresented in all subgroups. A relatively high prevalence of cleft lip, with or without cleft palate, was observed. Maternal smoking and medical radiation during the first trimester were associated with the severe cloacal exstrophy phenotype. Compliance with periconceptional folic acid supplementation was associated with the mildest phenotype (epispadias).nnnCONCLUSIONSnPericonceptional folic acid supplementation appears to prevent the development of the severe phenotype of BEEC.

Radical surgery and different types of urinary diversion in patients with rhabdomyosarcoma of bladder or prostate – A single institution experience

PURPOSEnIn a retrospective study we analyzed the outcome of patients treated for rhabdomyosarcoma (RMS) of the bladder/prostate with special attention to radical surgery.nnnMETHODSnIn 25 patients with genitourinary RMS (15 bladder/10 prostate) the median age at diagnosis was 4 years [1-18], and 8 patients had a stage II RMS, 12 stage III and 5 stage IV. In 19/25 (12 bladder/7 prostate), radical surgery and urinary diversion were performed. Urinary diversion comprised 2 continent anal diversions, 11 continent cutaneous diversions, 4 colon conduits and 2 urethral diversions (2xa0+xa03 years of age). In the younger child with urethral diversion, a cutaneous appendix stoma was additionally constructed in case of inability to void spontaneously.nnnRESULTSn4/19 patients who underwent radical surgery died of metastatic RMS; 1 patient with neurofibromatosis died of a secondary tumor. After median follow-up of 132 months (14-420), 14 patients currently have no evidence of disease. 8/14 patients who survived developed 17 complications requiring operative revision. All patients with a continent diversion are continent. The patients with orthotopic bladder substitution are continent day & night and void spontaneously.nnnCONCLUSIONnFor RMS confined to the bladder or bladder neck, radical cystoprostatectomy and orthotopic bladder substitution are an option. Urethral diversion using the ileocecal segment (Mainz-pouch I) offers the advantage of utilizing the appendix as an additional continent cutaneous stoma, which enables parents to evacuate residual urine in young boys, until able to empty the pouch completely themselves. For all other patients with vital tumor after primary chemotherapy, cutaneous urinary diversion is an option. Long-term complication rates in this complex group of patients are acceptable.

Ossifying renal tumor of infancy

A renal ossifying tumor of infancy is a rare event with few cases having been published, and the etiology has not yet been established. We report on two new cases of this unusual neoplasm. A 2-year-old boy presented with intermittent painless gross hematuria. After several diagnostic procedures, an open pyelolithotomy was performed and the histological diagnosis of renal tumor of infancy was finally made. The history of the second case is very similar. An 8-week-old infant presented with gross hematuria. As in the first case, an open pyelolithotomy was performed and a tumor entirely covered with blood clots was found in the renal pelvis and completely removed. A histological diagnosis of renal ossifying tumor of infancy was made. Using the literature available, the histological criteria and biological behavior are discussed, together with the diagnostic and therapeutic algorithm for this tumor. In infants with gross hematuria and a calcified (non-)invasive mass in the pelvi-calceal system, renal ossifying tumor should be considered in the differential diagnosis. MRI or CT scan offers a good diagnostic guide.

Use of buccal mucosa in urethral surgery

Buccal mucosa grafts have proven reliable in urethral surgery. For augmentation urethroplasty, the graft can be used as a ventral or dorsal onlay. If the graft was used as an onlay, the results were much better than in substitution urethroplasty with the graft used as a tube. In patients with complex strictures or severe cases of hypospadias or epispadias, a two-stage technique using a buccal mucosa inlay graft can be applied. After 6 months, the well-revascularized buccal mucosa strip can be tubularized and covered with a tunica dartos or tunica vaginalis flap. In the future, for correction of larger defects, buccal mucosa cells can be cultured in vitro on biodegradable matrices. These larger buccal mucosa transplants could minimize the morbidity at the donor site. Future studies must clarify if the new technology of nanofibers can be of advantage by producing better matrices.ZusammenfassungDas freie Mundschleimhauttransplantat hat in der Harnröhrenchirurgie seinen festen Platz. Es wird in ventraler oder dorsaler Onlaytechnik erfolgreich angewandt. Im Vergleich zur Verwendung eines tubularisierten Mundschleimhautstreifens sind die Erfolgsraten deutlich besser. Bei Patienten, bei denen die einzeitige Rekonstruktion nicht sinnvoll erscheint, wird ein Mundschleimhautinlay verwendet, das nach 6xa0Monaten gut vaskularisiert ist und tubularisiert werden kann.Zur Korrektur größerer Defekte kann es in Zukunft möglich sein, epitheliale Zellen auf resorbierbaren Matrices in vitro zu kultivierten und durch ein so gewonnenes autologes Mundschleimhauttransplantat auch die Morbidität an der Donorseite zu minimieren. Ob bei der Erstellung dieser Matrices die Nanofasertechnologie Vorteile bringt, müssen zukünftige Studien zeigen.AbstractBuccal mucosa grafts have proven reliable in urethral surgery. For augmentation urethroplasty, the graft can be used as a ventral or dorsal onlay. If the graft was used as an onlay, the results were much better than in substitution urethroplasty with the graft used as a tube. In patients with complex strictures or severe cases of hypospadias or epispadias, a two-stage technique using a buccal mucosa inlay graft can be applied. After 6xa0months, the well-revascularized buccal mucosa strip can be tubularized and covered with a tunica dartos or tunica vaginalis flap.In the future, for correction of larger defects, buccal mucosa cells can be cultured in vitro on biodegradable matrices. These larger buccal mucosa transplants could minimize the morbidity at the donor site. Future studies must clarify if the new technology of nanofibers can be of advantage by producing better matrices.

[Neurogenic bladder function disorders in patients with meningomyelocele: S2k guidelines on diagnostics and therapy].

ZusammenfassungDie Behandlung von Kindern und Jugendlichen mit Meningomyelozele hat in den letzten 30xa0Jahren einen deutlichen Wandel erfahren. Die Etablierung der Pharmakotherapie, des intermittierenden Einmalkatheterismus („clean intermittent catheterization“, CIC) und der Infektionsprophylaxe hat die Prognose der Patienten verbessert und zu neuen therapeutischen Strategien geführt. Die interdisziplinäre Zusammenarbeit von Neonatologen, Neurochirurgen, Neuropädiatern, Kinderurologen, pädiatrischen Nephrologen, Kinderorthopäden und Kinderchirurgen führt zu einer Optimierung der individuellen Therapie. In der vorliegenden Leitlinie werden Definitionen und Klassifikationen, Untersuchungen und Untersuchungszeitpunkte dargestellt und im Einzelnen erläutert. Die konservativen und operativen Therapieoptionen bei neurogener Blasenfunktionsstörung werden erläutert und anhand der aktuellen Literatur diskutiert. Der jeweils kurze Überblick soll für die behandelnden Ärzten eine Hilfe bei der Betreuung dieser Patientengruppe geben und die interdisziplinäre Zusammenarbeit erleichtern.AbstractThe treatment of children and adolescents with meningomyelocele has experienced a clear change in the last 30 years. The establishment of pharmacotherapy, clean intermittent catheterization (CIC) and infection prophylaxis have improved the prognosis for patients and have led to new therapeutic strategies. The interdisciplinary cooperation between neonatologists, neurosurgeons, pediatric neurologists, pediatric urologists, pediatric nephrologists, pediatric orthopedists and pediatric surgeons leads to optimization of individualized therapy. These guidelines present definitions and classifications, investigations and timing which are described in detail. The conservative and operative therapy options for neurogenic bladder function disorders are described and discussed with reference to the current literature. The brief overview provides in each case assistance for the treating physician in the care of this patient group and facilitates the interdisciplinary cooperation.The treatment of children and adolescents with meningomyelocele has experienced a clear change in the last 30 years. The establishment of pharmacotherapy, clean intermittent catheterization (CIC) and infection prophylaxis have improved the prognosis for patients and have led to new therapeutic strategies. The interdisciplinary cooperation between neonatologists, neurosurgeons, pediatric neurologists, pediatric urologists, pediatric nephrologists, pediatric orthopedists and pediatric surgeons leads to optimization of individualized therapy. These guidelines present definitions and classifications, investigations and timing which are described in detail. The conservative and operative therapy options for neurogenic bladder function disorders are described and discussed with reference to the current literature. The brief overview provides in each case assistance for the treating physician in the care of this patient group and facilitates the interdisciplinary cooperation.