Bilal Farhan

Squamous cell carcinoma of the urinary bladder: Systematic review of clinical characteristics and therapeutic approaches.

Abstract Objective: To highlight the current understanding of the epidemiology, clinicopathological characteristics, and management of squamous cell carcinoma (SCC) of the bladder, as it accounts for 2–5% of bladder tumours, with a focus on non-bilharzial-associated SCC (NB-SCC). The standard treatment for bladder SCC remains radical cystectomy (RC). We present an updated clinical profile of bladder SCC and a review of NB-SCC therapeutic approaches, including RC, neoadjuvant and adjuvant treatments, radiotherapy, chemotherapy, and immunotherapy. Methods: Using search terms relating to SCC, urinary bladder, and treatment modalities, we performed a search of the PubMed and Embase databases to identify NB-SCC treatment approaches and outcomes. Peer-reviewed English language reports from 1975 to present assessing SCC management were included. Two authors independently screened and extracted the data. Results: Of the 806 articles screened, 10 met the pre-defined inclusion criteria. RC was performed in seven of the 10 studies. Although radiotherapy alone yielded poor outcomes, preoperative radiotherapy and RC were associated with improved survival. There is little evidence supporting the use of chemotherapy in NB-SCC, and its efficacy in relation to RC is not known. Conclusion: Based on current literature, there is insufficient evidence to provide a treatment recommendation for NB-SCC. Whilst RC is the standard of care, the role of preoperative radiotherapy should be revisited and compared to RC alone. Additional studies incorporating multimodal approaches, contemporary radiation techniques, and systemic therapies are warranted. Immunotherapy as a treatment for bladder SCC has yet to be investigated.

The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review

Abstract Objective: To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research. Methods: We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: ‘detrusor underactivity’, ‘underactive bladder’, ‘post voiding residual’, ‘post micturition residual’, ‘acontractile bladder’, ‘detrusor failure’, and ‘detrusor areflexia’. Result: DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function. Conclusion: Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.

Are Electronic and Paper Questionnaires Equivalent to Assess Patients with Overactive Bladder

Purpose: Overactive bladder syndrome is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence in the absence of urinary tract infection or another obvious pathological condition. Electronic questionnaires have been used in a few specialties with the hope of improving treatment outcomes and patient satisfaction. However, they have not been widely used in the urological field. When treating overactive bladder, the main outcome is to improve patient quality of life. The primary objective of this study was to evaluate whether electronic questionnaires would be equally accepted as or preferred to paper questionnaires. The secondary objective was to look at the preference in relation to patient age, education and iPad® tablet familiarity. Materials and Methods: We prospectively evaluated the iList® electronic questionnaire application using a friendly iPad tablet in patients with overactive bladder who presented to the urology clinic at our institution. Each of the 80 patients who were recruited randomly completed the validated OABSS (Overactive Bladder Symptom Score) and the PPBC (Patient Perception of Bladder Condition) questionnaires in paper and electronic format on the tablet. Variables potentially associated with the outcomes of interest included demographic data, questionnaire method preference, patient response rate and iPad familiarity. We used the 2‐sided Z‐test to determine whether the proportion of patients who considered the tablet to be the same, better or much better than paper was significantly greater than 50%. The 2‐sided chi‐square test was applied to assess whether the intervention effect significantly differed among the demographic subgroups. Results: A total of 80 patients 21 to 87 years old were enrolled in the study from November 2015 to August 2016. Of the patients 53% were female and 49% were 65 years or younger. The incidence of those who considered the tablet to be the same or better than paper was 82.5% (95% CI 74.2–90.8, p <0.001). The incidence of patients who considered the tablet to be the same or better than paper ranged from 76% to 97% regardless of age, gender and education subgroup as well as in those with any familiarity with the tablet (each p <0.001). Of the 20 patients who were not familiar with the tablet 45% preferred the electronic questionnaire (p = 0.654). Conclusions: We found that the proportion of patients who considered electronic questionnaires to be equivalent to or better than paper versions was higher than those who preferred paper questionnaires regardless of age, gender or education level.

Face, Content, and Construct Validations of Endoscopic Needle Injection Simulator for Transurethral Bulking Agent in Treatment of Stress Urinary Incontinence

INTRODUCTION AND OBJECTIVES Endoscopic injection of urethral bulking agents is an office procedure that is used to treat stress urinary incontinence secondary to internal sphincteric deficiency. Validation studies important part of simulator evaluation and is considered important step to establish the effectiveness of simulation-based training. The endoscopic needle injection (ENI) simulator has not been formally validated, although it has been used widely at University of California, Irvine. We aimed to assess the face, content, and construct validity of the UC, Irvine ENI simulator. METHODS Dissected female porcine bladders were mounted in a modified Hysteroscopy Diagnostic Trainer. Using routine endoscopic equipment for this procedure with video monitoring, 6 urologists (experts group) and 6 urology trainee (novice group) completed urethral bulking agents injections on a total of 12 bladders using ENI simulator. Face and content validities were assessed by using structured quantitative survey which rating the realism. Construct validity was assessed by comparing the performance, time of the procedure, and the occlusive (anatomical and functional) evaluations between the experts and novices. Trainees also completed a postprocedure feedback survey. Effective injections were evaluated by measuring the retrograde urethral opening pressure, visual cystoscopic coaptation, and postprocedure gross anatomic examination. RESULTS All 12 participants felt the simulator was a good training tool and should be used as essential part of urology training (face validity). ENI simulator showed good face and content validity with average score varies between the experts and the novices was 3.9/5 and 3.8/5, respectively. Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.9-3.8/5). However, the bladder does not bleed, and sometimes thin. Experts significantly outperformed novices (p < 001) across all measure of performance therefore establishing construct validity. CONCLUSION The ENI simulator shows face, content and construct validities, although few aspects of simulator were not very realistic (e.g., bleeding).This study provides a base for the future formal validation for this simulator and for continuing use of this simulator in endourology training.

MP26-17 URINARY LEVEL OF MONOCYTE CHEMOTACTIC PROTEIN-1 (MCP-1) PREDICTS THE SEVERITY OF SYMPTOM IN PATIENT WITH OVERACTIVE BLADDER (OAB): PILOT PROSPECTIVE STUDY.

data showed that the contractile responses to KCl, carbachol and EFS were significantly increased in detrusor strips from Dahl control rats compared to those from the other three groups. CONCLUSIONS: Models of metabolic syndrome have obvious differences in bladder function compared with control rats. Chronic administration of succinate, as observed in vitro, alters detrusor contractility of Dahl rats. The absence of down-regulation of GPR91 in the Dahl bladder treated with succinate could explain the alterations in detrusor contractility observed only in this group. Increased urinary succinate levels may contribute to the development of bladder dysfunction.

Transvaginal Excision of Bilateral Single Ureteral Stumps of Refluxing Ectopic Ureters in an Adult Female With Urinary Incontinence.

OBJECTIVE To report a novel surgical technique of transvaginal excision of bilateral refluxing single ureteral stumps in an adult female, with emphasis on the technique, the difficulties of the procedure, and other surgical consideration such as bladder neck reconstruction and use of pubovaginal sling in patients with these congenital anomalies. METHODS The procedure starts with cystoscopy for identification and catheterization of the orifices of remnant ectopic ureters. This is important to facilitate close dissection of ureteral stumps without the risk of vascular and visceral injury. A wide inverted U incision is made in the anterior vaginal wall to complete the dissection and excision for the remnants of ectopic ureters followed by water-tight closure for each ureterourethral junction. The procedure is completed with bladder neck reconstruction and pubovaginal sling with autologous rectus fascia. RESULTS The operative time was 3 hours, estimated blood loss was 50 mL, and hospital stay was 1 day. There were no intraoperative complications, and the patient went home on catheter drainage for 10 days with prophylactic antibiotics and anticholinergic medications. One-year follow-up showed her global satisfaction of 80%, and she uses one small pad per day as needed. She reported no more recurrent urinary tract infections, no difficulty of voiding, and no pain. CONCLUSION Transvaginal approach for excision of bilateral infravesical remnant of ectopic ureters in an adult female is feasible. Successful surgical outcomes require bladder neck reconstruction and use of autologous rectus fascia in patient with bilateral single-system ectopic ureters, as the sphincteric mechanism of the bladder neck is absent.

Clinical Pathways of Third-Line Treatment of Overactive Bladder in the Elderly

Overactive bladder (OAB) is a syndrome of urinary urgency, usually accompanied by frequency, nocturia, and sometimes urinary urgency incontinence. There are many guidelines for the OAB treatment which are constructed on a stepwise fashion starting from the least invasive to the more invasive therapy. The emergence of third-line therapy (AUA/SUFU guidelines) has resulted in significant decrease of more invasive surgery and improved patients’ quality of life. The aim of a clinical pathway is to improve the quality of care, reduce risks, increase patient satisfaction, and increase the efficiency in the use of resources. The available options for the third-line OAB treatments include intravesical injection of botulinum toxin A, percutaneous tibial nerve stimulation (PTNS), and sacral nerve stimulation (SNS). The available evidence confirms that all three treatment approaches are well tolerated and effective, although only botulinum toxin type A (BoNTA) and SNS can achieve nearly a cure of urgency urinary incontinence (UUI). The choice among the different third-line treatment depends on patient preference, availability, and local expertise. The application of these pathways can improve incontinence care by letting physicians adequately communicate with patients and select individualized therapy at an early stage especially for elderly patients.