Cagri Akin Sekerci

Is 40 cm H2O detrusor leak point pressure cut-off reliable for upper urinary tract protection in children with myelodysplasia?

The purpose of this study, is to find out the most accurate cut‐off level for the detrusor leak point pressure (DLPP) in terms of upper urinary tract (UUT) protection in a cohort of children with myelodysplasia.

Clinical and Urodynamic Results of Repeated Intradetrusor Onabotulinum Toxin A Injections in Refractory Neurogenic Detrusor Overactivity: Up to 5 Injections in a Cohort of Children With Myelodysplasia

OBJECTIVE To determine the efficacy and safety of repeated intradetrusor onabotulinum toxin A (onaBoNT-A) injections in children with neurogenic detrusor overactivity due to myelodysplasia. MATERIALS AND METHODS The study group consisted of 19 children (4 boys and 15 girls) with a mean age of 10.3 ± 3.1 years old, who had received at least 2 injections of 10 U/kg onaBoNT-A for the treatment of urinary incontinence resistant to anticholinergic treatment and clean intermittent catheterization in our clinic, between 2010 and 2015. Controlled urodynamic studies were performed at the baseline and 3 months after each injection. RESULTS Eight of the children received 3 injections, 5 children had 4 injections, and 2 children had 5 injections. From the baseline to the fifth injection, the detrusor compliance (1.3, 4.5, 10, 20.7, 18.8, and 16.6 mL/cm H2O), the maximum bladder capacity (82.0, 157.0, 191.0, 272.0, 299.0, and 210.5 mL), and the maximum detrusor pressure (55.0, 33.0, 22.0, 12.5, 16.0, and 12.5 cm H2O) were assessed. The findings significantly improved following the first, second, and third injections, when compared with the previous bladder dynamics (P <.05), but the differences with the fourth were not statistically significant (P >.05). The continence periods were similar under clean intermittent catheterization after all of the injections (P <.05), and no severe side effects were observed. CONCLUSION Repeated onaBoNT-A injections are a safe treatment modality and can be offered as an effective alternative choice, instead of more invasive surgery, in children with neurogenic detrusor overactivity due to myelodysplasia.

The effect of intradetrusor botulinum neurotoxin type A on urinary NGF, TGF BETA‐1, TIMP‐2 levels in children with neurogenic detrusor overactivity due to myelodysplasia

The aim of this study was to determine the value of urine nerve growth factor (NGF), transforming growth factor beta 1 (TGF‐Beta‐1), tissue inhibitor of matrix metalloproteinase 2 (TIMP‐2) levels to predict the urodynamic profile before and after botulinum neurotoxin type A (BoNT‐A) treatment in children with myelodysplasia.

Is 40 cm H2O detrusor leak point pressure (DLPP) cut-off really reliable for upper urinary tract (UUT) protection in children with myelodysplasia?

INTRODUCTION AND OBJECTIVE: High DLPP is a risk factor for UUT in children with myelodysplasia, where 40 cm H2O is generally considered as the safe limit after McGuire’s study. The purpose of this study is to find out the most accurate cut-off level for the DLPP in terms of UUT protection in children with myelodysplasia. METHODS: We retrospectively reviewed 618 children with myelodysplasia followed at our multidisciplinary clinic between 1996 and 2008. Among these patients, 150 were included in the study based on the availability of urological follow-up data at age of 3 years. Children were assigned to 1 of 2 groups those who had UUT deterioration at age 3 (group 1), which means hydronephrosis, VUR or scar on DMSA, or not (group 2). We compared the incidence of febrile urinary tract infections (FUTI), timing of the primary neurosurgical repair, secondary tethering of the spinal cord (STSC) at age 3 years and urodynamic findings between the groups. RESULTS: Conservative treatment rates are shown in table 1 and urodynamic findings in table 2. Urological follow-up data at age 3 years revealed higher incidences of FUTI and STSC in children in group 1. Different cut-off values of DLPP showed that DLPP above 20 cm H2O has a higher sensitivity for UUT deterioration (table 3). CONCLUSIONS: Determining the cut-off value of the DLPP as 20 cm H2O instead of 40 cm H2O showed a higher sensitivity to predict the risk group for UUT deterioration. Children with myelodysplasia, who have a DLPP between 20 and 40 cm H2O, should be followed closer since % 38.4 of these children in this study had UUT deterioration at age of 3.

The Value of Urinary BDNF Levels on Assessment of the Botulinum Toxin Type A Treatment for Neurogenic Detrusor Overactivity in Children with Myelodysplasia

Purpose: Urinary cytokines are proposed to predict urodynamic findings and outcome of intradetrusor botulinum neurotoxin type A injection in children with myelodysplasia. The relationship between urinary brain-derived neurotrophic factor and neurogenic and nonneurogenic detrusor overactivity has been shown as well. We prospectively investigated the effect of intradetrusor botulinum neurotoxin type A injection on urine brain-derived neurotrophic factor levels in children with nonneurogenic detrusor overactivity due to myelodysplasia. Materials and Methods: Urine samples of 23 children with nonneurogenic detrusor overactivity due to myelodysplasia were collected and analyzed before and 1 and 3 months after intradetrusor botulinum neurotoxin type A injection, and urodynamics were performed before and 6 weeks after injection. Brain-derived neurotrophic factor levels and urodynamic findings were analyzed and statistical comparisons were done. Results: Mean ± SD age was 100.0 ± 34.5 months. Ratio of girls to boys was 2.8. Brain-derived neurotrophic factor levels significantly decreased (p <0.006), and maximum cystometric capacity and maximum detrusor pressure improved significantly following intradetrusor botulinum neurotoxin type A injection compared to preoperatively (p <0.001). No statistical correlations were determined between brain-derived neurotrophic factor levels and urodynamics. Of all analyses only bladder compliance 5 ml/cm H2O or less vs greater than 5 ml/cm H2O at postoperative urodynamics was associated with statistically increased urine brain-derived neurotrophic factor levels, suggesting that increased urine brain-derived neurotrophic factor predicts treatment failure. Conclusions: The present study does not suggest that urine brain-derived neurotrophic factor is a reliable followup marker in children with nonneurogenic detrusor overactivity due to myelodysplasia. However, this factor may have a role in treatment planning, which needs to be established in future large prospective studies.

PD35-07 PRELIMINARY RESULTS OF A PROSPECTIVE RANDOMIZED TRIAL OF SAFETY GUIDEWIRE USE IN URETEROSCOPIC STONE SURGERY: TO USE OR NOT TO USE

INTRODUCTION AND OBJECTIVES: Up-to-date, urology guidelines introduce safety guidewire (SGW) as an integral tool in ureteroscopy and recommended its routine use. However, the necessity of SGW placement in endourological procedures lack evidence and is being suggested as an expert opinion. Present study aimed to evaluate the use of SGW placement and its necessity in treatment of ureteral stones with semi-rigid ureteroscopy (s-URS). METHODS: A total of 160 patients with ureteral stones were stratified according to ureteral stone location and prospectively randomized into two groups’ according to SGW usage or not in s-URS between July 2014 and August 2016. Ureteroscopy and litotripsy were done with a semi-rigid ureteroscope of 6.4/7.8 Fr (Olympus) and laser. Chi-square and student t-test were used for comparing data. RESULTS: Of all patients, in 79 interventions were done under the guidance of SGW (SGW group) and in 81 without the guidance of SGW (NoSGW group). In No-SGW group 10 patients needed SGW introduction as it was difficult to access or advance the ureteroscope into the ureteral orifice or throughout the ureter and in SGW group SGW could not be introduced in 8 patients. These patients were excluded from the study. There were no significant differences in patient demographics and findings between the two groups, except female/male patient ratio and mean BMI which was higher in the SGW group (Table 1-2). Among all patients only 1 patient (1.3%) in SGW group experienced a complication of Clavien 3 and/or higher, which was ureteral perforation. CONCLUSIONS: The preliminary results of our study reveal that, routine use of SGW placement does not help to decrease complication and/or treatment failure rates. Safety guidewire concept has to be re-evaluated with further prospective randomized trials. Source of Funding: None

MP43-15 PROTECTIVE EFFECT OF PLATELET RICH PLASMA ON EXPERIMENTAL ISCHEMIA/REPERFUSION INJURY IN TORSION OF RAT TESTIS

INTRODUCTION AND OBJECTIVES: Previous reports have suggested an association between cold temperatures and the prevalence of testicular torsion. We hypothesized there is no association, and we used large-scale national data to evaluate this hypothesis. METHODS: For testicular torsion cases, we used the Pediatric Health Information System (PHIS) database to determine the date and city of a case of testicular torsion from 9/2006 to 7/2015. Cases were identified using ICD-9 diagnosis codes for testicular torsion (608.2) occurring concomitantly with procedure codes for reduction of torsion (63.52). For weather data, we used data from the National Climatic Data Center at the National Oceanic and Atmospheric Administration. For all cities with hospitals in the PHIS database, we determined the maximum and minimum daily atmospheric temperature at the weather station closest to each hospital. We then built cumulative distribution functions and density graphs for the distribution of (a) median daily temperature (calculated from measured temperature maximum and minimum) for cases of testicular torsion, and (b) median daily temperature for all days. Cumulative distribution curves and density graphs were compared using the KolmogorovSmirnov (K-S) test. All analyses were completed using the R software package. RESULTS: 9,126 cases of testicular torsions were identified and 154,542 days of temperature data across all hospital cities over the time period of interest. Days at each temperature across all hospitals and time from 9/2006 to 7/2015 were calculated, as were number of torsions at each temperature. The relative distribution of each temperature is compared in Figure 1, with all days portrayed in red and torsions portrayed in blue. The K-S test for similarity of distribution showed a D statistic of 0.019 (p-value 0.005), indicating the maximum deviation between these two distributions was 1.9%, a nearly imperceptible change. CONCLUSIONS: We therefore concluded that there is no clinically significant difference between the distribution of temperature in the United States and the distribution of temperature related to testicular torsion. We have shown using more than 150,000 individual days in individual cities and more than 9,000 cases of testicular torsion that there is no association between temperature and the prevalence of this disorder. We suggest abandoning this premise. Source of Funding: none

Resistant pediatric priapism: A real challenge for the urologist

Priapism in pediatric patients is a rare entity. We present an 8-year-old boy with known cerebral palsy. He came to the emergency department with sustained painful erection for 12 hours. Physical examination showed rigid penis. Blood count and biochemical analysis were normal. Although penile Doppler ultrasound revealed normal arterial and venous flow, cavernosal blood gas was hypoxic. A total of 50 mL of dark blood was aspirated, and 2 mL of 0.001% adrenalin solution was applied to both corpus cavernosum, twice within 20 minutes, which eventually did not achieve detumescence. A distal Winter shunt was performed at the end of which the penis was semi-flaccid. By the 18th hour of surgery, the penis re-gained painful erection status, so an Al-Ghorab shunt was performed. After the Al-Ghorab shunt, the penis was still in the semi-flaccid state. The next day, an angiography was performed and an arteriovenous fistula was discovered and treated by embolization. The flaccid state was achieved and the patient was discharged the day after the embolization.

593 URINE NGF, TGF BETA-1, TIMP-2 AND BLADDER WALL THICKNESS PREDICT UPPER URINARY TRACT DAMAGE AND URODYNAMIC FINDINGS IN CHILDREN WITH MYELODYSPLASIA

INTRODUCTION AND OBJECTIVES: Uroflowmetry or flow rate (FR) is frequently employed in daily paediatric urology (PU) practice both for diagnostic and follow-up purposes. Our goal was to determine the impact of FR in the management of patients seen in a tertiary care center. METHODS: Retrospective chart review of FR without electromyography (EMG) performed consecutively from January 1st to March 31st 2010. Patients that had a FR as part of their PU clinic appointment and available clinical information from the same date were included. Demographics, diagnosis, FR parameters and impact of the FR on management were collected. Impact on management was defined as indication for surgery, introduction of new medications, bladder retraining or biofeedback based on clinical AND FR findings. RESULTS: 524 patients (313 male, 211 female) were included in the study. Mean age was 8.2 years old. In 63 (12%) patients, FR was performed as part of the evaluation for the 1st clinic appointment. Most common diagnoses were: dysfunctional voiding (DV-32.5%), hypospadias (20.2%), vesicoureteric reflux without evidence of DV (VUR-12.8%), monosymptomatic nocturnal enuresis (NE-6.5%), posterior urethral valves (PUV-3.8%), post-circumcision meatal stenosis (MS-3.3%) and hydronephrosis (HN-3.1%). In the DV group, FR contributed to a management decision in 25.2% of patients. In the MS group, surgical intervention was based on symptoms and supported by the FR in 41% of patients; in the PUV group, 50% of patients demonstrated high ( 20cc) post-void residual (PVR), which aided in management decisions. In contrast, there were virtually no changes in management supported by the FR in the NE, HN, VUR and hypospadias groups. In fact, only 2 patients (1.9%) in the post-hypospadias repair group had surgery indicated based on FR findings coupled with symptoms, despite the finding of a prolonged or flat flow curve in 54% of patients in this group. Overall, FR parameters had direct influence in a management decision in only 67 (12.8%) patients. Nonetheless, a repeat test was ordered for 205 out of the remaining 457 patients (44.5%). CONCLUSIONS: In an era of financial restraints and in the context of a busy tertiary PU clinic, judicious use of FR for specific indications may translate into a more cost-effective use of time and resources. As expected, patients with DV were the ones that benefited the most from the test, as did patients with MS and PUV. Patients seen for NE and HN may not need a FR at all. Despite being frequently abnormal, FR in asymptomatic patients post-hypospadias repair had limited impact on management.