Jeroen R. Scheepe

Percutaneous nephrolithotomy for treating renal calculi in children

There are various topics covered in the paediatric section this month. Another series of percutaneous nephrolithotomy is reported, as is the necessity or not to use the GFR in the follow‐up of children who have had a unilateral nephrectomy.

TAILORED LAMINECTOMY: A NEW TECHNIQUE FOR NEUROMODULATOR IMPLANTATION

PURPOSEnNeuromodulation of sacral roots is an alternative mode of therapy for patients with urge incontinence or detrusor hypocontractility. We investigated the effects of sacral (S3) nerve stimulation in patients using a new surgical approach for sacral neuromodulator implantation. Modification of the implantation method with sacral laminectomy and bilateral electrode placement led to distinct improvement of stimulation, positioning and dislocation. We developed tailored laminectomy for bilateral neuromodulator electrode implantation to minimize surgical trauma.nnnMATERIALS AND METHODSnTailored laminectomy was performed in 6 patients with urge incontinence and 3 with a hypocontractile detrusor. After making a 10 cm. longitudinal skin incision we exposed the spinous processes of S2 and S3. Instead of complete 2-level laminectomy, only 2 oval laminectomy holes were made with a high speed ball drill. An electrode fixation hole was drilled at the edge of the laminectomy window and the wire was fixed with nonabsorbable suture material.nnnRESULTSnIn patients with idiopathic urge incontinence (followup 12.5 months, range 7 to 18) the number of leaks decreased from 7.2 to 0 daily and functional bladder capacity increased from 298 to 352 ml. In patients with a hypocontractile detrusor (followup 10.5 months, range 6 to 20) detrusor pressure increased during voiding from 12 to 34 cm. water and post-void residual decreased from 350 to 58 ml. Average surgery time was 2 hours 15 minutes. In 1 case a seroma developed near the impulse generator.nnnCONCLUSIONSnTailored laminectomy is a fast, minimally invasive and reliable technique for neuromodulator implantation.

Chronische sakrale bilaterale Neuromodulation Einsatz einer minimalinvasiven Implantationstechnik bei Patienten mit Blasenfunktionsstörungen

ZusammenfassungIn der Literatur werden die Misserfolgsraten mit der von Tanagho und Schmidt beschriebenen unilateralen Stimulation mit bis zu 50% angegeben. Zur Verbesserung der Modulationseffektivität und besseren Elektrodenplatzierung und Fixation führen wir eine minimale sakrale Laminektomie mit bilateraler Elektrodenplatzierung durch.Bei insgesamt 20 Patienten wurde nach erfolgreichem PNE-Test (periphere Nervenevaluierung) ein sakraler Neuromodulator mit bilateraler Elektrodenplatzierung implantiert. Zur besseren Elektrodenplatzierung und Fixierung wurde eine minimal-invasive Laminektomie durchgeführt.Bei den Patienten mit Detrusorinstabilität reduzierten sich die Inkontinenzepisoden von durschnittlich 7,2 auf 1 pro Tag, die Blasenkapazität stieg von 198 auf 352 ml. Bei den Patienten mit hypokontraktilem Detrusor reduzierten sich die Restharnwerte von 450 auf 108 ml. Der maximale Detrusorkontraktionsdruck während der Miktion stieg von 12 auf 34 cm H2O.Mit der bilateralen sakralen Neuromodulation und mit der von uns entwickelten Implantationstechnik sind optimale Ergebnisse bei Patienten mit therapierefraktären Detrusorinstabilitäten und Patienten mit hypokontraktilem Detrusor zu erzielen.AbstractThe implantable neuromodulation system described by Tanagho and Schmidt enables unilateral sacral nerve stimulation. Reports have been made on sacral neuromodulation failures of up to 50% in patients undergoing this procedure. We chose the bilateral electrode implantation and a minimal invasive laminectomy to ensure a more effective modulation and better placement and fixation of the electrodes.After successful assessment using a peripheral nerve evaluation test, 20 patients (14 with detrusor instability, 6 with hypocontractile detrusor) underwent minimally invasive laminectomy and bilateral electrode placement. In the patients with detrusor instability, the incontinence episodes were reduced from 7.2 to 1 per day and the bladder capacity improved from 198 to 352 ml. In patients with hypocontractile detrusor, the initial residual urine level of 450 ml dropped to 108 ml. Maximum detrusor pressure during micturition rose from 12 cmH2O initially to 34 cmH2O. The average follow up period was 17.5 months. There was no sign of deterioration in the modulation effect in any of the patients.Bilateral electrode implantation and the new sacral approach allow optimal neuromodulation in patients with bladder dysfunction. Laminectomy enables optimum electrode placement and fixation with minimal trauma.

Changes in bladder wall blood oxygen saturation in the overactive obstructed bladder.

PURPOSEnSeveral studies suggest that hypoxia of the bladder wall contributes to bladder dysfunction but the exact relation between bladder function and blood oxygen saturation, a surrogate marker for hypoxia, is not known. We determined bladder wall blood oxygen saturation in vivo in an animal model of bladder outlet obstruction to establish the exact relation between blood oxygen saturation and bladder function.nnnMATERIALS AND METHODSnIn 8 sham operated and 8 urethrally obstructed guinea pigs we measured blood oxygen saturation of the bladder wall by differential path length spectroscopy before surgery and 8 weeks postoperatively. Urodynamic investigations performed during the whole 8-week period provided data on bladder function.nnnRESULTSnBefore surgery and 8 weeks after sham surgery blood oxygen saturation in the bladder wall was between 88% and 95% during filling. It decreased during voiding and returned to greater than 90% within 30 seconds. Eight weeks after obstruction saturation was significantly lower than in the sham operated group during filling and voiding. The decrease was positively related to bladder pressure during filling and voiding, and was more pronounced when overactivity was present. Local bladder contractions occurred without a measurable increase in bladder pressure but were associated with a decrease in saturation.nnnCONCLUSIONSnA normal bladder maintains a high oxygen saturation level during filling. Bladder obstruction compromises this ability, especially when it involves overactivity. Local bladder contractions without a measurable increase in bladder pressure were associated with a decrease in blood saturation.

Female sexual dysfunction in multiple sclerosis: Results of a survey among Dutch urologists and patients

The objective of this study was to determine the prevalence of female sexual dysfunction (FSD) in patients with Multiple Sclerosis (MS) in one of the leading MS centers in the Netherlands. Furthermore, we evaluated the practice patterns of members of the Dutch Urological Association (DUA) with respect to FSD.

Recurrence After Radical Prostatectomy for Organ-Confined Prostate Cancer

Background: Some patients from our radical prostatectomy (RPx) series with organ-confined (pT2) prostate cancer and negative surgical margins show a PSA (prostate specific antigen) relapse. Aim of the study was to analyze this cohort of patients that otherwise would have been considered to be cured. Patients and Methods: Since the introduction of PSA measurement in the follow-up after RPx, 475 pelvic lymph node dissections with subsequent RPx were performed in our department from 1988 to 1997. Of these, 227 were classified as pT2, 34 (15%) exhibited positive surgical margins, and 4 others were excluded due to an inadequate follow-up. Of the remaining 189 patients (study cohort), 19 (10%) developed a biochemical progression, defined as a minimum of 2 consecutive PSA measurements ≧ 0.1 ng/ml. Only in one of them a G3 tumor was present. Median follow-up was 19.1 months. Results: The Kaplan-Meier analysis of biochemical progression showed that after 1, 2 and 5 years, 95% (confidence interval (Cl) 91–99%), 91% (Cl 86–96%), and 77% (Cl 55–89%) of the patients were free of progression, respectively. This means that roughly one fourth of pT2 tumors will become progressive despite negative surgical margins. These 19 patients were subdivided into 4 groups: 1: biopsy-proven local recurrence (n = 2); 2: suspected local recurrence defined as slowly rising PSA ≤ 2 ng/ml, but negative biopsies (n = 12); 3: distant metastasis proven by radiologic imaging (n = 1); 4: suspected distant metastasis defined as rapidly rising PSA > 9 ng/ml without direct radiologic evidence (n = 4). Preoperatively all patients from groups 3 + 4 had negative bone scans and 4/5 had preoperative PSA values < 10 ng/ml. In total 7 patients with proven recurrence or with proven metastasis had positive biopsies. Conclusion: A pathological diagnosis of organ-confined prostate cancer (pT2) and a meticulous analysis of negative surgical margins do not exclude the occurrence of local relapses in 7% (14/189), and there is evidence for suspect hematogenic spread of PC cells in at least 2% (4/189) of patients.

Influence of sildenafil on blood oxygen saturation of the obstructed bladder

BackgroundBlood oxygen saturation (BOS) is decreased in a low-compliant, overactive obstructed bladder. The objective of this study is to determine the effect of Sildenafil (SC) on bladder function and BOS) in an in vivo animal model of bladder outlet obstruction.MethodsThirty-two guinea pigs; sham operated (nu2009=u20098), sham operatedu2009+u2009SC (nu2009=u20098), urethrally obstructed (nu2009=u20098) and urethrally obstructedu2009+u2009SC (nu2009=u20098) were studied during an 8xa0week period. BOS of the bladder wall was measured by differential path-length spectroscopy (DPS) before obstruction, at day 0, and at week 8. The bladder function was evaluated by urodynamic studies every week.ResultsBefore surgery and after sham operation all study parameters were comparable. After sham operation, bladder function and BOS did not change. In the obstructed group the urodynamic parameters were deteriorated and BOS was decreased. In the group obstructionu2009+u2009SC, bladder compliance remained normal and overactivity occurred only sporadic. BOS remained unchanged compared to the sham group and was significantly higher compared to the obstruction group.ConclusionsIn an obstructed bladder the loss of bladder function is accompanied by a significant decrease in BOS. Treatment of obstructed bladders with SC yields a situation of high saturation, high bladder compliance and almost no overactivity. Maintaining the microcirculation of the bladder wall might result in better bladder performance without significant loss of bladder function. Measurement of BOS and interventions focussing on tissue microcirculation may have a place in the evaluation / treatment of various bladder dysfunctions.

In vivo measurement of bladder wall oxygen saturation using optical spectroscopy

Current diagnosis, follow-up and treatment of patients suffering from bladder dysfunction are mainly symptom-targeted. A recently recognized cause of continuing bladder function loss is a deteriorated bladder microvasculature. Incorporating this aspect into the clinical diagnostic toolbox may improve treatment results. Recent developments in the field of optical spectroscopy now allow for non-invasive measurement of microvascular blood oxygen saturation in living tissue. We have recently reported pre-clinical data that show that this marker can be successfully measured in an animal bladder. In the animal model the marker differentiated bladders with loss of function from those with normal function. In the present paper, we report on the first in vivo measurement of this marker in the human bladder, as proof of principle, in the muscle of bladders with a normal function.

Maximum Urethral Closure Pressure Increases After Successful Adjustable Continence Therapy (ProACT) for Stress Urinary Incontinence After Radical Prostatectomy

OBJECTIVEnTo evaluate changes of the urethral pressure profile (UPP) after implantation of adjustable continence therapy (ProACT), a minimally invasive procedure in which 2 volume-adjustable balloons are placed periurethrally for treatment of male stress urinary incontinence. The working mechanism of the ProACT to achieve continence has not been fully understood. We hypothesized that successful treatment with ProACT improves urinary continence by inducing a significant increase in static urethral pressure.nnnMATERIALS AND METHODSnWe included patients who underwent UPP before and after ProACT implantation. UPPs were initially performed with the Brown-Wickham water perfusion method and later with the T-DOC Air-Charged catheter method. Pre- and postoperative UPPs and International Prostate Symptom Scores were evaluated. UPP measurements of successfully (no or 1 precautionary pad per day) and unsuccessfully treated patients were compared.nnnRESULTSnTwenty-seven patients were included in the study; 23 patients were successfully and 4 patients were unsuccessfully treated. Maximum urethral closure pressure (MUCP) increased significantly from median 58.0 to 79.0u2009cmH2O in the successfully treated group (Pu2009=u2009.001). Within the subgroup of unsuccessfully treated patients, MUCP did not change significantly (Pu2009=u2009.715). The change in MUCP was statistically significantly different between the successful and unsuccessful group (Pu2009=u2009.034). Total score of the International Prostate Symptom Scores did not change significantly after ProACT implantation (Pu2009=u2009.097).nnnCONCLUSIONnSuccessful treatment with ProACT is associated with a significant increase of MUCP. This implies that increased static urethral pressure contributes to the working mechanism of the ProACT device to achieve continence.

Breaking the vicious circle: Onabotulinum toxin A in children with therapy-refractory dysfunctional voiding

INTRODUCTIONnAn increased activity of the external urethral sphincter or pelvic floor muscles during voluntary voiding leads to dysfunctional voiding. Frequently reported symptoms are urinary incontinence, urinary tract infections and high post-void residuals. Dysfunctional voiding is a common problem in school-aged children and despite various treatment options, 10-40% of the children remain therapy-refractory.nnnOBJECTIVEnThe aim of this study is to evaluate the effectiveness of Onabotulinum toxin-A (BTX-A) injections in the external urethral sphincter in children with therapy-refractory dysfunctional voiding.nnnPATIENTS AND METHODSnPatients with therapy-refractory dysfunctional voiding who have received BTX-A injections in the external urethral sphincter from 2010 to 2013 were analysed. Children with known neuropsychiatric disorders were excluded. All children had abnormal flow patterns and increased pelvic floor tone during uroflowmetry/EMG studies. They had received at least five sessions of urotherapy and two sessions of pelvic floor physical therapy prior to treatment. A total of 100 IU of BTX-A was injected in the external urethral sphincter at the 3, 9 and 12 oclock positions. Our main outcome measures were urinary incontinence, recurrent urinary tract infections and post-void residual.nnnRESULTSnA total of twenty patients, of whom 16 girls, with a median age of 9 years (range 5-14) were treated with BTX-A. The median follow-up was 13 months (range 5-34). Post-void residual decreased by 75% after BTX-A, from a median of 47.5 ml (16.3-88.5 ml) to 0 ml (0.0-28.0 ml) (p = 0.001) Six patients had a post-void residual < 20 ml prior to treatment. After BTX-A sixteen patients had a post-void residual <20 ml (Figure). No significant changes in uroflowmetry results was seen. Sixteen children are no longer daily incontinent, of whom 9 became completely dry (p = 0.0001). Eleven patients suffered from recurrent urinary tract infections prior to treatment. After BTX-A five children remained infection free, while the other six experienced only one urinary tract infection during follow-up (p = 0.003). Fourteen patients received additional urotherapy after BTX-A. Repeat injections were necessary in four patients after initial satisfactory results, with repeated good clinical responses. Two children showed no improvement after first BTX-A injection. No serious adverse events were reported.nnnDISCUSSIONnThe results in this homogenous group of patients confirm the conclusions of previous studies in opting BTX-A in the external urethral sphincter to be a viable treatment option for the therapy-refractory group of patients with dysfunctional voiding. What is new, is that in most of our patients post-injection urotherapy was used to amplify the BTX-A effect. During our long-term follow-up the satisfactory results were sustained, similar to the results of the long-term follow-up presented by Vricella et al. [1]. The retrospective character and relative small sample size are limitations of this study.nnnCONCLUSIONSnThis study shows safe and persistent satisfactory results during our average 13-month follow-up in 90% of our patients with therapy-refractory dysfunctional voiding. A prospective study using validated and standardized measurements will be performed to affirm our results and evaluate the exact role of post-injection urotherapy.