Johan Gani

Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: a study and review.

To compare the findings of multidetector computed tomography (CT) with surgical pathology and magnetic resonance imaging (MRI), to determine the accuracy of delineating the superior extent of inferior vena cava (IVC) thrombotic involvement in renal cell cancer (RCC).

Underactive Bladder: Clinical Features, Urodynamic Parameters, and Treatment

Purpose: Underactive bladder is a complex clinical condition that remains poorly understood due to limited literature. This study aimed to determine its prevalence among patients with voiding dysfunction, presenting symptoms, risk factors, urodynamic findings, and ongoing treatment. Methods: A retrospective chart review of consecutive urodynamic studies performed on voiding dysfunction between 2012 and 2014 was conducted to identify patients with detrusor underactivity. Detrusor underactivity was defined by a bladder contractility index of less than 100. Charts and urodynamic tracings were examined for patient demographics, suspected risk factors, presenting symptoms, urodynamic parameters, and treatment undertaken. Descriptive statistics were utilized to analyze the data. Results: The prevalence of detrusor underactivity in this study was 23% (79 of 343). Average age of the patients was 59.2 years (range, 19–90 years). Women represented 68.4% (54 of 79) of the patients. The most common reported symptoms were urinary urgency (63.3%), weak stream (61.0%), straining (57.0%), nocturia (48.1%), and urinary frequency (46.8%). Prior pelvic surgery and prior back surgery were noted in 40.5% and 19.0% of the patients, respectively. The most common management was intermittent self-catheterization in 54.4%, followed by observation/conservative treatment in 25.3% and sacral neuromodulation in 12.7%. Conclusions: Although underactive bladder is a common condition, its precise diagnosis and treatment remain a challenge. Its symptoms significantly overlap with those of other bladder disorders, and hence, urodynamic evaluation is particularly useful in identifying patients with impaired detrusor contractility. This will help prevent mismanagement of patients with surgery or medical therapy, as that may worsen their condition. Much work needs to be done to better understand this condition and establish optimal management of patients.

Long-term complications in men who have early or late radiotherapy after radical prostatectomy.

INTRODUCTION Choosing adjuvant radiotherapy (RT) or salvage RT after radical prostatectomy (RP) for locally advanced prostate cancer is controversial. Performing RT early after RP may increase the risk of urinary complications compared to RT performed later. We evaluated the urinary complication rates of men treated with surgery followed by early or late RT. METHODS Using a retrospective chart review, we compared rates of urinary incontinence (UI), bladder neck contracture (BNC), or urethral stricture in men with prostate cancer treated with early RT (<6 months after RP) or late RT (≥6 months after RP), 3 years after RT. RESULTS In total, 652 patients (between 2000 and 2007) underwent early RT (162, 24.8%) or late RT (490, 75.2%) after RP. The mean time to early RT was 3.6 months (range: 1-5 months) and to late RT was 30.1 months (range: 6-171 months). At 3 years post-RT, UI rates were similar in the early RT and the late RT groups (24.5% vs. 23.3%, respectively, p = 0.79). Prior to RT, 27/652 (4%) patients had a BNC and 11/652 (1.7%) had a urethral stricture, of which only 1 BNC persisted at 3 years post-RT. After RT, 17/652 (2.6%) BNC and 4/652 (0.6%) urethral stricture developed; of these, 6 BNC and 2 urethral strictures persisted at 3 years. CONCLUSION Rates of UI, BNC, and urethral stricture were similar with early and late RT at 3 years post-RT. These findings suggest that the timing of RT after RP does not alter the incidences of these urinary complications and can aid in the decision-making process regarding adjuvant RT versus salvage RT.

The underactive bladder: diagnosis and surgical treatment options

The underactive bladder (UAB)/detrusor underactivity (DU) is a relatively common condition. It is difficult to diagnose and can be difficult to manage. The aim of this review is to provide a review of the diagnosis and different surgical treatment options for UAB/DU. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, UAB, DU, TURP, reduction cystoplasty, bladder diverticulectomy and sacral neuromodulation (SNM). Search results were assessed for their overall relevance to this review. Definitions, general overview and management options were extracted from the relevant medical literature. DU affects up to 45% of men and women >70 years of age. The symptoms of DU overlap significantly with overactive bladder (OAB) and bladder outlet obstruction (BOO). Urodynamic findings include low voiding pressure combined with slow intermittent flow and incomplete bladder emptying. Non-operative management for DU is acceptable; only 1 in 6 male patients may need a TURP and acute urinary retention (AUR) is rare. TURP for DU is feasible and is associated with good short and medium term outcomes, but over time, there is a return to baseline symptoms. Bladder diverticulectomy can also improve DU, but there is a paucity of guidelines on patient selection. SNM provides excellent outcomes for DU, but patient selection is important.

Impact of bladder dysfunction in the management of post radical prostatectomy stress urinary incontinence—a review

Bladder dysfunction is a relatively common urodynamic finding post radical prostatectomy (RP). It can be the sole cause of post prostatectomy incontinence (PPI) or may be found in association with stress urinary incontinence (SUI). The aim of this review is to provide a comprehensive review of the diagnosis and different treatments of post RP bladder dysfunction. A comprehensive literature review using medical search engines was performed. The search included a combination of the following terms, PPI, detrusor overactivity (DO), detrusor underactivity (DU), impaired compliance, anticholinergic, onabotulinumtoxinA (Botox®) and sacral neuromodulation (SNM). Definitions, general overview and management options were extracted from the relevant medical literature. DO, DU and impaired compliance are common and may occur alone or in combination with SUI. In some patients the conditions exist pre RP, in others they arise due to denervation and surgical changes. DO can be treated with anticholinergics, Botox® and SNM. DO may need to be treated before SUI surgery. DU may be a contraindication to male sling surgery as some patients may go into urinary retention. Severely impaired bladder compliance may be a contraindication to SUI surgery as the upper tracts may be at risk. Each individual dysfunction may affect the outcome of PPI treatments and clinicians should be alert to managing bladder dysfunction in PPI patients.

Intravesical OnabotulinumtoxinA Injection for Overactive Orthotopic Ileal Neobladder: Feasibility and Efficacy

The efficacy of intravesical onabotulinumtoxinA (BTXA) in the treatment of overactive bladder (OAB) has been well documented. The use of BTXA injection in orthotopic neobladders is yet to be studied. We present 4 cases of patients injected with intravesical BTXA for overactive orthotopic ileal neobladder. We recorded patient demographics, presenting and follow-up symptoms, urodynamic profiles, and Patient Global Impression of Improvement (PGI-I) scores. The 4 patients reported varying degrees of subjective improvements in the symptoms, including urgency, urge incontinence, and pad usage. Mean follow-up duration was 8.3 months (range, 5–14 months). Average PGI-I score was 3 (“a little better”) (range, 2–4). To our knowledge, the current study is the first case series examining BTXA injection for orthotopic neobladder overactivity. BTXA injection yielded varying degrees of objective and subjective improvements, without significant complications. Intravesical BTXA injection is feasible and may be considered as a potential treatment alternative for OAB in orthotopic neobladders, although further study is warranted.

Position statement: a clinical approach to the management of adult non-neurogenic overactive bladder.

Introduction: Overactive bladder (OAB) is a highly prevalent medical condition that has an adverse impact on various health‐related quality‐of‐life domains, including a significant psychosocial and financial burden. This position statement, formulated by members of the Urological Society of Australia and New Zealand and the UroGynaecological Society of Australasia, summarises the current recommendations for clinical diagnosis and treatment strategies in patients with non‐neurogenic OAB, and guides clinicians in the decision‐making process for managing the condition using evidence‐based medicine.

JSM HIGHLIGHTSManagement of Erectile Dysfunction in Patients with Sickle Cell Disease (CME)

A 27-year-old man with a history of heterozygous sickle cell trait was referred with ED. Other than hypertension, he had no other significant medical history and, in particular, no history of priapism. He took amlodipine for his hypertension and had a smoking history of 15 cigarettes per day for 10 years. He was a migrant from an African nation 10 years ago and was found to have the sickle cell trait after arriving in North America. He was generally asymptomatic from the sickle cell trait. His hematologist’s instructions to him were to avoid severe exertion, especially dehydration, so as to prevent a sickle cell crisis. He described a gradual worsening of his ED in the last 6 months. He had been married for 5 years and was in a stable relationship. There was no history of premature ejaculation and his libido had been normal. Blood work, including bioavailable testosterone levels, was normal, and the cause of his ED was thought to be multifactorial (vasculogenic, medication related, and possibly psychogenic). We were concerned about his increased risks of priapism because there had been case reports of that even in sickle cell trait patients. He was given a trial dose of sildenafil (50 mg, on-demand), which was successful in treating his ED without causing priapism.

PD39-04 SACRAL NEUROMODULATION FOR DETRUSOR HYPERACTIVITY WITH IMPAIRED CONTRACTILITY

other groups. Mean UI episodes/day at BL were 3.9, 4.8, 5.2, 5.7 and 6.0 in the <40, 40-49, 50-59, 60-69 and 70 groups. A robust treatment response was noted in all groups including substantial reductions in UI episodes/day (-2.4, -2.6, -3.1, -3.6 and -2.9) and % change in UI (-60.8%, -50.4%, -62.4%, -64.4% and -46.8%). High proportions of pts in all groups achieved 50% UI reduction (range: 58.2%-71.1%), a positive TBS response (range: 66.2%-73.8%) and improvements from BL in KHQ domain scores ~3-6x the minimally important difference (-5 points). Urinary tract infection was the most common AE in all groups. CONCLUSIONS: In this large cohort of onabotA-treated OAB pts, CIC risk increased slightly with age but was low in all age groups and accompanied by substantial reductions in UI, improvements in QOL and treatment benefit. The <40 group had the lowest rate of CIC (1.1%) with a duration of 3 days. OnabotA was well tolerated in all age groups.

Urodynamic findings in Susac syndrome: first reported filling cystometrogram

Susac syndrome is a rare neurological disease, with only 300 cases reported in the literature. Lower urinary symptoms are not an uncommon feature of the disease, yet there is no information on specific dysfunction typical urodynamic findings associated with the disease. We present what we believe to be the first reported filling cystometrogram study of Susac syndrome for the evaluation of voiding dysfunction.