Julian Shah

Angiomyolipoma of the bladder wall

An 18-year-old man underwent magnetic resonance imaging for a lumbar disk hernia, which revealed a large solid 5.5 3 4 3 3.5 cm. mass between the prostate and left obturator internus muscle, apparently not invading the surrounding structures but causing an impression on the left bladder wall. The tumor seemed to be directly related to the bladder and there was no evidence of pelvic lymphadenopathy or distant metastases. Pelvic ultrasonography showed a heterogeneous mass arising from the left bladder wall, which seemed to be submucous and had hyperechoic central areas surrounded by a relatively hypoechoic structure (fig. 1). The patient was admitted to the hospital. He had no symptoms, and physical examination, urinalysis and laboratory studies were normal. A transperineal biopsy under transrectal ultrasonographic control was performed. Microscopic examination was consistent with a mesenchymal smooth muscle tumor without signs of malignancy (fig. 2, A). Immunoreactivity for HMB-45 suggested the diagnosis of angiomyolipoma, which is also known as perivascular epithelioid cell tumor. Because malignant degeneration of angiomyolipoma has rarely been described and to avoid possible future growth or hemorrhagic complications the patient agreed to surgical intervention. A 5.5 3 3.5 3 4 cm. solid mass, elastic in consistency and grayish-white, arising from the muscular wall of the bladder and loosely adherent to other pelvic structures was excised

THE RELATIONSHIP BETWEEN BLADDER MANAGEMENT AND HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH SPINAL CORD INJURY

Study design: Cross-sectional study. Objectives: (1) To assess the relationship between bladder management methods and the healthrelated quality of life (HRQL) in patients with spinal cord injury (SCI). (2) To identify any correlation between the two questionnaires used to assess the quality of life (one validated for SCI and one validated for bladder symptoms). Setting: Spinal Cord Injury Centre, Royal National Orthopaedic Hospital, Middlesex, UK. Methods: This study is based on two questionnaires with results collected from 142 people with SCI. The two questionnaires were based on information from the Short-Form 36-Item Health Survey (SF-36) and the King’s Health Questionnaire and included demographic characteristics, bladder management methods and the frequency of incontinence. Results: There is a moderate correlation between the results of the SF-36 and the King’s Health Questionnaire. Only 21% SCI patients report normal voiding without any other form of bladder management. The type of bladder management may influence the HRQL in patients with SCI. Clean intermittent catheterization by attendant, indwelling transurethral catheterization and indwelling suprapubic catheterization are the three groups with the worst mental status. In addition, the frequency of incontinence is a strong influence on HRQL. Conclusions: The results of this study may provide a general baseline HRQL for patients with SCI. Our findings show the relationships between bladder management methods and quality of life in patients with SCI. In addition, the impact of incontinence on quality of life was also confirmed. Spinal Cord (2010) 48, 319–324; doi:10.1038/sc.2009.132; published online 20 October 2009

MP85-16 COMPARISON OF URODYNAMIC PARAMETERS FOLLOWING INJECTION OF TWO DIFFERENT BOTULINUM TOXIN A PREPARATIONS IN MANAGEMENT OF NEUROGENIC DETRUSOR OVER-ACTIVITY FOLLOWING SPINAL CORD INJURY

CONCLUSIONS: This is the first study to demonstrate safety and efficacy of intravesical incobotulinumtoxin A in patients with neurogenic or idiopathic detrusor overactivity. Incobotulinumtoxin A may be an attractive alternative to onabotulinumtoxin A, especially given its lower cost. Small sample size limits this data, however early results suggest improvements in quality of life and bladder dynamics. A larger, prospective study will be required to validate these findings.

Male Stress Incontinence

All health professionals are familiar with the problem of stress urinary incontinence in females. Female anatomy predisposes to incontinence of urine due to sphincter weakness and in particular in association with childbirth. Health professionals however are less likely to be aware of the problem of stress incontinence in males, which does not usually occur as a primary condition. Since a male is not subjected to childbirth, the pelvic floor does not become weak unless it is affected by specific medical conditions. Thus stress urinary incontinence is much less common in males and less likely to present. Men have a tendency to draw less attention to the problem of urinary incontinence. Although a cause of much distress, incontinence in males tends to often remain a hidden condition. Incontinence is a common condition worldwide and leads to much suffering and in addition significant cost to society.

898 The medium term outcomes of stoma formation for patients undergoing conduit diversion for functional aetiology: 5 Year follow-up

INTRODUCTION AND OBJECTIVES: Clostridium difficile (CD) colitis is at historically high levels, leading to increased complications and costs in patients undergoing major abdominal surgery involving the gastrointestinal tract. We sought to assess if screening and empiric treatment of preoperative asymptomatic CD carriers would decrease symptomatic CD colitis in patients undergoing cystectomy and urinary diversion METHODS: A prospective evaluation of CD carrier status was undertaken in patients undergoing cystectomy and urinary diversion between January-September 2015 by testing stool samples at the time of surgery. Patients identified as CD carriers were treated with intravenous metronidazole until return of bowel function. The incidence of clinically symptomatic CD colitis was assessed in this intention to treat cohort and compared to a retrospective cohort of 562 patients that underwent cystectomy during 2010-2013. RESULTS: A total of 78 patients were included in the intention to treat analysis, of which 62 (79%) were screened intraoperatively for CD. Of those screened, 18 (30%) were asymptomatic carriers of CD. The incidence of patients who developed symptomatic CD colitis in the intention to treat cohort was 3.8% (3/78 patients). Of those 3 patients, 2 were negative for CD preoperatively and 1 was unknown. None of the treated patients developed CD colitis or adverse outcomes. When compared to the historical cohort which had aCD colitis incidence of 8.8%, the relative risk reduction was 57% with a number needed to treat of 20. CONCLUSIONS: Cystectomy patients were found to have a high incidence of asymptomatic CD. Identification and treatment of asymptomatic carriers at time of surgery seems to decrease the incidence of CD colitis. Further studies are warranted to assess the utility and cost of testing for CD status followed with empiric treatment.

PD11-12 PREDICTING A SUCCESSFUL OUTCOME WITH SACRAL NEUROMODULATION TESTING: ARE URODYNAMIC PARAMETERS DURING FILLING CYSTOMETRY PROGNOSTIC?

INTRODUCTION AND OBJECTIVES: Sacral neuromodulation (SNM) is an effective treatment modality for medically refractory overactive bladder (OAB). Standard selection criteria are based on frequency-volume charts, pad weight (objective) assessments, and patient reported (subjective) outcomes. Little is reported of the utility of urodynamic study in selecting patients for SNM therapy. We assessed whether the urodynamic parameters during filling cystometry correlated with successful outcome from first stage SNM testing. METHODS: All OAB patients were screened prior to first stage testing with urodynamics to confirm (idiopathic) detrusor overactivity (IDO). The mean voided volumes, peak amplitude of IDO contraction, compliance and end fill pressure was recorded. Primary outcomes were assessed using frequency-volume charts, pad testing and ICIQ/EQ5D questionnaires. Success was considered if patients achieved >50% improvement in urinary symptoms. Conversion to a permanent SNM implant was undertaken according to response. The predictive value of the four parameters was assessed using binary logistic regression analysis. RESULTS: 177 consecutive IDO patients had first stage SNM evaluation between 2010 and 2013. The mean voided volume for patients with successful response was 184 (147-223) mls and for those with failed response 171 (128-214) mls, peak DO pressure was 41.0 (29-52) cmH20 compared to 40 (28-52) cmH20, compliance pressure 12 (7-16) cmH20 compared to 49 (3-95) cmH20, and end fill pressure 25 (19-30) cmH20 compared to 24 (14-33) cmH20. Logistic regression analysis did not demonstrate any significant relationship between peak detrusor pressure and outcome (B 1⁄4 -0.005, 0.001, 0.026, 0.016 respectively) (Figure 1). Figure 1: Box plots representing the distribution of mean void volume, peak DO, compliance and end-fill pressures with first stage SNM testing. Box borders illustrate the upper, median and lower quartiles; whiskers depict the 99% interval. Extreme (star) and mild (circle) outliers are also shown. CONCLUSIONS: There was no correlation between any urodynamic parameter and successful SNM outcome. SNM is an option for all IDO patients, regardless of their dynamic bladder function on filling cystometry.

761 Outcomes of transobturator tape procedure for the treatment of stress incontinence in females with neuropathic bladders

Study design, materials and methods Thirty women (mean age 61.9 years; range 35-87 years) with neuropathic bladder dysfunction and Video-cystometrogram (VCMG) confirmed stress urinary incontinence were treated with transobturator tape procedure in a single institution. The clinical notes, yearly clinical follow-up, VCMG, and the Patient Global Impression of Improvement (PGI-I) were analysed. Success was defined as very much improved/ much improved on PGI-I, patient reported continence on physical activity and lack of evidence for stress incontinence on urodynamics.

Long-term Results of Surgery for Stress Urinary Incontinence — A Urologist’s View

29.3 Treatment for Stress Urinary Incontinence . . . . . . . . 398 29.3.1 Surgery for Stress Incontinence . . . . . . . . . . . . . . 398 29.3.1.1 Outcome of Surgery for Stress Incontinence . . . . . . . 399 29.3.2 Open Colposuspension . . . . . . . . . . . . . . . . . . . 399 29.3.3 Laparoscopic Colposuspension . . . . . . . . . . . . . . 400 29.3.4 Endoscopic Bladder Neck Suspensions . . . . . . . . . . 400 29.3.5 Suburethral Slings . . . . . . . . . . . . . . . . . . . . . 400 29.3.6 Periurethral Injections . . . . . . . . . . . . . . . . . . . 400 29.3.7 Artificial Urinary Sphincter . . . . . . . . . . . . . . . . 401