Paholo Barboglio Romo

Non-surgical urologic management of neurogenic bladder after spinal cord injury

PurposeTo review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function.MethodsA literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT).ResultsIntermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion.ConclusionThe Joint SIU-ICUD (Société Internationale d’Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

Multi-institutional Outcomes for Simultaneous and Staged Urinary and Fecal Diversions in Patients Without Cancer

OBJECTIVE To compare the morbidity and postoperative recovery between patients treated with urinary diversion after colostomy with patients undergoing simultaneous double diversion (DD). METHODS A multi-institutional retrospective review was performed in patients treated with urinary diversion after colostomy or simultaneous DD between 2007 and 2014 for noncancerous indications. The Clavien-Dindo system was used to classify complications occurring within 90 days of surgery, and high-grade adverse events (HGAE) were classified grade 3 or higher. RESULTS A total of 46 patients were identified with fecal and urinary diversions (19 in the after colostomy (AC) group, 27 in the DD group). Common indications for urinary diversion were neurogenic bladder (54%) and urinary fistula (44%). Mean hospital stay and return of bowel function after surgery for entire cohort was 13 and 7 days, respectively, with no differences between AC and DD groups. Almost 50% of patients in the cohort experienced an HGAE but there was no difference in HGAE incidence (8/19 AC, 13/27 DD; P = .69) or complication type between the groups. Increased operative time (5% risk per every 15 minutes over 7 hours, P = .03) was the only independent variable associated with increased risk of HGAE. DD was not independently associated with increased risk of HGAE compared with staged urinary diversion. CONCLUSION Morbidity and postoperative recovery appeared similar whether urinary diversion is performed after colostomy or during a DD.

Peripheral and Sacral Neuromodulation in the Treatment of Neurogenic Lower Urinary Tract Dysfunction

Sacral and peripheral neuromodulation are minimally invasive surgical procedures that are third-line therapy options for the treatment of patients with idiopathic overactive bladder syndrome. There has been interest in their efficacy in the management of neurogenic lower urinary tract dysfunction (NLUTD). Contemporary data suggest promising outcomes for urinary and bowel symptoms in carefully selected patients with spinal cord injury and/or multiple sclerosis. This article reviews the current literature regarding urinary and bowel outcomes in patients with NLUTD and also discusses contemporary studies that suggest that treatment during particular stages of neurologic injury may prevent long-term urinary sequelae.

Comparative evaluation of physical characteristics of different inflatable penile prostheses

Abstract Objective: The aim of this study was to describe and evaluate existing inflatable penile prostheses (IPPs) in an independent laboratory setting. Materials and methods: New IPPs were obtained from two manufacturers: American Medical Systems (AMS) and Coloplast. The AMS 700™ LGX (18 cm), CX (18 cm) and CXR (14 cm), and the Coloplast Titan® Touch (18 cm) and Titan Narrow (14 cm) were investigated. Internal pressure, length and girth of the cylinders were measured at 2 ml increments. A urodynamic individual transducer connected to an analogue amplifier and recording system was used to measure pressure. Rigidity and axial loading of the different IPPs were evaluated with a compression system. Results: Regular-size prostheses were inflated to 22 ml and narrow prostheses to 16 ml. The Titan Touch had a girth of 17.8 mm at 22 ml compared to 15.6 mm for the AMS 700 LGX and 16.5 mm for CX. The AMS 700 LGX increased in length by 13 mm from baseline, a feature that was unique among all the tested prostheses. Rigidity curves as assessed by compression showed significant variability, with both Titan prostheses and the AMS CXR exhibiting similar patterns and requiring a higher load to reach 50% compression. The buckling experiment showed different patterns of deformity. Conclusions: The results suggest that these prostheses exhibit significant physical differences. The clinical impact of these differences is poorly elucidated. These variations in behavior of the prostheses could be considered by physicians and patients when objectively assessing the choice of prosthesis. These findings could aid in objective patient counseling.

Neuromodulation in Neurourology

Data suggests that peripheral and sacral neuromodulation are minimally invasive surgical interventions to address and improve both urinary and bowel symptoms in patients with neurogenic bladder and/or bowel. There is lack of level one evidence and there is moderate data supporting the use of these therapies to address overactive bladder symptoms in patients with neurogenic bladder. There is still controversy about their utility for urinary retention, and data is limited regarding treatment of neurogenic bowel. Limitations include small sample size, heterogeneous neurologic etiologies of study populations, and measurement of different outcomes, and most studies are retrospective analyses. Nonetheless more contemporary data suggests promising outcomes in specific situations that could statistically and clinically improve urinary and bowel symptoms in patients with spinal cord injury and multiple sclerosis. Current research is studying the effect of early utilization of sacral neuromodulation after spinal cord injury. Targeting of specific stages of a neurologic injury will address the question of who is an optimal candidate and may ultimately benefit from this intervention. Avoiding the neurologic impairment that occurs at the bladder and bowel level may prevent detrimental changes in organ physiology and improve symptoms in the long term.

PD25-12 EVALUATION OF INFLATABLE PENILE PROSTHESES: HOW THEY PERFORM IN THE LAB?

RESULTS: A total of 210 AMS IPP with Conceal reservoirs were included in this study. From this data set, there were four cases (1.9%) with reservoir-related mechanical failure or complication requiring revision surgeries. Of those four, two cases (0.95%) were mechanical failures resulting from the reservoir leaking. In both cases, the cause of leak was identified as an intrinsic point of weakness at the apex of the reservoir caused by inward folding of an unfilled segment. The inward folding of the reservoir was observed at volumes of 60 to 80 mL. In the remaining two cases (0.95%), the reservoir complication observed was refractory abdominal muscle pain related to ectopic location and intra-fascial placement. In both cases, revision surgery with reservoir repositioning resolved the pain. CONCLUSIONS: While ectopic placement of the Conceal reservoir is mechanically reliable, it must be filled in excess of 80 mL to prevent inward reservoir folding and resultant reservoir leakage. Additionally, with surgical consent, it is prudent for the patient to be counseled on the possibility of abdominal muscle pain when the reservoir is placed ectopically, though they should be informed that such pain is a rare side effect.

PD34-09 THE UTILITY OF UROFLOWMETRY PARAMETERS IN URETHROPLASTY SURVEILLANCE IS LIMITED

INTRODUCTION AND OBJECTIVES: Urethral stricture disease is common condition with significant quality of life and economic implications. While endoscopic treatment with incision or dilation is the most common treatment approach, guidelines increasingly recommend urethroplasty based on its high success rates. Whether real world, community practice outcomes mirror those of large volume single center institutional series is unknown. For these reasons, we conducted a population-based study of patients treated with urethroplasty and their outcomes. METHODS: We identified male patients who underwent urethroplasty between 2001 and June 2015 based on ICD-9 codes and administrative claims from a large, national US health insurer (ClinformaticsTM Data Mart Database, OptumInsight, Eden Prairie, MN). We assessed utilization of endoscopic treatments (urethrotomy and dilation) prior to and after urethroplasty. We defined urethroplasty failure by any subsequent urethral dilation, urethrotomy, or urethroplasty after initial urethroplasty. We examined factors associated with failure using multivariable logistic regression and Cox proportional hazards models. RESULTS: We identified 1345 patients treated with urethroplasty. Urethroplasty failure occurred in 344 (26%) of patients. Repeat urethroplasty was performed in 139 (40%) of failures (range 28). Increased number of endoscopic treatments prior to first urethroplasty was associated with urethroplasty failure. The mean ( SD) time to failure was 270 42 days. CONCLUSIONS: Our population-based study demonstrated significantly lower success rates for urethroplasty than previously published reports. Strategies to achieve better outcomes for patients with urethral stricture disease include increasing referrals to reconstructive urologic surgeons, and knowledge and technique transfer to community urologists interested in providing this service rather than repeated, low-value endoscopic treatment.

Autologous Fascial Slings

The autologous pubovaginal continues to represent an efficacious anti-incontinence procedure to address both complex and uncomplicated stress urinary incontinence. Adverse events from this surgical procedure have been well described over the past nearly four decades and severe complications are rare. The scope of this chapter was to describe the complications from autologous pubovaginal and their management. These adverse events are the result of inadvertent injury to adjacent pelvic structures which are ideally addressed and repaired during surgery when recognized. Clinically significant unrecognized complications usually present within the first postoperative day when there is a vascular or nerve injury or can take up to a week to unveil when associated with a bowel injury or wound complication. Immediate postoperative lower urinary symptoms are very common during the first days or weeks after surgery, and these usually resolve with time. However, evaluation and management of persistent or delayed presentation of urinary symptoms is recommended to address urinary obstruction, if present.