Sara Lenherr

Urodynamics: with a focus on appropriate indications.

The purpose of this article is to update urologists on contemporary indications and techniques for adult urodynamic testing. The discussion includes examples of specific clinical questions and appropriate urodynamic testing techniques to address these questions. It includes quality control measures and examples of testing pitfalls with troubleshooting methods.

Glycaemic control and risk of incident urinary incontinence in women with Type 1 diabetes: results from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study

To study the impact of glycaemic control on urinary incontinence in women who participated in the Diabetes Control and Complications Trial (DCCT; 1983–1993) and its observational follow‐up study, the Epidemiology of Diabetes Interventions and Complications (EDIC; 1994–present).

Voiding Dysfunction and Upper Tract Deterioration after Spinal Cord Injury

This is a review of the most current literature on the evaluation and management of the urinary system after spinal cord injury (SCI). Spinal cord injury virtually always results in some degree of neurogenic bladder (NGB) dysfunction. While it is widely accepted that NGB dysfunction is associated with an increased risk of urologic complications, consensus regarding screening for those complications, and medical or surgical management is not widely accepted. Regarding screening for complications, an annual renal ultrasound is an appropriate screening test to assess for renal pathology including stones. General guidelines for urodynamic evaluation in patients with SCI were recently published and do not explicitly recommend routine testing. Regarding NGB complications, neurogenic bladders are most prone to urinary tract infections and stones. Medical, equipment and surgical options are all aimed at decreasing the risk of these complications in SCI patients.

The S-CAHPS Survey in Urology

Introduction: The S‐CAHPS survey assesses patient experience and satisfaction with 1 episode of surgical care. We describe the initial implementation, results and experience using S‐CAHPS in urology. Methods: This was a prospective, institutional review board approved, observational study at a tertiary care academic medical center. Adult patients who underwent elective outpatient or 23‐hour observation surgery during a 33‐month period were mailed the survey. Survey content was separated into composites 1 to 6 and percent top box scoring (percent of most positive responses) was performed. Summary scores for each composite were correlated with the mean of a global surgeon rating question. Results: A total of 430 surveys were returned for a 33.8% response rate. Respondents were statistically older than nonrespondents and more likely to reside in Michigan (p <0.05). Mean ± SD global surgeon rating was 9.50 ± 1.04 on a scale of 0—worst to 10—best surgeon possible. Global surgeon rating correlated most highly with the question composites for “How well surgeon communicates with patients after surgery” (composite 5, &tgr; = 0.459), followed by “Information to help you recover from surgery” (composite 4, &tgr; = 0.400). Conversely, there was lower correlation with composites pertaining to “Information to help you prepare for surgery” (composite 1, &tgr; = 0.251). Conclusions: Survey results suggest that patient satisfaction with the surgeon is more influenced by postoperative communication and information than by preoperative counseling and decision making processes. This underscores the importance of attention to continued postoperative care and interactions. The role of S‐CAHPS in urology requires further exploration in this era of quality improvement.Abbreviations and Acronyms: C: composite; CAHPS®: Consumer Assessment of Healthcare Providers and Systems; H‐CAHPS: Hospital CAHPS; S‐CAHPS: Surgical Care CAHPS.

Cystoscopic findings: a video tutorial.

Introduction and hypothesisCystoscopy is frequently performed by gynecologists to ensure ureteral patency and to prevent bladder injury when performing concomitant gynecological procedures. Generally, there are no additional findings on cystoscopy; however, when abnormalities arise, they may require either observation or intervention. Our aim was to create a visual library of benign, malignant, and foreign-body pathological conditions incidentally encountered on cystoscopy.MethodCystoscopic findings were videotaped at the time of routine surgical care. Regarding Institutional Review Board approval, individual consent was waived as the videos were de-identified and collected for educational purposes.ResultsBenign pathological conditions: squamous metaplasia, duplicated ureteral orifice, ureterocele, Hutch diverticulum, bladder trabeculation, urachal cyst, interstitial cystitis with and without Hunner’s lesion, endometriosis in the bladder, port-wine stain due to Klippel–Trénaunay–Weber syndrome, nephrogenic (mesonephric) metaplasia, and cystitis glandularis (intestinal metaplasia). Malignant pathological conditions: papillary urothelial neoplasm of low malignant potential (PUNLMP), carcinoma in situ (CIS), high-grade urothelial carcinoma, and urachal cancer. Foreign-body pathological conditions: edema from ureteral stents and stone-encrusted mesh.ConclusionThis video is intended to educate the audience on some incidental bladder findings seen on female cystoscopy. Many pathological conditions can be biopsied or treated immediately during the procedure; hence, early urology consultation is encouraged for most abnormalities.

Spinal cord injury and male infertility—a review of current literature, knowledge gaps, and future research

Spinal cord injury (SCI) affects nearly half a million new patients worldwide, with 17,700 in the US each year, and disproportionately impacts young males of reproductive age. Almost every aspect of male reproduction is affected by SCI, resulting in: erectile, endocrine and sexual dysfunction, decreased sperm motility despite an often-normal count, and abnormal semen emission and ejaculation. The aim of this review is to focus on how SCI impacts testicular spermatogenesis, sperm function, semen quality, and overall fecundity while discussing what is not known, and future avenues for research.

How to Measure Quality-of-Life Concerns in Patients with Neurogenic Lower Urinary Tract Dysfunction

There is an evolving role for quality-of-life measures and patient-reported outcomes in the evaluation of neurogenic lower urinary tract dysfunction. We review available health-related quality-of-life instruments and patient-reported outcomes measures used in the assessment of patients with neurogenic bladder. We also discuss considerations for incorporation of these measures into clinical and patient-reported research. Emphasizing patient-reported outcomes in neurogenic bladder research will guide clinicians and other stakeholders to improve quality of life in this patient population.

PD64-04 QUALITY OF LIFE ASSOCIATED WITH BLADDER MANAGEMENT STRATEGY AFTER SPINAL CORD INJURY

patterns of core and levator ani muscles during exoskeleton-assisted over ground walking vs treadmill walking with body-weight support in motor complete SCI vs able bodied controls. METHODS: Surface EMG were recorded from the rectus abdominis, external oblique, erector spinae (ES) and levator ani bilaterally. Foot switch signals linked heel strike to EMG activity (Biometrics Ltd, Newport, UK). Baseline, quiescent EMG activity were recorded for 20 sec. during sitting and support (by exoskeleton) standing. EMG activity during exoskeleton-assisted walking were recorded over ground with the Ekso and on the treadmill with Lokomat . 40-60 steps were recorded during each walking trial, and walking speed was matched. Protocol was matched in controls. Bladder diaries and validated LUTS scores were completed. RESULTS: 3 SCI (ASIA A levels T4, T4,C7; 2 male 1 female, age 33-39 yrs, 2-25 yrs since injury) participated. EMG from PFM, abdominal and ES showed heightened activity during over ground exoskeleton-assisted walking compared to treadmill in both complete SCI and controls. Robust rhythmic bursting was observed in PFM with exoskeleton walking, but not during supported standing or sitting. Fig MVC % exoskeleton (red) vs supported treadmill (black) vs quiet rest (grey). CONCLUSIONS: EMG activity of PFM was demonstrable using over ground exoskeleton-assisted walking in motor complete SCI below the level of injury. Assisted gait training may reveal this preservation of function by imposing a higher demand on PFM compared to standing only. Potential activation of PFM with robotic gait training supports a novel direction in urologic management of SCI to challenge the levator ani; an important aspect in urinary tract function.

PD64-01 THE NEUROGENIC BLADDER SYMPTOM SCORE (NBSS): AN ASSESSMENT OF ITS EXTERNAL VALIDITY AND ABILITY TO DETECT CHANGE

INTRODUCTION AND OBJECTIVES: The Neurogenic Bladder Symptom Score (NBSS) has been validated as a tool to assess bladder quality of life and symptoms. The objective of this study was to externally validate the NBSS and assess responsiveness (ability of a questionnaire to detect change). METHODS: Data from the “Patient reported outcomes for bladder management strategies in spinal cord injury” study was used. Adult SCI patients were eligible for enrollment through direct recruitment or an open online portal. At the initial visit, patients provided an extensive medical history, and completed the NBSS. Responsiveness was assessed in a separate prospective cohort of patients undergoing their first injection of onabotulinum toxin. Medians, interquartile range (IQR), and Pearson correlation coefficient (r) are reported. RESULTS: 609 patients had complete NBSS scores. Median age was 48 (IQR 36-57), and 67% were male. The majority had thoracolumbar lesions (51%) and managed their bladder by CIC (63%). The median NBSS total score was 22 (IQR 15-30, possible range 0 (no symptoms) to 74 (severe symptoms)), and median quality of life was ‘mixed’. The Cronbach’s alpha of the total score was 0.85, and 0.93, 0.76, and 0.49 for the incontinence, storage/ voiding, and consequences domains respectively. All item to domain correlations were moderate to strong (r 0.3) aside from 3/7 of the items from the consequences domain. Appropriate hypothesized correlations between the NBSS domains and external variables (such as the number of prior urinary infections and the NBSS consequences domain (r1⁄40.51, p 0.01) were observed. There was no significant correlation between overall quality of life and prior hospitalizations for urinary infections, or incontinence pad usage. A separate cohort of 15 patients with neurogenic bladder competed the NBSS pre and post onabotulinum toxin injection, and the mean change in the total NBSS score was -12 (IQR -2 to -25). The mean change of the incontinence domain was -9 (IQR -1 to -15) and -3 (IQR -2 to -5) for the storage/voiding domain. The change scores had a large to moderate effect size (total NBSS (0.91), incontinence domain (1.03), storage/voiding domain (0.69)) suggesting appropriate and clinically relevant responsiveness. CONCLUSIONS: The NBSS demonstrated good validity in a large cohort of SCI patients. Similarly, the total NBSS score and relevant domains were responsive to change, and can be used to assess the impact of an intervention.

MP14-14 MANAGEMENT OF RADIATION THERAPY ONCOLOGY GROUP (RTOG) GRADE 4 UROLOGIC COMPLICATIONS OF RADIOTHERAPY FOR PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Grade 4 RTOG complications after radiotherapy (XRT) for prostate cancer (CaP) are purportedly rare; however, the literature is limited by short follow up and lack of surgical management outcomes. We hypothesized that grade 4 complications require complex surgical management with high morbidity. METHODS: A retrospective/prospective review identified men with RTOG grade 4 urinary complications after XRT for CaP referred in a 5-year period to a tertiary care center. We excluded patients with progression to grade 4 complications after treatment for incontinence or erectile dysfunction. XRT was classified as dual therapy (radical prostatectomy (RRP) followed by external beam radiotherapy (EBRT), or various combinations of XRT) or monotherapy (single modality XRT). Complications were classified as outlet (urethral stricture, bladder neck contracture, prostate necrosis, and recto-urethral fistula) or bladder (contraction, necrosis, fistula, ureteral stricture, hemorrhage). RESULTS: We identified 67 men with a median age of 74 years. 42 (63%) had dual therapy, consisting of RRP + EBRT (18), high dose rate brachytherapy (HDR) + EBRT (18), low dose rate brachytherapy (LDR) + EBRT (4), and other dual XRT (2). 25 (37%) patients had monotherapy consisting of EBRT (4), HDR (9), LDR (10), or proton beam (2). Complications were isolated to the bladder in 4 (6%), the outlet in 46 (67%), and both in 17 (25%). The majority of outlet problems were identified as urethral obstruction (n1⁄448, 72%). Complications were managed conservatively in 17 (25%) cases (no intervention besides intermittent catheterization or local treatment), with indwelling catheters in 14 (21%), by urinary diversion (UD) in 21 (31%) (conduit or catheterizable pouch), and with reconstruction in 17 (25%). Reconstruction consisted of ureteral (4), recto-urethral fistula repair (2), and posterior urethroplasty (11). Success was achieved in 15/17 (88%) cases. Two failures were treated by UD and suprapubic tube. Hyperbaric oxygen (HBO2) was used in 25 (37%), gracilis flap in 14 (21%), and increased to 65% for both in the reconstructive group. CONCLUSIONS: RTOG grade 4 complications were most common in those patients that underwent dual therapy, but there was significant morbidity regardless of treatment modality. Reconstruction is successful in highly selected patients. Outcomes are improved with HBO2 and gracilis flaps. Grade 4 complications necessitated UD in one out of three patients. Further series with longer follow up are necessary to define and predict the outcomes in these patients.