Stephanie Knüpfer

Do We Need Surveillance Urethro-Cystoscopy in Patients with Neurogenic Lower Urinary Tract Dysfunction?

Purpose To examine the value of surveillance urethro-cystoscopy in patients with neurogenic lower urinary tract dysfunction (NLUTD) in regard to the conflicting literature as it is generally agreed that patients with NLUTD are at increased risk for bladder cancer. Materials and Methods In a cross-sectional study, a consecutive series of 129 patients (50 females, 79 males, mean age 51, range 18–88) suffering from NLUTD for at least 5 years was prospectively investigated using urethro-cystoscopy and bladder washing cytology at a single university spinal cord injury (SCI) center. Results Due to suspicious urethro-cystoscopy and/or bladder washing cytology findings, 13 (10%) of 129 patients underwent transurethral resection of the bladder lesion and/or random bladder biopsies. Overall, 9 relevant histological findings were found in 5% (7/129) of our patients: bladder melanosis (n = 1), nephrogenic adenoma (n = 3), keratinizing squamous metaplasia (n = 1), intestinal metaplasia (n = 3), and muscle-invasive adenocarcinoma of the bladder (n = 1). Conclusions Using surveillance urethro-cystoscopy, we found relevant histological findings in 5% of our patients suffering from NLUTD for at least 5 years. Thus, surveillance urethro-cystoscopy might be warranted, although the ideal starting point and frequency remain to be determined in further prospective studies.

Sensory evoked potentials of the bladder and urethra in middle-aged women: the effect of age.

To investigate feasibility, reproducibility and age dependency of sensory evoked cortical potentials (SEPs) after electrical stimulation of different locations in the lower urinary tract (LUT) in a cohort of middle‐aged healthy women.

[Sentinel lymph node biopsy for penile carcinoma : Assessment of reliability].

BACKGROUND The European Association of Urologists recommends dynamic sentinel node biopsy (DSNB) as the first choice diagnostic approach for lymph node staging of non-palpable inguinal lymph nodes in penile carcinoma. The aim of this study was to assess the reliability of minimally invasive inguinal DSNB. MATERIAL AND METHODS Between 2004 and 2012 DSNB was used in all patients with invasive penile carcinoma and non-palpable inguinal lymph nodes. For assessment of reliability the rate of false negative results was determined and complications were documented. The results were analyzed prospectively. RESULTS In the study period DSNB was performed in a total of 29 patients and it was possible to prove lymph node metastasis in 2 patients with 1 patient who developed lymph node metastasis after a negative DSNB. Thus the false negative rate was 3.70 %. A morbidity rate of 3.45 % was also observed. CONCLUSION Sentinel lymph node biopsy is a reliable diagnostic method. The sophisticated requirements both methodologically and logistically suggest that this procedure should only be performed in specialized centres.

Sentinel-Lymphknotenbiopsie beim Peniskarzinom

BACKGROUND The European Association of Urologists recommends dynamic sentinel node biopsy (DSNB) as the first choice diagnostic approach for lymph node staging of non-palpable inguinal lymph nodes in penile carcinoma. The aim of this study was to assess the reliability of minimally invasive inguinal DSNB. MATERIAL AND METHODS Between 2004 and 2012 DSNB was used in all patients with invasive penile carcinoma and non-palpable inguinal lymph nodes. For assessment of reliability the rate of false negative results was determined and complications were documented. The results were analyzed prospectively. RESULTS In the study period DSNB was performed in a total of 29 patients and it was possible to prove lymph node metastasis in 2 patients with 1 patient who developed lymph node metastasis after a negative DSNB. Thus the false negative rate was 3.70 %. A morbidity rate of 3.45 % was also observed. CONCLUSION Sentinel lymph node biopsy is a reliable diagnostic method. The sophisticated requirements both methodologically and logistically suggest that this procedure should only be performed in specialized centres.

Sensory function assessment of the human male lower urinary tract using current perception thresholds

To evaluate the feasibility and reliability of current perception threshold (CPT) measurement for sensory assessment of distinct locations in the male lower urinary tract (LUT).

Urodynamic Investigation: A Valid Tool to Define Normal Lower Urinary Tract Function?

Objectives To evaluate whether urodynamic investigation (UDI), the gold standard to assess refractory lower urinary tract symptoms (LUTS), is appropriate to select healthy volunteers with apparent normal lower urinary tract function as control subjects for comparative studies. Subjects and Methods 42 healthy subjects (22 women, mean age 32±10 years; 20 men, mean age 37±12 years) without LUTS were included into this prospective single-centre cohort study. All subjects recorded a 3-day bladder diary, completed validated questionnaires regarding LUTS, and underwent neuro-urological assessment as well as free uroflowmetry. Same session repeat UDI was performed according to “Good Urodynamic Practice” recommended by the International Continence Society, but using an air-charged instead of a water-filled catheter, and evaluated by a blinded investigator. Results All 3-day bladder diaries, LUTS questionnaires, neuro-urological assessments and free uroflowmetries were within normal limits. Overall (either during the first or second UDI), same session repeat UDI revealed pathological findings in 71% (30/42): Detrusor overactivity was detected in 14% (3/22) and 30% (6/20), post void residual >100mL in 14% (3/22) and 25% (5/20), bladder outlet obstruction in 9% (2/22) and 20% (4/20) and detrusor sphincter dyssynergia in 77% (17/22) and 65% (13/20) of our women and men, respectively. Repeatability of detrusor overactivity (κ = 0.78, 95% CI: 0.54–1.02) and detrusor sphincter dyssynergia (κ = 0.77, 95% CI: 0.55–0.98) showed substantial agreement between both UDIs. All other assessed urodynamic parameters had wide 95% limits of agreement for differences in the parameters indicating poor repeatability. Conclusions More than 70% of our healthy subjects showed pathological urodynamic findings. Although UDI is the gold standard to assess refractory LUTS, it seems not to be applicable in healthy subjects to define normal lower urinary tract function. Therefore, we do not recommend using UDI to select healthy control subjects.

Prediction of autonomic dysreflexia during urodynamics: a prospective cohort study

BackgroundAutonomic dysreflexia is a severe and potentially life-threatening condition in patients with spinal cord injury, as it can lead to myocardial ischemia, brain hemorrhage, or even death. Urodynamic investigation is the gold standard to assess neurogenic lower urinary tract dysfunction due to spinal cord injury and reveal crucial pathological findings, such as neurogenic detrusor overactivity. However, neurogenic detrusor overactivity and urodynamic investigation are known to be leading triggers of autonomic dysreflexia. Therefore, we aimed to determine predictors of autonomic dysreflexia in individuals with spinal cord injury during urodynamic investigation.MethodsThis prospective cohort study included 300 patients with spinal cord injuries and complete datasets of continuous non-invasive cardiovascular monitoring, recorded during same session repeat urodynamic investigation. We used logistic regression to reveal predictors of autonomic dysreflexia during urodynamic investigation.ResultsWe found that level of injury and presence of neurogenic detrusor overactivity were the only two independent significant predictors for autonomic dysreflexia during urodynamic investigation. A lesion at spinal segment T6 or above (odds ratio (OR) 5.5, 95% CI 3.2–9.4) compared to one at T7 or below, and presence of neurogenic detrusor overactivity (OR 2.7, 95% confidence interval (CI) 1.4–4.9) were associated with a significant increased odds of autonomic dysreflexia during urodynamic investigation. Both odds persisted after adjustment for age, sex, and completeness and stage of injury (adjusted OR (AOR) 6.6, 95% CI 3.8–11.7, and AOR 2.2, 95% CI 1.1–4.5, respectively). Further stratification by lesion level showed level-dependent significantly increased adjusted odds of autonomic dysreflexia, i.e., from C1–C4 (AOR 16.2, 95% CI 5.9–57.9) to T4–T6 (AOR 2.6, 95% CI 1.3–5.2), compared to lesions at T7 or below.ConclusionsIn patients with neurogenic lower urinary tract dysfunction due to spinal cord injury, autonomic dysreflexia is independently predicted by lesion level and presence of neurogenic detrusor overactivity. Considering the health risks associated with autonomic dysreflexia, such as seizures, stroke, retinal bleeding, or even death, we recommend both continuous cardiovascular monitoring during urodynamic investigation in all spinal cord-injured patients with emphasis on those with cervical lesions, and appropriate neurogenic detrusor overactivity treatment to reduce the probability of potentially life-threatening complications.Trial registrationClinicalTrials.gov, NCT01293110.

[Therapy-refractory overactive bladder: alternative treatment approaches].

The treatment of patients with overactive bladder (OAB) refractory to conventional treatment is gaining clinical significance. This article intends to review alternative therapy options for patients with OAB refractory to conventional treatment. A search of the PubMed database as well as the abstracts presented at the European Association of Urology and the American Urological Association annual meetings was conducted. Keywords used during this search included overactive bladder (OAB) refractory to conventional treatment, electromotive drug administration (EMDA), sacral neuromodulation, augmentation cystoplasty and cystectomy. Eighteen articles with an adequate number of patients were identified. All articles published before 2001 were not included in this analysis. Because of first-line treatment failure, 30% of the patients required alternative treatment. This included EMDA, botulinum toxin injections into the detrusor, sacral neuromodulation, augmentation cystoplasty or cystectomy. Based on this review it appears that a significant improvement in micturition parameters, continence and in quality of life was achieved. Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains the last choice of treatment in refractory cases.Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains to be the last choice of treatment in refractory cases.ZusammenfassungDie Therapie der anticholinergikarefraktären überaktiven Blase (OAB) ist ein Problem mit zunehmender klinischer Relevanz. Dieser Reviewartikel soll eine Übersicht über den aktuellen Stand der alternativen Therapieoptionen in Patienten geben, die refraktär auf anticholinerge Medikamente sind.Die Literaturrecherche erfolgte Online unter PubMed und es wurden Abstractbände der Jahrestagungen der europäischen und amerikanischen Urologenvereinigung berücksichtigt. Die Suchwörter waren: Anticholinergikarefraktäre OAB („overactive bladder“), Botulinumtoxininjektion, Electro-Motive-Drug Administration, sakrale Neuromodulation, Blasenaugmentation, Zystektomie. Es wurden 18 Artikel berücksichtigt. Die Einschlusskriterien waren Publikationsdatum sowie die Anzahl des Kollektivs. Ausgeschlossen wurden Artikel, deren Publikationsdatum länger als eine Dekade zurücklag. Alternative Therapieansätze aufgrund therapierefraktärer OAB benötigten 30% der betroffenen Patienten. Alternative Therapieansätze beinhalten die Electromotive-drug-administration- (EMDA-)Therapie sowie die Botulinumtoxin-Injektion (BTX), die weniger invasiv sind als die invasiven Therapieansätze wie die sakrale Neuromodulation oder als Ultima ratio die Blasenaugmentation bzw. die Zystektomie.In Zusammenschau der Arbeiten ergab sich eine signifikante Verbesserung der Miktionsverhältnisse, der Kontinenzsituation, sowie der Lebensqualität. Insgesamt scheinen EMDA, BTX sowie die sakrale Neuromodulation eine wirksame und sichere Alternative nach Versagen der primären konservativen Therapie zu sein. Als Ultima ratio gelten die Blasenaugmentation bzw. die Zystektomie.AbstractThe treatment of patients with overactive bladder (OAB) refractory to conventional treatment is gaining clinical significance. This article intends to review alternative therapy options for patients with OAB refractory to conventional treatment. A search of the PubMed database as well as the abstracts presented at the European Association of Urology and the American Urological Association annual meetings was conducted. Keywords used during this search included overactive bladder (OAB) refractory to conventional treatment, electromotive drug administration (EMDA), sacral neuromodulation, augmentation cystoplasty and cystectomy. Eighteen articles with an adequate number of patients were identified. All articles published before 2001 were not included in this analysis. Because of first-line treatment failure, 30% of the patients required alternative treatment. This included EMDA, botulinum toxin injections into the detrusor, sacral neuromodulation, augmentation cystoplasty or cystectomy. Based on this review it appears that a significant improvement in micturition parameters, continence and in quality of life was achieved. Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains the last choice of treatment in refractory cases.Overall EMDA, intradetrusor injections of botulinum toxin and sacral neuromodulation seem to be highly effective and safe. Augmentation cystoplasty or cystectomy remains to be the last choice of treatment in refractory cases.

Antibiotic prophylaxis may not be necessary in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections for neurogenic detrusor overactivity.

Many of the patients undergoing intradetrusor onabotulinumtoxinA injections for refractory neurogenic detrusor overactivity (NDO) present with chronic bacteriuria. In these patients, antibiotic prophylaxis has been widely recommended since bacteriuria might impair treatment efficacy and cause urinary tract infections (UTI) but the evidence is limited. The aim of this study was to evaluate if an antibiotic prophylaxis is needed in patients with asymptomatic bacteriuria undergoing intradetrusor onabotulinumtoxinA injections. Between 06/2012 and 12/2014, a consecutive series of 154 patients undergoing a total of 273 treatment cycles were prospectively evaluated. Before treatment urine samples were collected, patients with no clinical signs for UTI underwent onabotulinumtoxinA injections, no antibiotic prophylaxis was given. Asymptomatic bacteriuria was found in 73% (200/273 treatments). Following treatment, UTI occurred in 5% (9/200) and 7% (5/73) of patients with and without bacteriuria, respectively. Intradetrusor onabotulinumtoxinA injections were clinically and urodynamically successful in 70% (192/273). There was no association between bacteriuria and treatment-related adverse events (odds ratio 0.64, 95% CI 0.23–1.81, p = 0.4) nor between bacteriuria and therapy failure (odds ratio 0.78, 95% CI 0.43–1.43, p = 0.4). Thus, we conclude that antibiotic prophylaxis needs to be critically reconsidered in patients undergoing intradetrusor onabotulinumtoxinA injections, especially taking into account the alarming antibiotic resistance worldwide.

Value and Efficacy of Sentinel Lymph Node Diagnostics in Patients With Penile Carcinoma With Nonpalpable Inguinal Lymph Nodes: Five-Year Follow-up.

Purpose Sentinel lymph node biopsy (SLNB) has been described as a minimally invasive method for lymph node staging in patients with a penile carcinoma and nonpalpable inguinal nodes in national and international guidelines of involved professional societies. However, this method is rarely used. The aim of this study was to validate reliability and morbidity of this method and to discuss radiation exposure of persons involved. Methods Twenty-eight patients with histologically negative sentinel lymph nodes in 47 groins with nonpalpable inguinal lymph nodes were included in this study (17 T1(a/b)-, 8 T2- and 3 T3-stages). We recorded prospectively all cases of lymph node recurrence and complications in patients with initially nonpalpable inguinal lymph nodes and histologically negative sentinel lymph nodes. False-negative findings and morbidity were calculated as qualitative criteria. Inguinal regions with palpable lymph nodes and/or evidence of metastases were not considered in accordance with the guidelines. Results During a median follow-up of 68 (4–131) months, we observed one case of bilateral lymph node recurrence and one case of prolonged inguinal lymphorrhea, which could be managed conservatively. Per inguinal region, false-negative rate was 4.25%, and morbidity rate was 2.12%; seen per patient, the rates were both 3.57%. Conclusions Sentinel lymph node biopsy under use of radioactive tracers is a reliable method of lymph node staging in patients with penile carcinoma and nonpalpable inguinal lymph nodes. The methodical complexity is justified by high reliability and low radiation exposure for both patient and medical staff and low morbidity rates.