Yahir Santiago-Lastra

Long-Term Complications of the Neurogenic Bladder

It is widely accepted that neurogenic lower urinary tract dysfunction, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. However, certain patient profiles are at risk for this and other complications. This can be linked to their underlying neurologic disease process. Identifying risk profiles allows the provider to determine what surveillance strategies might be adopted. Risk factors for upper urinary tract deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and chronic indwelling catheterization. Other long-term complications include nephrolithiasis, refractory urinary incontinence, and malignancy.

Urinary Incontinence in Women: A Review.

Importance Urinary incontinence, the involuntary loss of urine, is a common health condition that may decrease quality of life. Ten to twenty percent of women and up to 77% of women residing in nursing homes have urinary incontinence, yet only 25% seek or receive treatment. Observations This review summarizes the evaluation and therapeutic options for women affected by urinary incontinence. The initial assessment should focus on understanding the effect of incontinence on quality of life, the patient’s goals and preferences for treatment, the results of previous treatments, and the presence of concomitant conditions, such as advanced pelvic organ prolapse, that may require referral. Infection and hematuria need to be ruled out. In the absence of urinary infection or serious underlying pathology (such as cancer or serious neurologic disease) associated with urinary incontinence, the clinician should initiate unsupervised pelvic muscle exercises and lifestyle modifications appropriate to the patient to reduce her symptoms. These recommendations can include weight loss, adequate hydration, avoidance of excessive fluids, and regular voiding intervals that reduce urgency incontinence episodes. Urgency incontinence medications, with timely reassessment of symptoms, can be started without extensive evaluation. Specialist treatments for urgency incontinence include onabotulinumtoxinA and percutaneous or implanted neuromodulators. Stress incontinence surgery, the midurethral sling, is associated with symptom improvement in 48% to 90% of women and has low rates of mesh complications (<5%). Conclusions and Relevance Urinary incontinence is common in women, although few seek care despite many effective treatment options. Clinicians should prioritize urinary incontinence detection, identify and treat modifiable factors, incorporate patient preference into evaluation and treatment, initiate conservative and medical therapy, and refer to specialists when underlying pathology is identified or conservative measures are ineffective.

Urinary Diversion for Severe Urinary Adverse Events of Prostate Radiation: Results from a Multi-Institutional Study

Purpose: We evaluated the short and long‐term surgical outcomes of urinary diversion done for urinary adverse events arising from prostate radiation therapy. We hypothesized that patient characteristics are associated with complications after urinary diversion. Materials and Methods: We performed a retrospective cohort study of 100 men who underwent urinary diversion (urinary conduit or continent catheterizable pouch) due to urinary adverse events after prostate radiotherapy from 2007 to 2016 from 9 academic centers in the United States. Outcome measurements included predictors of short and long‐term complications, and readmission after urinary diversion of patients who had prostate cancer treated with radiotherapy. The data were summarized using descriptive statistics and univariate associations with complications were identified with logistic regression controlling for center. Results: Mean patient age was 71 years and median time from radiotherapy to urinary diversion was 8 years. Overall 81 (81%) patients had combined modality therapy (radical prostatectomy plus radiotherapy or various combinations of radiotherapy). Grade 3a or greater Clavien‐Dindo complications occurred in 31 (35%) men, including 4 deaths (4.5%). Normal weight men had more short‐term complications compared to overweight (OR 4.9, 95% CI 1.3–23.1, p=0.02) and obese men (OR 6.3, 95% CI 1.6–31.1, p=0.009). Hospital readmission within 6 weeks of surgery occurred for 35 (38%) men. Surgery was needed to treat long‐term complications after urinary diversion in 19 (22%) patients with a median followup of 16.3 months. Conclusions: Urinary diversion after prostate radiotherapy has a considerable short and long‐term surgical complication rate. Urinary diversion most often cannot be avoided in these patients but appreciation of the risks allows for informed shared decision making between surgeons and patients.

Literature Review: Long-Term Complications of the Neurogenic Bladder

This is a review of the most recent literature on the long-term complications of the neurogenic bladder (NGB). It is widely accepted that this condition, when left untreated, has a natural history that has a potential for causing deterioration of renal function over time. Consensus has not been reached regarding what patient profiles are at highest risk for these complications, as well as what surveillance strategies should be adopted. Chronic kidney disease (CKD) may be more prevalent in the NGB population than previously reported in the literature, as creatinine may not accurately reflect true renal function in these patients. Risk factors for upper urinary tract (UUT) deterioration include loss of bladder compliance, repeated bouts of pyelonephritis, and presence indwelling catheterization. Reduced access to urologic care and lack of adequate surveillance are also correlated with increased risk of upper tract complications. The urodynamic evaluation (urodynamic study (UDS)) has an important role in diagnosing the patient’s underlying bladder pathology, but surveillance with UDS has not yet been linked to improved outcomes. Particularly vulnerable are those patients with decreased functional status or those requiring input from a multidisciplinary team. Some patients develop refractory NGB and UUT risk or overt deterioration. Treatment options that can offer benefit include onabotulinum A injections, augmentation cystoplasty with or without sling placement, or urinary diversion.

Extended Case Duration and Hypotension Are Associated With Higher-grade Postoperative Complications After Urinary Diversion for Non-oncological Disease

OBJECTIVE To report survival for patients who undergo urinary diversion for benign indications and to identify risk factors for morbidity at 90 days. METHODS This is a retrospective review of consecutive urinary diversions with or without cystectomy for non-oncological indications at a single institution. The indication for diversion was intractable incontinence, upper tract deterioration, urinary fistula, and unmanageable bladder pain. Patients were categorized according to their most severe complication within 90 days of surgery, using the Clavien-Dindo system. Multivariable analysis was performed to identify factors associated with high-grade complications. Survival analysis was performed. RESULTS Between 2007 and 2014, 141 patients underwent urinary diversion for non-oncological indications. The postoperative rate of high-grade adverse events (class III or greater) was 28%. Risk factors for class III or greater complications at 90 days included prolonged intraoperative mean arterial pressure below 75% of baseline, operative duration greater than 343 minutes, and postoperative vasopressor requirement. Kaplan-Meier survival analysis demonstrated a 1- and 5-year survival of 88.4% and 77.2%, respectively. The long-term survival of patients who experienced higher-grade complications was not statistically different from the survival of the rest of the group. The study was limited by a retrospective design and sample size in identifying additional variables associated with increased risk of long-term mortality. CONCLUSION Urinary diversion for non-oncological conditions has a good 5-year survival in this cohort. Extended case duration and hemodynamic instability during or immediately after urinary diversion are associated with a high-grade complication within 90 days of the procedure.

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.

Urologic Cancer Surveillance in Patients With Bladder Augmentation

Augmentation cystoplasty (AC) is a surgical enlargement of the bladder, typically performed by suturing detubularized colon or ileum to the superior aspect of the bladder to achieve an increase in volume. Augmentation is a surgical procedure most commonly performed in patients with neurogenic bladder (NGB) who have failed other therapies. Surgical treatment has an advantage over medical therapy by permanently increasing the bladder capacity and decreasing bladder overactivity, which in turn reduces incontinence episodes and improves bladder compliance. In the long term, however, it is uncertain what risk of malignancy exists for these patients given that this augmentation is often performed when the patient is a child or young adult. This review will explore the current and past literature on the risk for malignancy in this population and the available data on the best way to follow these patients for bladder cancer. Based on the available literature, bladder cancer in the NBG patient is rare, but often presents at higher stage and has a greater risk of mortality than bladder cancer in the general population. Surveillance, in the form of yearly cystoscopy (±random biopsies) and urine cytology, has not been successful at detecting bladder cancer at low stage and has not proven a cost-effective strategy. Symptomatic patients should always undergo prompt evaluation with a high index of suspicion, but yearly screening in the asymptomatic patient is not currently recommended.

The effects of cystoscopy and hydrodistention on symptoms and bladder capacity in interstitial cystitis/bladder pain syndrome

The use of cystoscopy and hydrodistention in the management of interstitial cystitis/bladder pain syndrome (IC/BPS) varies widely between providers. Current evidence regarding the risks and benefits of hydrodistention, as well as the long term effects of repeated hydrodistention are not well established. We sought to characterize the effects of hydrodistention on IC/BPS symptoms as well as bladder capacity.

Urological Surveillance and Medical Complications among Ault Spina Bifida Medicare Beneficiaries

OBJECTIVE To evaluate urologic follow-up and prevalence of medical complications among adult patients in the United States with myelomeningocele (MMC) who are Medicare beneficiaries. METHODS We performed a retrospective study using a 5% Medicare sample from 2007 to 2010. We defined acceptable minimum follow-up criteria as patients receiving all of the following: serum creatinine, upper urinary tract imaging, and a urologist evaluation within a 2-year period. We queried associated diagnoses and relevant complications using International Classification of Diseases, Ninth Revision codes, graded based on clinical impact. A regression model identified factors associated with evaluation completeness as well as with increased prevalence of medical complications. RESULTS We identified 825 patients with MMC, predominantly Caucasian (85.1%) and female (61.3%), with a mean age of 51.2 ± 17.2 years. Only 33.5% of the patients met the minimum acceptable follow-up criteria. Forty-four percent saw a urologist within the 2-year period. Most complications observed were mild, observed in 27.6% of patients. Moderate and severe complications were observed in 17.0% and 6.6% of patients, respectively. The most common complications were cystitis (16.4%), pressure ulcers (7.1%), chronic kidney disease (4.4%), and pyelonephritis (3.7%). Logistic regression indicated that younger age, male gender, and adequate follow-up were associated with increased prevalence of complications. CONCLUSION Despite high prevalence of complications in patients with MMC, most are not receiving the minimum recommended follow-up. The 33.5% of patients who received adequate surveillance were diagnosed with more complications, likely secondary to improved disease ascertainment. Prospective studies are needed to look at follow-up strategies and how these can improve outcomes for patients with MMC.

Introducing “The Impact of Neurologic Disease on the Urinary Tract”

cl in ic s. co m We are very pleased to deliver a comprehensive issue of Urologic Clinics, focusing on “The Impact of Neurologic Disease on the Urinary Tract.” We hope that this issue will serve as an excellent guide on the best and latest evidence on relevant topics within this theme, applicable to urologists and other health professionals spanning a wide range of expertise. Neurogenic lower urinary tract dysfunction, more commonly referred to as neurogenic bladder, can affect all ages and can occur because of a congenital condition, acutely acquired event, or chronically degenerative condition. Almost all neurologic conditions can be associated with some degree of neurogenic lower urinary tract dysfunction. The basic principles of Neurourology are straightforward: protecting renal function, maintaining continence, ensuring a safe bladder that stores and empties well without stones or infections, and preserving quality of life in this vulnerable population. However, there are a limited number of providers who are well versed in the treatment of neurogenic bladder, and there is great need for more health care professionals that are able to see and treat these patients. Our central theme for this issue was that neurogenic lower urinary tract dysfunction can be specific to the underlying neurologic condition. In short, not all patients with a diagnosis of neurogenic bladder are the same. Practitioners need an understanding of both how the underlying