Real-World Data Regarding Satisfaction to Botulinum Toxin A Injection into the Urethral Sphincter and Further Bladder Management for Voiding Dysfunction among Patients with Spinal Cord Injury and Voiding Dysfunction

Purpose: This study aimed to investigate improvement in voiding condition after the initial botulinum toxin A (BoNT-A) injection into the urethral sphincter among patients with chronic spinal cord injury (SCI) and voiding dysfunction. Moreover, subsequent surgical procedures and bladder management were evaluated. Materials and Methods: From 2011 to 2020, 118 patients with SCI and dysuria who wanted to void spontaneously received their first BoNT-A injection at a dose of 100 U into the urethral sphincter. Improvement in voiding and bladder conditions after BoNT-A treatment were assessed. Next, patients were encouraged to continually receive BoNT-A injections into the urethral sphincter, convert to other bladder managements, or undergo surgery. After undergoing bladder management and surgical procedures, the patients were requested to report improvement in voiding condition and overall satisfaction to bladder conditions. Then, data were compared. Results: In total, 94 male and 24 female participants were included in this analysis. Among them, 51 presented with cervical, 43 with thoracic, and 24 with lumbosacral SCI. After BoNT-A injections into the urethral sphincter, 71 (60.2%) patients, including 18 (15.3%) with excellent, and 53 (44.9%) with moderate improvement, had significant improvement in voiding condition. Patients with cervical SCI (66.6%), detrusor overactivity and detrusor sphincter dyssynergia (72.0%), partial hand function (80.0%), and incomplete SCI (68.4%) had a better improvement rate than the other subgroups. Only 42 (35.6%) patients continually received treatment with BoNT-A injections into the urethral sphincter. Meanwhile, more than 60% of patients who converted their treatment to augmentation enterocystoplasty (n = 5), bladder outlet surgery (n = 25), BoNT-A injections into the detrusor muscle (n = 20), and medical treatment (n = 55) had moderate and marked improvement in voiding dysfunction and overall satisfaction. Discussion: Although BoNT-A injections into the urethral sphincter could improve voiding condition, only patients with SCI who presented with voiding dysfunction were commonly satisfied. Those whose treatments were converted to other bladder managements, which can promote urinary continence, or to surgical procedures, which can facilitate spontaneous voiding, had favorable treatment outcomes.

Topographic and anatomical characteristics of the bladder neck in early fetuses

Aim. To determine macro-and microscopic anatomical characteristics and the dynamics in topographic and anatomical interactions of the bladder neck with adjacent organs and structures at the beginning of the fetal period. Material and methods. The study was carried out on 70 fetal specimens. The age of subjects included in the study was determined according to the tables of B.M. Patten, B.P. Khvatova, Yu.N. Shapovalov based on measurements of the parietal-calcaneal length (PCL), taking into account the Instructions for determining the perinatal period, live birth, and stillbirth criteria, approved by Order of the Ministry of Health of Ukraine No. 179 dated March 29, 2006. To achieve this goal, the following methods of anatomical research were used: anthropometry - to determine the age of the studied subjects; injection of arterial vessels with subsequent dissection under the control of a microscope – to study the peculiarities of the blood supply to the vesicoureteral segment; radiography - to determine the skeletotopy of the vesicoureteral segment; macro-microscopy – to explore the anatomical relationships of the components of the vesicoureteral segment, their structure, shape, position; histological – to study the structure of the wall of the vesicoureteral segment; morphometry – to determine the morphometric parameters of the vesicoureteral segment; 3-D reconstruction method – to study the spatial structure of the vesicoureteral segment; statistical – to analyze and establish the reliability of differences in organometric parameters.Results. Skeletopically, the projection of the vesicoureteral junction of early fetuses is located at the level of the upper third of the pubic symphysis. At the beginning of the perinatal period in female fetuses, the bladder neck (6.9 ± 2.6 mm) is longer than in male fetuses (6.4 ± 2.4 mm). Based on the analysis and generalization of the research results, it is substantiated that at the beginning of the fetal period, the internal urethral sphincter can be formed: a) by two loops of the outer longitudinal layer; b) the ring of the circular layer and the front bundles of the outer longitudinal layer; c) anterior bundles of the outer longitudinal layer and transverse bundles of the inner longitudinal layer within the trigone of urinary bladder; d) a ring of the circular layer, thickened in the anterolateral sections.Conclusions. Considering the topographic and anatomical characteristics of the angio- and myoarchitectonics of the vesicoureteral segment, we believe that its role as a physiological sphincter of the lower urinary tract is provided by the interaction of the vascular and muscle components. The vascular component of the sphincter apparatus of the vesicoureteral segment is provided by veins located in three layers: 1) cavernous-like veins of the submucosa; 2) veins of the muscular membrane; 3) veins of tunica adventitia. The second anatomical component of the sphincter function of the vesicoureteral segment is the muscular one, represented by the internal urethral sphincter.

DIAGNOSTIC VALUE OF URETHRAL PROFILOMETRY IN CHILDREN: RECOMMENDATIONS FOR PRACTICAL USE

In pediatric neuro-urology, the method of urodynamic studies – urethra profirometry (UP) – is one of the main ones, but still inferior in frequency to cystometry and uropometry. The main indications for use of the UP method are stress urinary incontinence and a comprehensive examination of neurological patients. The long-term focus of the UP results has been on decreasing the closure function of the urethral sphincter. The article summarizes the material on the application of the UP method in children, describes the techniques, indications and possible results of the research on the practical significance of the reduction of intraurethral pressure, its high rates and instability.

A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

PurposeOur primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.MethodsWe conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).ResultsRP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.ConclusionsThe anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.

Time course for urethral neuromuscular reestablishment and its facilitated recovery by transcutaneous neuromodulation after simulated birth trauma in rats

The aims of the study were to determine the time-course of urinary incontinence recovery after vaginal distension (VD), elucidate the mechanisms of injury from VD leading to external urethral sphincter (EUS) dysfunction, and assess if transcutaneous electrical stimulation (TENS) of the dorsal nerve of the clitoris facilitates recovery of urinary continence after VD. Rats underwent 4-h VD, 4-h sham VD (SH-VD), VD plus 1-h DNC TENS, and VD plus 1-h sham TENS (SH-TENS). TENS or SH-TENS were applied immediately and at days 2 and 4 post-VD. Micturition behavior, urethral histochemistry and histology, EUS and nerve electrophysiology, and cystometrograms were evaluated. VD induced urine leakage and disrupted EUS fibers and nerve-conduction. Urine leakage disappeared 13 days post-VD. Structural and functional recovery of the EUS neuromuscular circuitry started by day 6 post-VD but did not fully recovered by day 11 post-VD. TENS significantly decreased the frequency of urine leakage post-VD (p<0.01). We conclude that rat urinary continence function after VD requires 2 weeks to recover, although urethra structure is not fully recovered. Treatment to facilitate neuroregeneration should be applied within one-week after damage. TENS facilitated urinary continence recovery after VD. This treatment may have potential to decrease postpartum urinary incontinence in women.

The Right Instrument for the Right Purpose: Spreading the Use of Small Caliber Ureteroscope for the Inspection of the Male and Female Urethra

The inspection of the urethra in patients with documented or suspected urethral stricture should be carried out with small caliber ureteroscope of 6/7.5Ch. Different from flexible cystoscope (16Ch) or resectoscope (26Ch), small caliber ureteroscope allows a comprehensive evaluation of the stricture, including its length and the status of the mucosa in its proximity, without injuring or overstretching the urethra. With a small caliber ureteroscope it is also possible to cross the stricture, allowing the evaluation of the proximal urethra, the external urethral sphincter, and the bladder. A 6/7.5Ch ureteroscope also allows estimation of the real caliber of the stricture, providing a useful landmark for further treatment decisions.

A Preliminary Validation of a New Surgical Procedure for the Treatment of Primary Bladder Neck Obstruction Using a Computational Modeling Approach

A new surgical procedure for the treatment of primary bladder neck obstruction with maintenance of anterograde ejaculation is proposed. In place of monolateral or bilateral bladder neck incision, associated with a loss of ejaculation rate of up to 30%, the new surgical procedure consists of laser drilling the bladder neck with a number of holes and without muscle fiber disruption. The effect of this novel procedure has been studied numerically, with a simplified two-dimensional numerical model of the internal urethral sphincter, varying the position and the number of holes in the fibrotic region of the urethral tissue. Results show an improvement of the urethral sphincter opening by increasing the number of holes, ranging from about 6% to 16% of recovery. Moreover, a non-aligned position of holes positively influences the opening recovery. The concentrations of maximum principal strain and stress have been registered in the proximity of the interface between the physiologic and diseased sphincter, and in those regions where the radial thickness is significantly thinner. The effects on the first five patients have been included in the study, showing improvement in micturition, lower urinary tract symptoms, sustained ejaculatory function, and quality of life.

Novel Techniques to Improve Precise Cell Injection

We noted recently that the injection of cells with a needle through a cystoscope in the urethral sphincter muscle of pigs failed to deposit them nearby or at the intended target position in about 50% of all animals investigated (n > 100). Increasing the chance for precise cell injection by shotgun approaches employing several circumferential injections into the sphincter muscle bears the risk of tissue injury. In this study, we developed and tested a novel needle-free technique to precisely inject cells in the urethral sphincter tissue, or other tissues, using a water-jet system. This system was designed to fit in the working channels of endoscopes and cystoscopes, allowing a wide range of minimally invasive applications. We analyze key features, including the physical parameters of the injector design, pressure ranges applicable for tissue penetration and cell injections and biochemical parameters, such as different compositions of injection media. Our results present settings that enable the high viability of cells post-injection. Lastly, the method is suitable to inject cells in the superficial tissue layer and in deeper layers, required when the submucosa or the sphincter muscle of the urethra is targeted.