Therapeutic outcome of active management in male patients with detrusor underactivity based on clinical diagnosis and videourodynamic classification

Detrusor underactivity (DU) could be resulted from many different etiologies. Patients with DU might have reduced bladder sensation, low detrusor contractility, and large post-void residual volume. This study analyzed therapeutic outcome of active management for male DU patients, based on clinical and urodynamic characteristics. Male DU patients aged > 18 years old were retrospectively reviewed from the videourodynamic study (VUDS) records in recent 10 years. The patients’ demographics, VUDS results, treatment modalities, and treatment outcome were analyzed. The treatment outcomes were compared among patients with different DU subgroups, clinical diagnosis and treatment modalities. Patients with voiding efficiency of > 66.7% were considered having a successful treatment outcome. For comparison, 30 men with normal VUDS finding served as the control arm. Most of the DU patients had reduced bladder sensation. The reduced bladder sensation is closely associated with low detrusor contractility. After active treatment, a successful outcome was achieved in 68.4% of patients after bladder outlet surgery, 59.1% after urethral botulinum toxin A injection, and 57.6% after medical treatment, but only 18.2% after conservative treatment. A successful treatment outcome was achieved in patients with an intact detrusor contractility, either low (69.2%) or normal voiding pressure (81.8%), and in patients with a normal or increased bladder sensation (78.1%). However, patients with detrusor acontractile (41.3%) or absent bladder sensation (17.9%) had less favorable treatment outcome after any kind of urological management. This study revealed that active management can effectively improve voiding efficiency in patients with DU. The normal bladder sensation, presence of adequate detrusor contractility, and bladder outlet narrowing during VUDS provide effective treatment strategy for DU patients. Among all management, BOO surgery provides the best treatment outcome.

Predictive Factors in Sacral Neuromodulation: A Systematic Review

<b><i>Introduction:</i></b> Sacral neuromodulation (SNM) is an effective treatment in patients with overactive bladder syndrome or nonobstructive urinary retention when conservative treatment fails. Several factors that could impact outcome with SNM have been studied. This systematic review investigated these predictive factors and their relevance for clinical practice. <b><i>Methods:</i></b> Systematic review according to the PRISMA guidelines was conducted. This review is registered in the PROSPERO register (CRD42015016256). <b><i>Results:</i></b> Seventy-eight studies (of which 11 abstracts) were included. Females, younger patients, and a tined lead procedure tend to be predictive in successful SNM outcome. Factors that did not influence SNM outcome were prior back surgery, surgery for stress urinary incontinence, affective symptoms, and duration of complaints. Reduced detrusor contractility is associated with a lower success rate. The level of evidence of most studies (graded according to the Centre for Evidence-Based Medicine) was 3b. <b><i>Conclusion:</i></b> Even though this systematic review investigated predictive factors (gender, age, type of procedure, type of lead, and detrusor contractility), no general consensus on predictive factors could be made. Most studies are small, retrospective, and involve a heterogeneous population. Therefore, prospective research in larger specific patient groups remains necessary to find predictors of SNM outcome.

A neurogén húgyhólyag klinikuma és terápiás lehetőségei

Összefoglaló. Az alsó húgyutak fő funkciója a vizelet tárolása és ürítése, amely működések zavara az úgynevezett alsó húgyúti tünetegyüttes kialakulásához vezet, ami a kiváltó októl függően vizeletürítési zavarral és vizeletretencióval is járhat. Kezeletlen esetekben a felső húgyutak károsodása következik be a magas hólyagnyomás által kiváltott vesicoureteralis reflux következtében, amely ureter- és veseüregrendszeri tágulat kialakulására, illetve fertőzésekre és kőképződésre hajlamosít. A vizelettárolási/vizeletürítési zavarokat három fő csoportba sorolhatjuk, úgymint stressz- (terheléses) inkontinencia , hiperaktív hólyag (nedves/száraz) és neurogén hólyag. A jelen összefoglaló közlemény tárgyát képező neurogén hólyag egy gyűjtőfogalom, mely magában foglal minden, releváns neurológiai kórkép talaján kialakult vizelettárolási és vizeletürítési zavart. Mivel a húgyhólyag mellett a záróizomzat és a hátsó húgycső is érintett, ezt a kórképet napjainkban „neurogén alsó húgyúti diszfunkció” elnevezéssel is szokás illetni. A kórállapotot a neurológiai diszfunkciók széles spektruma okozhatja, kezdve a helyi funkcionális zavartól a helyi idegi sérülésen át a felső és alsó motoneuron-sérülésig vagy a centrális degeneratív folyamatokig. Az eltérő etiológia ellenére a klinikai tünetek rendszerint két alapvető klinikai típusban manifesztálódhatnak: túlműködő (fokozott detrusorkontraktilitást okozó automata) hólyag vagy alulműködő hólyag formájában. Tekintettel a neurogén alsó húgyúti diszfunkció következtében létrejövő felső húgyúti komplikációkra, a közlemény egyik célja a betegség diagnózisát segítő algoritmus bemutatása a legújabb nemzetközi szakirodalmi ismeretek alapján. A neurogén hólyag kezelése jobbára nem terjedhet ki a kiváltó ok kezelésére, ezért a jelen összefoglaló másik célja azon gyógyszeres és invazív terápiás beavatkozások összefoglalása, melyek a felső húgyutak védelmét szolgálják az alacsony hólyagnyomás fenntartása révén. Orv Hetil. 2021; 162(4): 135–143. Summary. Storage and urination are the main functions of the lower urinary tract and its lesions lead to the so-called lower urinary tract syndrome causing either urinary incontinence or retention. In untreated cases, the upper urinary tract becomes injured via a vesicoureteral reflux resulting from increased bladder pressure and resultant dilations of the ureter and the renal pelvis which predispose to infection and stone formation. Lower urinary tract storage/urination disorders can be classified as stress incontinence, hyperactive bladder (wet/dry) and neurogenic bladder. Neurogenic bladder which is the subject of this review, is a collective term that encompasses all urinary storage and emptying disorders which develop on the basis of neurological diseases. Being not only the bladder, but also the sphincter and posterior urethra (generally termed as the “bladder outlet”) affected, nowadays this condition is referred to as “neurogenic lower urinary tract dysfunction”. A wide range of neurological dysfunctions could contribute to the development of this condition, ranging from local dysfunction (autonomic dysreflexia) or local nerve injury to upper/lower motoneuron injury or central degenerative processes. Regardless of the diverse etiology, the clinical symptoms eventually manifest in two major forms, i.e., overacting (automatic bladder with increased detrusor contractility) and underactive bladder. Considering the severity of complication occurring in the upper urinary tract in response to the pathophysiological changes in the lower urinary tract, one of the aims of this paper was to present an algorithm aiming to build up a state of the art diagnosis of the disease based on current international literature data. Since treatment of the neurogenic bladder usually can not target elimination of the underlying cause, the other goal of the present paper is to summarize the pharmacological treatment regimen and invasive therapeutic interventions that protect the upper urinary tract by maintaining low pressure values in the bladder. Orv Hetil. 2021; 162(4): 135–143.

Decrease of urinary bladder contractility in patients with benign prostate hyperplasia

Aim of the study.Estimation of the decrease of urinary bladder contractility in patients with benign prostate hyperplasia (BPH). Patients and methods.In 146 BPH patients (mean age 62,1 0,8) urodynamic investigation including uroflowmetry and pressure-flow study was performed. The results of miction cystometry were evaluated using Shafer nomogram, the emptying idex was calculated as relation of voiding volume to maximal cystometric capacity. Results.56,2% BPH patients showed the decreased detrusor contractility. The results of urinary bladder contractility estimation by Shafer nomogram are dependent on the degree of infravesical obstruction (IVO). The emptying index is not related to the presence and degree of IVO and characterizes the degree of urinary bladder emptying as well as contraction duration. Concomitant lumbar osteochondrosis and diabetes detoriates urinary bladder emptying. Reliable contractility estimation may only be performed based on urodynamic study since basic BPH patients examination is not sufficient. Conclusion.In has to be considered during treatment strategy planning that in many BPH patients low urinary truct disfunction is determined by the decrease of urinary bladder contractility and not by IVO.

The Role of Apoptosis in Detrusor Contractility

Apoptosis has been found in bladder affected by various types of voiding dysfunction. In animal studies, higher levels of apoptosis were observed in conditions of both detrusor overactivity and underactivity than in normal bladders. However, it has been difficult to establish the exact underlying mechanism of apoptosis in these conditions and to find new therapeutic targets because the causes of voiding dysfunction are diverse and the coexistence of various types of voiding problems is common. Furthermore, the lack of studies of the human detrusor contributes to our incomplete understanding of these issues. Therefore, this revies discuss the role of apoptosis in detrusor contractility based on previous studies.