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Purpose: To report the genitourinary (GU) and gastrointestinal (GI) morbidity and erectile dysfunction in a randomized trial comparing 2 methods of dose escalation for high- and intermediate-risk prostate cancer., Methods and Materials: ASCENDE-RT (Androgen Suppression Combined with Elective Nodal and Dose Escalated Radiation Therapy) enrolled 398 men, median age 68 years, who were then randomized to either a standard arm that included 12 months of androgen deprivation therapy and pelvic irradiation to 46 Gy followed by a dose-escalated external beam radiation therapy (DE-EBRT) boost to 78 Gy, or an experimental arm that substituted a low-dose-rate prostate brachytherapy (LDR-PB) boost. At clinic visits, investigators recorded GU and GI morbidity and information on urinary continence, catheter use, and erectile function. Exclusion of 15 who received nonprotocol treatment and correction of 14 crossover events left 195 men who actually received a DE-EBRT boost and 188, an LDR-PB boost. Median follow-up was 6.5 years., Results: The LDR-PB boost increased the risk of needing temporary catheterization and/or requiring incontinence pads. At 5 years the cumulative incidence of grade 3 GU events was 18.4% for LDR-PB, versus 5.2% for DE-EBRT (P<.001). Compared with the cumulative incidence, the 5-year prevalence of grade 3 GU morbidity was substantially lower for both arms (8.6% vs 2.2%, P=.058). The 5-year cumulative incidence of grade 3 GI events was 8.1% for LDR-PB, versus 3.2% for DE-EBRT (P=.124). The 5-year prevalence of grade 3 GI toxicity was lower than the cumulative incidence for both arms (1.0% vs 2.2%, respectively). Among men reporting adequate baseline erections, 45% of LDR-PB patients reported similar erectile function at 5 years, versus 37% after DE-EBRT (P=.30)., Conclusions: The incidence of acute and late GU morbidity was higher after LDR-PB boost, and there was a nonsignificant trend for worse GI morbidity. No differences in the frequency of erectile dysfunction were observed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The aim of treatment in acute traumatic spinal cord injury is to preserve residual neurologic function, avoid secondary injury, and restore spinal alignment and stability. In this second part of the review, we describe the management of spinal cord injury focusing on issues related to short-term respiratory management, where the preservation of diaphragmatic function is a priority, with prediction of the duration of mechanical ventilation and the need for tracheostomy. Surgical assessment of spinal injuries based on updated criteria is discussed, taking into account that although the type of intervention depends on the surgical team, nowadays treatment should afford early spinal decompression and stabilization. Within a comprehensive strategy in spinal cord injury, it is essential to identify and properly treat patient anxiety and pain associated to spinal cord injury, as well as to prevent and ensure the early diagnosis of complications secondary to spinal cord injury (thromboembolic disease, gastrointestinal and urinary disorders, pressure ulcers)., (Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.)

Purpose: Circumcision is one of the oldest surgical procedures that originated for religious purposes. Circumcision in infancy is a common procedure in our country and secondary meatal stenosis due to circumcision is a common complication. The aim of our study is to determine the effect of meatal stenosis on the lower and upperurinary tract of circumcised boys by using ultrasonography., Materials and Methods: In this cross-sectional study, we enrolled 87 circumcised boys between 4 to 8 years old with severe meatal stenosis. Clinical findings of our subjects were gathered by a checklist that included: thin stream of urine, upward urine stream deviation, infrequent voiding, urinary tract infections, voiding dysfunction, and urge incontinency. In lab data analysis, complete blood cell count (CBC), urine analysis, urine culture, blood urea nitrogen (BUN), and plasma creatinine level were evaluated. Ultrasonography detected hydronephrosis, hydroureter, bladder wall thickening in a full and empty bladder, bladder volume, and residual urine volume., Result: Narrowing of urine stream is commonly seen (about 54%) among patients with severe meatal stenosis, and similarly in sonographic evaluations the most common symptoms among patients was thickening of the bladder wall that increased in an empty and a full bladder (about 82%)., Conclusion: The author of this study recommends performing long-term follow up after circumcision and ultrasonographyto detect meatal stenosis before permanent renal damage occurs.

Objective: To explore the radiological, pathological features and clinical characteristics of neuroendocrine prostate cancer patients(NEPC). Methods: The clinical characteristics and pathology data of 13 neuroendocrine prostate cancer patients treated in the Affiliated Hospital of Tianjin Medical University from January 2004 to January 2015 were analyzed retrospectively. Results: Of all 13 patients, three cases were primally diagnosed small cell cancer, and 10 cases were translated to neuroendocrine type from adenocarcinoma after endocrine therapy. Frequent urination, urgency, nocturia, and dysuria were main symptoms. Serum prostate-specific antigen (PSA) was (14.5±3.2)μg/L; the volume of prostate was enlarged, mean volume, range 28-176(45±4)ml. The lesion was moderately low signal intensity in T(2)WI, while slightly higher signal in DWI. Signal characteristic of dynamic enhanced MRI was "fast in fast out" . The expression of Synaptophysin, Chromogranin A , CD56 and Ki-67 in NEPC were highly expressed by immunohistochemistry analysis. Among them, five patients accepted intravenous chemotherapy, two cases received external radiation therapy, three cases received cryoablation and three cases received palliative therapy. Median survival time in all 13 patients was 10 months, while median survival time in patients treated by chemotherapy was 16 months . Conclusion: NEPC is a highly aggressive subtype of prostate cancer characterized by rapid disease progression, lack of treatment and worse prognosis. Therefore, patients with NEPC may benefit from early diagnosis and comprehensive treatment with chemotherapy.

Introduction: Disorders of the lower urinary tract are frequent in patients with multiple sclerosis throughout the course of the disease and reach variable prevalences close to 75%. It is essential to obtain an early diagnosis in the initial phases and to implement an optimal therapeutic management. Burks et al developed the Actionable Bladder Symptoms Screening Tool (ABSST) as a useful screening test in such disorders. Later, Bates et al developed a short version of the ABSST with the objective of minimising the time required to complete it and making it easier to use., Aims: To carry out the transcultural validation into Spanish of the short version of the ABSST., Patients and Methods: The ABSST was translated into Spanish and then back-translated into English, which confirmed the semantic equivalence. A field test was conducted on 40 patients with multiple sclerosis, with two extra questions being included at the end in order to check the comprehension and acceptability of the tool, together with a final item that asked for the time spent on completing it., Results: Forty patients were selected In accordance with the eligibility and exclusion criteria; 67.5% of them were females and the overall mean age was 46.2 years. The rate of comprehension of the test was 100%, and that of acceptability was 97.5%. Results showed that 57.5% obtained scores >= 3, and an average of 5.33 minutes were spent on completing it., Conclusions: As a brief screening questionnaire for urinary disorders in multiple sclerosis, the ABSST is a useful tool for detecting them at an early stage and has now been validated for use in Spanish.

Purpose of Review: Functional complications after orthotopic neobladder urinary diversion (ONB), including urinary incontinence and urinary retention, present unique challenges. The purpose of this review is to outline contemporary treatment options for voiding dysfunction after ONB in females., Recent Findings: Meticulous surgical technique in the form of urethral nerve-sparing has been shown to play an important role in maintaining continence, as has sparing the uterus when possible. Data supporting the effectiveness of lifestyle measures, urethral bulking, pubovaginal slings, and transobturator slings in the treatment of urinary incontinence are widely variable and limited to case reports. Urinary retention is still most effectively managed with self-catheterization. Voiding dysfunction after ONB can be devastating. Recent advances focus on improving surgical techniques to decrease the risk of incontinence and retention, as post-operative management options are limited.

Purpose and Objectives: We report on the clinical outcomes of a phase 2 study assessing image guided hypofractionated weekly radiation therapy in bladder cancer patients unsuitable for radical treatment., Methods and Materials: Fifty-five patients with T2-T4aNx-2M0-1 bladder cancer not suitable for cystectomy or daily radiation therapy treatment were recruited. A "plan of the day" radiation therapy approach was used, treating the whole (empty) bladder to 36 Gy in 6 weekly fractions. Acute toxicity was assessed weekly during radiation therapy, at 6 and 12 weeks using the Common Terminology Criteria for Adverse Events version 3.0. Late toxicity was assessed at 6 months and 12 months using Radiation Therapy Oncology Group grading. Cystoscopy was used to assess local control at 3 months. Cumulative incidence function was used to determine local progression at 1 at 2 years. Death without local progression was treated as a competing risk. Overall survival was estimated using the Kaplan-Meier method., Results: Median age was 86 years (range, 68-97 years). Eighty-seven percent of patients completed their prescribed course of radiation therapy. Genitourinary and gastrointestinal grade 3 acute toxicity was seen in 18% (10/55) and 4% (2/55) of patients, respectively. No grade 4 genitourinary or gastrointestinal toxicity was seen. Grade ≥3 late toxicity (any) at 6 and 12 months was seen in 6.5% (2/31) and 4.3% (1/23) of patients, respectively. Local control after radiation therapy was 92% of assessed patients (60% total population). Cumulative incidence of local progression at 1 year and 2 years for all patients was 7% (95% confidence interval [CI] 2%-17%) and 17% (95% CI 8%-29%), respectively. Overall survival at 1 year was 63% (95% CI 48%-74%)., Conclusion: Hypofractionated radiation therapy delivered weekly with a plan of the day approach offers good local control with acceptable toxicity in a patient population not suitable for radical bladder treatment., (Copyright © 2017 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: A 30-item Qualiveen questionnaire was developed to measure the impact of urinary problems on everyday living in spinal cord injury, and subsequently an 8-item SF-Qualiveen was developed for those with multiple sclerosis (MS). The validity of this short form has not been previously examined using modern psychometric techniques, such as the Rasch measurement model., Objective: The aim of this study is to test if the short form meets the requirements of the Rasch model., Methods: A total of 401 patients with clinically definite MS were given the questionnaire at three neuroscience centres in the UK., Results: A total of 258 patients (64.3% response) completed the questionnaire. The original scale failed to meet the expectations of the Rasch model. A two-testlet solution was sought to account for local dependence, differential item functioning and disordered thresholds. After the modifications were made the scale fitted the model (χ 2  = 5.93 P = 0.4305), had high internal consistency (α = 0.88) and was unidimensional., Conclusions: SF-Qualiveen is a simple and valid measure of the impact of urinary problems in multiple sclerosis, which meets the requirements of the Rasch measurement model. Summed ordinal scores can be converted to interval-level using the transformation table provided., (© 2016 Wiley Periodicals, Inc.)

A "buried penis" causes functional problems and embarrassment. In the past, this complex condition was only seen in extremely overweight patients or as a result of severe inflammations in this region. More recently, this problem has also been observed in patients with massive weight loss following bariatric surgery. In these patients there is an abundance of extremely flaccid skin in the suprapubic region, which covers the penis and causes it to "disappear". This leads to balanitis and, in turn, further retraction of the penis. The only solution to this condition is a sophisticated surgical approach in 3 phases: At first, suprapubic tissues must be lifted. Secondly, the penis must be completely denuded and debrided and the correct penopubic/penoscrotal angles must be reconstructed. The last phase includes a strainless coverage of the remaining defect of the penis. This condition has not been widely described in the literature. The general incidence and prevalence in the postbariatric population is unknown, probably due to patients' embarrassment and lack of knowledge on the physicians' end. Nevertheless, the buried penis can be successfully exposed through careful, structured surgical treatment and an interdisciplinary approach between plastic surgeons and urologists., Competing Interests: Interessenkonflikt: Nein, (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction and Hypothesis: The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery., Methods: We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively., Results: Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 - 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H 2 O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 - 5.60, 1.39 - 2.91 and 1.10 - 3.21, respectively)., Conclusions: Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H 2 O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

Aims: We determined whether or not replication-defective herpes simplex virus vector-mediated kynurenine aminotransferase II (HSVrd-KAT II) suppressed the tonic activity of the urethral sphincter in spinal cord-injured (SCI) rats., Methods: Thirty-six adult female Sprague-Dawley rats were used to produce a spinal cord injury model. One week after spinalization, HSVrd-KAT II was injected into the urethral wall of rats and another two groups of SCI rats were treated with saline and HSVrd as controls. Three weeks after viral injection, the urethral pressure profile (UPP), continuous cystometry, and gene expression in the L6-S1 spinal cords were evaluated in all three groups., Results: In the HSVrd-KAT II group, the maximum urethral closure pressure (Pclo.max) and maximum voiding pressure were significantly decreased (23.6-24.9% and 31.6-30.9%, respectively), in addition to an increase in voiding efficiency(48.8-76%), compared with the sham and HSVrd groups. The KAT II protein and mRNA levels were significantly increased in HSV-KAT II group compared with the HSVrd group., Conclusion: KAT II gene therapy effectively reduced the urethral pressure, improving detrusor-sphincter dyssynergia (DSD), and detrusor overactivity (DO), probably by blocking the N-methyl-D-aspartate receptor (NMDAr) in the L6-S1 spinal cord. Neurourol. Urodynam. 36:1046-1051, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Aims: Underactive bladder (UAB) is a symptom complex with poorly characterized causation. The aim of this study was to determine if clinical and UDS parameters differed between categories of presumed detrusor underactivity (DU) etiologies., Methods: A retrospective review was performed at a single institution from 2011 to 2015 to identify patients with symptoms of UAB. Patients were excluded if they were male, had anti-incontinence, or pelvic organ prolapse (POP) surgery within 1 year, or the UDS did not demonstrate DU as defined within. Subjects were stratified by etiology into four cohorts: cardiovascular disease manifestations (CV), cardiac risk factors (CVR), neurologic (N), or idiopathic (I). Patient demographics, comorbidities, symptomatology, physical exam, and UDS parameters were compared., Results: A total of 200 patients met inclusion criteria (CV: n = 53 [26.5%], CVR: n = 44 [22%] N: n = 81 [40.5%], I: n = 22 [11%]). Women in the CV cohort were significantly older and more likely to be post-menopausal (P < 0.001). There were no differences between cohorts for BMI (P = 0.48), recurrent UTI (P = 0.63), history of urinary retention (AUR) (P = 0.65), POP (0.49), American Urological Association Symptom Score (AUA-SS) (P = 0.06), presenting symptomatology [urgency, frequency, urgency urinary incontinence, AUR, incomplete emptying, hesitancy, UTI (P = 0.97)], or UDS parameters (first sensation [P = 0.25], normal desire [P = 0.80], strong desire [P = 0.58], capacity [P = 0.11], Q max [P = 0.50], P det at Q max [P = 0.22], post-void residual [P = 0.82])., Conclusions: Though differences were observed between cohorts for age and menopausal status, clinical or urodynamic parameters did not demonstrate distinct differences across presumed categories of etiology, suggesting that the etiology of DU may be multifactorial. Neurourol. Urodynam. 36:1151-1154, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

The buried penis, also called hidden or concealed penis, is associated with morbid obesity or seen after massive weight loss in adults. In highly obese, bariatric patients, the penile shaft invaginates into the pre-pubic fat masses, resulting in voiding problems and urine wetting of the surrounding tissue. This leads to infection, skin maceration, lichen sclerosus and eczema. Sole circumcision without mons pubis plasty or penile fixation does not suffice to alleviate the discomfort and leads to recurrence. In post-bariatric patients, penile retraction is only partially present or absent, but abundant pre-pubic skin tissue forms an apron covering the genitals with problems in hygiene and sexual intercourse. In these cases, plastic-reconstructive interventions include mons pubis plasty with or without penile fixation. This article provides a comprehensive overview on aetiology, a novel classification of the buried penis and plastic-surgical reconstructive interventions matched to the stages of the condition., Competing Interests: Interessenkonflikt: nein., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Diphallia is a very uncommon malformation, and glans duplication (GD) is its rarest form. In this last group, patients normally present with esthetic/sexual complaints or obstructed voiding late in life after pubertal genital development. Associated malformations are uncommon and relatively mild in those cases., Methods: After a case presented, we present herein an extensive review of GD, as the disease is rare, and there is very little about its treatment and there are diverse approaches to address the condition., Results: After an extensive review of the available literature, we carefully analyzed each published case to describe specific aspects of their clinical presentation (age, main complaint, voiding/urethral problems, and individual anatomy) and treatment., Conclusion: This review allowed us to propose a new classification for diphallia into four groups (true diphallia, hemiphallus, pseudodiphallia, and partial duplication), considering embryological, anatomical, clinical, and therapeutic implications (see Fig. 1). Glans duplications present as esthetic/sexual cases or show abnormal voiding patterns caused by urethral associated abnormalities. Reconstructive techniques may be simple (resection of a hypoplastic accessory glans + urethra) or relatively complex (glans and/or urethral reconstruction)., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: Lower urinary tract and sexual dysfunction are commonly reported sequelae of neurologic disease and have a significant impact on quality of life. This article presents an up-to-date summary of the clinical presentation, investigations, and treatment options for urogenital dysfunction in patients with neurologic disease., Recent Findings: The pattern of lower urinary tract dysfunction is influenced by the site of the neurologic lesion. The risk for developing upper urinary tract damage is considerably less in patients with slowly progressive nontraumatic neurologic disorders, as compared to those with spinal cord injury or spina bifida. Investigations such as urinalysis, ultrasonography, and urodynamics provide further information about the cause and nature of lower urinary tract dysfunction. Antimuscarinic agents are the first-line management of urinary incontinence; however, side effect profile and anticholinergic burden should be considered when prescribing medications. β3-Adrenergic receptor agonists are a promising alternative oral medication. Tibial and sacral neuromodulation have been shown to be effective for managing incontinence, as well as urinary retention due to Fowler syndrome. Intradetrusor injections of onabotulinumtoxinA have revolutionized the management of neurogenic detrusor overactivity., Summary: Neurologic patients reporting urogenital symptoms require a comprehensive evaluation for planning a patient-tailored approach to management. Neurologists are increasingly inquiring about lower urinary tract and sexual functions and becoming involved in the management of these disorders.

Importance: Understanding the adverse effects of contemporary approaches to localized prostate cancer treatment could inform shared decision making., Objective: To compare functional outcomes and adverse effects associated with radical prostatectomy, external beam radiation therapy (EBRT), and active surveillance., Design, Setting, and Participants: Prospective, population-based, cohort study involving 2550 men (≤80 years) diagnosed in 2011-2012 with clinical stage cT1-2, localized prostate cancer, with prostate-specific antigen levels less than 50 ng/mL, and enrolled within 6 months of diagnosis., Exposures: Treatment with radical prostatectomy, EBRT, or active surveillance was ascertained within 1 year of diagnosis., Main Outcomes and Measures: Patient-reported function on the 26-item Expanded Prostate Cancer Index Composite (EPIC) 36 months after enrollment. Higher domain scores (range, 0-100) indicate better function. Minimum clinically important difference was defined as 10 to 12 points for sexual function, 6 for urinary incontinence, 5 for urinary irritative symptoms, 5 for bowel function, and 4 for hormonal function., Results: The cohort included 2550 men (mean age, 63.8 years; 74% white, 55% had intermediate- or high-risk disease), of whom 1523 (59.7%) underwent radical prostatectomy, 598 (23.5%) EBRT, and 429 (16.8%) active surveillance. Men in the EBRT group were older (mean age, 68.1 years vs 61.5 years, P < .001) and had worse baseline sexual function (mean score, 52.3 vs 65.2, P < .001) than men in the radical prostatectomy group. At 3 years, the adjusted mean sexual domain score for radical prostatectomy decreased more than for EBRT (mean difference, -11.9 points; 95% CI, -15.1 to -8.7). The decline in sexual domain scores between EBRT and active surveillance was not clinically significant (-4.3 points; 95% CI, -9.2 to 0.7). Radical prostatectomy was associated with worse urinary incontinence than EBRT (-18.0 points; 95% CI, -20.5 to -15.4) and active surveillance (-12.7 points; 95% CI, -16.0 to -9.3) but was associated with better urinary irritative symptoms than active surveillance (5.2 points; 95% CI, 3.2 to 7.2). No clinically significant differences for bowel or hormone function were noted beyond 12 months. No differences in health-related quality of life or disease-specific survival (3 deaths) were noted (99.7%-100%)., Conclusions and Relevance: In this cohort of men with localized prostate cancer, radical prostatectomy was associated with a greater decrease in sexual function and urinary incontinence than either EBRT or active surveillance after 3 years and was associated with fewer urinary irritative symptoms than active surveillance; however, no meaningful differences existed in either bowel or hormonal function beyond 12 months or in in other domains of health-related quality-of-life measures. These findings may facilitate counseling regarding the comparative harms of contemporary treatments for prostate cancer.

Importance: Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects., Objective: To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance., Design, Setting, and Participants: Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015., Exposures: Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance., Main Outcomes and Measures: Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point., Results: Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains., Conclusions and Relevance: In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

Purpose: The aim of this review was to compare radiation toxicity in Localized Prostate Cancer (LPC) patients who underwent conventional fractionation (CV), hypofractionated (HYPO) or extreme hypofractionated (eHYPO) radiotherapy. We analyzed the impact of technological innovation on the management of prostate cancer, attempting to make a meta-analysis of randomized trials., Methods: PubMed database has been explored for studies concerning acute and late urinary/gastrointestinal toxicity in low/intermediate risk LPC patients after receiving radiotherapy. Studies were then gathered into 5 groups: detected acute and chronic toxicity data from phase II non randomized trials were analyzed and Odds Ratio (OR) was calculated by comparing the number of patients with G0-1 toxicity and those with toxicity > G2 in the studied groups. A meta-analysis of prospective randomized trials was also carried out., Results: The initial search yielded 575 results, but only 32 manuscripts met all eligibility requirements: in terms of radiation-induced side effects, such as gastrointestinal and genitourinary acute and late toxicity, hypofractionated 3DCRT seemed to be more advantageous than 3DCRT with conventional fractionation as well as IMRT with conventional fractionation compared to 3DCRT with conventional fractionation; furthermore, IMRT hypofractionated technique appeared more advantageous than IMRT with conventional fractionation in late toxicities. Randomized trials meta-analysis disclosed an advantage in terms of acute gastrointestinal and late genitourinary toxicity for Hypofractionated schemes., Conclusions: Although our analysis pointed out a more favorable toxicity profile in terms of gastrointestinal acute side effects of conventional radiotherapy schemes compared to hypofractionated ones, prospective randomized trials are needed to better understand the real incidence of rectal and urinary toxicity in patients receiving radiotherapy for localized prostate cancer.

Background: In this study of patients undergoing vaginal hysterectomy with either robotic or vaginal prolapse repair, there was no difference in quality of life in the weeks following surgery; however, less narcotics were used, less pain was documented by nurses and Surgical Pain Scale (SPS), and better performance on voiding trials was noted in those undergoing robotic sacrocolpopexy., Objectives: Minimally invasive surgery for pelvic organ prolapse is the preferred surgical route for optimal recovery. However, information regarding patient-centered outcomes among various techniques is lacking. We sought to describe pain and quality of life in patients undergoing vaginal hysterectomy with uterosacral ligament suspension (USLS) compared with robotic-assisted sacrocolpopexy (RSC)., Methods: This institutional review board-approved prospective cohort study enrolled consecutive patients undergoing vaginal hysterectomy with USLS or with RSC. The primary outcome was pain on postoperative day 1 using the SPS. Nursing verbal pain scores, narcotic usage, surgical data, and Short-Form Health Survey 12 at baseline and 2 and 6 weeks after surgery were collected. A sample size calculation revealed 37 subjects per group would be required., Results: Seventy-eight women were enrolled (USLS, n = 39; RSC, n = 39). There were no significant differences in scores on the SPS between groups. Subjects undergoing RSC had lower nursing verbal pain scores (P = 0.04), less narcotic consumption (P = 0.02), and lower estimated blood loss (P = 0.01) and were less likely to fail voiding trials (P < 0.001); however, surgery duration was longer (P < 0.001). After controlling for age, regression analysis revealed SPS "worst pain" was lower in the robotic arm (P = 0.01), but not in other scales of the SPS. At 2 and 6 weeks postoperatively, Short-Form Health Survey 12 scores were not different between cohorts., Conclusions: Both USLS and RSC are minimally invasive, with similar quality-of-life scores after surgery. However, the robotic approach may be associated with less pain, less narcotic use, and better performance in voiding trials. Surgeons should consider these findings when counseling patients regarding treatment options.

In Parkinson's disease, motor signs have long been the main targets of the management of the disease. In recent years, non-motor disorders have elicited increasing interest. These disorders are under diagnosed and managed more difficultly than motor signs and are sometimes perceived as more disturbing by the patients. These signs are polymorphous, sometimes occurring before the motor symptoms but increase with the disease duration and complicating always the late stages. They may fluctuate as the motor signs, while being under the control of dopaminergic pathways, or be linked to the degeneration of other neuronal circuits. These clinical manifestations, whether or not fluctuating are classified into three major categories: psycho-cognitive including sleep disorders, autonomic and sensory., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Even though micturition, defecation, and sexual function are substantially affected in cauda equina syndrome (CES), data on outcome are scarce., Methods: Medical files of patients operated on lumbar herniated disc were screened for CES and retrospectively analyzed for baseline characteristics, outcome of micturition, defecation, and sexual function and possible predictors., Results: Seventy-five CES patients (52% men) were included with a mean age of 44 years. L5-S1 was the most common affected level. Duration of CES complaints at presentation was, on average, 84 h (median 48 h). Prevalence of symptoms at presentation: sciatica (97%), altered sensation of the saddle area (93%), micturition dysfunction (92%), and defecation dysfunction (74%). Only 26 patients were asked about sexual dysfunction of whom 25 patients experienced dysfunction. Female gender was associated with more defecation dysfunction at presentation than male gender (OR 4.11; p = 0.039). All patients underwent decompressive surgery. Two post-operative follow-up (FU) moments took place after a mean of 75 h and 63 days. Outcomes at second FU moment: micturition dysfunction 48%, defecation dysfunction 42%, sexual dysfunction 53%, sciatica 48%, and altered sensation of the saddle area 57%. A shorter time to decompression was associated with more sciatica at FU 1 (p = 0.042) which effect had disappeared at FU 2., Conclusion: This study is unique in (1) displaying the presenting features in a large cohort of CES patients, (2) demonstrating that recovery after decompression is slow and far from complete in the majority of patients with regard to micturition, defecation, and sexual function and (3) evaluating predictors for outcome.

Aims: Urinary disorders (UD) secondary to multiple sclerosis (MS) are common and can be responsible for complications. Since 2004, we organized in our region their management through a neuro-urological activity and a care network that established and distributed an algorithm for screening and first line care. The objective was to assess the effects of this organization on the management of UD and its impact for patients., Methods: Between January 2004 and December 2009, 328 patients were seen in neuro-urological consultation. The data of a group of 168 patients consulting during the deployment of our organization (before January 2007: group 1) were compared to those of 160 patients taken when the organization was well established (from January 2007: group 2). In parallel, the modification of the prescription rate of the first-line examination patients was evaluated., Results: The two groups were significantly different concerning age, duration of MS, EDSS score (Group 1 vs. Group 2 respectively 51.6 ± 12.6 vs. 48 ± 11.8 years, P = 0.008; 19 ± 9.7 vs. 13.8 ± 10.5 years, P < 0.0001; 5.8 ±2.0 vs. 5.1 ± 2.1, P = 0.008). The occurrence of urinary complications in group 1 was more frequent than in group 2 (66.3% vs. 40%, P < 0.0001). The rate of first-line examinations rose from 1/16 patient seen in January 2006 to 9/12 patients in January 2008., Conclusion: The multidisciplinary management of UD in MS led to patients being cared for sooner in the evolution of MS, with fewer complications and to an improvement in the rate of prescription of first-line examinations. Neurourol. Urodynam. 36:706-709, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: Urinary and sexual dysfunction is the potential complication of rectal cancer surgery. The aim of this study was to evaluate the urinary and sexual function in male patients with robotic surgery for rectal cancer., Methods: This prospective study included 137 of the 336 male patients who underwent surgery for rectal cancer. Urinary and male sexual function was studied by means of a questionnaire based on the International Prostatic Symptom Score and International Index of Erectile Function. All data were collected before surgery and 12 months after surgery., Results: Patients who underwent robotic surgery had significantly decreased incidence of partial or complete erectile dysfunction and sexual dysfunction than patients with laparoscopic surgery. The pre- and post-operative total IPSS scores in patients with robotic surgery were significantly less than that with laparoscopic surgeries., Conclusions: Robotic surgery shows distinct advantages in protecting the pelvic autonomic nerves and relieving post-operative sexual dysfunction., (Copyright © 2016 John Wiley & Sons, Ltd.)

A 24-year-old man presented with symptoms of difficulty in passage of urine, mixed with gas and stool from penoscrotal junction since birth. He had a history of surgery (posterior sagittal anorectoplasty) for imperforate anus in first week of his life. On physical examination, external meatus was adequate with small 5×5 mm fistulous opening noted at penoscrotal junction with normal anal tone and opening. On evaluation with retrograde urethrography, voiding cystourethrogram, cystoscopy and barium enema, he was found to have penile urethrocutaneous fistula of 0.5×0.5 cm with Y-type incomplete urethral duplication. Urethroanal fistula (Y-type urethral duplication) was of small size (<5 mm), so closed primarily through perineal route with interposition of ischiorectal fat. Penile urethrocutaneous fistula (4 mm) too was closed primarily and covered with tunica vaginalis flap in single sitting. It has been 6 months since surgery and the patient is fully continent and voiding well with no urinary or faecal leak., (2017 BMJ Publishing Group Ltd.)

Purpose: We assessed the association of the spatial distribution of dose to the bladder surface, described using dose-surface maps, with the risk of urinary dysfunction., Methods and Materials: The bladder dose-surface maps of 754 participants from the TROG 03.04-RADAR trial were generated from the volumetric data by virtually cutting the bladder at the sagittal slice, intersecting the bladder center-of-mass through to the bladder posterior and projecting the dose information on a 2-dimensional plane. Pixelwise dose comparisons were performed between patients with and without symptoms (dysuria, hematuria, incontinence, and an International Prostate Symptom Score increase of ≥10 [ΔIPSS10]). The results with and without permutation-based multiple-comparison adjustments are reported. The pixelwise multivariate analysis findings (peak-event model for dysuria, hematuria, and ΔIPSS10; event-count model for incontinence), with adjustments for clinical factors, are also reported., Results: The associations of the spatially specific dose measures to urinary dysfunction were dependent on the presence of specific symptoms. The doses received by the anteroinferior and, to lesser extent, posterosuperior surface of the bladder had the strongest relationship with the incidence of dysuria, hematuria, and ΔIPSS10, both with and without adjustment for clinical factors. For the doses to the posteroinferior region corresponding to the area of the trigone, the only symptom with significance was incontinence., Conclusions: A spatially variable response of the bladder surface to the dose was found for symptoms of urinary dysfunction. Limiting the dose extending anteriorly might help reduce the risk of urinary dysfunction., (Copyright © 2016. Published by Elsevier Inc.)

Background: Transanal total mesorectal excision (TaTME) has rapidly become an important component of the treatment of rectal cancer surgery. Cohort studies have shown feasibility concerning procedure, specimen quality and morbidity. However, concerns exist about quality of life and ano(neo)rectal function. The aim of this study was to prospectively evaluate quality of life in patients following TaTME for rectal cancer with anastomosis., Methods: Consecutive patients who underwent restorative TaTME surgery for rectal adenocarcinoma in an academic teaching center with tertiary referral function were evaluated. Validated questionnaires were prospectively collected. Quality of life was assessed by the EuroQol 5D (EQ-5D), European Organization for Research and Treatment of Cancer's QLQ-C30 and QLQ-CR29 and low anterior resection syndrome (LARS) scale. Outcomes of the questionnaires at 1 and 6 months were compared with preoperative (baseline) values., Results: Thirty patients after restorative TaTME for rectal cancer were included. Deterioration for all domains was mainly observed at 1 month after surgery compared to baseline, but most outcomes had returned to baseline at 6 months. Social function and anal pain remained significantly worse at 6 months. Major LARS (score >30) was 33% at 6 months after ileostomy closure. No end colostomies were required., Conclusions: TaTME is associated with acceptable quality of life and functional outcome at 6 months after surgery comparable to published results after conventional laparoscopic low anterior resection., Competing Interests: The authors declare that they have no conflict of interest. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. We are pleased to confirm that the Medical Research Involving Human Subjects Act (WMO) does not apply to the above-mentioned study and that an official approval of this study by our committee is not required. The Medical Ethics Review Committee of VU University Medical Center is registered with the US Office for Human Research Protections (OHRP) as IRB00002991. The FWA number assigned to VU University Medical Center is FWA00017598. Informed consent Informed consent was obtained from all individual participants included in the study.

Background: Decompression sickness may involve the central nervous system. The most common site is spinal cord. This study was conducted to determine the relationship between magnetic resonance(MR) imaging findings of spinal damage., Methods: We conducted a retrospective review of 12 patients (male=10, female=2) who presented with spinal cord symptoms. We investigated their clinical features, neurological findings and radiologic findings., Results: The depth and bottom time of the dive were 34.5 meters (range 22-56) and 22.7 minutes (range 10-55) respectively. Most divers ascended within appropriate time frame as shown by the decompression tables. The most frequent initial symptoms were lower limb weakness (n=12), followed by sensory disturbances (n=10) and bladder dysfuction (n=5). The chief radiologic abnormalities were continuous (n=3), or non-continuous (n=5) high-signal intensity on T2-weighted images at posterior paramedian portion of the spinal cord, mainly thoracic level. There were no abnormal findings in the remaining four (4) patients, and they showed good prognosis. All patients were treated with hyperbaric oxygen therapy and some received high-dose dexamethasone. On discharge, five (5) patients had made a full recovery, seven (7) had some residual neurological sequelae, and all patients except one (1) regained normal bladder function., Conclusions: Spinal cord decompression sickness is a neurological emergency. Early recognition and treatment may minimize neurological damage. Initial normal finding in MR imaging was a good predictor for prognosis in spinal decompression sickness., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission.

Parkinson's disease (PD), a multiorgan neurodegenerative disorder associated with α-synuclein deposits throughout the nervous system and many organs, is clinically characterized by motor and nonmotor features, many of the latter antedating motor dysfunctions by 20 or more years. The causes of the nonmotor manifestations such as olfactory, autonomic, sensory, neuropsychiatric, visuospatial, sleep, and other disorders are unlikely to be related to single lesions. They are mediated by the involvement of both dopaminergic and nondopaminergic systems, and diverse structures outside the nigrostriatal system that is mainly responsible for the motor features of PD. The nonmotor alterations appear in early/prodromal stages of the disease and its further progression, suggesting a topographical and chronological spread of the lesions. This lends further support for the notion that PD is a multiorgan proteinopathy, although the exact relationship between presymptomatic and later developing nonmotor features of PD and neuropathology awaits further elucidation., (© 2017 Elsevier Inc. All rights reserved.)

Purpose: To report the toxicity and preliminary clinical outcomes of a prospective trial evaluating 19-Gy, single-fraction high-dose-rate (HDR) brachytherapy for men with low- and intermediate-risk prostate cancer., Methods and Materials: A total of 63 patients were treated according to an institutional review board-approved prospective study of single-fraction HDR brachytherapy. Eligible patients had tumor stage ≤T2a, prostate-specific antigen level ≤15 ng/mL, and Gleason score ≤7. Patients with a prostate gland volume >50 cm 3 and baseline American Urologic Association symptom score >12 were ineligible. Patients underwent transrectal ultrasound-guided transperineal implantation of the prostate, followed by single-fraction HDR brachytherapy. Treatment was delivered using 192 Ir to a dose of 19 Gy prescribed to the prostate, with no additional margin applied., Results: Of the 63 patients, 58 had data available for analysis. Five patients had withdrawn consent during the follow-up period. The median follow-up period was 2.9 years (range 0.3-5.2). The median age was 61.4 years. The median gland volume at treatment was 34.8 cm 3 . Of the 58 patients, 91% had T1 disease, 71% had Gleason score ≤6 (29% with Gleason score 7), and the median pretreatment prostate-specific antigen level was 5.1 ng/mL. The acute and chronic grade 2 genitourinary toxicity incidence was 12.1% and 10.3%, respectively. No grade 3 urinary toxicity occurred. No patients experienced acute rectal toxicity grade ≥2, and 2 experienced grade ≥2 chronic gastrointestinal toxicity. Three patients experienced biochemical failure, yielding a 3-year cumulative incidence estimate of 6.8%., Conclusions: Single-fraction HDR brachytherapy is well-tolerated, with favorable preliminary biochemical and clinical disease control rates., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Nonmotor symptoms (NMS) of Parkinson's disease (PD) were recognized by James Parkinson himself and are now considered to be an integral part of PD. While clinical assessment had focused on prevalence and severity of individual NMS such as dementia and depression, work in the last decade has concentrated on global or holistic assessment of NMS using validated tools such as the NMS questionnaire and NMS scale. These studies from cohorts of varying sizes have allowed comparison of NMS across different disease stages, duration, age, and ethnicity in PD. The data also allow exploration of the concept of the nonlinear relationship of NMS to disease duration of PD and motor stages as well as nonmotor subtypes of PD. In this chapter, these aspects of epidemiological studies of NMS in PD cohorts are described., (© 2017 Elsevier Inc. All rights reserved.)

Sterile leukocyturia is an important and difficult clinical problem in children. In this paper, we described the most common nephrologic causes of sterile leukocyturia, including infectious, non-infectious and extrarenal etiology. We stressed an the importance of appropriate urine collection for urinalysis. There is a need for treatment of inflammation and also for diagnosis of potential anomalies of urethral orifice as causes of sterile leukocyturia in children.

(Objectives) We report the clinical features about polymicrobial bacteria detection cases in the uncomplicated urinary tract infection of the premenopausal woman from the voided midstream urine culture. (Methods) We retrospectively reviewed the premenopausal woman from 18-49 years patients visited Sendai City Hospital from April, 2006 to December, 2014, diagnosed uncomplicated cystitis or uncomplicated pyelonephritis. We analyzed for 375 specimens from the voided midstream urine culture. (Results) Among 375 specimens, the urine culture-positive for uropathogens were 211 specimens. The monomicrobial bacterial were detected in 184 specimens (87.2%) and polymicrobial bacterial specimens were 27 specimens (12.8%). The most combination group was the caused bacteria and periurethral microorganisms in 20 specimens (74.1%). Then 6 periurethral microorganisms specimens (22.2%), the caused bacteria were only 1 specimen was overlapped (3.7%). The case of urinary tract infections recurrence or revealed voiding dysfunction that need periodic treatment were more prevalent in the polymicrobial than the monomicrobial group (22.2% vs 9.8%, p=0.043). (Conclusions) When polymicrobial bacteria were detected in uncomplicated urinary tract infection in premenopausal woman, it was confirmed that there were the most combinations of caused bacteria and periurethral microorganisms. In these cases, treatment intended for only the caused bacteria. A risk of the infection recurrence and voiding dysfunction were statistically significant higher rate in the polymicrobial bacteria detection cases, and it might be necessary to consider that search to complicated urinary tract infection.

A comparative examination of 100 patients at different ages, suffering from disorders of micturition, erectile function and pelvic pain, identified age-related peculiarities of these pathological manifestations. Irritative disorders of urination was detected significantly more frequently among persons of young and middle age than the elderly, and obstructive-related disorders were more frequent in the elderly. In elderly and senile age more prevalent was reducing of the contractility of the detrusor, and at a younger age - increased tone of striated sphincter of the urethra and bladder hyperactivity. It was shown that the participation of long-existing spasm of some muscle formation of the lumbar, pelvic and femoral region in the genesis of urinary symptoms, erectile dysfunction and pelvic pain. When using manual therapy, physiotherapy and botuline-therapy high effectiveness against disorders of micturition, erectile function and pelvic pain was achieved regardless of the age of the patients. It is recommended for the diagnosis of urological pathology to involve specialists in the field of neurology and manual therapy. In cases of diagnosis of musculo-tonic disorders not etiologically associated with pathological processes in the organs of the urogenital system, in the complex of therapeutic measures it is recommended to include methods such as manual-therapy, physiotherapy, botuline-therapy.

The purpose of this study was to estimate locally accumulated dose to the bladder in multi-fraction high-dose-date (HDR) image-guided intracavitary brachytherapy (IG-ICBT) for cervical cancer, and study the locally-accumulated dose parameters as predictors of late urinary toxicity. A retrospective study of 60 cervical cancer patients who received five HDR IG-ICBT sessions was performed. The bladder outer and inner surfaces were segmented for all sessions and a bladder-wall contour point-set was created in MATLAB. The bladder-wall point-sets for each patient were registered using a deformable point-set registration toolbox called coherent point drift (CPD), and the fraction doses were accumulated. Various dosimetric and volumetric parameters were calculated using the registered doses, including [Formula: see text] (minimum dose to the most exposed n-cm 3 volume of bladder wall), r V n Gy (wall volume receiving at least m Gy), and [Formula: see text] (minimum equivalent biologically weighted dose to the most exposed n-cm 3 of bladder wall), where n  =  1/2/5/10 and m  =  3/5/10. Minimum dose to contiguous 1 and 2 cm 3 hot-spot volumes was also calculated. The unregistered dose volume histogram (DVH)-summed equivalent of [Formula: see text] and [Formula: see text] parameters (i.e. [Formula: see text] and [Formula: see text]) were determined for comparison. Late urinary toxicity was assessed using the LENT-SOMA scale, with toxicity Grade 0-1 categorized as Controls and Grade 2-4 as Cases. A two-sample t-test was used to identify the differences between the means of Control and Case groups for all parameters. A binomial logistic regression was also performed between the registered dose parameters and toxicity grouping. Seventeen patients were in the Case and 43 patients in the Control group. Contiguous values were on average 16 and 18% smaller than parameters for 1 and 2 cm 3 volumes, respectively. Contiguous values were on average 26 and 27% smaller than parameters. The only statistically significant finding for Case versus Control based on both methods of analysis was observed for r V 3 Gy (p  =  0.01). DVH-summed parameters based on unregistered structure volumes overestimated the bladder dose in our patients, particularly when contiguous high dose volumes were considered. The bladder-wall volume receiving at least 3 Gy of accumulated dose may be a parameter of interest in further investigations of Grade 2+  urinary toxicity.

Purpose: Health-related quality of life (QOL) has not been well-studied in survivors of muscle-invasive bladder cancer (MIBC). The present study compared long-term QOL in MIBC patients treated with radical cystectomy (RC) versus bladder-sparing trimodality therapy (TMT)., Methods and Materials: This cross-sectional bi-institutional study identified 226 patients with nonmetastatic cT2-cT4 MIBC, diagnosed in 1990 to 2011, who were eligible for RC and were disease free for ≥2 years. Six validated QOL instruments were administered: EuroQOL EQ-5D, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire and EORTC MIBC module, Expanded Prostate Cancer Index Composite bowel scale, Cancer Treatment and Perception Scale, and Impact of Cancer, version 2. Multivariable analyses of the mean QOL scores were conducted using propensity score matching., Results: The response rate was 77% (n=173). The median follow-up period was 5.6 years. Of the 173 patients, 64 received TMT and 109, RC. The median interval from diagnosis to questionnaire completion was 9 years after TMT and 7 years after RC (P=.009). No significant differences were found in age, gender, comorbidities, tobacco history, performance status, or tumor stage. On multivariable analysis, patients who received TMT had better general QOL by 9.7 points of 100 compared with those who had received RC (P=.001) and higher physical, role, social, emotional, and cognitive functioning by 6.6 to 9.9 points (P≤.04). TMT was associated with better bowel function by 4.5 points (P=.02) and fewer bowel symptoms by 2.7 to 7.1 points (P≤.05). The urinary symptom scores were similar. TMT was associated with better sexual function by 8.7 to 32.1 points (P≤.02) and body image by 14.8 points (P<.001). The patients who underwent TMT reported greater informed decision-making scores by 13.6 points (P=.01) and less concern about the negative effect of cancer by 6.8 points (P=.006). The study limitations included missing baseline QOL data and different follow-up times., Conclusions: Both TMT and RC result in good long-term QOL outcomes in MIBC survivors, supporting TMT as a good alternative to RC for selected patients. Whether TMT leads to superior QOL requires prospective validation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The study sought to determine the symptomatic profile of men with lower urinary tract symptoms (LUTS) who visited a urology clinic in Spain and its impact on their health-related quality of life (HRQL)., Materials and Methods: A national, epidemiological cross-sectional study was conducted and included 291 urology clinics. The prevalence of storage LUTS was investigated in 25,482 men. The study collected sociodemographic and clinical data from a subgroup of 1015 patients with storage LUTS who filled out the International Prostate Symptom Score (IPSS), Overactive Bladder Questionnaire Short Form (OABq-SF) and Patient Perception of Bladder Condition (PPBC) questionnaires. The impact of urinary urgency on HRQL was analysed., Results: The prevalence of storage LUTS was 41%, increasing with age: 14.1%, 41.5% and 60.8% for patients aged 18-49, 50-64 and ≥65 years, respectively. Of the 1015 selected patients, only 2.6% had storage symptoms exclusively. Symptom severity (IPSS) increased with age. Nocturia, frequency and urgency were the most common symptoms and had the most impact on HRQL (IPSS and OABq-SF). The number of urgency episodes was inversely correlated with the HRQL (r=-.773; P<.0001). In the multivariate analysis, only the IPSS and OABq-SF bother scores were significant predictors of HRQL (P<.001)., Conclusion: Storage LUTS are highly prevalent among patients attending urology clinics in Spain. The severity of the urgency (number of urgency episodes) predicted a poorer quality of life for the patient., (Copyright © 2016 AEU. Publicado por Elsevier España, S.L.U. All rights reserved.)

Rationale: A variety of therapeutic modalities are available for the treatment of interstitial cystitis. However, among them, the less invasive therapies are usually ineffective, whereas the invasive ones carry potential risks of serious side effects and complications. Pulsed radiofrequency (PRF) treatment of the superior hypogastric plexus may be an alternative to conventional treatments, as it provides nondestructive neuromodulation to the superior hypogastric plexus, which transmits the majority of pain signals from the pelvic viscera., Patient Concerns: For 7 years, a 35-year-old female patient had been experiencing lower abdominal pain provoked by urinary bladder filling, perivulvar pain developing spontaneously during sleep or upon postural change, urinary urgency and frequency with 15- to 60-min intervals between urinations, and nocturia with 10 voids per night. Hydrodistension of the bladder, monthly intravesical administration of sterile sodium chondroitin sulfate, and oral medications including gabapentin and pentosan polysulfate had not been effective in managing the pain and symptoms., Diagnoses and Interventions: Given the satisfactory result of a diagnostic block of the superior hypogastric plexus, 2 sessions of PRF treatment of the superior hypogastric plexus, which applied radiofrequency pulses with a pulse frequency of 2 Hz and a pulse width of 20 ms for 120 s twice per session to maintain the tissue temperature near the electrode at 42°C, were performed at a 6-month interval., Outcomes: This treatment relieved the pain and symptoms for 2 years and 6 months., Lessons: PRF treatment of the superior hypogastric plexus results in long-term improvements in the pain and symptoms associated with interstitial cystitis., Competing Interests: The authors have no funding and conflicts of interest to disclose.

Background: The rates reported for postoperative urinary retention following midurethral sling procedures are highly variable. Determining which patients have a higher likelihood of failing a voiding trial will help with preoperative counseling prior to a midurethral sling., Objective: The objective of the study was to identify preoperative predictors for failed voiding trial following an isolated midurethral sling., Study Design: A retrospective, multicenter, case-control study was performed by including all isolated midurethral sling procedures performed between Jan. 1, 2010 to June 30, 2015, at 6 academic centers. We collected demographics, medical and surgical histories, voiding symptoms, urodynamic evaluation, and intraoperative data from the medical record. We excluded patients not eligible for attempted voiding trial after surgery (eg, bladder perforation requiring catheterization). Cases failed a postoperative voiding trial and were discharged with an indwelling catheter or taught intermittent self-catheterization; controls passed a voiding trial. We also recorded any adverse events such as urinary tract infection or voiding dysfunction up to 6 weeks after surgery. Bivariate analyses were completed using Mann-Whitney and Pearson χ 2 tests as appropriate. Multivariable stepwise logistic regression was used to determine predictors of failing a voiding trial., Results: A total of 464 patients had an isolated sling (70.9% retropubic, 28.4% transobturator, 0.6% single incision); 101 (21.8%) failed the initial voiding trial. At follow-up visits, 90.4% passed a second voiding trial, and 38.5% of the remainder passed on the third attempt. For the bivariate analyses, prior prolapse or incontinence surgery was similar in cases vs controls (31% vs 28%, P = .610) as were age, race, body mass index, and operative time. Significantly more of the cases (32%) than controls (22%) had a Charlson comorbidity index score of 1 or greater (P = .039). Overactive bladder symptoms of urgency, frequency, and urgency incontinence were similar in both groups as was detrusor overactivity in those with a urodynamic evaluation (29% vs 22%, P = .136), but nocturia was reported more in the cases (50% vs 38%, P = .046). Mean (SD) bladder capacity was similar in both groups (406 [148] mL vs 388 [122] mL, P = .542) as was maximum flow rate with uroflowmetry and pressure flow studies. Cases were significantly more likely to have a voiding type other than detrusor contraction: 37% vs 25%, P = .027, odds ratio, 1.79 (95% confidence interval, 1.07-3.00). There was no difference in voiding trial failures between retropubic and transobturator routes (23.1% vs 18.9%, P = .329). Within 6 weeks of surgery, the frequency of urinary tract infection in cases was greater than controls (20% vs 6%, P < .001; odds ratio, 3.51 [95% confidence interval, 1.82-6.75]). After passing a repeat voiding trial, cases were more likely to present with acute urinary retention (10% vs 3%, P = .003; odds ratio, 4.00 [95% confidence interval, 1.61-9.92]). For multivariable analyses, increasing Charlson comorbidity index increased the risk of a voiding trial failure; apart from this, we did not identify other demographic information among the patients who did not undergo urodynamic evaluation that reliably forecasted a voiding trial failure., Conclusion: The majority of women will pass a voiding trial on the first attempt after an isolated midurethral sling. Current medical comorbidities are predictive of a voiding trial failure, whereas other demographic/examination findings are not. Patients failing the initial voiding trial are at an increased risk of postoperative urinary tract infection or developing acute retention after passing a subsequent voiding trial., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Ideal therapy for lower urinary tract dysfunction in patients with spinal cord injury (SCI) should decrease detrusor overactivity, thereby promoting urine storage at low intravesical pressure and promoting efficient voiding at low pressure by decreasing detrusor-sphincter dyssynergia. Here we investigated blockade of various α-adrenoceptors to determine the subtype that was principally responsible for improving the voiding dysfunction. The effects of the intravenous α-blocker naftopidil, the α-blocker BMY 7378, and the α-blocker silodosin were evaluated using cystometrography and external urethral sphincter-electromyography (EMG) in decerebrated, unanesthetized female Sprague-Dawley rats with chronic SCI following transection at Th8. Parameters measured included the voided volume, residual volume, voiding efficiency, and burst and silent periods on EMG. Compared with values in decerebrated non-SCI rats, EMG of decerebrated SCI rats revealed more prominent tonic activity, significantly shorter periods of bursting activity, and a reduced ratio of the silent to active period during bursting. Compared with the value before drug administration (control), the voiding efficiency was significantly increased by naftopidil (1 and 3 mg/kg) (<0.05 each), and the burst (<0.01 and <0.05, respectively) and silent periods (<0.01 each) on EMG were significantly lengthened. BMY 7378 (1 mg/kg) significantly increased voiding efficiency and lengthened the burst periods (<0.05 each). Silodosin did not affect any parameters. These results suggest that α-blockade reduces the urethral resistance associated with detrusor-sphincter dyssynergia, thus improving voiding efficiency in SCI rats., (Copyright © 2016 the American Physiological Society.)

Background: Various minimally invasive techniques are available for the surgical treatment of benign prostatic obstruction. Besides resection and enucleation, vaporization of the prostate is an attractive alternative., Objectives: The aim of the present article is to provide a comprehensive literature review on long-term results of GreenLight™ laser vaporisation and electrovaporisation of the prostate., Materials and Methods: A literature search on long-term (≥5 years) results of GreenLight™ laser vaporization of the prostate and electrovaporisation of the prostate., Results: Laser vaporization of the prostate with the GreenLight™ laser leads to an immediate and long-lasting improvement of voiding symptoms beyond 5 years. Currently, no long-term data of the 180 W laser model are available. With the former 80 W laser, an increased rate of reoperation due to recurrent obstruction has been described. As reoperation mainly occurs within the first 2 postoperative years, this suggests insufficient tissue ablation. Electrovaporisation of the prostate also leads to an improvement of voiding symptoms. However, only few studies on long-term results are available which report a relatively high rate of treatment failure. In addition, these studies have limitations in study design., Conclusions: Laser vaporisation of the prostate with the GreenLight™ laser seems to be an effective minimally invasive treatment alternative for BPO. However, long-term results of the current 180 W laser are still awaited. Based on limited data, electrovaporisation of the prostate currently cannot be recommended as an established treatment alternative.

Background: For many transgender women, vaginoplasty is the final stage in the gender-confirming process. Penile inversion vaginoplasty is considered the gold standard for vaginal construction in transgender women. In this study, the authors assessed intraoperative and postoperative complications after penile inversion vaginoplasty., Methods: All patients who underwent penile inversion vaginoplasty between January of 2000 and January of 2014 were identified retrospectively from the authors' hospital registry. A retrospective chart review was conducted. Outcome measures were intraoperative and postoperative complications, reoperations, secondary surgical procedures, and possible risk factors., Results: Between January of 2000 and January of 2014, 475 patients underwent penile inversion vaginoplasty, 405 of whom did not have and 70 of whom did have additional full-thickness skin grafts. The median patient age at surgery was 38.6 years (range, 18.1 to 70.8 years). Median follow-up was 7.8 years (range, 1.0 to 15.9 years). The most frequently observed intraoperative complication was rectal injury [n = 11 (2.3 percent)]. Short-term postoperative bleeding that required transfusion [n = 23 (4.8 percent)], reoperation [n = 7 (1.5 percent)] or both [n = 2 (0.4 percent)] occurred in some cases. Major complications comprised three (0.6 percent) rectoneovaginal fistulas, which were successfully treated. Revision vaginoplasty was performed in 14 patients (2.9 percent). Comorbid diabetes was associated with a higher risk of local infection (OR, 9.8; p = 0.003; 95 percent CI, 2.8 to 34.4), and use of psychotropic medication predisposed to postoperative urinary retention (OR, 2.1; p = 0.006; 95 percent CI, 1.2 to 3.5)., Conclusions: Successful vaginal construction without the need for secondary functional reoperations was achieved in the majority of patients. Intraoperative complications are scarce. Postoperative complications occur frequently but are generally minor and easily treated., Clinical Question/level of Evidence: Therapeutic, IV.

A 42-year-old female with remote history of intrauterine device (IUD) placement presented with gross hematuria, urinary urgency, and dyspareunia. Cystoscopy showed an encrusted, free-floating intravesical foreign body consistent with a heavily calcified IUD. It was removed endoscopically using holmium laser cystolitholapaxy. The patient remained symptom free postoperatively. While most intravesical IUDs are thought to be the result of migration after several months, this patient became pregnant within 4 weeks after initial insertion. Therefore this may represent a case either of early intravesical migration or of accidental IUD placement into the bladder at the time of initial insertion.

Background: After low anterior resection for rectal cancer, visual assessment of pelvic autonomic nerve preservation can be difficult due to the complexity of neuroanatomy, as well as surgery- and patient-related factors. The present study aimed to evaluate nerve-sparing quality assurance using the laparoscopic neuromapping (LNM) technique., Methods: We prospectively investigated a series of 30 patients undergoing laparoscopic low anterior resection. Nerve-sparing was evaluated both visually and electrophysiologically. LNM was performed using stimulation of pelvic autonomic nerves under simultaneous cystomanometry and processed electromyography of the internal anal sphincter. Urogenital and anorectal functions were evaluated using validated and standardized questionnaires preoperatively, at short-term follow-up, and at mid-term follow-up at a median of 9 months (range 6-12 months) after surgery., Results: One patient reported new onset of urinary dysfunction, and another patient reported new onset of anorectal dysfunction. Of the 20 sexually active patients, five reported sexual dysfunction. Visual assessment by laparoscopy confirmed complete nerve preservation in 28 of 30 cases. For prediction of urinary and anorectal function, LNM sensitivity, specificity, positive and negative predictive value, and overall accuracy were each 100 %. LNM with combined assessment for prediction of sexual function yielded a sensitivity of 80 %, specificity of 93 %, positive predictive value of 80 %, negative predictive value of 93 %, and overall accuracy of 90 %., Conclusions: LNM is an appropriate method for reliable quality assurance of laparoscopic nerve-sparing.

Background: Overactive bladder (OAB) is very common in the urological and gynecological practice. It is well known that the correlation between clinical features and urodynamics findings is often poor. In this observational study urodynamic findings of an OAB population have been retrospectively analyzed with the aim to identify a possible role of voiding disorders in the pathophysiology of OAB syndrome., Methods: Urodynamics executed between January 2005 and December 2010 have been analyzed. Female patients presenting characteristics of OAB syndrome according to International Continence Society definition were identified. Urodynamic investigations have been carried out according to the good practice guidelines for urodynamics. The Blaivas-Groutz cut off for female urinary obstruction was to detect voiding disorders., Results: According to the selection criteria 258 patients presenting OAB syndrome have been considered eligible to join the study. Eighty-one patients (30%) showed voiding difficulties: in 21 of them pressure-flow study was diagnostic for frank outlet obstruction, in 47 a mild form and 13 bladder sphincter pseudo-dyssynergia., Conclusions: OAB syndrome can be related to voiding disorders mostly represented by a mild degree of obstruction. Such condition could trigger irritative symptoms. These clinical findings require an instrumental assessment represented by a pressure-flow analysis. This approach seems to be mandatory in patients refractory to drug therapy.