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Neurogenic bladder often occurs after pelvic ganglia injury. Its symptoms, like severe urinary retention and incontinence, have a significant impact on individuals' quality of life. Unfortunately, there are currently no effective treatments available for this type of injury. Here, we designed a fiber-enhanced tissue bandage for injured pelvic ganglia. Tight junctions formed in tissue bandages create a mini tissue structure that enhances resistance in an in vivo environment and delivers growth factors to support the healing of ganglia. Strength fibers are similar to clinical bandages and guarantee ease of handling. Furthermore, tissue bandages can be stored at low temperatures over 5 months without compromising cell viability, meeting the requirements for clinical products. A tissue bandage was applied to a male rat with a bilateral major pelvic ganglia crush injury. Compared to the severe neurogenic bladder symptoms observed in the injury and scaffold groups, tissue bandages significantly improved bladder function. We found that tissue bandage increases resistance to mechanical injury by boosting the expression of cytoskeletal proteins within the major pelvic ganglia. Overall, tissue bandages show promise as a practical therapeutic approach for ganglia repair, offering hope for developing more effective treatments for this thorny condition. Neurogenic bladder often occurs after pelvic ganglia injury. Here, the authors designed a fiber-enhanced tissue bandage for injured pelvic ganglia that facilitates the delivery of growth factors essential for ganglia healing. [ABSTRACT FROM AUTHOR]

Objective: To establish experimental models of radical hysterectomy based on Querleu-Morrow classification, and clarify the quantitative evaluation of pelvic neural injuries and acute voiding changes postoperatively. Methods: Female Sprague Dawley rats were randomized and received sham operation, type A, B1, C1 and C2 radical hysterectomies (as the injury gradually increased), respectively. The excised specimens were collected for hematoxylin and eosin staining and Pgp9.5 (pan-neuronal marker) immunohistochemistry to evaluate the facial and neural resection of paracervix. At 21 days after operation, 5 rats in each group were used for urine spot test, awake cystometry and leak point pressure test, and the other 5 ones were used for hematoxylin and eosin staining of bladder and pelvic neural plane, and Masson's trichrome staining of bladder. Results: Paracervical Pgp9.5 immunohistochemistry revealed that the resected neural area in C2 group was significantly larger than that in type A, B1, and C1 groups. Compared with type A and B1 groups, the excised paracervical facial area was significant higher in type C1 and C2 groups. The occurrence of urinary retention was 0%, 10%, 40% and 100% in type A, B1, C1 and C2 groups, respectively, which was further confirmed by average residual volume. The incidence of neurogenic bladder and its severity gradually increased from type A to type C2 groups, consistent with the findings of leakage point pressure, bladder size, bladder weight, pathological changes and collagen deposition. Neuropathological evaluation revealed neural injuries involved the main components of pelvic neural plane. Conclusion: The novel rat models of radical hysterectomy based on Querleu-Morrow classification revealed the structural and functional changes of voiding after operation, which reflected the situation in humans. [ABSTRACT FROM AUTHOR]

BACKGROUND: Numerous clinical and basic studies have shown that electroacupuncture can improve the function of neurogenic bladder after suprasacral spinal cord injury. OBJECTIVE: To observe the effects of electroacupuncture on bladder function and connective tissue growth factor expression in rats with suprasacral spinal cord injury. METHODS: Forty-eight female Sprague-Dawley rats were randomly divided into four groups (n=12 per group): the blank group did not receive any treatment; the sham-operated group only exposed the T8 subvertebral spinal cord; in the model group established, a T8 subvertebral spinal cord transection injury model was established; in the electroacupuncture group, the T8 subvertebral spinal cord transection injury model was established, and electroacupuncture intervention at Ciliao (BL32), Zhongji (RN03) and Sanyinjiao (SP06) was given at 19 days after modeling, 20 minutes once a day, for 10 continuous days. After the intervention, the relevant indicators were detected. RESULTS AND CONCLUSION: Urodynamics: Compared with the blank group, the leakage point pressure, maximum bladder capacity and maximum bladder pressure of rats in the model group increased (P < 0.05). Compared with the model group, the leakage point pressure, maximum bladder capacity and maximum bladder pressure of rats in the electroacupuncture group decreased (P < 0.05). Hematoxylin-eosin staining: Compared with the blank group, the bladder epithelial cells in the model group were arranged in a disordered manner, the lamina propria was destroyed, the detrusor muscle bundles were hypertrophied, the muscle fibers were arranged in a disordered manner, and the tissue edema was obvious. Compared with the model group, the bladder epithelial cells in the electroacupuncture group were arranged in a regular and orderly manner, and the degree of bladder fibrosis and tissue edema was relatively reduced. Masson staining: The degree of bladder detrusor muscle fibrosis was severe in the model group and it was lighter in the electroacupuncture group than in the model group. Transmission electron microscopy: Mitochondria in the bladder tissue in the model group were swollen and vacuolated, the morphology of the detrusor muscle was twisted and distorted, and the muscle gap was widened. Compared with the model group, mitochondria in the electroacupuncture group had a slightly clearer contour and were less vacuolated, and the muscle gap was narrowed. Western blot detection: The protein expression of connective tissue growth factor in the detrusor muscle of the bladder was elevated in the model group compared with the blank group (P < 0.05). Compared with the model group, the protein expression of connective tissue growth factor in the bladder detrusor muscle was decreased in the electroacupuncture group (P < 0.05). To conclude, electroacupuncture at Ciliao (BL32), Zhongji (RN03) and Sanyinjiao (SP06) acupoints can improve the morphology, structure and function of the bladder in rats with suprasacral spinal cord injury, and the mechanism of action may be related to the down-regulation of connective tissue growth factor protein expression in the detrusor muscle. [ABSTRACT FROM AUTHOR]

Background: Organophosphate-Induced Delayed Neuropathy (OPIDN) is a rare neurological disorder triggered by exposure to organophosphorus compounds. These compounds exert their neurotoxic effects by impacting the nervous system, leading to systemic manifestations. Urinary system symptoms are infrequently observed in clinical settings. Currently, effective therapeutic interventions for OPIDN-related urinary symptoms are lacking. Sacral nerve modulation therapy, an FDA-approved approach for managing lower urinary tract symptoms, presents as a promising option. Herein, we present a case of OPIDN-induced lower urinary tract obstruction successfully treated with sacral nerve modulation therapy, resulting in substantial symptom relief. Case report: A 27-year-old male patient presented with severe bilateral hydronephrosis, attributed to low bladder compliance and accompanied by a fever persisting for 6 days. The patient's medical history revealed accidental ingestion of organophosphate pesticide (Dimethoate) with no concomitant underlying diseases. In consideration of the potential for OPIDN, surgical intervention in the form of sacral neuromodulation (phase I) was undertaken. Subsequent evaluation one month post-surgery revealed notable improvements in both bladder compliance and bilateral hydronephrosis, necessitating sacral neuromodulation (phase II). Presently, following a 5-month follow-up period, the patient remains asymptomatic and in favorable health. Conclusion: This patient achieved long-term relief using sacral neuromodulation. [ABSTRACT FROM AUTHOR]

Background/Objectives: Bladder outlet obstruction (BOO) resulting from benign prostate enlargement (BPE) is a common cause of lower urinary tract symptoms (LUTS) in men. Patients with central nervous system (CNS) diseases, such as spinal cord injury (SCI), Parkinson's disease (PD), cerebrovascular accident (CVA) and multiple systemic atrophy (MSA), commonly experience lower urinary tract dysfunction. Men who suffer from CNS diseases may also experience symptoms related to BPE and BOO, which pose an additional burden to their overall clinical status and result in the need for catheter use and a deterioration in quality of life. The aim of this study was to identify if prostate surgery will benefit men with CNS diseases who have been diagnosed with BPE-related BOO. Methods: The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. EMBASE, MEDLINE, Cochrane systematic reviews, Cochrane Central Register of Controlled Trials, Google Scholar, and ClinicalTrials.gov were searched from 1946 up to July 2023 for peer-reviewed publications addressing the primary outcome (success rate) and the secondary outcomes (postoperative changes in incontinence episodes, urodynamic parameters, questionnaire scores, and quality of life). In addition, the perioperative outcomes (adverse events and the need for further medical or surgical therapy) were reported. Results: A total of 1572 abstracts were screened, and 13 studies involving 1144 patients were eligible for inclusion. Six studies assessed the effect of prostate surgery for BPE-related BOO in SCI, four studies in CVA, two studies in PD, and one study in the MSA population. All studies were considered to have a high risk of bias. Transurethral resection of the prostate (TURP) was the most common de-obstruction procedure, followed by prostatic artery embolism and open prostatectomy. The overall pooled success rate was calculated as 81.4% (65–100%) in SCI, 27.1% (9–70%) in PD, and 66.7% (50–79%) in CVA populations. The risk of de novo incontinence was 24.7–50% in SCI, 20% in PD, 21–50% in CVA, and 60% in MSA population. In patients with SCI with BPE-related BOO, prostate surgery improved mean bladder compliance and detrusor filling pressure and resolved detrusor overactivity in up to 50% of patients. Improvement of free flow rate, voided volume, and post-void residual was observed in all patients. Patients with CVA had an increased risk of perioperative mortality compared to non-CVA patients, and the risk of postoperative complications was inversely proportional to the timing of the CVA insult since surgery. Conclusions: This systematic review provides an overview of the available evidence on the outcome of prostate surgery in patients with neurologic diseases and BPE-related BOO. Identifying the optimal practice was challenging due to the limited availability of high-quality studies and the high variability of the reported outcomes. Properly selected patients with neurological diseases may benefit from prostate surgery, provided that preoperative investigations indicate BPE-related BOO. [ABSTRACT FROM AUTHOR]

Spina bifida (SB) is a developmental disorder of the central nerve system. Due to incomplete closure of the neural tube, there is a congenital spinal cord lesion, which can be accompanied by cerebral anomalies. Due to folic acid suppletion and antenatal screening, the incidence of SB has decreased. Improvements in urological and specialized health care have led to a longer life expectancy and better quality of life. Lifelong care should take place in a multidisciplinary team, including a urologist experienced in the diagnosis and treatment of neurogenic bladder disorders and concomitant problems, such as urinary tract infections, urolithiasis and malignancies. [ABSTRACT FROM AUTHOR]

Introduction: Patient expectations and baseline health are important drivers of outcomes following major genitourinary reconstructive surgery for neurogenic bladder (NGB). Differences in expectations and quality of life (QoL) improvements among different populations with NGB remain insufficiently explored in the literature. Objective: To compare decisional regret (DR) and urinary‐related QoL (UrQoL) in patients undergoing urinary diversion for NGB arising from spinal cord injury of acquired (A‐SCI) and congenital (C‐SCI) etiologies. We hypothesize that patients with A‐SCI have higher expectations of improvement in QoL following surgery when compared with C‐SCI, which may lead to higher DR and decreased UrQoL, postoperatively. Design: In this cross‐sectional survey study, we compared A‐SCI to C‐SCI in terms of DR, UrQoL, and postoperative changes in self‐reported physical health, mental health, and pain using validated patient‐reported outcome measures. Setting: Participants were enrolled from a quaternary care institution via mail and MyChart. Participants: The A‐SCI group consisted of 17 patients with traumatic spinal cord injury; the C‐SCI group was composed of 20 patients with spina bifida. Interventions: Not applicable. Main Outcome Measures: The Decisional Regret Scale, Short form‐ Qualiveen (SF‐Qualiveen), and Patient‐reported outcomes measurement Information system‐10 (PROMIS‐10) Global Health surveys. Results: The A‐SCI group displayed poorer preoperative physical health than the C‐SCI cohort, but absolute postoperative changes in this score, along with mental health score and pain level, were not significant after adjusting for baseline scores and follow‐up time. SF‐Qualiveen scores revealed significantly worse impact of NGB in UrQoL for A‐SCI than for C‐SCI when adjusted for other factors. No differences in DR were seen between the groups. Conclusions: Patients with A‐SCI demonstrate lower self‐reported baseline physical health compared with patients with C‐SCI, which may have implications in setting patient expectations when undergoing urinary diversion. In this small cohort, we found a milder self‐reported postoperative impact of NGB in UrQoL in patients with C‐SCI. [ABSTRACT FROM AUTHOR]

The National Spina Bifida Patient Registry (NSBPR) assesses bladder and bowel incontinence using ordinal categories, but prior NSBPR analyses employed binary classification. Our aims were to 1) perform the first NSBPR analysis of bladder and bowel incontinence as ordinal outcomes to compare to the binary definition and subject variables; 2) explore the correlation of incontinence with undergarment usage, and 3) assess incontinence status following continence surgeries. Data from NSBPR participants' most recent clinic visit from 2013 to 2020 were analyzed. Ordinal categories of incontinence were compared to previously used binary definitions. Incontinence surgical outcomes were analyzed for those with data at least three months post-operatively. Chi-square tests evaluated associations among categorical variables. Univariate and ordinal logistic regression models were used to test associations of ordinal incontinence status with patient and condition factors. Statistical tests were 2-sided; p values < 0.05 were considered significant. Analysis of 7217 individuals using ordinal incontinence outcomes showed little difference from previously used binary outcomes. The final multivariable logistic regression models with ordinal multinomial outcomes showed that associations of incontinence with age, sex, race/ethnicity, health insurance, level of lesion, and continence management technique were similar to prior studies. Among those reporting never being incontinent of both bladder and bowel, 14% reported using protective undergarments. Of the 500 individuals who had bladder outlet surgery, 38% reported never being incontinent of urine. Of 1416 individuals who had appendicostomy (ACE) bowel surgery, 48% reported never being incontinent of stool. Our current analysis showed that ordinal continence outcome classification had similar continence findings as previous studies using the binary definition of continence. Expanding the binary definition of continence to include monthly episodes of incontinence did not greatly increase the proportion of continent individuals and, therefore, would have not likely made meaningful differences in continence outcomes in prior NSBPR analyses. However, it is known that even mild incontinence can affect quality of life, therefore, capturing any level of incontiennce is of clinical importance. Confirmation of the association of continence outcomes with sociodemographic, condition-related, and interventional factors with both approaches further validates previous analyses using the binary definition of continence. The previously used binary definition of bladder and bowel continence appears robust. Undergarment choice was a poor surrogate for reported incontinence. After bladder and bowel continence surgeries, 38% and 48%, respectively, reported never being incontinent. [ABSTRACT FROM AUTHOR]

Purpose: To describe the prevalence of nocturia and obstructive sleep apnea (OSA) in a cohort of spinal cord injury (SCI) patients and to describe their association. Additionally, to assess clinical and urodynamic data explaining nocturia and to evaluate the effect of OSA management with continuous positive airway pressure (CPAP). Method: Retrospective analysis of data from patients with SCI followed in a tertiary care rehabilitation center with a specialized sleep and neuro-urology units. All adult SCI patients who underwent urodynamic assessment before polysomnography (PSG) between 2015 and 2023 were eligible. Subjective (nocturia) and objective data (urodynamic data, polysomnography, CPAP built-in software) were collated from the Handisom database (database register no. 20200224113128) and the medical records of SCI patients. Statistical testing used Mann-Whitney test for non-parametric variables, Fisher's exact test for contingency analysis and the Spearman correlation test to assess correlations. A p-value < 0.05 was considered significant. Statistical analyses were performed using GraphPad Prism v9. Results: 173 patients (131 males, 42 females) were included. The majority of patients were paraplegic (n = 111 (64,2%)) and had complete lesions (n = 75 (43,4%)). A total of 100 patients had nocturia (57,5%). The prevalence of OSA (Apnea Hypopnea Index (AHI) ≥ 15/h) in the studied population was 61,9%. No correlation was found between nocturia and OSA. A significant difference was observed between patients with and without nocturia in terms of the presence of neurogenic detrusor overactivity (p = 0,049), volume at the first detrusor contraction (p = 0,004) and the bladder functional capacity (p < 0,001). Conclusion: Nocturia and OSA are highly prevalent in patients with SCI, but no statistical association was found between these two disorders. A prospective study focusing on nocturnal polyuria will be needed to assess the impact of OSA on lower urinary tract symptoms in SCI patients. [ABSTRACT FROM AUTHOR]

Sacral spinal cord injury (SSCI) can disrupt bladder neuromodulation and impair detrusor function. Current studies provide limited information on the histologic and genetic changes associated with SSCI-related neurogenic lower urinary tract dysfunction (NLUTD), resulting in few treatment options. This study aimed to establish a simple animal model of SSCI to better understand the disease progression. Ninety 8-week-old Sprague-Dawley (SD) rats were randomly separated into sham operation and SSCI groups. The SSCI group underwent sacral spinal cord injury, while the sham group did not. Urodynamic and histological assessments were conducted at various intervals (1, 2, 3, 4, and 6 weeks) post-injury to elucidate the disease process. Urodynamic examinations revealed significant bladder dysfunction in the SSCI group compared to the sham group, stabilizing around 3–4 weeks post-injury. Histological examination, including hematoxylin–eosin and Masson's trichrome staining, correlated these functional changes with bladder microstructural alterations. RNA-seq was performed on bladder tissues from the sham group and SSCI group at 6 weeks to identify differentially expressed genes and pathways. Selected genes were further analyzed using polymerase chain reaction (PCR). The findings indicated a pronounced inflammatory response in the first 2 weeks post-SSCI, progressing to bladder fibrosis at 3–4 weeks. In conclusion, this study presents a reliable, reproducible, and straightforward SSCI model, providing insights into bladder functional and morphological alterations post-SSCI and laying the groundwork for future therapeutic research. [ABSTRACT FROM AUTHOR]

• rTMS might improve neurogenic OAB symptoms. • rTMS might be cost-effective. • Participants might positively experience rTMS. Neurogenic overactive bladder (OAB) is a distressing condition in stroke. Existing neurogenic OAB management is expensive, unstandardized regimens, or invasive. Evaluating the effectiveness of repetitive transcranial magnetic stimulation (rTMS) remains crucial. We aimed to (1) compare the effectiveness of active-rTMS with sham-rTMS on neurogenic OAB symptoms, (2) analyze whether rTMS is cost-effective, and (3) explore the rTMS's experiences on participants' symptoms. This is a randomized, sham-controlled, double-blinded trial with embedded qualitative and cost-effectiveness studies. A total of 110 stroke survivors with neurogenic OAB symptoms were screened for eligibility; 60 participants were eligible for inclusion and were randomly assigned to either the active (n = 30) or sham-rTMS (n = 30) groups using a computer-generated randomization schedule. The active-rTMS group received low-frequency rTMS of 1200 pulses per session lasting 20 min thrice weekly to pelvic floor muscle representation at the contralesional primary motor cortex. The sham-rTMS group received low-frequency stimulation at a 20 % resting motor threshold using the same coil as the active-rTMS but was configured to reduce the TMS-induced electrical fields significantly. The primary and secondary outcome measures were assessed at baseline, post-intervention (week 4) and follow-up (week 8). The analysis of covariance (ANCOVA) analysis compared changes in the study groups. Quality-adjusted life-years (QALY) were measured to evaluate the cost-effectiveness while EQ-5D-5L estimated QALY changes. Additionally, the focus group discussion data were thematically analyzed. The findings from this rTMS intervention study will be useful in alleviating neurogenic OAB symptoms and enhancing patient satisfaction in a cost-effective way. [ABSTRACT FROM AUTHOR]

Purpose of Review: To report on our experience in establishing a formal transition urology clinic in Victoria, Australia, and review current literature on transition urology processes, as well as identified challenges and future avenues for research and development in the field of transition and adolescent urology. Recent Findings: Paediatric to adult urology transition processes are increasingly reported and supported by the literature; however, to date, there is no consensus on a best model. In 2013, a formal urology transition clinic was established between The Royal Children's Hospital and The Royal Melbourne Hospital. Since then, 122 patients have been referred for transition, with the main reasons for referral being spina bifida (n=52), posterior urethral valve (n=11), and exstrophy (n=8). The transition rate success is 90.2%, and 27.3% of patients required reconstructive surgery. Summary: Transition urology is an emerging and important field of urology that requires dedicated multi-disciplinary teams and collaboration to ensure continued care of the congenital urology patient in a patient-driven manner with goals focused on integration and independence. Our local experience results are comparable to global reports and further evidence of the importance of this process. [ABSTRACT FROM AUTHOR]

Purpose of Review: This review explores the literature that currently exists regarding quality of life for patients with spina bifida and assesses screening tools available for practitioners to assess these outcomes. Domains addressed include health related quality of life, relationships, bowel and bladder dysfunction, sexuality, pain, and mood. Recent Findings: Several recent papers have assessed available questionnaires and reviewed findings of key quality of life domains, with varying results. Summary: Historically, the literature has focused on surgical outcomes for patients with spina bifida. Though some authors have begun to explore quality of life for this patient population, particularly in the short-term, a paucity of quality, long-term studies exist that describe quality of life domains or offer potential targets for improvements in outcomes. [ABSTRACT FROM AUTHOR]

Purpose: Post-procedural urinary tract infections (ppUTIs) following voiding cystourethrography (VCUG) vary widely, with rates from 0 to 42%, though recent studies suggest rates typically below 5%. Verifying urine sterility before VCUG is traditionally done but questioned. This study assessed the 7-day ppUTI rate post-VCUG without prior urine sterility confirmation and identified associated risk factors. Methods: A retrospective review of VCUG cases in children under three years at a pediatric hospital over two years was conducted. Exclusions included neuropathic bladder, bladder exstrophy, pre-VCUG urine cultures, and lost-to-follow-up cases. Achieving a ppUTI rate below 5% would support safe VCUG practice without pre-urine culture. Results: Of 318 VCUGs performed on 300 children, 248 (78%) were males (8% circumcised) with a median age of 5 months. Retrograde VCUG was more common than suprapubic cystography (63% vs. 37%). Before the test, 33.6% received antibiotics, mostly prophylactically. Hydronephrosis was present in 66.4%, and 69% had a history of UTI. VCUG results were abnormal in 43% of cases: 85% had vesicoureteral reflux (VUR), 10% had posterior urethral valves (PUV), and 28% had other abnormalities. The 7-day ppUTI rate was 3.8%, with 67% of ppUTI cases having abnormal VCUG results versus 41% without ppUTI (p = 0.06). No significant risk factors for ppUTI were identified. Conclusions: Omitting systematic urine culture before VCUG was not associated with a high ppUTI rate, even in children with pre-existing urologic conditions or a history of UTI, indicating that VCUG can be safely performed without prior urine sterility confirmation. No risk factors for ppUTI were identified. [ABSTRACT FROM AUTHOR]

Purpose: We investigated whether inflammatory cell infiltration (ICI), fibrosis, and mitochondrial viability of the neurogenic bladder urothelium are involved in the mechanism of persistent vesicoureteral reflux (VUR) after sigmoidocolocystoplasty (SCP). Methods: Bladder biopsies obtained 1994–2023 from 62 neurogenic bladder patients were examined by hematoxylin and eosin for ICI, Masson's trichrome for fibrosis, and immunofluorescence for urothelial growth differentiation factor 15 (GDF15; a mitochondrial stress-responsive cytokine) (positive/negative) and heat shock protein 60 (HSP60; a mitochondrial matrix marker) (strong ≥ 50%/weak≤ 50%) expression. GDF15 + /weak HSP60 indicated compromised mitochondrial viability. Cystometry measured neobladder compliance/capacity. Results: Mean ages (years) at SCP and bladder biopsies were 9.4 ± 4.6 and 14.2 ± 7.1, respectively. VUR was present in 38/62 patients (51 ureters) at SCP and resolved with SCP alone in 4/38 patients, with SCP and ureteroneocystostomy in 17/38, and persisted in 17/38. Fibrosis was significantly denser in GDF15 + (n = 24)/weak HSP60 (n = 31) compared with GDF15- (n = 38)/strong HSP60 (n = 31) (p < 0.001 and p < 0.01, respectively). Differences in ICI were significant for GDF15 + vs. GDF15- (p < 0.05) but not for HSP60. Patients with VUR after SCP had higher incidence of GDF15 + /weak HSP60 compared with cases without VUR (p < 0.05 and p < 0.001, respectively). Conclusion: Viability of mitochondria appears to be compromised with possible etiologic implications for VUR persisting after SCP. [ABSTRACT FROM AUTHOR]

Urinary incontinence is a common complication in stroke survivors for whom new interventions are needed. This study investigated the therapeutic effect of low-frequency (LF) repeated transcranial magnetic stimulation (rTMS) on the contralesional primary motor cortex (M1) in patients with poststroke urinary incontinence (PSI). A total of 100 patients were randomly assigned to the rTMS group or sham-rTMS group on basis of the intervention they received. Both groups underwent five treatment sessions per week for 4 weeks. Data from the urodynamic examination were used as the primary outcome. The secondary outcome measures were questionnaires and pelvic floor surface electromyography. After 4 weeks of intervention, the maximum cystometric capacity (MCC), maximum detrusor pressure (Pdet.max), residual urine output, overactive bladder score (OABSS) (including frequency, urgency, and urgency urinary incontinence), and the ICIQ-UI SF improved significantly in the rTMS group compared with those in the sham-rTMS group (P < 0.05). However, no changes in pelvic floor muscle EMG were detected in patients with PSI (both P > 0.05). Our data confirmed that 4 weeks of LF-rTMS stimulation on the contralateral M1 positively affects poststroke urinary incontinence in several aspects, such as frequency, urgency urinary incontinence, MCC, end-filling Pdet, OABSS, and ICIQ-UI SF scores. [ABSTRACT FROM AUTHOR]

Background/Objectives: Data on the long-term effects of oxybutynin in patients with neurogenic bladder (NGB) due to spinal cord injury (SCI) are limited. This study aimed to evaluate the long-term effects of oxybutynin and the combination of oxybutynin with trospium in these patients, under real-world medical conditions. Methods: A total of 107 patients with NGB due to SCI were included. The mean treatment duration was 2.8 years ± 0.8 years. The patients were categorized into three groups: (1) low-dose oxybutynin (5–15 mg/day), (2) high-dose oxybutynin (20–40 mg/day), and (3) oxybutynin combined with trospium. The main outcomes were maximal detrusor pressure (MDP) and cystometric bladder capacity (CBC). Both were assessed at baseline and at three subsequent follow-up visits. Generalized estimation equation models were used to estimate the overall mean reduction in MDP and CBC for each group. Results: The overall adjusted mean reduction from baseline of MDP in groups 1, 2, and 3 were 2.5 (95% CI: −5.4 to 10.4; p = 0.540), 16.9 (95% CI: 4.4 to 29.4; p = 0.008), and 21.9 (95% CI: 4.1 to 39.8; p = 0.016) cmH2O, respectively. For the CBC, the mean reduction was not significant in any group at any visit, nor were the overall mean reductions. Conclusions: These findings suggest that high-dose oxybutynin and oxybutynin–trospium combination achieve a significant long-term reduction in MDP in patients with NGB after SCI. The effects were sustained across all three follow-up periods. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to compare holmium laser enucleation of the prostate (HoLEP) outcomes in patients with and without neurologic diseases (ND). Methods: A prospectively maintained database of patients undergoing HoLEP from January 2021 to April 2022 was reviewed. The following NDs were included: diabetes-related neuropathy/neurogenic bladder, Parkinson’s disease, dementia, cerebrovascular accident, multiple sclerosis, traumatic brain injury, transient ischemic attack, brain/spinal tumors, myasthenia gravis, spinal cord injury, and other. Statistical analysis was performed using t-tests, Chi-squared, and binomial tests (p<0.05). Results: A total of 118 ND patients were identified with 135 different neurologic diseases. ND patients were more likely to have indwelling catheters (57% vs. 39%, p=0.012) and urinary tract infections (UTIs) preoperatively (32% vs. 19%, p=0.002). Postoperatively, ND patients were more likely to fail initial trial of void (20% vs. 8.1%, p<0.001) and experience an episode of acute urinary retention (16% vs. 8.5%, p=0.024). Within 90 days postoperative, the overall complication rate was higher in the ND group (26% vs. 13%, p=0.001). Within the ND group, 30/118 (25%) had ≥1 UTI within 90 days preoperative, which decreased to 10/118 (8.7%) 90 days postoperative (p<0.001). At last followup (mean 6.7 months [ND] vs. 5.4 months [nonND], p=0.03), four patients (4.4%) in the ND group required persistent catheter/clean intermittent catheterization compared to none in the non-ND group (p=0.002). Conclusions: Patients with ND undergoing HoLEP are more likely to experience postoperative retention and higher complication rates compared to non-ND patients. While UTI rates are higher in this population, HoLEP significantly reduced three-month UTI and catheterization rates. [ABSTRACT FROM AUTHOR]

Neurogenic bladder dysfunction (NB) represents a challenge in pediatric urology. Intravesical botulin toxin-A (BTX-A) bladder injection is part of the armamentarium for the treatment of this condition, usually after failed first-line medical strategies and before the escalation to more invasive options such as neuromodulation or augmented cystoplasty in severe cases. However, there is still a lack of consensus about the appropriate treatment modality for the pediatric population. A review of the last 10 years' research was performed on the PubMed database by two authors. Articles doubly selected and meeting the inclusion criteria were collected and analyzed for their study type, demographics, neurological disease(s) at diagnosis, BTX-A treatment modality and duration, previous treatment, clinical and urodynamic parameters, adverse events, outcomes, and follow-ups. A total of 285 studies were initially selected, 16 of which matched the inclusion criteria. A cohort of 630 patients was treated with BTX-A at a median age of 9.7 years, 40% of which had a diagnosis of myelomeningocele. The results of the selected publications show the overall efficacy and safety of BTX-A injections in children and confirmed BTX-A as a valuable strategy for NB treatment in pediatric population. Nevertheless, up to now, the literature on this topic offers scarce uniformity among the published series and poor protocol standardization. [ABSTRACT FROM AUTHOR]

Spinal cord injury (SCI) often leads to neurogenic lower urinary tract dysfunction, causing dysuria and affecting patients' well-being. This study aimed to evaluate the efficacy of a urethral sphincter botulinum toxin A (BoNT-A) injection in patients with SCI and dysuria. This was a retrospective study including 118 patients with SCI who underwent a urethral BoNT-A injection following a standardized protocol for refractory voiding dysfunction. The protocol involved injecting BoNT-A into the urethral sphincter under cystoscopic guidance. Patient demographics, bladder condition parameters, and treatment outcomes were analyzed. Logistic regression and receiver operating characteristic curve analyses were performed to identify predictors of treatment success. Of the 118 patients, 71 (60.1%) showed satisfactory treatment outcomes after the injection. Post-injection status, bladder management, and injection frequency varied significantly among patients with satisfactory and unsatisfactory treatment outcomes. Age, bladder compliance, intravesical pressure, and bladder contractility were indicators of satisfactory outcomes. The first sensation of bladder filling of ≤263 mL, intravesical pressure of ≤28, and bladder contractility index of ≥14 were highly correlated with satisfactory outcomes. A urethral sphincter BoNT-A injection shows promise in managing dysuria in patients with SCI. Understanding bladder condition parameters and patient demographics helps optimize patient selection for this intervention. Further studies are needed to validate these findings and refine treatment protocols. [ABSTRACT FROM AUTHOR]

Aims: Lower urinary tract dysfunctions (LUTD) are very common and, importantly, affect patients' quality of life (QoL). LUTD can range from urinary retention to urgency incontinence and includes a variety of symptoms. Nerve stimulation (NS) is an accepted widespread treatment with documented success for LUTD and is used widely. The aim of this review is to report the results of the discussion about how to improve the outcomes of NS for LUTD treatment. Methods: During its 2023 meeting in Bristol, the International Consultation on Incontinence Research Society discussed a literature review, and there was an expert consensus discussion focused on the emerging awareness of NS suitable for LUTD. Results: The consensus discussed how to improve techniques and patients' selection in NS, and high‐priority research questions were identified. Conclusions: Technique improvement, device programming, and patient selection are the goals of the current approach to NS. The conditional nerve stimulation with minimally invasive wireless systems and tailored algorithms hold promise for improving NS for LUTD, particularly for patients with neurogenic bladder who represent the new extended population to be treated. [ABSTRACT FROM AUTHOR]

One of the most common complications of neurogenic bladder secondary to spinal cord injury (SCI) is urinary incontinence, which is possibly related to bladder-emptying methods and changes in quality of life. This study aimed to identify the occurrence of this complication in adults with SCI and analyze its relationship with bladder-emptying methods, satisfaction, and lifestyle. This is a quantitative, exploratory, and cross-sectional study. The variables were collected using the Bowel and Bladder Treatment Index during a telephone interview with 290 participants from February to November 2021. According to the results, 70% of the participants were male and 74.1% performed clean intermediate catheterization (CIC) as the main bladder-emptying method. Moreover, 55.6% were considered incontinent in the last year. Emptying by normal urination and bladder reflex triggering had a statistically significant relationship with urinary incontinence. A statistical association was observed between all the variables of satisfaction and lifestyle with urinary incontinence. Although CIC reduced urine leakage, a considerable number of participants still presented with frequent urine leakage. Urinary incontinence had a negative impact on satisfaction with the bladder-emptying method, effectiveness of bladder management, quality of life, and personal and social relationships. [ABSTRACT FROM AUTHOR]

Abstract Background Organophosphate-Induced Delayed Neuropathy (OPIDN) is a rare neurological disorder triggered by exposure to organophosphorus compounds. These compounds exert their neurotoxic effects by impacting the nervous system, leading to systemic manifestations. Urinary system symptoms are infrequently observed in clinical settings. Currently, effective therapeutic interventions for OPIDN-related urinary symptoms are lacking. Sacral nerve modulation therapy, an FDA-approved approach for managing lower urinary tract symptoms, presents as a promising option. Herein, we present a case of OPIDN-induced lower urinary tract obstruction successfully treated with sacral nerve modulation therapy, resulting in substantial symptom relief. Case report A 27-year-old male patient presented with severe bilateral hydronephrosis, attributed to low bladder compliance and accompanied by a fever persisting for 6 days. The patient’s medical history revealed accidental ingestion of organophosphate pesticide (Dimethoate) with no concomitant underlying diseases. In consideration of the potential for OPIDN, surgical intervention in the form of sacral neuromodulation (phase I) was undertaken. Subsequent evaluation one month post-surgery revealed notable improvements in both bladder compliance and bilateral hydronephrosis, necessitating sacral neuromodulation (phase II). Presently, following a 5-month follow-up period, the patient remains asymptomatic and in favorable health. Conclusion This patient achieved long-term relief using sacral neuromodulation.

Urinary tract infections caused by Aerococcus urinae have rarely been reported in children, and the clinical characteristics remain unclear. We reviewed medical records of children whose urine cultures grew A. urinae (≥104 CFU/mL) at a tertiary children's hospital in Tokyo, Japan. We found 17 pediatric patients in a review of 22,769 urine cultures between June 2006 and May 2022. The median age of 17 patients was 10.7 years (IQR 8–13 years), and males represented 76.5 % of the patients. Sixteen patients (94.1 %) had underlying urological conditions (neurogenic bladder, vesicoureteral reflux, urethral stenosis, bladder exstrophy, or urinary catheterization). The chief symptoms were fever (35.3 %), malodorous urine (23.5 %), nausea (11.8 %), and back pain (5.9 %). Ten patients were asymptomatic. Pyelonephritis was diagnosed in five male patients. All of them had underlying abnormal conditions of the bladder, and two had malodorous urine. All patients had favorable outcomes after 10–14 days of ampicillin/amoxicillin-based antimicrobial therapy. [ABSTRACT FROM AUTHOR]

Objectives: Evaluating the effectiveness and safety of repeated high‐dose intradetrusor abobotulinumtoxin A (Dysport®) injections for the treatment of pediatric neurogenic bladders refractory to medications. Design: Retrospective interventional study. Participants: The cohort included 37 children (22 boys and 15 girls) of median age 9.2 years. Inclusion criteria were diagnosis of neurogenic bladder and failure to respond to medical treatment. Exclusion criteria were augmented bladder, insufficient data, and interval of > 11 months between video‐urodynamic study and Dysport injection. Interventions: All participants were treated with an intra‐detrusor injection of Dysport 30 IU/kg (up to 1000 IU) under general anesthesia. Repeated (second and third) injections were scheduled (6–12 months) in patients who demonstrated an improvement in cystometric parameters. All participants underwent video urodynamic testing before onset of treatment and 4–5 months after subsequent injection. Main Outcome Measures: Success of treatment was defined as a decrease in end filling pressure (EFP) to < 40 cm H2O and/or a 20% increase in maximal cystometric capacity (MCC). These parameters along with initial bladder features were evaluated for ability to predict treatment success. Results: No side effects of Dysport were observed or reported. The overall success rate was 62%. MCC increased by a median of 30% (IQR 200–300, p < 0.001), 37% (IQR 197–310, p = 0.001) and 45% (IQR 245–300, p = 0.025) after the first, second and third injections, respectively. Median EFP decreased from 45 cm H2O to 34 cm H2O (IQR 20–45, p = 0.029), 23 cm H2O (IQR 20–37, p = 0.004), and 20 cm H2O (IQR 12–32, p = 0.049) after the first, second, and third injections, respectively. No predicting factor of success of treatment were found; However, three of five cases of "end stage" bladder showed improvement. Conclusions: High‐dose Dysport injection is safe and effective for the treatment of neurogenic bladder. Studies with larger cohort and a control group would further elucidate which bladders would benefit most. At present, we recommend treating also bladders with "end stage" features with botulinum toxin before considering augmentation. [ABSTRACT FROM AUTHOR]

Introduction: A continent catheterizable channel (CCC) may be a solution for patients with impaired bladder emptying and difficult transurethral access. Leakage of the CCC is a common complication. To prevent leakage, the pressure in the CCC has to be higher than the reservoir (bladder/pouch) pressure in at least one location. It has not been clearly defined through which mechanism(s) the CCC achieves continence. In this feasibility study, we measured the CCC pressure profile in adult patients with various types of CCC's with and without stomal leakage. Methods: Adult patients with a CCC on a (augmented) bladder or pouch who underwent a urodynamic investigation between January and March 2023 were included. Next to the standard urodynamic investigation, a continuous stomal pressure measurement (CSP) and stomal pressure profilometry with empty bladder (SPP‐1) and with filled bladder (SPP‐2) of the CCC were performed. Results: A total of 17 patients were included. It was technically possible to perform SPP‐1 and SPP‐2 in all patients, and to measure the CSP in 16/17 patients. The median maximum stomal pressures in SPP‐1 and SPP‐2 were 112 (interquartile range [IQR], 76–140) cmH2O and 120 (IQR, 92–140) cmH2O, respectively. Nine patients had stomal leakage during the urodynamic investigation. In five patients, the detrusor leak point pressure (dLPP) was low (<20 cmH2O). A pressure peak at the beginning of SPP‐2 was absent in all patients with stomal leakage at low dLPP. Conclusion: SPP and CSP measurement in CCCs are feasible. We found differences in SPP‐2 between patients with and without leakage at low dLPP, indicative of a role of the intravesical tunnel in continence or high dLPP. The results of this study may improve our understanding of the physiology and dynamics of CCCs as well as the management of CCC‐related complications. [ABSTRACT FROM AUTHOR]

Objective: Guanyuan (CV4), Zhongji (CV3) and Sanyinjiao (SP6) are the most frequently used acupoints for treating neurogenic bladder after spinal cord injury (SCI). However, there has been no investigation to clarify the differences in effects of these acupoints in different types of neurogenic bladder. Methods: The study was structured with a randomized, two‐phase cross over design with a washout period. A routine urodynamic examination was performed first, then, in the order of grouping, electroacupuncture was performed on CV4, CV3, and SP6, respectively，and urodynamic examination was performed to observe the changes of urodynamic indexes in real time. Results: When undergoing electroacupuncture at CV4, CV3, and SP6 in patients with neurogenic detrusor overactivity (DO), the bladder volume at the first occurrence of DO and maximum cystometric capacity increased (p < 0.05), but maximum detrusor pressure (Pdetmax) at DO decreased (p < 0.05), and the changes using CV4 and CV3 was more significantly than using SP6 (p < 0.05). And in patients with in neurogenic detrusor underactivity, there were no significant changes in maximum urinary flow rate and Pdetmax during urination (p > 0.05). Conclusion: The immediate relief effect of electroacupuncture at CV4, CV3 on DO was greater than at SP6. [ABSTRACT FROM AUTHOR]

Introduction: Patients with neurogenic lower urinary tract dysfunction (NGLUTD) who require catheterization either with clean intermittent catheters (CIC) or indwelling catheters suffer with frequent urinary tract infections (UTIs). This study assessed the efficacy, patient persistence, satisfaction, and the impact on quality of life (QoL) of gentamicin nightly bladder instillations with 15 mg. Methods: This is a prospective survey of 36 patients with NGLUTD and recurrent UTIs prescribed long‐term gentamicin to prevent UTIs. Eligible patients completed a questionnaire about their use and satisfaction with gentamicin therapy, as well as survey questionnaires to address QoL. A retrospective chart review was also performed to obtain medical history, confirm drug persistence, and obtain accurate UTI data for the 12 months preceding and after starting instillations. Results: The rate of laboratory proven symptomatic UTI requiring antibiotic treatment decreased from 3.9 to 1.1 infections per year with no increase in antibiotic resistance and no significant side effects reported by patients. Eight patients stopped therapy before a full year for various reasons, but the remaining 72% of patients have continued to use the therapy now with a mean of 4.2 years later. Satisfaction among those continuing the medication was very high. Conclusion: Gentamicin bladder instillations with 15 mg nightly in patients with indwelling catheters or CIC with NGLUTD are very effective and safe with high patient satisfaction. This therapy can be maintained long‐term with continued efficacy. [ABSTRACT FROM AUTHOR]

Abstract This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

Neurogenic lower urinary tract dysfunction (NLUTD) is common in patients with central nervous system (CNS) lesions. Cases of cerebrovascular accidents (CVA), Parkinson’s disease, dementia, and other intracranial lesions develop poor bladder control with or without urinary difficulty due to loss of cortical perception of bladder filling sensation and poor coordination of urethral sphincter relaxation during reflex micturition. Patients with CNS lesions usually have overactive bladder (OAB) symptoms, including urgency, frequency, incontinence, voiding symptoms of dysuria, large postvoid residual volume, and retention. In elderly patients with severe CNS disease the OAB symptoms are usually difficult to adequately relieve by medical treatment, and thus, their quality of life is greatly. Botulinum toxin A (BoNT-A) is currently licensed and has been applied in patients with idiopathic and neurogenic OAB due to spinal cord injury or multiple sclerosis. However, the application of BoNT-A in the treatment of urinary incontinence due to NLUTD in chronic CNS lesions has not been well-documented. Although cohort studies and case series support BoNT-A treatment for neurogenic OAB, chronic urine retention after intravesical BoNT-A injection for OAB and exacerbated urinary incontinence after urethral BoNT-A injection for voiding dysfunction have greatly limited its application among patients with NLUTD due to CNS lesions. This article reviews the pathophysiology and clinical characteristics of NLUTD in patients with CNS lesions and the clinical effects and adverse events of BoNT-A injection for patients with NLUTD. A flowchart was created to outline the patient selection and treatment strategy for neurogenic OAB.

Purpose: To evaluate efficacy and safety of beta-3 adrenergic agonists in adults with neurogenic lower urinary tract dysfunction. Materials and Methods: According to a protocol (CRD42022350079), we searched multiple data sources for published and unpublished randomized controlled trials (RCTs) up to 2nd August 2022. Two review authors independently screened studies and abstracted data from the included studies. We performed statistical analyses by using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We used GRADE guidance to rate the certainty of evidence (CoE). Results: We found data to inform two comparisons: beta-3 adrenergic agonists versus placebo (4 RCTs) and anticholinergics (2 RCTs). Only mirabegron was used for intervention in all included studies. Compared to placebo, beta-3 adrenergic agonists may have a clinically unimportant effect on urinary symptoms score (mean difference [MD] -2.50, 95% confidence interval [CI] -4.78 to -0.22; I2=92%; 2 RCTs; 192 participants; low CoE) based on minimal clinically important difference of 3. We are very uncertain of the effects of beta-3 adrenergic agonists on quality of life (MD 10.86, 95% CI 1.21 to 20.50; I2=41%; 2 RCTs; 98 participants; very low CoE). Beta-3 adrenergic agonists may result in little to no difference in major adverse events (cardiovascular adverse events) (risk ratio 0.57, 95% CI 0.14 to 2.37; I2=0%; 4 RCTs; 310 participants; low CoE). Compared to anticholinergics, no study reported urinary symptom scores and quality of life. There were no major adverse events (cardiovascular adverse events) in either study group (1 study; 60 participants; very low CoE). Conclusions: Compared to placebo, beta-3 adrenergic agonists may have similar effects on urinary symptom scores and major adverse events. There were uncertainties about their effects on quality of life. Compared to anticholinergics, we are either very uncertain or have no evidence about urinary symptom scores, quality of life, and major adverse events.

Objective To explore the effect of Omaha system-based continuous care intervention in pa- tients with neurogenic bladder with spinal cord injury. Methods A total of 72 patients with neurogenic blad- der due to spinal cord injury were selected from June 2019 to June 2022 in the No. 908th Hospital of Joint Logistic Support Force. The patients were randomly divided into the control group (36 cases) and the observation group (36 cases) by random number table method. The control group received routine nursing care, while the observation group received Omaha system-based continuous care on the basis of routine nursing care. The cognition, behavior and status of the patients in the observation group were scored by the effect/outcome evaluation system at three and six months after discharge. Simple residual urine volume and volume of bladder were used to compare the bladder function of the two groups at six months after discharge. Urinary tract infection six months after discharge was compared between the two groups by urine laboratory examination. The quality of life in six months after discharge of the two groups was compared by using the comprehensive assessment questionnaire-74. The nursing satisfaction of the two groups was compared with the nursing satisfaction questionnaire made by the hospital, Results After half a year follow-up the scores of cognition behavior and condition in the observation group were significantly improved compared with those before intervention, with statistical significance (P<0.01). The bladder function, quality of life score and satisfaction in observation group were higher than those in control group, but the incidence of urinary tract infection was lower than that in control group, with statistical significance (P<0,05). Conclusion Omaha system-based continuous care model can effectively improve the bladder function, quality of life and nursing satisfaction of patients, reduce urinary tract infection and improve the outcome of nursing care. [ABSTRACT FROM AUTHOR]

Objective: Unusual clinical course Background: Non-neurogenic neurogenic bladder involves fluctuating flow rates due to involuntary muscle contractions during voiding in those with normal neurological function. The diagnostic challenge lies in distinguishing between massive urinary bladder distension and ovarian tumors. While various pathologies mimicking ovarian tumors are documented, cases of a massively distended urinary bladder, known as giant urinary bladder, posing as such are notably scarce. Case Report: This case report presents the unique clinical scenario of a 31-year-old woman with Down syndrome who was initially misdiagnosed with an ovarian tumor due to progressive abdominal distention, reduced appetite, and weight loss. On presentation, she appeared dehydrated, with an abnormal renal profile. Despite hydration, the renal profile worsened. Initial ultrasound showed a large, uniloculated cystic lesion measuring 11×15 cm in the pelvis. Due to the size of the cyst, which appeared to be ovarian in origin, ovarian tumor was suspected. However, tumor markers were normal. A computed tomography scan subsequently showed a massively distended urinary bladder measuring 11.6×13.6×17.6 cm causing bilateral obstructive uropathy, with moderate hydronephrosis and hydroureter. Needing intermittent catheterization at first, the patient subsequently passed urine on her own following behavioral modification. Conclusions: This rare case of non-neurogenic neurogenic bladder causing a giant urinary bladder in a patient with Down syndrome highlights the importance of an awareness of this condition for effective assessment and patient treatment. [ABSTRACT FROM AUTHOR]

Background/Objectives: This study aimed to identify the unique characteristics of neurogenic bladders and associated symptoms in patients with cervical or thoracic myelopathy using clinical surveys and urodynamic studies (UDSs). Methods: Patients with degenerative cervical (DCM) or thoracic (DTM) myelopathy and lower urinary tract symptoms (LUTSs) scheduled for decompressive surgery were prospectively enrolled. A UDS was performed one day preceding surgery to evaluate the preoperative urological function. Subjective symptoms were evaluated using the International Prostate Symptom Score (IPSS) and the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire before surgery and one year postoperatively. Results: Sixty-two patients (DCM: 50, DTM: 12) with a mean age of 63.2 years (men: 30, women: 32) were enrolled. The UDS revealed that 5 (8.1%) patients, all with DCM, exhibited completely normal UDS results, and the remaining 57 had at least one abnormal finding. Based on the International Continence Society classification, an underactive bladder was significantly more common in patients with DTM compared to patients with DCM (75.0% vs. 18.0%, p < 0.001). The results of the questionnaire showed that the voiding symptom IPSS were significantly worse, preoperatively, in patients with DTM (5.0 ± 4.4 [DCM] vs. 8.7 ± 4.5 [DTM]; p = 0.013). One year postoperatively, the IPSS grade of 24.0% of patients with DCM improved, whereas only one (8.3%) patient with DTM showed improvement. Conclusions: Patients with DTM reported worse voiding symptoms and exhibited more underactive bladders on UDS than patients with DCM before decompression. One year postoperatively, more patients with DCM showed subjective improvements in urinary function than those with DTM. [ABSTRACT FROM AUTHOR]

Onabotulinum Toxin-A (BTX-A) is a second-line treatment for neurogenic bladder (NB). It requires repeated injections over time, which is a possible limit for long-term adherence, especially in children, as general anesthesia is required. Almost 50% of adults discontinue therapy; few data on pediatric patients are present. The aim of this study is to share our long-term experience of BTX-A adherence in children. This study is a retrospective review of 230 refractory NB patients treated with BTX-A. The inclusion criteria were ≥3 treatments and the first injection performed ≥10 years before the study endpoint. Fifty-four patients were included. Mean follow-up was 10.2 years; mean treatment number was 6.4 for each patient. During follow-up, 7% did not need BTX-A anymore; 76% discontinued therapy, with a prevalence of acquired NB (64% acquired vs. 34% congenital; p = 0.03); sex-based and urodynamic findings did not influence the discontinuation rate (p = 0.6, p = 0.2, respectively). Considering those who withdrew from the therapy, 43% were lost to follow-up/died after a mean of 7.5 years (although 33% still experienced clinical efficacy); 33% changed therapy after a mean of 5.8 years (with reduced efficacy in 22%, persistent efficacy in 11%). BTX-A is a safe and effective therapy for pediatric patients. The treatment abandonment rate is higher for children than for adults; no specific reasons were highlighted. It is necessary to evaluate any age-specific factors to explain these data. [ABSTRACT FROM AUTHOR]

Introduction: Transurethral injections into the bladder wall with botulinum toxin are an established treatment for refractory overactive bladder or detrusor overactivity. With the current injection technique, an average of approx. 18% and up to 40% of botulinum toxin is injected next to the bladder wall, potentially causing reduced efficacy or non-response. The article aims to evaluate the reasons for incorrect injections and propose strategies for complete delivery of the entire botulinum toxin fluid into the bladder wall. Material and Methods: Unstructured literature search and narrative review of the literature. Results: Incorrect injection of botulinum toxin fluid next to the bladder wall is caused by pushing the injection needle too deep and through the bladder wall. Bladder wall thickness decreases with increasing bladder filling and has a thickness of less than 2 mm beyond 100 mL in healthy individuals. Ultrasound imaging of the bladder wall before botulinum toxin injection can verify bladder wall thickness in individual patients. Patient movements during the injection therapy increase the chance of incorrect placement of the needle tip. Conclusions: Based on the literature search, it is helpful and recommended to (1) perform pretreatment ultrasound imaging of the bladder to estimate bladder wall thickness and to adjust the injection depth accordingly, (2) fill the bladder as low as possible, ideally below 100 mL, (3) use short needles, ideally 2 mm, and (4) provide sufficient anesthesia and pain management to avoid patient movements during the injection therapy. [ABSTRACT FROM AUTHOR]

Key Clinical Message: As there is no significant mutual relationship between Helicobacter pylori infection and chronic kidney disease in children, its routine study is not justified and is recommended only in symptomatic cases. Children suffering from chronic kidney disease (CKD) often complain of indigestion but, if it is accompanied by abdominal pain, it is necessary to investigate and rule out Helicobacter pylori infection to confirm functional dyspepsia. Epidemiological studies in adults have conflicting results regarding the association between Helicobacter pylori infection and CKD. In this study, we determined the prevalence of H. pylori in children with kidney failure and its relationship to their gastrointestinal symptoms. In this retrospective study, 54 children with chronic kidney failure admitted to the hemodialysis ward of the Children's Medical Center, Tehran, Iran between 2012 and 2020 were studied. The mean age of our patients was 11.89 ± 3.99 years and their sex distribution was equal. H. pylori infection was reported in only three patients with 5.6%. Based on our findings, epigastric pain in children was the most common gastrointestinal symptom (70.4%). Among all patients, three patients (5.6%) died, all of them were male (P = 0.075). The most prevalent underlying cause of kidney failure in our patients was neurogenic bladder. We did not find any significant relationship between the increased risk of chronic kidney failure and co‐infection with H. pylori. Investigating the cause of epigastric pain and looking for H. pylori is very important in CKD children under hemodialysis because if they receive a transplant the possibility of gastrointestinal complications will be increased with the use of steroid and immunosuppressive drugs. [ABSTRACT FROM AUTHOR]

Rett syndrome is characterized by the loss of speech and purposeful hand movements, ambulation problems, and typical hand stereotypies. Preserved speech variant of the Rett syndrome (Zappella Variant) is a much less common form where speech is relatively preserved. We aimed to emphasize neurogenic bladder due to autonomic dysfunction in a patient with preserved speech variant of the Rett syndrome. A 7-year-old female patient who had been diagnosed with severe neurogenic bladder when 11 months old was suspected of suffering from Rett syndrome after observing intense eye contact and the stereotypic movement of hand wringing. The patient could talk with phrases, can walk, and have purposeful hand movements. The presence of the c.961C>T (p.Arg321Trp) heterozygous mutation in the C terminal region of the methyl-CpG-binding protein 2 (MECP2) gene was demonstrated. The patient is currently 13 years old. She continues to be monitored for chronic renal disease. The presence of hand stereotypies and intense eye pointing could indicate the Zappella variant Rett syndrome since the patient has developmental problems, even though the patient can talk and has purposeful hand skills. The development of intermittent urinary retention associated with neurogenic bladder caused by autonomic dysfunction should be considered in these patients. [ABSTRACT FROM AUTHOR]

The inclusion of people living with spinal cord injury (SCI) in research has allowed for an informed understanding of priorities of recovery of which bowel dysfunction and bladder dysfunction have been continuously identified. Research has also demonstrated the global disparities in SCI outcomes particularly when comparing high- and low-income countries. Currently, there is a lack of direct comparison between countries when assessing SCI outcomes. This is an exploratory study to better understand bowel and bladder dysfunction amongst individuals with SCI in India and Canada. Data from 33 participants were analyzed. Participants completed an online questionnaire assessing demographic information and the Neurogenic Bowel Dysfunction (NBD) score, Wexner score, Neurogenic Bladder Symptom Score (NBSS), and the Incontinence Quality of Life Instrument (I-QOL). Continuous data were compared using t tests. For not normally distributed data, the independent Mann-Whitney U test was used. Categorical variables were evaluated for association using Fisher's exact or chi-square test, depending on the sample size. Independent Mann-Whitney U test demonstrated that the Canadian participants had poorer bowel function with higher total NBD scores (p =.007) and less frequent bowel movements (p =.036), and they were more likely to experience uneasiness, headaches, and perspiration during bowel movements (p <.001). NBSS results indicated a small but significantly higher proportion of the Indian participants were unsatisfied or unhappy with their bladder function (p =.049). The distribution of Wexner and I-QOL scores were the same across countries. Potential explanations for differences include lifestyle, management, financial resources, patient and caregiver education, and societal pressures, which are all heavily influenced by cultural, geographical, and economic circumstances. [ABSTRACT FROM AUTHOR]

Background and Purpose: Clean intermittent catheterization (CIC) nonadherence may lead to renal compromise, incontinence, and frequent urinary tract infections in patients with spinal cord injury and spinal dysraphism. Adherence to CIC lacks definition in the nursing literature despite implications for research and clinical practice, including patient education. The aim of this concept analysis was to analyze how CIC adherence is conceptualized and synthesize a definition for nursing. Method: Rodgers' evolutionary concept analysis method was used to analyze the concept of CIC adherence in patients and caregivers. We searched databases to identify studies describing CIC adherence and identified common attributes, antecedents, and consequences. A definition was synthesized, and an exemplar was developed to illustrate the concept in practice. Results: Sixteen sources were analyzed. The attributes of CIC adherence were initiation, execution, including prescribed process and prescribed frequency, and persistence. Antecedents included the presence of neurogenic bladder, acceptance, and engagement. Consequences included improved health outcomes and quality of life. Implications for Practice: Adherence to CIC lacks definition in the nursing literature despite implications for research and clinical practice. A unified definition of CIC adherence will facilitate nurses' efforts to plan effective care, anticipate support barriers and opportunities, and develop strategies for improving CIC adherence. [ABSTRACT FROM AUTHOR]

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Considerable research efforts have been directed towards investigating neurogenic bladder dysfunction over the preceding decade. This condition stands as the most prevalent and incapacitating pelvic floor disorder amidst patients afflicted with specific upper motor neuron syndromes, including multiple sclerosis, stroke, and spinal cord injury. The current study aims to bring up-to-date findings on rehabilitation methods for treating neurogenic bladder. The Web of Science database (MEDLINE, PsychINFO, EMBASE, CENTRAL, ISRCTN, and ICTRP) was screened for randomized controlled studies and clinical studies using combinations of keywords including "neurogenic bladder", "stroke", "multiple sclerosis", and "spinal cord injury". The PEDro scale was used to assess the quality of the articles included in this study. After a thorough examination, eleven articles met the criteria for inclusion in our research. The outcome measures showed a variety of forms of electrostimulation that can be combined with or without PFMT. These interventions significantly enhance health-related quality of life, as evidenced by various assessment methods. The physical approach constitutes an effective therapeutic method that can reduce the severity of urinary incontinence. [ABSTRACT FROM AUTHOR]

BACKGROUND: The dysfunction of bladder function caused by spinal cord injury is a difficult point in clinical treatment and a hot spot in research. Repairing the injured spinal cord and remodeling the bladder micturition reflex pathway are the fundamental treatment methods. OBJECTIVE: To summarize the reconstruction of the bladder innervation pathway after spinal cord transection injury and its related influencing factors. METHODS: The relevant literature concerning the reconstruction of bladder micturition reflex, neurogenic bladder and urinary reflex and spinal cord repair was retrieved on CNKI, WanFang Data, PubMed and Web of Science. Chinese and English search terms were “neurogenic bladder; spinal cord injury; micturition reflex; spinal cord repair”. RESULTS AND CONCLUSION: In the process of reconstructing the bladder micturition reflex, there are many factors involved, including the repair and reconstruction of the injured spinal cord, the remodeling of micturition center, the changes of bladder tissue and substances and hormones in and out of the body. In this process, there are mainly the following problems: (1) As a complex process, there are many sites involved in the reconstruction of the micturition reflex, so the main sites of action can be selected for in-depth study, so as to break through the doubts existing in the reconstruction of the micturition reflex pathway. (2) The mechanism of the normal micturition reflex is complex. After spinal cord transection injury, whether the central nucleus mass controlling or participating in the micturition reflex is compensated and the corresponding compensatory mechanism needs to be further investigated. (3) Information communication between the center and the bladder is interrupted after spinal cord transection injury. Whether there is a direct information connection between the center and the bladder remains to be further investigated. (4) The relationship between reconstructing micturition reflex and body fluid after spinal cord transection injury needs further study. In the reconstruction of the bladder micturition reflex, the key treatment is to promote spinal cord repair, nerve reflex reconstruction, substance metabolism and bladder tissue structure adjustment through intervention. Chinese medicine and Western medicine have their methods. [ABSTRACT FROM AUTHOR]

Objective: To observe the efficacy of different frequency functional magnetic stimulation (FMS) combined with motor imagery therapy in the treatment of neurogenic bladder (NB) urinary retention after spinal cord injury (SCI). Methods: 116 patients with NB urinary retention after SCI who were admitted to our hospital from August 2021 to April 2023 were divided into 5Hz group (n=58, 5HzFMS combined with motor imagery therapy) and 20Hz group (n=58, 20HzFMS combined with motor imagery therapy) according to the random number table method. The urination, urodynamic indexes, electromyography indexes and various scale scores were com- pared between two groups. Results: After treatment, the number of daily spontaneous urination in 20Hz group was less than that in 5Hz group, and the average daily single urination volume and the maximum daily single urination volume were more than those in 5Hz group (P<0.05). The maximum urinary flow rate, maximum bladder capacity, detrusor pressure during filling period, H reflex amplitude, F wave extraction rate and quality of life comprehensive scale-74 (GQOL-74) score in 20Hz group were higher than those in 5Hz group, and the bladder residual urine volume, H reflex latency, F wave latency, NB symptom score (NBSS) and international lower urinary tract function symptom (LUTS) score were lower than those in 5Hz group (P<0.05). Conclusion: Compared with 5Hz frequency FMS, 20Hz frequency FMS combined with motor imagery therapy for NB urinary retention after SCI can alleviate clinical symptoms, promote bladder function recovery, and further improve the quality of life of patients. [ABSTRACT FROM AUTHOR]

Background: Neurogenic bladder dysfunction is a major problem for spinal cord injury (SCI) patients not only due to the risk of serious complications but also because of the impact on quality of life. The main aim of this study is to compare the rate of urinary tract infection (UTI) associated with hydrophilic-coated catheters versus uncoated polyvinyl chloride (PVC) catheters among SCI patients presenting with functional neurogenic bladder sphincter disorders. Methodology: This was a retrospective cohort study from 2005 to 2020 including adult male or female patients who have an SCI at least more than 1 month ago with neurogenic bladder dysfunction and were using intermittent catheterization (single-use hydrophilic-coated or the standard-of-care polyvinyl chloride uncoated standard catheters) at least 3 times a day to maintain bladder emptying. Results: A total of 1000 patients were selected and recruited through a stratified random sampling technique with 467 (47.60%) patients in the uncoated catheter arm and 524 (52.60%) in the coated catheter groups. The three outcome measures, namely: symptomatic UTI, Bacteriuria, and pyuria were significantly higher in the group using uncoated polyvinyl chloride (PVC) catheters compared to hydrophilic-coated catheters at the rate of 79.60% vs.46.60%, 81.10% vs. 64.69, and 53.57% versus 41.79% respectively. Males, elder patients, longer duration, and severity of SCI were associated with increased risk of symptomatic UTI. Conclusions: The results indicate a beneficial effect regarding clinical UTI when using hydrophilic-coated catheters in terms of fewer cases of symptomatic UTI. Bacteriuria is inevitable in patients with long-term catheterization, however, treatment should not be started unless the clinical symptoms exist. More attention should be given to the high-risk group for symptomatic UTIs. [ABSTRACT FROM AUTHOR]

Objective To investigate the effect and mechanism of Yiyuan moxibustion on urinary storage function in rats with neurogenic bladder (NB) after suprasacral spinal cord injury (SCI) based on adenosine activated protein kinase (AMPK)-connexin 43 (Cx43) pathway. Methods Twelve female Sprague-Dawley rats were selected as the sham operation group using the random number table method, and 68 rats were used to prepare the suprasacral SCI model according to the modified Hassan Shaker spinal cord transection method. After the SCI model was stable, the standard NB model after SCI was screened out. The rats with successful modeling were divided into the model group (n = 14), the Yiyuan moxibustion group (n = 14), the inhibitor group (n = 14), and the Yiyuan moxibustion + inhibitor group (n = 14) according to the random number table method. The rats in the Yiyuan moxibustion group were treated with Yiyuan moxibustion. The rats in the inhibitor group were injected with AMPK inhibitor dorsomorphin (0.2 mg/kg) by tail vein. The rats in the Yiyuan moxibustion + inhibitor group were treated with Yiyuan moxibustion combined with tail vein injection of dorsomorphin (0.2 mg/kg). The sham operation group and the model group did not receive any intervention for 14 days. After the intervention, the bladder function of rats was evaluated by urodynamics. HE staining was used to observe morphological changes of the bladder tissue; the content of adenosine triphosphate (ATP) in bladder tissue was detected by colorimetry. The positive expressions of phosphorylated AMPK (p-AMPK), Cx43 and tyrosine protein kinase receptor (C-kit) in bladder tissue were detected by immunohistochemistry. The protein expressions of AMPK, p-AMPK, Cx43 and C-kit in bladder tissue were detected by Western blotting. Results Compared with the model group, the maximum bladder capacity and bladder compliance of the rats in the Yiyuan moxibustion group were increased, the leak point pressure was decreased, the cells in the Yiyuan moxibustion group were relatively regular and orderly, the vacuolar cells were reduced, and the tissue edema was reduced; the ATP content in the bladder tissue was decreased, the positive expression rate of p-AMPK was increased, the positive expression rate of Cx43 and C-kit were decreased, the protein expressions of p-AMPK protein was increased, the expression of Cx43 and C-kit were decreased, and the mRNA expression of Cx43 and C-kit were decreased (P<0.05). Compared with the Yiyuan moxibustion + inhibitor group, the maximum bladder capacity and bladder compliance of the rats in the Yiyuan moxibustion group increased, the leak point pressure decreased, the cells in the Yiyuan moxibustion group were arranged more closely and the tissue edema was reduced; the ATP content in the bladder tissue decreased, the positive expression rate of p-AMPK increased, the positive expression rates of Cx43 and C-kit decreased, the protein expression of p-AMPK increased, the protein expressions of Cx43 and C-kit decreased, and the mRNA expressions of Cx43 and C-kit decreased (P<0.05). Conclusion Yiyuan moxibustion can improve the urinary storage function of NB rats after suprasacral SCI, and its mechanism may be related to activating the AMPK-Cx43 pathway in bladder tissue, reducing the excitation transmission between bladder detrusor cells, thereby reducing the frequency of smooth muscle contraction. [ABSTRACT FROM AUTHOR]

Objective To observe the clinical efficacy of "three modulation acupuncture" combined with repeated functional magnetic stimulation (rFMS) in the treatment of neurogenic bladder with detrusor muscle weakness after spinal cord injury. Methods A total of 120 patients with neurogenic bladder with detrusor muscle weakness after spinal cord injury were divided into conventional treatment group, "three modulation acupuncture" treatment group, rFMS treatment group and comprehensive treatment group according to the random number table method, with 30 patients per group. The conventional treatment group was given conventional rehabilitation treatment, the "three modulation acupuncture" treatment group was treated with "three modulation acupuncture" (modulating spirit, modulating reflex arc, and modulating lower jiao and waterway) based on conventional rehabilitation treatment, the rFMS treatment group was treated with rFMS based on conventional rehabilitation treatment, and the comprehensive treatment group was treated with "three modulation acupuncture" and rFMS based on conventional rehabilitation treatment. The first desire to void (FDV), maximum cystometric capacity (MCC), maximum detrusor pressure of urine storage period (Pdet.max), maximum intravesical pressure of urine storage period (Pves.max), average daily urination frequency, average daily urine leakage, residual urine volume, and neurogenic bladder symptom scores of the patients were compared before and after treatment, and the clinical effectiveness of each group was evaluated. Results After treatment, the FDV, MCC, and Pdet.max of the four groups were all increased compared with those before treatment, and Pves.max, the average daily urination frequency, the average daily frequency of urine leakage, the residual urine volume, and the neurogenic bladder symptom scores were all decreased (P<0.05). After treatment, the FDV, MCC, and Pdet.max of the " three modulation acupuncture" treatment group, the rFMS treatment group and the comprehensive treatment group were all higher than those of the conventional treatment group, and Pves.max, the average daily urination frequency, the average daily frequency of urine leakage, the residual urine volume, and the neurogenic bladder symptom scores were all lower (P<0.05). After treatment, the comprehensive treatment group had a higher FDV, MCC, and Pdet.max than the " three modulation acupuncture" treatment group and rFMS treatment group, and Pves.max, the average daily urination frequency, the average daily frequency of urine leakage, the residual urine volume, and the neurogenic bladder symptom scores were lower (P<0.05). The curative efficiency rates were 86.2% (25/29) in the " three modulation acupuncture" treatment group, 85.7% (24/28) in the rFMS treatment group, and 92.6% (25/27) in the comprehensive treatment group, which was higher than that of the conventional treatment group, which was 75.9% (22/29). Conclusion "Three modulation acupuncture" and rFMS can effectively improve the functional status of the bladder in patients of neurogenic bladder with detrusor muscle weakness after spinal cord injury, and their combined application has a synergistic effect. [ABSTRACT FROM AUTHOR]

BACKGROUND: Urinary dysfunction is linked to spinal cord injury (SCI). The quality of life (QoL) declines in both neurogenic bladder impairment and non-disordered patients. OBJECTIVE: To ascertain the effectiveness of pulsed magnetic therapy on urinary impairment and QoL in individuals with traumatic incomplete SCI. METHODS: This study included forty male paraplegic subjects with neurogenic detrusor overactivity (NDO) for more than one year following incomplete SCI between T6-T12. Their ages ranged from 20 to 35 and they engaged in therapy for three months. The subjects were divided into two groups of equal size. Individuals in Group I were managed via pulsed magnetic therapy once per week plus pelvic floor training three times a week. Individuals in Group II were managed with only three times a week for pelvic floor training. All patients were examined for bladder cystometric investigations, pelvic-floor electromyography (EMG), and SF-Qualiveen questionnaire. RESULTS: There was a noteworthy increment in individuals in Group I in volume of bladder at first desire to void and maximum cystometric capacity, detrusor pressure at Qmax, and maximum flow rate. There was a momentous increment in Group I in measures of evaluation of EMG biofeedback. There was a notable rise in Group I in SF-Qualiveen questionnaire. CONCLUSION: Magnetic stimulation should be favored as beneficial adjunct to traditional therapy in the management of bladder impairment and enhancing QoL in individuals with SCI. [ABSTRACT FROM AUTHOR]

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population. [ABSTRACT FROM AUTHOR]

To evaluate the correlation of intraoperative neuromonitoring (IONM) data in surgery for tethered cord syndrome (TCS) in children to the neurological outcome at 1-year follow-up. 208 consecutive patients operated on for TCS, between January 2011 to February 2020, under electrophysiological monitoring in the Division of Paediatric Neurosurgery, AIMS, Kochi, India, were included. Their preoperative neurological, urological and orthopaedic status were compared with the postoperative status at 1 year follow-up. Our study prospectively collected the IONM data and retrospectively correlated it to the children's neurological outcome on follow-up. Out of 208 children, 28% (n = 59/208) had motor, 35% (n = 73/208) had bladder and 26% (n = 54/208) had bowel disturbances. Postsurgery, at one-year follow-up, 91% (n = 52/57) of the patients who had motor deficits had improvement, 82.3% (n = 51/62) of patients who had bladder deficits showed an improvement, and 88.8% (n = 48/54) with bowel deficits showed improvement. The monitorability for motor and sphincter potentials were 99.4% and 89.3%, respectively. Except for four patients (3 with bladder and 1 with motor worsening), all the patients who were monitorable with no deficits remained intact except for four patients, all the patients who had deficits and were monitorable improved after detethering (at 1 year). Clinical worsening corresponded to those who had a drop in amplitude of baseline TcMEP (n = 4). 18 events showed an increase in amplitude compared to the baseline TcMEP. These patients improved clinically on follow-up (at 1 year). IONM complements the preoperative clinical details in predicting immediate and long-term outcomes. [ABSTRACT FROM AUTHOR]