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Van Der Aa F.,University Hospitals Leuven | Drake M.J.,Bristol Urological Institute | Kasyan G.R.,Moscow State University | Petrolekas A.,Henri Dynant Hospital | Cornu J.-N.,University Pierre and Marie Curie
European Urology | Year: 2013

Context: The artificial urinary sphincter (AUS) has historically been considered the gold standard for the surgical management of non-neurogenic stress urinary incontinence (SUI) in men. As new surgical alternatives attempt to offer alternatives to treat male SUI, a contemporary assessment of the evidence supporting the use of AUS appears mandatory for clinical decision making. Objective: To conduct a critical systematic review of long-term outcomes after AUS implantation in male patients with non-neurogenic SUI. Evidence acquisition: A literature search was conducted in PubMed/Medline and Embase databases using the keywords urinary incontinence and urinary sphincter, artificial and male, restricted to articles published in Dutch, English, French, and German between 1989 and 2011. Studies were included if they reported outcomes after AUS implantation in patients with non-neurogenic SUI with a minimum follow-up of 2 yr. Studies with heterogeneous populations were included if information about non-neurogenic patients was displayed separately. Evidence synthesis: Twelve reports were identified, gathering data about 623 patients. Only three studies were prospective. Continence, evaluated only by patient-reported pad use and various questionnaires, was achieved in 61-100% of cases (no pad or one pad per day). Dry rates (no pad) were only available in seven studies and varied from 4% to 86%. A pooled analysis showed that infection or erosion occurred in 8.5% of cases (3.3-27.8%), mechanical failure in 6.2% of cases (2.0-13.8%), and urethral atrophy in 7.9% (1.9-28.6%). Reoperation rate was 26.0% (14.8-44.8%). Patient satisfaction was evaluated in four studies with four different tools and seems to improve after AUS implantation. Conclusions: Quality of evidence supporting the use of AUS in non-neurogenic male patients with SUI is low, based on heterogeneous data, low-quality studies, and mostly out-of-date efficacy outcome criteria. AUS outcomes need to be revisited to be compared with new surgical alternatives, all of which should be prospectively evaluated according to current evidence-based medicine standards. © 2012 European Association of Urology.

Abrams P.,Bristol Urological Institute
Journal of Urology | Year: 2013

Purpose: The 6th International Consultation on New Developments in Prostate Cancer and Prostate Diseases met from June 24-28, 2005 in Paris, France to review new developments in benign prostatic disease. Materials and Methods: A series of committees were asked to produce recommendations on the evaluation and treatment of lower urinary tract symptoms in older men. Each committee was asked to base recommendations on a thorough assessment of the available literature according to the International Consultation on Incontinence level of evidence and grading system adapted from the Oxford system. Results: The Consultation endorsed the appropriate use of the current terminology lower urinary tract symptoms/benign prostatic hyperplasia/benign prostate enlargement and benign prostatic obstruction, and recommended that terms such as "clinical benign prostatic hyperplasia" or "the benign prostatic hyperplasia patient" be abandoned, and asked the authorities to endorse the new nomenclature. The diagnostic evaluation describes recommended and optional tests, and in general places the focus on the impact (bother) of lower urinary tract symptoms on the individual patient when determining investigation and treatment. The importance of symptom assessment, impact on quality of life, physical examination and urinalysis is emphasized. The frequency volume chart is recommended when nocturia is a bothersome symptom to exclude nocturnal polyuria. The recommendations are summarized in 2 algorithms, 1 for basic management and 1 for specialized management of persistent bothersome lower urinary tract symptoms. Conclusions: The use of urodynamics and transrectal ultrasound should be limited to situations in which the results are likely to benefit the patient such as in selection for surgery. It is emphasized that imaging and endoscopy of the urinary tract have specific indications such as dipstick hematuria. Treatment should be holistic, and may include conservative measures, lifestyle interventions and behavioral modifications as well as medication and surgery. Only treatments with a strong evidence base for their clinical effectiveness should be used. © 2013 American Urological Association Education and Research, Inc.

Hashim H.,Bristol Urological Institute | Woodhouse C.R.J.,University College London
European Urology, Supplements | Year: 2012

Ureteropelvic junction obstruction (UPJO) is the most common cause of postnatal hydronephrosis. However, hydronephrosis now is usually diagnosed antenatally and affects approximately 1 in 1500 live births. Ultrasonographic scanning is the imaging modality of choice to diagnose hydronephrosis but is unable to differentiate between obstructed and nonobstructed kidneys. Mercaptoacetyltriglycine (MAG3) scanning is essential to distinguish an obstructed renal pelvis from a renal pelvis that is dilated but otherwise normal. Occasionally, vesicoureteric reflux may give a similar picture. Reflux can usually be ruled out with a well-performed MAG3 scan, but if not, micturating cystourethrography should be performed.There is no consensus on how to manage patients with UPJO and when to treat them conservatively or surgically. Some indications for surgery include <40% differential function of the hydronephrotic kidney on MAG3 scanning, a >20-mm anterior-posterior diameter of the renal pelvis on ultrasonographic scan, pain, and infection.Pyeloplasty is the gold-standard treatment if surgery is indicated. This procedure can be open, laparoscopic, or robot-assisted. Endopyelotomy and ureterocalicostomy have also been performed in children with some success.There is also no consensus on how to follow up patients who have had surgery. Some guidelines recommend 2-3-yr follow-up with ultrasonographic and MAG3 scanning, and if stable, the patient then should be discharged. Follow-up of patients who have conservative treatment must be more rigorous to avoid deterioration of the kidneys.There is increasing interest in using different diagnostic modalities, including urinary markers and magnetic resonance urography, in the diagnosis of UPJO and in correlating the findings with the best treatment option. An individualized approach to management including functional evaluation of the obstructed kidney is required for ureteropelvic junction obstruction. Surgery remains the most efficient treatment with less invasive options leading more often to treatment failures. © 2012 European Association of Urology.

Parsons B.A.,Bristol Urological Institute | Drake M.J.,Bristol Urological Institute
Handbook of Experimental Pharmacology | Year: 2011

Overactive bladder syndrome (OAB) is a symptom-based diagnosis characterised by the presence of urinary urgency. It is highly prevalent and overlaps with the presence of bladder contractions during urine storage, which characterises the urodynamic diagnosis of detrusor overactivity. Animal models are needed to understand the pathophysiology of OAB, but the subjective nature of the symptom complex means that interpretation of the findings in animals requires caution. Because urinary urgency cannot be ascertained in animals, surrogate markers such as frequency, altered toileting areas, and non-micturition contractions have to be used instead. No model can recapitulate the subjective, objective, and related factors seen in the clinical setting. Models used include partial bladder outlet obstruction, the spontaneous hypertensive rat, the hyperlipidaemic rat, various neurological insults and some gene knock-outs. Strengths and weaknesses of these models are discussed in the context of the inherent difficulties of extrapolating subjective symptoms in animals. © 2011 Springer-Verlag Berlin Heidelberg.

Winstock A.R.,Addiction CAG | Mitcheson L.,Addiction CAG | Gillatt D.A.,Bristol Urological Institute | Cottrell A.M.,Bristol Urological Institute
BJU International | Year: 2012

Study Type - Symptom prevalence (prospective cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Case series have described lower urinary tract symptoms associated with ketamine use including severe pain, frequency, haematuria and dysuria. Little is known regarding the frequency of symptoms, relationship of symptoms with dose and frequency of use and natural history of symptoms once the ketamine user has stopped. This study describes the prevalence of ketamine use in a population of recreational drug users in a dance music setting. It shows a dose-frequency relationship with ketamine use. It shows that urinary symptoms associated with recreational ketamine use may lead to a considerable demand on health resources in the primary-, secondary- and emergency-care settings. It shows that symptoms may improve once ketamine use is decreased. OBJECTIVE To investigate the prevalence and natural history of urinary symptoms in a cohort of recreational ketamine users. PATIENTS AND METHODS A purposeful sampling technique was used. Between November 2009 and January 2010 participants were invited to undertake an on-line questionnaire promoted by a national dance music magazine and website. Data regarding demographics and illicit drug-use were collected. Among respondents reporting recent ketamine use, additional information detailing their ketamine use, experience of urinary symptoms and use of related healthcare services was obtained. RESULTS In all, 3806 surveys were completed, of which 1285 (33.8%) participants reported ketamine use within the last year. Of the ketamine users, 17% were found to be dependent on the drug; 26.6% (340) of recent ketamine users reported experiencing urinary symptoms. Urinary symptoms were significantly related to both dose of ketamine used and frequency of ketamine use. Of 251 users reporting their experience of symptoms over time in relationship to their use of ketamine, 51% reported improvement in urinary symptoms upon cessation of use with only eight (3.8%) reporting deterioration after stopping use. CONCLUSIONS Urinary tract symptoms are reported in over a quarter of regular ketamine users. A dose and frequency response relationship has been shown between ketamine use and urinary symptoms. Both users and primary-care providers need to be educated about urinary symptoms that may arise in ketamine users. A multi-disciplinary approach promoting harm reduction, cessation and early referral is needed to manage individuals with ketamine-associated urinary tract symptoms to avoid progression to severe and irreversible urological pathologies. © 2012 BJU INTERNATIONAL.

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