Neuromodulation in Urology: Current Trends and Future Applications

Urological applications of neuromodulation and neurostimulation are among the most evolving fields for these technologies. First approved for management of refractory urge incontinence, different modalities of neuromodulation and stimulation have been tested, applied and verified for a vast spectrum of voiding and pelvic floor dysfunction disorders. The modalities of delivering this treatment have also evolved in the last three decades, with a focus on sacral neuromodulation. The experimental and established “off-label” applications of neuromodulation have also encompassed chronic pelvic pain disorders, including chronic prostatitis and bladder pain syndrome, among others. In this chapter, we discuss all the hypothesized theories suggested on how this technology provides therapeutic potential for a number of chronic and debilitating urological conditions, the modes of delivery be it anterior, sacral, and posterior tibial to name a few, and the evolving and future applications

Urological Applications of Botulinum Toxin A

Botulinum toxin A (BoNT-A) has seen in the last two decades an increased level of application in urological practice, first FDA approved in 2011 for neurogenic detrusor overactivity and then later in 2013 for refractory overactive bladder. Hundreds of studies have been published in literature assessing the chemical structure of botulinum toxins and how urothelial injections in the lower urinary tract and vesical instillations can be employed in the management of a spectrum of urological conditions particularly voiding dysfunction. The consensus is still out on toxin A preparations, mode and pattern of application whether instilled or injected intradetrusally, units used, as well as time to onset and duration of effect of injections and is still a dense research topic. This is reflected in the continuously changing and differing grades of recommendations between societies of urological practitioners such as the EAU and AUA, among others. This chapter discusses both the FDA-approved and experimental applications of botulinum toxin A in urology, indications, techniques, and points of debate

Spermatic Cord Knot: A Clinical Finding in Patients with Spermatic Cord Torsion

Pertinent history taking and careful examination often taper the differentials of the acute scrotum; congruently the ability to diagnose acute spermatic cord torsion (SCT) when radiological adjuncts are not available is highly imperative. This observational study serves to present a series of 46 cases of spermatic cord torsion whereby we hypothesize the identification of a clinical knot on scrotal examination as an important clinical aid in making a decision to surgical exploration in patients with acute and subacute SCT, especially in centers where imaging resources are unavailable

A 42 Year Old Female with Pyonephrosis and Multiple Subcapsular Abscesses: Saving a Threatened Kidney

Abstract Objective: The following report entails how the use of appropriate treatment and imaging leads to an excellent outcome. This description of dealing with a threatened kidney delineates the importance of critical thinking and application of least invasive techniques to provide optimum treatment and satisfaction to the patient, avoiding unnecessary loss of a viable kidney. Clinical Presentation: The following case is of a 42 year old woman, presenting with left loin pain and fever, eventually diagnosed to have a left obstructed kidney due to a Intervention: While in hospital, the patient received appropriate antibiotics, had a ureteric stent placed initially while the stone was manipulated into the left kidney, followed by drainage of two large subcapsular abscesses. Following discharge, during follow up she had the stent and stone removed rendering her symptom and stone free. CT was the imaging modality used in hospital and for follow up. Conclusion: When faced with multiple pathologies, such as our case, using gold standard imaging and tapering treatment to patient characteristics and needs, helped us tackle different pathologies in a step-wise manner with an excellent endpoint. The use of ureteric stenting, combined with percutaneous drainage of the subcaspular abscesses, was an excellent choice, one that saved the patient her left kidney

[33] Sacral neuromodulation: Report of initial experience in Kuwait

Objective: To present our 6-year experience with sacral neuromodulation (SNM) since starting implantation in a single centre in Kuwait, as SNM is an established management for several urological and non-urological conditions, and devices and techniques have improved over the past decade. Methods: We conducted a combined retrospective file review and prospective follow-up of patients who had undergone SNM implants since March 2012 up to May 2018 in Amiri Hospital, Kuwait. We analysed: biometric data; clinical presentation; medical and drug history; surgical history; timeline after the first stage of implantation, including complications and level of satisfaction; and any need for review or explantation of the device. Results: In all, 21 patients underwent SNM implantation between March 2012 and May 2018, 17 (81%) of which were females. The mean age of the patients was 35.9 years, 52.4% had urinary retention, 38.1% had overactive bladder, and 11.8% had dysfunctional voiding. Almost all patients (19) failed or were unsatisfied with prior conservative treatment. Right- and left-sided Stage 1 insertions were of almost equal frequency, and no devices were initially implanted on the contralateral side in the second stage. The mean hospital stay for both stages was just over 1 day postoperatively, and the time between stages was on average 4.4 weeks. Only one patient, who had an unsatisfactory response (<50% resolution of symptoms) after the second stage of implantation, requested explantation. Another patient requested explantation after revision of the procedure failed to improve her symptoms. This patient is one of five who required some form of revision after implantation within a mean of 8.6 months, all but her reporting satisfactory responses. There were no major complications in our series. Conclusion: We report the successful experience of the only unit in Kuwait performing SNM implantation. Our patients report overwhelming satisfactory results both objectively and subjectively

[63] Traumatic testicular displacement and torsion: A case report and literature review

Objective: To report on a case of traumatic testicular displacement (TTD) and torsion, which is a rare consequence of pelvic trauma. Methods: A 34-year-old motorcycle rider who presented immediately following a head-on collision with a car. His past surgical history included bilateral inguinal varicocoele repair. The patient recalled that his genitals collided with a part of the motorcycle before coming off the vehicle. He complained of left-sided groin pain and was found to have an empty left hemi-scrotum, a tender palpable lump in the left suprapubic region, and bruising in the area. A contrast-enhanced computed tomography (CT) scan revealed an empty scrotum and an ovoid structure measuring 5 × 3 × 4 cm in the subcutaneous tissue with an adjacent spermatic cord and surrounding fat stranding. He was immediately transferred to the operating theatre for surgical exploration of the lower abdomen. Results: After anaesthesia, the testis was repositioned into the scrotum and then we proceeded with exploration of the scrotum that revealed a torted left testicle. De-torsion, warm fomentation and orchidopexy of a viable left testicle was performed. He made an uneventful recovery. He was then transferred to a tertiary trauma centre for further management of his injuries. TTD is defined as migration of one or both testicle outside the scrotum. The most common mechanism of trauma is a rapid deceleration straddle injury against a motorcycle fuel tank. Predisposing factors include inguinal hernia repair, wide external inguinal ring, and atrophic testes. Radiological examinations of choice include colour-flow Doppler ultrasonography and CT scans of the abdomen and pelvis. Management consists of either closed reduction of the testicle or surgical exploration. Conclusion: Early diagnosis and management of TTD is imperative to preserve the displaced testicle

[31] Effect of urodynamic urethral catheter on uroflowmetry parameters: A prospective study

Objective: To investigate the effect of urodynamic urethral catheter on uroflowmetry (UFM) parameters, as urodynamic studies (UDS) are an integral part in assessing voiding symptoms in both genders and its settings and components are points of debate for possible effects on results that sometimes vary from preliminary diagnoses, particularly the urethral or vesical catheters used in filling and voiding cystometry and their effect on UFM parameters. Methods: We prospectively enrolled 150 patients undergoing UDS for established voiding symptoms from January 2016 to March 2018. Exclusion criteria were pre-UDS voided volume of <150 mL and/or inability to void during UDS with the catheter in place. Biometric data and clinical history were collected. Free UFM preceded the UDS. A double-lumen 8-F air-charged urethral catheter was inserted to measure intra-vesical pressure and for filling and voiding cystometry. Parameters of free UFM were compared with that of voiding cystometry using t-tests. Results: The study included 105 eligible patients (mean age 55 years), 54% of which were females. Urge urinary incontinence was most frequent form of leak (28 patients) and 69% of strips showed detrusor overactivity. Statistically significantly better results were observed between pre-UDS UFM and pressure-flow UFM for the mean values of maximum urinary flow (Qmax; +4.33 mL/s, P  <  0.001), average flow (+1.95 mL/s, P< 0.05), voiding time (-16.6 s, P< 0.001), and time to Qmax (-6.6 s, P< 0.001), but not post-void residual volume (PVR; 12.2 mL, P = 0.16) and percentage PVR of cystometric capacity (0.55%, P = 0.7). Time to Qmax becomes insignificant when compared amongst males only (P = 0.2), whilst all PVR assessments become significant amongst females alone (P< 0.05). Analysis was repeated including those who voided ⩾120 mL (120 patients) on pre-UDS UFM and yielded results of similar significance. Conclusion: The insertion of a urethral catheter has a significant effect on UFM parameters in patients regardless of gender. Pre-UDS UFM studies are important to identify such effects that may influence the final diagnosis