Die überaktive Blase. Differenzialdiagnostik und therapeutisches Management

Die über- oder hyperaktive Blase kann die Befindlichkeit der Betroffenen erheblich stören. Abklärung und Therapie sollen patientinnenorientiert in verschiedenen Stufen erfolgen. Bei Therapieversagen trotz Verhaltensänderung, Blasentraining und Anticholinergika als primäre Therapien ist die intravesikale Injektion von Botulinumneurotoxin, aber auch Neuromodulation eine sehr wirksame Option. Neu erweitern β3-Adrenozeptor- Agonisten in Europa seit 2013* das therapeutische Spektrum

Genital Dysplasia and Immunosuppression: Why Organ-Specific Therapy Is Important

Background Young patients with Crohn's disease (CD) show a high prevalence of human papillomavirus (HPV) which is the main cause of high-grade squamous intraepithelial lesions (HSIL). A major complication for patients undergoing immunocompromising therapy is the development of genital dysplasia. Methods We report the case of a 32-year-old patient with recurrent genital dysplasia under long-term therapy for CD with a focus on different drug-related, immunosuppressive mechanisms. Results Gynecological examination and biopsy revealed high-grade vulvar intraepithelial neoplasia (VIN) positive for HPV 16 treated with laser vaporization. Due to the combination of HPV positivity, intraoperative multilocularity, and CD, follow-up examinations were performed every 6 months. One year later, the patient showed a VIN at a new location and additionally, a cervical intraepithelial neoplasia (CIN), which were surgically treated. Catch-up HPV vaccination was applied accessorily. After the switch from a TNF-α blocker to vedolizumab, which acts as a gut-selective anti-integrin, the subsequent PAP smear, vulvoscopy, and colposcopy showed no more evidence of dysplasia. Conclusions This case report highlights that gut-selective immunosuppression with vedolizumab might be favorable in young HPV-positive patients due to a good side effect profile. Regular screening and HPV vaccination are a mainstay of dysplasia prevention and control. The risk for HPV-associated dysplasia in immunosuppressed patients is highly dependent on the choice of immunosuppressive therapy

Twelve months effect on voiding function of retropubic compared with outside-in and inside-out transobturator midurethral slings

Introduction and hypothesis: The purpose of this study is to compare retropubic tension-free vaginal tape (TVT) with transobturator out-in TOT and in-out TVT-O for female stress urinary incontinence. Uroflow rate was primary; continence rates, quality of life (QoL) and complication pattern were secondary endpoints. Methods: A prospective randomised trial with 2:1:1 randomisation at two Swiss teaching hospitals. Patients were followed up at 12months. Results: Eighty TVT, 40 transobturator tape (TOT) and 40 TVT-O were randomised. At 12months, there was no difference in Qmax among the groups. Continence was comparable (≥89%). QoL was improved significantly in all groups (P < 0.05). Five vaginal tape exposures occurred (one TVT, four TOT, zero TVT-O; P = 0.028). Two percent (1/52) of sexually active patients after TVT, 17% (5/29) after TOT, but 0% (0/25) after TVT-O reported de novo female sexual dysfunction (P = 0.011). We considered this clinically important enough to stop enrolment. Conclusions: There was no difference for Qmax at 12months between TVT, TOT and TVT-O. Female sexual dysfunction and tape exposure may be higher with a transobturator tap

Patient satisfaction after retropubic and transobturator slings: first assessment using the Incontinence Outcome Questionnaire (IOQ)

Introduction and hypothesis: The aim of the Incontinence Outcome Questionnaire (IOQ) is to assess quality of life and patient-reported outcome after midurethral slings. Methods: In this retrospective study, 626 patients with a minimum follow-up period of 1year were sent the IOQ. Four hundred twenty-two of 626 (67.4%) patient responses were evaluated. Results: The mean IOQ QoL extended score was 33.7 ± 17.5 and comparable for tension-free vaginal tape (TVT), outside-in transobturator tape (TOT), and inside-out transobturator vaginal tape (TVT-O). Evaluation of IOQ question about readmission revealed a total of 32 patients (18 TVT, 12 TOT, and 2 TVT-O) who underwent a subsequent operation due to sling-related complications. Freedom from reoperation for recurrent SUI at 1, 2, and 5years was 100%, 99.7 ± 0.3%, and 99.7 ± 0.3% for TVT, 100% for TVT-O, and 94.2 ± 2.5%, 91.9 ± 2.9%, and 89.9 ± 3.5% for TOT, respectively (p < 0.001). Conclusions: Patient satisfaction, assessed using the IOQ, is high after retropubic and transobturator slings. In our collective, relapse incontinence is higher after TO

Pelvic organ movements in asymptomatic nulliparous and symptomatic premenopausal women with pelvic organ prolapse in dynamic MRI: a feasibility study comparing midsagittal single-slice with multi-slice sequences

PURPOSE To compare multi-slice (MS) MRI sequences of the pelvis acquired at rest and straining to dynamic midsagittal single-slice (SS) sequences for the assessment of pelvic organ prolapse (POP). METHODS This IRB-approved prospective single-center feasibility study included 23 premenopausal symptomatic patients with POP and 22 asymptomatic nulliparous volunteers. MRI of the pelvis at rest and straining was performed with midsagittal SS and MS sequences. Straining effort, visibility of organs and POP grade were scored on both. Organ points (bladder, cervix, anorectum) were measured. Differences between SS and MS sequences were compared with Wilcoxon test. RESULTS Straining effort was good in 84.4% on SS and in 64.4% on MS sequences (p = 0.003). Organ points were always visible on MS sequences, whereas the cervix was not fully visible in 31.1-33.3% on SS sequences. At rest, there were no statistically significant differences of organ point measurements between SS and MS sequences in symptomatic patients. At straining, positions of bladder, cervix, and anorectum were + 1.1 cm (± 1.8 cm), - 0.7 cm (± 2.9 cm), and + 0.7 cm (± 1.3 cm) on SS and + 0.4 mm (± 1.7 cm), - 1.4 cm (± 2.6 cm), and + 0.4 cm (± 1.3 cm) on MS sequences (p < 0.05). Only 2 cases of higher-grade POP were missed on MS sequences (both with poor straining effort). CONCLUSION MS sequences increase the visibility of organ points compared to SS sequences. Dynamic MS sequences can depict POP if images are acquired with sufficient straining effort. Further work is needed to optimize the depiction of the maximum straining effort with MS sequences

Radiological imaging following pelvic prolapse surgery

CLINICAL/METHODICAL ISSUE Pelvic organ prolapse is a common condition in women, for which both conservative and surgical interventions are available. Knowledge of the different surgical procedures and the materials used is essential for adequate radiological diagnosis after prolapse surgery in order to differentiate potential complications from normal postoperative changes. STANDARD RADIOLOGICAL METHODS In the immediate postoperative period, computed tomography (CT) is often the modality of choice for evaluating acute complications such as bleeding or organ injuries. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and is therefore generally preferred for assessing subacute and chronic complications. METHODICAL INNOVATIONS Innovative techniques such as dynamic MRI protocols can improve the radiological assessment after prolapse surgery by enabling the evaluation of organ mobility. PERFORMANCE Radiological standard procedures such as computed tomography (CT) and MRI provide detailed and reliable information about the postoperative site and potential complications following prolapse surgery. ACHIEVEMENTS Radiological imaging plays an important role in the evaluation of patients after prolapse surgery, particularly when complications are suspected. Accurate radiological diagnosis can guide further appropriate therapeutic measures

Bryophyllum pinnatum and Improvement of Nocturia and Sleep Quality in Women: A Multicentre, Nonrandomised Prospective Trial

Nocturia is a pathologic condition that significantly affects the quality of sleep. The aetiology of nocturia is multifactorial, and the evidence available on its management remains limited. Besides behavioural measures, validated pharmaceutical treatment options exist but are, however, associated with marked side effects. Prospective clinical studies with tablets prepared from the leaf press juice of the plant Bryophyllum pinnatum revealed a tendency towards reduction of micturition in patients with overactive bladder (OAB) and several improvements in sleep quality. These observations are in part supported by in vitro and in vivo data. In the present study, we investigated the effectiveness of Bryophyllum 50% chewable tablets in the treatment of nocturia and associated sleep disorders. Altogether, 49 women with idiopathic OAB and nocturia of ≥2 voids/night were treated with Bryophyllum 50% tablets for 3 weeks (350 mg chewable tablets, dosage 0-0-2-2 oral tablets; WELEDA AG, Arlesheim, Switzerland). Nocturia, voiding volumes at night (ml), quality of life, sleep quality, and daily sleepiness were assessed before and after treatment with a 3-day micturition diary, the International Consultation on Incontinence evaluating overactive bladder and related impact on quality of life (QoL) [ICIQ-OAB], the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS), respectively. The age of the study population was 68.5 ± 11.6 y. After treatment, nocturia diminished from 3.2 ± 1.4 to 2.3 ± 1.3 ( ) and the PSQI score decreased from 7.7 ± 3.7 to 6.6 ± 3.4 ( ). Urgency, the ICIQ score, and the ESS lowered significantly, and the micturition volume showed a tendency to increase. No serious adverse drug reactions were reported, and compliance was good. The results show a beneficial effect on the nocturnal voids and sleep quality of women with OAB. Bryophyllum 50% tablets can be regarded as a well-tolerated alternative in the treatment of nocturia and broaden the repertoire of standard management

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users

Delphi consensus; Pelvic organ prolapse; Robotic surgeryConsenso Delphi; Prolapso de órganos pélvicos; Cirugía robóticaConsens Delphi; Prolapse d'òrgans pèlvics; Cirurgia robòticaBackground Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. Methods We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons’ characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. Results The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. Conclusion Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.Open access funding provided by Università di Pisa within the CRUI-CARE Agreement. The project was funded with research funds from the University of Pisa to Tommaso Simoncini