Publications by authors named "Jan Groen"

60 Publications

Vaccination with a bacterial peptide conjugated to SARS-CoV-2 receptor-binding domain accelerates immunity and protects against COVID-19.

iScience 2022 Aug 5;25(8):104719. Epub 2022 Jul 5.

Angiogenesis Laboratory, Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands.

Poor immunogenicity of critical epitopes can hamper vaccine efficacy. To boost immune recognition of non- or low-immunogenic antigens, we developed a vaccine platform based on the conjugation of a target protein to a chimeric designer peptide (CDP) of bacterial origin. Here, we exploited this immune Boost (iBoost) technology to enhance the immune response against the receptor-binding domain (RBD) of the SARS-CoV-2 spike glycoprotein. Despite its fundamental role during viral infection, RBD is only moderately immunogenic. Immunization studies in mice showed that the conjugation of CDP to RBD induced superior immune responses compared to RBD alone. CDP-RBD elicited cross-reactive antibodies against the variants of concern Delta and Omicron. Furthermore, hamsters vaccinated with CDP-RBD developed potent neutralizing antibody responses and were fully protected from lung lesion formation upon challenge with SARS-CoV-2. In sum, we show that the iBoost conjugate vaccine technology provides a valuable tool for both quantitatively and qualitatively enhancing anti-viral immunity.
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http://dx.doi.org/10.1016/j.isci.2022.104719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9252865PMC
August 2022

Two-Staged Sacral Neuromodulation for the Treatment of Nonobstructive Urinary Retention: A Multicenter Study Assessing Predictors of Success.

Neuromodulation 2022 Jun 9. Epub 2022 Jun 9.

Department of Urology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands.

Objectives: The aims of this study were to 1) determine the success rate of the tined lead test phase in patients with nonobstructive urinary retention (NOUR), 2) determine predictive factors of a successful test phase in patients with NOUR, and 3) determine long-term treatment efficacy and satisfaction in patients with NOUR.

Materials And Methods: The first part was a multicenter retrospective study at two centers in The Netherlands. Patients with NOUR received a four-week tined lead test phase. Success was defined as a ≥50% reduction of clean intermittent catheterization frequency or postvoid residual. We analyzed possible predictors of success with multivariable logistic regression. Second, all patients received a questionnaire to assess efficacy, perceived health (Patient Global Impression of Improvement), and treatment satisfaction.

Results: This study included 215 consecutive patients (82 men and 133 women) who underwent a tined lead test phase for the treatment of NOUR. The success rate in women was significantly higher than in men, respectively 62% (83/133) and 22% (18/82, p < 0.001). In women, age per ten years (odds ratio [OR] 0.74, 95% CI: 0.59-0.93) and a history of psychiatric illness (OR 3.92, 95% CI: 1.51-10.2), including posttraumatic stress disorder (PTSD), significantly predicted first stage sacral neuromodulation (SNM) success. In men, age per ten years (OR 0.43, 95% CI: 0.25-0.72) and previous transurethral resection of the prostate and/or bladder neck incision (OR 7.71, 95% CI: 1.43-41.5) were significant predictors of success. Conversely, inability to void during a urodynamic study (for women, OR 0.79, 95% CI: 0.35-1.78; for men, OR 3.06, 95% CI: 0.83-11.3) was not predictive of success. Of the patients with a successful first stage, 75% (76/101) responded to the questionnaire at a median follow-up of three years. Of these patients, 87% (66/76) continued to use their SNM system, and 92% (70/76) would recommend SNM to other patients.

Conclusions: A history of psychiatric illness, including PTSD, in women with NOUR increased the odds of first stage SNM success 3.92 times. A previous transurethral resection of the prostate and/or bladder neck incision in men increased the odds of success 7.71 times. In addition, a ten-year age increase was associated with an OR of 0.43 in men and 0.74 in women, indicating a 2.3- and 1.3-times decreased odds of success, respectively.
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http://dx.doi.org/10.1016/j.neurom.2022.04.042DOI Listing
June 2022

European Association of Urology Guidelines on the Diagnosis and Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 1: Diagnostics, Overactive Bladder, Stress Urinary Incontinence, and Mixed Urinary Incontinence.

Eur Urol 2022 Jul 23;82(1):49-59. Epub 2022 Feb 23.

Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.

Context: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guideline expands the remit to include these symptoms and conditions.

Objective: To summarise the diagnostic section of the non-neurogenic female LUTS guideline and the management of female overactive bladder (OAB), stress urinary incontinence (SUI), and mixed urinary incontinence (MUI).

Evidence Acquisition: New literature searches were carried out in September 2021 and evidence synthesis was conducted using the modified GRADE criteria as outlined for all EAU guidelines. A new systematic review (SR) on OAB was carried out by the panel for the purposes of this guideline.

Evidence Synthesis: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

Conclusions: Non-neurogenic female LUTS are an important cause of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion based on the best available evidence. This guideline serves to present this evidence to health care providers in an easily accessible and digestible format.

Patient Summary: This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to diagnosis of these conditions, as well as the treatment of overactive bladder, stress urinary incontinence, and mixed urinary incontinence.
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http://dx.doi.org/10.1016/j.eururo.2022.01.045DOI Listing
July 2022

European Association of Urology Guidelines on the Management of Female Non-neurogenic Lower Urinary Tract Symptoms. Part 2: Underactive Bladder, Bladder Outlet Obstruction, and Nocturia.

Eur Urol 2022 Jul 16;82(1):60-70. Epub 2022 Feb 16.

Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.

Context: Female lower urinary tract symptoms (LUTS) are a common presentation in urological practice. Thus far, only a limited number of female LUTS conditions have been included in the European Association of Urology (EAU) guidelines compendium. The new non-neurogenic female LUTS guidelines expand the remit to include these symptoms and conditions.

Objective: To summarise the management of underactive bladder (UAB), bladder outlet obstruction (BOO), and nocturia in females.

Evidence Acquisition: The literature search was updated in September 2021 and evidence synthesis was conducted using modified GRADE approach as outlined for all EAU guidelines. A new systematic review on BOO was carried out by the panel for purposes of this guideline.

Evidence Synthesis: The important considerations for informing guideline recommendations are presented, along with a summary of all the guideline recommendations.

Conclusions: Non-neurogenic female LUTS are an important presentation of urological dysfunction. Initial evaluation, diagnosis, and management should be carried out in a structured and logical fashion on the basis of the best available evidence. This guideline serves to present this evidence to practising urologists and other health care providers in an easily accessible and digestible format.

Patient Summary: This report summarises the main recommendations from the European Association of Urology guideline on symptoms and diseases of the female lower urinary tract (bladder and urethra) not associated with neurological disease. We cover recommendations related to the treatment of underactive bladder, obstruction of the bladder outlet, and nighttime urination.
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http://dx.doi.org/10.1016/j.eururo.2022.01.044DOI Listing
July 2022

Benefits and Harms of Conservative, Pharmacological, and Surgical Management Options for Women with Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.

Eur Urol Focus 2021 Oct 23. Epub 2021 Oct 23.

Freeman Hospital, Newcastle-upon-Tyne, UK.

Context: While the management of bladder outlet obstruction (BOO) in men has been a topic of several systematic reviews and meta-analyses, no such evidence base exists for female BOO.

Objective: The aim of this systematic review was to evaluate the benefits and harms of therapeutic interventions for the management of BOO in women.

Evidence Acquisition: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. The study protocol was registered with PROSPERO (CRD42020183839). A systematic literature search was performed and updated by a research librarian in May 2021. The study population consisted of adult female patients diagnosed with BOO, who underwent treatment.

Evidence Synthesis: Out of 6344 records, we identified 33 studies enrolling 1222 participants, of which only six randomized controlled trials (RCTs) were found. One placebo-controlled crossover randomized trial assessed the role of baclofen in 60 female patients with dysfunctional voiding. The trial met its primary endpoint with a significantly greater decrease in the number of voids per day in the baclofen group (-5.53 vs -2.70; p = 0.001). The adverse events were mild and comparable in both groups (25% vs 20%). One placebo-controlled crossover randomized trial assessed the role of sildenafil in 20 women with Fowler's syndrome. There were significant improvements from baseline in maximum urinary flow rate (Qmax), International Prostate Symptom Score (IPSS), and postvoid residual (PVR), but with no statistically significant difference when compared with placebo. In a large RCT including 197 female patients with functional BOO, the alpha-blocker alfuzosin significantly improved IPSS, Qmax, and PVR compared with baseline, but the differences were not statistically significant compared with the placebo group. Several small single-arm prospective series reported improvement of BOO-related symptoms and voiding parameters with urethroplasty, sling revision, urethral dilation, vaginal pessary, and pelvic organ prolapse repair.

Conclusions: Evidence to support the use of conservative, pharmacological, and surgical treatments for BOO is scarce.

Patient Summary: According to the present systematic review of the literature, evidence to support the use of conservative, pharmacological, and surgical treatments for either anatomical or functional bladder outlet obstruction is scarce.
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http://dx.doi.org/10.1016/j.euf.2021.10.006DOI Listing
October 2021

Diagnostic Tests for Female Bladder Outlet Obstruction: A Systematic Review from the European Association of Urology Non-neurogenic Female LUTS Guidelines Panel.

Eur Urol Focus 2021 Sep 16. Epub 2021 Sep 16.

Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK.

Context: Female bladder outlet obstruction (fBOO) is a relatively uncommon condition compared with its male counterpart. Several criteria have been proposed to define fBOO, but the comparative diagnostic accuracy of these remains uncertain.

Objective: To identify and compare different tests to diagnose fBOO through a systematic review process.

Evidence Acquisition: A systematic review of the literature was performed according to the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. The EMBASE/MEDLINE/Cochrane databases were searched up to August 4, 2020. Studies on women ≥18 yr of age with suspected bladder outlet obstruction (BOO) involving diagnostic tests were included. Pressure-flow studies or fluoroscopy was used as the reference standard where possible. Two reviewers independently screened all articles, searched reference lists of retrieved articles, and performed data extraction. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2).

Evidence Synthesis: Overall, 28 nonrandomised studies involving 10 248 patients were included in the qualitative analysis. There was significant heterogeneity regarding the characteristics of women included in BOO cohorts (ie, mixed cohorts including both anatomical and functional BOO). Pressure-flow studies ± fluoroscopy was evaluated in 25 studies. Transperineal Doppler ultrasound was used to evaluate bladder neck dynamics in two studies. One study tested the efficacy of transvaginal ultrasound. The urodynamic definition of fBOO also varied amongst studies with different parameters and thresholds used, which precluded a meta-analysis. Three studies derived nomograms using the maximum flow rate (Q) and voiding detrusor pressure at Q. The sensitivity, specificity, and overall accuracy ranges were 54.6-92.5%, 64.6-93.9%, and 64.1-92.2%, respectively.

Conclusions: The available evidence on diagnostic tests for fBOO is limited and heterogeneous. Pressure-flow studies ± fluoroscopy remains the current standard for diagnosing fBOO.

Patient Summary: Evidence on tests used to diagnose female bladder outlet obstruction was reviewed. The most common test used was pressure-flow studies ± fluoroscopy, which remains the current standard for diagnosing bladder outlet obstruction in women. TAKE  HOME MESSAGE: The available evidence on diagnostic tests for female bladder outlet obstruction is limited and heterogeneous. The most common test used was video-urodynamics, which remains the current standard for diagnosing bladder outlet obstruction in women.
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http://dx.doi.org/10.1016/j.euf.2021.09.003DOI Listing
September 2021

Efficacy and Safety of Surgical Treatments for Neurogenic Stress Urinary Incontinence in Adults: A Systematic Review.

Eur Urol Focus 2021 Sep 8. Epub 2021 Sep 8.

Department of Urology, University College London and London Spinal Injuries Unit, London, UK.

Context: Controversy still exists regarding the balance of benefits and harms for the different surgical options for neurogenic stress urinary incontinence (N-SUI).

Objective: To identify which surgical option for N-SUI offers the highest cure rate and best safety without compromising urinary tract function and bladder management.

Evidence Acquisition: A systematic review was performed under the auspices of the European Association of Urology Guidelines Office and the European Association of Urology Neuro-Urology Guidelines Panel according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.

Evidence Synthesis: A total of 32 studies were included. Overall, 852 neurourological patients were surgically treated for N-SUI. The treatment offered most often (13/32 studies) was an artificial urinary sphincter (AUS; 49%, 416/852) and was associated with a need for reintervention in one-third of patients. More than 200 surgical revisions were described. Overall, 146/852 patients (17%) received concomitant bladder augmentation, mainly during placement of an AUS (42%, 62/146) or autologous sling (34% of women and 14% of men). Following pubovaginal sling placement, dryness was achieved in 83% of cases. A significant improvement in N-SUI was observed in 87% (82/94) of women following placement of a synthetic midurethral sling. Efficacy after insertion of an adjustable continence therapy device (ACT 40%, proACT 60%) was reported for 38/128 cases (30%). The cure rate for bulking agents was 35% (9/25) according to 2/32 studies, mainly among men (90%). The risk of bias was highly relevant. Baseline and postoperative cystometry were missing in 13 and 28 studies, respectively.

Conclusions: The evidence is mainly reported in retrospective studies. More than one intervention is often required to achieve continence because of coexisting neurogenic detrusor overactivity, low compliance, or the onset of complications in the medium and long term. Urodynamic data are needed to better clarify the success of N-SUI treatment with the different techniques.

Patient Summary: Our review shows that insertion of an artificial urinary sphincter for urinary incontinence is effective but is highly associated with a need for repeat surgery. Other surgical options may have lower continence rates or a risk of requiring intermittent catheterization, which patients should be informed about before deciding on surgery for their incontinence.
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http://dx.doi.org/10.1016/j.euf.2021.08.007DOI Listing
September 2021

Definitions of Urinary Tract Infection Used in Interventional Studies Involving Neurourological Patients-A Systematic Review.

Eur Urol Focus 2021 Aug 14. Epub 2021 Aug 14.

Neuro-Urology, Swiss Paraplegic Center, Nottwil, Switzerland.

Context: Neurourological patients often encounter bacteriuria without any symptoms or may experience symptoms suspicious of urinary tract infections (UTIs). However, there is a lack of guidelines that unequivocally state the definition of UTIs in this specific patient group.

Objective: To present all used definitions of UTIs in neurourological patients.

Evidence Acquisition: This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Studies were identified by electronic search of Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov without a time limitation (last search September 2020) and by screening of reference lists and reviews. The occurrences of the various UTI definitions were counted and the frequencies calculated.

Evidence Synthesis: After screening 7164 abstracts, we included 32 studies enrolling a total of 8488 patients with a neurourological disorder who took part in an interventional clinical study. UTI definitions were heterogeneous. The concordance to predefined definitions was low.

Conclusions: Interventional clinical studies rarely report specific definitions for UTIs, and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.

Patient Summary: Patients suffering from neurological disorders often experience symptoms in their lower urinary tract that resemble urinary tract infections. Furthermore, they can have positive urine cultures without symptoms (the so-called asymptomatic bacteriuria). However, clinical studies rarely report specific definitions for urinary tract infections, and when it is done, they are heterogeneous. A generally accepted urinary tract infection definition for neurourological patients is urgently needed. TAKE  HOME MESSAGE: Interventional clinical studies on neurourological patients rarely report specific definitions for urinary tract infections (UTIs), and both clinical and laboratory criteria used are heterogeneous. A generally accepted UTI definition for neurourological patients is urgently needed.
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http://dx.doi.org/10.1016/j.euf.2021.07.012DOI Listing
August 2021

A systematic review and activation likelihood estimation meta-analysis of the central innervation of the lower urinary tract: Pelvic floor motor control and micturition.

PLoS One 2021 3;16(2):e0246042. Epub 2021 Feb 3.

Department of Urology, Erasmus Medical Center, Erasmus University, Rotterdam, The Netherlands.

Purpose: Functional neuroimaging is a powerful and versatile tool to investigate central lower urinary tract (LUT) control. Despite the increasing body of literature there is a lack of comprehensive overviews on LUT control. Thus, we aimed to execute a coordinate based meta-analysis of all PET and fMRI evidence on descending central LUT control, i.e. pelvic floor muscle contraction (PFMC) and micturition.

Materials And Methods: A systematic literature search of all relevant libraries was performed in August 2020. Coordinates of activity were extracted from eligible studies to perform an activation likelihood estimation (ALE) using a threshold of uncorrected p <0.001.

Results: 20 of 6858 identified studies, published between 1997 and 2020, were included. Twelve studies investigated PFMC (1xPET, 11xfMRI) and eight micturition (3xPET, 5xfMRI). The PFMC ALE analysis (n = 181, 133 foci) showed clusters in the primary motor cortex, supplementary motor cortex, cingulate gyrus, frontal gyrus, thalamus, supramarginal gyrus, and cerebellum. The micturition ALE analysis (n = 107, 98 foci) showed active clusters in the dorsal pons, including the pontine micturition center, the periaqueductal gray, cingulate gyrus, frontal gyrus, insula and ventral pons. Overlap of PFMC and micturition was found in the cingulate gyrus and thalamus.

Conclusions: For the first time the involved core brain areas of LUT motor control were determined using ALE. Furthermore, the involved brain areas for PFMC and micturition are partially distinct. Further neuroimaging studies are required to extend this ALE analysis and determine the differences between a healthy and a dysfunctional LUT. This requires standardization of protocols and task-execution.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246042PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857581PMC
July 2021

Transcutaneous Electrical Nerve Stimulation and Percutaneous Tibial Nerve Stimulation to Treat Idiopathic Nonobstructive Urinary Retention: A Systematic Review.

Eur Urol Focus 2021 Sep 22;7(5):1184-1194. Epub 2020 Oct 22.

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.

Context: Transcutaneous electrical nerve stimulation (TENS) and percutaneous tibial nerve stimulation (PTNS) provide minimally invasive ways to treat idiopathic nonobstructive urinary retention (NOUR).

Objective: To assess the efficacy of TENS and PTNS for treating idiopathic NOUR.

Evidence Acquisition: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Embase, Medline, Web of Science Core Collection, and the Cochrane CENTRAL register of trials were searched for all relevant publications until April 2020.

Evidence Synthesis: A total of 3307 records were screened based on the title and abstract. Eight studies met the inclusion criteria and none of the exclusion criteria. Five studies, all from the same group, reported the efficacy of PTNS and two that of TENS in adults with idiopathic NOUR. One study reported the efficacy of TENS in children with idiopathic NOUR. Objective success was defined as a ≥50% decrease in the number of catheterizations per 24 h or in the total catheterized volume in 24 h. The objective success rate of PTNS ranged from 25% to 41%. Subjective success was defined as the patient's request for continued chronic treatment with PTNS, and ranged from 46.7% to 59%. Eighty percent of women who underwent transvaginal stimulation reported an improvement such as a stronger stream when voiding. TENS in children reduced postvoid residual and urinary tract infections.

Conclusions: The efficacy of TENS and PTNS in the treatment of idiopathic NOUR is limited and should be verified in larger randomized studies before application in clinical practice.

Patient Summary: The outcomes of transcutaneous electrical nerve stimulation and percutaneous tibial nerve stimulation for the treatment of urinary retention of unknown origin were reviewed. Whether these treatments are superior to other treatments could not be established.
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http://dx.doi.org/10.1016/j.euf.2020.09.019DOI Listing
September 2021

Acute effect of sacral neuromodulation for treatment of detrusor overactivity on urodynamic parameters.

Neurourol Urodyn 2020 02 5;39(2):695-701. Epub 2019 Dec 5.

Department of Urology, Erasmus MC, Rotterdam, The Netherlands.

Aim: The aim of this study is to evaluate the acute effects of sacral neuromodulation (SNM) on various urodynamic parameters.

Methods: Patients with overactive bladder and detrusor overactivity (DO) who were planned for percutaneous nerve evaluation (PNE) were included. Directly after the PNE, a urodynamic study (UDS) was performed. The stimulation was turned off during the first UDS (UDS 1), and during the second filling cycle, stimulation was turned on (UDS 2). The UDS was followed by a test phase of 1 week and the bladder diaries were evaluated during an outpatient clinic visit. Primary outcome measures were the differences in UDS parameter values with SNM off and on.

Results: Ten female patients were included in the study and completed the study protocol. Eight patients showed ≥50% improvement of symptoms following a test phase. There were no differences between UDS 1 and UDS 2 in the UDS parameters; bladder volume at first sensation, bladder volume at first DO, highest DO pressure, bladder capacity, maximum flow rate, and pressure at maximum flow rate.

Discussion: None of the aforementioned urodynamic parameters was influenced by acute SNM in patients who responded to SNM. To the best of our knowledge, this is the first study investigating the acute effects of SNM on bladder function.
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http://dx.doi.org/10.1002/nau.24252DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028062PMC
February 2020

Silent volumetric multi-contrast 7 Tesla MRI of ocular tumors using Zero Echo Time imaging.

PLoS One 2019 16;14(9):e0222573. Epub 2019 Sep 16.

Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.

Magnetic Resonance Imaging (MRI) has become a valuable imaging modality in ophthalmology, especially for the diagnosis and treatment planning of patients with uveal melanoma, the most common primary intra-ocular tumor. We aim to develop and evaluate the value of silent Zero Echo Time (ZTE) MRI to image patients with ocular tumors at 7Tesla. Therefore, ZTE and different types of magnetization-prepared ZTE (FLAIR, SPIR, T2 and Saturation recovery), have been developed. After an initial validation with 7 healthy subjects, nine patients with an eye tumor have been evaluated. The ZTE scans were compared to their Cartesian equivalent in terms of contrast, motion-sensitivity, diagnostic quality and patient comfort. All volunteers and especially the patients reported a more comfortable experience during the ZTE scans, which had at least a 10 dB lower sound pressure. The image contrast in the native ZTE was poor, but in the different magnetization-prepared ZTE, the eye lens, cornea and retina were clearly discriminated. Overall the T2-prepared scan yielded the best contrast, especially between tumor and healthy tissue, and proved to be robust against eye motion. Although the intrinsic 3D nature of the ZTE-technique provides an accurate analysis of the tumor morphology, the quality of the ZTE-images is lower than their Cartesian equivalent. In conclusion, the quality of magnetization-prepared ZTE images is sufficient to assess the 3D tumor morphology, but insufficient for more detailed evaluations. As such this technique can be an option for patients who cannot comply with the sound-levels of Cartesian scans, but for other patients the conventional Cartesian scans offer a better image quality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222573PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746372PMC
March 2020

Surgical Management of Anatomic Bladder Outlet Obstruction in Males with Neurogenic Bladder Dysfunction: A Systematic Review.

Eur Urol Focus 2019 Sep 15;5(5):875-886. Epub 2018 Mar 15.

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.

Context: Surgical treatment of anatomic bladder outlet obstruction (BOO) may be indicated in males with neurogenic bladder dysfunction. A bothersome complication after surgery is urinary incontinence.

Objective: To identify the optimal practice in the surgical treatment of anatomic BOO in males with neurogenic bladder dysfunction, due to multiple sclerosis, Parkinson disease, spinal cord injury (SCI), spina bifida, or cerebrovascular accident (CVA).

Evidence Acquisition: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Medline, Embase, Cochrane controlled trial databases, Web of Science, and Google Scholar were searched for publications until January 2017.

Evidence Synthesis: A total of 930 abstracts were screened. Eight studies were included. The types of anatomic BOO discussed were benign prostate obstruction, urethral stricture, and bladder neck sclerosis. The identified surgical treatments were transurethral resection of the prostate (TURP) in patients with Parkinson, CVA or SCI, endoscopic treatment of urethral stricture by laser ablation or urethrotomy (mainly in SCI patients), and bladder neck resection (BNR) in SCI patients. The outcome of TURP may be highly variable, and includes persistent or de novo urinary incontinence, regained normal micturition control, and urinary continence. Good results were seen in BNR and endoscopic urethrotomy studies. Laser ablation and cold knife urethrotomy resulted in restarting intermittent catheterization or adequate voiding. Overall, a high risk of bias was found.

Conclusions: This systematic review provides an overview of the current literature on the outcome of several surgical approaches of different types of anatomic BOO in males with neurogenic bladder dysfunction. Identifying the optimal practice was impossible due to limited availability of high-quality studies.

Patient Summary: The outcome of several surgical approaches in males with neurogenic bladder dysfunction with benign prostate obstruction, urethral stricture, or bladder neck sclerosis is overviewed. The optimal practice could not be identified.
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http://dx.doi.org/10.1016/j.euf.2018.02.009DOI Listing
September 2019

Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review.

Neurourol Urodyn 2018 06 2;37(5):1522-1540. Epub 2018 Feb 2.

Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain.

Aim: The main goals of neurogenic lower urinary tract dysfunction (NLUTD) management are preventing upper urinary tract damage (UUTD), improving continence, and quality of life. Here, we aimed to systematically assess all available evidence on urodynamics predicting UUTD in patients with NLUTD.

Methods: A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in March 2017. Only neuro-urological patients assessed by urodynamics were included. Any outcome of upper urinary tract function were evaluated.

Results: Forty-nine studies (1 randomized controlled trial, 9 prospective, and 39 retrospective case series) reported urodynamic data on 4930 neuro-urological patients. Of those, 2828 (98%) were spina bifida (SB) children. The total number of adults was 2044, mainly having spinal cord injury (SCI) (60%). A low bladder compliance was found in 568 (46.3%) and 341 (29.3%) of the paediatric and adult population, respectively. Hydronephrosis (HDN) was detected in 557 children (27.8%) in 19/28 studies and 178 adults (14.6%), mainly SCI, in 14/21 studies. Nine out of 30 multiple sclerosis (MS) patients affected by HDN (16.8%) showed low compliance in 4/14 studies.

Conclusions: Patients with SB and SCI have a higher risk of developing UUTD (mainly reported as HDN) compared to those with MS. Reduced compliance and high DLPP were major risk factors for UUTD. Although our findings clarify the mandatory role of urodynamics in the management of NLUTD, standardization and better implementation of assessments in daily practice may further improve outcomes of neuro-urological patients based on objective measurements, that is, urodynamics.
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http://dx.doi.org/10.1002/nau.23501DOI Listing
June 2018

Heterogeneity in reporting on urinary outcome and cure after surgical interventions for stress urinary incontinence in adult neuro-urological patients: A systematic review.

Neurourol Urodyn 2018 02 9;37(2):554-565. Epub 2017 Aug 9.

Department of Urology, Erasmus MC, Rotterdam, The Netherlands.

Aims: To describe all outcome parameters and definitions of cure used to report on outcome of surgical interventions for stress urinary incontinence (SUI) in neuro-urological (NU) patients.

Methods: This systematic review was performed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The study protocol was registered and published (CRD42016033303; http://www.crd.york.ac.uk/PROSPERO). Medline, Embase, Cochrane controlled trials databases, and clinicaltrial.gov were systematically searched for relevant publications until February 2017.

Results: A total of 3168 abstracts were screened. Seventeen studies reporting on SUI surgeries in NU patients were included. Sixteen different outcome parameters and nine definitions of cure were used. Six studies reported on objective outcome parameters mainly derived from urodynamic investigations. All studies reported on one or more subjective outcome parameters. Patient-reported pad use (reported during interview) was the most commonly used outcome parameter. Only three of 17 studies used standardized questionnaires (two on impact of incontinence and one on quality of life). Overall, a high risk of bias was found.

Conclusions: We found a considerable heterogeneity in outcome parameters and definitions of cure used to report on outcome of surgical interventions for SUI in NU patients. The results of this systematic review may begin the dialogue to a future consensus on this topic. Standardization of outcome parameters and definitions of cure would enable researchers and clinicians to consistently compare outcomes of different studies and therapies.
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http://dx.doi.org/10.1002/nau.23364DOI Listing
February 2018

A Quality Assessment of Patient-Reported Outcome Measures for Sexual Function in Neurologic Patients Using the Consensus-based Standards for the Selection of Health Measurement Instruments Checklist: A Systematic Review.

Eur Urol Focus 2017 10 23;3(4-5):444-456. Epub 2016 Jun 23.

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.

Context: Impaired sexual function has a significant effect on quality of life. Various patient-reported outcome measures (PROMs) are available to evaluate sexual function. The quality of the PROMs to be used for neurologic patients remains unknown.

Objective: To systematically review which validated PROMs are available to evaluate sexual function in neurologic patients and to critically assess the quality of the validation studies and measurement properties for each identified PROM.

Evidence Acquisition: A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. The included publications were assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments checklist.

Evidence Synthesis: Twenty-one studies for PROMs regarding sexual function were identified for the following patient groups: spinal cord injury (11 studies), multiple sclerosis (MS; 6 studies), Parkinson's disease (2 studies), traumatic brain injury (1 study), and epilepsy (1 study). The evidence for the quality of PROMs was found to be variable, and overall evaluation of measurement properties was lacking in 71% of the studies. The measurement error and responsiveness were not studied in any of the publications.

Conclusions: Several PROMs have been identified to evaluate sexual function in neurologic patients. Strong evidence was found only for the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 and Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 for patients with MS, although evidence was lacking for certain measurement properties as well. Future research should focus on identifying relevant PROMs and establishing adequate quality for all measurement properties in studies with high methodological quality.

Patient Summary: A quality assessment of patient-reported outcome measures (PROMs) for sexual function in neurologic patients was made. The evidence found for good PROMs was limited. Studies with high methodological quality are needed to improve the quality of PROMs to evaluate sexual function in neurologic patients.
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http://dx.doi.org/10.1016/j.euf.2016.06.009DOI Listing
October 2017

Long-term effectiveness and complication rates of bladder augmentation in patients with neurogenic bladder dysfunction: A systematic review.

Neurourol Urodyn 2017 Sep 7;36(7):1685-1702. Epub 2017 Feb 7.

Department of Neuro-Urology, London Spinal Injuries Centre, Stanmore, United Kingdom.

Aims: To systematically evaluate effectiveness and safety of bladder augmentation for adult neuro-urological patients.

Methods: The Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement was followed for review of publications. The Medline, Embase, and Cochrane controlled trial databases and clinicaltrial.gov were searched until January 2015. No limitations were placed on date or language. Non-original articles, conference abstracts, and publications involving children and animals were excluded. Risk-of-bias and confounder assessment was performed.

Results: A total of 20 studies including 511 patients were eligible for inclusion. The level of evidence for the included studies was low, most level 4 studies with only one level 3 study. The data were narratively synthesized. Across all studies high risk-of bias and confounding was found. Primary outcomes were assessed in 16 of the 20 studies and showed improved quality of life and anatomical changes as well as stable renal function. The secondary outcomes were reported in 17 of the 20 studies and urodynamic parameters and continence all demonstrated improvement after bladder reconstruction. Long-term complications continued up to 10 years post-operatively, including bowel dysfunction in 15% of the patients, stone formation in 10%, five bladder perforations and one bladder cancer.

Conclusions: Available studies are not plentiful and of relatively poor quality, appropriately designed prospective studies are urgently needed. Despite this, bladder augmentation appears to be a highly effective procedure at protecting the upper urinary tract and improving quality of life. However, it is associated with relatively high morbidity in both the short and long term.
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http://dx.doi.org/10.1002/nau.23205DOI Listing
September 2017

Continent catheterizable tubes/stomas in adult neuro-urological patients: A systematic review.

Neurourol Urodyn 2017 Sep 31;36(7):1711-1722. Epub 2017 Jan 31.

Department of Urology, La Conception Hospital, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France.

Aims: To systematically review all available evidence on the effectiveness and complications of continent cutaneous stoma or tube (CCS/T) to treat bladder-emptying difficulties in adult neuro-urological patients.

Methods: The search strategy and studies selection were performed on Medline, Embase, and Cochrane using the PICOS method according to the PRISMA statement (CRD42015019212; http://www.crd.york.ac.uk/PROSPERO).

Results: After screening 3,634 abstracts, 11 studies (all retrospective, enrolling 213 patients) were included in a narrative synthesis. Mean follow-up ranged from 21.6 months to 8.7 years (median: 36 months, IQR 28.5-44). At last follow-up, the ability to catheterize rate was ≥84% (except in one study: 58.3%) and the continence rate at stoma was >75%. Data comparing health-related quality-of-life before and after surgery were not available in any study. Overall, 85/213 postoperative events required reoperation: 7 events (7 patients) occurring ≤3 months postoperatively, 22 events (16 patients) >3 months, and 56 events (55 patients) for which the time after surgery was not specified. Sixty additional complications (60 patients) were reported but did not require surgical treatment. Tube stenosis occurred in 4-32% of the cases (median: 14%, IQR 9-24). Complications related to concomitant procedures (augmentation cystoplasty, pouch) included neovesicocutaneous fistulae, bladder stones, and bladder perforations. Risk of bias and confounding was high in all studies.

Conclusions: CCS/T appears to be an effective treatment option in adult neuro-urological patients unable to perform intermittent self-catheterization through the urethra. However, the complication rate is meaningful and the quality of evidence is low, especially in terms of long-term outcomes including the impact on the quality-of-life.
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http://dx.doi.org/10.1002/nau.23213DOI Listing
September 2017

Maximum Urethral Closure Pressure Increases After Successful Adjustable Continence Therapy (ProACT) for Stress Urinary Incontinence After Radical Prostatectomy.

Urology 2016 Aug 26;94:188-92. Epub 2016 Apr 26.

Department of Urology, Erasmus MC, Rotterdam, The Netherlands.

Objective: To evaluate changes of the urethral pressure profile (UPP) after implantation of adjustable continence therapy (ProACT), a minimally invasive procedure in which 2 volume-adjustable balloons are placed periurethrally for treatment of male stress urinary incontinence. The working mechanism of the ProACT to achieve continence has not been fully understood. We hypothesized that successful treatment with ProACT improves urinary continence by inducing a significant increase in static urethral pressure.

Materials And Methods: We included patients who underwent UPP before and after ProACT implantation. UPPs were initially performed with the Brown-Wickham water perfusion method and later with the T-DOC Air-Charged catheter method. Pre- and postoperative UPPs and International Prostate Symptom Scores were evaluated. UPP measurements of successfully (no or 1 precautionary pad per day) and unsuccessfully treated patients were compared.

Results: Twenty-seven patients were included in the study; 23 patients were successfully and 4 patients were unsuccessfully treated. Maximum urethral closure pressure (MUCP) increased significantly from median 58.0 to 79.0 cmH2O in the successfully treated group (P = .001). Within the subgroup of unsuccessfully treated patients, MUCP did not change significantly (P = .715). The change in MUCP was statistically significantly different between the successful and unsuccessful group (P = .034). Total score of the International Prostate Symptom Scores did not change significantly after ProACT implantation (P = .097).

Conclusion: Successful treatment with ProACT is associated with a significant increase of MUCP. This implies that increased static urethral pressure contributes to the working mechanism of the ProACT device to achieve continence.
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http://dx.doi.org/10.1016/j.urology.2016.04.019DOI Listing
August 2016

Noninvasive Diagnosis of Bladder Outlet Obstruction in Patients with Lower Urinary Tract Symptoms Using Ultrasound Decorrelation Analysis.

J Urol 2016 Aug 3;196(2):490-7. Epub 2016 Mar 3.

Department of Urology, Sector Furore, Erasmus Medical Centre, Rotterdam, The Netherlands.

Purpose: We developed a noninvasive method to diagnose bladder outlet obstruction. An ultrasound based decorrelation method was applied in male patients with lower urinary tract symptoms.

Materials And Methods: In 60 patients ultrasound data were acquired transperineally while they were voiding while sitting. Each patient also underwent a standard invasive pressure flow study.

Results: High frequent sequential ultrasound images were successfully recorded during voiding in 45 patients. The decorrelation (decrease in correlation) between subsequent ultrasound images was higher in patients with bladder outlet obstruction than in unobstructed patients and healthy volunteers. ROC analysis resulted in an AUC of 0.96, 95% specificity and 88% sensitivity. A linear relationship was fitted to the decorrelation values as a function of the degree of obstruction represented by the bladder outlet obstruction index, measured in the separate pressure flow studies.

Conclusions: It is possible to noninvasively diagnose bladder outlet obstruction using the ultrasound decorrelation technique.
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http://dx.doi.org/10.1016/j.juro.2016.02.2966DOI Listing
August 2016

Transcutaneous Electrical Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review.

Eur Urol 2016 06 29;69(6):1102-11. Epub 2016 Jan 29.

Neuro-Urology, Spinal Cord Injury Center & Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland. Electronic address:

Context: Transcutaneous electrical nerve stimulation (TENS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option in patients with an underlying neurological disorder.

Objective: We systematically reviewed all available evidence on the efficacy and safety of TENS for treating neurogenic lower urinary tract dysfunction.

Evidence Acquisition: The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Evidence Synthesis: After screening 1943 articles, 22 studies (two randomised controlled trials, 14 prospective cohort studies, five retrospective case series, and one case report) enrolling 450 patients were included. Eleven studies reported on acute TENS and 11 on chronic TENS. In acute TENS and chronic TENS, the mean increase of maximum cystometric capacity ranged from 69ml to 163ml and from 4ml to 156ml, the mean change of bladder volume at first detrusor overactivity from a decrease of 13ml to an increase of 175ml and from an increase of 10ml to 120ml, a mean decrease of maximum detrusor pressure at first detrusor overactivity from 18 cmH20 to 72 cmH20 and 8 cmH20, and a mean decrease of maximum storage detrusor pressure from 20 cmH20 to 58 cmH2O and from 3 cmH20 to 8 cmH2O, respectively. In chronic TENS, a mean decrease in the number of voids and leakages per 24h ranged from 1 to 3 and from 0 to 4, a mean increase of maximum flow rate from 2ml/s to 7ml/s, and a mean change of postvoid residual from an increase of 26ml to a decrease of 85ml. No TENS-related serious adverse events have been reported. Risk of bias and confounding was high in most studies.

Conclusions: Although preliminary data suggest TENS might be effective and safe for treating neurogenic lower urinary tract dysfunction, the evidence base is poor and more reliable data from well-designed randomised controlled trials are needed to make definitive conclusions.

Patient Summary: Early data suggest that transcutaneous electrical nerve stimulation might be effective and safe for treating neurogenic lower urinary tract dysfunction, but more reliable evidence is required.
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http://dx.doi.org/10.1016/j.eururo.2016.01.010DOI Listing
June 2016

Intermittent sacral neuromodulation for idiopathic urgency urinary incontinence in women.

Neurourol Urodyn 2017 02 3;36(2):385-389. Epub 2015 Dec 3.

Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.

Aims: SNM has been proven to be effective in the treatment of refractory UUI. Total costs and patient burden due to regular battery changes may prevent broad implementation of this treatment. The aim was to achieve a minimal improvement of 50% in incontinence episodes compared to pre-SNM by using iSNM.

Methods: This prospective cohort study was performed in women with UUI receiving treatment with SNM for a minimum of 6 months. The neurostimulator was programmed to 8 hr "on" and 16 hr "off" per day for 12 weeks. Prior to iSNM, data were collected during no SNM and cSNM. Bladder diaries and various patient reported outcome measures were collected at predetermined time points: 1-5 weeks, and 8, 12, and 16 weeks. Nonparametric tests were used for the statistical analysis.

Results: Of the 19 patients 63% showed an improvement of >50% of incontinence episodes during iSNM compared to pre-SNM. Bladder diary parameters showed a difference between pre-SNM and iSNM median (P-value); incontinence episodes/24 hr, 4.1-1.0 (P = 0.04), incontinence severity, 2.0-1.0 (P = 0.001), voiding episodes/24 hr, 13.0-8.0 (P = 0.001), and voided volume, 149-219 ml (P = 0.04). The UDI-6, 50.0-27.8 (P = 0.03), and the IIQ-7 scores, 50.0-9.5 (P = 0.04) also showed a significant improvement. No difference was demonstrated between iSNM and cSNM.

Conclusions: Compared to pre-SNM parameters, iSNM shows an improvement in both objective and subjective outcomes. Specifically no difference was found between iSNM and cSNM, indicating that iSNM could be a feasible and cost-effective alternative. Neurourol. Urodynam. 36:385-389, 2017. © 2015 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/nau.22938DOI Listing
February 2017

Summary of European Association of Urology (EAU) Guidelines on Neuro-Urology.

Eur Urol 2016 Feb 22;69(2):324-33. Epub 2015 Aug 22.

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.

Context: Most patients with neuro-urological disorders require life-long medical care. The European Association of Urology (EAU) regularly updates guidelines for the diagnosis and treatment of these patients.

Objective: To provide a summary of the 2015 updated EAU Guidelines on Neuro-Urology.

Evidence Acquisition: Structured literature searches in several databases were carried out to update the 2014 guidelines. Levels of evidence and grades of recommendation were assigned where possible.

Evidence Synthesis: Neurological disorders often cause urinary tract, sexual, and bowel dysfunction. Most neuro-urological patients need life-long care for optimal life expectancy and quality of life. Timely diagnosis and treatment are essential to prevent upper and lower urinary tract deterioration. Clinical assessment should be comprehensive and usually includes a urodynamic investigation. The neuro-urological management must be tailored to the needs of the individual patient and may require a multidisciplinary approach. Sexuality and fertility issues should not be ignored. Numerous conservative and noninvasive possibilities of management are available and should be considered before a surgical approach is chosen. Neuro-urological patients require life-long follow-up and particular attention has to be paid to this aspect of management.

Conclusions: The current EAU Guidelines on Neuro-Urology provide an up-to-date overview of the available evidence for adequate diagnosis, treatment, and follow-up of neuro-urological patients.

Patient Summary: Patients with a neurological disorder often suffer from urinary tract, sexual, and bowel dysfunction and life-long care is usually necessary. The update of the EAU Guidelines on Neuro-Urology, summarized in this paper, enables caregivers to provide optimal support to neuro-urological patients. Conservative, noninvasive, or minimally invasive approaches are often possible.
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http://dx.doi.org/10.1016/j.eururo.2015.07.071DOI Listing
February 2016

Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review.

Eur Urol 2015 Nov 18;68(5):859-67. Epub 2015 Jul 18.

Neuro-Urology, Spinal Cord Injury Center & Research, University of Zürich, Balgrist University Hospital, Zürich, Switzerland. Electronic address:

Context: Tibial nerve stimulation (TNS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option for patients with an underlying neurological disorder.

Objective: We systematically reviewed all available evidence on the efficacy and safety of TNS for treating neurogenic lower urinary tract dysfunction (NLUTD).

Evidence Acquisition: The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement.

Evidence Synthesis: After screening 1943 articles, 16 studies (4 randomized controlled trials [RCTs], 9 prospective cohort studies, 2 retrospective case series, and 1 case report) enrolling 469 patients (283 women and 186 men) were included. Five studies reported on acute TNS and 11 on chronic TNS. In acute and chronic TNS, the mean increase of maximum cystometric capacity ranged from 56 to 132mL and from 49 to 150mL, and the mean increase of bladder volume at first detrusor overactivity ranged from 44 to 92mL and from 93 to 121mL, respectively. In acute and chronic TNS, the mean decrease of maximum detrusor pressure during the storage phase ranged from 5 to 15cm H2O and from 4 to 21cm H2O, respectively. In chronic TNS, the mean decrease in number of voids per 24h, in number of leakages per 24h, and in postvoid residual ranged from 3 to 7, from 1 to 4, and from 15 to 55mL, respectively. No TNS-related adverse events have been reported. Risk of bias and confounding was high in most studies.

Conclusions: Although preliminary data of RCTs and non-RCTs suggest TNS might be effective and safe for treating NLUTD, the evidence base is poor, derived from small, mostly noncomparative studies with a high risk of bias and confounding. More reliable data from well-designed RCTs are needed to reach definitive conclusions.

Patient Summary: Early data suggest tibial nerve stimulation might be effective and safe for treating neurogenic lower urinary tract dysfunction, but more reliable evidence is required.
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http://dx.doi.org/10.1016/j.eururo.2015.07.001DOI Listing
November 2015

Urinary Bladder Contractility Revisited. Correlation of Noninvasively and Invasively Measured Contractility Parameters in Patients Eligible for Transurethral Resection of the Prostate.

Urology 2015 Jul;86(1):128-32

Department of Urology, Erasmus MC, Rotterdam, The Netherlands.

Objective: To validate a noninvasively estimated measure of urinary bladder contractility by correlating it with 3 existing invasive contractility parameters and to compare and correlate those invasive parameters.

Methods: A group of 74 patients, recruited in 3 different hospitals, and eligible for transurethral resection of the prostate on clinical grounds, were noninvasively studied preoperatively using the condom catheter method. The maximum condom pressure pcond.max measured during a mechanical interruption of flow rate was considered an estimate of urinary bladder contractility and compared to conventional contractility parameters calculated from preoperative (invasive) pressure-flow studies.

Results: The highest correlations were found between the invasive parameters. The correlation between the noninvasive parameter on the one hand and the invasive parameters on the other hand was lower, but mostly significant. In a number of patients, pcond.max underestimated the isovolumetric bladder pressure. The underestimated patients were more obstructed than those who were not underestimated and had a higher (invasively measured) contractility. When the underestimated patients were deselected, the correlation between the noninvasive pcond.max and the invasive parameters in the remaining 52 patients was higher.

Conclusion: The 4 tested contractility parameters represent different aspects of urinary bladder contractility. Nevertheless, there was a significant correlation among them supporting the concept of a common basis, that is, detrusor contractility. The invasive contractility parameter bladder contractility index overestimated contractility in patients with lower urinary tract symptoms and/or benign prostatic enlargement. A modified parameter is suggested.
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http://dx.doi.org/10.1016/j.urology.2015.03.031DOI Listing
July 2015

Surgical management of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction.

Cochrane Database Syst Rev 2014 May 24(5):CD004927. Epub 2014 May 24.

Department of Urology, Erasmus Medical Center, Room Na-1708, 's-Gravendijkwal 230, Rotterdam, Zuid-Holland, Netherlands, 3015 CE.

Background: The most common type of functional bladder outlet obstruction in patients with neurogenic bladder is detrusor-sphincter dyssynergia (DSD). The lack of co-ordination between the bladder and the external urethral sphincter muscle (EUS) in DSD can result in poor bladder emptying and high bladder pressures, which may eventually lead to progressive renal damage.

Objectives: To assess the effectiveness of different surgical therapies for the treatment of functional bladder outlet obstruction (i.e. DSD) in adults with neurogenic bladder dysfunction.

Search Methods: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, and handsearching of journals and conference proceedings (searched 20 February 2014), and the reference lists of relevant articles.

Selection Criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing a surgical treatment of DSD in adults suffering from neurogenic bladder dysfunction, with no treatment, placebo, non-surgical treatment, or other surgical treatment, alone or in combination.

Data Collection And Analysis: Two review authors independently assessed trial quality and extracted data.

Main Results: We included five trials (total of 199 participants, average age of 40 years). The neurological diseases causing DSD were traumatic spinal cord injury (SCI), multiple sclerosis (MS), or congenital malformations.One trial compared placement of sphincteric stent prosthesis with sphincterotomy. For urodynamic measurements, results for postvoid residual urine volume (PVR) and cystometric bladder capacity were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy at three, six, 12, and 24 months. Results for maximum detrusor pressure (Pdet.max) were also inconclusive at three, six, and 12 months; however, after two years, the Pdet.max after sphincterotomy was lower than after stent placement (mean difference (MD) -30 cmH2O, 95% confidence interval (CI) 8.99 to 51.01).Four trials considered botulinum A toxin (BTX-A) injection in the EUS, either alone or in combination with other treatments. The comparators included oral baclofen, oral alpha blocker, lidocaine, and placebo. The BTX-A trials all differed in protocols, and therefore we did not undertake meta-analysis. A single 100 units transperineal BTX-A injection (Botox®) in patients with MS resulted in higher voided urine volumes (MD 69 mL, 95% CI 11.87 to 126.13), lower pre-micturition detrusor pressure (MD -10 cmH2O, 95% CI -17.62 to -2.38), and lower Pdet.max (MD -14 cmH2O, 95% CI -25.32 to -2.68) after 30 days, compared to placebo injection. Results for PVR using catheterisation, basal detrusor pressure, maximal bladder capacity, maximal urinary flow, bladder compliance at functional bladder capacity, maximal urethral pressure, and closure urethral pressure at 30 days were inconclusive and consistent with benefit of either BTX-A injection or placebo injections. In participants with SCI, treatment with 200 units of Chinese manufactured BTX-A injected at eight different sites resulted in better bladder compliance (MD 7.5 mL/cmH2O, 95% CI -10.74 to -4.26) than participants who received the same injections with the addition of oral baclofen. Results for maximum uroflow rate, maximal cystometric capacity, and volume per voiding were inconclusive and consistent with benefit of either BTX-A injection or BTX-A injection with the addition of oral baclofen. However, the poor quality of reporting in this trial caused us to question the relevance of bladder compliance as an adequate outcome measure.In participants with DSD due to traumatic SCI, MS, or congenital malformation, the results for PVRs after one day were inconclusive and consistent with benefit of either a single 100 units transperineal BTX-A (Botox®) injection or lidocaine injection. However, after seven and 30 days of BTX-A injection, PVRs were lower (MD -163 and -158 mL, 95% CI -308.65 to -17.35 and 95% CI -277.57 to -39.03, respectively) compared to participants who received lidocaine injections. Results at one month for Pdet.max on voiding, EUS activity in electromyography, and maximal urethral pressure were inconclusive and consistent with benefit of either BTX-A or lidocaine injections.Finally, one small trial consisting of five men with SCI compared weekly BTX-A injections with normal saline as placebo. The placebo had no effect on DSD in the two participants allocated to the placebo treatment. Their urodynamic parameters were unchanged from baseline values until subsequent injections with BTX-A once a week for three weeks. These subsequent injections resulted in similar responses to those of the three participants who were allocated to the BTX-A treatment. Unfortunately, the report presented no data on placebo treatment.Only the trial that compared sphincterotomy with stent placement reported outcome measures renal function and urologic complications related to DSD. Results for renal function at 12 and 24 months, and urologic complications related to DSD at three, six, 12, and 24 months were inconclusive and consistent with benefit of either sphincteric stent prosthesis or sphincterotomy.Adverse effects reported were haematuria due to the cystoscopic injection and muscle weakness, of which the latter may be related to the BTX-A dose used.All trials had some methodological shortcomings, so insufficient information was available to permit judgement of risk of bias. At least half of the trials had an unclear risk of selection bias and reporting bias. One trial had a high risk of attrition bias, and another trial had a high risk of reporting bias.

Authors' Conclusions: Results from small studies with a high risk of bias have identified evidence of limited quality that intraurethral BTX-A injections improve some urodynamic measures after 30 days in the treatment of functional bladder outlet obstruction in adults with neurogenic bladder dysfunction. The necessity of reinjection of BTX-A is a significant drawback; a sphincterotomy might therefore be a more effective treatment option for lowering bladder pressure in the long-term.However, because of the limited availability of eligible trials, this review was unable to provide robust evidence in favour of any of the surgical treatment options. More RCTs are needed, measuring improvement on quality of life, and on other types of surgical treatment options for DSD since these are lacking. Future RCTs assessing the effectiveness of BTX-A injections also need to address the uncertainty about the optimal dose and mode of injection for this specific type of urological condition.
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http://dx.doi.org/10.1002/14651858.CD004927.pub4DOI Listing
May 2014

Diagnostic power of the noninvasive condom catheter method in patients eligible for transurethral resection of the prostate.

Neurourol Urodyn 2014 Apr 11;33(4):408-13. Epub 2013 Jun 11.

Department of Urology, Sector Furore, Erasmus MC, Rotterdam, The Netherlands.

Aims: The aim of this study was to determine the accuracy of the non-invasive condom catheter method for diagnosing B(ladder) O(utlet) O(bstruction) in patients eligible for T(rans)U(rethral) R(esection) of the P(rostate).

Methods: A group of 71 patients eligible for TURP on clinical grounds were invasively and non-invasively studied. On the basis of invasive pressure-flow studies they were stratified into obstructed, equivocal or unobstructed, according to the International Continence Society standard. Subsequently they were diagnosed non-invasively on the basis of a free flowrate measurement, or on the basis of the free flowrate measurement plus the isovolumetric bladder pressure measured with the condom catheter method. R(eceiver) O(perating) C(haracteristic)s were calculated.

Results: The A(rea) U(nder) the (RO)C for discriminating unobstructed/equivocal patients from obstructed patients was 0.68 in our population. This improved to 0.84 for the 50 patients in whom the isovolumetric bladder pressure was not underestimated by the non-invasive method.

Conclusions: In our population of TURP patients, the low flowrates affected the accuracy of the condom method to a degree that it did not perform better than a free flowrate measurement, which performed remarkably well. By excluding measurements in which the condom pressure underestimated the isovolumetric bladder pressure this method may contribute to a more accurate, patient friendly diagnosis of BOO in these patients. In the present study this exclusion was done by comparison with an invasive pressure measurement. A practical non-invasive test would necessitate a non-invasive exclusion criterion, which might be based on the risetime of the condom pressure.
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http://dx.doi.org/10.1002/nau.22427DOI Listing
April 2014

Urodynamic effects of volume-adjustable balloons for treatment of postprostatectomy urinary incontinence.

Urology 2013 Jun 7;81(6):1308-14. Epub 2013 Mar 7.

Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands.

Objective: To evaluate the urodynamic changes in patients treated with Adjustable Continence Therapy for men (ProACT) for postprostatectomy incontinence and to explore the clinical and urodynamic preimplantation parameters as predictors of clinical outcome.

Materials And Methods: Patients underwent urodynamic studies before and after ProACT implantation. ProACT was considered successful if patients used none or 1 dry precautionary pad and nonsuccessful if the patient reported ≥1 wet pad/d. The pre- and postimplantation assessments were retrospectively compared within and between the success and nonsuccess groups. Multivariate logistic regression analysis was performed to investigate the association between the preimplantation variables and the clinical outcomes of ProACT implantation.

Results: A total of 49 patients were included, 37 with successful and 12 with nonsuccessful clinical outcome. Postimplantation urodynamic studies were performed a median of 9 months after ProACT implantation. In the successfully treated patients, maximum free flow rate, bladder contractility index, maximum of bladder contractility parameter W, and bladder voiding efficiency were significantly lower after implantation. The detrusor pressure at maximum flow rate, postvoid residual urine volume, and bladder outlet obstruction index were significantly higher. A longer duration of urinary incontinence, the use of >5 pads daily, and a smaller cystometric bladder capacity were all independently associated with nonsuccessful clinical outcome after ProACT implantation.

Conclusion: ProACT implantation with successful clinical outcome resulted in greater urethral resistance during voiding and reduced bladder contraction strength. A longer duration of incontinence, the use of >5 pads daily, and a smaller cystometric bladder capacity were independent predictors of unsuccessful clinical outcomes, suggesting ProACT implantation should be considered sooner, rather than later, after conservative treatment of postprostatectomy incontinence has failed.
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http://dx.doi.org/10.1016/j.urology.2013.01.020DOI Listing
June 2013

Urodynamic quantification of decrease in sphincter function after radical prostatectomy: relation to postoperative continence status and the effect of intensive pelvic floor muscle exercises.

Neurourol Urodyn 2012 Jun 6;31(5):646-51. Epub 2012 Apr 6.

Department of Urology, St. Elisabeth Hospital, Tilburg, The Netherlands.

Aims: We analyzed the impact of radical retropubic prostatectomy (RRP) on the urethral sphincter function as assessed by urethral pressure profilometry (UPP) and its relation to post-radical prostatectomy continence status. Furthermore, we analyzed the effect of intensive pelvic floor muscle exercises (PFME) on the urethral sphincter function.

Methods: Sixty-six patients were included in the study. UPP was performed before RRP and 26 weeks after catheter removal. All patients were instructed in PFME, however, the intensity of PFME varied between instructions based on an information folder only (F-PFME) and intensive guidance by a physiotherapist, in addition to the folder (PG-PFME).

Results: In 66 patients, pre- as well as postoperative UPP was evaluable. After surgery, the functional profile length and the maximum urethral closure pressure (MUCP) showed a median decrease of 64% and 41%, respectively. For men who had regained continence after 6 months the median MUCP was significantly higher both before and after operation as compared to men who were still incontinent. In multivariate analysis, non-nerve sparing approach was a prognostic factors for a higher relative decrease of the MUCP after RRP. Comparing the PG-PFME group with the F-PFME group there were no significant differences in changes in UPP parameters.

Conclusions: A poor preoperative MUCP seems to be an important prognostic factor for persistent incontinence after RRP. Non-nerve sparing approach seems to be an important prognostic factor for impairment of the urethral sphincter function as measured by UPP. More intensive physiotherapy seems to have no additional effect on the postoperative urethral sphincter function as measured by UPP.
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http://dx.doi.org/10.1002/nau.21243DOI Listing
June 2012
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