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REVIEW ARTICLE
Year : 2023 | Volume
: 34
| Issue : 3 | Page : 109-116
Clinical guidelines of patient-centered bladder management of neurogenic lower urinary tract dysfunction due to chronic spinal cord injury – Part 3: Surgical treatment in chronic spinal cord injured patients
Yu-Hua Lin1, Yu-Hua Fan2, Chun-Te Wu3, Yuan-Chi Shen4, Ju-Chuan Hu5, Shi-Wei Huang6, Po-Ming Chow7, Po-Chih Chang8, Chun-Hou Liao9, Yu-Chen Chen10, Victor Chia-Hsiang Lin11, Chih-Chen Hsu12, Shang-Jen Chang7, Chung-Cheng Wang13, Wei-Yu Lin12, Chih-Chieh Lin2, Yuan-Hong Jiang14, Hann-Chorng Kuo14
1 Division of Urology, Department of Surgery, Cardinal Tien Hospital; Department of Chemistry, Fu Jen Catholic University, Taipei, Taiwan
2 Department of Urology, Taipei Veterans General Hospital and College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
3 Department of Surgery, Division of Urology, Chang Gung Memorial Hospital, Keelung; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
4 School of Medicine, College of Medicine, Chang Gung University, Taoyuan; Department of Urology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
5 Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
6 Department of Urology, National Taiwan University Hospital, Yunlin Branch, Yunlin, Taiwan
7 Department of Urology, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
8 Department of Urology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
9 Department of Urology, Cardinal Tien Hospital and College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
10 Department of Urology, Kaohsiung Medical University Hospital and Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
11 Department of Urology, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan
12 Department of Urology, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
13 Department of Urology, En Chu Kong Hospital, Taipei; Department of Biomedical Engineering, Chung Yuan Christian University, Taoyuan, Taiwan
14 Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
Correspondence Address:
Hann-Chorng Kuo
Department of Urology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien 97002
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/UROS.UROS_118_22
This article reports the current evidence and expert opinions on patient-centered bladder management of neurogenic lower urinary tract dysfunction (NLUTD) among chronic spinal cord injured (SCI) patients in Taiwan. The main problems with SCI-NLUTD are failure to store, empty, or both. The management of SCI-NLUTD should be prioritized as follows: (a) preservation of renal function, (b) freedom from urinary tract infection, (c) efficient bladder emptying, (d) freedom from indwelling catheters, (e) patient agreement with management, and (f) avoidance of medication after proper management. The management of NLUTD in SCI patients must be based on urodynamic findings rather than neurologic evaluation inferences. It is important to identify high-risk patients to prevent renal functional deterioration in those with chronic SCI-NLUTD. Urodynamic studies should be performed on patients with SCI on a regular basis, and any urological complications should be adequately treated. When surgery is required, less invasive and reversible procedures should be considered first, and any unnecessary surgery in the lower urinary tract should be avoided. The most important aspect of treatment is to improve the quality of life in SCI patients with NLUTD. Annual active surveillance of bladder and renal function is required to avoid renal function deterioration and urological complications, particularly in high-risk SCI patients.
Keywords: Bladder management, guidelines, lower urinary tract dysfunction, neurogenic bladder, spinal cord injury, surgery
Neurogenic lower urinary tract dysfunction (NLUTD) refers to the urinary bladder and urethral dysfunction caused by the central nervous system or peripheral nerve lesions. The most challenging disorder to manage in patients with spinal cord injury (SCI) is NLUTD. Such patients may have failure to store urine due to detrusor overactivity (DO) or urethral sphincter incompetence, failure to empty the bladder due to acontractile detrusor (AcD), detrusor underactivity, bladder neck (BN) dysfunction, or detrusor sphincter dyssynergia (DSD), or combined failure to store and empty due to DSD or detrusor hyperreflexia and inadequate contractility.[1],[2]
NLUTD in SCI causes decreased bladder compliance, upper tract damage, significant morbidity, and occasionally death. NLUTD in SCI patients not only imposes a significant disease burden on patients, but it also has a negative impact on their quality of life (QoL), self-esteem, and family relationships.[3] Patients with SCI should be managed conservatively at first. If they have poor QoL, inadequate bladder storage, or an emptying problem, they can benefit from minimally invasive therapy, such as detrusor or urethral sphincter botulinum toxin A (BoNT/A) injections.
If a severely contracted bladder, vesicoureteral reflux (VUR), exacerbated upper urinary tract dysfunction, or severe urinary incontinence or retention occur in patients with SCI, surgical intervention may be required. The major goals of therapy and treatment for NLUTD include protecting the kidneys from progressive damage, preserving renal function, and reducing urinary incontinence levels to improve QoL.[4],[5] Treatment selection should be based on urodynamic findings and individualized based on patients' disability, mental and physical condition, and urinary tract function.[6],[7]
This article's clinical guidelines provide information on surgical procedures for chronic SCI patients with NLUTD. These guidelines could help physicians manage patients with chronic SCI and NLUTD in a patient-centered manner.
Current Surgical Treatment for Neurogenic Lower Urinary Tract Dysfunction in Chronic Spinal Cord Injured PatientsFor patients without therapeutic effects after medical treatment or intravesical BoNT/A injection, surgical intervention is required to treat urological complications, preserve renal function, improve urinary continence, facilitate spontaneous bladder emptying, and improve QoL. There are several surgical procedures available to treat NLUTD in SCI patients.[8] To improve urinary storage, bulking agent injection into the BN, BN reconstruction, suburethral sling surgery, and artificial urinary sphincter were performed. Individual SCI patients may also benefit from BN closure, followed by continent cystostomy or incontinent urinary diversion. External sphincterotomy or urethral stent placement is recommended for patients with SCI and severe DSD, autonomic dysreflexia (AD), low bladder compliance, hydronephrosis, recurrent urinary tract infection (UTI), and VUR to facilitate bladder emptying. Transurethral external sphincterotomy significantly reduces voiding pressure and AD in male SCI patients.[9] Meanwhile, in patients with incomplete cervical SCI, transurethral incision of the BN can reduce AD and facilitate spontaneous voiding.[10] In tetraplegic patients, a urethral stent implant can relieve urethral resistance and facilitate spontaneous voiding, but such patients should be monitored for possible stent migration.[11] For SCI patients, the following interventions are available to increase bladder capacity, reduce intravesical pressure, increase bladder compliance, and treat hydronephrosis and VUR: Augmentation enterocystoplasty, bladder autoaugmentation, and continent or incontinent urinary diversion [Table 1]. Sacral neuromodulation was recently attempted to reduce DO and increase bladder capacity, but the procedure was not well accepted.[12]
Table 1: Treatments and procedures for neurogenic lower urinary tract dysfunction in chronic spinal cord injured patientsRecommendations
Only after conservative treatments have failed and patients have fully understood the potential complications of further bladder management should surgical operations to facilitate bladder storage and bladder emptying be performed.The surgical procedure selected should meet the needs of SCI patients. Role of Autoaugmentation and Enterocystoplasty in Chronic Spinal Cord Injured PatientsBladder augmentation using an intestine segment[13] or autoaugmentation using myomectomy[14] can result in increased capacity, lower intravesical pressure, and reflux treatment. Most SCI patients reported no significant change in bowel function after this procedure.[15] However, long-term complications of enterocystoplasty, such as stone formation, loose stools, metabolic acidosis, and chronic UTI, remain.[16] Although enterocystoplasty appears to be a highly effective procedure for protecting the upper urinary tract and improving QoL, it is also associated with a high complication rate and relatively high morbidity.[17],[18] In patients with cervical SCI or severe urethral sphincter deficiency, a continent lower urinary tract reconstruction (such as a Kock pouch) or BN closure, combined with a continent ileostomy and bladder augmentation, may restore urinary continence and evacuate the bladder via clean intermittent catheterization (CIC) from an ileostoma.[19]
Augmentation enterocystoplasty is typically performed to reduce bladder storage pressure and increase bladder capacity in patients with refractory bladder disease.[20] However, the short-term and long-term complication rates of the procedure remain high, and some of these complications can be life-threatening.[18] Recent studies revealed that renal function can deteriorate in up to 15% of patients after enterocystoplasty, with 5% of patients experiencing unexplained renal deterioration.[21],[22] The possible complications of augmentation enterocystoplasty include chronic diarrhea or constipation, recurrent UTI/chronic UTI, stone formation (bladder and upper tract), the need for CIC, mucus retention, and metabolic acidosis. A study that reported long-term follow-up results for bladder capacity and compliance found that 24% of augmentation enterocystoplasty patients required revision surgery with ileocystoplasty for poorly compliant bladders.[23],[24] To avoid the complications of augmentation enterocystoplasty, bladder autoaugmentation through detrusor myomectomy was performed to increase bladder capacity and bladder compliance.[25] However, reports have shown that bladder capacity improves only slowly and re-augmentation is required in such cases.[26] Surgical technique and experience are critical in avoiding suboptimal surgical outcomes. Patients should be treated conservatively at first, with behavioral therapy, lifestyle changes, pharmacologic therapy, and intravesical interventions.
Recommendations
Augmentation enterocystoplasty appears to be effective in increasing bladder capacity, lowering intravesical pressure, restoring urinary continence, and treating VUR.After augmentation enterocystoplasty, there is a high rate of chronic retention requiring catheterization and other complications.Autoaugmentation has a limited increase in capacity compared with augmentation enterocystoplasty, and the procedure does not preclude further interventions. Management of Stress and Urgency Urinary Incontinence in Chronic Spinal Cord Injured PatientsMost of the patients with suprasacral SCI had neurogenic DO (NDO) with or without DSD.[27] Patient-assisted bladder management relies on good hand dexterity, powerful abdominal muscles, intact bladder sensation, and coordination of the urethral sphincter during stimulation to voiding.[28] Currently, detrusor BoNT/A injections can be used to decrease detrusor contractility and reduce urinary incontinence,[8],[29] urethral sphincter BoNT/A injections to reduce urethral resistance,[30],[31] or a combination of detrusor and urethral BoNT/A injections to simultaneously improve bladder storage and emptying.[32] Pelvic floor muscle training or medical treatment is typically ineffective in completely eradicating symptoms in SCI patients with stress urinary incontinence (SUI) and urgency urinary incontinence. A suburethral sling followed by CIC is recommended for male and female SCI patients with AcD and intrinsic sphincter deficiency (ISD).[33] Bladder augmentation, with or without the use of an intestine segment, is effective in increasing bladder capacity, lowering DO, and improving urinary incontinence.[34] Urodynamic studies are recommended before the surgical procedure is performed, and postoperative follow-up of bladder function and upper urinary tract condition is required to avoid urological complications.
Recommendations
Urodynamic studies should be performed on patients with chronic SCI and urinary incontinence to determine the cause of the incontinence.For patients with urethral incompetence, urethral bulking agent injection, suburethral sling, and artificial urinary sphincter are optins.Anticholinergic agents, detrusor BoNT/A injection, neuromodulation, and bladder augmentation can be used to treat incontinence caused by NDO.Every SCI patient should receive personalized care based on their therapeutic priority. Artificial Urinary Sphincter Placement in Spinal Cord Injured Patients with Urethral IncompetenceThe most common treatment for SCI patients with neurogenic SUI is artificial urinary sphincter placement, with cure rates ranging from 22% to 100%.[34],[35],[36] New-onset or persistent DO was observed in 8% of patients, and bladder augmentation was required in 6% of patients. Following artificial urinary sphincter failure, surgical revision rates of more than 50% have been reported, primarily due to mechanical failure.[34],[36] Bersch et al. reported another series study in which artificial urinary sphincter cuff erosion rates in women and men were as high as 41% and 26%, respectively. Complete continence was achieved by 83% of women and 74% of men. Overall, 50% of women and 78% of men underwent concurrent bladder augmentation.[37] However, the rate of concurrent bladder augmentation during artificial urinary sphincter implantation varies across studies. A recent systemic review found that 32% of patients in seven studies underwent simultaneous bladder augmentation.[34] Placement of an artificial urinary sphincter at the BN is a preferred approach in SCI patients because some patients can retain spontaneous voiding. Another advantage of artificial urinary sphincter placement over BN as recommended by International Continence Society guidelines[38] is the reduction of perineal pressure sores, which is important because most SCI patients are wheelchair bound. However, this approach is more technically demanding, requiring a lower abdominal incision, BN exposure, and circumferential dissection of the vesicoprostatic junction. However, a small retrospective study discovered no differences in functional outcomes and revision-free survival after implantation of an artificial urinary sphincter over the bulbar urethra and BN.[39] Nonetheless, even when placed at the BN, artificial urinary sphincter placement has a very high revision rate. AUS placement in the BN can be done safely during augmentation cystoplasty.
Recommendations
Artificial urinary sphincter placement provides a high cure rate and clinical improvement of male SCI patients with urethral incompetence and SUI.Prior to artificial urinary sphincter placement, patients should be informed about the high incidence of complications and the high revision rate. Role of Suburethral Sling in Treating Urinary Incontinence in Chronic Spinal Cord Injured and Myelomeningocele PatientsPatients with SCI below the sacral micturition center may develop an incompetent urinary sphincter and neurogenic SUI. Up to 96% of patients with spina bifida have impaired bladder function, and 68% of school-aged children with spina bifida have neurogenic SUI. For patients with SCI or myelomeningocele, surgical treatments, such as BN closure, urethral lengthening, artificial urinary sphincter, suburethral sling, BN wrap procedure, and urethral bulking agents, are available. Surgeries for neurogenic SUI, such as artificial urinary sphincter, slings, and bulking agents, have a relatively high success rate and a high complication rate, albeit in a highly heterogeneous population.[40] Autologous fascial slings are the standard treatment for ISD in neurogenic SUI, but synthetic slings are also an option in female neurogenic SUI. However, CIC is still required after urethral sling placement.[41] Approximately 91% of men routinely performed CISC before surgery, and there was no difficulty catheterizing after fascial sling placement. Rare complications included erosion, vesicovaginal fistula, and urethral stenosis.[42]
In male neurogenic SUI, synthetic slings, such as the advance male sling, showed a 65% success rate, with a 40% cure rate and a 25% improvement rate. Pediatric myelomeningocele and adult SCI patients have satisfactory therapeutic efficacy.[43],[44],[45] In a 25-year follow-up of 60 children with neurogenic SUI who had a bladder outlet procedure, 77% were dry, and augmentation cystoplasty was performed concomitantly in 80% of patients, depending on urodynamic parameters (capacity, compliance, and DO). In such cases, careful follow-up is required to detect any adverse changes in the bladder.[46] For some patients, perineal placement of a female urethral synthetic mesh sling may be a viable alternative to fascial slings.[47] The male suburethral sling procedure, which employs a polypropylene mesh and a cardiovascular patch, is a safe, effective, and low-cost surgical treatment for urethral incompetence in neurogenic and nonneurogenic urinary incontinence.[48]
Recommendations
An autologous or synthetic urethral sling can be used in female SCI patients with urinary incontinence, acceptable bladder storage parameters, and the ability to self-catheterize.To achieve urinary continence in female SCI patients with urethral incompetence, a suburethral sling or bulking agent injection can be used.A synthetic sling is a viable option in male SCI patients with SUI who can self-catheterize.It is recommended that urodynamic parameters of the bladder be monitored regularly to detect any deterioration in bladder compliance. Management of Low Compliant Bladder and Recurrent Urinary Tract Infection in Chronic Spinal Cord Injured PatientsMost SCI patients have NLUTD, which has a significant impact on their QoL and inevitably leads to urological complications, such as bacteriuria, febrile UTI, hydronephrosis, severe urinary incontinence, urolithiasis, and renal failure.[49],[50],[51] Patients with sacral injuries had high rates of low bladder compliance and high detrusor leak point pressure.[52] Thus, it is important to screen SCI patients who are at high risk for complications, particularly those with a detrusor leak point pressure >40-cm H2O, indicating that the upper urinary tract is endangered.[53],[54] When bladder capacity decreases and bladder pressure increases, the risk of upper tract deterioration increases. The most common cause of hydronephrosis in SCI patients is a poorly compliant bladder, and cases of grade 3–4 hydronephrosis are also common in patients with poor bladder compliance.[48] Pharmacologic therapy with anticholinergics, antispasmodics, or calcium channel blockers is the first-line treatment for such cases. Detrusor BoNT/A injections and surgical intervention, such as augmentation enterocystoplasty, can increase bladder capacity and reduce intravesical pressure in patients with low bladder compliance who have not responded to medical treatment.[55],[56] CIC is required after these procedures because most of these patients cannot urinate completely even with abdominal pressure. Patients who do not want to undergo surgical treatment may continue to have a suprapubic cystostomy or an indwelling urethral catheter for bladder drainage. UTI was reported to occur in 100% of patients with SCI in one study with at least 40 year of follow-up.[57] UTI occurs more frequently in SCI patients who require additional bladder emptying methods than in those who continue to void normally.[58] UTI is strongly associated with having an indwelling catheter, increased intravesical pressure, large postvoid residual (PVR), and vesicoureteral reflux (VUR).[59],[60] Regular urodynamic studies and upper urinary tract assessment are required in high-risk chronic SCI patients. Furthermore, selecting the optimal management to maintain bladder function and avoid UTI is crucial.
Recommendations
In patients with chronic SCI, low bladder compliance and high intravesical pressure are risk factors for renal failure.UTI is frequently associated with high intravesical pressure, insufficient bladder emptying, and VUR.Based on urodynamic findings, SCI patients with low bladder compliance and UTI should be actively managed to increase bladder capacity, lower intravesical pressure, and treat VUR.For chronic SCI, common interventions include pharmacologic therapy, intravesical BoNT/A injections, and bladder augmentation.Active surveillance is indicated in patients who are managed conservatively. Management of Low Bladder Compliance and Vesicoureteral Reflux in Chronic Spinal Cord Injured PatientsThe goals of bladder management in patients with SCI include upper urinary tract preservation or improvement, absence or control of UTI, adequate storage at low intravesical pressure, adequate emptying at low detrusor pressure, control over micturition, no catheter or stoma, social acceptability and adaptability, and vocational acceptability and adaptability. There are several conservative and invasive procedures available to treat a poorly compliant bladder in SCI patients. NLUTD patients may undergo nonsurgical and surgical treatment options depending on their level of risk, symptoms, and urodynamic findings.[61] Among the procedures to increase bladder capacity and lower intravesical pressure, augmentation cystoplasty can provide satisfactory improvement in bladder function and QoL.[62] Continence can be achieved in 70%–100% of cases, but 80% of patients required CIC, and around 93.3% were still catheter-dependent after augmentation cystoplasty.[17] Patients with SCI are at risk of developing VUR, which is associated with recurrent UTI and renal failure. Medical treatment and adequate bladder drainage by CIC are feasible in patients with low-grade VUR who do not have recurrent UTI. However, high-grade VUR, hydronephrosis, and recurrent UTI require active management to avoid renal failure. Ureteral reimplantation has an immediate and long-lasting result in over 90% of SCI patients.[63],[64] Endoscopic injections of bulking agents may be tried first in patients with NLUTD and VUR.[65] When treating VUR, the physician should consider lowering the intravesical pressure at the same time.[66] Ureteral reimplantation alone or in combination with bladder augmentation are effective procedures for patients with contracted bladder who have failed initial injection procedures.[67] In the treatment decision-making process for SCI patients, less invasive management should be considered first (although it may be associated with less effective outcomes). External sphincterotomy by cold knife or laser is feasible in SCI patients with tetraplegia for the resolution of low bladder compliance combined with AD, hydronephrosis, recurrent UTI, large PVR, and VUR.[8] Although reoperation is required in half of patients after sphincterotomy, the procedure is safe and effective and has fewer complications.[61]
Recommendations
Augmentation cystoplasty and urinary diversion are indicated in selected SCI patients with NLUTD and low bladder compliance who are at high risk or have failed less invasive treatments.External sphincterotomy may be offered to patients with high-level SCI who are unable to undergo CIC to help with bladder emptying. Urinary Diversion and Ileal Conduit for the Treatment of Refractory Autonomic DysreflexiaAD is a potentially fatal disorder. AD is most common in individuals with SCI above the T6 level.[68] AD is considered a medical emergency that requires immediate attention. The most common causes of AD are bladder distention and stool impaction. UTI, whether with or without an indwelling catheter, can also cause AD. Previous treatments for AD included removing triggering stimuli and administering antihypertensive or vasodilator agents. Detrusor BoNT/A injection for NDO treatment, decreased AD severity, and AD abolition have also been observed and reported.[69],[70] Although repeated BoNT/A injections are required to achieve the desired effects, most patients are willing to tolerate the procedure in exchange for improved QoL.[71] Repeated BoNT/A injections can either restore renal function or halt renal deterioration in patients with SCI.[72] Urinary diversion using an ileal conduit, ileovesicostomy, vesicostomy, or a continent urinary reservoir can be effective in eradicating AD from an over-extended urinary bladder in chronic SCI patients who are refractory to detrusor or trigonal BoNT/A injections, such as patients with a severely contracted bladder and chronic recurrent UTI.
Recommendations
Patients with AD refractory to medical treatment can be treated with detrusor BoNT/A injection, cystostomy, urinary diversion, or ileal conduit diversion.The ileal conduit procedure has the best long-term results for noncontinent diversion in SCI patients with AD. Long-Term Complication and Satisfaction of Enterocystoplasty in Chronic Spinal Cord Injured PatientsDetrusor BoNT/A injections have been shown to be effective in treating NDO caused by SCI or other spinal cord lesions. Repeat BoNT/A injections must be repeated every 6–9 months to maintain its therapeutic effects. Patients with SCI may consider augmentation enterocystoplasty to obtain life-long therapeutic effects rather than repeated BoNT/A injections, especially because adverse events can occur after each BoNT/A injection.[73] Patients reported higher QoL with augmentation enterocystoplasty compared with detrusor BoNT/A injections.[74] Augmentation enterocystoplasty is indicated in patients with reduced bladder capacity and compliance due to NLUTD or other chronic inflammatory bladder diseases.[20],[75] It can effectively decrease intravesical pressure during bladder storage and increase bladder capacity in patients with end-stage bladder diseases or refractory DO.[76] Although augmentation enterocystoplasty is a procedure with long-term durability and high satisfaction, bothersome complications do exist.[3] In a recent study, 86.9% of patients were satisfied with the treatment outcome of augmentation enterocystoplasty, with only 16.5% experiencing postoperative incontinence. However, 76% of patients were entirely dependent on CIC. For the convenience of bladder emptying, patients may eventually choose an indwelling urethral catheter or cystostomy.[18] Because of the high complication rate, augmentation enterocystoplasty is typically considered the final step of treatment of NDO in SCI patients.
Recommendations
Augmentation enterocystoplasty should be considered in patients who have failed to respond to less invasive methods, such as pharmacologic therapy or repeated intravesical treatment.After augmentation enterocystoplasty, CIC should be performed by the patient or caregiver, and patients should receive regular follow-up.Enterocystoplasty should be performed first on the terminal ileum. ConclusionNLUTD after SCI encompasses a wide range of pathologies, making NLUTD management in chronic SCI patients a significant urological challenge. Because different therapeutic strategies would be implemented as NLUTD progresses, repeated urodynamic investigations are frequently requested for re-evaluation. Diverse surgical treatments for preserving renal function, lowering the risk of recurrent UTI and urinary incontinence, and improving the QoL of SCI patients have been developed. However, clinicians must advise NLUTD SCI patients on the risks, benefits, alternatives, and the high risk of requiring additional treatment or surgery. Appropriate follow-up after treatment is required for better functional outcomes and the prevention of therapeutic failure. The final patient-tailored management decision should meet the needs of the individual patient, and a multidisciplinary team of experts is often involved.
Data availability statement
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
Financial support and sponsorship
This study was funded by TCMF-MP 110-03-01 (111), Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
Conflicts of interest
Dr. Yuan-Chi Shen, Chun-Hou Liao, Victor Chia-Hsiang Lin, Shang-Jen Chang, Chung-Cheng Wang and Hann-Chorng Kuo, the editorial board members at Urological Science, had no roles in the peer review process of or decision to publish this article. The other authors declared no conflicts of interest in writing this paper.
References
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