Faculty Bibliography

PURPOSE/OBJECTIVE:To assess the urodynamic findings in patients with Parkinson disease (PD) with overactive bladder symptoms. METHODS:We performed a retrospective chart review of all PD patients who were seen in an outpatient clinic for lower urinary tract symptoms (LUTS) between 2010 and 2017 in a single-institution. Only patients who complained of overactive bladder (OAB) symptoms and underwent a video-urodynamic study for these symptoms were included. We excluded patients with neurological disorders other than PD and patients with voiding LUTS but without OAB symptoms. RESULTS:We included 42 patients (29 men, 13 women, 74.5±8.1 years old). Seven patients (16.7%) had a postvoid residual (PVR) bladder volume >100 mL and only one reported incomplete bladder emptying. Detrusor overactivity (DO) was found in all 42 patients (100%) and was terminal in 19 (45.2%) and phasic in 22 patients (52.4%). Eighteen patients had detrusor underactivity (DU) (42.3%). Later age of PD diagnosis was the only parameter associated with DU (P=0.02). Patients with bladder outlet obstruction (BOO) were younger than patients without BOO (70.1 years vs. 76.5 years, P=0.004), had later first sensation of bladder filling (173.5 mL vs. 120.3 mL, P=0.02) and first involuntary detrusor contraction (226.4 mL vs. 130.4 mL, P=0.009). CONCLUSION/CONCLUSIONS:DO is almost universal in all patients with PD complaining of OAB symptoms (97.1%). However, a significant percentage of patients also had BOO (36.8%), DU (47%), and increased PVR (16.7%) indicating that neurogenic DO may not be the only cause of OAB symptoms in PD patients.

AIMS/OBJECTIVE:To perform a systematic review of studies reporting the outcomes of AMS-800 artificial urinary sphincter (AUS) implantation in female patients with stress urinary incontinence (SUI) resulting from intrinsic sphincter deficiency (ISD). METHODS:A systematic literature search of the Medline and Embase databases was performed in June 2018 in accordance with the PRISMA statement. No time limit was used. The protocol was registered in PROSPERO (CRD42018099612). Study selection and data extraction were performed by two independent reviewers. RESULTS:Of 886 records screened, 17 were included. All were retrospective or prospective non-comparative case series. One study reported on vaginal AUS implantation, 11 on open AUS implantation, two on laparoscopic AUS implantation, two on robot-assisted AUS implantation and one compared open and robot-assisted implantations. The vast majority of patients had undergone at least one anti-incontinence surgical procedure prior to AUS implantation (69.1-100%). The intraoperative bladder neck injury rates ranged from 0% to 43.8% and the intraoperative vaginal injury rates ranged from 0 to 25%. After mean follow-up periods ranging from 5 to 204 months, the complete continence rates ranged from 61.1% to 100%. The rates of explantation, erosion and mechanical failure varied from 0% to 45.3%, 0% to 22.2% and 0% to 44.1%, respectively. CONCLUSIONS:AMS-800 AUS can provide excellent functional outcomes in female patients with SUI resulting from ISD but at the cost of a relatively high morbidity. High level of evidence studies are needed to help better define the role of AUS in the female SUI armamentarium.

OBJECTIVE:To characterize the current evaluation, and efficacy of treatments in patients with the primary complaint of nocturia. METHODS:A retrospective chart review was performed of new patient encounters seen in a tertiary urology practice from May 2010 to September 2016 with the primary diagnosis of nocturia (ICD-9 788.43 and ICD-10 R35.1). RESULTS:595 patients were identified. 403 met inclusion criteria. The median patient reported that nocturia episodes were 4 (1-20). 192 patients (48%) reported previous treatment for nocturia. After the index visit, a bladder diary (BD) was utilized in 50% of patients, with a 62% (n = 124) completion rate at follow-up visit. On BD analysis, the most common etiologies of nocturia were nocturnal polyuria 76% (n = 90) and overactive bladder in 21% (n = 26). Patient reported improvement with therapy after BD completion was 46% (n = 34), similar to patients without voiding diaries (43% improvement, n = 153). Anticholinergics and alpha blockers were the most commonly recommended drug, but no specific medication was associated with nocturia improvement. Oral desmopressin was used in 5% of patients. CONCLUSION/CONCLUSIONS:Nocturia is a common condition and very commonly patients have sought treatment prior to presentation. Bladder diaries were recommended to half of the patients. Patient reported that improvement did not seem to correlate with completion of a bladder diary. Though most patients had NP the use of desmopressin was very low. Current treatments used in managing nocturia may lack efficacy.

Introduction: This prospective, multicenter, single arm study evaluated changes from baseline in OAB symptoms as measured by urinary voiding diaries and patient reported outcomes through 12 weeks of percutaneous tibial neuromodulation (PTNM) therapy in drug naive subjects.
Method(s): Qualified subjects underwent 12 PTNM therapy sessions, administered weekly using the NURO system. Subjects completed urinary voiding diaries (3-day) to assess change in voiding symptoms from baseline through 12 weeks. Voiding diary analyses were conducted for subjects with data at baseline and follow-up study visits (PTNM sessions 1, 4, 8, and 12). Quality of life (QOL) was assessed using the Overactive Bladder Symptom QOL Questionnaire (OAB-q) at the same visits. A repeated measures analysis was used to assess session effect on symptom reduction and QOL improvement. P-values for pairwise comparisons were obtained from the Bonferroni t-test after adjusting for multiple comparisons.
Result(s): One hundred and fifty-four subjects enrolled in the study, of which 120 qualified and received PTNM therapy. Over 12 weeks of therapy, there was a statistically significant session effect on reduction in urinary urge incontinence (UUI) episodes per day from baseline (p<0.0001), see Figure 1. In pairwise comparisons, there was a statistically significant increase of therapy effect on UUI reduction from PTNM sessions 1 to 4 and from sessions 4 to 8 (p<0.001 for both). There was a further trend of improvement in therapy efficacy from session 8 to 12, even though the further decrease in UUI episodes per day did not represent a statistically significant change between treatments 8 and 12. Over 12 weeks, there was a statistically significant session effect on improvement in total health-related QoL (HRQL) and subscales of Coping, Concern, Sleep, and Social; as well as symptom bother (all p<0.0001). Each measure (except Social) had significantly greater improvement at sessions 4, 8, and 12 compared to the previous visit (all p<0.05). Of the subjects who were responders at 12 weeks, 22.1% first responded at PTNM session 8 or later.
Conclusion(s): Both efficacy and quality of life continue to improve as treatment progresses through 12 weeks. These results indicate a decision on patient benefit from the therapy should not be made until 12 therapy sessions are completed

Introduction: Despite the widespread use of synthetic mid urethral slings (MUS) in clinical practice, autologous fascial pubovaginal sling (AFPVS) continues to have an important role in women with stress urinary incontinence (SUI), notably in those who failed previous anti-incontinence procedures. The aim of this study was to assess the prevalence, risk factors and management of persistent SUI following AFPVS in patients who failed previous anti-incontinence procedures.
Method(s): The charts of all female patients who underwent AFPVS for SUI from 2012 to 2017 at a single academic center were retrospectively reviewed. Only patients who had failed at least one previous anti-incontinence procedure were included in the present study. Patients with neurogenic bladder were excluded. The primary endpoint was persistent SUI at 3 months defined as patient reporting the need to wear one pad per day or more. Univariate and multivariate logistic regression analysis was performed to assess predictors of persistent SUI at 3 months.
Result(s): After exclusion of 29 patients with no prior anti-incontinence procedures and 6 patients with neurogenic bladder, 70 patients were included in the present study. The mean patient age was 58.2 years, and the most common prior SUI surgeries were MUS (85.7%), bulking agents (25.7%) and Burch Colposuspension (8.6%). Most patients reported improvement of SUI at 3 months (83.2%), however 24 reported persistent SUI (34.3%), of which 14 reported improvement (22.9%) and 10 unchanged or worsened SUI (16.8%). The median number of pads per day at 3 months in those with persistent SUI was 1 (range: 1-10). After a median follow-up of 14.4 months, 10 patients (14.3%) had retreatment for SUI. Those who failed prior MUS had lower risk of persistent SUI than those who failed prior Burch and/or bulking (32.7% vs. 77.8%; p=0.02). This was the only predictor of persistent SUI in univariate analysis (OR=0.14; p=0.02) and in multivariate analysis adjusting for age, BMI and urethral hypermobility (OR=0.10; p=0.01).
Conclusion(s): AFPVS is an effective treatment option for women who failed previous anti-incontinence procedures. Patients who failed MUS may have a lower risk of persistent SUI when compared to this who failed Burch and/or Bulking agents

Introduction: To date, only very few series have aimed to assess the outcomes of botulinum toxin injections in patients with Parkinson's Disease (PD). The aim of this study was to assess the safety and efficacy of intradetrusor onabotulinum toxin A injections for the treatment of overactive bladder (OAB) in patients with PD.
Method(s): All PD patients who underwent intradetrusor injections of onabotulinum toxin A (BoNT-A) for storage symptoms between 2010 and 2017 were included in a retrospective study. A 100 U dose of BoNT-A (Botox, Allergan Irvine, CA) was used for the first injection in all patients. The primary endpoint was clinical success defined as any subjective improvement in OAB symptoms self-assessed by the patients four weeks after the injections.
Result(s): Out of 24 patients analyzed, 19 reported improvement of their OAB symptoms four weeks after the first injection (79.2%) with complete resolution of urgency urinary incontinence in 7 patients (29.1%; p<0.001). The average post-void residual (PVR) increased significantly after the first injection from 17.6 to 125.3 ml (p<0.001). Three of the patients had to start clean intermittent catheterization (CIC) after the first injection (12.5%). Out of 49 injections in total, only five caused incomplete bladder emptying requiring the use of CIC (10.2%). Higher pre-injection PVR was significantly associated with both a lower chance of symptomatic improvement (p=0.04) and a higher risk of incomplete bladder emptying with institution of CIC (p=0.047).
Conclusion(s): Botox appeared effective in PD patients with a relatively low rate of retention requiring CIC. Higher preoperative PVR was the stronger predictor of both treatment failure and postoperative urinary retention requiring CIC while urodynamic obstruction was also associated with treatment failure in male patients. Intradetrusor injections of BoNT-A 100 U appeared as a safe and effective option in PD patients with OAB symptoms and a low PVR before the injection

PURPOSE/OBJECTIVE:Urinary incontinence after prostate treatment (IPT) is one of the few urologic diseases that is iatrogenic, and, therefore, predictable and perhaps preventable. Evaluation of the incontinent patient, risk factors for IPT, the assessment of the patient prior to intervention, and a stepwise approach to management are covered in this guideline. Algorithms for patient evaluation, surgical management, and device failure are also provided. MATERIALS AND METHODS/METHODS:, 2017 using Ovid, MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Databases of Systematic Reviews. Additional references through 12/31/2018 were identified. RESULTS:This guideline was developed by a multi-disciplinary panel to inform clinicians on the proper assessment of patients with IPT and the safe and effective management of the condition in both surgical and non-surgical contexts. Statements guiding the clinician on proper management of device failure are also included. CONCLUSION/CONCLUSIONS:Most patients who undergo radical prostatectomy (RP), and some patients who undergo radiation therapy (RT) or surgery for benign prostatic hyperplasia (BPH), will experience IPT. Although non-surgical options, such as pelvic floor muscle exercises (PFME), can hasten continence recovery, patients who remain incontinent at one-year post-procedure, or have severe incontinence at six months, may elect to undergo surgical treatment (e.g. artificial urinary sphincter). Prior to IPT surgery, the risks, benefits, alternatives, and additional likely procedures should be discussed with the patient.

AIMS/OBJECTIVE:To present the development of the International Consultation on Incontinence Questionnaire-underactive bladder (ICIQ-UAB) as the first patient reported outcome measure for the assessment of the symptoms and impact on the health-related quality of life of UAB developed in-line with the Food and Drug Administration Guidance for Industry. METHODS:Draft items were developed following 44 semi-structured concept elicitation interviews in the UK and refined using 36 cognitive interviews. A pilot study was designed to assess the draft ICIQ-UAB's initial psychometric properties with 54 patients recruited from European hospitals. Further concept elicitation interviews were also carried out with 11 patients in the US and 10 patients in Japan. All participants had a prior urodynamic diagnosis of detrusor underactivity. RESULTS:The cognitive interviews confirmed the initial items to be understood and interpreted as intended. Pilot testing showed that both internal consistency (Cronbach's α ≥ 0.85) and test-retest reliability (stable patients; intraclass correlation coefficient ≥ 0.88) were high. The interviews in the US and Japan elicited symptoms and impacts that support previous findings in the UK and provided further insight into the experiences of patients in those countries. The developmental ICIQ-UAB was refined using the evidence from all substudies. CONCLUSIONS:The validity and reliability of the ICIQ-UAB were supported in a pilot study setting and the wider cultural applicability by the additional interviews in the US and Japan. Following further validation in future clinical trials, the developmental ICIQ-UAB is envisaged as an important tool for the monitoring of future UAB treatment strategies.

OBJECTIVE:To evaluate the effect of radiation on male stress urinary incontinence (SUI) and to assess the relative value of preoperative urodynamic (UDS) testing in radiated vs nonradiated men with SUI. METHODS:A retrospective chart review of all male patients with SUI who underwent UDS testing from 2010 to 2016 was performed. The impact of UDS findings on treatment decision making was assessed. UDS parameters and treatment patterns of radiated vs nonradiated patients were compared as well as the fates of storage symptoms in each group. RESULTS:Two hundred seven men were identified that underwent UDS with a clinical diagnosis of SUI. Sixty-five out of 207 (31.4%) were exposed to radiation as a treatment modality for prostate cancer. All patients that underwent UDS testing moved on to surgical correction of SUI, and the UDS findings did not alter plan to treat SUI in any patients. Men who were radiated prior to surgical correction of SUI were more likely to have detrusor overactivity (70% vs 38%, P <.0001) and had lower maximum cystometric capacity (255 vs 307.4 mL, P = .01) when compared to nonradiated on UDS. After artificial urinary sphincter or sling implantation, the proportion of patients requiring overactive bladder medications was higher in radiated vs nonradiated men (44.3% vs 25.3%; P = .01). CONCLUSION/CONCLUSIONS:Radiation therapy appears to increase the likelihood of bladder dysfunction in male patients with SUI. The UDS findings did not alter the plan to treat SUI in any patients in our series, and its role before SUI surgery in male patients, including those receiving radiation, may be limited.

Objective: To report the current clinical features, treatment patterns and outcomes of female patients who were seen at a tertiary referral centre with a primary diagnosis of nocturia, and to assess the predictive factors of therapeutic management failure. Patients and methods: A retrospective chart review of all new female patients seen in a single-centre functional urology practice with the diagnosis of nocturia was performed. Up to three visits within a 12-month period from the time of presenting were reviewed. The primary endpoint was patient-reported improvement assessed at each follow-up visit and the change in the number of nocturia episodes. Results: In all, 239 female patients were included for analysis. The prevalence of nocturnal polyuria, reduced bladder capacity, and global polyuria were 75%, 40.2%, and 18.1%, respectively. Within the first two visits, 72.7% of patients had started a treatment beyond behavioural therapies. Anticholinergics were the most commonly initiated treatment (47.2% of patients). At the latest considered visit, 80 patients reported improvement in nocturia (45.5%) and there was a mean - 0.8 decrease in the number of nocturia episodes from 4 to 3.2, which was statistically significant (P < 0.001). There was no statistically significant association between any of the bladder diary findings and treatment outcomes. A smaller number of nocturia episodes was the only predictive factor of therapeutic management failure in multivariate analysis (odds ratio 0.10; P = 0.01). Conclusions: Whilst the prevalence of nocturnal polyuria in women with nocturia is high, the therapeutic management until 2016 seemed to rely mostly upon overactive bladder medications with a relatively low success rate. Abbreviations: BD: bladder diary; BPS: bladder pain syndrome; ICD(-9)-(10): International Classifications of Disease (ninth revision) (10th revision); NPI: Nocturnal Polyuria Index; OAB: overactive bladder; OR: odd ratio; POP: pelvic organ prolapse.