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.

OBJECTIVE:This study assessed stress urinary incontinence (SUI) outcomes after sling excision for urinary tract perforation or vaginal exposure, and compared the outcomes of concomitant versus staged autologous fascia pubovaginal sling (AFPVS). METHODS:A retrospective chart review of all patients who underwent midurethral sling (MUS) excision for urinary tract perforation or vaginal exposure at a tertiary referral center between 2010 and 2015 was performed. Therapeutic strategies were categorized as concomitant AFPVS, staged AFPVS, and no anti-incontinence procedure. RESULTS:In all, 32 patients were included for analysis: 13 with vaginal tape exposure (40.6%) and 19 with urinary tract tape exposure (59.4%). In patients who had SUI prior to sling excision (43.8%), the rate of resolved or improved SUI postoperatively was higher in the concomitant AFPVS group than in those who underwent sling excision alone (83.3% vs 12.5%, respectively; P = 0.03). Of 18 patients with no SUI prior to sling excision, 12 experienced recurrent SUI after sling removal (66.7%). The rate of recurrent SUI was lower in patients with vaginal MUS exposure than urinary tract MUS perforation, but this did not reach statistical significance (57.1% vs 72.7%, respectively; P = 0.63). The rates of resolved SUI after AFPVS were comparable in patients with concomitant and staged AFPVS (66.7% vs 71.4%, respectively; P = 0.99). CONCLUSIONS:Many patients with MUS perforations or exposures will have SUI at initial presentation or develop SUI after removal of the synthetic sling. The decision to perform a concomitant AFPVS or to stage the surgical management of SUI can be individualized.

PURPOSE/OBJECTIVE:We aimed to review the current knowledge on the epidemiology, diagnosis, and management of urinary and sexual dysfunction in patients with TTR amyloidosis (ATTR). METHODS:We performed a review of the literature, screening for randomized controlled trials, prospective and retrospective series, position papers, and guidelines on urinary and sexual dysfunction in ATTR patients published in PubMed and Embase. RESULTS:Lower urinary tract dysfunction is present in up to 83% of patients with ATTR. Voiding symptoms are the most common, reported in 34.8-87.5% of patients, while urinary tract infections are reported in up to 50%. Urinary incontinence is observed in 16.7-37.5% of the ATTR population, mostly due to decreased urethral resistance. Sexual dysfunction affects over 40% of ATTR patients, with erectile dysfunction and sexual arousal disorder being the most common symptoms in male and female patients, respectively. In addition to a thorough clinical examination, invasive pressure-flow urodynamic testing is a cornerstone in the assessment of ATTR lower urinary tract dysfunction. The most common finding is detrusor underactivity and intrinsic sphincter deficiency. Poor bladder compliance can also be observed in patients, due to amyloid deposits on the bladder wall. Urinary tract imaging may be of interest to rule out upper urinary tract deterioration. Given the paucity of data in the ATTR population, treatment should be tailored to the individual patient. CONCLUSION/CONCLUSIONS:Urinary and sexual dysfunction are highly prevalent in ATTR patients. Comprehensive assessment and multidisciplinary management are keys to avoiding upper urinary tract damage and improving patients' quality of life.

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: Nocturia is a highly prevalent and underrecognized condition associated with disrupted sleep, increased risks of falls and fractures and negative effects on quality of life (QOL). Long-term consequences may include depression and risks of cardiovascular diseases. Two nocturic voids per night is the threshold at which the impact of nocturia becomes more problematic. A large online poll was conducted to assess women's awareness of nocturia, engagement with healthcare practitioners, and effects on QOL.
Method(s): This was a self-reported online survey conducted by Harris Poll within the US in August 2018 among adults aged 18 years and older. Propensity weighting matched respondents to the US general adult population. Descriptive statistics were used to summarize the results of the survey.
Result(s): Of 2040 respondents, 1104 were female (1056 on a weighted basis). Mean (SD) age of female respondents was 47.1 (17.45) years. Seventy-one percent of the female respondents had never heard of nocturia. Of the 1056 female respondents, 36% reported waking to urinate on average 2 or more times per night (nocturia). Among the female nocturia sufferers, 65% had never heard of nocturia, and 74% were not aware waking up to urinate at least twice per night is a diagnosable medical condition. Seventy-four percent had not spoken with their doctor about waking up to urinate, and only 39% reported that their doctor had ever asked them about frequency of nighttime urination. Of those who had not spoken with their doctor about this condition, 53% thought it was a normal part of aging, and 26% thought nothing could be done about it. Seventy-three percent of the female nocturia sufferers reported negative effects on quality of life during nighttime, and 63% are negatively affected during daytime. The specific nighttime and daytime effects are detailed in the Figure.
Conclusion(s): In this large national survey, more than one-third of women had symptoms of nocturia. Most were not aware nocturia is a medical condition, had not spoken with their doctors about it, and experienced negative nighttime and daytime effects from the condition

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

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

PURPOSE/OBJECTIVE:Antidiuretic therapy with desmopressin for nocturia has been hampered by formulations with high doses, low bioavailability and variable pharmacokinetics. AV002 (SER120), a novel, emulsified, microdose desmopressin nasal spray, with a permeation enhancer (cylcopentadecanolide), was developed to have pharmacokinetic characteristics suitable for nocturia treatment. METHODS:Twelve healthy subjects participated in an open-label, dose-escalating study. Water-loaded subjects were sequentially dosed every 48 h with AV002 0.5, 1.0, 2.0 μg and 0.12 μg desmopressin subcutaneous (SC) bolus injection. RESULTS:and area under the curve showed dose proportionality. Coefficient of variation for AV002 was similar to that observed for the SC dose. Bioavailability of AV002 was approximately 8% compared to SC injection. AV002 demonstrated pharmacodynamic effects within 20 min of dosing and showed increasing magnitude and duration with escalating doses. AV002 2.0 μg had maximum median urine osmolality of 629 mOsm/kg and median urine output ≤2 mL/min for 5-6 h. CONCLUSIONS:AV002 demonstrated rapid absorption, high bioavailability, limited duration of action, and low coefficient of variation, suggesting it may be a suitable formulation for nocturia treatment. Trial registration not required (single-center, phase 1).

Introduction & Objectives: Nocturia is a highly prevalent medical condition. Approximately 80% of patients with nocturia (average of >=2 nocturnal voids)have nocturnal polyuria (NP), and 21% also have overactive bladder (OAB). These patients report sleep disruption and negative effect on nighttime symptoms. First-line therapies for OAB, have limited efficacy in treating nocturia. Combination therapy with an antimuscarinic and an antidiuretic may provide better relief of nocturia for patients with this multifactorial pathophysiology. AV002 is an emulsified microdose desmopressin nasal spray indicated for the treatment of nocturia due to NP and may be suitable concomitant therapy for these patients. Material(s) and Method(s): Data from a subgroup of OAB patients with concomitant NP enrolled in two double-blind Phase 3 trials of AV002 for treatment of nocturia were pooled. Studies were approved by an institutional review board. Patients with >=2 nocturic voids for >=6 months received AV002 1.66 mcg, AV002 0.83 mcg, or placebo every night for 12 weeks. No fluid restrictions or behavioral modifications were required. Efficacy endpoints, based on patient voiding diaries, included first uninterrupted sleep period (FUSP; elapsed time from bedtime to first nocturic void). Patients in one trial also completed the validated Impact of Nighttime Urination (INTU)questionnaire to assess changes in quality of life (QoL; range, 0-100; 0, no impact; 100, greatest impact). Result(s): Of 1045 randomized NP patients, 275 with OAB were included in the FUSP analysis. Of these, 136 patients from one study were included in the INTU analysis. Baseline and change from baseline for FUSP and INTU are shown in Table 1. After 12 weeks of treatment, FUSP was extended to 4.0 hours and 3.9 hours in the AV002 1.66 mcg and 0.83 mcg groups, respectively (change from baseline, p<0.05 vs. placebo for each AV002 group). INTU overall impact scores were significantly improved in patients receiving AV002 compared with placebo. [Table Presented]Conclusions: AV002 treatment over 12 weeks significantly extended FUSP and improved INTU (QoL)scores compared with placebo in OAB patients with nocturia due to NP. AV002 may be an appropriate treatment for nocturia in patients with OAB and nocturia due to NP.