Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Radical prostatectomy (RP) is the standard surgical treatment for localized prostate cancer. One of the side effects after RP impacting quality of life is urinary incontinence. Because of the impact in quality of life, more patients are seeking treatment for post-prostatectomy incontinence. Urodynamics are an important tool to help understand how prostate surgery changes bladder and urethral function. We reviewed the current literature in order to determine the role of urodynamics in post-prostatectomy incontinence. RECENT FINDINGS/RESULTS:Studies have been done to demonstrate the anatomical and functional changes in incontinent men after radical prostatectomy compared to continent men, as well as to evaluate the use of urodynamics in the work-up for post-prostatectomy incontinence prior to treatment. However, there is not a consensus about the indications of urodynamics in this population and new studies have questioned the real role of urodynamics in this setting. Because of the impact in quality of life, more patients are seeking treatment for post-prostatectomy incontinence. Urodynamics have been used to have a better understanding of the anatomical and functional changes in incontinent men after radical prostatectomy; however, the role of urodynamic testing to assess these patients and offer treatment is still to be determined.

AIMS: To assess the reliability of urinary cytology and cystoscopy to screen and diagnose bladder cancer in patients with NB. PATIENTS AND METHODS: A systematic literature search of the Medline and Embase databases was performed in April 2017. Data extraction was performed by two independent reviewers. A narrative synthesis was made. RESULTS: Out of 220 records assessed, 15 were included in this systematic review. All studies were prospective or retrospective series with no control group. Cystoscopy allowed the detection of asymptomatic bladder cancer in 0-10 patients, with a screening sensitivity (available in only one study) of 0%, a screening specificity ranging from 65% to 90%, and a yield in detecting asymptomatic bladder cancer of 0% in all series where it could be calculated. Urinary cytology allowed the detection of bladder cancer in asymptomatic patients in 0-12 patients, with a screening sensitivity of 71%, a screening specificity ranging from 92% to 97% and a yield ranging from 0% to 1.25%. Sensitivity of cystoscopy for diagnosis of bladder cancer ranged from 27% to 81% and specificity was 54% in the only study where it could be calculated. Sensitivity of urinary cytology for diagnosis of bladder cancer was 0-72% and specificity was 100%. CONCLUSION: There is currently insufficient data to support formal recommendations of using both tools in the screening of bladder cancer in patients with neurogenic bladder. Urinary cytology outperformed cystoscopy for screening and might be the best tool currently available.

OBJECTIVES: The use of fluoroscopy during urodynamics can be helpful in the evaluation of patients with lower urinary tract dysfunction. However, fluoroscopy introduces the potential hazards of ionizing radiation, including malignancy. In this study we analyzed the data for radiation exposure during videourodynamic study (VUDS) at our center; we have also tried to establish the factors associated with increased exposure to radiation during VUDS. METHODS: We reviewed all VUDS from August 2010 to May 2011. Patients were included if they were >/=18 years old and had data recorded on total radiation exposure (radcm2 ). Age, sex, body mass index, fluoroscopy time, diagnosis, and urodynamic findings were recorded. Multivariate linear regression analysis was used to identify independent risk factors that influenced increased radiation exposure. RESULTS: A total of 203 videourodynamic studies were assessed in 106 female and 97 male patients with a mean age of 64.3 and body mass index of 26.8. The average fluoroscopy time was 100.2 sec and exposure was 560.9 radcm2 . The most common indication for videourodynamics was incontinence, 40.9%. On multivariate linear regression analysis body mass index, vesico-ureteral reflux, sex, number of fill cycles, and larger capacity were independent predictors of increased radiation exposure. CONCLUSIONS: We have shown that increased radiation exposure as measure with Dose Area Product during VUDS was significantly associated with larger BMI, female gender, larger bladder capacity, presence of VUR, junior operator, and higher number of fill cycles. Further studies are now underway to attempt to reduce exposure based on these findings.

Introduction: The potential need for clean intermittent catheterization (CIC) is known to increase in overactive bladder (OAB) patients after onabotulinumtoxinA treatment. We determined the risk of CIC and assessed the efficacy and quality of life (QoL) outcomes after treatment with onabotulinumtoxinA in different age groups by performing a post-hoc analysis of a large cohort of OAB patients. Methods: Data from two onabotulinumtoxinA randomized, placebo-controlled, phase 3 trials and a post-marketing study were pooled for analysis (N=1177). Patients treated with onabotulinumtoxinA 100U in treatment 1 and placebo patients who received open-label onabotulinumtoxinA in treatment 2 were grouped by age: <40 (n=90), 40-49 (n=156), 50-59 (n=263), 60-69 (n=343), and >=70 (n=325) years. Assessments at week 12 after treatment were: incidence and duration of CIC, mean and percent change from baseline in urinary incontinence (UI) episodes/day, proportions of patients with >=50% UI reduction, a positive response (urinary symptoms 'improved'/'greatly improved') on the treatment benefit scale (TBS), and change from baseline in Kings Health Questionnaire (KHQ) domains of social limitations and role limitations. Adverse events (AEs) were assessed. Results: CIC rates after onabotulinumtoxinA treatment were lowest in the <40 group (1.1%) and increased slightly with age (3.2%, 5.3%, 5.3%, and 7.2% in the 40-49, 50-59, 60-69, and >=70 groups, respectively). Mean CIC duration was three and 44 days in the <40 and 40-49 groups, respectively, and ranged from 78-88 days in the other groups. Mean UI episodes/day at baseline were 3.9, 4.8, 5.2, 5.7, and 6.0 in the <40, 40-49, 50-59, 60-69, and >=70 groups, respectively. A robust treatment response was noted in all groups, including substantial reductions in UI episodes/day (-2.4, -2.6, -3.1, -3.6, and -2.9) and percent change in UI (-60.8%, -50.4%, -62.4%, -64.4%, and -46.8%). High proportions of patients in all groups achieved >=50% UI reduction (range 58.2-71.1%) and had a positive TBS response (range 66.2-73.8%). Improvements from baseline in KHQ domain scores were approximately 3-6 times the minimally important difference. Urinary tract infection was the most common AE in all groups. Conclusions: In this large cohort of onabotulinumtoxinA-treated OAB patients, CIC risk increased slightly with age, but was low in all age groups and accompanied by substantial reductions in UI episodes/day, improvements in QoL, and treatment benefit. The <40 group had the lowest rate of CIC (1.1%), with a duration of three days. OnabotulinumtoxinA was well-tolerated in all age groups

Purpose: We sought to assess for impact on management trends in new patients presenting to our institution with stress urinary incontinence (SUI) following the release of the FDA Health Notification in July 2011 for vaginal mesh. Materials and methods: Chart analysis was performed on patients assigned a primary International Classification of Diseases (ICD-9) diagnosis code of 625.6 for SUI at initial consultation by two providers at our institution between June 1, 2010 and November 30, 2014. Rates of treatment and types of procedures performed were analyzed: urethral bulking, mesh sling, or pubovaginal sling. Results: A total of 333 new patients were identified with an increasing trend over time. One hundred and twenty-three patients underwent 153 procedures for stress incontinence. The mean proportion that had a procedure per six-month period was 37%, with decreasing proportions over time. Initially all procedures were midurethral mesh slings, with a decline at the time of and after the notification, and a temporary increase in bulking procedures. Subsequently, there was a rise again in sling placement, namely with an increase in pubovaginal slings. Of the 20 pubovaginal slings placed, 13 were placed in patients who had a prior anti-incontinence surgery (eight for sling failure, vaginal mesh, or fixed urethra, and two in patients with mesh extrusion/erosion). Seven were performed in patients who had never had prior surgery (two for very high-grade incontinence, two with urethral diverticulectomy, and three in patients who expressed concern about mesh). Conclusions: Although there were an increasing number of patients seen for management of SUI over time, there was a progressive decrease in the proportion of patients having anti-incontinence procedures after release of the FDA notification. There was an overall decrease in the use of mesh slings and an increase in bulking, and more notably, placement of pubovaginal slings.

Parkinson's disease (PD) and atypical Parkinsonism are the second most common neurodegenerative movement disorders. Lower urinary tract dysfunction is among the most common types of associated autonomic dysfunctions. Differentiating the subtypes of PD is important for symptom management and understanding prognosis, because Lower urinary tract symptoms (LUTS) can evolve differently depending on the primary disease. LUTS are caused by storage and/or voiding dysfunctions. Urodynamics is a key investigative tool. The complex pathophysiology of this bladder dysfunction is not responsive to levodopa, and add-on therapy is necessary. Newer interventions hold promise as therapy to improve bladder dysfunction.

OBJECTIVES: To compare the efficacy of onabotulinumtoxinA, mirabegron, and anticholinergics in adults with idiopathic overactive bladder (OAB) using network meta-analysis (NMA). SUBJECTS AND METHODS: Information sources were searched for randomized blinded controlled trials, of at least 2 weeks duration, comparing any dose of onabotulinumtoxinA, eligible oral/transdermal anticholinergics, or mirabegron, with each other or placebo, in adults with OAB. Bayesian random-effects models were used to synthesize the results at week 12: NMA for responder analyses and network meta-regression (NMR) for change from baseline analyses. The NMR was used to adjust for differences in baseline severity between studies. Sensitivity analysis, excluding studies considered to be at a high risk of methodological bias, was conducted. RESULTS: 56 randomized trials were included in the networks. For each outcome, results are reported for all licensed treatment doses. For each NMR, results are based on patients with an average number of episodes of the outcome at baseline. After 12 weeks, all treatments are more efficacious than placebo. Patients who received onabotulinumtoxinA (100U) had, on average, the greatest reductions in urinary incontinence episodes (UIE), urgency, and micturition frequency, and the highest odds of achieving decreases of 100% and >/=50% in the daily number of UIE. When comparing onabotulinumtoxinA with other pharmacotherapies, mean differences favoured onabotulinumtoxinA 100U over all comparators for UIE and urgency (credible intervals excluded zero) and all but two of the comparators for micturition frequency. OnabotulinumtoxinA 100U was also associated with higher odds of achieving a 100% and >/=50% decrease in daily UIE than most other licensed treatments in the network. The exclusion of studies with a high risk of bias had little impact on the conclusions. CONCLUSION: The results indicate that, after 12 weeks, onabotulinumtoxinA 100U provides greater relief of OAB symptoms compared with most other licensed doses of other pharmacotherapies in the network

Gynecologic and urologic etiologies are the sources of pelvic pain for many individuals. This article aims to provide a comprehensive review of the various genitourinary sources of pelvic pain. It is important to recognize that although these disorders predominantly affect women, there are various conditions that affect both men and women, and these should be considered in the differential diagnosis of patients presenting with pelvic pain. Providers who encounter patients with pelvic pain should attempt to localize these symptoms and obtain a comprehensive history from the patient to help direct diagnostic evaluation.

AIMS: Antibiotic prophylaxis before urodynamic testing (UDS) is widely utilized to prevent urinary tract infection (UTI) with only limited guidance. The Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) convened a Best Practice Policy Panel to formulate recommendations on the urodynamic antibiotic prophylaxis in the non-index patient. METHODS: Recommendations are based on a literature review and the Panel's expert opinion, with all recommendations graded using the Oxford grading system. RESULTS: All patients should be screened for symptoms of UTI and undergo dipstick urinalysis. If the clinician suspects a UTI, the UDS should be postponed until it has been treated. The first choice for prophylaxis is a single oral dose of trimethoprim-sulfamethoxazole before UDS, with alternative antibiotics chosen in case of allergy or intolerance. Individuals who do NOT require routine antibiotic prophylaxis include those without known relevant genitourinary anomalies, diabetics, those with prior genitourinary surgery, a history of recurrent UTI, post-menopausal women, recently hospitalized patients, patients with cardiac valvular disease, nutritional deficiencies or obesity. Identified risk factors that increase the potential for UTI following UDS and for which the panel recommends peri-procedure antibiotics include: known relevant neurogenic lower urinary tract dysfunction, elevated PVR, asymptomatic bacteriuria, immunosuppression, age over 70, and patients with any indwelling catheter, external urinary collection device, or performing intermittent catheterization. Patients with orthopedic implants have a separate risk stratification. CONCLUSIONS: These recommendations can assist urodynamic providers in the appropriate use of antibiotics for UDS testing. Clinical judgment of the provider must always be considered.