Patterns and predictors of Hunner lesion recurrence in patients with interstitial cystitis

Optimal endoscopic treatment and partial cystectomy with or without bladder augmentation for Hunner-type interstitial cystitis

Interstitial cystitis/bladder pain syndrome (IC/BPS) presents a significant challenge for urologists in terms of management, owing to its chronic nature and adverse impact on patient quality of life. Given the potential distinction between two disease entities within IC/BPS, namely Hunner-type IC and BPS without Hunner lesion, there is a need for an optimal therapeutic approach that focuses on the bladder lesions in Hunner-type IC. In cases where Hunner lesions are observed, complete transurethral ablation of these lesions should be prioritized as the initial intervention, as it has demonstrated effectiveness in symptom control. However, recurrence remains a limitation of this intervention. The techniques of resection and coagulation are equally effective in terms of symptom relief and recurrence prevention. Reconstructive surgery becomes necessary in cases of end-stage IC/BPS where various therapeutic approaches have failed. Patient selection is crucial in reconstructive surgery, particularly for patients with clear Hunner lesions and small bladder capacity who have not responded to previous treatments. Furthermore, it is vital to consider the patients' expectations and preferences adequately. Based on a comprehensive review of the literature and our own clinical experiences, subtotal cystectomy followed by bladder augmentation is considered a safe and effective surgical option. This stepwise and tailored therapeutic approach aims to optimize patients' quality of life by specifically targeting Hunner-type IC.

Cystoscopy, an indispensable tool for the diagnosis and prognosis of bladder pain syndrome, takes nomograms for predicting recurrence

PURPOSE

We aimed to illustrate the importance of cystoscopy for the diagnosis and prognosis of bladder pain syndrome (BPS) or interstitial cystitis (IC).

METHODS AND MATERIALS

We designed a 4-year prospective follow-up study. Patients who underwent cystoscopy between May 2011 and July 2021 with a diagnosis of BPS/IC before surgery or positive cystoscopic findings during initial surgery at Peking University People's Hospital were enrolled. Data related to symptom recurrence were obtained through clinic visits and telephone follow-up. We compared the differences in clinical features of BPS/IC subtypes differentiated by cystoscopy and first created clinical predictive nomograms for BPS/IC.

RESULTS

A total of 141 patients were included. There was an 8.51% chance of BPS/IC being misdiagnosed as other diseases or other diseases being misdiagnosed as BPS/IC without cystoscopy. Patients with HIC had higher pain scores and ICPI, higher residual urine volume, lower first-sense-to-void, and maximum cystometric bladder capacities than NHIC. Nomogram Models showed that patients who with higher ICPI, ICSI and lower AMBC have a greater recurrence probability, and lesions in the trigone may indicate a greater likelihood of recurrence than lesions in other bladder walls.

CONCLUSIONS

Timely detection of bladder cancer and other diseases using cystoscopy can avoid poor treatment effects. BPS/IC subtypes can be classified according to mucosal changes under cystoscopy. Lesions in the bladder triangle can indicate a higher recurrence risk, which is important in follow-up treatment. We strongly recommend that cystoscopy should be included in the international BPS/IC diagnostic criteria.

Diagnostic and therapeutic cystoscopy in bladder pain syndrome/interstitial cystitis: systematic review of literature and consensus on methodology

INTRODUCTION AND HYPOTHESIS

Cystoscopy has been routinely performed in patients suspected to be suffering from bladder pain syndrome/interstitial cystitis (BPS/IC) across the globe. The methodology reported by various guidelines appears to have differences in the techniques and hence there is a need for a review of all those techniques in order to arrive at a consensus. The aim was to review the literature describing the prevalent techniques of cystoscopy for patients of BPS/IC and try to evolve a consensus.

METHODS

The group the Global Interstitial Cystitis, Bladder Pain Society (GIBS) has worked collectively to systematically review the literature using the key words, "Cystoscopy in Hunner's lesions, bladder pain syndrome, painful bladder syndrome and interstitial cystitis" in the PubMed, COCHRANE, and SCOPUS databases. A total of 3,857 abstracts were studied and 96 articles referring to some part of technique of cystoscopy were short-listed for review as full-length articles. Finally, six articles with a description of a technique of cystoscopy were included for final tabulation and comparison. The group went on to arrive at a consensus for a stepwise technique of diagnostic and therapeutic cystoscopy in cases of BPS/IC. This technique has been compared with the previously described techniques and may serve to be a useful practical guide for treating physicians.

CONCLUSION

It is important to have a uniform standardized technique for performing a diagnostic and therapeutic cystoscopy in patients with BPS/IC. Consensus on one such a technique has been arrived at and described in the present article.

Safety of Human Embryonic Stem Cell-derived Mesenchymal Stem Cells for Treating Interstitial Cystitis: A Phase I Study

There are still no definite treatment modalities for interstitial cystitis (IC). Meanwhile, stem cell therapy is rising as potential alternative for various chronic diseases. This study aimed to investigate the safety of the clinical-grade mesenchymal stem cells (MSCs) derived from human embryonic stem cells (hESCs), code name MR-MC-01 (SNU42-MMSCs), in IC patients. Three female IC patients with (1) symptom duration >6 months, (2) visual pain analog scale (VAS) ≥4, and (3) one or two Hunner lesions <2 cm in-office cystoscopy within 1 month were included. Under general anesthesia, participants received cystoscopic submucosal injection of SNU42-MMSCs (2.0 × 107/5 mL) at the center or margin of Hunner lesions and other parts of the bladder wall except trigone with each injection volume of 1 mL. Follow-up was 1, 3, 6, 9, and 12 months postoperatively. Patients underwent scheduled follow-ups, and symptoms were evaluated with validated questionnaires at each visit. No SNU42-MMSCs-related adverse events including immune reaction and abnormalities on laboratory tests and image examinations were reported up to 12-month follow-up. VAS pain was temporarily improved in all subjects. No de novo Hunner lesions were observed and one lesion of the first subject was not identifiable on 12-month cystoscopy. This study reports the first clinical application of transurethral hESC-derived MSC injection in three patients with IC. hESC-based therapeutics was safe and proved to have potential therapeutic efficacy in IC patients. Stem cell therapy could be a potential therapeutic option for treating IC.

A Prospective Observational Study of the Recurrence Characteristics of Hunner Lesion After Repeated Transurethral Ablation in Patients With Interstitial Cystitis/Bladder Pain Syndrome

Purpose

The aim of this study was to investigate the rate and pattern of recurrence for patients with Hunner lesion (HL) type interstitial cystitis/bladder pain syndrome (IC/BPS) after transurethral ablation.

Methods

This prospective study included 210 patients with HL type IC/BPS. The primary outcomes were the recurrence rate according to three patterns of recurrence: pattern A (according to the relationship with the previous surgical site), pattern B (according to the bladder zone), and pattern C (according to the number of lesions). The secondary outcomes were recurrence-free time after treatment according to pattern A and pattern C.

Results

The pattern A recurrence rate was 50.8% in the same site (A1), 6.7% at a new site (A2), and 42.5% at mixed sites (A3). The pattern B recurrence rate was 10.5% for the anterior wall, 59.0% for the posterior wall, 69.5% for the lateral wall, and 69.0% for the dome area. Multiple lesions recurred as multiple lesions in 75.8% of cases. The pattern C recurrence rate was 10.8% for C1 (single → single), 6.7% for C2 (single → multiple), 6.7% for C3 (multiple → single) and 75.8% for C4 (multiple → multiple). The recurrence-free time in pattern A was 13 months for A1, 12.5 months for A2, and 8 months for A3, with a significant difference between A1 and A3 (p=0.008). There was no significant difference in recurrence-free time in pattern C, either with single or multiple HLs.

Conclusions

The distinct recurrence characteristics of HLs was not predictable despite repeated ablations. Complete remission should not be expected because the whole bladder was to have the potential to develop the HLs even after repeated transurethral ablation.

Possible Association between Bladder Wall Morphological Changes on Computed Tomography and Bladder-Centered Interstitial Cystitis/Bladder Pain Syndrome

This study aimed to evaluate the clinical significance of urinary bladder wall thickening on computed tomography (CT) among patients with interstitial cystitis/bladder pain syndrome (IC/BPS). Patients with IC/BPS were prospectively enrolled and classified into three groups according to bladder CT finding: smooth bladder wall, focal bladder thickening, and diffuse bladder thickening. Among the 100 patients with IC/BPS, 49, 36, and 15 had smooth bladder wall, focal bladder thickening, and diffuse bladder thickening on CT, respectively. Patients with Hunner’s lesion showed a higher proportion of diffuse and focal bladder thickening compared to those without the same (p < 0.001). Patients with diffuse bladder thickening displayed smaller first sensation of filling, cystometric bladder capacity, and voided volume compared to the rest (all p < 0.001). Patients with focal and diffuse thickening had a higher proportion of inflammatory cell infiltration, uroepithelial cell denudation, and granulation tissue compared to those with smooth bladder wall (p = 0.045, 0.002, and 0.005, respectively). Bladder wall thickening on CT was correlated with clinical phenotypes of IC/BPS, including histopathological findings. Focal or diffuse bladder wall thickening on CT might indicate the presence of chronic bladder wall inflammation and fibrosis and could be used to differentiate bladder-centered IC/BPS.