A new validated score for detecting patient-reported success on postoperative ICIQ-SF: a novel two-stage analysis from two large RCT cohorts

The Safety and Efficacy of Vascular-Targeted Photodynamic Therapy in Low-Risk Prostate Cancer

BACKGROUND

Prostate cancer (PCa) is one of the most prevalent cancers in the world. Standard methods of screening and diagnosis for prostate cancer have been effective but can result in overtreatment of indolent prostate cancer, leading to increased morbidity. Multiparametric magnetic resonance imaging (MRI) and fusion biopsy are effective tools to achieve better diagnostic accuracy. A combination of multiparametric MRI and photodynamic therapy can be used as an alternative to active surveillance in low-risk prostate cancer to better detect disease progression while avoiding overtreatment.

METHODS

We conducted a retrospective multicenter study on 13 patients with low-risk prostate cancer who underwent vascular-targeted photodynamic therapy. The patients were evaluated for up to 15 months after the procedure using biochemical parameters like serum Prostate Specific Antigen (PSA), digital rectal examination, multiparametric MRI, and functional parameters like the International Prostate Symptom Score (IPSS), the 15-question International Index of Erectile Function questionnaire (IIEF-5), quality of life score (QoL), the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and a uroflowmetry examination.

RESULTS

The patients did not experience any significant complications during or after the treatment. A decrease in serum PSA and prostate volume was observed from 7.38 ng/mL to 3.8 ng/ml with functional improvement evidenced by a decrease in the IPSS (from 15.4 to 11), QoL (from 3.15 to 2), and the IIEF-5 (from 17.23 to 16) score, and an improvement in uroflowmetry.

CONCLUSION

Vascular-targeted photodynamic therapy is a safe and effective alternative to active surveillance in patients with low-risk prostate cancer.

Psychosocial risk factors of lower urinary tract symptoms among working women

OBJECTIVES

Lower urinary tract symptoms (LUTS) are prevalent among women, affecting not only their physical well-being but also their quality of working life. This study aimed to assess the relationship between psychosocial factors at work and LUTS among working women. Additionally, we sought to investigate whether women with psychosocial risk factors at work reported reduced quality of life (QOL) and a higher degree of productivity loss from absenteeism and presenteeism.

METHODS

An online survey was conducted to collect the demographic characteristics, occupational risk factors, and LUTS among employed Korean women. Shift work, weekly working hours, occupational stress, and emotional labor were surveyed as psychosocial risk factors at work. The association between psychosocial risk factors and LUTS was assessed using adjusted logistic regression. The relationships between psychosocial risk factors and LUTS-related outcomes, such as were examined using a generalized linear model.

RESULTS

Of the 1057 participants, 260 (24.6%) and 294 (27.81%) had overactive bladder and urinary incontinence, respectively. Job stress, emotional labor, and night-shift work are significantly associated with a higher prevalence of LUTS, which reduce workers' QOL and labor productivity through absenteeism and presenteeism due to urination symptoms.

CONCLUSIONS

Psychosocial factors at work, particularly job stress, emotional labor, and night-shift work, were significantly associated with a higher prevalence of LUTS, leading to reduced QOL and labor productivity due to urination symptoms.

Non-inferiority, randomised, open-label clinical trial on the effectiveness of transurethral microwave thermotherapy compared to prostatic artery embolisation in reducing severe lower urinary tract symptoms in men with benign prostatic hyperplasia: study protocol for the TUMT-PAE-1 trial

BACKGROUND

One-fourth of men older than 70 years have lower urinary tract symptoms (LUTS) that impair their quality of life. Transurethral resection of the prostate (TURP) is considered the gold standard for surgical treatment of LUTS caused by benign prostatic hyperplasia (BPH) that cannot be managed conservatively or pharmacologically. However, TURP is only an option for patients fit for surgery and can result in complications. Transurethral microwave thermotherapy (TUMT) and prostatic artery embolisation (PAE) are alternative minimally invasive surgical therapies (MISTs) performed in an outpatient setting. Both treatments have shown to reduce LUTS with a similar post-procedure outcome in mean International Prostate Symptom Score (IPSS). It is however still unknown if TUMT and PAE perform equally well as they have never been directly compared in a randomised clinical trial. The objective of this clinical trial is to assess if PAE is non-inferior to TUMT in reducing LUTS secondary to BPH.

METHODS

This study is designed as a multicentre, non-inferiority, open-label randomised clinical trial. Patients will be randomised with a 1:1 allocation ratio between treatments. The primary outcome is the IPSS of the two arms after 6 months. The primary outcome will be evaluated using a 95% confidence interval against the predefined non-inferiority margin of + 3 points in IPSS. Secondary objectives include the comparison of patient-reported and functional outcomes at short- and long-term follow-up. We will follow the patients for 5 years to track long-term effect. Assuming a difference in mean IPSS after treatment of 1 point with an SD of 5 and a non-inferiority margin set at the threshold for a clinically non-meaningful difference of + 3 points, the calculated sample size was 100 patients per arm. To compensate for 10% dropout, the study will include 223 patients.

DISCUSSION

In this first randomised clinical trial to compare two MISTs, we expect non-inferiority of PAE to TUMT. The most prominent problems with MIST BPH treatments are the unknown long-term effect and the lack of proper selection of candidates for a specific procedure. With analysis of the secondary outcomes, we aspire to contribute to a better understanding of durability and provide knowledge to guide treatment decisions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05686525. Registered on January 17, 2023, https://clinicaltrials.gov/study/NCT05686525 .

Urinary Incontinence Care-Seeking Barriers Among Latina Patients: What Are We Missing?

IMPORTANCE

The Latina population is the largest growing ethnic group in the United States with high levels of health disparities in urinary incontinence (UI) treatment and complications rates, which may be due to disproportionately high barriers to UI care-seeking among Latinas.

OBJECTIVES

The objectives of this study were to compare barriers to UI care-seeking among Latina, non-Latina Black, and non-Latina White patients by utilizing the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q) total scores, and to compare specific barriers utilizing BICS-Q subscales.

STUDY DESIGN

In this cross-sectional study, patients accessing primary care were recruited to complete the BICS-Q, International Consultation on Incontinence Questionnaire-Short Form, and Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence. The BICS-Q total and subscale scores were compared among ethnic/racial groups.

RESULTS

A total of 298 patients were included in the study with 83 Black, 144 Latina, and 71 White participants per self-identified ethnicity/race. The total BICS-Q score was highest for Latina participants, followed by White and Black participants (11.2 vs 8.2 vs 4.9, respectively, P < 0.0001). Latina participants had significantly higher BICS-Q subscale scores compared with Black participants with no significant differences between Latina and White participants. After controlling for potential confounders, Latina ethnicity/race was still associated with a higher BICS-Q score when compared to Black ethnicity/race (P = 0.0077), and lower Prolapse and Incontinence Knowledge Questionnaire-Urinary Incontinence scores remained independently associated with higher BICS-Q scores (P = 0.0078).

CONCLUSIONS

In our study population, Latina patients and patients with lower UI knowledge experience higher barriers to UI care-seeking compared with Black patients and patients with higher UI knowledge. Addressing these barriers may increase care-seeking and improve health equity in the field.

Comparing Patient-Reported Outcome Measures for Pain in Women With Pelvic Floor Disorders: A Scoping Review

Women with pelvic floor disorders (PFDs) typically undergo surgery involving transvaginal mesh implants; however, transvaginal mesh surgery is associated with many adverse events including post-surgical pain. Assessment of pain as a symptom is necessary using patient-reported outcome measures (PROMs). This scoping review aimed to describe and compare existing PROMs previously used to measure pain in women with PFDs. A scoping search of Ovid MEDLINE, EMBASE, CINAHL Plus, Ovid PsycInfo, and grey literature was conducted. Studies published in English describing the development, implementation, and application of PFD-associated pain PROMs among adult women before and after pelvic floor surgery were included. From each article, a descriptive summary organised by study first author, publication year, country, setting, aim, study characteristics, and results were extracted. From 2,604 articles identified, 54 studies were included, describing 44 PROMs. Most studies described at least 2 to 3 instruments. The Pelvic Floor Distress Inventory-20 was most commonly described by 12 studies followed by the Patient Global Impression of Improvement scale. Of the 44 PROMs, 27 were condition-specific, of which 9 included items on pain; 17 generic PROMs, 4 of which contained items on pain; and 6 pain-specific PROMs. PROMs identified in our review measured pain not related to PFDs or pelvic floor surgery and quantified the pain experienced. These PROMs did not measure all areas of pain including region, sensation, impact, and triggers. The findings of this review will assist with developing a new pain-specific PROM in this population. PERSPECTIVE: Women with pelvic floor disorders often undergo surgery involving transvaginal mesh, from which they experience debilitating pain. Pain is a major issue impacting women's lives. Patient-reported outcome measures can be used to assess the pain; however, it is unclear whether existing instruments are relevant.

Minimally Invasive Treatment of Stress Urinary Incontinence in Women: A Prospective Comparative Analysis between Bulking Agent and Single-Incision Sling

INTRODUCTION

The study aims to compare the efficacy and safety of bulking agents and single-incision slings in the treatment of urinary incontinence in 159 patients during a 29-month follow-up period.

MATERIAL AND METHODS

Of the 159 patients suffering from stress urinary incontinence, 64 were treated with bulking agents (PAHG Bulkamid®) and 75 with a single-incision sling (Altis®). The ICIQ-UI-SF (Incontinence Questionnaire-Urine Incontinence-Short Form), PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaires short form), FSFI (Female Sexual Function Index), FSDS (Female Sexual Distress Scale), and PGI-I (Patient Global Improvement Index) were used to assess efficiency and quality of life.

RESULTS

The bulking agents showed high efficacy and safety during the 29-month follow-up. Post-operative complications were recorded in both groups, with only two significant differences. The Bulkamid group experienced no pain, while 10.8% of the ALTIS group experienced groin pain and 5% experienced de novo urgency. Furthermore, patients treated with bulking agents experienced reduced nicturia (0.78 vs. 0.92 in patients treated with single-incision slings.). In both groups, we noticed a significant improvement in QoL (quality of life), with a halved ICIQ-UI-SF (International Consultation on Incontinence Questionnaire-Urine Incontinence-Short Form) score which was completed to assess the impact of urine symptoms. After 24 months of therapy, the Bulkamid group saw a decrease from 14.58 ± 5.11 at baseline to 5.67 ± 1.90 (p < 0.0001), whereas the ALTIS group experience a decrease from 13.75 ± 5.89 to 5.83 ± 1.78. Similarly, we observed an improvement in sexual function, with the number of sexually active patients increasing from 29 to 44 (56.4%) in the Bulkamid group (p = 0.041) and from 31 to 51 (61.7%) in the ALTIS group (p = 0.034). According to the most recent statistics, the PISQ-12, FSFI, and FSDS scores all demonstrated an improvement in women's sexual function.

CONCLUSIONS

In terms of efficacy and safety, bulking agents had notable results over the 29-month follow-up period. Furthermore, the patients treated with bulking agents reported a lower incidence of postoperative complications and a no discernible difference in terms of quality of life and sexual activity compared to the ones treated with single-incision slings. Bulking agents can be considered a very reliable therapeutic option based on accurate patient selection.

Effects of health education on women with urinary incontinence: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the effects of health education (HE) on urinary symptoms and quality of life in women with urinary incontinence (UI).

METHODS

A systematic review and meta-analysis of trials evaluating HE for women with UI. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials.

RESULTS

The search identified 5,118 articles. Eighteen papers were considered eligible. The interventions investigated included health education (HE), combined intervention, self-management (SM), and structured training (ST). Outcomes included quality of life (QoL), UI frequency, UI severity, impression of improvement, incontinence symptoms, urine leakage, fear of leakage, urgency, and incontinence impact. Compared with the control group there was a significant improvement in the frequency, severity, and impact on the QoL for women with UI (assessed by the total score of the International Consultation on Incontinence Questionnaire Short Form (ICIQ SF); RR = -1.47, 95% CI [-2.07, -0.88]; two trials; low certainty of the evidence).

CONCLUSIONS

This review shows that HE seems to be beneficial in the treatment of women with UI when compared with control women (no treatment or general health care), improving the frequency, severity, and impact on QoL assessed by the ICIQ SF total score. However, the certainty of this evidence is low.

Does Significant Weight Loss After Bariatric Surgery Affect Sexual Function and Urinary Symptoms? An Iranian Study

INTRODUCTION

For sexual dysfunction and lower urinary tract symptoms (LUTS), obesity is identified as an independent risk factor. The current study aimed to evaluate the effect of significant rapid weight loss by bariatric surgery on LUTS and sexual function among men and women with class III obesity.

METHOD

A group of patients who were planned to undergo bariatric surgery was enrolled in the study. Male patients were given the International Index of Erectile Function (IIEF) and the International Prostate Symptom Score (IPSS) questionnaires. In the female group, they filled in the female sexual function index (FSFI) and the International Consultation on Incontinence Questionnaire short form (ICIQ-SF) questionnaires. Patients were followed up 1 year after their bariatric surgery.

RESULTS

All questionnaires were completed by eighty-one patients. (mean age ± SD: 39.4 ± 9.2 years; mean body mass index (BMI) ± SD: 47.15 ± 5.4 kg/m2). The total score of the IPSS questionnaire decreased from 5.83 ± 3.01 preoperatively to 2.37 ± 1.66 postoperatively. The weight loss caused significant improvement in the storage phase of LUTS domains, but there were no considerable changes in the voiding phase. In the IIEF questionnaire, domains of sexual desire, overall satisfaction, and orgasmic function improved significantly. There was not a significant change in any FSFI domains after bariatric surgery. Mean ICIQ-SF decreased, but it was not substantial.

CONCLUSION

Bariatric surgery can significantly improve the storage phase in men, but not the voiding phase. Sexual desire, orgasmic function, and overall satisfaction were significantly improved in men. No significant improvement in sexual function and UI in women was observed.

POSTPROSTATECTOMY CONTINENCE AFTER FUNCTIONAL MAGNETIC PELVIC STIMULATION

Although radical prostatectomy is considered the gold standard for optimal treatment of localized prostate cancer, this radical surgery carries a significant risk of erectile dysfunction and urinary incontinence which can be present as transient or permanent side effects in many patients. We have made significant advances in diagnostic and surgical approach to prostate cancer, using a number of new methods that are becoming increasingly available, resulting in better treatment outcomes. However, we still do not use all the possibilities for the prevention and treatment of these side effects, probably due to their insufficient research, or unclear effectiveness. Functional magnetic stimulation is a method used to treat a large number of diseases, i.e., to alleviate their symptoms and ailments. Its role through pelvic stimulation has been proven in the treatment of incontinence in women, and in our study, we want to determine its role in more detail, primarily in the treatment of urinary incontinence in patients after prostate cancer surgery. In case of positive results, this method may be recommended for wider use in patients with adverse effects of radical prostatectomy.

Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence

OBJECTIVE

To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC).

METHODS

A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis.

RESULTS

Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure.

CONCLUSION

This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.

Autologous adipose-derived mesenchymal stem cell therapy reverses detrusor underactivity: open clinical trial

BACKGROUND

Detrusor underactivity is a disease that can cause chronic urinary tract infection, urinary tract infection, urinary retention and kidney failure and has no effective treatment in traditional medicine. The present research evaluated the effects of cell therapy with adipose tissue-derived stem cells on the treatment of detrusor underactivity in men.

METHODS

Nine male patients diagnosed with a clinical and urodynamic diagnosis of detrusor underactivity were evaluated and underwent two transplants via cystourethroscopy, with 2 × 10⁶ cells/transplant, performed by intravesical injection at five points on the bladder body above the vesical trigone.

RESULTS

Cell therapy increased the maximum flow from 7.22 ± 1.58 to 13.56 ± 1.17, increased the mean flow from 3.44 ± 0.74 to 5.89 ± 0.45, increased the urinated volume from 183.67 ± 49.28 to 304.78 ± 40.42 and reduced the residual volume in the uroflowmetry exam from 420.00 ± 191.41 to 118.33 ± 85.51; all of these changes were significant (p < 0.05). There were also significant increases (p < 0.05) in maximum flow (from 7.78 ± 0.76 to 11.56 ± 1.67), maximum detrusor pressure (from 20.22 ± 8.29 to 41.56 ± 5.75), urinary volume (from 244 ± 27.6 to 418.89 ± 32.73) and bladder contractility index (from 44.33 ± 4.85 to 100.56 ± 8.89) in the pressure flow study. Scores on the International Consultation on Incontinence Questionnaire decreased from 11.44 ± 1.43 to 3.78 ± 0.78 after cell therapy, which indicates an improvement in quality of life and a return to daily activities. No complications were observed in the 6-month follow-up after cell therapy. Before treatment, all patients performed approximately five intermittent clean catheterizations daily. After cell therapy, 7/9 patients (77.78%) did not need catheterizations, and the number of catheterizations for 2/9 patients (22.28%) was reduced to two catheterizations/day.

CONCLUSIONS

The results indicate that stem cell therapy led to improvements in voiding function. Cell therapy with adipose tissue-derived stem cells is safe and should be considered a new therapeutic option for the treatment of detrusor underactivity. Trial registration ISRCTN, ISRCTN23909398; Registered 15 March 2021-Retrospectively registered, https://doi.org/10.1186/ISRCTN23909398.

The effect of 12 weeks of estriol cream on stress urinary incontinence post-menopause: A prospective multinational observational study

OBJECTIVE

To quantitate the changes in stress urinary incontinence (SUI) outcome measures after 12 weeks of vaginal estriol cream in women with stress incontinence.

METHODS

A prospective multicentre observational study conducted in tertiary urogynaecology centers. Postmenopausal women with pure SUI or stress predominant mixed urinary incontinence (MUI), not receiving any other treatment for their incontinence were given written instructions regarding digital application of a standard dose of vaginal estriol cream. Outcomes were measured at baseline and 12 weeks. The primary objective outcome was vaginal pH. The primary subjective outcome was the stress domain of the Urogenital Distress Inventory-6 (UDI-6). The secondary objective outcome used was the erect cough stress test. Two quality of life questionnaires and two patient reported outcomes were also included.

RESULTS

The 46 postmenopausal recruits had a median age of 62.1 interquartile range (IQR 56.2-65.4). At follow up, the primary subjective outcome SUI domain [UDI-6] significantly improved from 83.3 (IQR 50-100) to 33.3 (33.3-66.7, p ≤ 0.001) as did vaginal pH [from 5.1 (4.9-5.9) to 4.9 (4.6-5.0] p ≤ 0.001; 18/43 patients (42%) were dry on cough stress test.

CONCLUSIONS

Twelve weeks of vaginal estriol cream significantly reduced symptoms of stress urinary incontinence in this sample of postmenopausal women.

Urologic latency time during uroflow stop test with electromyography: an incontinence detector in rehabilitation after robotic radical prostatectomy

BACKGROUND

Stress urinary incontinence (UI) is the most common presentation following robot-assisted radical prostatectomy (RARP), but a postoperative non-invasive and objective test is still lacking. To assess pelvic floor integrity after RARP, we recently proposed Uroflow Stop Test (UST) with surface electromyography (EMG).

AIM

Here we provide two new clinical parameters: the neurologic latency time (NLT) and the urologic latency time (ULT) derived from UST-EMG Test. Principal outcome was to evaluate their variation during one year follow-up and ULT ability to predict post-RARP UI.

DESIGN

Observational and longitudinal study.

SETTING

Interdivisional Urology Clinic (Perugia-Terni, Italy).

POPULATION

Patients with prostate cancer treated with a full nerve-sparing RARP who underwent postoperative pelvic floor muscles training (PFMT): a diurnal functional home program and a weekly hospital program with the use of biofeedback, between 1 and 3 months postoperatively.

METHODS

All patients consecutively performed a UST-EMG test at one, three, six, and twelve months after surgery. At each follow-up visit we collected NLT values, ULT values, 5-item 26-Expanded Prostate Cancer Index (EPIC), Incontinence Developed on Incontinence Questionnaire (ICIQ-UI) Short Form and International Prostate Symptom Score (IPSS). We analysed statistically significant differences in NLT and ULT between continent and incontinent patients and we evaluate the diagnostic ability of 1-month post-surgery ULT value to diagnose the presence of postoperative UI.

RESULTS

Sixty patients were enrolled. The mean time to PFMT was 31.08 (range: 30-35) days. Overall IPSS, NLT and ULT had similar trends: progressive decrease until the six months after surgery (1-month vs. 3 months vs. 6 months, P<0.05) to plateau thereafter. When considering the two group of patients, IPSS and NLT were significantly higher in the incontinent group only one month after surgery, while ULT became similar between the two groups at 6 months after surgery. The best cut-off of 1-month ULT values that maximized the Youden function at 12-months resulted 3.13 second.

CONCLUSIONS

NLT and ULT may respectively account for the nerve and the urethral closure system integrity post-RARP. In the first month after RARP, both NLT and ULT differs between incontinent vs. continent patients. NLT become similar between two group after one month, confirming the recovery from neuropraxia, but ULT remains statistically significant different until 3 months postoperatively. The value of 1-month ULT resulted a valid tool to predict incontinence status at 12 months.

CLINICAL REHABILITATION IMPACT

ULT and NLT may be also useful tools to monitor the continence progressive recovery after RARP and they may help rehabilitation specialists to evaluate the ongoing results during postoperative follow-up.

Association between overweight, obesity, and quality of life of patients receiving an anticancer treatment for prostate cancer: a systematic literature review

BACKGROUND

Prostate cancer (PCa) and obesity are two ever-increasing public health issues that can independently impair the quality of life (QOL) of affected patients. Our objective was to evaluate the impact of overweight and obesity on the QOL of patients with PCa receiving an anticancer treatment.

METHODS

We performed a systematic review of the literature using PubMed, Embase, Cochrane Library and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The search equation targeted studies that included PCa patients who had a body mass index (BMI) greater than 25 kg/m², who were receiving anticancer therapy, and whose QOL was analyzed according to validated or non-validated scores.

RESULTS

Of 759 identified articles, we selected 20 studies published between 2000 and 2019 of 12,529 patients treated for PCa, including 5549 overweight or obese patients. QOL assessment was performed using nine validated scales and two non-validated questionnaires. Of seven studies on radiotherapy, six found obesity to have a negative impact on patients' QOL (especially urinary, sexual, and bowel-related QOL). Thirteen studies assessed the QOL of patients who underwent radical prostatectomy, with a BMI > 25 kg/m² having no observed impact. In obese patients under 65 years of age and without comorbidities, nerve-sparing surgery appeared to limit the deterioration of QOL. Four studies on brachytherapy found discordant results. One study showed greater QOL impairment in obese patients receiving first-generation hormone therapy than in those with normal or decreased BMI. No study evaluated the QOL of overweight or obese patients receiving other types of systemic treatment.

CONCLUSION

Based on the published data, the level of evidence for an association between QOL and overweight or obesity in patients treated for PCa is not high. Prospective cohort studies including this type of patient population are warranted to answer this topical public health issue.

Mesenchymal Stromal Cell Therapy Reverses Detrusor Hypoactivity in a Chronic Kidney Patient

Detrusor hypoactivity (DH) is characterized by low detrusor pressure or a short contraction associated with low urinary flow. This condition can progress to chronic renal failure (CRF) and result in the need for dialysis. The present case report demonstrates that a patient diagnosed with DH and CRF who received two transplants with 2 × 10⁶ autologous mesenchymal stromal cells at an interval of 30 days recovered the contractile strength of the bladder and normalized his renal function. The patient had a score of 19 on the ICIQ-SF before cell therapy, and that score was reduced to 1 after transplantation. These results demonstrate that there was an improvement in his voiding function, urinary stream and urine volume as evaluated by urofluxometry. In addition, a urodynamic study carried out after treatment showed an increase in the maximum flow from 2 mL/s to 23 mL/s, the detrusor pressure in the maximum flow from 21 cm H₂O to 46 cm H₂O and a BCI that went from 31 to 161, characterizing good detrusor contraction. Thus, in the present case, the transplantation of autologous mesenchymal stromal cells proved to be a viable therapeutic option to allow the patient to recover the contractile strength of the bladder, and reversed the CRF.

Effect of Electroacupuncture Added to Pelvic Floor Muscle Training in Women with Stress Urinary Incontinence: A Randomized Clinical Trial

BACKGROUND

Pelvic floor muscle training (PFMT) is a first-line conservative therapy for stress urinary incontinence (SUI). Electroacupuncture (EA) has been used to treat SUI recently.

OBJECTIVE

To compare the effectiveness of PFMT + EA versus PFMT + sham EA for SUI in women.

DESIGN, SETTING, AND PARTICIPANTS

A prospective, multicenter, randomized, controlled clinical trial was conducted at four hospitals in China involving 304 women with SUI from May 20, 2014 to November 21, 2017. Data were analyzed from April 20 to December 21, 2018.

INTERVENTION

Participants were randomized to receive 8 wk of PFMT+ EA (n = 154) or PFMT + sham EA (n = 150).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the change in the amount of urine leakage measured on a 1-hr pad test. Student's t test, the χ² test, and the Wilcoxon rank-sum test were used for data analysis.

RESULTS AND LIMITATIONS

Among the 304 participants randomized, 286 completed the study. The mean age was 57.6 yr (standard deviation [SD] 8.9) for the PFMT + sham EA group and 57.2 yr (SD 9.1) for the PFMT + EA group. The mean urine leakage at baseline was 13.6 g for the PFMT + sham EA group and 13.9 g for the PFMT + EA group. After the 8-wk intervention, the PFMT + EA group had a greater decrease in mean urine leakage (-9.8 g) than the PFMT + sham EA group (-5.8 g) with a mean difference of 4.0 g (95% confidence interval [CI] 0.8-7.2). Significantly more patients experienced a ≥50% reduction in urine leakage and the mean number of incontinence episodes in 24 h in the PFMT + EA group than in the PFMT + sham EA group (26.3%, 95%CI 15.8-36.8%). The PFMT + EA group experienced better improvement in participant-reported SUI severity at 6 wk (p < 0.001) and 8 wk (p < 0.001) and self-evaluated therapeutic effects at 2-32 wk (p < 0.001) after the intervention. Lack of measurement of the amount of urine leakage during follow-up is a limitation.

CONCLUSIONS

In this randomized clinical trial, 8-wk combined treatment with PFMT + EA led to a greater improvement in SUI symptoms and better outcomes than with PFMT + sham EA.

PATIENT SUMMARY

We evaluated the effectiveness and safety of pelvic floor muscle training combined with electroacupuncture for stress urinary incontinence in women, Our results show that this is a promising therapeutic approach for the treatment of stress urinary incontinence.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery - Non-inferiority study

OBJECTIVE

Urinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery.

STUDY DESIGN

A sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection.

RESULTS

Women suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007.

CONCLUSION

Femistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Efficacy and patient acceptability of the continence dish

INTRODUCTION AND HYPOTHESIS

The continence dish has been a treatment option since 2002 for women with stress urinary incontinence (SUI) who decline surgery, but few quantitative objective efficacy data are published. We aimed to determine the efficacy and acceptability of this device for pure SUI or mixed incontinence (MUI).

METHODS

Prospective interventional cohort study of 100 women with SUI or stress-predominant MUI who were interested to use the device; International Consultation on Incontinence Questionnaire (ICIQ) was primary outcome measure; 24-h pad test and Incontinence Impact Questionnaire (IIQ) were secondary outcomes. Acceptability was determined by device retention for 4 weeks, adverse events and ability to self-insert the device.

RESULTS

Of 100 suitable women, 9 were not actually fitted, and 27 did not complete (acceptability: 64/100). The rate of adverse events was 7.7%, with 62.5% of users able to self-insert the device: 22 (34%) had pure SUI; 66% had MUI. In SUI, 68% were 'dry' on ICIQ median value 4.0 (IQR 2.5-8.5); 88% were dry on 24-h pad test (median 0.0, IQR 0.0-8.5). The "dry rate" was lower in MUI: 36% for ICIQ (median 9.0, IQR 5.0-15.0) and 62% for 24-h pad test (median 6.2, IQR 0.95-19.7). A "good" response on IIQ occurred in 88% of SUI and 69% of MUI.

CONCLUSION

These new data showing strong objective benefits of the continence dish should be further validated by randomized trials, but this information should be made available to women seeking treatment options for SUI/MUI (particularly in view of concerns regarding mesh mid-urethral slings).

Pelvic floor rehabilitation in the treatment of mixed urinary incontinence among women

Background

Mixed urinary incontinence (MUI) is a common underreported problem among females; it has a major effect on patients’ quality of life. Treatment may be difficult since a single modality cannot be enough to alleviate both the urge and the stress symptoms. Biofeedback-assisted pelvic floor muscle training (PFMT) has a great role in strengthening the pelvic floor muscles especially when accompanied by electrical stimulation. Neuromodulation is another safe well-tolerated method that may improve symptoms of female voiding dysfunction. There are no previous studies that assessed the efficacy of biofeedback-assisted pelvic floor muscle training versus two different types of peripheral neuromodulation which are transcutaneous posterior tibial nerve stimulation (TPTNS) and anogenital neuromodulation in the treatment of mixed urinary incontinence among women. The aim of this work is to study the effectiveness of biofeedback-assisted pelvic floor muscle training with electrostimulation versus two different methods of peripheral neuromodulation techniques in the treatment of women with MUI. Patients were subjected to history taking, assessment questionnaires (Questionnaire for female Urinary Incontinence Diagnosis (QUID), Australian Pelvic Floor Questionnaire (PFQ), and International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF)), clinical examination, and manometric pressure assessment. The patients were allocated randomly into three groups. Group I received biofeedback-assisted pelvic floor muscle training and faradic electrical stimulation, group II received posterior tibial neuromodulation, and group III received anogenital neuromodulation.

Results

The present study included 68 non-virgin female patients with mixed urinary incontinence. Significant improvement was noticed in the three studied groups on the subjective and objective levels. No statistically significant difference was reported between the studied groups following the different types of intervention.

Conclusions

Biofeedback-assisted pelvic floor muscle training with electrostimulation is as effective as anogenital neuromodulation and posterior tibial neuromodulation in the treatment of mixed urinary incontinence among females.

Trial registration

PACTR, PACTR202107816829078. Registered 29 July 2021 - Retrospectively registered.

Holmium:YAG Laser for the Treatment of Genital and urethral Warts: Multicentre Prospective Evaluation of Safety and Efficacy

Introduction: Genital condylomatosis is a highly contagious disease caused by the human papilloma virus (HPV). The aim of this prospective multicentre study was to evaluate the safety and efficacy of the Holmium:YAG (yttrium-aluminium-garnet) laser in the treatment of genital and intra-urethral warts; the secondary aim was to assess the patients' postoperative satisfaction and cosmetic results. Methods: From December 2016 to March 2019, patients with genital warts were prospectively enrolled in three hospitals. The inclusion criteria were male gender, age over 18 years-old and treatment-naïve. External and urethral genitalia warts were treated by the Holmium YAG laser. The follow-up analysis consisted of physical examination, flexible urethro-cystoscopy in case of meatal lesions, and administration of Dermatology Quality of Life Index (DLQI) and Patient Global Impression of Improvement (PGI-I) questionnaires at 1, 3, 6 and 12 months after surgery and subsequently yearly. Results: Sixty patients were enrolled. The single treatment was effective in 57/60 patients (95%). At a mean follow-up of 26 months, recurrences occurred in 8 patients (13.3%). No peri- or post-operative complication occurred. An improvement in pre-operative condition was highlighted with PGI-I and DLQI questionnaires. Conclusion: Our prospective multicentre study showed that holmium laser surgery seems to be a safe and effective treatment for external genital and urethral warts. Good dermatological outcomes aid to further improve patient satisfaction.

Development and Usability Testing of a Mobile Application to Monitor Patient-Reported Outcomes after Stress Urinary Incontinence Surgery

OBJECTIVE

To develop and perform a usability testing of a mobile application (app) with representative users of surgeons and female patients undergoing stress urinary incontinence (SUI) surgery.

METHODS

A mobile app was developed with the Medical Device Epidemiology Network (MDEpiNet) High-Performance Integrated Virtual Environment (HIVE) to streamline the collection of patient-reported outcomes following SUI surgery using validated questionnaires. It was designed as a collaborative effort with the Women's Health Initiative (WHI), including patient and surgeon involvement. The app evaluation questions addressed the user's rating on the clarity and length of the questions and the comfort level in using the interface for patients to report post-operative outcomes and surgeons to review them.

RESULTS

A total of twenty patients and 5 surgeons tested the mobile app and reported their experience and level of satisfaction. The average patient experience score was 9 out of ten, with ten being the best. Eleven patients (55%) were interested in replacing in-person follow-up visits with the app. The surgeons reported an average user experience score of 8.6 out of ten. Four surgeons (80%) were interested in replacing in-person visits with the app. The combined experience score between all users was 8.9 out of ten. Fifteen out of twenty-five users (60%) showed interest in replacing in-person visits with the app.

CONCLUSION

The mobile app for SUI captured important patient-reported outcomes with a high satisfaction reporting from patients and surgeons.

Preliminary report of post-Ophira mini sling implantation voiding pattern: What to learn from pressure-flow studies?

BACKGROUND

The study is amined to correlate the voiding pattern after successful mini sling Ophira implantation with postoperative symptoms and satisfaction, in addition to identifying obstructions.

MATERIALS AND METHODS

From 2012 to 2015 in a single institution, all consecutive patients who had stress urinary incontinence treated by using the mini sling Ophira had a pre- and 12 months postoperative urodynamic test. The International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF) and the International Consultation on Incontinence Questionnaire - Overactive Bladder (ICIQ-OAB) translated into Portuguese, were given. Patients were objectively considered cured when presenting no urinary incontinence at the Valsalva test and subjectively cured when the ICIQ-UI-SF was zero.

RESULTS

Questionnaire scores were obtained from 29 patients and urodynamic data from 20 patients. Mini sling Ophira implantation resulted in a significant improvement of urinary symptoms evidenced by a significant mean reduction in ICIQ-UI-SF from 16 to 5 (p < 0.0001) and ICIQ-OAB from 8 to 4 (p = 0.0001). The subjective and objective cure rates were 55% and 45%, respectively. The urodynamic changes were not related to success even when adjusted for age, hormonal status, or anterior pelvic organ prolapse. The mean maximum flow decreased to 4.9 mL/s (95% CI: 0.62-10.8; p = 0.035), and the mean detrusor pressure at maximum flow increased to 11.4 cmH2O (95% CI: 4-18; p = 0.0078).

CONCLUSIONS

Mini sling Ophira implantation decreased maximum urinary flow and increased the detrusor pressure at the maximum urinary flow and these urodynamic changes were not related to success.

A systematic review of utility-based and disease-specific quality of life measurement instruments for women with urinary incontinence

AIM

This systematic review aims to identify disease-specific and generic quality of life (QoL) outcome measurement instruments used in populations of women with urinary incontinence (UI) and to determine the most psychometrically robust and appropriate disease-specific and generic tools for measuring the quality of life in this population.

METHODS

A systematic search was conducted of PubMed, Embase, SCIELO, and CINAHL databases for studies evaluating measurement properties of QoL instruments in women with UI. The methodological quality of studies and the quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement INtruments (COSMIN) checklist and quality criteria. Overall, evidence for measurement properties was graded using the modified grading of recommendations, assessment, development & evaluation approach.

RESULTS

A total of 73 studies were included, and 27 specific and 6 generic instruments were identified. The Incontinence QoL questionnaire (IQoL) had the highest overall psychometric quality for English-speaking populations and was the most widely translated tool. Evidence for generic QoL tools in this population is limited. Few studies evaluated measurement error or cross-cultural validity.

CONCLUSION

The IQoL is the most psychometrically robust disease-specific tool for use in this population. More research is needed to determine the most psychometrically robust generic tool. Future studies should also evaluate measurement error and cross-cultural validity as evidence for these properties is particularly lacking.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study

BACKGROUND

There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making.

OBJECTIVE

This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling.

STUDY DESIGN

A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding.

RESULTS

The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00).

CONCLUSION

This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Prophylactic intravenous gentamicin with sedation-free cystoscopic injection of BoNT-A: No demonstrable adverse extravesical neuromuscular effects in a pilot safety study of 220 idiopathic overactive bladder patients

Objectives:

To determine whether administration of single dose prophylactic intravenous gentamicin prior to intravesical injection of botulinum toxin type A (BoNT-A) is associated with adverse extravesical neuromuscular effects in idiopathic overactive bladder syndrome.

Patients and methods:

A retrospective analysis of 220 consecutive idiopathic overactive bladder patients following sedation-free flexible cystoscopic injection of intravesical BoNT-A. All patients received a single dose of intravenous gentamicin (160 mg) followed by 100-200 IU of BoNT-A. They were followed up at intervals to determine whether they had experienced any adverse extravesical neuromuscular side effects.

Results:

None of our patients developed adverse extravesical neuromuscular side effects from intravesical botulinum injections with concomitant administration of intravenous gentamicin.

Conclusion:

Single dose intravenous gentamicin is safe to use as a prophylaxis for intravesical BoNT-A injections of 200 IU or below in idiopathic overactive bladder patients.

Level of evidence:

Not applicable.

Identification of the Urogenital Distress Inventory-6 and the Incontinence Impact Questionnaire-7 cutoff scores in urinary incontinent women

Purpose

Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7) and The International Consultation on Incontinence (ICIQ-SF) Short Form are used to diagnose individuals with urinary incontinence (UI) and to assess the impact of the dysfunction on patient quality of life. While ICIQ-SF has fixed cutoff values—UDI-6 and IIQ-7 do not. We aimed to find the cutoff scores for UDI-6 and IIQ-7 in women with UI.

Methods

The study involved 205 women aged between 31 and 83 years—155 with, and 50 without UI symptoms. All participants completed all three questionnaires: ICIQ-SF, UDI-6 and IIQ-7. Patients were categorized according to their ICIQ-SF scores, as symptomatic ICIQ-SF ≥ 6 (n = 134) and asymptomatic ICIQ < 6 (n = 60). The Receiver Operating Characteristics (ROC) curve was used to test how well UDI-6 allowed a discrimination between patients suffering from UI and those who do not. Area under Curve (AUC) statistic was calculated to measure the UDI-6 and IIQ-7 Total Score efficiency.

Results

The cutoff values were selected. On the basis of the ROC curve analysis, the UDI-6 Total Score of 33.33 and IIQ-7 Total Score of 9.52 were determined to be the optimal cutoff for distinguishing between symptomatic and asymptomatic women (AUC = 0.94-UDI-6 and 0.91-IIQ-7).

Conclusions

For UDI-6 scores more than 33.33 indicate higher distress caused by UI symptoms. Moreover, the higher impact of UI on health- related quality of life is seen in women who scored 9 or more in the IIQ-7 questionnaire, and such women felt impaired quality of life.

Trial registration number NCT04433715, 11.06.2020 “retrospectively registered”.

Impact of vesicovaginal fistula repair on urinary and sexual function: patient-reported outcomes over long-term follow-up

INTRODUCTION AND HYPOTHESIS

While the anatomical closure rates of vesicovaginal fistula (VVF) following transabdominal (TA) and transvaginal (TV) repairs seem comparable, studies comparing urinary and sexual outcomes following successful repair are lacking. We aimed to report patient-reported outcomes on sexual and urinary functions after long-term follow-up with successful repair.

METHODS

We retrospectively reviewed 81 women who had successful VVF repair at our institute. Pre-, intra- and post-operative details were retrieved from electronic data software. Patient-reported sexual and urinary function outcomes were assessed using the Female Sexual Function Index (FSFI) questionnaire and International Consultation of Incontinence Questionnaire-Short Form (ICIQ-SF), respectively, at last follow-up. We also compared such outcomes among TA and TV repairs.

RESULTS

Of 81 women, 28 (34.6%) had TA and 53 (65.4%) had TV repairs. Mean age was 37.5 years and mean fistula diameter was 12.9 mm. The most common aetiology was hysterectomy. Thirty-three patients (40.7%) had previous failed repairs. At a mean follow-up of 29.8 months, 24 (34.3%) women had sexual dysfunction and 15 (18.5%) women experienced urinary dysfunction. The TA and TV groups had comparable mean FSFI scores (28.7 ± 6.1 vs. 30.9 ± 5.2, p = 0.13) and ICIQ-SF scores (0.7 ± 1.7 vs. 0.5 ± 1.4, p = 0.59). In multivariate analysis, fistula size and site were significant predictors of urinary dysfunction whereas multiparity was the most significant predictor of sexual dysfunction.

CONCLUSIONS

Sexual and urinary dysfunction is found in a considerable number of women after VVF repair. However, our data suggest comparable long-term sexual and continence outcomes between TA and TV repairs.

Satisfaction and Regret Following Uterosacral Ligament Suspension and Sacrocolpopexy: A Prospective Multicenter Analysis From the Fellows' Pelvic Research Network

OBJECTIVES

The primary objective was to compare levels of satisfaction, regret, and Patient Global Impression of Improvement (PGI-I) scores between women who underwent vaginal uterosacral ligament suspension (USLS) and minimally invasive sacrocolpopexy (SCP). Secondary objectives were to identify which preoperative counseling resources were most useful.

METHODS

This was a multicenter, retrospective cohort study through the Fellows' Pelvic Research Network that included women who underwent a USLS or SCP between January 2013 and January 2016 with 1-year follow-up. Women completed the Decision Regret Scale for Pelvic Floor Disorders, Satisfaction with Decision Scale for Pelvic Floor Disorders, and PGI-I. Data were also collected on usefulness of various educational preoperative resources.

RESULTS

A total of 175/367 (47.6%) women participated; 45 (25.7%) and 130 (74.3%) in the USLS and SCP groups, respectively. Mean Decision Scale for Pelvic Floor Disorders scores were 4.6 ± 0.8 and 4.5 ± 0.7 (P = 0.30) in the USLS and SCP groups, respectively, indicating a high level of satisfaction with surgical decision. The mean Decision Regret Scale for Pelvic Floor Disorders score was 1.5 ± 0.8 in USLS and 1.6 ± 0.8 in SCP (P = 0.53). The SCP group had higher PGI-I scores (1.7 ± 1.4 vs 2.0 ± 1.3, P = 0.02), indicating lower perceived postoperative improvement. Most women (151 [86.3%] of 175) reported that verbal counseling was sufficient and would not have found additional resources helpful.

CONCLUSIONS

Women have high satisfaction and low regret with their decision to pursue surgical correction with USLS or SCP. Most are satisfied with only verbal preoperative counseling.

Er:YAG laser in hysterectomized women with stress urinary incontinence: a VELA retrospective cohort, non-inferiority study

Objective: To test whether the erbium-doped yttrium aluminum garnet (Er:YAG) SMOOTH^® laser treatment efficacy on stress urinary incontinence (SUI) in hysterectomized patients is non-inferior to its efficacy in non-hysterectomized patients.Methods: In this real-world, retrospective cohort study performed in Turkey, Croatia and Italy, we enrolled a consecutive sample of 35 hysterectomized and 34 non-hysterectomized patients with SUI. We used the Er:YAG SMOOTH^® laser (Fotona, Slovenia) with a wave length of 2940 nm. The primary outcome was median reduction of SUI symptoms measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short-Form (ICIQ-SF) with the non-inferiority margin defined as the minimum clinically important difference of ICIQ-SF (δ < 2.52 points).Results: In hysterectomized patients, the ICIQ-SF was reduced by 5 points (95% confidence interval 3-8; p < 0.001), a reduction of 45% (95% confidence interval 36-67%). After adjustment for baseline ICIQ-SF and five covariates, the reduction of symptoms in the hysterectomized group was not inferior to the reduction in the non-hysterectomized group.Conclusion: The Er:YAG SMOOTH^® laser treatment seems to improve the symptoms of SUI in hysterectomized women not clinically relevantly less than in non-hysterectomized women. It seems that the beneficial effect of Er:YAG SMOOTH^® laser treatment for SUI in hysterectomized women is time-limited.

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence

OBJECTIVES

To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

PATIENTS AND METHODS

Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

RESULTS

At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

CONCLUSIONS

Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

Surgical treatments for women with stress urinary incontinence: the ESTER systematic review and economic evaluation

BACKGROUND

Urinary incontinence in women is a distressing condition that restricts quality of life and results in a large economic burden to both the NHS and women themselves.

OBJECTIVE

To evaluate the clinical effectiveness, safety and cost-effectiveness of surgical treatment for stress urinary incontinence (SUI) in women and explore women's preferences.

DESIGN

An evidence synthesis, a discrete choice experiment (DCE) and an economic decision model, with a value-of-information (VOI) analysis. Nine surgical interventions were compared. Previous Cochrane reviews for each were identified and updated to include additional studies. Systematic review methods were applied. The outcomes of interest were 'cure' and 'improvement'. Both a pairwise and a network meta-analysis (NMA) were conducted for all available surgical comparisons. A DCE was undertaken to assess the preferences of women for treatment outcomes. An economic model assessed the cost-effectiveness of alternative surgeries and a VOI analysis was undertaken.

RESULTS

Data from 175 studies were included in the effectiveness review. The majority of included studies were rated as being at high or unclear risk of bias across all risk-of-bias domains. The NMA, which included 120 studies that reported data on 'cure' or 'improvement', showed that retropubic mid-urethral sling (MUS), transobturator MUS, traditional sling and open colposuspension were more effective than other surgical procedures for both primary outcomes. The results for other interventions were variable. In general, rate of tape and mesh exposure was higher after transobturator MUS than after retropubic MUS or single-incision sling, whereas the rate of tape or mesh erosion/extrusion was similar between transobturator MUS and retropubic MUS. The results of the DCE, in which 789 women completed an anonymous online questionnaire, indicate that women tend to prefer surgical treatments associated with no pain or mild chronic pain and shorter length of hospital stay as well as those treatments that have a smaller risk for urinary symptoms to reoccur after surgery. The cost-effectiveness results suggest that, over a lifetime, retropubic MUS is, on average, the least costly and most effective surgery. However, the high level of uncertainty makes robust estimates difficult to ascertain. The VOI analysis highlighted that further research around the incidence rates of complications would be of most value.

LIMITATIONS

Overall, the quality of the clinical evidence was low, with limited data available for the assessment of complications. Furthermore, there is a lack of robust evidence and significant uncertainty around some parameters in the economic modelling.

CONCLUSIONS

To our knowledge, this is the most comprehensive assessment of published evidence for the treatment of SUI. There is some evidence that retropubic MUS, transobturator MUS and traditional sling are effective in the short to medium term and that retropubic MUS is cost-effective in the medium to long term. The VOI analysis highlights the value of further research to reduce the uncertainty around the incidence rates of complications. There is a need to obtain robust clinical data in future work, particularly around long-term complication rates.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016049339.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Patients' satisfaction and safety of bulk injection therapy Urolastic for treatment of stress urinary incontinence: A cross-sectional study

Aims

Primary outcome was to evaluate patients' satisfaction after being treated with bulk injection therapy polydimethylsiloxane Urolastic (PDMS‐U) for stress urinary incontinence (SUI). Secondary outcomes were: subjective cure, objective cure, severity of SUI symptoms, complications, reintervention rate, and disease‐specific quality of life. Furthermore, to determine if outcomes worsened during time‐after‐treatment (time‐frames: 0‐12, 13‐24, and ≥25 months).

Methods

In a cross‐sectional design, patients treated with PDMS‐U were recruited for hospital revisit. The primary outcome, patients' satisfaction, was assessed by the surgical satisfaction questionnaire. Subjective cure, objective cure, and severity of symptoms were assessed by the patients global impression of improvement, standardized cough stress test, and Sandvik severity scale, respectively. Medical charts and face‐to‐face interviews were used to determine complications and reinterventions.

Results

About 110 patients participated, 87 revisited the hospital. Median follow‐up was 25 months (interquartile range: 14;35 months). Patients' satisfaction rate was 51%. Subjective and objective cure were respectively 46% and 47%. Most prevalent complications were: urinary retention (22%), pain (15%), and dyspareunia (15%). Exposure and erosion occurred in 7% and 5%, respectively. Reintervention rate of reinjection and excision of bulk material was 6% and 18.0%, respectively. Objective cure significantly worsened during time‐after‐treatment (P = < .05).

Conclusions

About half of the patients being treated with PDMS‐U were satisfied and subjectively cured 2 years after treatment, although the majority still experienced symptoms of SUI. Most complications were mild and transient, however, in 18% excision of bulk material was indicated for severe or persistent complications such as pain, exposure, or erosion.

Interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women

BACKGROUND

Surgery is a common treatment modality for stress urinary incontinence (SUI), usually offered to women for whom conservative treatments have failed. Midurethral tapes have superseded colposuspension because cure rates are comparable and recovery time is reduced. However, some women will not be cured after midurethral tape surgery. Currently, there is no consensus on how to manage the condition in these women.This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To assess the effects of interventions for treating recurrent stress urinary incontinence after failed minimally invasive synthetic midurethral tape surgery in women; and to summarise the principal findings of economic evaluations of these interventions.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 9 November 2018). We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in women who had recurrent stress urinary incontinence after previous minimally invasive midurethral tape surgery. We included conservative, pharmacological and surgical treatments.

DATA COLLECTION AND ANALYSIS

Two review authors checked the abstracts of identified studies to confirm their eligibility. We obtained full-text reports of relevant studies and contacted study authors directly for additional information where necessary. We extracted outcome data onto a standard proforma and processed them according to the guidance in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included one study in this review. This study was later reported in an originally unplanned secondary analysis of 46 women who underwent transobturator tape for recurrent SUI after one or more previous failed operations. We were unable to use the data, as they were not presented according to the nature of the first operation.We excluded 12 studies, five because they were not randomised controlled trials (RCTs) and four because previous incontinence surgery was not performed using midurethral tape. We considered a further three to be ineligible because neither the trial report nor personal communication with the trialists could confirm whether any of the participants had previously undergone surgery with tape.We had also planned to develop a brief economic commentary summarising the principal findings of relevant economic evaluations but supplementary systematic searches did not identify any such studies.

AUTHORS' CONCLUSIONS

There were insufficient data to assess the effects of any of the different management strategies for recurrent or persistent stress incontinence after failed midurethral tape surgery. No published papers have reported exclusively on women whose first operation was a midurethral tape. Evidence from further RCTs and economic evaluations is required to address uncertainties about the effects and costs of these treatments.

Patient-Reported Outcome Measures (PROMs) in Pelvic Floor Disorders

PURPOSE OF REVIEW

Patient-reported outcome measures (PROMs) are tools that are widely used by clinicians and researchers across different medical specialties. In this review, we examine the use of PROMs in the evaluation of female pelvic floor disorders (PFD).

RECENT FINDINGS

PROM development in the assessment of urinary incontinence is more advanced than other pelvic disorders. Work is ongoing in the scientific community to improve currently available measures and create new robust tools where needed. Hundreds of PROMs are available for use in the evaluation of PFD, some more rigorously validated than others. They are used to screen for diseases, evaluate their impact on quality of life, determine the results of treatment, and measure patient's satisfaction with treatment. Careful consideration is required to choose the appropriate PROMs to care for a patient or include in a research study. The topic was reviewed in the Textbook of Female Urology and Urogynecology published in 2017. We reviewed recent literature (2015-2018) on the topic and summarized our findings.

Patient goal achievement 2 years after a tension-free vaginal tape operation

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to investigate long-term patient-reported goals after a tension-free vaginal tape (TVT) operation for stress urinary incontinence (SUI).

METHODS

In this prospective study involving 67 women, patients completed the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) preoperatively and stated three goals for the operation. Postoperatively, a visual analog scale (VAS) ranging from zero (none) to ten (worst) estimated the extent to which goals were achieved. Goals were divided into five groups: symptoms, quality of life (QoL) (physical), QoL (emotional), sexual function, avoidance, and others. Short-term achievement of goal was estimated after 3 months and long-term achievement of goals after a mean of 28.2 months.

RESULTS

A total of 201 goals were stated, most of which (38%) were in the group concerning QoL in physical domains. Mean VAS score for all goals was 9.1 after 3 months and 8.5 at long-term follow-up. ICIQ-UI SF preoperatively was mean 14.9; 3 months' postoperatively mean 1.4; and at long-term 3.8. The small rise in ICIQ-UI SF at long-term follow-up was statistically insignificant and due to urge urinary incontinence (UUI).

CONCLUSIONS

Our study showed that patients achieved their goals to a high degree and maintained them at long-term follow-up. Most goals concerned QoL in physical domains. Although a proportion of women experienced episodes of UUI at the long-term follow-up, VAS score was not significantly changed.

The Effect of Pelvic Floor Muscle Training On Incontinence Problems After Radical Prostatectomy

The aim of the current study was to determine the effect of pelvic floor muscle exercises (PFME/Kegel) training administered to patients scheduled for robot-assisted radical prostatectomy on postprocedural incontinence problems.

This study was a randomized controlled trial. Pelvic floor muscle exercises were applied to the procedure group three times a day for 6 months. No exercises were applied to the control group. Incontinence and quality-of-life assessments of the 60 patients in the experimental and control groups were performed on months 0 (10 days after removal of the urinary catheter), 1, 3, and 6 through face-to-face and telephone interviews.

Total Incontinence Consultation on Incontinence-Short Form scores, which provide an objective criterion for the evaluation of individuals with incontinence problems, decreased over time. This decrease was statistically highly significant in the third and sixth months.

Pelvic muscle floor exercises are suitable for patients experiencing incontinence after radical prostatectomy.