1
|
Khullar V, Lemmon B, Acar O, Abrams P, Vahabi B. Does COVID-19 cause or worsen LUT dysfunction, what are the mechanisms and possible treatments? ICI-RS 2023. Neurourol Urodyn 2024. [PMID: 38506116 DOI: 10.1002/nau.25441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and produced a worldwide pandemic in 2020. There have been 770,875,433 confirmed cases and 6,959,316 attributed deaths worldwide until September 19, 2023. The virus can also affect the lower urinary tract (LUT) leading to bladder inflammation and producing lower urinary tract symptoms (LUTS) in both the acute and chronic phases of disease. METHODS At the 2023 meeting of the International Consultation on Incontinence-Research Society (ICI-RS), the literature relating to COVID-19 and bladder dysfunction was reviewed. The LUTS reported, as well as the pathophysiology of these bladder symptoms, were the subject of considerable discussion. A number of different topics were discussed including lower LUTS reported in COVID-19, how SARS-CoV-2 may infect and affect the urinary tract, and proposed mechanisms for how viral infection result in new, worsened, and in some persisting LUTS. CONCLUSIONS The workshop discussed the interaction between the virus and the immune system, covering current evidence supporting theories underlying the causes of acute and chronic LUTS related to COVID-19 infection. Research questions for further investigation were suggested and identified.
Collapse
Affiliation(s)
- Vik Khullar
- Department of Urogynaecology, St Mary's Hospital, Imperial College, London, UK
| | - Berni Lemmon
- Department of Urogynaecology, St Mary's Hospital, Imperial College, London, UK
| | - Omer Acar
- Department of Urology, University of Illinois, Chicago, Illinois, USA
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital Bristol, Bristol, UK
| | - Bahareh Vahabi
- School of Applied Sciences, University of the West of England, Bristol, UK
| |
Collapse
|
2
|
Tarcan T, Hashim H, Malde S, Sinha S, Sahai A, Acar O, Selai C, Agro EF, Abrams P, Wein A. Can we predict and manage persistent storage and voiding LUTS following bladder outflow resistance reduction surgery in men? ICI-RS 2023. Neurourol Urodyn 2024. [PMID: 38477358 DOI: 10.1002/nau.25435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
AIMS Lower urinary tract symptoms (LUTS) persist in up to 50% of patients after bladder outflow resistance reduction surgery (BORRS) in men. Our think tank aims to address the predictive factors for persistent LUTS after BORRS and to propose the recommendations for future research to enable improved better patient counseling and selection by more accurate prediction of treatment outcome. METHODS A think tank of ICI-RS gathered in 2023, Bristol, UK, to discuss the pre and postsurgical clinical and urodynamic evaluation of men undergoing BORRS and whether it is possible to predict which men will have persistent LUTS after BORRS. RESULTS Our think tank agrees that due to the multifactorial, and still not fully understood, etiology of male LUTS it is not possible to precisely predict in many men who will have persistent LUTS after BORRS. However, severe storage symptoms (overactive bladder, OAB) in association with low volume and high amplitude detrusor overactivity and low bladder capacity in preoperative urodynamics, increase the likelihood of persistent OAB/storage symptoms after BORRS. Furthermore, patients who are clearly obstructed and have good bladder contractility on preoperative pressure flow studies do better postoperatively compared to their counterparts. However, the benefit of pressure flow studies is decreased in patients who do not acceptably void during the study. Poor voiding after BORRS may occur due to persistent obstruction or detrusor underactivity. CONCLUSION Future research is needed to increase our understanding of why male LUTS persist after surgery, and to enable better patient selection and more precise patient counseling before BORRS.
Collapse
Affiliation(s)
- Tufan Tarcan
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust & King's College London, London, UK
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | - Arun Sahai
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Omer Acar
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
- College of Medicine, Department of Urology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Caroline Selai
- University College London - Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery/UCLH NHS Foundation Trust, London, UK
| | - Enrico Finazzi Agro
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Alan Wein
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
3
|
Pauwaert K, Goessaert AS, Robinson D, Cardozo L, Bower W, Calders P, Mariman A, Abrams P, Tubaro A, Dmochowski R, Weiss JP, Hervé F, Depypere H, Everaert K. Nocturia in Menopausal Women: The Link Between Two Common Problems of the Middle Age. Int Urogynecol J 2024:10.1007/s00192-024-05743-1. [PMID: 38436669 DOI: 10.1007/s00192-024-05743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 12/29/2023] [Indexed: 03/05/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of this review is to discuss the link between menopause and nocturia and to give an overview of the increasing prevalence, risk factors, causative factors, treatment needs and options for nocturia in peri-menopausal women. METHODS This opinion article is a narrative review based on the expertise and consensus of a variety of key opinion leaders, in combination with an extensive literature review. This literature search included a thorough analysis of potential publications on both the PubMed Database and the Web of Science and was conducted between November 2022 and December 2022. The following key words were used "nocturia" and "menopause" or "nocturnal frequency and menopause." Moreover, key words including "incidence," "prevalence," "insomnia," "estrogen therapy," "metabolic syndrome," and "hot flushes" were used in combination with the aforementioned key words. Last, the reference lists of articles obtained were screened for other relevant literature. RESULTS The perimenopause can be a trigger for inducing nocturia. Typically, obesity, body mass index (BMI), and waist circumference are risk factors for developing peri-menopausal nocturia. Presumably the development of peri-menopausal nocturia is multifactorial, with interplay among bladder, sleep, and kidney problems due to estrogen depletion after the menopause. First, impaired stimulation of estrogen receptors in the urogenital region leads to vaginal atrophy and reduced bladder capacity. Moreover, menopause is associated with an increased incidence of overactive bladder syndrome. Second, estrogen deficiency can induce salt and water diuresis through blunted circadian rhythms for the secretion of antidiuretic hormone and the activation of the renin-angiotensin-aldosterone system. Additionally, an increased incidence of sleep disorders, including vasomotor symptoms and obstructive sleep apnea signs, is observed. Oral dryness and a consequent higher fluid intake are common peri-menopausal symptoms. Higher insulin resistance and a higher risk of cardiovascular diseases may provoke nocturia. Given the impact of nocturia on general health and quality of life, bothersome nocturia should be treated. Initially, behavioral therapy should be advised. If these modifications are inadequate, specific treatment should be proposed. Systemic hormone replacement is found to have a beneficial effect on nocturia, without influencing sodium and water clearance in patients with nocturnal polyuria. It is presumed that the improvement in nocturia from hormonal treatment is due to an improvement in sleep disorders.
Collapse
Affiliation(s)
- Kim Pauwaert
- Department of Urology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | - An-Sofie Goessaert
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Dudley Robinson
- Department of Urogynecology, King's College Hospital, London, UK
| | - Linda Cardozo
- Department of Urogynecology, King's College Hospital, London, UK
| | - Wendy Bower
- Department of Urology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
- Department of Aged Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Australia
| | - Patrick Calders
- Department of General Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - An Mariman
- Department of Physical Therapy, Ghent University Hospital, Ghent, Belgium
- Department of Psychiatry, Ghent University Hospital, Ghent, Belgium
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Andrea Tubaro
- Department of Urology, Sant'Andrea Hospital, School of Health Sciences, Sapienza University of Rome, Rome, Italy
| | - Roger Dmochowski
- Department of Urology, Vanderbilt University, Nashville, TN, USA
| | - Jeffrey P Weiss
- Department of Urology, SUNY Health Science University, Brooklyn, NY, USA
| | - Francois Hervé
- Department of Urology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Herman Depypere
- Department of Gynecology, Ghent University Hospital, Ghent, Belgium
| | - Karel Everaert
- Department of Urology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| |
Collapse
|
4
|
Chapple C, Abrams P, Lam T, Mangera A, Belal M, Curtis C, Emkes J, Hillery S, Irwin K, Logan K, Weston P, Yates A. A consensus statement on when to start clean intermittent self-catheterization: An untapped resource? Neurourol Urodyn 2024; 43:459-463. [PMID: 38078751 DOI: 10.1002/nau.25353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/11/2023] [Accepted: 11/25/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Clean intermittent self-catheterisation (CISC or ISC) is used by patients/carers to empty the bladder if needed. Sometimes the urethral lumen leading out of the bladder is blocked; sometimes, the bladder (detrusor) muscle itself or the autonomic motor nerves innervating the bladder are damaged, resulting in a failure of the detrusor muscle to work, leading to a failure of the bladder being able to empty adequately. Prior consensus as to the indications and timing of CISC has yet to be provided. This article aims to provide a multidisciplinary consensus view on this subject. CONCLUSION It is evident that every patient needs to be considered individually, bearing in mind the symptoms and investigations to be considered. We emphasise the importance of considering the term Bladder Voiding Efficiency (BVE). One group of patients who might find CISC helpful are those with a neurological disorder; these include spinal injury patients, multiple sclerosis, Parkinson's, and a condition called cauda equina. Sometimes bladder problems are treated with anticholinergics, and others may be treated with Botox. These may cause the bladder not to empty at all, which is good for leaks but needs self-catheterisation to empty the bladder. In the past, hospitals used a permanent catheter called an 'indwelling' or a 'suprapubic' catheter. These can have side effects, including infections, stones, and pain. For CISC, disposable catheters are the best option for patients as they come in different sizes and styles to provide individualised care. In conclusion, we would like hospitals to consider each patient separately and not use a general 'one-size-fits-all' bladder function for these patients.
Collapse
Affiliation(s)
- Christopher Chapple
- Department of Urology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- University of Sheffield, Sheffield, UK
- Sheffield Hallam University, Sheffield, UK
| | - Paul Abrams
- University of Bristol, Bristol, UK
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
- Bristol Health Research Charity, Bristol, UK
| | - Thomas Lam
- Aberdeen Royal Infirmary - NHS Grampian, Aberdeen, UK
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Altaf Mangera
- Spinal Injuries Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mohammed Belal
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- The British Association of Urological Surgeons, London, UK
| | - Carmel Curtis
- King's College Hospital NHS Foundation Trust, London, UK
| | - Jacqueline Emkes
- National Bladder and Bowel Health Project NHS England and Excellence in Continence Care Board - Chair Patient and Carer forum, Manchester, UK
- Bladder Health UK, Birmingham, UK
| | - Sarah Hillery
- York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
- The British Association of Urological Nurses, Bathgate, UK
| | | | - Karen Logan
- Aneurin Bevan University Health Board, Newport, UK
| | - Polly Weston
- University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK
| | - Ann Yates
- Cardiff & Vale University Health Board, Cardiff, UK
| |
Collapse
|
5
|
Tarcan T, Acar Ö, Malde S, Sinha S, Sahai A, Perrouin-Verbe MA, Hashim H, Agro EF, Wein A, Abrams P. Can we predict whether a man with acute or chronic urinary retention will void after bladder outflow resistance reduction surgery? ICI-RS 2023. Neurourol Urodyn 2024. [PMID: 38291822 DOI: 10.1002/nau.25404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/17/2024] [Indexed: 02/01/2024]
Abstract
AIMS To address the predictive factors of a successful voiding after bladder outflow resistance reduction surgery (BORRS) in men presenting with acute or chronic urinary retention (UR). METHODS A think tank (TT) of ICI-RS was gathered in 2023, Bristol, UK, to discuss several aspects of the problem, such as the pathophysiology of UR, the clinical and urodynamic evaluation of men with UR and whether it is possible to predict which men will be able to successfully void after treatment with contemporary surgical options. RESULTS The TT agreed that successful voiding after BORRS depends on several factors but that a strong recommendation cannot be made regarding preoperative evaluation and whether there are predictive factors of success because of the heterogeneity of patients and methodology in published trials. The diagnosis of obstruction in men with UR may be challenging when there is apparent reduced detrusor contraction during urodynamic studies. Even in the absence of bladder contractility there is documentation of such cases that have voided adequately after BORRS. Still, detrusor underactivity and inadequate relief of prostatic obstruction are the main causes of an unsuccessful voiding after BORRS. Conventional resection and enucleation methods remain the most successful surgeries in relieving UR in men, whereas the efficacy of minimally invasive surgical treatments needs to be assessed further. CONCLUSION Research is needed to understand the pathophysiology of UR and the predictors of successful voiding after different types of BORRS in men with UR.
Collapse
Affiliation(s)
- Tufan Tarcan
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
| | - Ömer Acar
- Department of Urology, Koc University School of Medicine, Istanbul, Turkey
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust and King's College, London, UK
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | - Arun Sahai
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust and King's College, London, UK
| | | | - Hashim Hashim
- Bristol Urological Institute, Southmead hospital, Bristol, UK
| | - Enrico Finazzi Agro
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Alan Wein
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Paul Abrams
- Bristol Urological Institute, Southmead hospital, Bristol, UK
| |
Collapse
|
6
|
Taithongchai A, Mohamed-Ahmed R, Sinha S, Gibson W, Giarenis I, Robinson D, Abrams P. Should hormone replacement therapy (any route of administration) be considered in all postmenopausal women with lower urinary tract symptoms? Report from the ICI-RS 2023. Neurourol Urodyn 2024. [PMID: 38289324 DOI: 10.1002/nau.25384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024]
Abstract
AIMS This International Consultation on Incontinence-Research Society report aims to summarize the evidence and uncertainties regarding the use of hormone replacement therapy by any route in the management of lower urinary tract symptoms (LUTS) including recurrent urinary tract infections (rUTI), with a review of special considerations for the elderly. Research question proposals to further this field have been highlighted. METHODS An overview of the existing evidence, guidelines, and consensus regarding the use of topical or systemic estrogens in the management of LUTS. RESULTS There are currently evidence and recommendations to offer topical estrogens to postmenopausal women with overactive bladder symptoms as well as postmenopausal women with rUTIs. Systemic estrogens however have been shown in a meta-analysis to have a negative effect on LUTS and, therefore are not currently recommended. CONCLUSIONS Although available evidence and recommendations exist for the use of topical estrogens, few women are commenced on these in primary care. There remain large gaps still within our knowledge of the use of estrogens within the management of LUTS, particularly on when it should be commenced, the length of time treatment should be continued for, and barriers to prescribing.
Collapse
Affiliation(s)
| | | | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | - William Gibson
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ilias Giarenis
- Department of Urogynaecology, Norfolk and Norwich Hospital, Norwich, UK
| | - Dudley Robinson
- Department of Urogynaecology, King's College Hospital, London, UK
| | | |
Collapse
|
7
|
Bou Kheir G, Verbakel I, Vande Walle J, Wyndaele M, Sinha S, Arlandis S, Raes A, Abrams P, Wein A, Hervé F, Everaert K. Exploring lifelong overactive bladder: Transitions, evidence, and clinical implications; A modified Delphi process. Neurourol Urodyn 2024. [PMID: 38289322 DOI: 10.1002/nau.25307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Overactive bladder (OAB) is a prevalent urological condition characterized by urinary urgency, with or without urgency urinary incontinence, accompanied by increased daytime frequency and nocturia. However, the current definition of OAB lacks a specified time frame, hindering our understanding of the temporal aspects and transitions that occur within the OAB spectrum. METHODS A modified Delphi study was conducted in three rounds, involving a panel of international experts in functional urology, urogynaecology, geriatrics, transitional medicine, and pediatric urology. The study took place between February 2023 and June 2023 and employed two sequential rounds of online surveys, followed by a final hybrid group discussion session in June 2023. RESULTS The Delphi process resulted in a consensus definition of lifelong OAB as a persistent and continuous condition that may manifest differently from birth and evolve over time, with varying levels of clinical perception. The course of its progression is influenced by transition periods and modifying factors, mainly anatomical, hormonal, and psychosocial/stressors. Three main transition periods were identified: achievement of daytime continence, adulthood to elderly, and transition to frail elderly. The panel also considered the therapeutic and diagnostic implications of lifelong OAB, as well as future research prospects in terms of importance and feasibility. CONCLUSIONS Future longitudinal research is needed to develop this concept and further identify transitions and temporal dynamics.
Collapse
Affiliation(s)
- George Bou Kheir
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| | - Irina Verbakel
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Paediatric Nephrology and Rheumatology, ERknet Center, Ghent University Hospital, Ghent, Belgium
| | - Michel Wyndaele
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, Telangana, India
| | - Salvador Arlandis
- Urology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Ann Raes
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Alan Wein
- Department of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - François Hervé
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| | - Karel Everaert
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
8
|
Sahai A, Robinson D, Abrams P, Wein A, Malde S. What is the best first choice oral drug therapy for OAB? Neurourol Urodyn 2024. [PMID: 38270332 DOI: 10.1002/nau.25397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 12/29/2023] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
AIMS The management of overactive bladder (OAB) involves lifestyle changes and conservative measures in the first instance with the use of liquid/dietary advice, weight loss, and bladder training. Thereafter oral pharmacotherapy is instigated in symptomatic patients. Antimuscarinics and beta 3 agonists form the main classes of drug therapy in this field. Views on what is the best first line OAB treatment is changing based on recent evidence and adverse event profiles of these medications. METHODS At the ICI-RS meeting 2023, Bristol, UK this topic was discussed and debated as a proposal. The following article summarizes the concepts presented that day as well as the interactive discussion that took place thereafter. RESULTS OAB guidelines are moving in many circumstances to an either antimuscarinic or beta 3 agonist approach based on patient factors. Several studies have raised concerns on the long-term impact of antimuscarinics, in relation to cognition, dementia, cardiovascular events, and mortality all related to antimuscarinic load. Neither antimuscarinics nor beta 3 agonists have good persistence and adherence rates in the medium to long term. Several barriers also exist to prescribing including guidelines recommending utilizing drugs with the lowest acquisition cost and "step therapy." A newer approach to managing OAB is personalized therapy in view of the many possible etiological factors and phenotypes. These concepts are highlighted in this article. CONCLUSIONS Current oral pharmacotherapy in managing OAB is limited by adverse events, adherence and persistence problems. Both antimuscarinics and beta 3 agonists are efficacious but most clinical trials demonstrate significant placebo effects in this field. Personalizing treatment to the individual seems a logical approach to OAB. There is a need for better treatments and further studies are required of existing treatments with high quality longer term outcomes.
Collapse
Affiliation(s)
- Arun Sahai
- Department of Urology, Guy's Hospital & King's College, London, UK
| | - Dudley Robinson
- Department of Urogynaecology, King's College Hospital & King's College, London, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
- University of Bristol, Bristol, UK
| | - Alan Wein
- Desai Sethi Urology Institute, University of Miami Miller School of medicine, Miami, Florida, USA
- University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sachin Malde
- Department of Urology, Guy's Hospital & King's College, London, UK
| |
Collapse
|
9
|
Finazzi Agrò E, Rosato E, Wagg A, Sinha S, Fede Spicchiale C, Serati M, Mancini V, de Rijk M, Tarcan T, Wein A, Abrams P, Bou Kheir G. How do we make progress in phenotyping patients with lower urinary tract such as overactive bladder and underactive detrusor, including using urine markers and microbiome data, to personalize therapy? ICI-RS 2023-Part 2. Neurourol Urodyn 2024. [PMID: 38178629 DOI: 10.1002/nau.25379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Overactive bladder (OAB) and underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction. OBJECTIVES The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment. METHODS A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU using urodynamic tests, functional neuro-imaging, urinary markers, and microbiome. RESULTS AND CONCLUSIONS The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract (LUT) symptoms, such as OAB and UAB. The intricate interplay between the LUT and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.
Collapse
Affiliation(s)
- Enrico Finazzi Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Eleonora Rosato
- School of Specialization in Urology, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | | | - Maurizio Serati
- Department Obstetrics and Gynecology. Urogynecology Unit, University of Insubria, Varese, Italy
| | - Vito Mancini
- Urinary Incontinence Center, Urology and Renal Transplantation Unit, Policlinico di Foggia Hospital and University of Foggia, Foggia, Italy
| | - Mathijs de Rijk
- Department of Urology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Tufan Tarcan
- Marmara University School of Medicine, Istanbul, Turkey
- Koç University, Istanbul, Turkey
| | - Alan Wein
- Desai Sethi Institute of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Paul Abrams
- Department of Urology, University of Bristol, Bristol, UK
| | | |
Collapse
|
10
|
Finazzi Agrò E, Rosato E, Wagg A, Sinha S, Fede Spicchiale C, Serati M, Mancini V, de Rijk M, Tarcan T, Wein A, Abrams P, Bou Kheir G. How do we make progress in phenotyping patients with LUT such as OAB and underactive detrusor, including using urine markers and microbiome data, in order to personalize therapy? ICI-RS 2023: Part 1. Neurourol Urodyn 2024. [PMID: 38178627 DOI: 10.1002/nau.25377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Overactive bladder (OAB) and Underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction. OBJECTIVES The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment. METHODS A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU investigating metabolic, neurogical, psychological and gastrointestinal aspects with the aim to personalize the treatment. RESULTS AND CONCLUSIONS The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract symptoms, such as OAB and UAB. The intricate interplay between the lower urinary tract and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.
Collapse
Affiliation(s)
- Enrico Finazzi Agrò
- Department of Surgical Sciences, University of Rome Tor Vergata and Urology Unit, Policlinico Tor Vergata University Hospital, Rome, Italy
| | - Eleonora Rosato
- School of specialization in Urology, Policlinico Tor Vergata University Hospital, University of Rome Tor Vergata and Urology Unit, Rome, Italy
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | | | - Maurizio Serati
- Department Obstetrics and Gynecology, Urogynecology Unit, University of Insubria, Varese, Italy
| | - Vito Mancini
- Urology and renal transplantation Unit, Urinary incontinence center, Policlinico di Foggia Hospital and University of Foggia, Foggia, Italy
| | - Mathijs de Rijk
- Department of Urology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Tufan Tarcan
- Marmara University School of Medicine, Istanbul, Turkey and Koç University School of Medicine, Istanbul, Turkey
| | - Alan Wein
- University of Miami Miller School of Medicine, Desai Sethi Institute of Urology, Miami, Florida, USA
| | - Paul Abrams
- Department of Urology, University of Bristol, Bristol, UK
| | | |
Collapse
|
11
|
Ito H, Sakamaki K, Young GJ, Blair PS, Hashim H, Lane JA, Kobayashi K, Clout M, Abrams P, Chapple C, Malde S, Drake MJ. Predicting Prostate Surgery Outcomes from Standard Clinical Assessments of Lower Urinary Tract Symptoms To Derive Prognostic Symptom and Flowmetry Criteria. Eur Urol Focus 2024; 10:197-204. [PMID: 37455216 DOI: 10.1016/j.euf.2023.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Assessment of male lower urinary tract symptoms (LUTS) needs to identify predictors of symptom outcomes when interventional treatment is planned. OBJECTIVE To develop a novel prediction model for prostate surgery outcomes and validate it using a separate patient cohort and derive thresholds for key clinical parameters. DESIGN, SETTING, AND PARTICIPANTS From the UPSTREAM trial of 820 men seeking treatment for LUTS, analysis of bladder diary (BD), International Prostate Symptom Score (IPSS), IPSS-quality of life, and uroflowmetry data was performed for 176 participants who underwent prostate surgery and provided complete data. For external validation, data from a retrospective database of surgery outcomes in a Japanese urology department (n = 227) were used. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Symptom improvement was defined as a reduction in total IPSS of ≥3 points. Multiple logistic regression, classification tree analysis, and random forest models were generated, including versions with and without BD data. RESULTS AND LIMITATIONS Multiple logistic regression without BD data identified age (p = 0.029), total IPSS (p = 0.0016), and maximum flow rate (Qmax; p = 0.066) as predictors of outcomes, with area under the receiver operating characteristic curve (AUC) of 77.1%. Classification tree analysis without BD data gave thresholds of IPSS <16 and Qmax ≥13 ml/s (AUC 75.0%). The random forest model, which included all clinical parameters except BD data, had an AUC of 94.7%. Internal validation using the bootstrap method showed reasonable AUCs (69.6-85.8%). Analyses using BD data marginally improved the model fits. External validation gave comparable AUCs for logistic regression, classification tree analysis, and random forest models (all without BD; 70.9%, 67.3%, and 68.5%, respectively). Limitations include the significant number of men with incomplete baseline data and limited assessments in the external validation cohort. CONCLUSIONS Outcomes of prostate surgery can be predicted preoperatively using age, total IPSS, and uroflowmetry data, with prognostic thresholds of 16 for IPSS and 13 ml/s for Qmax. PATIENT SUMMARY This study identified key preoperative factors that can predict outcomes of prostate surgery for bothersome urinary symptoms, including which patients are at risk of a poor outcome.
Collapse
Affiliation(s)
- Hiroki Ito
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK; Department of Urology, Yokohama City University, Yokohama, Japan
| | - Kentaro Sakamaki
- Center for Data Science, Yokohama City University, Yokohama, Japan
| | - Grace J Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter S Blair
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hashim Hashim
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - J Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kazuki Kobayashi
- Department of Urology, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Madeleine Clout
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Christopher Chapple
- Sheffield Teaching Hospitals NHS Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Sachin Malde
- Urology Centre, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Marcus J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK; Department of Surgery and Cancer, Imperial College, London, UK.
| |
Collapse
|
12
|
Mancini V, Damaser MS, Chermansky C, Ochoa CD, Hashim H, Przydacz M, Hervé F, Martino L, Abrams P. Can we improve techniques and patients' selection for nerve stimulation suitable for lower urinary tract dysfunctions? ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 38048061 DOI: 10.1002/nau.25346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 12/05/2023]
Abstract
AIMS Lower urinary tract dysfunctions (LUTD) are very common and, importantly, affect patients' quality of life (QoL). LUTD can range from urinary retention to urgency incontinence and includes a variety of symptoms. Nerve stimulation (NS) is an accepted widespread treatment with documented success for LUTD and is used widely. The aim of this review is to report the results of the discussion about how to improve the outcomes of NS for LUTD treatment. METHODS During its 2023 meeting in Bristol, the International Consultation on Incontinence Research Society discussed a literature review, and there was an expert consensus discussion focused on the emerging awareness of NS suitable for LUTD. RESULTS The consensus discussed how to improve techniques and patients' selection in NS, and high-priority research questions were identified. CONCLUSIONS Technique improvement, device programming, and patient selection are the goals of the current approach to NS. The conditional nerve stimulation with minimally invasive wireless systems and tailored algorithms hold promise for improving NS for LUTD, particularly for patients with neurogenic bladder who represent the new extended population to be treated.
Collapse
Affiliation(s)
- Vito Mancini
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Margot S Damaser
- Department of Biomedical Engineering, Lerner Research Institute and Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, and Advanced Platform Technology Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | | | - Carolina D Ochoa
- Bristol Urological Institute, North Bristol Trust, University of Bristol, Bristol, UK
| | - Hashim Hashim
- Bristol Urological Institute, North Bristol Trust, University of Bristol, Bristol, UK
| | - Mikolaj Przydacz
- Department of Urology, Jagiellonian University Medical College, Krakow, Poland
| | - François Hervé
- Department of Urology, ERN Accredited Centrum, Ghent University Hospital, Ghent, Belgium
| | - Leonardo Martino
- Department of Urology and Renal Transplantation, University of Foggia, Foggia, Italy
| | - Paul Abrams
- Bristol Urological Institute, University of Bristol, Bristol, UK
| |
Collapse
|
13
|
Sinha S, Everaert K, Kheir GB, Roberts N, Solomon E, Belal M, Selai C, Perrouin-Verbe MA, Spicchiale CF, Wein A, Abrams P. Could a better understanding of the underlying pathophysiologies lead to more informed treatment choices in patients with lower urinary tract dysfunction due to an acontractile or underactive detrusor? ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37960931 DOI: 10.1002/nau.25329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION The underlying pathophysiology behind a diagnosis of acontractile or underactive detrusor at invasive urodynamics is very heterogeneous. Lack of etiological classification currently limits the possibility of stratifying therapy. METHODS This subject was discussed at a think-tank on the subject at the International Consultation on Incontinence-Research Society held in Bristol, June 2023. This manuscript is a result of those deliberations and the subsequent discussions of the think-tank. RESULTS There are challenges in defining abnormalities of detrusor contraction with resultant implications for available evidence. Pathology at any level of the neuromuscular pathway can impair or prevent a detrusor voiding contraction. Attempts have been made to identify clinical markers that might predict an underactive detrusor but strong supporting evidence is lacking. Hence, a holistic approach to phenotyping requires specialized neuro-imaging as well as physiological investigations. Several general measures can help individuals with an abnormal detrusor contraction. The search for a molecule to enhance the detrusor voiding contraction remains elusive but there are promising new candidates. Neuromodulation can help select individuals but data is not well stratified by underlying etiology. Manipulation of central neurotransmitters might offer an alternate therapeutic option. CONCLUSIONS A better understanding of the underlying pathophysiologies behind an abnormality of the detrusor voiding contraction is needed for improving management. Towards this goal, the think-tank proposes a classification of the underactive detrusor that might help in selecting and reporting more well-defined patient cohorts.
Collapse
Affiliation(s)
- Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, India
| | | | | | - Neil Roberts
- Division of Cell Matrix Biology and Regenerative Medicine, The University of Manchester, Bristol, UK
| | - Eskinder Solomon
- Department of Functional Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mohammed Belal
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - Caroline Selai
- UCL Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, London, UK
| | | | | | - Alan Wein
- Department of Urology, Desai-Seth Institute of Urology, University of Miami, Miami, Florida, USA
| | - Paul Abrams
- Department of Urology, University of Bristol, Bristol, UK
| |
Collapse
|
14
|
Verbakel I, Lazar J, Sinha S, Hashim H, Weiss JP, Abrams P, Everaert K. How should we assess the cardiovascular system in patients presenting with bothersome nocturia? ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37942826 DOI: 10.1002/nau.25331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 10/29/2023] [Indexed: 11/10/2023]
Abstract
AIMS The link between nocturia and cardiovascular disease (CVD) is frequently discussed in literature, yet the precise nature of this relationship remains poorly characterized. The existing literature was reviewed in order to address issues concerning the origin, diagnosis, management, and implications of the co-occurrence of CVD and nocturia. METHODS This review summarizes literature and recommendations regarding the link between CVD and nocturia discussed during a think-tank meeting held at the 2023 International Consultation on Incontinence-Research Society. RESULTS Cardiovascular disorders are often underestimated contributors to nocturia, with various potential mechanisms influencing nighttime urination, such as impact on fluid retention, atrial natriuretic peptide, and glomerular filtration rate. The redistribution of fluid from leg edema in supine position can lead nocturnal polyuria (NP). Additionally, sleep disturbances due to nocturia in itself may lead to CVD through an increase in blood pressure, insulin resistance, and inflammation. Disrupted circadian rhythms (e.g., in sleep pattern and urine production) were identified as critical factors in most etiologies of nocturia, and their contribution is deemed imperative in future research and treatment approaches, particularly in the aging population. NP can be detected through a simple bladder diary and can even be used to distinguish cardiac from noncardiac causes of nocturia. For the treatment of NP, desmopressin can be effective in select patients, however, caution and close monitoring is warranted for those with CVD due to increased risk of side effects. CONCLUSIONS Gaps were identified in the available evidence and clear cut recommendations were put forth for future research. It is essential to gain a deeper understanding of the mechanisms linking nocturia and CVD to develop optimal management strategies.
Collapse
Affiliation(s)
- Irina Verbakel
- Department of Urology, ERN Accredited Center, Ghent University Hospital, Gent, Belgium
| | - Jason Lazar
- Department of Urology, State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Sanjay Sinha
- Department of Urology, Apollo Hospital, Hyderabad, Telangana, India
| | - Hashim Hashim
- Bristol Urological Institute, SoUthmead Hospital, Bristol, UK
| | - Jeffrey P Weiss
- Department of Urology, State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Paul Abrams
- Bristol Urological Institute, SoUthmead Hospital, Bristol, UK
| | - Karel Everaert
- Department of Urology, ERN Accredited Center, Ghent University Hospital, Gent, Belgium
| |
Collapse
|
15
|
Ockrim J, Kearney R, Carolina Ochoa D, Hashim H, Van Koeveringe G, Chermansky C, Cardozo L, Wein A, Abrams P. Which parameters, related to the female urethra and pelvic floor, determine therapy selection for recurrent female stress urinary incontinence: ICI-RS 2023? Neurourol Urodyn 2023. [PMID: 37937374 DOI: 10.1002/nau.25327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION The evidence basis for therapy selection in women who have failed primary stress urinary incontinence (SUI) surgery is limited. The ICI-RS group discussed the available data at its meeting in June 2023, particularly the anatomical characteristics as assessed using magnetic resonance imaging (MRI) and ultrasound (US) modalities, functional characteristics associated with storage and voiding urodynamic assessment, as well as the patient characteristics that might influence outcomes. This paper summarizes the evidence base that supported these discussions and offers the basis for research proposals for future groups. METHODS A literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was performed, and the data is presented. Research questions are based on the knowledge gaps highlighted. RESULTS Possible MRI parameters that may influence outcomes were striated urethral sphincter volume, bladder and proximal urethral funneling, pubo-urethral ligament integrity, distance of the bladder neck below the pubococcygeal line, posterior urethra-vesical angle, and bladder neck to levator ani distance. US parameters included sling distance to the urethral lumen and pubis, sling position, bladder neck mobility, and lateral arm asymmetry, twisting, or curling. Urodynamic parameters included detrusor overactivity, Valsalva leak point pressure, maximum urethral closure pressure, and bladder outlet obstruction. Important patient parameters included body mass index, age, and previous interventions. CONCLUSIONS Identifying and quantifying causative factors in patients with recurrent SUI, that allow clinicians to modify subsequent treatment choices and techniques may help reduce treatment failure and complications. Formulating algorithms is the next step in optimizing patient counseling, surgical selection, and healthcare allocation.
Collapse
Affiliation(s)
- Jeremy Ockrim
- University College London Hospital NHS Trust, University College London, London, UK
| | - Rohna Kearney
- Warrell Unit, Saint Mary's Hospital, Manchester University NHS Trust, UK
- Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester, UK
| | | | | | | | - Christopher Chermansky
- UPMC Magee Women's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Alan Wein
- Desai Sethi Institute of Urology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Paul Abrams
- Division of Developmental Biology & Medicine, School of Medical Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
16
|
Kanai A, Chakrabarty B, Winder M, Hashim H, Wein A, Abrams P, Fry C. New therapeutic targets to prevent benign prostatic enlargement and symptomatic progression to benign prostatic obstruction-ICI-RS 2023. Neurourol Urodyn 2023:10.1002/nau.25326. [PMID: 37916442 PMCID: PMC11063119 DOI: 10.1002/nau.25326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/03/2023]
Abstract
AIMS Benign prostatic enlargement (BPE) can impact lower urinary tract function due to its potential progression to benign prostatic obstruction (BPO). Treatment options include removal of the obstruction by surgery or through use of therapeutics designed to slow growth or reduce tissue stress imposed by muscular stromal components. Inflammation and development of fibrosis can also raise intrinsic tissue stress within the gland, further impacting obstruction. Outflow tract obstruction can also impact emission and ejaculation if the obstruction persists. METHODS This review summarizes an ICI-RS think tank considering novel drug treatments that might address BPO caused by progressive development of BPE, as well as manage decompensation changes to bladder function. RESULTS Topics included recent advances in our understanding of pathological changes occurring to the prostate and other lower urinary tract tissues during progressive development of BPE, and how prevention or reversal might benefit from the identification of novel drug targets. These included contractile properties of prostatic tissues, the impact of BPE and its effects on bladder function, the deposition of intramural fibrotic tissue with protracted BPO, the role of inflammation in the development of BPE and its progression to BPO. In particular, we discussed current therapeutic options for treating BPE/BPO, and new therapeutic targets, what they treat and their advantage over current medications. CONCLUSION Several new drug targets were identified, including soluble guanylate cyclase (sGC), the receptor for nitric oxide (NO•), and sGC activators that promotes sGC-mediated cGMP production when sGC is inactivated and unresponsive to NO•.
Collapse
Affiliation(s)
- Anthony Kanai
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, US
- Department of Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, US
| | - Basu Chakrabarty
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| | - Michael Winder
- Department of Pharmacology, University of Gothenburg, Gothenburg, SE
| | - Hashim Hashim
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Alan Wein
- Desai Sethi Institute of Urology, University of Miami Miller School of Medicine, Miami, Florida, US
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Christopher Fry
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| |
Collapse
|
17
|
Malde S, Belal M, Mohamed-Ahmed R, Gibson W, Padilla-Fernandez B, Rantell A, Selai C, Solomon E, Abrams P. Can we define the optimal postvoid residual volume at which intermittent catheterization should be recommended, and are there other measures that could guide an intermittent catheterization protocol: ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37905437 DOI: 10.1002/nau.25324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023]
Abstract
AIMS The postvoid residual (PVR) volume of urine in the bladder is widely used in clinical practice as a guide to initiate treatment, including clean-intermittent self-catheterization (CISC). It is often believed that an elevated PVR causes complications such as recurrent urinary tract infections (UTI) and renal failure. However, evidence for this is limited and identifying alternative measures to guide treatment decisions may optimize patient care. At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2023 a Think Tank addressed the question of whether we can define the optimal PVR at which CISC should be recommended, and whether there are other measures that could guide a CISC protocol. METHODS The Think Tank conducted a literature review and expert consensus meeting focusing on current limitations in defining and measuring PVR, and highlighting other measures that may optimize selection for, and persistence with, CISC. RESULTS There is no consensus on the threshold value of PVR that is considered "elevated" or "significant." There is a lack of standardization on terminology, and the normal range of PVR in different populations of different ages remains to be well-studied. The measurement of PVR is influenced by several factors, including intraindividual variation, timing and method of measurement. Furthermore, the evidence linking an elevated PVR with complications such as UTI and renal failure is mixed. Other measures, such as bladder voiding efficiency or urodynamic parameters, may be better at predicting such complications, and therefore may be more relevant at guiding a CISC protocol. CONCLUSIONS There is a lack of high quality evidence to support PVR as a predictor for complications of UTI or renal failure. Threshold values for normal PVR in different populations are unknow, and so threshold values for "elevated" or "significant" PVR cannot be determined. Other factors, such as urodynamic findings, may be better at predicting complications and therefore guiding management decisions, and this remains to be studied. Areas for further research are proposed.
Collapse
Affiliation(s)
- Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mo Belal
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | | | - William Gibson
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Barbara Padilla-Fernandez
- Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Angela Rantell
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Caroline Selai
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Eskinder Solomon
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | |
Collapse
|
18
|
Grundy L, Wyndaele JJ, Hashitani H, Vahabi B, Wein A, Abrams P, Chakrabarty B, Fry CH. How does the lower urinary tract contribute to bladder sensation? ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37902296 DOI: 10.1002/nau.25316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 10/17/2023] [Indexed: 10/31/2023]
Abstract
AIM Bladder sensation is critical for coordinating voluntary micturition to maintain healthy bladder function. Sensations are initiated by the activation of sensory afferents that innervate throughout the bladder wall. However, the physiological complexity that underlies the initiation of bladder sensory signaling in health and disease remains poorly understood. This review summarises the latest knowledge of the mechanisms underlying the generation of bladder sensation and identifies key areas for future research. METHODS Experts in bladder sensory signaling reviewed the literature on how the lower urinary tract contributes to bladder sensation and identified key research areas for discussion at the 10th International Consultation on Incontinence-Research Society. RESULTS The importance of bladder sensory signals in maintaining healthy bladder function is well established. However, better therapeutic management of bladder disorders with exaggerated bladder sensation, including overactive bladder syndrome (OAB) and interstitial cystitis/bladder pain syndrome (IC/BPS) is limited by a lack of knowledge in a number of key research areas including; the contribution of different nerves (pudendal, pelvic, hypogastric) to filling sensations in health and disease; the relative contribution of stretch sensitive (muscular) and stretch-insensitive (mucosal) afferents to bladder sensation in health and disease; the direct and indirect contributions of the muscularis mucosae to bladder contraction and sensation; and the impact of manipulating urothelial release factors on bladder sensation. CONCLUSION Disturbances in bladder sensory signaling can have severe consequences for bladder sensation and function including the development of OAB and IC/BPS. Advancing therapeutic treatments for OAB and IC/BPS requires a deeper understanding of the mechanisms underlying the generation of bladder sensation, and key areas for future research have been identified.
Collapse
Affiliation(s)
- Luke Grundy
- Neurourology Research Group, Flinders Health and Medical Research Institute, Flinders University, South Australia, Australia
| | | | - Hikaru Hashitani
- Department of Cell Physiology, Nagoya City University, Nagoya, Japan
| | - Bahareh Vahabi
- School of Applied Sciences, University of the West of England, Bristol, UK
| | - Alan Wein
- Perelman School of Medicine, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Desai Sethi Institute of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital Bristol, Bristol, UK
| | - Basu Chakrabarty
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| |
Collapse
|
19
|
Chakrabarty B, Winder M, Kanai AJ, Hashitani H, Drake M, Abrams P, Fry CH. Nitric oxide signaling pathways in the normal and pathological bladder: Do they provide new pharmacological pathways?-ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37902298 DOI: 10.1002/nau.25321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 10/22/2023] [Indexed: 10/31/2023]
Abstract
AIMS The nitric oxide (NO•)/soluble guanylate cyclase/cyclic-GMP (cGMP) signaling pathway is ubiquitous and regulates several functions in physiological systems as diverse as the vascular, nervous, and renal systems. However, its roles in determining normal and abnormal lower urinary tract functions are unclear. The aim was to identify potential therapeutic targets associated with this pathway to manage lower urinary tract functional disorders. METHODS This review summarizes a workshop held under the auspices of ICI-RS with a view to address these questions. RESULTS Four areas were addressed: NO• signaling to regulate neurotransmitter release to detrusor smooth muscle; its potential dual roles in alleviating and exacerbating inflammatory pathways; its ability to act as an antifibrotic mediator; and the control by nitrergic nerves of lower urinary tract vascular dynamics and the contractile performance of muscular regions of the bladder wall. Central to much of the discussion was the role of the NO• receptor, soluble guanylate cyclase (sGC) in regulating the generation of the enzyme product, the second messenger cGMP. The redox state of sGC is crucial in determining its enzymic activity and the role of a class of novel agents, sGC activators, to optimize activity and to potentially alleviate the consequences of lower urinary tract disorders was highlighted. In addition, the consequences of a functional relationship between nitrergic and sympathetic nerves to regulate vascular dynamics was discussed. CONCLUSIONS Several potential NO•-dependent drug targets in the lower urinary tract were identified that provide the basis for future research and translation to clinical trials.
Collapse
Affiliation(s)
- Basu Chakrabarty
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| | - Michael Winder
- Department of Pharmacology, University of Gothenburg, Gothenburg, Sweden
| | - Anthony J Kanai
- Departments of Medicine and Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hikaru Hashitani
- Department of Cell Physiology, Nagoya City University, Nagoya, Japan
| | - Marcus Drake
- Department of Surgery and Cancer, Hammersmith Hospital, London, UK
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Christopher H Fry
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol, UK
| |
Collapse
|
20
|
Wyndaele M, Charrua A, Hervé F, Aronsson P, Grundy L, Khullar V, Wein A, Abrams P, Cruz F, Cruz CD. Beyond the urothelium: Interplay between autonomic nervous system and bladder inflammation in urinary tract infection, bladder pain syndrome with interstitial cystitis and neurogenic lower urinary tract dysfunction in spinal cord injury-ICI-RS 2023. Neurourol Urodyn 2023. [PMID: 37876314 DOI: 10.1002/nau.25310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Inflammation and neuronal hypersensitivity are reactive protective mechanisms after urothelial injury. In lower urinary tract dysfunctions (LUTD), such as urinary tract infection (UTI), bladder pain syndrome with interstitial cystitis (BPS/IC) and neurogenic LUTD after spinal cord injury (SCI), chronic inflammation can develop. It is unclear how the protective reactionary inflammation escalates into chronic disease in some patients. METHODS During its 2023 meeting in Bristol, the International Consultation on Incontinence-Research Society (ICI-RS) reviewed the urothelial and inflammatory changes after UTI, BPS/IC and SCI. Potential factors contributing to the evolution into chronic disease were explored in a think-tank. RESULTS Five topics were discussed. (1) Visceral fat metabolism participates in the systemic pro-inflammatory effect of noradrenalin in BPS/IC and SCI. Sympathetic nervous system-adipocyte-bladder crosstalk needs further investigation. (2) Sympathetic hyperactivity also potentiates immune depression in SCI and needs to be investigated in BPS/IC. Gabapentin and tumor necrosis factor-α are promising research targets. (3) The exact peripheral neurons involved in the integrative protective unit formed by nervous and immune systems need to be further identified. (4) Neurotransmitter changes in SCI and BPS/IC: Neurotransmitter crosstalk needs to be considered in identifying new therapeutic targets. (5) The change from eubiosis to dysbiosis in SCI can contribute to UTI susceptibility and needs to be unraveled. CONCLUSIONS The think-tank discussed whether visceral fat metabolism, immune depression through sympathetic hyperactivity, peripheral nerves and neurotransmitter crosstalk, and the change in microbiome could provide explanations in the heterogenic development of chronic inflammation in LUTD. High-priority research questions were identified.
Collapse
Affiliation(s)
- Michel Wyndaele
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ana Charrua
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, Porto, Portugal
- Translational Neurourology, Instituto de Investigação e Inovação em Saúde-i3S and IBMC University of Porto, Porto, Portugal
| | - François Hervé
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Patrik Aronsson
- Department Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Luke Grundy
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, Australia
| | - Vik Khullar
- Department of Urogynaecology, St Mary's Hospital, Imperial College, London, UK
| | - Alan Wein
- Department of Surgery, Division of Urology, Perelman School of Medicine, Penn Medicine, University of Pennsylvania Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Urology, Desai Sethi Institute of Urology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Francisco Cruz
- Translational Neurourology, Instituto de Investigação e Inovação em Saúde-i3S and IBMC University of Porto, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine of Porto, University of Porto, Porto, Portugal
- Department of Urology, Hospital São João, Porto, Portugal
| | - Célia Duarte Cruz
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, Porto, Portugal
- Translational Neurourology, Instituto de Investigação e Inovação em Saúde-i3S and IBMC University of Porto, Porto, Portugal
| |
Collapse
|
21
|
Saul H, Deeney B, Cassidy S, Kwint J, Constable L, Abrams P. Male sling is as good as more complex surgery for incontinence after prostate surgery. BMJ 2023; 381:p1179. [PMID: 37277136 DOI: 10.1136/bmj.p1179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The studyConstable L, Abrams P, Cooper D, et. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health Technol Assess 2022;26:1-152To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/male-sling-is-as-good-as-more-complex-surgery-for-incontinence-after-prostate-surgery/.
Collapse
|
22
|
O'Kane M, Robinson D, Cardozo L, Wagg A, Abrams P. Mirabegron in the Management of Overactive Bladder Syndrome. Int J Womens Health 2022; 14:1337-1350. [PMID: 36147890 PMCID: PMC9487925 DOI: 10.2147/ijwh.s372597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/08/2022] [Indexed: 11/23/2022] Open
Abstract
Overactive bladder (OAB) negatively affects work productivity and quality of life in sufferers. Its overall impact is likely to increase as a result of increasing prevalence in an ageing population. The pathophysiology of OAB is not completely understood but the β3-adrenoceptor, which is highly expressed in the urinary bladder, is thought to be important for mediating human detrusor relaxation during the storage phase. Clinical trial results have demonstrated that mirabegron, a selective β3-adrenoceptor agonist offers substantial clinical efficacy and good adherence rates over 12 months. Furthermore, due to its different mechanism of action, it is likely to offer a favourable tolerability profile when compared with antimuscarinic agents, resulting in improved persistence over long-term treatment. Finally, from a health economic perspective, despite its higher drug acquisition cost, mirabegron has been found to be cost-effective, owing to the greater increase in quality-adjusted-life-years gained, when compared to antimuscarinic medications. The PubMed database was searched for English language articles published between 1 January 2005 to 31 January 2022, on the subject of mirabegron. Search terms included "mirabegron", "overactive bladder", "β3-adrenoceptor agonist", "urinary incontinence". This review summarises the evidence for mirabegron as a treatment option for the management of OAB.
Collapse
Affiliation(s)
- Miriam O'Kane
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Dudley Robinson
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
23
|
Young GJ, Metcalfe C, Lane JA, Lewis AL, Abrams P, Blair PS, Ito H, Chapple C, Drake MJ. Prostate Surgery for Men with Lower Urinary Tract Symptoms: Do We Need Urodynamics to Find the Right Candidates? Exploratory Findings from the UPSTREAM Trial. Eur Urol Focus 2022; 8:1331-1339. [PMID: 34922898 PMCID: PMC9705260 DOI: 10.1016/j.euf.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/21/2021] [Accepted: 11/30/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Identifying men whose lower urinary tract symptoms (LUTS) may benefit from surgery is challenging. OBJECTIVE To identify routine diagnostic and urodynamic measures associated with treatment decision-making, and outcome, in exploratory analyses of the UPSTREAM trial. DESIGN, SETTING, AND PARTICIPANTS A randomised controlled trial was conducted including 820 men, considering surgery for LUTS, across 26 hospitals in England (ISCTRN56164274). INTERVENTION Men were randomised to a routine care (RC) diagnostic pathway (n = 393) or a pathway that included urodynamics (UDS) in addition to RC (n = 427). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Men underwent uroflowmetry and completed symptom questionnaires, at baseline and 18 mo after randomisation. Regression models identified baseline clinical and symptom measures that predicted recommendation for surgery and/or surgical outcome (measured by the International Prostate Symptom Score [IPSS]). We explored the association between UDS and surgical outcome in subgroups defined by routine measures. RESULTS AND LIMITATIONS The recommendation for surgery could be predicted successfully in the RC and UDS groups (area under the receiver operating characteristic curve 0.78), with maximum flow rate (Qmax) and age predictors in both groups. Surgery was more beneficial in those with higher symptom scores (eg, IPSS >16), age <74 yr, Qmax <9.8 ml/s, bladder outlet obstruction index >47.6, and bladder contractility index >123.0. In the UDS group, urodynamic measures were more strongly predictive of surgical outcome for those with Qmax >15, although patient-reported outcomes were also more predictive in this subgroup. CONCLUSIONS Treatment decisions were informed with UDS, when available, but without evidence of change in the decisions reached. Despite the small group sizes, exploratory analyses suggest that selective use of UDS could detect obstructive pathology, missed by routine measures, in certain subgroups. PATIENT SUMMARY Baseline clinical and symptom measurements were able to predict treatment decisions. The addition of urodynamic test results, while useful, did not generally lead to better surgical decisions and outcomes over routine tests alone.
Collapse
Affiliation(s)
- Grace J. Young
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Trials Centre (BRTC), University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Trials Centre (BRTC), University of Bristol, Bristol, UK
| | - J. Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Trials Centre (BRTC), University of Bristol, Bristol, UK
| | - Amanda L. Lewis
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Trials Centre (BRTC), University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Peter S. Blair
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Trials Centre (BRTC), University of Bristol, Bristol, UK
| | - Hiroki Ito
- Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Christopher Chapple
- Sheffield Teaching Hospitals NHS Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marcus J. Drake
- Bristol Medical School, University of Bristol, Bristol, UK,Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol, UK,Corresponding author. University of Bristol and Bristol Urological Institute, Level 3, Learning and Research Building, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK. Tel. +44 7764662017.
| |
Collapse
|
24
|
McGeagh L, Robles LA, Persad R, Rowe E, Bahl A, Aning J, Koupparis A, Abrams P, Perks C, Holly J, Johnson L, Shiridzinomwa C, Challapalli A, Shingler E, Taylor H, Oxley J, Sandu M, Martin RM, Lane JA. Prostate cancer-Exercise and Metformin Trial (Pre-EMpT): study protocol for a feasibility factorial randomized controlled trial in men with localised or locally advanced prostate cancer. Pilot Feasibility Stud 2022; 8:179. [PMID: 35962445 PMCID: PMC9372971 DOI: 10.1186/s40814-022-01136-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Evidence from observational studies have shown that moderate intensity physical activity can reduce risk of progression and cancer-specific mortality in participants with prostate cancer. Epidemiological studies have also shown participants taking metformin to have a reduced risk of prostate cancer. However, data from randomised controlled trials supporting the use of these interventions are limited. The Prostate cancer–Exercise and Metformin Trial examines that feasibility of randomising participants diagnosed with localised or locally advanced prostate cancer to interventions that modify physical activity and blood glucose levels. The primary outcomes are randomisation rates and adherence to the interventions over 6 months. The secondary outcomes include intervention tolerability and retention rates, measures of insulin-like growth factor I, prostate-specific antigen, physical activity, symptom-reporting, and quality of life. Methods Participants are randomised in a 2 × 2 factorial design to both a physical activity (brisk walking or control) and a pharmacological (metformin or control) intervention. Participants perform the interventions for 6 months with final measures collected at 12 months follow-up. Discussion Our trial will determine whether participants diagnosed with localised or locally advanced prostate cancer, who are scheduled for radical treatments or being monitored for signs of cancer progression, can be randomised to a 6 months physical activity and metformin intervention. The findings from our trial will inform a larger trial powered to examine the clinical benefits of these interventions. Trial registration Prostate Cancer Exercise and Metformin Trial (Pre-EMpT) is registered on the ISRCTN registry, reference number ISRCTN13543667. Date of registration 2nd August 2018–retrospectively registered. First participant was recruited on 11th September 2018.
Collapse
Affiliation(s)
- Lucy McGeagh
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Supportive Cancer Care Research Group, Faculty of Health and Life Sciences, Oxford Institute of Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | - Luke A Robles
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Raj Persad
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Edward Rowe
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Amit Bahl
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jonathan Aning
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | | | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Bristol, UK
| | - Claire Perks
- Insulin-like Growth Factors and Metabolic Endocrinology Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeffrey Holly
- Insulin-like Growth Factors and Metabolic Endocrinology Group, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lyndsey Johnson
- Clinical Research Centre, North Bristol NHS Trust, Bristol, UK
| | | | - Amarnath Challapalli
- Bristol Haematology and Oncology Centre, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ellie Shingler
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Hilary Taylor
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Meda Sandu
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Richard M Martin
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK.,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - J Athene Lane
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK. .,Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
| |
Collapse
|
25
|
Constable L, Abrams P, Cooper D, Kilonzo M, Cotterill N, Harding C, Drake MJ, Pardoe MN, McDonald A, Smith R, Norrie J, McCormack K, Ramsay C, Uren A, Mundy T, Glazener C, MacLennan G. Synthetic sling or artificial urinary sphincter for men with urodynamic stress incontinence after prostate surgery: the MASTER non-inferiority RCT. Health Technol Assess 2022; 26:1-152. [PMID: 35972773 PMCID: PMC9421661 DOI: 10.3310/tbfz0277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Stress urinary incontinence is common in men after prostate surgery and can be difficult to improve. Implantation of an artificial urinary sphincter is the most common surgical procedure for persistent stress urinary incontinence, but it requires specialist surgical skills, and revisions may be necessary. In addition, the sphincter is relatively expensive and its operation requires adequate patient dexterity. New surgical approaches include the male synthetic sling, which is emerging as a possible alternative. However, robust comparable data, derived from randomised controlled trials, on the relative safety and efficacy of the male synthetic sling and the artificial urinary sphincter are lacking. OBJECTIVE We aimed to compare the clinical effectiveness and cost-effectiveness of the male synthetic sling with those of the artificial urinary sphincter surgery in men with persistent stress urinary incontinence after prostate surgery. DESIGN This was a multicentre, non-inferiority randomised controlled trial, with a parallel non-randomised cohort and embedded qualitative component. Randomised controlled trial allocation was carried out by remote web-based randomisation (1 : 1), minimised on previous prostate surgery (radical prostatectomy or transurethral resection of the prostate), radiotherapy (or not, in relation to prostate surgery) and centre. Surgeons and participants were not blind to the treatment received. Non-randomised cohort allocation was participant and/or surgeon preference. SETTING The trial was set in 28 UK urological centres in the NHS. PARTICIPANTS Participants were men with urodynamic stress incontinence after prostate surgery for whom surgery was deemed appropriate. Exclusion criteria included previous sling or artificial urinary sphincter surgery, unresolved bladder neck contracture or urethral stricture after prostate surgery, and an inability to give informed consent or complete trial documentation. INTERVENTIONS We compared male synthetic sling with artificial urinary sphincter. MAIN OUTCOME MEASURES The clinical primary outcome measure was men's reports of continence (assessed from questions 3 and 4 of the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form) at 12 months post randomisation (with a non-inferiority margin of 15%). The primary economic outcome was cost-effectiveness (assessed as the incremental cost per quality-adjusted life-year at 24 months post randomisation). RESULTS In total, 380 men were included in the randomised controlled trial (n = 190 in each group), and 99 out of 100 men were included in the non-randomised cohort. In terms of continence, the male sling was non-inferior to the artificial urinary sphincter (intention-to-treat estimated absolute risk difference -0.034, 95% confidence interval -0.117 to 0.048; non-inferiority p = 0.003), indicating a lower success rate in those randomised to receive a sling, but with a confidence interval excluding the non-inferiority margin of -15%. In both groups, treatment resulted in a reduction in incontinence symptoms (as measured by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form). Between baseline and 12 months' follow-up, the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score fell from 16.1 to 8.7 in the male sling group and from 16.4 to 7.5 in the artificial urinary sphincter group (mean difference for the time point at 12 months 1.30, 95% confidence interval 0.11 to 2.49; p = 0.032). The number of serious adverse events was small (male sling group, n = 8; artificial urinary sphincter group, n = 15; one man in the artificial urinary sphincter group experienced three serious adverse events). Quality-of-life scores improved and satisfaction was high in both groups. Secondary outcomes that showed statistically significant differences favoured the artificial urinary sphincter over the male sling. Outcomes of the non-randomised cohort were similar. The male sling cost less than the artificial sphincter but was associated with a smaller quality-adjusted life-year gain. The incremental cost-effectiveness ratio for male slings compared with an artificial urinary sphincter suggests that there is a cost saving of £425,870 for each quality-adjusted life-year lost. The probability that slings would be cost-effective at a £30,000 willingness-to-pay threshold for a quality-adjusted life-year was 99%. LIMITATIONS Follow-up beyond 24 months is not available. More specific surgical/device-related pain outcomes were not included. CONCLUSIONS Continence rates improved from baseline, with the male sling non-inferior to the artificial urinary sphincter. Symptoms and quality of life significantly improved in both groups. Men were generally satisfied with both procedures. Overall, secondary and post hoc analyses favoured the artificial urinary sphincter over the male sling. FUTURE WORK Participant reports of any further surgery, satisfaction and quality of life at 5-year follow-up will inform longer-term outcomes. Administration of an additional pain questionnaire would provide further information on pain levels after both surgeries. TRIAL REGISTRATION This trial is registered as ISRCTN49212975. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 36. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Lynda Constable
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nikki Cotterill
- Faculty of Health and Applied Sciences (HAS), University of the West of England, Bristol, UK
| | - Chris Harding
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marcus J Drake
- Bristol Urological Institute, University of Bristol, Bristol, UK
| | - Megan N Pardoe
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Smith
- Research and Innovation, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - John Norrie
- Usher Institute, Centre of Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsty McCormack
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alan Uren
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Tony Mundy
- Urology, University College Hospital, London, UK
| | - Cathryn Glazener
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| |
Collapse
|
26
|
Gingell C, Abrams P. John Clive Gingell. BMJ 2022. [DOI: 10.1136/bmj.o1124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
27
|
van Till JWO, Arita E, Kuroishi K, Croy R, Oelke M, van Koeveringe GA, Chapple CR, Yamaguchi O, Abrams P. Muscarinic-3-receptor positive allosteric modulator ASP8302 in patients with underactive bladder. A randomized controlled trial. Neurourol Urodyn 2022; 41:1139-1148. [PMID: 35419807 DOI: 10.1002/nau.24931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 11/07/2022]
Abstract
AIM The aim of this study is to evaluate safety and efficacy of ASP8302, a novel positive allosteric modulator for the muscarinic M3 receptor (M3-PAM), in patients with underactive bladder (UAB). METHODS A randomized, double-blind, placebo-controlled multicenter study was performed in adult male/female subjects with UAB, defined as incomplete bladder emptying (postvoid residual volume [PVR] > 100 ml) without significant bladder outlet obstruction and/or overactive bladder. Subjects were randomized (1:1) to receive 4-week oral once-daily administration of 100 mg ASP8302 or matching placebo. Primary endpoint was a change from baseline in PVR measured by catheterization after standardized bladder filling (PVRC2 ). Other endpoints included PVR and bladder voiding efficiency (BVE) measured in various ways, uroflowmetry, bladder diary, and questionnaires. Pressure-flow studies were performed in a subgroup. RESULTS One hundred and thirty-five patients were randomized (ASP8302 group: 65 patients, placebo group: 70 patients). The median change in PVRC2 was -40.0 ml (ASP8302) versus -35.0 ml (placebo) and the difference between groups was -5.0 ml (p = 0.960). In males, functional and symptomatic outcomes improved, for example, maximum urine flow rate (Qmax ) and detrusor pressure at Qmax (Pdet.Qmax ) increased (mean difference in change ASP8302 vs. placebo: 3.8 ml/s, p = 0.031 and 12.7 cm H2 O, p = 0.034, respectively). Urinary incontinence episodes/24 h decreased in males with preexisting incontinence (mean difference: -0.35; p = 0.028). The incidence of adverse events was similar between study groups (ASP8302: 33.3%, placebo: 31.4%). In the included subjects, both baseline urine flow and bladder voiding pressure was low. Compared with PVR, simultaneous BVE measurements were more consistent between various methods (spontaneous vs. standardized bladder filling, catheterization vs. ultrasound [US]). CONCLUSIONS ASP8302 was safe and well tolerated in patients with UAB identified by nonurodynamic clinical criteria, but it did not show efficacy in the primary endpoint. However, in males it showed improvement of symptoms and functional parameters. BVE (using US) is a more optimal outcome measure than PVR in UAB.
Collapse
Affiliation(s)
| | - Eri Arita
- Medical and Development, Astellas Pharma Inc., Cambridge, Massachusetts, USA
| | - Kentaro Kuroishi
- Medical and Development, Astellas Pharma Inc., Cambridge, Massachusetts, USA
| | - Richard Croy
- Medical and Development, Astellas Pharma Inc., Cambridge, Massachusetts, USA
| | - Matthias Oelke
- Department of Urology, Paediatric Urology and Uro-Oncology, St. Antonius Hospital, Gronau, Germany
| | | | | | - Osamu Yamaguchi
- Department of Urology, Fukushima Medical University, Fukushima, Japan
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| |
Collapse
|
28
|
Song QX, Li J, Gu Y, Xu L, Abrams P, Xue W. The Clinical Features and Predictive Factors of Nocturnal Enuresis in Adult Women. Front Med (Lausanne) 2022; 8:744214. [PMID: 35111771 PMCID: PMC8801585 DOI: 10.3389/fmed.2021.744214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveOur current knowledge on nocturnal enuresis (NE) in adults is scarce due to its uncommon nature. The present study was designed to investigate symptom characteristics and risk factors of NE in adult women to improve the current clinical understanding and management of this rare disease.MethodsOver a 3-year period, we enrolled 70 adult women who complained of bedwetting, with a frequency of at least once per week and a symptom duration of 3 months or longer. Patients were excluded if they had known pregnancy, current urinary tract infection, untreated malignancies, anatomical abnormalities, and irregular sleep cycle. The International Consultation on Incontinence Modular Questionnaire—female lower urinary tract symptoms and bladder diary were employed to appraise lower urinary tract symptoms and voiding behavior. Urodynamics was performed to assess the bladder function. A linear regression analysis was applied to determine potential risk factors for NE frequency.ResultsAmong the recruited subjects, comorbidities and lower urinary tract symptoms were frequently reported. On bladder diary, patients commonly presented with nocturnal polyuria (NP), reduced nocturnal voided volumes (RNVVs), or both. Urodynamics revealed multiple dysfunctions, namely, detrusor overactivity (DO), urodynamic stress incontinence (USI), reduced compliance, bladder outlet obstruction, detrusor underactivity (DU), and simultaneous DO and DU. Patients with more frequent NE (≥4/week) demonstrated markedly increased body mass index, more comorbid conditions, worse incontinence symptoms, NP or NP plus RNVVs, reduced compliance, and poorer voiding possibly owing to DU. Whereas, RNVVs alone and worse overactive bladder-related parameters were associated with milder NE. Multivariate analysis indicated that frequency/urgency quality of life, incontinence symptom, NP + RNVVs, poor flow, increased bladder sensation, USI, and simultaneous detrusor overactivity plus DU were independent risk factors for NE severity.ConclusionNE in adult women may have both urological and non-urological pathophysiology. Imbalanced circadian urine production, jeopardized continence mechanisms, overactive bladder, and DU-induced poor voiding are major factors that contribute to the pathogenesis of NE in adult women. Focused treatments on restoring these functions should be individually considered.
Collapse
Affiliation(s)
- Qi-Xiang Song
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
- Qi-Xiang Song
| | - Jiayi Li
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiyuan Gu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Xu
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, United Kingdom
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Wei Xue
| |
Collapse
|
29
|
Gammie A, Hashim H, Abrams P. Bristol UTraQ: A proposed system for scoring the technical quality of urodynamic traces. Neurourol Urodyn 2022; 41:672-678. [PMID: 35032349 DOI: 10.1002/nau.24872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/09/2021] [Accepted: 12/25/2021] [Indexed: 11/08/2022]
Abstract
AIM To develop and test a scoring system for the technical quality of a urodynamic trace METHODS: Rasch analysis was used to select the most discriminating questions relating to good urodynamic practices. The questions were taken from International Continence Society standard documents and tested on 60 traces of varying quality and from different sources. RESULTS Twenty-five questions were selected by this process. These were tested with 10 traces by seven scorers, and with 60 traces by a single scorer. A pass quality score of 75% resulted in good discrimination between good and poor traces. Further editing and clarification resulted in a final score sheet of 23 Yes/No questions. CONCLUSION A proposed scoring system, "Bristol UTraQ," for the technical quality of urodynamic traces has been developed and tested. We suggest a score above 75% indicates acceptable trace technical quality. High technical quality is the essential first step in ensuring that urodynamic studies can answer the urodynamic questions for every patient. Plans for further validation are outlined.
Collapse
Affiliation(s)
- Andrew Gammie
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| |
Collapse
|
30
|
Ito H, Abrams P, Lewis AL, Young GJ, Blair PS, Cotterill N, Lane JA, Drake MJ. Use of the International Consultation on Incontinence Questionnaires Bladder Diary in Men Seeking therapy for Lower Urinary Tract Symptoms. Eur Urol Focus 2022; 8:66-74. [PMID: 35027329 DOI: 10.1016/j.euf.2021.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 12/28/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Completion rates and correspondence to other measures need to be established for the International Consultation on Incontinence Questionnaire (ICIQ) bladder diary (ICIQ-BD) in the assessment of male lower urinary tract symptoms (LUTS). OBJECTIVE To evaluate ICIQ-BD completion rates, frequency, volume, and sensation reporting for men. DESIGN, SETTING, AND PARTICIPANTS Baseline data from the Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) randomised controlled trial evaluating 820 men at 26 UK hospitals, looking at the ICIQ-BD, uroflowmetry, International Prostate Symptom Score, and ICIQ symptom score for male LUTS (ICIQ-MLUTS), were assessed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The ICIQ-BD, IPSS, ICIQ-MLUTS, and uroflowmetry data at baseline obtained from UPSTREAM were assessed. Correlations were analysed by Pearson's correlation coefficient, and comparison between groups were performed using paired or unpaired t tests or Tukey's test. All statistical tests were two sided and the strength of evidence was presented using p values. RESULTS AND LIMITATIONS Of the participants, 25.0% (205/820) provided complete voiding and bedtime information for 3 d, 41.2% (338/820) omitted bedtime information, and the remainder omitted some or all voiding information. Median values (minimum - maximum) of 24-h, daytime, and night-time frequencies were 9.7 (3.3-24.0), 7.7 (3.3-22.7), and 1.7 (0.0-5.7), respectively. The mean voided volume per micturition for day and night times were 175.8 ± 74.2 and 264.4 ± 150.7 ml (p < 0.001), respectively. For fully completed diaries, day- and night-time frequency showed a weak-to-moderate correlation with symptom score questionnaires. More severe nocturia was generally reported in symptom scores than in the ICIQ-BD. In patients with high bother for increased daytime frequency (symptom), the mean daytime frequency (ICIQ-BD) was 9.6 ± 3.2 versus 7.6 ± 2.2 for low bother (p < 0.001). High bother for nocturia showed night-time frequency of 2.3 ± 1.2 versus 1.5 ± 1.1 for low bother (p < 0.001). For fully and partially completed diaries, ICIQ-BD sensation scores correlated weakly with symptom scores. Voided volumes from the bladder diary and uroflowmetry correlated weakly. CONCLUSIONS Two-thirds of men (543/820) fully completed voiding information in the ICIQ-BD, but many omitted bedtime information, limiting the ability to quantify nocturia and diagnose nocturnal polyuria. PATIENT SUMMARY Most men with urinary symptoms complete a bladder diary fully but may fail to indicate bedtimes. Extra information from a diary helps support symptom questionnaires to explain a patient's urinary habits.
Collapse
Affiliation(s)
- Hiroki Ito
- Department of Urology, Yokosuka Kyosai Hospital, Yokosuka, Japan; Department of Urology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Paul Abrams
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Amanda L Lewis
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Bristol, UK
| | - Grace J Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Bristol, UK
| | - Peter S Blair
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Bristol, UK
| | - Nikki Cotterill
- School of Health and Social Wellbeing, University of the West of England, Bristol, UK
| | - J Athene Lane
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK; Bristol Randomised Trials Collaboration (BRTC), University of Bristol, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK; Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| |
Collapse
|
31
|
Song QX, He F, Sun X, Liu K, Chen Z, Li M, Lin J, Xu Z, Li Y, Zhang Y, Huang H, Zhang Y, Ye X, Peng Y, Li L, Yin L, Gao X, Song B, Sun Y, Wang J, Xue W, Abrams P. The characteristics and risk factors of healthcare-seeking men with lower urinary tract symptoms in China: Initial report from the POInT group. Neurourol Urodyn 2021; 40:1740-1753. [PMID: 34252243 DOI: 10.1002/nau.24737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/18/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022]
Abstract
AIMS To investigate the clinical characteristics of health care-seeking men presenting with lower urinary tract symptoms (LUTS) in China and to reveal risk factors for symptom severity. METHODS This multicenter, hospital-based, cross-sectional study recruited 1477 eligible male subjects, who were at least 45 years, seeking health care at 9 participating hospitals across the mainland China. The general medical information and subjective symptoms were recorded, followed by the measurement of prostate volume, urodynamic indices, and laboratory tests for kidney function, plus glucose/lipid metabolism. Univariate and multivariate linear regression were employed for the detection of risk factors for symptom severity. RESULTS The proportion of mild, moderate, and severe LUTS was 14.6%, 32.6%, and 52.8%, respectively, with 62.2% reporting the triple combination of storage, voiding, and postmicturition symptoms. Median prostate volume was 44.6 ml, and 71.1% were experiencing comorbidities. Thirteen independent risk factors for LUTS severity were identified, namely, nocturnal voiding episodes and the presence of straining and weak steam; the triple combination of symptom subtypes; general and nocturia quality of life; Qmax and bladder outlet obstruction index; and numbers of comorbidities, hypertension, estimated glomerular filtration rate, and cholesterol and glycosylated hemoglobin. CONCLUSIONS The majority of health care-seeking LUTS men present with moderate-to-severe and overlapping symptoms, with a high prevalence of both lower urinary tract dysfunction and systemic comorbidities. The evidence from both urological and nonurological independent risk factors demonstrate the multifactorial nature of LUTS, for which a multidisciplinary management is essential.
Collapse
Affiliation(s)
- Qi-Xiang Song
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Fan He
- Department of Urology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xionglin Sun
- Department of Urology, The First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Ke Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Zhong Chen
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingzhao Li
- Department of Urology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jianhai Lin
- Department of Urology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Zhihui Xu
- Department of Urology, Zhejiang Provincial People's Hospital, Hangzhou, Shanghai, China
| | - Yan Li
- Department of Urology, Qilu Hospital, Shandong University, Shandong, China
| | - Yaoguang Zhang
- Department of Urology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Hai Huang
- Department of Urology, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Yi Zhang
- Department of Military Health Service, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Yonghan Peng
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Longkun Li
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | | | - Xiaofeng Gao
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Song
- Department of Urology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yinghao Sun
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianye Wang
- Department of Urology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Wei Xue
- Department of Urology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | | |
Collapse
|
32
|
Uren AD, Cotterill N, Abrams P, Catto JWF, Patel B, McGrath J, Ahmed I, Rowe E. The development of the Cystectomy-Pathway Assessment Tool (C-PAT): a concise tool to assess the quality of care in the cystectomy pathway. BJU Int 2021; 129:708-717. [PMID: 34218507 DOI: 10.1111/bju.15539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 06/01/2021] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To develop and test the psychometric properties of a concise, patient-reported questionnaire, designed to assess key aspects of the radical cystectomy (RC) patient pathway that are important to both patients and clinicians. PATIENTS AND METHODS Draft items were developed by a consultation with a 13-member expert clinical panel, and the in-depth qualitative analysis of 14 semi-structured interviews with patients who had received RC within the previous 18 months. A further nine cognitive interviews with patients refined the items and ensured they were easy to complete. Pilot testing in 122 patients recruited from five hospitals in England tested the properties of validity and reliability of the resulting 17-item questionnaire. RESULTS Patients and clinicians identified the following aspects as important for the delivery of quality patient care. These included timely referral and initial test results; an explanation of risk/benefits of treatment; access to a cancer nurse specialist; training and support in stoma management; timely surgery, surgical complications, and timely follow-up. Pilot testing showed missing data was low (≤3% for all items), and between 73% and 89% of the responses to items were the most positive about their care (indicating ceiling effects). Five items were identified using factor analysis as being statistically related (Cronbach's α 0.76, intraclass correlation coefficient test-retest reliability of 0.95) and formed the scored part of the tool 'care and support', scored 0-16. There was insufficient evidence at this stage to show the tool was capable of measuring differences between cancer centres. CONCLUSION We have developed a questionnaire that captures aspects of quality of care within the RC patient pathway. The results support the validity and reliability of the 17-item Cystectomy-Pathway Assessment Tool (C-PAT). We envisage the tool can be the basis for audit of the patient reported assessment of the quality of care for individual cancer centres.
Collapse
Affiliation(s)
- Alan D Uren
- Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Nikki Cotterill
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol and the Bristol Urological Institute, Bristol, UK
| | - Paul Abrams
- Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - James W F Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK.,Department of Urology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Biral Patel
- Department of Urology, Gloucestershire Hospitals NHS Foundation Trust UK, Cheltenham, UK
| | | | - Iram Ahmed
- Medway Maritime Hospital, Medway NHS Foundation Trust, Gillingham, UK
| | - Edward Rowe
- Department of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
| |
Collapse
|
33
|
Abrams P, Constable LD, Cooper D, MacLennan G, Drake MJ, Harding C, Mundy A, McCormack K, McDonald A, Norrie J, Ramsay C, Smith R, Cotterill N, Kilonzo M, Glazener C. Outcomes of a Noninferiority Randomised Controlled Trial of Surgery for Men with Urodynamic Stress Incontinence After Prostate Surgery (MASTER). Eur Urol 2021; 79:812-823. [PMID: 33551297 PMCID: PMC8175331 DOI: 10.1016/j.eururo.2021.01.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 01/17/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Stress urinary incontinence (SUI) is common after radical prostatectomy and likely to persist despite conservative treatment. The sling is an emerging operation for persistent SUI, but randomised controlled trial (RCT) comparison with the established artificial urinary sphincter (AUS) is lacking. OBJECTIVE To compare the outcomes of surgery in men with bothersome urodynamic SUI after prostate surgery. DESIGN, SETTING, AND PARTICIPANTS A noninferiority RCT was conducted among men with bothersome urodynamic SUI from 27 UK centres. Blinding was not possible due the surgeries. INTERVENTION Participants were randomly assigned (1:1) to the male transobturator sling (n = 190) or the AUS (n = 190) group. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was patient-reported SUI 12 mo after randomisation, collected from postal questionnaire using a composite outcome from two items in validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (ICIQ-UI SF). Noninferiority margin was 15%, thought to be of acceptable lower effectiveness, in return for reduced adverse events (AEs) and easier operation, for the sling. Secondary outcomes were operative and postoperative details, patient-reported measures, and AEs, up to 12 mo after surgery. RESULTS AND LIMITATIONS A total of 380 participants were included. At 12 mo after randomisation, incontinence rates were 134/154 (87.0%) for male sling versus 133/158 (84.2%) for AUS (difference 3.6% [95% confidence interval {CI} -11.6 to 4.6], pNI = 0.003), showing noninferiority. Incontinence symptoms (ICIQ-UI SF) reduced from scores of 16.1 and 16.4 at baseline to 8.7 and 7.5 for male sling and AUS, respectively (mean difference 1.4 [95% CI 0.2-2.6], p = 0.02). Serious AEs (SAEs) were few: n = 6 and n = 13 for male sling and AUS (one man had three SAEs), respectively. Quality of life scores improved, and satisfaction was high in both groups. All other secondary outcomes that show statistically significant differences favour the AUS. CONCLUSIONS Using a strict definition, urinary incontinence rates remained high, with no evidence of difference between male sling and AUS. Symptoms and quality of life improved significantly in both groups, and men were generally satisfied with both procedures. Overall, secondary and post hoc analyses were in favour of AUS. PATIENT SUMMARY Urinary incontinence after prostatectomy has considerable effect on men's quality of life. MASTER shows that if surgery is needed, both surgical options result in fewer symptoms and high satisfaction, despite most men not being completely dry. However, most other results indicate that men having an artificial urinary sphincter have better outcomes than those who have a sling.
Collapse
Affiliation(s)
- Paul Abrams
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Lynda D Constable
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK.
| | - David Cooper
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, UK
| | - Chris Harding
- Department of Urology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Anthony Mundy
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kirsty McCormack
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Alison McDonald
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Craig Ramsay
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Rebecca Smith
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Nikki Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; Faculty of Health and Applied Science, University of West of England, Bristol, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Cathryn Glazener
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| |
Collapse
|
34
|
Lee SM, Gammie A, Abrams P. Assessment of quality in urodynamics: Cough versus valsalva. Neurourol Urodyn 2021; 40:1021-1026. [PMID: 33792955 DOI: 10.1002/nau.24661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION To ensure quality, the International Continence Society recommends asking the patient to cough every minute or 50 ml of infused volume. However, on occasions, it was noticed that if cough transmission was poor, Valsalva maneuvers could show pressure transmission was satisfactory. Hence, a study was designed to compare the two methods. METHODS Cough and Valsalva maneuver pressures were compared in 40 patients, 20 consecutive men and 20 consecutive women, undergoing urodynamics at three time points: baseline (20 ml filling), prevoid and postvoid. RESULTS At baseline, the percentage difference between pabd and pves was significantly lower for Valsalva maneuvres compared with coughs for all patients (median 5.1% vs. 10.2%). This association was consistent in male patients, but not for female. At prevoid, this was reversed with coughs providing more consistent pressure spikes than Valsalva maneuvers (median 7.0% vs. 24.1%), for all patients. Postvoid, no difference was noted in either men or women. CONCLUSIONS Quality control during urodynamics is important to ensure diagnostic accuracy. This is the first study to compare two methods of quality control, coughs, and Valsalva maneuvers. Coughs are a useful indicator of pressure transmission quality at all time points throughout urodynamic studies. However, at low volumes, Valsalva maneuvers give a better indication of quality, with lower variability, whereas at cystometric capacity coughs performed better. Therefore, if poor pressure transmission occurs with cough during urodynamics, particularly at low volumes, it is recommended that a Valsalva maneuver is used to further assess whether pressure transmission and thus urodynamic quality is satisfactory.
Collapse
Affiliation(s)
- Su-Min Lee
- Bristol Urological Insitute, Southmead Hospital, Bristol, UK
| | - Andrew Gammie
- Bristol Urological Insitute, Southmead Hospital, Bristol, UK
| | - Paul Abrams
- Bristol Urological Insitute, Southmead Hospital, Bristol, UK
| |
Collapse
|
35
|
Drake MJ, Lewis AL, Young GJ, Abrams P, Blair PS, Chapple C, Glazener CM, Horwood J, McGrath JS, Noble S, Taylor GT, Lane JA. Diagnostic Assessment of Lower Urinary Tract Symptoms in Men Considering Prostate Surgery: A Noninferiority Randomised Controlled Trial of Urodynamics in 26 Hospitals. Eur Urol 2020; 78:701-710. [DOI: 10.1016/j.eururo.2020.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/02/2020] [Indexed: 10/24/2022]
|
36
|
Selman LE, Clement C, Ochieng CA, Lewis AL, Chapple C, Abrams P, Drake MJ, Horwood J. Treatment decision-making among men with lower urinary tract symptoms: A qualitative study of men's experiences with recommendations for patient-centred practice. Neurourol Urodyn 2020; 40:201-210. [PMID: 33053240 DOI: 10.1002/nau.24533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/18/2020] [Accepted: 09/26/2020] [Indexed: 11/09/2022]
Abstract
AIMS To inform and guide patient-centred care for men with lower urinary tract symptoms (LUTS), by providing in-depth qualitative evidence regarding men's perspectives on treatment decision-making for LUTS. METHODS An interview study of men recruited from 26 English urology departments. Purposive sampling captured surgical/nonsurgical treatment decisions, and diversity in demographics and symptom burden, in men who had urodynamics and those who did not. After diagnostic assessments, men were interviewed either pre-treatment or after LUTS surgery. Thematic analysis was conducted. Participants' descriptions of how LUTS treatment decisions were made were categorised as patient-led, doctor-led, or shared. RESULTS A total of 41 men participated (25 pre-treatment, 16 post-surgery), ages 52-89. Twenty out of 41 described the treatment decision as shared with their consultant, 14 as doctor-led, and seven as patient-led. There was no obvious association between treatment decision-making style and patients' satisfaction with either clinicians' role in their decision or their treatment decision. Incomplete or rushed discussions and misperceptions of LUTS and its treatment were reported, indicating a risk of suboptimal decision-making support by clinicians. As well as clinician opinion, men's treatment decision-making was influenced by the results of urological assessments, comparing current symptoms with possible side-effects of surgery, and others' experiences and opinions. CONCLUSIONS Men with LUTS report and prefer different kinds of decision-making support from their clinicians, who must tailor their input to patients' preferences and needs. Patients' treatment decision-making involves multiple factors and can be challenging, and areas of inadequate clinician support were identified. Recommendations for patient-centred consultations about LUTS treatment are presented.
Collapse
Affiliation(s)
- Lucy E Selman
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cynthia A Ochieng
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Amanda L Lewis
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christopher Chapple
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK.,Translational Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
37
|
Lewis AL, Young GJ, Selman LE, Rice C, Clement C, Ochieng CA, Abrams P, Blair PS, Chapple C, Glazener CM, Horwood J, McGrath JS, Noble S, Taylor GT, Lane JA, Drake MJ. Urodynamics tests for the diagnosis and management of bladder outlet obstruction in men: the UPSTREAM non-inferiority RCT. Health Technol Assess 2020; 24:1-122. [PMID: 32902375 DOI: 10.3310/hta24420] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Lower urinary tract symptoms (LUTS) in men may indicate bladder outlet obstruction (BOO) or weakness, known as detrusor underactivity (DU). Severe bothersome LUTS are a common indication for surgery. The diagnostic tests may include urodynamics (UDS) to confirm whether BOO or DU is the cause, potentially reducing the number of people receiving (inappropriate) surgery. OBJECTIVES The primary objective was to determine whether a care pathway including UDS is no worse for symptom outcome than one in which it is omitted, at 18 months after randomisation. Rates of surgery was the key secondary outcome. DESIGN This was a pragmatic, multicentre, two-arm (unblinded) randomised controlled trial, incorporating a health economic analysis and qualitative research. SETTING Urology departments of 26 NHS hospitals in England. PARTICIPANTS Men (aged ≥ 18 years) seeking further treatment, potentially including surgery, for bothersome LUTS. Exclusion criteria were as follows: unable to pass urine without a catheter, having a relevant neurological disease, currently undergoing treatment for prostate or bladder cancer, previously had prostate surgery, not medically fit for surgery and/or unwilling to be randomised. INTERVENTIONS Men were randomised to a care pathway based on non-invasive routine tests (control) or routine care plus invasive UDS (intervention arm). MAIN OUTCOME MEASURES The primary outcome was International Prostate Symptom Score (IPSS) at 18 months after randomisation and the key secondary outcome was rates of surgery. Additional secondary outcomes included adverse events (AEs), quality of life, urinary and sexual symptoms, UDS satisfaction, maximum urinary flow rate and cost-effectiveness. RESULTS A total of 820 men were randomised (UDS, 427; routine care, 393). Sixty-seven men withdrew before 18 months and 11 died (unrelated to trial procedures). UDS was non-inferior to routine care for IPSS 18 months after randomisation, with a confidence interval (CI) within the margin of 1 point (-0.33, 95% CI -1.47 to 0.80). A lower surgery rate in the UDS arm was not found (38% and 36% for UDS and routine care, respectively), with overall rates lower than expected. AEs were similar between the arms at 43-44%. There were more cases of acute urinary retention in the routine care arm. Patient-reported outcomes for LUTS improved in both arms and satisfaction with UDS was high in men who received it. UDS was more expensive than routine care. From a secondary care perspective, UDS cost an additional £216 over an 18-month time horizon. Quality-adjusted life-years (QALYs) were similar, with a QALY difference of 0.006 in favour of UDS over 18 months. It was established that UDS was acceptable to patients, and valued by both patients and clinicians for its perceived additional insight into the cause and probable best treatment of LUTS. LIMITATIONS The trial met its predefined recruitment target, but surgery rates were lower than anticipated. CONCLUSIONS Inclusion of UDS in the diagnostic tests results in a symptom outcome that is non-inferior to a routine care pathway, but does not affect surgical rates for treating BOO. Results do not support the routine use of UDS in men undergoing investigation of LUTS. FUTURE WORK Focus should be placed on indications for selective utilisation of UDS in individual cases and long-term outcomes of diagnosis and therapy. TRIAL REGISTRATION Current Controlled Trials ISRCTN56164274. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 42. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Amanda L Lewis
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Grace J Young
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy E Selman
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caoimhe Rice
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Cynthia A Ochieng
- Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Peter S Blair
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Jeremy Horwood
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - J Athene Lane
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| |
Collapse
|
38
|
Worthington J, Lane JA, Taylor H, Young G, Noble SM, Abrams P, Ahern A, Brookes ST, Cotterill N, Johnson L, Khan R, Fernandez AM, Page T, Swami S, Hashim H. Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT. Health Technol Assess 2020; 24:1-96. [PMID: 32901611 PMCID: PMC7520718 DOI: 10.3310/hta24410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction (BPO). Thulium laser transurethral vaporesection of the prostate (ThuVARP) vaporises and resects the prostate using a technique similar to TURP. The small amount of existing literature suggests that there may be potential advantages of ThuVARP over TURP. OBJECTIVE To determine whether or not the outcomes from ThuVARP are equivalent to the outcomes from TURP in men with BPO treated in the NHS. DESIGN A multicentre, pragmatic, randomised controlled parallel-group trial, with an embedded qualitative study and economic evaluation. SETTING Seven UK centres - four university teaching hospitals and three district general hospitals. PARTICIPANTS Men aged ≥ 18 years who were suitable to undergo TURP, presenting with bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO. INTERVENTIONS Patients were randomised 1 : 1 to receive TURP or ThuVARP and remained blinded. MAIN OUTCOME MEASURES Two co-primary outcomes - patient-reported International Prostate Symptom Score (IPSS) and clinical measure of maximum urine flow rate (Qmax) at 12 months post surgery. RESULTS In total, 410 men were randomised, 205 to each arm. The two procedures were equivalent in terms of IPSS [adjusted mean difference 0.28 points higher for ThuVARP (favouring TURP), 95% confidence interval (CI) -0.92 to 1.49 points]. The two procedures were not equivalent in terms of Qmax (adjusted mean difference 3.12 ml/second in favour of TURP, 95% CI 0.45 to 5.79 ml/second), with TURP deemed superior. Surgical outcomes, such as complications and blood transfusion rates, and hospital stay were similar for both procedures. Patient-reported urinary and sexual symptoms were also similar between the arms. Qualitative interviews indicated similar patient experiences with both procedures. However, 25% of participants in the ThuVARP arm did not undergo their randomised allocation, compared with 2% of participants in the TURP arm. Prostate cancer was also detected less frequently from routine histology after ThuVARP (65% lower odds of detection) in an exploratory analysis. The adjusted mean differences between the arms were similar for secondary care NHS costs (£9 higher for ThuVARP, 95% CI -£359 to £376) and quality-adjusted life-years (0.01 favouring TURP, 95% CI -0.04 to 0.01). LIMITATIONS Complications were recorded in prespecified categories; those not prespecified were excluded owing to variable reporting. Preoperative Qmax and IPSS data could not be collected for participants with indwelling catheters, making adjustment for baseline status difficult. CONCLUSIONS TURP was superior to ThuVARP in terms of Qmax, although both operations resulted in a Qmax considered clinically successful. ThuVARP also potentially resulted in lower detection rates of prostate cancer as a result of the smaller volume of tissue available for histology. Length of hospital stay after ThuVARP, anticipated to be a key benefit, was equal to that after TURP in this trial. Overall, both ThuVARP and TURP were effective procedures for BPO, with minor benefits in favour of TURP. Therefore, the results suggest that it may be appropriate that new treatment alternatives continue to be compared with TURP. FUTURE WORK Longer-term follow-up to assess reoperation rates over time, and research into the comparative effectiveness of ThuVARP and TURP in large prostates. TRIAL REGISTRATION Current Controlled Trials ISRCTN00788389. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 41. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Jo Worthington
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hilary Taylor
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Grace Young
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian M Noble
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Aideen Ahern
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sara T Brookes
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nikki Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Lyndsey Johnson
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rafiyah Khan
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Aida Moure Fernandez
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Tobias Page
- Department of Urology, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Satchi Swami
- Urology Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| |
Collapse
|
39
|
Alwis US, Haddad R, Monaghan TF, Abrams P, Dmochowski R, Bower W, Wein AJ, Roggeman S, Weiss JP, Mourad S, Delanghe J, Everaert K. Impact of food and drinks on urine production: A systematic review. Int J Clin Pract 2020; 74:e13539. [PMID: 32441853 DOI: 10.1111/ijcp.13539] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 12/09/2022] Open
Abstract
CONTEXT The impact of food and drinks on body fluid metabolism is of direct clinical relevance but current evidence remains fragmented. AIM Synthesise current evidence on the role of food and drinks in urine production. METHODS Systematic review as per PRISMA guidelines using MEDLINE and EMBASE databases (completed October 2019). Studies reporting on the effect of food, food constituents, and drinks on urine production were included. Two authors performed an independent extraction of relevant articles using predetermined data sets and completed quality-of-study indicators. RESULTS A total of 49 studies were included, of which 21 enroled human subjects, and 28 were clinically relevant animal studies (all of which utilised rodent models). The included studies were determined to be of variable quality. High dietary sodium, as well as wine, spirits, high-caffeine coffee, and caffeinated energy drinks, increased urine production in human studies. Decreased urine production was associated with low dietary sodium and consumption of milk, orange juice, and high-salt/high-sugar drinks. In animal models, a variety of fruits, vegetables, herbs, spices, and honey were associated with increased urine production. CONCLUSION Current evidence suggests that although several types of food and drinks may impact body fluid metabolism, the quality of the data is variable. Urine production appears to be influenced by multiple factors including composition (ie, moisture, macronutrients, and electrolytes), metabolite load, and the presence of specific diuresis-promoting substances (eg, caffeine, alcohol) and other bioactive phytochemicals. Future research is needed to support current evidence and the physiologic mechanisms underlying these findings.
Collapse
Affiliation(s)
- Upeksha S Alwis
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Rebecca Haddad
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
- Sorbonne Université, GRC 001, GREEN Groupe de recherche en Neuro-Urologie, AP-HP, Hôpital Rothschild, Paris, France
| | - Thomas F Monaghan
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Paul Abrams
- Department of Urology, Bristol Urological Institute, Bristol, UK
| | - Roger Dmochowski
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wendy Bower
- Department of Medicine and Community Care, University of Melbourne, Melbourne, Australia
| | - Alan J Wein
- Department of Urology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Saskia Roggeman
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| | - Jeffrey P Weiss
- Department of Urology, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Sherif Mourad
- Department of Urology, Ain Shams University, Cairo, Egypt
| | - Joris Delanghe
- Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
| | - Karel Everaert
- Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
40
|
Noble SM, Ahern AM, Worthington J, Hashim H, Taylor H, Young GJ, Brookes S, Abrams P, Johnson L, Khan R, Page T, Swami KS, Lane JA. The cost-effectiveness of transurethral resection of the prostate vs thulium laser transurethral vaporesection of the prostate in the UNBLOCS randomised controlled trial for benign prostatic obstruction. BJU Int 2020; 126:595-603. [PMID: 32558178 DOI: 10.1111/bju.15138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 04/29/2020] [Accepted: 06/03/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of the current 'gold standard' operation of transurethral resection of the prostate (TURP) compared to the new laser technique of thulium laser transurethral vaporesection of the prostate (ThuVARP) in men with benign prostatic obstruction (BPO) within the UK National Health Service (NHS). PATIENTS AND METHODS The trial was conducted across seven UK centres (four university teaching hospitals and three district general hospitals). A total of 410 men aged ≥18 years presenting with either bothersome lower urinary tract symptoms (LUTS) or urinary retention secondary to BPO, and suitable for surgery, were randomised (whilst under anaesthetic) 1:1 to receive the TURP or ThuVARP procedure. Resource use in relation to the operation, initial inpatient stay, and subsequent use of NHS services was collected for 12 months from randomisation (equivalent to primary effectiveness outcome) using hospital records and patient questionnaires. Resources were valued using UK reference costs. Quality adjusted life years (QALYs) were calculated from the EuroQoL five Dimensions five Levels (EQ-5D-5L) questionnaire completed at baseline, 3- and 12-months. Total adjusted mean costs, QALYs and incremental Net Monetary Benefit statistics were calculated: cost-effectiveness acceptability curves and sensitivity analyses addressed uncertainty. RESULTS The total adjusted mean secondary care cost over the 12 months in the TURP arm (£4244) was £9 (95% CI -£376, £359) lower than the ThuVARP arm (£4253). The ThuVARP operation took on average 21 min longer than TURP. The adjusted mean difference of QALYs (0.01 favouring TURP, 95% CI -0.01, 0.04) was similar between the arms. There is a 76% probability that TURP is the cost-effective option compared with ThuVARP at the £20 000 per QALY willingness to pay threshold used by National Institute for Health and Care Excellence (NICE). CONCLUSION One of the anticipated benefits of the laser surgery, reduced length of hospital stay with an associated reduction in cost, did not materialise within the study. The longer duration of the ThuVARP procedure is important to consider, both from a patient perspective in terms of increased time under anaesthetic, and from a service delivery perspective. TURP remains a highly cost-effective treatment for men with BPO.
Collapse
Affiliation(s)
- Sian M Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Aideen M Ahern
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jo Worthington
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Hilary Taylor
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Grace J Young
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sara Brookes
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Lyndsey Johnson
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rafiyah Khan
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Toby Page
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Janet Athene Lane
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK
| |
Collapse
|
41
|
Abrams P, Cardozo L, Dmochowski R, Wein A. Ninth International Consultation on Incontinence-Research Society 2019: Introduction. Neurourol Urodyn 2020; 39 Suppl 3:S7-S8. [PMID: 32662558 DOI: 10.1002/nau.24435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/23/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Linda Cardozo
- Urogynaecology Unit, King's College Hospital, London, UK
| | - Roger Dmochowski
- Department of Urology, Vanderbilt University, Nashville, Tennessee
| | - Alan Wein
- Division of Urology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| |
Collapse
|
42
|
Hashim H, Worthington J, Abrams P, Young G, Taylor H, Noble SM, Brookes ST, Cotterill N, Page T, Swami KS, Lane JA. Thulium laser transurethral vaporesection of the prostate versus transurethral resection of the prostate for men with lower urinary tract symptoms or urinary retention (UNBLOCS): a randomised controlled trial. Lancet 2020; 396:50-61. [PMID: 32622397 PMCID: PMC7339133 DOI: 10.1016/s0140-6736(20)30537-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Transurethral resection of the prostate (TURP) is the standard operation for benign prostatic obstruction. Thulium laser transurethral vaporesection of the prostate (ThuVARP) is a technique with suggested advantages over TURP, including reduced complications and hospital stay. We aimed to investigate TURP versus ThuVARP in men with lower urinary tract symptoms or urinary retention secondary to benign prostatic obstruction. METHODS In this randomised, blinded, parallel-group, pragmatic equivalence trial, men in seven UK hospitals with bothersome lower urinary tract symptoms or urinary retention secondary to benign prostatic obstruction were randomly assigned (1:1) at the point of surgery to receive ThuVARP or TURP. Patients were masked until follow-up completion. Centres used their usual TURP procedure (monopolar or bipolar). All trial surgeons underwent training on the ThuVARP technique. Co-primary outcomes were maximum urinary flow rate (Qmax) and International Prostate Symptom Score (IPSS) at 12-months post-surgery. Equivalence was defined as a difference of 2·5 points or less for IPSS and 4 mL per s or less for Qmax. Analysis was done according to the intention-to-treat principle. The trial is registered with the ISRCTN Registry, ISRCTN00788389. FINDINGS Between July 23, 2014, and Dec 30, 2016, 410 men were randomly assigned to ThuVARP or TURP, 205 per study group. TURP was superior for Qmax (mean 23·2 mL per s for TURP and 20·2 mL per s for ThuVARP; adjusted difference in means -3·12, 95% CI -5·79 to -0·45). Equivalence was shown for IPSS (mean 6·3 for TURP and 6·4 for ThuVARP; adjusted difference in means 0·28, -0·92 to 1·49). Mean hospital stay was 48 h in both study groups. 91 (45%) of 204 patients in the TURP group and 96 (47%) of 203 patients in the ThuVARP group had at least one complication. INTERPRETATION TURP and ThuVARP were equivalent for urinary symptom improvement (IPSS) 12-months post-surgery, and TURP was superior for Qmax. Anticipated laser benefits for ThuVARP of reduced hospital stay and complications were not observed. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
Collapse
Affiliation(s)
- Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Jo Worthington
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Grace Young
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Hilary Taylor
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sian M Noble
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sara T Brookes
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Nikki Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Tobias Page
- Department of Urology, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - K Satchi Swami
- Urology Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| |
Collapse
|
43
|
Ito H, Young G, Lewis A, Blair P, Cotterill N, Abrams P, Lane A, Drake M. Post micturition dribble is a highly bothersome urinary symptom: Sub analysis from the urodynamics for prostate surgery trial; randomised evaluation of assessment methods (upstream) study. EUR UROL SUPPL 2020. [DOI: 10.1016/s2666-1683(20)33576-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
44
|
Uren AD, Cotterill N, Pardoe M, Abrams P. The International Consultation on Incontinence Questionnaires (ICIQ): An update on status and direction. Neurourol Urodyn 2020; 39:1889-1896. [PMID: 32573011 DOI: 10.1002/nau.24437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/07/2020] [Indexed: 11/08/2022]
Abstract
AIMS In its 22nd year, the International Consultation on Incontinence Questionnaire (ICIQ) project continues to promote its primary objective; the development and dissemination of patient completed questionnaires for the standardized, high-quality assessment of urinary, bowel, and vaginal symptoms. The paper gives an update on the ICIQ in the context of current scientific developments of PROM design and regulatory requirements, and plans are outlined for its future direction. METHODS An online library of all questionnaires, including over 300 translations has been launched to facilitate access through a semi-automated registration system. The ICIQ project continues to update its protocol to meet current scientific standards and incorporate methodological advances within PROM development. RESULTS Nineteen psychometrically validated patient-reported outcome measures (PROMs) are published for use in clinical practice and research, including amongst others, a bladder diary, male and female lower urinary tract symptoms, long term catheter, pad use, and bowel symptom questionnaires. The original ICIQ-UI Short Form for the assessment of urinary incontinence continues to be the most internationally used questionnaire and has been translated into over 60 languages. New questionnaires which are under development include the ICIQ-Underactive Bladder and ICIQ-Satisfaction. We anticipate the new website and online library will further facilitate the ease of dissemination and availability of the questionnaires for clinical practice and research. CONCLUSION The ICIQ continues to successfully achieve its primary objective. Going forward, a greater focus on promoting routine clinical use and the potential for electronic integration into databases and medical records is envisaged.
Collapse
Affiliation(s)
- Alan D Uren
- Department of Urology, Southmead Hospital, Bristol Urological Institute, Bristol, UK
| | - Nikki Cotterill
- Department of Urology, Southmead Hospital, University of the West of England and the Bristol Urological Institute, Bristol, UK
| | - Megan Pardoe
- Department of Urology, Southmead Hospital, Bristol Urological Institute, Bristol, UK
| | - Paul Abrams
- Department of Urology, Southmead Hospital, Bristol Urological Institute, Bristol, UK
| |
Collapse
|
45
|
Song QX, Wang L, Cheng X, Hao Y, Liu Z, Abrams P. The clinical features and predictive factors of nocturnal enuresis in adult men. BJU Int 2020; 126:472-480. [PMID: 32475016 PMCID: PMC7589435 DOI: 10.1111/bju.15126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/02/2020] [Accepted: 05/22/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To characterise the clinical features and to discover predictive factors of adult males with nocturnal enuresis (NE). PATIENTS AND METHODS A total of 43 eligible adult male patients (mean age was 57.8 years) were recruited prospectively over a 2-year period. After documentation of medical history, lower urinary tract symptoms (LUTS) were assessed using the International Consultation on Incontinence Modular Questionnaire-male LUTS (ICIQ-MLUTS), and a 3-day ICIQ-bladder diary (ICIQ-BD). Video-urodynamic studies (VUDS) were conducted conforming to the International Continence Society standards. Univariate and multivariate linear regressions were performed to determine potential predictive factors. RESULTS Patients with NE had a variety of LUTS and had a high incidence of obesity and comorbidities. On the ICIQ-BD, NE was associated with nocturnal polyuria (NP), reduced nocturnal bladder capacity (NBC), or a combination of both. Subgroup analysis indicated that patients with more frequent NE had: higher body mass index (BMI); more comorbidities; reduced daytime urinary frequency and urgency quality of life (QoL) sub-scores; and increased stress urinary incontinence (SUI) and nocturnal bedwetting sub-scores. Patients with reduced NBC only, had fewer NE episodes, while patients with NP, or with both NP and reduced NBC were more likely have frequent NE. Multivariate analysis confirmed that: BMI; neurogenic causes; sub-scores of SUI QoL and bedwetting domain; the presence of reduced NBC, and both NP and reduced NBC; and bladder outlet obstruction, were all independent predictive factors for the severity of NE. CONCLUSIONS NE n the adult male should be systemically assessed and treated, as obesity, neurogenic disorders, excessive urine production, bladder storage and emptying dysfunctions are risk factors. Bladder diaries and VUDS provide valuable information on potential pathophysiological causes, which could assist clinical evaluation and selection of focussed treatment.
Collapse
Affiliation(s)
- Qi-Xiang Song
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Wang
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xin Cheng
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yiru Hao
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhiyong Liu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| |
Collapse
|
46
|
Uren AD, Cotterill N, Hashim H, Worthington J, Kapoor D, Abrams P. International Consultation on Incontinence Questionnaire‐Satisfaction: psychometric testing of a new patient‐reported outcome measure for the evaluation of satisfaction after urological surgery. BJU Int 2020; 126:286-291. [PMID: 32320131 DOI: 10.1111/bju.15091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Alan D. Uren
- Bristol Urological Institute Southmead Hospital Bristol UK
| | - Nikki Cotterill
- Bristol Urological Institute Southmead Hospital Bristol UK
- University of the West of England Bristol UK
| | - Hashim Hashim
- Bristol Urological Institute Southmead Hospital Bristol UK
| | | | | | - Paul Abrams
- Bristol Urological Institute Southmead Hospital Bristol UK
| |
Collapse
|
47
|
Panicker JN, Marcelissen T, von Gontard A, Vrijens D, Abrams P, Wyndaele M. Bladder-bowel interactions: Do we understand pelvic organ cross-sensitization? International Consultation on Incontinence Research Society (ICI-RS) 2018. Neurourol Urodyn 2020; 38 Suppl 5:S25-S34. [PMID: 31821639 DOI: 10.1002/nau.24111] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 06/30/2019] [Indexed: 12/26/2022]
Abstract
AIMS Mounting evidence from experimental animal and human studies suggests that cross-sensitization exists between different organs. Lower urinary tract (LUT) and bowel dysfunction commonly overlap, and the role of cross-sensitization between pelvic visceral organs is uncertain. METHODS At the International Consultation on Incontinence Research Society (ICI-RS) meeting in 2018, a panel of clinicians participated in a discussion on bladder and bowel interactions in the context of pelvic organ cross-sensitization. RESULTS Bladder and bowel problems commonly co-occur in adults and children across different disorders, and the mechanism responsible for overlapping dysfunction is uncertain in most instances. At a neuronal level, cross-sensitization occurs as a result of afferent signaling from the LUT and lower bowel through different central and peripheral mechanisms. Studies in animals and humans have demonstrated evidence for cross-organ sensitization following experimental inflammation or distension of the lower bowel, affecting the LUT. Nerve stimulation is an effective treatment for different functional LUT and bowel disorders, and whether this treatment may influence cross-organ sensitization remains uncertain. The role of physiologically dormant C-fibers, the bladder-gut-brain axis, and gut microbiome in cross-sensitization are speculative. CONCLUSION Recommendations for research were made to explore the role of cross-organ sensitization in the pathogenesis of co-occurring LUT and bowel dysfunction in humans.
Collapse
Affiliation(s)
- Jalesh N Panicker
- Department of Uro-Neurology and UCL Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Tom Marcelissen
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alexander von Gontard
- Department of Child and Adolescent Psychiatry, Saarland University Hospital, Homburg, Germany
| | - Desiree Vrijens
- Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Paul Abrams
- Professor of Urology, Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Michel Wyndaele
- Department of Urology, University Medical Centre Utrecht, Utrecht, The Netherlands
| |
Collapse
|
48
|
Rantell A, Veit-Rubin N, Giarenis I, Khullar V, Abrams P, Cardozo L. Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018. Neurourol Urodyn 2020; 38 Suppl 5:S104-S110. [PMID: 31821638 DOI: 10.1002/nau.24053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/19/2019] [Accepted: 05/19/2019] [Indexed: 11/05/2022]
Abstract
With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.
Collapse
Affiliation(s)
- Angie Rantell
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Nikolaus Veit-Rubin
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Ilias Giarenis
- Department of Urogynaecology, Norfolk and Norwich Hospital, Norwich, UK
| | - Vik Khullar
- Department of Urogynaecology, Imperial College London, London, UK
| | - Paul Abrams
- Department of Urology, Bristol Urological Institute, Bristol, UK
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| |
Collapse
|
49
|
Harding C, Rantell A, Cardozo L, Jacobson SK, Anding R, Kirschner-Hermanns R, Greenwell T, Swamy S, Malde S, Abrams P. How can we improve investigation, prevention and treatment for recurrent urinary tract infections - ICI-RS 2018. Neurourol Urodyn 2020; 38 Suppl 5:S90-S97. [PMID: 31821632 DOI: 10.1002/nau.24021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/13/2019] [Accepted: 03/04/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recurrent urinary tract infection (rUTI) is a chronic condition and has a significant impact on health-related quality of life. The commonly used definition for rUTI is greater than three episodes in a year or more than two in 6 months. Current diagnostic methods have been used worldwide for over five decades, despite well evidenced criticism. Enhanced culture techniques demonstrate that the microbiome of the bladder is far more complex than previously thought and begs a reappraisal of our current testing. Treatment of rUTI is based on a small number of antibiotic trials with some evidence showing a reduction in the number of positive cultures, but one must be cautious in interpreting the results and weigh against the risk of generation of antimicrobial resistance (AMR). AIM The International Consultation on Incontinence-Research Society think tank reviewed the literature with a view to improving investigation, prevention and treatment of rUTI. METHODS A multidisciplinary team of experts were invited to present evidence regarding the current diagnostic methods, recent advances related to bladder biome mapping and current treatment strategies, including antibiotic and nonantibiotic options. Current guidelines regarding antibiotic stewardship and concerns regarding AMR were discussed. DISCUSSION Outcome of the think tank discussions are summarised with a set of recommendations to inform future research. Particular consideration is given to bacterial survival in the bladder after treatment as well as defects in urothelial barrier function which may play a significant part in the failure to eradicate UTI.
Collapse
Affiliation(s)
- Chris Harding
- Department of Urology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Angela Rantell
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Susan Kim Jacobson
- Infection Sciences, Severn Pathology, North Bristol NHS Trust, Bristol, UK
| | - Ralf Anding
- Department of Neuro-Urology/Urology, University Clinic, Friedrich Wilhelms University Bonn and Neurological Rehabilitation Center "Godeshöhe" e.V, Bonn, Germany
| | - Ruth Kirschner-Hermanns
- Department of Neuro-Urology/Urology, University Clinic, Friedrich Wilhelms University Bonn and Neurological Rehabilitation Center "Godeshöhe" e.V, Bonn, Germany
| | - Tamsin Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - Sheela Swamy
- Division of Medicine, University College London, London, UK
| | - Sachin Malde
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul Abrams
- Southmead Hospital, Bristol Urological Institute, Bristol, UK
| |
Collapse
|
50
|
Aiello M, Jelski J, Lewis A, Worthington J, McDonald C, Abrams P, Gammie A, Harding C, Biers S, Hashim H, Lane JA, Drake MJ. Quality control of uroflowmetry and urodynamic data from two large multicenter studies of male lower urinary tract symptoms. Neurourol Urodyn 2020; 39:1170-1177. [PMID: 32187720 DOI: 10.1002/nau.24337] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/04/2020] [Indexed: 11/10/2022]
Abstract
AIM The International Continence Society (ICS) has standardized quality control and interpretation of uroflowmetry and urodynamics. We evaluated traces from two large studies of male lower urinary tract symptoms (UPSTREAM and UNBLOCS) against ICS standards of urodynamic equipment and practice. METHODS Ten percent of uroflowmetry and urodynamics traces were selected at random from hospital sites. A data capture template was designed from the ICS Fundamentals of Urodynamic Practice checklist. Two pretrained blinded assessors extracted the data, with a third assessor to arbitrate. Departmental records of calibration checks and equipment maintenance were scrutinized. RESULTS Seven out of twenty-five (28%) departments reported no calibration checks. Four sites (16%) could not provide annual service records. In 32 out of 296 (10.8%) uroflowmetry traces, findings were affected by artifact. One hundred ten urodynamic study traces were reviewed; in 11 records (10%), key pressure traces were incompletely displayed. In 30 (27.2%), reference zero was not set to atmospheric pressure. Resting pressures were outside the expected range for 36 (32.7%). Pressure drift was seen in 18 traces (16.4%). At pressure-flow study commencement, permission to void was omitted in 15 (13.6%). Cough testing after voiding was done in 71.2%, but the resulting cough spikes were significantly different in 16.5%. Erroneous diagnosis of bladder outlet obstruction (BOO) was identified in six cases (5.5%). CONCLUSIONS Erroneous diagnosis of BOO is a serious error of interpretation, as it could lead to unnecessary surgery. Other errors of standardization, testing, and interpretation were identified with lower risk of adverse implications. Inconsistent documentation of service records mean equipment accuracy is uncertain.
Collapse
Affiliation(s)
- Martino Aiello
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Joseph Jelski
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Amanda Lewis
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jo Worthington
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Charlotte McDonald
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Abrams
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Andrew Gammie
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - Chris Harding
- Urology Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Suzanne Biers
- Urology Department, Addenbrooke's Hospital, Cambridge, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
| | - J Athene Lane
- Bristol Randomised Trials Collaboration (BRTC), Bristol Trials Centre, University of Bristol, Bristol, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus J Drake
- Urology Department, Freeman Hospital, Newcastle upon Tyne, UK.,Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|