Ashley Cox

Overactive Bladder and Storage Lower Urinary Tract Symptoms Following Radical Prostatectomy

OBJECTIVE To describe the rate of overactive bladder (OAB) and storage lower urinary tract symptoms following radical prostatectomy (RP) and determine if subsequent radiation increases the risk of OAB. METHODS We reviewed all patients who underwent open RP at our tertiary care institution from January 2006 to June 2011. Primary outcomes were the proportion of patients with new OAB and time to development of OAB in those treated with RP alone vs RP plus radiation. Secondary outcomes included the proportion of patients treated for OAB. A Cox survival analysis was used to assess the impact of radiation on development of OAB. RESULTS Of the 875 patients who met study criteria, 19% of patients developed de novo OAB defined as urgency with or without frequency and nocturia. A total of 256 patients (29%) developed 1 or more urinary symptoms including nocturia (22%), frequency (21%), urgency (19%), and urge incontinence (6%) following RP. After adjusting for age, body mass index, smoking status, cancer stage, and nerve-sparing status, radiation therapy was associated with an increased relative hazard of OAB (5.59; 95% CI 3.63-8.61, P < .001). Among men classified with de novo OAB, only 41% received treatment. CONCLUSION OAB and storage lower urinary tract symptoms are prevalent in men post-RP. Adjuvant or salvage radiation therapy increases the risk of developing OAB after RP. OAB may be undertreated in men following prostate cancer treatment.

Urological Follow-up in Adult Spina Bifida Patients: Is There an Ideal Interval?

OBJECTIVE To establish the time to development of urological issues over time in adult spina bifida (SB) patients. MATERIALS AND METHODS This is a retrospective study of adult patients attending a multidisciplinary adult SB clinic from 2000 to 2013. Patient age, sex, number of clinic visits, and length of follow-up were recorded. For each unique visit, presence of symptoms, type of urological issue (if any), and time lapsed since last appointment were obtained. The interval between the development of urological issues was assessed using a time-to-event analysis. RESULTS One hundred twenty-three patients (46% male, 54% female, median age 26.8years) were followed for a median of 48 months, contributing to 586 unique clinic visits. Urological issues were identified in 109 patients (88.5%) during 267 visits (46%), and of those 21% were asymptomatic. In symptomatic patients, the median time to present with a urological issue was 12 months. Among the asymptomatic cases, 12%, 23%, and 34% had developed a urological issue at 12, 24, and 36 months of follow-up, respectively. Eighty-one percent of the urological issues seen in the clinic required some form of treatment or intervention. The treatment or intervention in 56% of asymptomatic urological issues was surgery. CONCLUSION Most adult SB patients with urological issues are symptomatic by 2 years of follow-up; however, over time the proportion of asymptomatic patients with urological issues rises steadily, reaching a worrisome 34% at 3 years. Closer follow-up seems warranted.

Non-surgical urologic management of neurogenic bladder after spinal cord injury

PurposeTo review the available data on non-surgical management for neurogenic bladder in patients with spinal cord injury (SCI). Before the introduction of urinary catheters and antibiotics, neurogenic bladder was one of the main culprits for death in those patients with SCI. Currently, the management of neurogenic bladder is focused in improving quality of life and preserving renal function.MethodsA literature review was performed and therapeutic management for neurogenic bladder was divided in six sections: (1) intermittent bladder catheterization; (2) indwelling catheters; (3) condom catheter drainage; (4) reflex voiding and bladder expression with Valsalva or Credé; (5) oral drug therapy of the spinal cord injured bladder; and (6) botulinum neurotoxin (BoNT).ResultsIntermittent catheterization is recommended as the preferable method for management of neurogenic bladder in patients with SCI based on limited high-quality data. However, this may not be feasible or available to all and other alternative options include condom catheter drainage or indwelling catheters such as urethral catheters or suprapubic tube, reflex voiding, and bladder expression with Valsalva or Credé. Non-invasive medical therapies are the key to improve incontinence, urodynamic parameters, and quality of life in this population. Botulinum neurotoxin has revolutionized the management of neurogenic bladder in the last two decades decreasing the need for reconstruction or diversion.ConclusionThe Joint SIU-ICUD (Société Internationale d’Urologie) (International Consultation on Urological Diseases) International Consultation reviewed the available presented data and provided specific conclusions and recommendations for each non-surgical urologic method to address neurogenic bladder after SCI.

Transitioning children with urological issues into adulthood

It could be said that pediatric urologists (and their patients) have fallen victim to their own success. With advances in surgical technique and medicine in general, the child with a urological issue should expect to live a long and fruitful life, hopefully cured of the original issue. However, as pointed out in the hypospadias, exstrophy and urinary diversion articles, the risk of long-term complications is never completely eliminated. Therefore, even after the pediatric urologist has discharged the patient from care and he has entered into the adult domain, issues may re-emerge or develop de novo. The cancer survivor is an often overlooked example of this phenomenon. We also have the scenario where the condition never resolves, but rather evolves as the patient ages, as discussed in the articles on varicocele, posterior urethral valves, and dysfunctional voiding. This collection of articles on various topics pertinent to the transition of children with urological issues to adulthood fills a gap that has historically existed. The target audience is the general urologist, although we hope that pediatric and adult subspecialists will find some useful perspectives as well. Each article has a pediatric and an adult urologist author who is an expert on the topic, with deliberate intertwining of their respective views. We have used clinical vignettes in an attempt to make each topic as relevant as possible to the practicing urologist, keeping in mind that not every point can be drawn directly from such cases. We have avoided discussion of esoteric points relevant only to subspecialists in a specific field. Throughout the process of creating this series, we have challenged ourselves to think about not only what can be done, but what should be done for a particular patient. Some of the conditions discussed are relatively common, while others are likely to be encountered rarely in a general urology practice, but in all cases we must strive to serve our patients to the best of our ability. We hope that the reader finds a few kernels of wisdom to help in the management of these challenging scenarios; we certainly did.

Catheterization for treating neurogenic lower urinary tract dysfunction in patients with multiple sclerosis: A systematic review. A report from the Neuro-Urology Promotion Committee of the International Continence Society (ICS)

To systematically assess all available evidence on efficacy and safety of catheterization for treating neurogenic lower urinary tract dysfunction (NLUTD) in patients with multiple sclerosis (MS).

Urological issues arising after treatment of pediatric malignancies

Pediatric oncology survivors are not traditionally considered when reviewing the patient groups in need of transitional care in urology.1,2 When assessing urological issues that arise related to childhood malignancies, there are two separate scenarios. First, there are children treated for genitourinary malignancies that may have ongoing or de novo urological issues to be followed by an adult urologist. Second, there are children treated for non-genitourinary malignancies that may acquire secondary urological complications, of which the adult urologist must be aware. This article will outline examples of each situation with the hopes of providing both the pediatric and adult urologist information that will ease the transition and treatment of these complex patients. Children are now living longer following treatment of pediatric malignancies, with the overall survival rate approaching 75%.3 Delayed side effects of treatment happen to a significant proportion of patients and up to 25% may be severe or life-threatening. Many clinical sequelae of pediatric cancer treatment may not become apparent until the adult years.3

Management of interstitial cystitis/bladder pain syndrome

Managing patients with IC/BPS is a very challenging situation at times. All other potential causes of a patient’s symptoms should be excluded, but this should not delay treatment if suspicions are high that a patient has IC/BPS. All patients should be counselled on the importance of dietary modifications and conservative therapies. Realistic patient expectations should be set early on to enhance the patient-physician relationship. As there is no cure for this poorly understood condition, many treatment options are available. An algorithmic approach to treatment of these patients may not work. Instead, an individualized, multimodal, multidisciplinary approach should be followed.

Current Practices in the Surgical Management of Female Stress Urinary Incontinence: A Survey of Canadian Urologists and Gynecologists

Introduction: We assessed the practices of urologists and gynecologists who manage stress urinary incontinence surgically to examine the impact of the FDA (U.S. Food and Drug Administration) and/or Health Canada statements on pelvic floor mesh. We also determined how urologists and gynecologists manage recurrent stress urinary incontinence and complications of mesh mid urethral slings. Methods: We conducted an online survey of urologists and gynecologists who were members of the Canadian Urological Association or Society of Obstetricians and Gynaecologists of Canada. Results: Mid urethral sling was the most common surgery for stress urinary incontinence performed by urologists and gynecologists (100% vs 84%, p=0.0002). The majority of respondents (87%, 119 of 137) were aware of the FDA and/or Health Canada statements and 66% of physicians altered the way they counseled patients before mid urethral sling surgery. An equal proportion of urologists and gynecologists altered their surgical management of stress urinary incontinence due to patient concerns (31% vs 36%) and due to FDA and/or Health Canada statements (16% vs 13%). Repeat mid urethral sling was the most common method of treating recurrent stress urinary incontinence and urologists were more likely than gynecologists to manage complications of mid urethral sling (58% vs 41%, p=0.0286). Chronic pain (33%) and vaginal mesh erosion (26%) were the most common concerns overall. Conclusions: Mid urethral sling was reported as the most commonly performed surgery for stress urinary incontinence by urologists and gynecologists after the FDA and Health Canada statements. Both groups altered their surgical practices most commonly due to patient concerns, indicating that negative media attention is impacting the way in which urologists and gynecologists practice when surgically managing stress urinary incontinence in Canada. Variation exists between urologists and gynecologists when it comes to managing complications related to mid urethral sling.

Process Improvements Positively Impact the Use of Intravesical Mitomycin C after Transurethral Resection of Nonmuscle Invasive Bladder Cancer in a Large, Urban Urology Practice

Introduction: We assessed the rate of intravesical mitomycin C therapy in patients with nonmuscle invasive bladder cancer who underwent transurethral resection of the bladder, as well as the impact of procedural changes governing its use. Methods: A retrospective review of our bladder cancer database identified patients who underwent transurethral resection of the bladder with mitomycin C therapy during January 2008 to July 2014. Since our mitomycin C protocols were revised during 2013, patients were stratified based on date of service. Patient demographics and data describing mitomycin C use were tabulated. Results: During January 2008 to May 2013, 276 of 737 (37.5%) ideal patients received mitomycin C (not accounting for patients in whom mitomycin C was contraindicated). Conversely 461 of 737 patients (62.5%) did not receive mitomycin C. Shortages of mitomycin C were responsible for nonuse in 18.4% of cases while no specified reason for nonuse was given in 59%. When cases in which mitomycin C use was contraindicated were taken into account, mitomycin C was used in 51.6% overall. After the implementation of new mitomycin C operating procedures, mitomycin C use increased significantly to 76.0% (p <0.001) (accounting for appropriate nonuse). During this period mitomycin C shortages were not responsible for any case in which mitomycin C was not used. Conclusions: During 2008 to 2013 mitomycin C was not used in a significant proportion of patients who underwent transurethral resection of the bladder. The implementation of a revised protocol governing mitomycin C use significantly and positively impacted mitomycin C use. Importantly, pharmacy shortages no longer contribute to the nonuse of mitomycin C in patients with bladder cancer. These data highlight the impact of continual improvement initiatives on standard clinical practice.