Giulia I. Lane

Tolerability of Repeat Use of Blue Light Cystoscopy with Hexaminolevulinate for Patients with Urothelial Cell Carcinoma.

Purpose: Hexaminolevulinate hydrochloride with blue light cystoscopy is approved by the U.S. Food and Drug Administration as an adjunct to white light cystoscopy for the detection of urothelial cell carcinoma. In this study we examined the tolerability of the repeat use of white light cystoscopy with blue light cystoscopy. Materials and Methods: We retrospectively reviewed the records of all patients who underwent white light cystoscopy with blue light cystoscopy using hexaminolevulinate hydrochloride during a 34‐month period at 2 institutions. We compared the incidence of adverse events after initial and subsequent procedures. We grouped, graded and assigned the degree of attribution for all adverse events. Results: A total of 180 patients underwent 269 white light cystoscopy with blue light cystoscopy procedures. Of those 180 patients 118 (65%) underwent white light cystoscopy with blue light cystoscopy only 1 time. The other 62 (35%) patients underwent white light cystoscopy with blue light cystoscopy 2 or more times, including 43 (24%) 2 times and 19 (10%) 3 or more times. We noted 89 adverse events out of 269 procedures (33%), of which 66 (74%) occurred after the first white light cystoscopy with blue light cystoscopy; 14 (16%) after the second time and 9 (10%) after the third time or more. We found no statistically significant difference in adverse events between those patients undergoing 1 vs 2 or more white light cystoscopy with blue light cystoscopy procedures (p=0.134). We observed 1 grade 3 adverse event and no grade 4 or 5 adverse events. None of the adverse events were classified as probably or definitely related to hexaminolevulinate hydrochloride. Conclusions: In this retrospective study we found no statistically significant difference in the frequency or the grade of adverse events between first and repeat use of white light cystoscopy with blue light cystoscopy using hexaminolevulinate hydrochloride.

Patient-Reported Outcomes Measurement System (PROMIS®) for Patients with Urolithiasis: Initial Report

Purpose: Health related quality of life is increasingly important in quality improvement efforts for medical conditions. However, it has proved challenging to measure health related quality of life for urolithiasis, given the distinct chronic and acute phases of this disease. We evaluated the use of PROMIS® (Patient‐Reported Outcomes Measurement System) to assess the patient experience through acute stone episode stages. Materials and Methods: PROMIS pain measures (intensity and interference) were obtained from patients at a subspecialty kidney stone clinic. Four types of clinical encounters were considered, including emergency department followup, trial of passage, stent removal and 1‐month postoperative findings. Raw scores were translated into population normed T‐scores with a T‐score of 50 considered the reference population mean and a score of 60 considered 1 SD above the mean. T‐scores were compared across encounter types on univariate and multivariate analysis. Results: A total of 2,018 complete surveys were available from 1,162 patients. Mean pain intensity and pain interference T‐scores differed significantly by encounter type (p <0.001). On multivariate analysis the OR of T‐scores greater than 60 was higher for pain intensity and interference for all encounter types relative to postoperative findings, including emergency department followup 37.9 vs 124.9, passage trial 5.4 vs 10.5 and stent removal 9.4 vs 30.2 (p <0.001). Additionally, female gender and younger age were independent risk factors for T‐scores greater than 60. Conclusions: PROMIS pain measures are responsive to the phase of care during symptomatic stone events. Further application of this instrument holds great potential as a valuable tool to improve the quality of urolithiasis care.

Squamous cell carcinoma at bladder exstrophy site after early cystectomy.

Patients with bladder exstrophy–epispadias complex (BEEC) are at risk for bladder cancer, usually this presents as adenocarcinoma (Smeulders “BJU Int” 87:623–628, 2001). Squamous cell carcinoma (SCC) is rare, with only 13 documented case reports. This is a case of SCC in a 78-year-old man with BEEC who underwent cystectomy and ureterosigmoidostomy in childhood.

A cross-sectional study of the catheter management of neurogenic bladder after traumatic spinal cord injury

This cross‐sectional study describes the catheter management of neurogenic bladder (NGB) in patients with traumatic spinal cord injury (tSCI) with emphasis on the motivations behind transitions between intermittent (IC) and indwelling catheters.

Clinical outcomes of non-surgical management of detrusor leak point pressures above 40 cm water in adults with congenital neurogenic bladder

Neurogenic bladders (NGB) with detrusor leak point pressures >40 cm H2O (dLPP > 40) have been associated with deterioration of renal function in children with myelomeningocele. For these children, careful pressure management preserves renal function. However, similar evidence is lacking in adult congenital urology (ACU) patients with NGB. We describe renal functional outcomes of non‐surgical management of adults with dLPP > 40 or premicturition detrusor pressure (PMDP) >40 cm H2O, consisting of close follow‐up with urodynamic studies (UDS) and renal ultrasound (RUS), paired with adjustments to clean intermittent catheterization (CIC) frequency, anticholinergics, and addition of onabotulinumtoxinA toxin (BTX) injection.

Innovation in Surgery: Idea, Development, Assessment, Exploration, and Long-Term Monitoring (IDEAL) Guidelines

The evidentiary standards to support the regulatory approval and dissemination of surgical innovation have historically been low. The IDEAL Collaboration has developed a framework and specific recommendations how to improve the development of surgical innovation that is finding increase recognition by researchers, editors, funders and regulators worldwide. In this chapter, we describe the IDEAL recommendations as they apply to robotic-assisted surgery in urology.

Safely Avoiding Surgery in Adult Neurogenic Bladder

PurposeTo evaluate the literature regarding non-surgical management of adult patients with high-pressure neurogenic bladder.Recent FindingsEstablished therapies that facilitate bladder storage and emptying include anticholinergic medications, intradetrusor onabotulinum toxin injection, and intermittent catheterization. Application of these strategies to patients with elevated detrusor leak point pressures has shown improvement in bladder compliance and preservation of renal function. New interventions in the algorithm of management of patients with poor bladder compliance, such as beta-3 agonists and sacral neuromodulation to facilitate bladder storage the use of alpha antagonists and intraurethral onabotulinum toxin to facilitate bladder emptying are developing.SummaryA multimodal approach to adult patients with high-pressure neurogenic bladder which includes intermittent catheterization, pharmacologic therapy, and intravesical onabotulinumtoxin injection has been associated with improved bladder compliance and preservation of renal function. Augmentation cystoplasty may be reserved for refractory cases. Data is emerging regarding new interventions that can facilitate bladder storage and emptying.

Persistent muscle-invasive bladder cancer after neoadjuvant chemotherapy: an analysis of Surveillance, Epidemiology and End Results-Medicare data

To evaluate whether patients with persistent muscle‐invasive bladder cancer (MIBC) after undergoing neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) have worse overall survival (OS) and cancer‐specific survival (CSS) than patients with similar pathology who undergo RC alone.

MP85-08 NON-SURGICAL MANAGEMENT OF DETRUSOR LEAK POINT PRESSURES ABOVE 40 CM H20 IN ADULTS WITH CONGENITAL NEUROGENIC BLADDER

INTRODUCTION AND OBJECTIVES: Lower urinary tract symptoms (LUTS) are common and poorly understood; treatment is often ineffective. Failure of neural control of bladder function likely contributes to LUTS symptoms in many patients. Prior studies have shown that the pontine micturition center (PMC) directly controls voiding. Within the PMC corticotropin releasing hormone neurons (PMC) project axons directly to spinal sacral cord nuclei that control bladder contraction. Here we show that PMC neurons are critical for voiding, and identify neurons, particularly in the ventrolateral periaqueductal gray (PAGVL) which directly modulate PMC CRH and alter voiding. METHODS: We inject adeno-associated viruses expressing proteins in a Cre-dependent fashion into anatomically defined regions of mice expressing Cre recombinase in specific neural types, to cause highly selective expression of these probes in target neuron populations. We monitor conscious voiding with micturition video thermography (MVT), and CMG under anesthesia while monitoring/ stimulating specific neuron groups. RESULTS: Stimulating PMC neurons using designer receptors exclusively activated by designer drugs (DREADDs) produces urinary frequency in awake mice and on anesthetized CMG. Also, ablating PMC neurons by selective expression of diphtheria toxin A disrupts normal voiding and the normal CMG voiding reflex. To identify neurons which provide input to PMC, we used modified rabies virus and cholera toxin B labeling of PMC and confirmed our results with viral anterograde tracing. Afferents to PMC are located in PAGVL, the preoptic area, the lateral hypothalamic area, and other sites. Because sacral afferents sensing bladder filling project to PAGVL we determined the impact of stimulating Glutamatergic or GABA-ergic neurons (PAGVL GLUT or PAG VL ) in this region. Chemogenetic or optogenetic stimulation of PAGVL GLUT neurons leads to voiding and detrusor contraction. By contrast, chemogenetic or optogenetic activation of PAGVL GABA inhibits voiding and delays detrusor contraction on CMG. CONCLUSIONS: 1. PMC are driver neurons for detrusor contraction/voiding. 2. PAGVL GLUT project to PMC, and when fired drive voiding/detrusor contraction. 3. PAGVL GABA project to PMC and inhibit voiding/detrusor contraction. PAGVL, which receives bladderbased sacral afferents, likely controls bladder filling, and is a potential target in efforts to control urge incontinence and urgency symptoms of LUTS.