Ilias Giarenis

Is there a difference between women with or without detrusor overactivity complaining of symptoms of overactive bladder

Overactive bladder syndrome (OAB) is a highly prevalent medical condition, which is linked to the urodynamic observation of detrusor overactivity (DO). Urodynamics detect DO in about half of female patients with OAB. Our study detects significant differences between female patients with OAB with and without DO. DO could be considered as a more severe form in the wide OAB spectrum and the two terms should not be used interchangeably. The detected differences should be taken into account in the design of studies for the assessment of new selective or combination treatments of OAB and in the provision of treatment in everyday clinical practice.

Prolapse and sexual function in women with benign joint hypermobility syndrome

To determine whether pelvic organ prolapse (POP) and sexual dysfunction are more severe in women with benign joint hypermobility syndrome (BJHS) than in the normal population.

Do patients with symptoms and signs of lower urinary tract dysfunction need a urodynamic diagnosis? ICI-RS 2013.

The ICI‐RS Think Tank discussed the diagnostic process for patients who present with symptoms and signs of lower urinary tract (LUT) dysfunction. This manuscript reflects the Think Tanks summary and opinion.

What is the value of urodynamic studies before stress incontinence surgery

Stress urinary incontinence (SUI) is the most common type of urinary incontinence, and up to 86% of incontinent women report this among their symptoms. SUI is increasingly managed surgically, mainly because of the introduction of minimally invasive operative techniques. Urodynamic studies (UDS) involve the assessment of the function and dysfunction of the urinary tract by any appropriate method. As subjective reporting of symptoms does not always concur with urodynamic findings, UDS have played a central role in the preoperative assessment of SUI sufferers. The lack of robust evidence regarding the clinical impact of preoperative UDS was identified by the National Institute for Health and Clinical Excellence in 2006 and by the International Consultation on Incontinence in 2008. Two recently published randomised controlled trials (RCTs), the Value of Urodynamic Evaluation (ValUE) in the USA and the Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) in the Netherlands, provided evidence about the role of preoperative UDS for women with uncomplicated, demonstrable SUI. Both of these studies recruited women with SUI or stress-predominant mixed urinary incontinence (MUI) with a positive provocative stress test, and excluded patients with pelvic organ prolapse (POP–Q stage 3 or more), with previous surgery for incontinence and with a postvoid residual of more than 150 ml. In their carefully selected group of patients, office evaluation alone was not inferior to UDS for a selection of subjective and objective outcomes at 12 months. In the ValUE trial, 66% (2708 out of 4083) of the screened women with urinary incontinence did not meet the inclusion criteria. In the urodynamic testing group of this trial, with the standardised office evaluation, the diagnosis of SUI was confirmed in 97% of the women, detrusor overactivity (DO) was diagnosed in 25% and intrinsic sphincter deficiency (ISD) was diagnosed in 12% of the study population. The VUSIS trial was terminated prematurely after recruiting only 22% (59/260) of its planned sample size. In the urodynamic testing group of this significantly underpowered trial, urodynamic stress incontinence (USI) was confirmed in only 52% of the women, and DO was diagnosed in 13% of the participants. In both of these studies the majority of the participants (93% in ValUE and 96% in VUSIS) underwent midurethral tapes (MUTs). These studies, although very interesting, may not be representative of usual clinical practice, and may only aid decision making prior to MUT and not other types of stress incontinence surgery. Interestingly, a recent survey in the UK showed that most British urogynaecologists and urologists consider UDS essential before surgery in SUI, with or without other symptoms. Before undertaking preoperative UDS, all clinicians should consider what is the urodynamic question being asked and how it is going to change the management of the patient. UDS may prevent surgical intervention in women without USI. Certain urodynamic variables could guide the choice of the operation and potentially the surgical technique. They may also identify patients at risk of failure and at risk of the development of postoperative urgency, urgency incontinence and voiding dysfunction. This could help patients accurately assess the risks and benefits of surgery, and facilitate optimal preoperative counselling directed towards appropriate patient expectations, as well as guide the proactive management of postoperative symptoms. As MUTs were used almost exclusively in recent studies, we have mainly included data from studies involving similar type of surgery. We decided to use evidence from a combination of RCTs and observational studies, as specific subgroups are excluded or under-represented in RCTs.

Role of urodynamics before prolapse surgery

The role of urodynamic studies (UDS) before prolapse surgery is contentious and a hotly debated topic in urogynaecology. Previous studies in women with prolapse and women with uncomplicated stress urinary incontinence (SUI) have focused on women without preoperative incontinence. Currently, it has not been possible to reach a universal consensus on the role of UDS before prolapse surgery in women with concomitant symptomatic or occult SUI. It is clear that UDS could add some information in women undergoing pelvic organ prolapse surgery and could facilitate counselling of patients. However, there is no evidence that the outcome of surgery is altered by prior UDS. New well-designed randomized studies are necessary to improve our understanding of this topic.

Prevention and management of pelvic organ prolapse.

Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. Despite the lack of robust evidence, selective modification of obstetric events or other risk factors could play a central role in the prevention of prolapse. While the value of pelvic floor muscle training as a preventive treatment remains uncertain, it has an essential role in the conservative management of prolapse. Surgical trends are currently changing due to the controversial issues surrounding the use of mesh and the increasing demand for uterine preservation. The evolution of laparoscopic and robotic surgery has increased the use of these techniques in pelvic floor surgery.

Phase II drugs that target cholinergic receptors for the treatment of overactive bladder

Introduction: Overactive bladder (OAB) is a term used to describe the symptom syndrome of urgency, with or without urgency incontinence, usually associated with frequency and nocturia. Antimuscarinics are the most widely prescribed class of drugs for OAB, although their systemic adverse effects limit their use in clinical practice as compliance. This has led to developments in the field. Areas covered: In this review, the authors describe Phase II drugs that target cholinergic receptors. First, the authors present the new antimuscarinics (tarafenacin and afacifenacin). This is followed by reports on a combination drug (tolenix) containing a muscarinic antagonist (tolterodine) associated with a muscarinic agonist (pilocarpine). Further, the authors discuss the trials of well-known drugs in either new combination therapy (solifenacin and mirabegron) or with new routes of delivery (oxybutynin vaginal ring). Finally, the authors examine the option of targeting nicotinic acetylcholine receptors (dexmecamylamine). Expert opinion: Different strategies have been adopted to improve the efficacy and tolerability of therapeutics for OAB. Nicotinic receptors represent a novel therapeutic target; however, it is unlikely that antimuscarinic agents will be replaced as standard first-line therapy in the near future.

Early investigational β3 adreno-receptor agonists for the management of the overactive bladder syndrome

Introduction: Antimuscarinic drugs form the mainstay of medical treatment for Overactive bladder Syndrome (OAB). With a proven efficacy but poor tolerability, other treatment modalities have been sought. Recent concerns regarding cumulative anticholinergic load and risk of dementia have provided further impetus to find novel OAB treatments. β3-adrenoceptor (β3-AR) agonists improve OAB symptoms by relaxing bladder tissue. As such, the search is underway to develop β3-AR agonist drugs for the treatment of OAB. Areas covered: The authors discuss studies on the only approved β3-AR agonist, mirabegron, followed by reports on β3-AR agonists in development, namely ritobegron and solabegron. The authors also discuss the early investigations of novel and putative β3-AR agonist drugs which are being assessed for management of OAB, including aryloxypropanolamine, TRK-380, AJ-9677, BRL37344 and CL 316,243. These investigations have also highlighted alternative unexpected modes of β3-AR action. Expert opinion: There are a number of β3-ARs in the pipeline but it is uncertain which, if any, will come to market and aid in the management of OAB. A picture of a β3-AR dual action which was unknown previously is emerging. Overall, the authors believe that it is an exciting time for the pharmacological management of OAB with new drugs on the horizon which could potentially improve the patient’s quality of life.

Combined Vaginal and Vesicoscopic Collaborative Repair of Complex Vesicovaginal Fistulae

INTRODUCTION This study aimed to describe and demonstrate the feasibility of a minimally invasive surgical technique for the repair of complex vesicovaginal fistulae that may not be amenable to vaginal repair. TECHNICAL CONSIDERATIONS Nine cases of vesicovaginal fistulae, which were repaired laparoscopically at Kings College Hospital, London and Ygia Polyclinic Private Hospital, Limassol between 2011 and 2013, were identified. The repair was carried out by direct placement of the ports into the urinary bladder (vesicoscopy). Preoperative, intraoperative, and postoperative data were collected from a prospective database. All 9 operations were completed without any conversion to open surgery. Four ureteric reimplantations were necessary for ureteric involvement. There were no intraoperative complications but some intraoperative technical difficulties. No early postoperative complications were documented, and the hospital stay varied from 2 to 8 days. The fistula repair success rate was 89% at a median follow-up of 30 months. CONCLUSION This surgical technique is feasible and offers an alternative approach to the classical open or laparoscopic transperitoneal approach. It supplements the vaginal approach for fistulae that are not suitable for pure vaginal approach, allowing close collaboration between the laparoscopic urologist and the vaginal surgeon.

Overactive Bladder and the β3-Adrenoceptor Agonists: Current Strategy and Future Prospects.

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence, and is usually associated with frequency and nocturia. It is a common, under-diagnosed and therefore under-treated condition that can have a detrimental effect on physical functioning and psychological well-being. Initial treatment of OAB includes lifestyle advice, behavioural modifications, bladder retraining and pelvic floor muscle training, usually in combination with antimuscarinic agents. The β3-adrenoceptor agonist mirabegron is the first of a new class of drugs that are now competing with the more established antimuscarinics for the treatment of OAB. Our review focuses on the mode of action, efficacy and tolerability of mirabegron. The place of β3-adrenoceptor agonists in the treatment algorithm of OAB is discussed, considering the adverse events associated with antimuscarinics. Drug therapy tailored to different population groups appears a promising future prospect. Development of other β3-adrenoceptor agonists is expected, and combination therapy regimens might revolutionise the treatment of OAB.