J. Quentin Clemens

AUA Guideline for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome

PURPOSEnTo provide a clinical framework for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome.nnnMATERIALS AND METHODSnA systematic review of the literature using the MEDLINE® database (search dates 1/1/83-7/22/09) was conducted to identify peer reviewed publications relevant to the diagnosis and treatment of interstitial cystitis/bladder pain syndrome. Insufficient evidence-based data were retrieved regarding diagnosis and, therefore, this portion of the Guideline is based on Clinical Principles and Expert Opinion statements. The review yielded an evidence base of 86 treatment articles after application of inclusion/exclusion criteria. These publications were used to create the majority of the treatment portion of the Guideline. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinion when insufficient evidence existed. See text and algorithm for definitions, and detailed diagnostic management, and treatment frameworks.nnnRESULTSnThe evidence-based guideline statements are provided for diagnosis and overall management of interstitial cystitis/bladder pain syndrome as well as for various treatments. The panel identified first through sixth line treatments as well as developed guideline statements on treatments that should not be offered.nnnCONCLUSIONSnInterstitial cystitis/bladder pain syndrome is best identified and managed through use of a logical algorithm such as is presented in this Guideline. In the algorithm the panel identifies an overall management strategy for the interstitial cystitis/bladder pain syndrome patient. Diagnosis and treatment methodologies can be expected to change as the evidence base grows in the future.

Diagnosis and Treatment of Overactive Bladder (Non-Neurogenic) in Adults: AUA/SUFU Guideline

PURPOSEnThe purpose of this guideline is to provide a clinical framework for the diagnosis and treatment of non-neurogenic overactive bladder (OAB).nnnMATERIALS AND METHODSnThe primary source of evidence for this guideline is the systematic review and data extraction conducted as part of the Agency for Healthcare Research and Quality (AHRQ) Evidence Report/Technology Assessment Number 187 titled Treatment of Overactive Bladder in Women (2009). That report searched PubMed, MEDLINE®, EMBASE and CINAHL for English-language studies published from January 1966 to October 2008. The AUA conducted additional literature searches to capture treatments not covered in detail by the AHRQ report and relevant articles published between October 2008 and December 2011. The review yielded an evidence base of 151 treatment articles after application of inclusion/exclusion criteria. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). Additional treatment information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.nnnRESULTSnThe evidence-based guideline statements are provided for diagnosis and overall management of the adult with OAB symptoms as well as for various treatments. The panel identified first through third line treatments as well as non-FDA approved, rarely applicable and treatments that should not be offered.nnnCONCLUSIONSnThe evidence-based statements are provided for diagnosis and overall management of OAB, as well as for the various treatments. Diagnosis and treatment methodologies can be expected to change as the evidence base grows and as new treatment strategies become obtainable.

Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome

OBJECTIVESnPelvic floor tension myalgia may contribute to the symptoms of male patients with chronic pelvic pain syndrome (CPPS). Therefore, measures that diminish pelvic floor muscle spasm may improve these symptoms. Based on this hypothesis, we enrolled 19 patients with CPPS in a 12-week program of biofeedback-directed pelvic floor re-education and bladder training.nnnMETHODSnPre-treatment and post-treatment symptom assessments included daily voiding logs, American Urological Association (AUA) symptom score, and 10-point visual analog pain and urgency scores. Pressure-flow studies were obtained before treatment in most patients. Instruction in pelvic floor muscle contraction and relaxation was achieved using a noninvasive form of biofeedback at biweekly sessions. Home exercises were combined with a progressive increase in timed-voiding intervals.nnnRESULTSnMean age of the 19 patients was 36 years (range 18 to 67). Four patients completed less than three treatment sessions, 5 patients completed three to five sessions, and 10 attended all six sessions. Mean follow-up was 5.8 months. Median AUA symptom scores improved from 15.0 to 7.5 (P = 0.001), and median bother scores decreased from 5.0 to 2.0 (P = 0.001). Median pain scores decreased from 5.0 to 1.0 (P = 0.001), and median urgency scores decreased from 5.0 to 2.0 (P = 0.002). Median voiding interval increased from 0.88 hours to 3.0 hours (P = 0.003). Presence of detrusor instability, hypersensitivity to filling, or bladder-sphincter pseudodyssynergia on pretreatment urodynamic studies was not predictive of treatment results.nnnCONCLUSIONSnThis preliminary study confirms that a formalized program of neuromuscular re-education of the pelvic floor muscles together with interval bladder training can provide significant and durable improvement in objective measures of pain, urgency, and frequency in patients with CPPS.

AUA Best Practice Statement for the Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery

Summary of VTE prophylaxis recommendations Level of risk Prophylactic treatmentLow Risk ● No prophylaxis other than early ambulationModerate Risk ● Heparin 5000 units every 12 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highHigh Risk ● Heparin 5000 units every 8 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highVery High Risk ● *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily and adjuvant pneumatic compression device, or ● Heparin 5000 units every 8 hours subcutaneous starting after surgery and adjuvant pneumatic compression device* Guidelines and Cautions for Enoxaparin Use ● In patients with a body weight 150 Kg. consider increasing prophylaxis dose of Enoxaparin to 40 mg. subcutaneous every 12 hours. ● Withhold Enoxaparin generally for at least 2 to 3 days after major trauma, and then only consider use after review of current patient condition and risk benefit ratio.

Hoxa‐10 deficient male mice exhibit abnormal development of the accessory sex organs

The role of mammalian Hox genes in regulating segmental patterning of axial structures and the limb is well established. A similar role in development of soft tissue organ systems has recently been suggested by observations linking several 5′ members of the HoxA and HoxD clusters to segmentation events and morphogenesis in the gastrointestinal and genitourinary systems. We have specifically examined the role of Hoxa‐10 in development of the male accessory sex organs by characterizing expression of Hoxa‐10 in the developing male reproductive tract and correlating expression to morphologic abnormalities in knockout mice deficient for Hoxa‐10 function. We report that Hoxa‐10 expression in the Wolffian duct and urogenital sinus is regionally restricted and temporally regulated. The domain of expression is defined anteriorly by the caudal epididymis and extends posteriorly to the prostatic anlagen of the urogenital sinus. Expression was maximal at E18 and down‐regulated postnatally, well before accessory sex organ morphogenesis is completed. Expression in the prostatic anlagen of the urogenital sinus cultured in vitro does not depend upon the presence of testosterone. Loss of Hoxa‐10 function is associated with diminished stromal clefting of the seminal vesicles and decreased size and branching of the coagulating gland. The ductal architecture of the coagulating gland was altered in approximately 30% of mutants examined and suggests a partial posterior morphologic transformation of the coagulating gland. We interpret these data to indicate that Hoxa‐10 is expressed in a region specific manner during late gestation and into the perinatal period and that Hoxa‐10 is required for normal accessory sex organ development. Dev Dyn 1999;214:1–12.

A Prospective Study of Laparoscopic Radical Nephrectomy for T1 Tumors—Is Transperitoneal, Retroperitoneal or Hand Assisted the Best Approach?

PURPOSEnWe designed a prospective, randomized clinical trial to compare 3 common approaches to laparoscopic radical nephrectomy, namely transperitoneal, retroperitoneal and hand assisted.nnnMATERIALS AND METHODSnA total of 33 patients with a solid renal mass of 7 cm or less were prospectively enrolled in alternating fashion to a hand assisted procedure, a transperitoneal procedure with morcellation and a retroperitoneal procedure with intact specimen extraction. A single surgeon performed all operations. Preoperative, intraoperative and postoperative criteria were compared among the 3 techniques.nnnRESULTSnA total of 11 patients underwent each type of procedure. There was no significant difference in age, American Society of Anesthesiologists class, body mass index or tumor size among the groups. Mean operative time was significantly lower using the hand assisted approach, whereas estimated blood loss was similar in all 3 groups. Incision size, hospital stay and time to normal daily activity were less using the transperitoneal approach. While not significant, there was a trend toward less narcotic use in the transperitoneal group. Hernia formation was seen with increased frequency in the hand assisted group.nnnCONCLUSIONSnIn our series the hand assisted approach had significantly shorter operative time than the transperitoneal or retroperitoneal approach but it had the greatest risk of hernia formation. The transperitoneal approach was associated with a significantly shorter hospital stay and the earliest resumption of normal activity.

Predictors of symptom severity in patients with chronic prostatitis and interstitial cystitis

PURPOSEnNumerous studies have been performed to identify potential risk factors for CP/CPPS and IC. However, few studies have been done to identify predictors of disease severity.nnnMATERIALS AND METHODSnA total of 174 men with CP/CPPS and 111 women with IC completed questionnaires to quantify symptom severity and identify demographic, medical and psychosocial characteristics. Symptom severity was assessed with the National Institutes of Health CPSI in men, and the OLeary-Sant ICSI and problem index in women. Univariate and multivariate analyses were performed to identify characteristics predictive of worse symptoms.nnnRESULTSnThe mean National Institutes of Health CPSI score in men was 15.32, and the mean OLeary-Sant ICSI and problem index in women was 19.17. The most commonly reported comorbidities were allergies, sinusitis, erectile dysfunction and irritable bowel syndrome in men, and allergies, urinary incontinence, sinusitis and irritable bowel syndrome in women. In the 2 sexes self-reported urinary frequency and urgency, worse depression scores and lower education level were independent predictors of worse symptom severity. In men additional independent predictors were self-reported pelvic pain, fibromyalgia and previous heart attack, and in women an additional independent predictor was postmenopausal status.nnnCONCLUSIONSnThere are several common medical conditions associated with urological pelvic pain syndromes in men and women. Few of them were predictive of symptoms severity in this analysis. Self-reported pelvic pain symptoms, education and depression severity were the factors most strongly predictive of symptom severity in patients with CP/CPPS and IC.

QUESTIONNAIRE BASED RESULTS OF THE BULBOURETHRAL SLING PROCEDURE

PURPOSEnThe success rate of the bulbourethral sling procedure to treat post-radical prostatectomy incontinence has been reported in a previous chart review analysis. We present further evaluation of the procedure using postoperative mailed questionnaires.nnnMATERIALS AND METHODSnBetween October 1994 and October 1997, 66 men underwent the bulbourethral sling procedure at our hospital. Postoperatively all patients with indwelling bolsters were mailed questionnaires to assess continence status, discomfort and voiding patterns.nnnRESULTSnOf the 66 patients 4 required bolster removal for infection (2), erosion (1) or pain (1), and 1 died. These patients were not assessed further. Questionnaire data were obtained from the remaining 61 patients. At a median followup of 9.6 months (mean 11.9, range 3 to 30) 25 patients (41%) reported complete cure of incontinence, 32 (53%) required no pad for protection and 52 (85%) required 2 pads or less. Persistent perineal numbness or discomfort was present in 32 patients (52%). Of 12 patients who received adjuvant radiation therapy only 1 (8%) was cured.nnnCONCLUSIONSnThe short-term success rate following the bulbourethral sling procedure is high but persistent perineal discomfort is common. Adjuvant radiation predisposes to treatment failure.

Comparison of Economic Impact of Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Interstitial Cystitis/Painful Bladder Syndrome

OBJECTIVESnTo perform a comparison of the economic impact of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and interstitial cystitis/painful bladder syndrome (IC/PBS) because limited information is available. Furthermore, no direct comparisons of the costs of these 2 conditions have been performed. Such a comparison is relevant because the distinction between the 2 conditions is not always clear.nnnMETHODSnWe recruited 62 men with CP/CPPS and 43 women with IC/PBS from a tertiary care outpatient urology clinic. Information about hospitalizations, laboratory tests, physician visits, telephone calls, medication use, and lost productivity was obtained from written questionnaires. Direct medical cost estimates were determined from hospital cost accounting data, the 2005 Physician Fee Schedule Book, and the 2005 Redbook for pharmaceuticals. Indirect costs were determined from patient-reported annual income and patient-reported hours lost from work during the most recent 3-month period.nnnRESULTSnUsing Medicare rates, the annualized direct costs per person were

LONG-TERM RESULTS OF THE STAMEY BLADDER NECK SUSPENSION: DIRECT COMPARISON WITH THE MARSHALL-MARCHETTI-KRANTZ PROCEDURE

3631 for IC/PBS and