Jamie Bartley

Neuromodulation for overactive bladder

Overactive bladder (OAB) affects millions of people worldwide yet first-line treatments are often poorly tolerated and compliance rates are low. Neuromodulation works via afferent nerve modulation and offers a minimally invasive and reversible alternative treatment option for patients with OAB who have failed first-line therapy. Neuromodulation has revolutionized the management of OAB and is now well established as a safe and effective treatment for those refractory to conservative treatments. Multiple neuroanatomical pathways have been described for sacral neuromodulation including the S3 nerve root, pudendal nerve and tibial nerve. The S3 nerve root is currently the main treatment target and has the most long-term data on safety and efficacy to support its use. However, studies on neuromodulation at the pudendal nerve or posterior tibial nerve have been positive and their role in treatment continues to evolve. Most urologists who are experienced in voiding dysfunction can become proficient in each technique. Patient selection, surgical techniques and postoperative management differ slightly between approaches and urologists should familiarize themselves with these differences. Treatment of OAB should progress from the least to most invasive modality, and neuromodulation provides an attractive option owing to its minimally invasive approach, tolerability, positive outcomes and reversibility.

Predictors of reoperation after sacral neuromodulation: A single institution evaluation of over 400 patients.

To explore factors that may predispose patients to reoperation after sacral neuromodulation (SNM).

Understanding Clinic Options for Overactive Bladder

Overactive bladder (OAB) is a symptom complex of urinary frequency, nocturia and urgency with or without urgency incontinence that adversely impacts patient’s quality of life. Conservative management begins in the outpatient clinic, often with significant improvement and patient satisfaction. In this review we will discuss the evaluation of OAB and review treatment options focusing on behavioral modification, medical therapy, and neuromodulation. These treatment options are offered in a stepwise fashion, remembering that more than one may be needed and can be used concomitantly.

The Impact of Baseline Functional Bladder Capacity on Short-term Neuromodulation Outcomes

OBJECTIVE To evaluate the impact of functional bladder capacity (FBC) on clinical outcomes after a staged neuromodulation procedure. MATERIALS AND METHODS Adults in our prospective neuromodulation database were evaluated. Data were collected from medical records, voiding diaries (FBC defined as average volume per void), Interstitial Cystitis Symptom Index-Problem Index, Overactive Bladder Questionnaire, and Global Response Assessment over 3 months. Descriptive statistics, Pearsons chi-square tests, Wilcoxon rank sum tests, logistic regression, repeated measures analyses, and Spearman correlation coefficients were performed. RESULTS Of the 216 patients (mean age 59 years; 84% female), most had urinary urgency and frequency with or without urge incontinence (71%), a sacral lead placement (82%), and implantable pulse generator (IPG) implantation (92%). Baseline FBC was similar between implanted and not implanted patients (P = .17); however implanted patients had a median 19 mL increase in FBC after lead placement compared to a 2.7 mL decrease in explanted patients (P = .0014). There was a strong association between percent change in FBC after lead placement and IPG implantation (P = .021; C-statistic 0.68), but baseline FBC (mL) was not associated. Baseline FBC (mL), or percent change in FBC after lead placement, was not related to symptom improvement. When grouped by baseline FBC < 150 mL and FBC  ≥ 150 mL, FBC only improved significantly in the <150 group but both demonstrated significant improvements in symptoms. CONCLUSION FBC improvements were associated with IPG implantation but not other symptom measures. Patients with low FBC (baseline FBC < 150) also achieved significant improvements in symptoms.

Coexisting depressive symptoms do not limit the benefits of chronic neuromodulation: A study of over 200 patients

To examine the relationship between coexisting depressive symptoms and outcomes after staged neuromodulation procedures for refractory urological symptoms.

PD44-01 CHARACTERISTICS AND OUTCOMES OF WOMEN PRESENTING TO A MULTIDISCIPLINARY WOMEN'S UROLOGY CLINIC

INTRODUCTION AND OBJECTIVES: We report on women with a variety of complex, often pain-based pelvic floor conditions managed in a comprehensive multidisciplinary Women’s Urology Center (WUC) that offers urological, gynecological, colorectal, psychological, pelvic floor physical therapy and integrative medicine treatments. METHODS: Women presenting 2011-2015 were reviewed. Descriptive statistics were performed. A mailed survey to patients presenting in 2013-2014 assessed current status and satisfaction with treatment. Baseline and follow up Pelvic Floor Distress Inventory (PFDI20) overall and subscale scores (Pelvic Organ Prolapse Distress Inventory (POPDI-6), Colorectal and Anal Distress Inventory (CRADI-8) and Urinary Distress Inventory (UDI-6)) were analyzed. RESULTS: 693 new patients were seen in the specified time period. Mean age was 51 (range 17-91). Most common chief complaints were pelvic pain (219/687, 32%), urine incontinence (110/687, 16%), and overactive bladder (75/687, 11%). WUC treats women with complicated pelvic floor issues, provides 30-90 minute appointments including multidisciplinary care, yet even with this careful, tailored personal management only 89/567 (16%) patients returned the follow up survey. 85% (71/84) of responders were satisfied with the care and 35% (31/88) were still managed at the WUC. Of those who did not return, 44% (19/43) were improved / satisfied and did not need to return, 49% (21/43) had logistical reasons (live out of area, insurance issues, or inconvenient appointment times) and only7% (3/43) were unhappy with their care. Compared to non-responders, survey respondents had similar age and chief complaint, were more educated (p1⁄40.02), and were less likely to smoke (p<0.01) but more likely to have diabetes (p1⁄40.04). Rates of anxiety and depression were similar between groups (p1⁄40.25, p1⁄40.67). Most common treatments included pelvic floor physical therapy (55%), pelvic floor trigger point injections (15%), medications (24%), and coping strategies (58%). Mean PFDI-20 scores improved (82 to 64), all subscale scores improved (POPDI-6 from 24 to 17, CRADI-8 from 19 to 17 UDI-6 from 37 to 29) however, only the CRADI-8 met the minimally important difference. CONCLUSIONS: Complex pelvic floor issues are difficult. Many patients were outside our catchment area, had seen multiple providers and were refractory to standard therapies. Although survey response was low, the majority of patients were pleased with their care. A multidisciplinary clinic providing individualized, comprehensive care is effective for pelvic floor symptoms.

PD39-07 PELVIC FLOOR PHYSICAL THERAPY SIGNIFICANTLY IMPROVES PAIN AND VOIDING SYMPTOMS IN WOMEN WITH PELVIC PAIN

Frequency of urination is the most commonly reported symptom at 12 months (62%) followed by difficulty postponing urination (40%), leakage (35%) and nocturia (3.7%). Younger men (median 61 vs 59 year, p1⁄40.032) and those with a higher BMI (27.5 vs 28.2, p1⁄40.049) are more likely to report worsening symptoms. However, differences between groups are small. For example, the probability of storage dysfunction is 23% for a patient with a BMI of 25 compared to 26% for a patient with a BMI of 30. No significant association was identified between prostate volume, prior TURP, EBL, operative time, postoperative leakage or hematoma, ASA, Charlson comorbidity index score or pathologic tumor characteristics. CONCLUSIONS: There is a subgroup of patients post-RP who will experience de novo storage symptoms in the absence of an anastomotic stricture. Younger patients and those with a higher BMI may be at a higher risk, reflecting a broader clinical picture where patients with little to no urinary bother may be more acutely aware of new storage symptoms and those with a higher preoperative weight may more commonly develop urinary leakage that stimulates a reflex detrusor contraction. At risk patients should be counseled on the incidence of de novo storage symptoms in the perioperative period.

Outcomes of Sacral Neuromodulation in Patients with Prior Surgical Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse

Objectives The aim of this study was to evaluate the efficacy of sacral neuromodulation in patients with prior stress urinary incontinence (SUI) or pelvic organ prolapse (POP) surgery. Methods Women in our prospective neuromodulation database were evaluated. Patients with a history of prior SUI/POP surgery were compared to those without. Medical records at baseline were reviewed, and primary outcome was defined as moderate/marked improvement on Global Response Assessment (GRA) at 3 months. Secondary outcomes were measured using bladder diaries and Overactive Bladder Symptom Severity (OABq-SS)/health-related quality of life (HRQOL). Data were analyzed with Pearson &khgr;2 test, Fisher exact test, Wilcoxon rank-sum test, and repeated-measures analyses. Results Of 210 subjects, 108 (51%) had prior SUI/POP surgery. Patients with SUI/POP surgery had more prior hysterectomies. At 3 months, there was no difference between groups on GRA outcomes. On the bladder diary, both groups had improvement in median voids per 24 hours, urgency severity, and urge incontinence over 2 years. On the GRA, fewer patients in the SUI/POP group were treatment responders at 12 and 24 months. For urinary urgency, a few in this group were moderately/markedly improved at 6 months, and a higher proportion are reported still leaking urine at 6 and 12 months. Similar proportions in each group reported moderate/marked improvement in leaking. Satisfaction was similar between groups. The OABq-SS/HRQOL scores improved, and there was no difference between the groups. Conclusion Sacral neuromodulation improves bladder symptoms in women with prior SUI/POP surgery, but response may be slightly less in those with prior surgery due to underlying bladder or pelvic floor issues.

MP89-03 THE IMPACT OF PRIOR BACK SURGERY ON UROLOGIC DIAGNOSES AND NEUROMODULATION OUTCOMES

INTRODUCTION AND OBJECTIVES: Many patients benefit from sacral neuromodulation (SNM) yet some do not achieve significant clinical improvements. Patients that fail SNM may benefit from increased afferent stimulation via tined lead placement at the pudendal nerve. We evaluated 2-year outcomes in patients that had a pudendal lead placed after failed sacral neuromodulation (SNM). METHODS: Adults enrolled in our prospective observational neuromodulation study that had a pudendal lead placed were evaluated. Medical records were reviewed. Outcomes were measured at 3, 6, 12 and 24 months with Interstitial Cystitis Symptom/Problem Indices (ICSI-PI), Overactive Bladder Questionnaire (OABq) symptom and quality of life (QOL) domains, voiding diaries, and Global Response Assessments (GRA). Data were examined with Pearson’s Chi-square, Fisher’s Exact, and Wilcoxon rank sum tests. RESULTS: Of 103 patients that had a pudendal lead placed, 48 (46.6%) had prior SNM (mean age 54 18 years; 85% female). Primary urologic diagnoses were urinary urgency/frequency with urge incontinence (18/48; 37.5%), interstitial cystitis/bladder pain syndrome (11/48; 22.9%), urgency/frequency (8/48: 16.7%), urinary retention (8/48; 16.7%), and pelvic pain (3/48; 6.3%). Mean operative time for lead placement was 48 19 minutes and 45/48 (93.8%) underwent generator implantation. Overall, 11 patients required 12 reoperations after lead implant; 5 of these occurred within the first 2 years. 4 were explanted at median 42 months (25th, 75th: 21.9, 50.9 months). 10/11 patients had symptom worsening as a reason for reoperation. Lead migration was identified in 2 patients. On average, 45% (range 31 to 50%) of survey responders that had prior SNM reported moderate or marked improvement in urgency, frequency, and urge incontinence at 3, 6, 12, and 24 months on the GRA. Significant improvements were seen over 2 years in ICSI PI composite score (p<0.0001), OABq symptom severity (p<0.0001), and QOL improved (p<0.0001). When compared to pudendal patients that had not had prior SNM, urologic diagnoses, operative time, generator implant rate, reoperations, lead migration, and GRA responses were similar; ICSI-PI and OABq scores also improved significantly over time (p<0.0001 and p<0.0001 respectively). CONCLUSIONS: Pudendal neuromodulation is a reasonable alternative for patients regardless of prior sacral failure.

MP2-17 DOES THE INTERSTITIAL CYSTITIS SYMPTOM AND PROBLEM INDEX RELIABLY MEASURE OVERACTIVE BLADDER SYMPTOMS?

INTRODUCTION AND OBJECTIVES: The validated Interstitial Cystitis Symptom and Problem Index (ICSI-PI) reliably measures symptoms and associated bother in patients with interstitial cystitis. We evaluated whether the ICSI-PI reliably measures overactive bladder (OAB) symptoms in patients with OAB with/without incontinence (OAB wet/dry). METHODS: Adults in our prospective observational neuromodulation study were evaluated. Inclusion criteria were OAB wet/dry and staged lead and generator implant. Subjects completed the ICSI-PI and Overactive Bladder Questionnaire-short form (OAB-q) at baseline and 3, 6, and 12 months post implant. The ICSI-PI is comprised of a symptom index (IC-SI) and bother index (IC-PI) which assess voiding symptoms and pain. The OAB-q contains symptom severity (SS) and health related quality of life (HRQOL) scales. Descriptive statistics were performed for sample characteristics. At each time point, IC-SI and OAB-q SS responses, and IC-PI and OAB-q HRQOL responses were compared with Spearman’s Correlations in patients that completed both measures. RESULTS: Of 215 patients (mean age 65.1 14.2 years), 80% were female, 94% were caucasian, 67.4% had attended at least some college, 24.5% had an income >