Peri-Urethral and Anterior Vaginal Wall Masses: Does Radiological Imaging Change the Predicted Diagnosis?

INTRODUCTION: This study aims to determine the accuracy of radiological imaging compared with surgical pathology in patients with periurethral (PU) and anterior vaginal wall (AVW) lesions. METHODS: This study is a retrospective analysis of 126 women who underwent surgical treatment for PU and AVW masses between 2011 and 2020. Clinicopathological data were extracted along with radiological findings from medical records. The primary outcome was the diagnostic accuracy of preoperative imaging compared to the gold standard, pathological diagnosis. The secondary outcome was the rate of imaging correcting the clinical diagnosis. RESULTS: A total of 126 women with a median age of 42 underwent surgical treatment for PU and AVW masses. The most diagnoses were periurethral cysts (PUC) (52%) and urethral diverticulum (UD) (39%). Clinical diagnosis was accurate in 102 cases (81%) for the group of pathological diagnoses. Magnetic resonance imaging (MRI) and transvaginal ultrasound (TV US) were performed in 82 (65%) and 22 (17%) cases. The accuracy of MRI and TV US for the diagnosis of PU and AVW lesions was 76% and 82%, respectively. MRI and TV US corrected the clinical diagnosis in five (6%) and two (9%) cases, respectively. Voiding cystourethrography (VCUG) and double balloon urethrography (DBU), each performed in six (5%) cases, were accurate in four (67%) and three (50%) cases. No statistical difference was found for any imaging modality compared to clinical diagnosis. CONCLUSION: Clinical diagnosis based on pelvic and cystoscopy examinations was sufficient for diagnosing PU and AVW masses and was not significantly different from imaging diagnosis. Imaging may be helpful with preoperative surgical planning in selected cases.

Persistent storage symptoms following Y-V plasty reconstruction for the treatment of refractory bladder neck contracture.

PURPOSE: Refractory bladder neck contracture (BNC) following transurethral prostatectomy is rare and difficult to manage. Success rate of endoscopic treatment decline considerably after repeated treatments. Bladder neck reconstruction are often the last resort to treat refractory BNC failing endoscopic treatments. In general, experience is limited with this type of bladder neck reconstruction, particularly in adult patients. This study aims to determine the success rate, functional and patient-reported outcomes (PRO) of open Y-V plasty in treatment of refractory BNC after transurethral prostatectomy. The study also aims to determine the rate, and potential predictors of persistent storage symptoms after Y-V plasty. MATERIALS AND METHODS: Between January 2016 and February 2021, 18 consecutive patients with refractory BNC who underwent open Y-V plasty were included in this study. All patients presented with voiding dysfunction after two or more failed attempts of endoscopic treatments followed by a 3-month period of outpatient serial dilation program. Clinicopathological data were extracted from medical records including baseline demographics, aetiology of BNC, previous endoscopic treatment, operative time, length of stay, complications, uroflow findings, International Prostate Symptom Score (IPSS) and OAB-V8. Primary outcome was the success of open YV plasty, defined as no need for further instrumentation such as indwelling catheterization, urethral dilatation, urethrotomy, or open surgery. Simple linear regression analysis was performed to determine predictor factors for postoperative OAB-V8. Variables that showed p < 0.25 were included in the multiple linear regression analysis. RESULTS: Most common aetiology of BNC was transurethral resection of prostate gland (n = 18, 100%). Mean age at surgery age (SD) was 65.5 (7.3) years. Mean follow-up was 14.8 (7) months. Success rate was 100%. Postoperative Qmax improved significantly [pre-OP 6.7 (8.1) ml/s vs. post-OP was 14.8 (7.3) ml/s, p < 0.001]. Mean postvoid residual decreased significantly [pre-OP 223.3 (254.3) ml vs. post-OP 45.1 (71.0) ml, p < 0.01)]. Persistent storage symptoms were reported in 61% of patients. BMI and baseline IPSS score are significant predictors for the postoperative OAB V8 change (adjusted b (95% confidence interval) = 1.037 (0.2-1.9), 0.64 (0.28-0.99), respectively, R2 = 0.59). CONCLUSION: Y-V plasty reconstruction for refractory BNC represents a feasible and successful option with high success rate and favorable outcomes. While functional and patient-reported outcomes had significantly improved post-operatively, persistent storage symptoms after this procedure still exist. BMI and baseline IPSS score are significant predictors for persistent storage symptoms after bladder neck reconstruction.

The use of onabotulinumtoxinA to treat idiopathic overactive bladder in elderly patients is in need of study.

BACKGROUND: Injecting onabotulinumtoxinA (BoTN-A) into the bladder has been established as an effective treatment of overactive bladder (OAB) and well-tolerated by patients. However, there evidence suggests the efficacy and safety of this treatment may decrease with age due to increased comorbidities and frailty. This study's objective was to establish empirical evidence regarding age-related differences in outcomes related to BoTN-A for the treatment of idiopathic OAB. METHODS: MEDLINE, EMBASE, and the Cochrane Central Registry for Controlled Trials were systematically searched. Results were restricted to randomized control trials of BoTN-A bladder injections for the treatment of idiopathic OAB. The resulting articles' abstracts were screened independently by two reviewers. Those passing the screen were reviewed in full. Articles were excluded if participants were <18 years old, diagnosed with neurogenic overactivity, or treated with both oral medications and BoTN-A; if the frequency and severity of OAB symptoms were not specified; or, if symptoms were not stratified by age. RESULTS: The initial search resulted in 1572 articles; 166 were reviewed in full. None met all inclusion/exclusion criteria. However, 21 studies met all criteria except age stratification. Authors were contacted to obtain raw data to perform an independent age-based analysis, but sufficient data was not received. CONCLUSION: While the initial systematic review did not generate the expected results, it did reveal that age-related outcomes of BoTN-A for the treatment of OAB are significantly under-studied. Given that the prevalence of OAB increases with age, this is an important knowledge gap. Our article explains the rationale for further study in this area.

Impact of radiotherapy for localized prostate cancer on bladder function as demonstrated on urodynamics study: A systematic review.

INTRODUCTION: This study aimed to describe the effects of bladder function following radiotherapy for localized prostate cancer by performing a systematic review on studies reporting on urodynamic findings after radiotherapy. METHODS: This systematic review was conducted in accordance with PRISMA guidelines. The review protocol was registered at PROSPERO (CRD42021229037). A systematic search was conducted using PubMed, Cochrane Library, Scopus, and OVID Embase. Studies were included if they involved men who underwent urodynamic studies following radiotherapy for localized prostate cancer. A total of 798 articles were screened and five articles included. A qualitative analysis was performed. RESULTS: Bladder compliance appears to be impaired following radiotherapy, especially with longer followup. Impaired bladder compliance was reported in 18.8-62.5% of patients following radiotherapy. Bladder capacity was found to be statistically significantly lower following radiotherapy compared to pre-radiotherapy, and when compared with patients who did not undergo pelvic radiotherapy. Bladder outlet obstruction (BOO) persists post-radiotherapy in most patients at three and 18 months post-radiotherapy. De novo detrusor overactivity (DO) of 13.3% has been reported at 18 months post-radiotherapy. This review is limited by the absence of level I/II studies. CONCLUSIONS: Radiotherapy for localized prostate cancer results in decreased bladder compliance and capacity demonstrated on urodynamic studies. Resolution of BOO appears less likely in comparison to series on radical prostatectomy. De novo DO may develop following radiotherapy, especially with longer followup. With only low level of evidence studies available at present, further high-quality, prospective studies are important to elucidate the impact of radiotherapy on bladder and urethral function.

Persistence with mirabegron or antimuscarinic treatment for overactive bladder syndrome: Findings from the PERSPECTIVE registry study.

OBJECTIVES: This analysis from the PERSPECTIVE (a Prospective, Non-interventional Registry Study of Patients Initiating a Course of Drug Therapy for Overactive Bladder) study evaluated treatment persistence with mirabegron or antimuscarinics over a 12-month period. METHODS: Participants were adults diagnosed with overactive bladder (OAB) by their health care provider (HCP), who were initiating mirabegron or antimuscarinic treatment. The HCP made all treatment decisions, and patients were followed for 12 months with no mandatory scheduled visits. Information requests were sent to patients at baseline and months 1, 3, 6, and 12. Patients were nonpersistent if they switched, discontinued, or added OAB medications/therapies to their initial treatment. Reasons for discontinuation and switching patterns were investigated. RESULTS: Overall, 1514 patients were included (613 mirabegron and 901 antimuscarinic initiators). Persistence rates decreased steadily over time in both groups. A low proportion of patients added or switched medication at each time point. Unadjusted Kaplan-Meier analysis showed similar persistence rates for both groups. When the data were adjusted for patient characteristics (age, sex, and OAB treatment status), mirabegron initiators had higher persistence rates. No significant differences were noted in unadjusted median time to end of persistence. However, end of treatment persistence by any cause was longer with mirabegron (median: 9.5 vs 6.7 months for antimuscarinics). HCPs stated that the most common reasons for nonpersistence were no symptomatic improvement and side effect aversion. CONCLUSIONS: Treatment persistence was longer for mirabegron compared with antimuscarinic initiators after controlling for patient characteristics. End of treatment persistence by any cause was also longer with mirabegron.

The relationship between overactive bladder and prostate cancer: A scoping review.

INTRODUCTION: The relationship between prostate cancer (PCa) and overactive bladder (OAB) is poorly understood. PCa and OAB are frequently diagnosed in elderly populations, so it could be expected that both conditions would be observed in older patients. Whether PCa and OAB occur independently with age, or the presence of PCa leads to the onset of OAB/lower urinary tract symptoms (LUTS) has not been explored. This review aimed to investigate whether men newly diagnosed with PCa are more likely to have OAB compared to the general population, and if the various treatment modalities for PCa are likely to impact the incidence or exacerbation of OAB. METHODS: The University of Calgary's databases for Medline and PubMed were searched for relevant publications. No restrictions were placed on the study design reported. Any publications reporting OAB and a PCa diagnosis and/or observation relating to PCa diagnosis and rates of OAB/LUTS in an adult population were included for full review. RESULTS: Of the studies examining the relationship between PCa and LUTS, results varied, but frequently indicated an inverse association between PCa and LUTS in which patients newly diagnosed with PCa were more unlikely to have LUTS compared to the general population. Following treatment, brachytherapy resulted in a higher prevalence of OAB symptoms compared to surgical treatment and external beam radiation therapy. CONCLUSIONS: Diverse evidence was found regarding the relationship between the prevalence of pre-treatment OAB and PCa diagnosis. However, limited evidence, as well as uncertainty regarding pre-treatment symptoms and their impact on post-treatment outcomes, restricts potential conclusions.

Impact of radical prostatectomy on bladder function as demonstrated on urodynamics study-A systematic review.

AIMS: This study aims to describe the effects of radical prostatectomy (RP) on bladder function by performing a systematic review of urodynamics study findings before and after RP. METHODS: This systematic review was conducted in accordance with the PRISMA guideline and registered on PROSPERO (CRD42020206844). A systematic search was conducted using PubMed, Cochrane, and Embase. Studies were included if they involved men who underwent RP and had urodynamics study performed preoperatively, postoperatively, or both. Studies that included only subgroups of patients based on symptoms were excluded. Three hundred and four articles were screened, with 20 articles included. A qualitative analysis was performed. RESULTS: The rate of baseline bladder outlet obstruction (BOO) pre-RP was 19%-67%. All six studies with comparative data pre- and postoperatively demonstrated a decrease in the rate of patients with equivocal or clear obstruction. The baseline rates of detrusor overactivity (DO) varied widely from 11% to 61.2%. Six of eight studies with 6 months or more follow-up showed an improvement in the rates of DO ranging from 3.0% to 12.5%. The rate of de novo DO ranged from 0% to 54.5%. Four studies reported an increased rate of impaired bladder contractility and two of three studies showed a worsening rate of impaired bladder compliance following RP. This review is limited by the absence of level I/II studies. CONCLUSIONS: Urodynamics study shows that BOO is improved following RP in most patients. RP resolves DO in some patients and cause de novo DO in others. The net effect is a reduced overall rate of DO in most studies. Bladder compliance and contractility may be impaired after RP.

Multicentered Assessment of Clinical Outcomes and Factors Associated With Failure of the Adjustable TransObturator Male System (ATOMS).

OBJECTIVE: To assess postoperative outcomes from the Adjustable TransObturator Male System (ATOMS) and identify factors influencing failure to achieve continence. PATIENTS AND METHODS: A multicentered analysis was performed on all patients treated for postprostatectomy incontinence using the third-generation ATOMS at 9 Canadian tertiary referral centers. The primary outcome was continence (defined as requiring ≤1 pad postoperatively for patients requiring ≥2 pads preoperatively and 0 pads for those requiring 1 pad preoperatively). Secondary outcomes included improvement (>50% change in pad use), patient satisfaction, explantation, and postoperative complications. RESULTS: Two hundred and eighty nine patients with a mean age of 68.9 years were analyzed. Pre-operatively mean pad per day use was 4.2 (1-12), 31.5% of patients reported severe incontinence (≥5 pads/day), 33.9% had concurrent radiotherapy and 19.4% had failed previous incontinence surgery. Overall continence rate was 73.3% (n = 212) at a mean follow-up of 19.6 months. More than eighty nine percent (89.3%) (n = 258) of patients experienced >50% improvement, 84.4% (n = 244) of patients were satisfied with the results of surgery. More than seven percent (7.9%) (n = 23) required device explantation. On multivariate Cox regression analysis, concurrent radiotherapy (hazard ratio [H.R.] 2.3, P < .001), diabetes (H.R. 2.2, P = .007) and increased pre-operative pad usage (H.R. 1.1, P = .02) were each associated with failure to achieve continence, while patient age (P = .60), obesity (P = .08), prior urethral stenosis (P = .56), and prior incontinence surgery (P = .13) were not. Radiation therapy was also associated with device explantation (H.R. 2.7, P = .02). CONCLUSION: ATOMS is a safe and efficacious for treatment of postprostatectomy incontinence. However, patients with prior radiation, increased pre-operative pad use, or diabetes are less likely to achieve continence.

Baseline patient reported outcomes data shows high prevalence of overactive bladder, sexual dysfunction, depression and anxiety in Canadian men with newly diagnosed localized prostate cancer.

BACKGROUND: Research on prostate cancer survivorship patients has largely been on oncological outcome, incontinence and erectile dysfunction, with less data on the relationship between prostate cancer, bladder function and mental health. This study aims to elucidate the prevalence of lower urinary tract symptoms (LUTS), overactive bladder (OAB), sexual dysfunction, depression and anxiety in Canadian men with newly diagnosed localised prostate cancer. METHODS: This is a single-centre prospective cross-sectional study of men with newly diagnosed localized prostate cancer recruited from June 2017 to July 2018. The patient-reported outcomes (PRO) instruments used in this study included the international prostate symptoms score (IPSS), OAB-V8, EQ-5D™, and the Expanded Prostate Cancer Index Composite short form (EPIC-26). Clinico-pathological data were extracted from medical records. The prevalence of LUTS, OAB, sexual dysfunction, depression and anxiety were determined from the PROs. RESULTS: A total of 83 patients were included in this study. The median age was 63. Based on IPSS scores, 55.3% of men had mild LUTS, 36.8% had moderate LUTS and 7.9% had severe LUTS. Based on OAB-V8 scores, 55.8% of men had a score of 8 or higher, suggestive of OAB. Only 55.8% of men reported erections adequate for intercourse. 23.1% of men reported to have a moderate to big problem with depression, and 28.8% of men reported to have a degree of anxiety or depression. CONCLUSIONS: OAB is a significant problem in men with newly diagnosed localized prostate cancer, with a prevalence of 55.8% based on this study. Baseline sexual dysfunction, anxiety and depression are also prevalent in this population.

Two Intraoperative Techniques for Midurethral Sling Tensioning: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether the use of a Mayo Scissor as a suburethral spacer compared with a Babcock clamp holding a loop of tape under the urethra results in different rates of abnormal bladder outcomes 12 months after retropubic midurethral sling surgery. METHODS: The MUST (Mid-Urethral Sling Tensioning) trial was a block-randomized, double-blind, multicenter clinical trial that allocated women to have their retropubic midurethral slings tensioned by Scissor or Babcock technique. The primary outcome (abnormal bladder) was a composite of persistent stress urinary incontinence (SUI), overactive bladder, and urinary retention. Secondary outcomes included outcomes of the composite, postoperative catheterization, incontinence-related questionnaires, repeat incontinence treatment, and uroflowmetry. Sample size of 159 in each arm (N=318) was planned for a superiority trial, hypothesizing a 10% difference in primary outcome. RESULTS: From September 2015 to December 2017, 506 women were screened and 318 were randomized. Baseline characteristics were similar in each arm. At 12 months, 253 (79.6%) women provided information on primary outcome: 40 of 128 (31.3%) patients with midurethral slings tensioned by Scissor experienced abnormal bladder, compared with 23 of 125 (18.4%) of those with midurethral slings tensioned by Babcock (P=.018, relative difference 12.9%). Secondary analyses favored Babcock for median duration of catheterization and the proportions of women experiencing urinary retention requiring sling lysis. Uroflowmetry parameters suggest the Scissor technique is more restrictive. Rates of mesh erosion were lower for the Scissor arm. No differences occurred in proportions of women experiencing patient reported persistent SUI after surgery. CONCLUSION: Abnormal bladder outcomes were 12.9% less frequent for women with midurethral slings tensioned by Babcock. Both techniques provided a comparable patient reported cure for SUI at 12 months. Women with midurethral slings tensioned by Scissors experienced more intervention for obstruction, whereas those with midurethral slings tensioned by Babcock experienced higher rates of mesh erosion. This information about how the postoperative courses differ allows surgeons to better counsel patients preoperatively or tailor their choice of technique. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02480231. FUNDING SOURCE: Boston Scientific.

Evaluating the measurement properties of the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) with a multicenter cohort.

INTRODUCTION: We aimed to evaluate the psychometric properties of the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) for measuring the quality of life in patients treated for localized prostate cancer. The EPIC-26 is a patient-reported outcome instrument recommended for use with patients treated for localized prostate cancer. METHODS: This study is based on data collected prospectively between September 2014 and February 2017 in Alberta, Canada. Men were treated with either radical prostatectomy or radiation therapy and administered the EPIC-26. Responses to the EPIC-26 were the primary outcome. Construct validity was measured using confirmatory factor analysis. Reliability was measured using Chronbach's alpha and item-total correlation. Ceiling and floor effects were also investigated. RESULTS: EPIC-26 response data from 205 participants (prostatectomy =138; radiation=60; both=7) were used in this analysis. The EPIC-26 was administered an average of 33.8 weeks after treatment. The confirmatory factor analysis model did not meet the threshold for adequate fit. Several items had near-zero factor loadings and were non-significant. Four out of the EPIC-26's five domains met the acceptable reliability threshold based on Cronbach's alpha. Ceiling effects were observed in four out of five domains. CONCLUSIONS: The EPIC-26 demonstrated poor construct validity, adequate reliability, and large ceiling effects. Several issues were observed, suggesting that the instrument's five domains were not well-defined by their respective items. The original EPIC's conceptual framework should be reviewed and the shortened instrument revised to improve its performance for measuring post-treatment quality of life.

Factors Associated with Improvements in Patient-Reported Outcomes During Mirabegron or Antimuscarinic Treatment of Overactive Bladder Syndrome: A Registry Study (PERSPECTIVE).

INTRODUCTION: Patient-reported outcomes (PROs) provide valuable insights about the effectiveness of overactive bladder (OAB) treatments. The aim of PERSPECTIVE (a Prospective, non-intErventional Registry Study of PatiEnts initiating a Course of drug Therapy for overactIVE bladder) was to provide real-world evidence from the USA and Canada on patient-perceived effectiveness and safety of mirabegron and antimuscarinics for treating OAB symptoms. METHODS: This prospective, non-interventional registry followed adult patients with OAB who were starting treatment with mirabegron or antimuscarinics. All treatment decisions were made at the discretion of the treating healthcare provider with no mandatory visits after enrollment. The primary objective was to identify factors associated with improved treatment effectiveness from a patient perspective mainly using the OAB Questionnaire Short-Form (OAB-q SF). The form was sent to patients via email link at baseline and months 1, 3, 6, and 12. Treatment-emergent adverse event (TEAE) data were collated from investigator reports. RESULTS: Overall, 1514 patients were included (female 73.5%, mean age 62.2 years). Mirabegron was initiated by 613 patients and antimuscarinics by 901 patients. A PRO response rate of approximately 60% was achieved (575 patients did not complete baseline PROs). Similar improvements in OAB-q SF symptom bother score and health-related quality of life (HRQoL) total score were observed for mirabegron and antimuscarinic initiators. Covariate-adjusted models demonstrated that worse baseline PRO score, Hispanic ethnicity, being treatment naïve, and use of complementary/supportive OAB therapies at baseline were significantly associated with greater improvements in both scores. The most frequent TEAEs were gastrointestinal disorders (dry mouth, constipation, and nausea) and nervous system disorders (headache, somnolence, and dizziness). CONCLUSION: There are no differences between mirabegron and antimuscarinics in terms of patient-reported OAB symptom bother and HRQoL. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02386072. FUNDING: Astellas Pharma Global Development, Inc. Plain language summary available for this article.

Diabetic Bladder Dysfunction:A Review.

Diabetic bladder dysfunction affects almost half of all diabetic patients, making it one of the most common complications of diabetes mellitus. The clinical presentation of diabetic bladder dysfunction can be varied and may be extremely bothersome to patients, negatively impacting their quality of life. Despite this, it remains understudied and under-represented in the medical literature. This review summarizes the current literature on pathophysiology, clinical presentation, urodynamic findings, evaluation, and management. Through this, we hope to provide guidance to clinicians involved with the management of this condition.

A Prospective, non-intErventional Registry Study of PatiEnts initiating a Course of drug Therapy for overactIVE bladder (PERSPECTIVE): Rationale, design, and methodology.

INTRODUCTION: Pharmacotherapy of overactive bladder (OAB) typically involves treatment with an antimuscarinic or mirabegron, a ß3-adrenoceptor agonist, but real-world evidence on their use, including treatment access, persistence, and switching, is limited. Here, we describe the design of a prospective, multicenter, non-interventional registry of patients beginning a new course of OAB pharmacological therapy in routine clinical practice. METHODS: Adults with an OAB diagnosis for at least 3 months who either initiated a new course of mirabegron or antimuscarinic, or who switched therapy were enrolled into PERSPECTIVE (a Prospective, non-intErventional Registry Study of PatiEnts initiating a Course of drug Therapy for overactIVE bladder). The primary objective was to identify factors associated with improved OAB treatment effectiveness from a patient perspective. Secondary objectives were to compare persistence rates, reasons for discontinuation, and switching patterns between patients taking mirabegron or antimuscarinics. Healthcare centers and sites involving medical specialties who routinely participate in the care and treatment of patients with OAB (e.g., gynecology, urology, and primary care practices) were targeted for recruitment. Patient-reported outcomes (PROs), including quality of life, symptom bother, and treatment satisfaction from OAB-validated scales, were collected at baseline, months 1, 3, 6, and 12, and when patients switched or discontinued their current OAB medication. CONCLUSIONS: PERSPECTIVE is the first real-world observational study in the United States and Canada on clinical and patient perspectives in OAB management. Recruitment was reflective of centers where patients are treated for OAB to maximize generalizability to the real-world population. TRIAL REGISTRATION: ClinicalTrials.gov, ID number NCT02386072 (date of registration March 6, 2015).

Canadian Urological Association position statement on the use of transvaginal mesh.

Stress incontinence (SUI) and pelvic organ prolapse (POP) are common conditions. There is high-level evidence that midurethral mesh slings for stress incontinence are effective and safe; however, the rare but serious potential risks of this surgery must be discussed with the patient. The use of transvaginal mesh for prolapse repair does not appear to be supported by the current evidence, and its use should be restricted to specialized pelvic floor surgeons and specific clinical situations.