How Would You Manage This Patient With Benign Prostatic Hyperplasia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Lower urinary tract symptoms due to benign prostatic hyperplasia (BPH) are common in older patients assigned male sex at birth, regardless of gender identity, and treatment of these symptoms is therefore common in primary care practice. In 2021, the American Urological Association published guidelines for management of BPH. They recommend using a standardized scoring system such as the International Prostate Symptom Score to help establish a diagnosis and to monitor the efficacy of interventions, α-blockers as the first-choice pharmacotherapy option, and 5α-reductase inhibitors for patients with prostate size estimated to be at least 30 cc. Tadalafil is another option regardless of erectile dysfunction. Combination therapies with α-blockers and 5α-reductase inhibitors, anticholinergic agents, or ß3-agonists are effective options. A surgical referral is warranted if the BPH results in chronic kidney disease, refractory urinary retention, or recurrent urinary tract infections; if there is concern for bladder or prostate cancer; or if symptoms do not respond to medical therapy. In this article, a general internal medicine physician and a urologist discuss the treatment options and how they would apply their recommendations to a patient who wishes to learn more about his options.

The International Continence Society (ICS) report on the terminology for adult male lower urinary tract and pelvic floor symptoms and dysfunction.

INTRODUCTION: In the development of terminology of the lower urinary tract, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction needs to be updated using a male-specific approach and via a clinically-based consensus report. METHODS: This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) in a Working Group with recognized experts in the field, assisted by many external referees. Appropriate core clinical categories and a subclassification were developed to give a numeric coding to each definition. An extensive process of 22 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction, encompassing around 390 separate definitions/descriptors, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in male lower urinary tract and pelvic floor dysfunction. Male-specific imaging (ultrasound, radiology, CT, and MRI) has been a major addition whilst appropriate figures have been included to supplement and help clarify the text. CONCLUSIONS: A consensus-based Terminology Report for male lower urinary tract and pelvic floor symptoms and dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Female underactive bladder - Current status and management.

Underactive bladder (UAB) is defined by the International Continence Society as a symptom complex characterized by a slow urinary stream, hesitancy, and straining to void, with or without a feeling of incomplete bladder emptying sometimes with storage symptoms. Until recently, the topic has received little attention in the literature probably due to a lack of consistent definitions and diagnostic criteria. We performed a literature review to identify articles related to the diagnosis and management of UAB, specifically in female patients. UAB is a common clinical entity, occurring in up to 45% of females depending on definitions used. Prevalence increases significantly in elderly women and women who live in long-term care facilities. The exact etiology and pathophysiology for developing UAB is unknown, though it is likely a multifactorial process with contributory neurogenic, cardiovascular, and idiopathic causes. There are currently no validated questionnaires for diagnosing or monitoring treatment for patients with UAB. Management options for females with UAB remain limited, with clean intermittent catheterization, the most commonly used. No pharmacotherapies have consistently been proven to be beneficial. Neuromodulation has had the most promising results in terms of symptom improvement, with newer technologies such as stem-cell therapy and gene therapy requiring more evidence before widespread use. Although UAB has received increased recognition and has been a focus of research in recent years, there remains a lack of diagnostic and therapeutic tools. Future research goals should include the development of targeted therapeutic interventions based on pathophysiologic mechanisms and validated diagnostic questionnaires.

Evaluation and surgery for stress urinary incontinence: A FIGO working group report.

AIMS: To review available evidence regarding evaluation and treatment of stress urinary incontinence (SUI) and provide recommendations for management of urinary incontinence under specific conditions determined by the International Federation of Gynecology and Obstetrics (FIGO) Working Group. METHODS: The FIGO Working Group discussed the management of SUI during meetings and assessed the evidence. The search of evidence was performed using MEDLINE® and Cochrane databases as well as additional searches from societies and major organizations for additional guidelines and recommendations and hand searches from bibliographies. Initial searches from 1985 to December 31, 2012 extended until July 15, 2015. After review, recommendations are made based on levels of evidence according to the recommendations from Oxford EBM Center. RESULTS: Initial evaluation of SUI consists of history and physical examination; cough stress test, evaluation for urinary tract infections (UTI), assessment of urethral mobility, and post-void residual volumes (LOE 5). Urodynamic studies are not necessary to evaluate patients with uncomplicated SUI (LOE 1a). Conservative treatment should be tried prior to surgery and more importantly in areas of low resources (LOE 5). Midurethral slings (MUS), pubovaginal (traditional suburethral) slings (PVS), and Burch colposuspension are effective in treating SUI (LOE 1a). Patients with SUI with ISD or UUI appear to have lower cure rates than patients without (LOE 2-4). There are limited data on surgical outcomes under limited resources (LOE 5). CONCLUSIONS: MUS, PVS, and Burch colposuspension are effective treatments for SUI. Evidence for recommendations to treat patients in underserved low resource areas is lacking. Neurourol. Urodynam. 36:518-528, 2017. © 2016 Wiley Periodicals, Inc.

Pharmacokinetic comparison and bioequivalence evaluation of losartan/ hydrochlorothiazide tablet between Asian Indian and Japanese volunteers.

OBJECTIVES: To demonstrate the bioequivalence between the test and reference formulations of losartan/hydrochlorothiazide 50 + 12.5 mg tablet and evaluate the effect of ethnicity on pharmacokinetics properties of losartan, losartan carboxylic acid and hydrochlorothiazide on healthy Asian Indian and Japanese volunteers. METHODS: Randomized, open-label, crossover, bioavailability studies were conducted separately in healthy Asian Indian and Japanese volunteers. One tablet either of test or of reference product was administered after 10 hours of overnight fasting. After dosing, serial blood samples were collected for a period of 48 hours for both the studies. Plasma samples were analyzed for losartan, losartan carboxylic acid and hydrochlorothiazide by a validated liquid chromatographic and mass spectrometric method (LC-MS/MS). The pharmacokinetic parameters AUC0-t, AUC0-∞, Cmax, tmax, and other pharmacokinetics parameters were determined from plasma concentration-time profiles for both test and reference formulations of losartan/hydrochlorothiazide 50 + 12.5 mg tablets. Statistical evaluations were done to evaluate bioequivalence between generic test formulation (EPR0001) and Japanese reference product (Preminent®). RESULTS: Losartan, losartan carboxylic acid and hydrochlorothiazide were well tolerated by subjects in all periods of each study under fasted conditions. No serious adverse events were observed. The ratios of least square means for AUC0-t and Cmax and the affiliated 90% confidence intervals were within acceptance range recommended by PMDA. Marginal differences were observed in pharmacokinetic values of Asian Indian and Japanese volunteers. CONCLUSIONS: The results of these bioavailability studies indicate that the test formulation of losartan/hydrochlorothiazide 50 + 12.5 mg (EPR0001) tablets is bioequivalent to marketed Preminent® reference formulation in Asian Indian and Japanese volunteers, when administered under fasting conditions. Both test and reference formulations were well tolerated as a single oral dose when administered to healthy adult subjects under fasted conditions. Although Asian Indian and Japanese volunteers are ethnically different, results of these studies indicate that pharmacokinetic parameters of Asian Indian and Japanese volunteers are comparable to each other in terms of bioavailability of losartan, losartan carboxylic acid and hydrochlorothiazide. Similar least square means ratios were obtained in Asian Indian and Japanese volunteers demonstrating that a bioequivalence study conducted on Japanese volunteers seems to be substituted by Asian Indian volunteers' studies.

Is lower urinary tract dysfunction an early marker of Portuguese type familial amyloidotic polyneuropathy in women? Preliminary results.

Type 1 Portuguese Familial Amyloid Polyneuropathy was first observed in 1939 and described in 1951 by Corino Andrade. FAP is a rare autosomal dominant disease caused by a mutant gene in chromosome 18, characterized by a variant transthyretin in which valine is substituted for methionine at position 30 (ATTR V30M), affecting mainly young adults. ATTR V30M positivity does not imply disease, but the disease is only present with ATTR V30M in serum. The clinical manifestations of FAP on the pelvic floor and genitourinary system are frequent at early disease onset. Phenotypic diversity can depend on modulating agents in the deposition of the mutant TTR, such as incomplete penetration and environmental influence. Functional vesicourethral disorders appear to be primarily at the bladder filling phase, namely diminished bladder sensation, and associated with a decrease in detrusor contractility during the emptying phase. Unbalanced voiding takes place in this context, with high post-void residuals, increasing the rate of co-morbidity, namely recurrent urinary tract infections and chronic renal failure.This study describes the lower urinary tract dysfunctions in ATTR V30M positive carriers, particularly during the asymptomatic period and early stages of the disease, and additionaly it describes its association with the clinical evolution of the disease. In the preliminary phase of the study, the lower urinary tract dysfunction in FAP-women may present itself as an early manifestation in asymptomatic patients. Uroflowmetry and the evaluation of post-voiding residual volume are non-invasive and low cost tests that should be done during routine initial evaluation. Reduced bladder sensation and poor detrusor contractility may be considered initial markers of FAP. The neurogenic factor (bladder afferent neurons) appears to be mechanical in nature with myogenic repercussions. This further aggravates the bladder underactivity secondary to pelvic efferent parasympathetic neuropathy and amyloid infiltration in the bladder wall. Early diagnostic and therapeutic intervention may avoid secondary end stage renal disease.

Adjustable continence therapy (ProACT) and bone anchored male sling: Comparison of two new treatments of post prostatectomy incontinence.

OBJECTIVES: To compare the efficacy of two surgical treatments for male urinary stress incontinence: adjustable continence therapy (ProACT) and bone anchored male sling (BAMS). METHODS: Eighty-four consecutive post radical prostatectomy incontinent patients received ProACT (n = 46) or BAMS (n = 38) implantation by two different operators in two different centres. Eighty of them had a complete follow up. Both groups were prospectively assessed by number of pads per day and a validated questionnaire (UCLA/RAND). Complications rate and mean operating times were compared. All comparisons were analyzed using the t test, Fischer's exact test and chi(2) analysis (significance P < 0.05). RESULTS: At a mean follow up of 19 and 33 months respectively, 30/44 (68%) patients treated with ProACT were dry (0/1 safety pad) in comparison with 23/36 (64%) patients treated with BAMS (P > 0.05). Stratifying the results, ProACT had 33/39 (85%) dry patients in severe (more than three pads/day) preoperative incontinence, in comparison with 21/26 (81%) for BAMS (P > 0.05). The UCLA/RAND questionnaire showed an average increase of 11.7 points (from 10.2 to 21.9) for ProACT and of 10 points (from 11.9 to 21.9) for BAMS (P > 0.05). Complications included removal of ProACT and BAMS in 6/44 (14%) and 2/36 (6%), respectively. Mean operating time was 18 min and 45 min (P < 0.05) for ProACT and BAMS, respectively. CONCLUSIONS: ProACT and BAMS are both associated with a satisfactory rate of success. ProACT results seem to be better for severe incontinence and BAMS for mild incontinence. The operation time of ProACT is shorter.

Comparison of solvent-dehydrated allograft dermis and autograft rectus fascia for pubovaginal sling: questionnaire-based analysis.

OBJECTIVES: To evaluate the efficacy of pubovaginal sling using human cadaveric dermis processed by solvent dehydration and compare results to those of another group in which autograft rectus fascia was used. MATERIAL AND METHODS: The efficacy of autologous rectus fascia (group 1, n=25) or solvent-dehydrated cadaveric dermis (group 2, n=24) for pubovaginal sling were compared in women with stress urinary incontinence (SUI). Surgical outcome, patient satisfaction and quality of life was assessed by the urogenital distress inventory (UDI-6) and the incontinence impact questionnaire (IIQ-7). RESULTS: Mean follow-up for patients in group 1 and group 2 were 18 and 13 months, respectively. Our questionnaire-based assessment revealed that SUI was either cured or improved in a total of 21 (84%) patients in group 1 and 19 (79%) patients in group 2. No statistically significant difference was found for the overall success (P<0.05) and no major complications were encountered in both groups. CONCLUSIONS: Use of allograft dermis as an alternative to autologous rectus fascia for pubovaginal sling had comparable improvement in patient satisfaction and quality of life at intermediate term.

The Urology Applicant: An Analysis of Contemporary Urology Residency Candidates.

OBJECTIVE: To better understand today's urology applicant. METHODS: All 2016 Urology Residency Match applicants to the study-participating institutions were provided a survey via email inquiring about their paths to urology, their career aspirations, how they evaluate a training program, and how they perceive residency programs evaluate them. RESULTS: Of a possible 468 applicants registered for the match, 346 applicants completed the survey. Only 8.7% had a mandatory urology rotation, yet 58.4% believed that a mandatory urology rotation would influence their career decision. Most applicants (62.1%) spent more than 8 weeks on urology rotations, and 79.2% completed 2 or more away rotations. Applicants were attracted to urology by the diversity of procedures, prior exposure to the field, and the mix of medicine and surgery, with mean importance scores of 4.70, 4.52, and 4.45 of 5, respectively. Female applicants were more likely to be interested in pediatric urology, trauma or reconstructive urology, and female pelvic medicine and reconstructive surgery. Significant differences in survey results were noted when applicants were separated by gender. Three-fourths of respondents (75.7%) applied to more than 50 residency programs. Applicants ranked operative experience, interactions with current residents, and relationships between faculty and residents as the most important criteria when evaluating training programs. Of the subspecialties, 62.1% of applicants expressed most interest in urologic oncology. At this stage in their career, a significant majority (83.5%) expressed interest in becoming academic faculty. CONCLUSION: This study provides new information that facilitates a more comprehensive understanding of today's urology applicants.

Male incontinence: Pathophysiology and management.

Post-prostatectomy incontinence in men is a devastating condition. It impacts the quality of life profoundly. Various types of male sling procedures have been introduced over the years. Bone anchored male sling appears to be effective and safe in intermediate term follow up. It certainly more effective than collagen implant and may provide alternative treatment option in patient with mild to moderate incontinence. In short term, other novel procedures seem to be promising. In spite of new technology, artificial urinary sphincter continues to provide high patient satisfaction and cure rates.

Evaluation and Management of Lower Urinary Tract Symptoms After Outlet Surgery for Benign Prostatic Hyperplasia.

There are many options available in the surgical treatment of outlet obstruction secondary to benign prostatic hyperplasia (BPH). While most patients exhibit improvement in their lower urinary tract symptoms (LUTS) following intervention, up to 35 % of patients may exhibit persistent or recurrent LUTS. In the present review, we discuss the patho-physiology of LUTS after bladder outlet surgery and discuss considerations in evaluating and managing such patients. We highlight the crucial role of thorough evaluation with complete urodynamics testing, as pure obstruction only accounts for a minority of post-operative LUTS. Hence, detrusor contractility, detrusor overactivity, urethral sphincter function, and urinary incontinence must be assessed to appropriately guide subsequent therapy and improve patients' quality of life.

Artificial urinary sphincters for male stress urinary incontinence: current perspectives.

The artificial urinary sphincter (AUS), which has evolved over many years, has become a safe and reliable treatment for stress urinary incontinence and is currently the gold standard. After 4 decades of existence, there is substantial experience with the AUS. Today AUS is most commonly placed for postprostatectomy stress urinary incontinence. Only a small proportion of urologists routinely place AUS. In a survey in 2005, only 4% of urologists were considered high-volume AUS implanters, performing >20 per year. Globally, ~11,500 AUSs are placed annually. Over 400 articles have been published regarding the outcomes of AUS, with a wide variance in success rates ranging from 61% to 100%. Generally speaking, the AUS has good long-term outcomes, with social continence rates of ~79% and high patient satisfaction usually between 80% and 90%. Despite good outcomes, a substantial proportion of patients, generally ~25%, will require revision surgery, with the rate of revision increasing with time. Complications requiring revision include infection, urethral atrophy, erosion, and mechanical failure. Most infections are gram-positive skin flora. Urethral atrophy and erosion lie on a spectrum resulting from the same problem, constant urethral compression. However, these two complications are managed differently. Mechanical failure is usually a late complication occurring on average later than infection, atrophy, or erosions. Various techniques may be used during revisions, including cuff relocation, downsizing, transcorporal cuff placement, or tandem cuff placement. Patient satisfaction does not appear to be affected by the need for revision as long as continence is restored. Additionally, AUS following prior sling surgery has comparable outcomes to primary AUS placement. Several new inventions are on the horizon, although none have been approved for use in the US at this point.

Review of single-surgeon 10-year experience with artificial urinary sphincter with report of sterile cuff erosion managed nonsurgically.

OBJECTIVE: To review our experience with artificial urinary sphincter (AUS) and to consider the role of nonsurgical management of sterile AUS cuff erosion. METHODS: We retrospectively reviewed our 10-year experience with AUS implantation, including complication rates. We focus on the outcomes of eroded sphincters including 2 unique patients who were managed nonsurgically for sterile cuff erosion. RESULTS: Between 2002 and 2012, 126 AUS units were implanted in 79 adult male patients by single surgeon (A.K.S.). Twenty-five patients (31.6%) required at least 1 additional procedure because of urethral atrophy (22.8%) or erosion or infection (8.9%). In addition, 2 patients with congenital anomalies underwent AUS implantation at bladder neck and were followed up nonsurgically for several years after cuff erosion. Both refused surgical management and have since remained continent and infection-free despite chronic erosion for 15 years' duration in 1 patient and for 5 years' duration in the other. Of note, the patient with the longer duration of erosion developed bladder stones requiring surgical removal. CONCLUSION: Our AUS complication rates are consistent with those of prior series. Our unique experience with 2 patients suggests that immediate removal of AUS after sterile cuff erosion may occasionally be instituted only in difficult cases where repeat AUS implantation is not possible. To our knowledge, this is the first report of nonsurgical management of eroded AUS cuff in the literature. Larger prospective series concerning patient selection for salvaging eroded AUS may be warranted.

Post-prostatectomy incontinence: Etiology, evaluation, and management.

Urinary incontinence after prostatectomy or radiation is a devastating problem in men and remains the most feared complication following the treatment of localized prostate cancer. With an increasing number of radical prostatectomies performed globally for prostate cancer, the impact of urinary incontinence on quality of life assumes an even greater importance. With the advent of male sling procedures, more men are now seeking treatment for incontinence. Since the introduction of the artificial urinary sphincter almost four decades ago, several surgical procedures have emerged to manage post-prostatectomy incontinence, including the male sling for milder forms of incontinence. Several of the newer procedures have shown promise in the United States; many others have been developed and utilized in other parts of the world, though they have not yet gained FDA approval in the United States. The present review seeks to illuminate the etiology, evaluation, and management of post-prostatectomy incontinence. An effort has been made to provide an algorithm to clinicians for appropriate surgical management. The surgical techniques of commonly performed procedures and their outcomes are described.

Robotic-Assisted Surgery: Urological Applications and Outcomes.

The introduction of robotic technology and minimally invasive surgical techniques has revolutionized the field of urological surgery over the last 25 years. Robotic technology has been proven to be both safe and efficacious in the management of several urological malignancies and benign urological conditions. While some robotic applications have been well established, others are still at varying stages of evolution. In comparison to conventional open approaches, the robot has been shown to enhance intraoperative visualization and precision, mitigate surgeon tremor, hasten post-operative recovery, and shorten length of hospital stay for certain indications. This technology has not yet been universally adopted, however, due to its relatively high cost, longer associated operative times, and limited outcomes data. We herein review the current applications, outcomes, and drawbacks of robotic technology within the field of urological surgery and speculate on the future directions and implications within the field.

Evolution of Robotic Technology in Urologic Surgery.

Over the last 25 years, the field of urology has seen the advent and evolution of minimally invasive surgical techniques. The robot in particular has been shown to be safe and efficacious in managing malignancies. More recently its application has been expanded to benign urological conditions. While some robotic applications have been well established, others remain at varying stages of evolution. Relative to open approaches, the robot has been shown to enhance intraoperative visualization and precision, mitigate surgeon tremor, hasten post-operative recovery, and shorten length of hospital stay for certain indications; however, it has also been associated with higher costs, longer operative times, and limited outcomes data. We review the evolution of robotic applications within urology and speculate on the future directions and implications within the field.

A comparative study evaluating the in vivo incorporation of biological sling materials.

OBJECTIVES: To comparatively investigate biological tissues that are clinical products currently used for implantation in urological reconstruction. Specifically, we examined biological materials in vivo and evidence regarding the tissue response observed. Biological tissues are widely used in urological surgeries to treat conditions such as pelvic organ prolapse and stress urinary incontinence. METHODS: Histologic data from 4 biological sling materials, that is, small intestinal submucosa (SIS), cadaveric fascia lata, cadaveric dermis, and porcine dermis, implanted within mice (n = 64) were evaluated at 2, 4, 8, and 12 weeks. Recovered tissue was assessed by several biocompatibility parameters such as capsule formation (collagen deposition), cellular number, cell morphology, and angiogenesis. RESULTS: Data provide a scientific depiction of the cellular response to these biomaterials through a 12-week evaluation. SIS had a significantly higher level of angiogenesis and cell infiltrate as compared with all other material tested. Collectively, the data suggest that SIS has improved biocompatibility over other tested materials. CONCLUSIONS: This study compared SIS with other biological tissues in an animal model and was found to have superior biocompatibility as seen in humans. This may be helpful for clinicians while selecting a particular biological material. The study provides evidence of the varying stages of remodeling each implant, with hopes to better understand the material response in vivo.