Summary Paper on Underactive Bladder from the European Association of Urology Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms.

BACKGROUND AND OBJECTIVE: The European Association of Urology (EAU) Guidelines Panel on non-neurogenic male lower urinary tract symptoms (LUTS) aimed to develop a new subchapter on underactive bladder (UAB) in non-neurogenic men to inform health care providers of current best evidence and practice. Here, we present a summary of the UAB subchapter that is incorporated into the 2024 version of the EAU guidelines on non-neurogenic male LUTS. METHODS: A systematic literature search was conducted from 2002 to 2022, and articles with the highest certainty evidence were selected. A strength rating has been provided for each recommendation according to the EAU Guideline Office methodology. KEY FINDINGS AND LIMITATIONS: Detrusor underactivity (DU) is a urodynamic diagnosis defined as a contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or failure to achieve complete bladder emptying within a normal time span. UAB is a terminology that should be reserved for describing symptoms and clinical features related to DU. Invasive urodynamics is the only widely accepted method for diagnosing DU. In patients with persistently elevated postvoid residual (ie, >300 ml), intermittent catheterization is indicated and preferred to indwelling catheters. Alpha-adrenergic blockers are recommended before more invasive techniques, but the level of evidence is low. In men with DU and concomitant benign prostatic obstruction (BPO), benign prostatic surgery should be considered only after appropriate counseling. In men with DU and no BPO, a test phase of sacral neuromodulation may be considered. CONCLUSIONS AND CLINICAL IMPLICATIONS: The current text represents a summary of the new subchapter on UAB. For more detailed information, refer to the full-text version available on the EAU website (https://uroweb.org/guidelines/management-of-non-neurogenic-male-luts). PATIENT SUMMARY: The European Association of Urology guidelines on underactive bladder in non-neurogenic adult men are presented here. Patients must be fully informed of all relevant options and, together with their treating physicians, decide on the most optimal management for them.

Intra/inter-observer reliability of cystoscopic sphincter evaluation in men undergoing sling surgery.

OBJECTIVES: To assess the intra/inter-observer reliability of cystoscopic sphincter evaluation (CSE) in men undergoing sling surgery for urinary incontinence and if possible to evaluate its correlation with the final clinical decision. PATIENTS AND METHODS: Two expert urologists prospectively filmed and recorded, incontinent patient's cystoscopies according to a standard scenario. Anonymised recordings where randomly offered to the same observer twice. The observers (medical students, urology residents and full urologist with 0-5, 5-10, >10 years of practice, respectively) were asked to assess and score the recordings without knowing any of the patients' characteristics. RESULTS: In total, 37 recordings were scored twice by the 26 observers. The intraclass correlation coefficient (ICC) for intra-observer reliability of the CSE was 0.54 (moderate), 0.58 (moderate) and 0.60 (substantial) for medical students, residents, and urologists, respectively. However, when stratifying observers according to their experience, the lowest agreement values were found between experts with >10 years of experience. The inter-observer reliability for the CSE ICCs ranged between 0.31and 0.53, with the lowest ICC value observed between urologists (0.31). CONCLUSIONS: The study demonstrates poor intra- and inter-observer reliability of the CSE. According to these results, a CSE does not add valuable information to the clinical evaluation. In this scenario, it should not be considered in isolation from the patient's characteristics.

Urinary outcomes of new ultra-minimally invasive treatments for prostate cancers.

PURPOSE OF REVIEW: The aim of this narrative review is to evaluate the current available literature on urinary outcomes following cryotherapy and high-intensity focused ultrasound (HIFU) for localized prostate cancer (PCa). RECENT FINDINGS: The available literature is heterogeneous in terms of intervention modalities and assessment of urinary outcome measures. Nevertheless, ultra-minimally invasive treatments seem to provide good urinary outcomes. Technological advancement and the adoption of more conservative ablation templates allow for a further reduction of toxicity and better preservation of urinary function. Urinary incontinence occurs in 0-10% of the patients and, is mostly transient. Voiding and storage lower urinary tract symptoms (LUTS) mostly occur in the early postoperative period and rarely require surgical treatment. Focal therapies performed with a salvage intent after external beam radiotherapy have a significantly higher impact on patient's urinary function. SUMMARY: Ultra-minimally invasive treatment for PCa show a good safety profile concerning urinary function, but consensus on when and how best to assess this is still lacking. Efforts should be made to standardize the report of preoperative and postoperative urinary function to provide higher level of evidence.

Incidence of urological cancers in neurological patients: a review of the literature from the EAU Young Academic Urologist Functional Group.

INTRODUCTION: Urological cancers can be challenging in the diagnosis and treatment of patients with neurological diseases. As a result, there are still uncertainties regarding the incidence and risk factors favouring the development of urological cancers in these patients. The aim of this study was to review the available evidence regarding the incidence for the development of urological cancers in neurological patients to provide a basis for future recommendations and research. EVIDENCE ACQUISITION: A narrative review of the literature in Medline and Scopus up to June 2019 was performed. EVIDENCE SYNTHESIS: After screening 1729 records, 30 retrospective studies were retained. For bladder cancer (BC), 21 articles were identified, including a total of 673,663 patients. Among these patients, 4744 had a diagnosis of BC (1265 females, 3214 males, gender not reported in 265). In this group, 2514 were diagnosed with BC associated with a neurological disease. For prostate cancer (PC), 14 articles were identified, including a total of 831,889 men. Among these patients, 67,543 had a diagnosis of PC and 1457 had PC and a neurological disease. Two articles reported kidney cancer (KC), one reported testicular cancer (TC) and none described penile cancer or urothelial carcinomas of the upper urinary tract in neurological patients. CONCLUSIONS: The incidence of urological cancers, especially BC and PC, in patients with neurological diseases appears comparable to the general population. However due to the paucity of studies, specific recommendations for the management are lacking in neurologically disabled patients. In this report we investigated the frequency of urinary tract cancers in patients with neurological diseases. We conclude that urological cancers, especially bladder and prostate cancer, in patients with neurological diseases occur with similar frequency as in the general population.

The key role of levator ani thickness for early urinary continence recovery in patients undergoing robot-assisted radical prostatectomy: A multi-institutional study.

BACKGROUND: Urinary continence (UC) recovery dramatically affects quality of life after robot-assisted radical prostatectomy (RARP). Membranous urethral length (MUL) has been the most studied anatomical variable associated with UC recovery. OBJECTIVE: To investigate whether levator ani thickness (LAT), assessed with multi-parametric magnetic resonance imaging (mpMRI), correlates with UC recovery after RARP. DESIGN, SETTING, AND PARTICIPANTS: The study included 209 patients treated with RARP by expert surgeons with extensive robotic experience from 2017 to 2019. All patients had complete, clinical, mpMRI, pathological, and postoperative data including pelvic floor muscle training (PFMT) protocols. INTERVENTION: After a radiologist-specific training, two urologists independently examined the files, blinded to clinical and pathological findings as well as to postoperative continence status. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: On mpMRI, LAT, bladder neck (BN) shape, MUL, and apex overlapping (AO) were measured. UC recovery was defined as use of 0 or 1 safety pad at follow-up. Multivariable models were used to assess the association between variables and UC recovery. RESULTS AND LIMITATIONS: Overall, 173 (82.8%) patients were continent after a median follow-up of 23 months (interquartile range [IQR]: 17-28). Of these, 98 (46.9%) recovered within 3 months after surgery, 42 (20.1%) from 3 to 6 months, and 33 (15.8%) from 6 months onwards. A significant higher rate of patients with LAT > 10 mm (88.1 vs.75.8%; p = 0.03) experienced UC recovery, compared to those with LAT < 10 mm. This difference was observed in the first 3 months after surgery. At multivariable analysis, LAT (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.37; p = 0.02), Preoperative ICIQ score (OR: 0.91, 95% CI: 0.82-0.98, p = 0.03) and PFMT (OR: 1.98, 95% CI: 1.01-3.93; p = 0.04) independently predict higher UC recovery within 3 months, after accounting for age, BMI, preoperative PSA, D'Amico risk group, MUL, BN shape and AO. CONCLUSIONS: LAT greater than 1 cm was associated with greater UC recovery. Specifically, LAT greater than 1 cm seems to be associated with higher UC rate at 3 months after RARP, compared to those with LAT < 1 cm. PATIENT SUMMARY: Magnetic resonance features can help in predicting the risk of incontinence after robot-assisted radical prostatectomy and should be taken into account when counseling patients before surgery.

Long-term Functional Outcomes and Patient Satisfaction After AdVance and AdVanceXP Male Sling Surgery.

BACKGROUND: Transobturator male sling has gained increasing acceptance for the treatment of male urinary incontinence. Several prospective trials have demonstrated the safety and efficacy of the AdVance and AdVanceXP slings. OBJECTIVE: To evaluate long-term functional outcomes after AdVance or AdVanceXP sling implant for non-neurogenic male stress urinary incontinence and identify factors associated with a higher risk for incontinence or decreased satisfaction. DESIGN, SETTING, AND PARTICIPANTS: Patients who underwent AdVance or AdVanceXP implant surgery between June 2007 and April 2018 were retrospectively included in this single-institution, consecutive series. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: In April 2020, patients were recontacted to evaluate long-term functional outcomes and satisfaction by standardized, validated questionnaires. RESULTS AND LIMITATIONS: A total of 216 patients were included in this study; 172 of them could be contacted for the assessment of long-term patient reported outcomes. The median follow-up period was 49 mo. Overall social continence (ie, needing no more than one pad per 24 h) at 5-yr follow-up was 66% (confidence interval [CI]: 58-73%). In an ideal population (ie, needing no more than four pads per 24 h and naïve for pelvic radiotherapy, prior incontinence surgery, or urethral stricture surgery), 5-yr social continence rates were markedly better and reached 79% (CI: 69-85%). Overall social continence rates tended to decrease at 10-yr follow-up to 42% (CI: 33-52%). Overall, totally dry rate at 5-yr follow-up was 53% (CI: 46-60%), which again was significantly better in the ideal population (62%, CI: 51-70%). According to the Patient Global Improvement Indices score, 71% (CI: 63-78%) of patients indicated to be satisfied after 5 yr, which improved to 77% (CI: 67-85%) in the ideal patient population. In a multivariate analysis, prior pelvic radiotherapy and previous incontinence or urethral stricture surgery were associated with decreased continence rates and patient satisfaction. CONCLUSIONS: In general, long-term continence rates and patient satisfaction after AdVance and AdVance XP sling surgery are acceptable but deteriorate significantly as time from surgery progresses. Especially patients with a history of pelvic radiotherapy, prior incontinence surgery, or urethral stricture surgery should be counseled properly about their higher risk for sling failure. PATIENT SUMMARY: In this report, we investigated long-term outcomes after Advance and AdvanceXP sling implant for male stress urinary incontinence. We found that, in general, continence and patient satisfaction are acceptable but deteriorate significantly as time from surgery progresses. Patients with previous pelvic radiotherapy, incontinence surgery, or urethral stricture surgery are at higher risk for sling failure.

Can We Rely Solely on the International Prostate Symptoms Score to Investigate Storage Symptoms in Men with Lower Urinary Tract Symptoms Associated with Benign Prostatic Enlargement? Findings from a Cross-sectional Study.

BACKGROUND: Discrepancies exist between patient-reported storage phase symptoms severity and International Prostate Symptom Score (IPSS) scores. OBJECTIVE: To investigate whether the Overactive Bladder questionnaire (OABq) can detect further storage phase lower urinary tract symptoms (LUTS) among patients complaining solely of voiding LUTS based on the IPSS questionnaire, and to address the real-life impact of voiding LUTS towards patients' quality of life (QoL). DESIGN, SETTING, AND PARTICIPANTS: Data from 233 consecutive men seeking medical help for LUTS/benign prostate enlargement for the first time were analysed. All patients completed both the OABq and the IPSS questionnaire. In order to investigate patients with predominantly voiding phase symptoms, men with storage phase symptoms at IPSS were eventually excluded from the analysis. Patients with an OABq score of ≥40 were considered as those having moderate-to-severe storage LUTS. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and linear regression models tested the associations between OABq scores, IPSS, and IPSS-QoL. RESULTS AND LIMITATIONS: OABq scores were higher in men with severe voiding symptoms than in men with mild voiding symptoms (p < 0.001). More than half of patients with predominant voiding symptoms, according to the IPSS questionnaire, depicted a pathologic OABq score. A higher rate of pathologic OABq scores was found in men with moderate/severe voiding symptoms than in those with mild scores (67.4% vs 49.6%, p < 0.001). At multivariable analysis, younger age (beta -0.1, p < 0.01), IPSS voiding subscore (beta 0.3, p < 0.001), and OABq score ≥40 (beta 1.1, p < 0.001) emerged as independent predictors of IPSS-QoL after accounting for prostate volume and flow max. CONCLUSIONS: The OABq can detect the presence of further storage phase LUTS in patients presenting solely with voiding LUTS and IPSS suggestive of voiding phase symptoms. In addition, the OABq was associated with worse patient QoL regardless of the severity of voiding symptoms. PATIENT SUMMARY: The Overactive Bladder questionnaire (OABq) is able to detect the presence of additional storage lower urinary tract symptoms (LUTS) in patients presenting solely with voiding LUTS according to the IPSS questionnaire. Moreover, the OABq is associated with worse quality of life in these patients regardless of the severity of voiding symptoms.

Current Management of Post-radical Prostatectomy Urinary Incontinence.

Prostate cancer is the second most common cancer in men worldwide. Radical prostatectomy and radiation beam therapy are the most common treatment options for localized prostate cancer and have different associated complications. The etiology of post prostatectomy incontinence is multifactorial. There is evidence in the literature that anatomic support and pelvic innervation are important factors in the etiology of post-prostatectomy incontinence. Among the many surgical and technical factors proposed in the literature, extensive dissection during surgery, damage to the neurovascular bundle and the development of postoperative fibrosis have a substantial negative impact on the continence status of men undergoing RP. Sparing of the bladder neck and anterior, and possibly posterior, fixation of the bladder-urethra anastomosis are associated with better continence rates. Overactive bladder syndrome (OAB) is multifactorial and the exact role of prostate surgery in the development of OAB is still under debate. There are several variables that could contribute to detrusor overactivity. Detrusor overactivity in patients after radical prostatectomy has been mainly attributed to a partial denervation of the bladder during surgery. However, together with bladder denervation, other hypotheses, such as the urethrovesical mechanism, have been described. Although there is conflicting evidence regarding the importance of conservative treatment after post-prostatectomy urinary incontinence, pelvic floor muscle training (PFMT) is still considered as the first treatment choice. Duloxetin, either alone or in combination with PFMT, may hasten recovery of urinary incontinence but is often associated with severe gastrointestinal and central nervous side effects. However, neither PFMT nor duloxetine may cure male stress urinary incontinence. The therapeutic decision and the chosen treatment option must be individualized for each patient according to clinical and social factors. During the recent years, the development of new therapeutic choices such as male sling techniques provided a more acceptable management pathway for less severe forms of urinary incontinence related to radical prostatectomy. Following this perspective, technological improvements and the emergence of new dedicated devices currently create the premises for a continuously positive evolution of clinical outcomes in this particular category of patients.

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence.

OBJECTIVES: To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option. PATIENTS AND METHODS: Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool. RESULTS: At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score. CONCLUSIONS: Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review.

PURPOSE: To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP). MATERIALS AND METHODS: A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer. RESULTS: Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI. CONCLUSIONS: To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

Efficacy and safety of artificial urinary sphincter (AUS): Results of a large multi-institutional cohort of patients with mid-term follow-up.

AIMS: To assess efficacy and safety as well as predictive factors of dry rate and freedom from surgical revision in patients underwent AUS placement. The artificial urinary sphincter (AUS) is still considered the standard for the treatment of moderate to severe post-prostatectomy stress urinary incontinence (SUI). However, data reporting efficacy and safety from large series are lacking. METHODS: A multicenter, retrospective study was conducted in 16 centers in Europe and USA. Only primary cases of AUS implantation in non-neurogenic SUI after prostate surgery, with a follow-up of at least 1 year were included. Efficacy data (continence rate, based on pad usage) and safety data (revision rate in case of infection and erosion, as well as atrophy or mechanical failure) were collected. Multivariable analyses were performed in order to investigate possible predictors of the aforementioned outcomes. RESULTS: Eight hundred ninety-two men had primary AUS implantation. At 32 months mean follow-up overall dry rate and surgical revision were 58% and 30.7%, respectively. Logistic regression analysis showed that patients without previous incontinence surgery had a higher probability to be dry after AUS implantation (OR: 0.51, P = 0.03). Moreover institutional case-load was positively associated with dry rate (OR: 1.18; P = 0.005) and freedom from revision (OR: 1.51; P = 0.00). CONCLUSIONS: The results of this study showed that AUS is an effective option for the treatment of SUI after prostate surgery. Moreover previous incontinence surgery and low institutional case-load are negatively associated to efficacy and safety outcomes.

Efficacy and Safety of Sacral and Percutaneous Tibial Neuromodulation in Non-neurogenic Lower Urinary Tract Dysfunction and Chronic Pelvic Pain: A Systematic Review of the Literature.

CONTEXT: Neuromodulation is considered in patients with non-neurogenic lower urinary tract dysfunction (LUTD) not responsive to conservative treatment. OBJECTIVE: To systematically review the available studies on efficacy and safety of sacral neuromodulation (SNM) and percutaneous tibial nerve stimulation (PTNS) in non-neurogenic LUTDs not responsive to conservative treatments. EVIDENCE ACQUISITION: A literature research was conducted in PubMed/Medline and Scopus, restricted to articles in English, published between January 1998 and June 2017, with at least 20 patients and 6 mo of follow-up. EVIDENCE SYNTHESIS: Twenty-one reports were identified. Concerning SNM, the improvement of ≥50% in leakage episodes ranged widely between 29% and 76%. Overall dry rate ranged between 43% and 56%. Overall success/improvement rate in PTNS varied between 54% and 59%. Symptom improvement or efficacy in interstitial cystitis/bladder pain syndrome patients appeared to be lower compared with other indications in both techniques. Safety data showed fewer side effects in patients submitted to PTNS. CONCLUSIONS: Neuromodulation gives good results and is a safe therapy for patients with overactive bladder or chronic nonobstructive urinary retention with long-lasting efficacy. Moreover, PTNS has been shown to have good success rates and fewer side effects compared with SNM. These data have to be confirmed with long-term follow-up. PATIENT SUMMARY: Sacral neuromodulation can improve low urinary tract symptoms in selected patients; it appears to be a safe therapy for nonresponders to standard medical therapies. Percutaneous tibial nerve stimulation (PTNS) is a less invasive technique that gives good results in short time with fewer side effects. However, we must consider that PTNS has not been tested in the long term and results are lower if compared with SNM.

Comparison of Functional Outcome after Extended versus Super-Extended Pelvic Lymph Node Dissection during Radical Prostatectomy in High-Risk Localized Prostate Cancer.

BACKGROUND: Urinary continence and erectile function (EF) are best preserved when meticulous dissection of prostate and nerve sparing technique are used during radical prostatectomy (RP). However, extent of lymph node dissection (LND) may also adversely affect functional results. OBJECTIVE: To determine whether performing a super-extended LND (seLND) has a significant effect on recovery of urinary continence and EF after RP. DESIGN SETTING AND PARTICIPANTS: All patients who underwent RP from January 2007 until December 2013 were handed questionnaires assessing continence and EF. All patients in whom at least an extended LND (eLND) was performed were selected. This search yielded 526 patients. 172 of these patients had filed out 2 or more questionnaires and were included in our analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All questionnaires were reviewed. We used Kaplan-Meier analyses and multivariate Cox analysis to assess the difference in recovery of continence and EF over time for eLND/seLND. Primary endpoints were full recovery of continence (no loss of urine) and full recovery of EF (successful intercourse possible). Patients who did not reach the endpoint when the last questionnaire was filled out were censored at that time. Median follow-up was 12.43 months for continence, and 18.97 months for EF. RESULTS AND LIMITATIONS: Patients undergoing seLND have a lower chance of regaining both urinary continence [hazard ratio (HR) 0.59, 95% CI 0.39-0.90, p = 0.026] and EF (HR 0.28, 95% CI 0.13-0.57, p = 0.009). Age at surgery had a significant influence on both continence and EF in multivariate analysis. Major limitation of the study was that no formal preoperative assessment of continence and potency was done. CONCLUSION: Extending the LND template beyond the eLND template may cause at least a significant delay in recovery of urinary continence and leads to less recovery of EF.

A prospective randomized controlled multicentre trial comparing intravesical DMSO and chondroïtin sulphate 2% for painful bladder syndrome/interstitial cystitis

ABSTRACT Objective To compare effectiveness of intravesical chondroïtin sulphate (CS) 2% and dimethyl sulphoxide (DMSO) 50% in patients with painful bladder syndrome/interstitial cystitis (PBS/IC). Materials and methods Patients were randomized to receive either 6 weekly instillations of CS 2% or 50% DMSO. Primary endpoint was difference in proportion of patients achieving score 6 (moderately improved) or 7 (markedly improved) in both groups using the Global Response Assessment (GRA) scale. Secondary parameters were mean 24-hours frequency and nocturia on a 3-day micturition dairy, changes from baseline in O’Leary-Sant questionnaire score and visual analog scale (VAS) for suprapubic pain. Results Thirty-six patients were the intention to treat population (22 in CS and 14 in DMSO group). In DMSO group, 57% withdrew consent and only 6 concluded the trial. Major reasons were pain during and after instillation, intolerable garlic odor and lack of efficacy. In CS group, 27% withdrew consent. Compared with DMSO group, more patients in CS group (72.7% vs. 14%) reported moderate or marked improvement (P=0.002, 95% CI 0.05-0.72) and achieved a reduction in VAS scores (20% vs. 8.3%). CS group performed significantly better in pain reduction (-1.2 vs. -0.6) and nocturia (-2.4 vs. -0.7) and better in total O’Leary reduction (-9.8 vs. -7.2). CS was better tolerated. The trial was stopped due to high number of drop-outs with DMSO. Conclusions Intravesical CS 2% is viable treatment for PBS/IC with minimal side effects. DMSO should be used with caution and with active monitoring of side effects. More randomized controlled studies on intravesical treatments are needed.

A prospective randomized controlled multicentre trial comparing intravesical DMSO and chondroïtin sulphate 2% for painful bladder syndrome/interstitial cystitis.

OBJECTIVE: To compare effectiveness of intravesical chondroïtin sulphate (CS) 2% and dimethyl sulphoxide (DMSO) 50% in patients with painful bladder syndrome/interstitial cystitis (PBS/IC). MATERIALS AND METHODS: Patients were randomized to receive either 6 weekly instillations of CS 2% or 50% DMSO. Primary endpoint was difference in proportion of patients achieving score 6 (moderately improved) or 7 (markedly improved) in both groups using the Global Response Assessment (GRA) scale. Secondary parameters were mean 24-hours frequency and nocturia on a 3-day micturition dairy, changes from baseline in O'Leary-Sant questionnaire score and visual analog scale (VAS) for suprapubic pain. RESULTS: Thirty-six patients were the intention to treat population (22 in CS and 14 in DMSO group). In DMSO group, 57% withdrew consent and only 6 concluded the trial. Major reasons were pain during and after instillation, intolerable garlic odor and lack of efficacy. In CS group, 27% withdrew consent. Compared with DMSO group, more patients in CS group (72.7% vs. 14%) reported moderate or marked improvement (P=0.002, 95% CI 0.05-0.72) and achieved a reduction in VAS scores (20% vs. 8.3%). CS group performed significantly better in pain reduction (-1.2 vs. -0.6) and nocturia (-2.4 vs. -0.7) and better in total O'Leary reduction (-9.8 vs. -7.2). CS was better tolerated. The trial was stopped due to high number of drop-outs with DMSO. CONCLUSIONS: Intravesical CS 2% is viable treatment for PBS/IC with minimal side effects. DMSO should be used with caution and with active monitoring of side effects. More randomized controlled studies on intravesical treatments are needed.

A minimum of 1-year follow-up for MiniArc single incision slings compared to Monarc transobturator slings: An analysis to evaluate durability of continence and medium-term outcomes.

AIMS: To compare efficacy and safety of two commercially available single incision slings (SIS) and trans-obturator vaginal tapes (TOT), namely MiniArc™ and Monarc™ slings, and report the results at 5-year follow-up. METHODS: A retrospective-observational study of prospectively collected data was conducted on 381 women with primary stress urinary incontinence (SUI) in a single tertiary referral center. Patients treated with MiniArc™ and Monarc™ were compared. Data regarding intraoperative and post-operative outcomes were collected and compared. Kaplan-Meier analyses assessed continence rate (CR), objective cure (OC) rate, de novo overactive bladder symptoms (OAB), surgical failure (SF), and erosion free rates at 1-, 3-, and 5-year follow-up. The log-rank test was used to compare efficacy and complication between patients stratified according to the type of surgery. RESULTS: Median follow-up was 60 months. Of 381 patients, 215 (56%) were treated with Monarc™ slings and 166 (44%) with MiniArc™. The two groups were homogeneous in terms of pre-operative characteristics. At 5-year follow-up, no difference was found in CR between Monarc™ and Miniarc™ patients (87% vs. 89%; P = 0.41). Monarc™ showed better OAB free rates (97% vs. 92%; P = 0.012). No significant differences have been found in terms of SF, erosion, and OC rates. These results are limited by their retrospective nature. CONCLUSIONS: We demonstrated that the short-term results of MiniArc™, are maintained over time, defining the comparability of the two slings at 5 years in terms of subjective and objective outcomes and complications. Neurourol. Urodynam. 36:803-807, 2017. © 2016 Wiley Periodicals, Inc.

Are patients willing to trade cure rate against less pain? Patients' preferences for single incision midurethral sling or transobturator standard midurethral sling.

AIMS: To quantify to what extent patients are willing to trade their chance of cure of stress urinary incontinence (SUI) against less postoperative groin pain. Randomized, controlled trials show less postoperative pain following single-incision mini-sling (SIMS), but slightly higher cure rates following a transobturator standard midurethral sling (SMUS). METHODS: A multi-center, interview-based trade-off experiment for treatment preference among 100 women with predominant SUI and undergoing SIMS. A hypothetical cure rate of SIMS was systematically varied from 10% to 70%, while keeping the cure rate of SMUS constant at 70%. The trade-off was assessed for two hypothetical durations of substantial postoperative pain after SMUS-2 days or 2 weeks-while simultaneously assuming the absence of substantial postoperative pain after SIMS. RESULTS: To prevent 2 days of substantial postoperative pain with SMUS, patients were willing to accept a 4.3% mean decrease in cure rate of SIMS, while a 7.1% mean decrease was acceptable to forego 2 weeks of substantial pain. Younger women (P = 0.04) and single women (P = 0.04) were associated with the trade-off limit for 2 days, respectively, 2 weeks of substantial postoperative pain. Single women were willing to accept lower cure rates. No correlations with trade-off limits were found for patients' actual severity, duration, and frequency of SUI. CONCLUSIONS: Patients are willing to accept a slightly lower probability of cure to prevent substantial post-operative pain by undergoing a less invasive procedure. These results are relevant for counselling of patients indicated for SUI surgery.