Laparoscopic Sacral Mesh Fixation for Ventral Rectopexy: Clinical Implications From a Cadaver Study.

BACKGROUND: Correct tack placement at the sacral promontory for mesh fixation in ventral mesh rectopexy is crucial to avoid bleeding, nerve dysfunction, and spondylodiscitis. OBJECTIVE: The present cadaver study was designed to assess the true location of tacks after mesh fixation during laparoscopic ventral mesh rectopexy in relation to vascular and nerve structures and bony landmarks. DESIGN: This was an interventional cadaver study. SETTING: This study was conducted after laparoscopic mesh fixation detailed pelvic dissection was performed following a standardized protocol. In addition, 64-row multidetector computed tomography was conducted to further define lumbosacral anatomy and tack positioning. PATIENTS: Eighteen fresh cadavers (10 female, 8 male) were included in this study. MAIN OUTCOME MEASURES: True tack position and vascular and neuronal involvement served as outcome measures. RESULTS: A total of 52 tacks were deployed (median 3, range 2-3 tacks). Median tack distance to the midsacral promontory was 16.1 mm (0.0-54.2). Only a total of 22 tacks (42.3%) were found on the right surface of the S1 vertebra, correlating with the planned deployment area. In 7 cadavers (38.8%), all tacks were deployed on the planned deployment area. The median distance to the major vessels was 10.5 mm (0.0-35.0), which was the internal iliac artery in half of the cases. Median distance of tacks to the right ureter was 32.1 mm (7.5-46.1). Neither major vessels nor the ureter was injured. Dissection of the hypogastric plexus was undertaken in 14 cadavers, and in each cadaver, tacks affected the hypogastric nerve plexus. LIMITATIONS: This study was limited by the moderate number of cadavers. CONCLUSIONS: Tack placement showed significant variation in our specimen, emphasising the need for reliable anatomic landmarks and sufficient exposure during ventral mesh rectopexy. Hypogastric nerve plexus involvement is common, thus detailed functional assessment after surgery is required. It also points out the importance of cadaver studies before implementing new surgical techniques into clinical practice. See Video Abstract at http://links.lww.com/DCR/B827. FIJACIN LAPAROSCPICA DE MALLA SACRA PARA RECTOPEXIA VENTRAL IMPLICACIONES CLNICAS DE UN ESTUDIO SOBRE CADAVERS: ANTECEDENTES:La colocación correcta de la tachuela en el promontorio sacro para la fijación de la malla en la rectopexia con malla ventral es crucial para evitar hemorragias, disfunción nerviosa y espondilodiscitis.OBJETIVO:El presente estudio en cadáveres fue diseñado para evaluar la verdadera ubicación de las tachuelas después de la fijación de la malla durante la rectopexia laparoscópica con malla ventral en relación con las estructuras vasculares y nerviosas y los puntos de referencia óseos.DISEÑO:Estudio intervencionista de cadáveres.AJUSTE:Después de la fijación laparoscópica de la malla, se realizó una disección pélvica detallada siguiendo un protocolo estandarizado. Además, se realizó una tomografía computarizada multidetector de 64 cortes para definir mejor la anatomía lumbosacra y la posición de la tachuela.PACIENTES:Se incluyeron en este estudio dieciocho cadáveres frescos (10 mujeres, 8 hombres).PRINCIPALES MEDIDAS DE RESULTADO:Posición real de tachuela y compromiso vascular y neuronal.RESULTADOS:Se utilizaron un total de 52 tachuelas (mediana 3, 2-3 tachuelas). La distancia media de tachuela al promontorio sacro medio fue de 16,1 mm (0,0-54,2). Solo se encontraron un total de 22 tachuelas (42,3%) en la superficie derecha de la vértebra S1, correlacionándose con el área planificada. En siete cadáveres (38,8%) todas las tachuelas se utilizaron en el área de planificada. La distancia media a los vasos principales fue de 10,5 mm (0,0-35,0), que era la arteria ilíaca interna en la mitad de los casos. La distancia media de las tachuelas al uréter derecho fue de 32,1 mm (7,5-46,1). No se lesionó ni los grandes vasos ni el uréter. La disección del plexo hipogástrico se realizó en 14 cadáveres y en cada cadáver, las tachuelas afectaron el plexo nervioso hipogástrico.LIMITACIONES:Número moderado de cadáveres incluidos en el estudio.CONCLUSIONES:La colocación de tachuelas mostró una variación significativa en nuestra muestra, enfatizando la necesidad de puntos de referencia anatómicos confiables y una exposición suficiente durante la rectopexia con malla ventral. La afectación del plexo nervioso hipogástrico es común, por lo que se requiere una evaluación funcional detallada después de la cirugía. También destaca la importancia de los estudios sobre cadáveres antes de implementar nuevas técnicas quirúrgicas en la práctica clínica. Consulte Video Resumen en http://links.lww.com/DCR/B827. (Traducción-Dr Yolanda Colorado).

Laparoscopic lateral suspension for anterior and apical prolapse: a prospective cohort with standardized technique.

INTRODUCTION AND HYPOTHESIS: Laparoscopic lateral suspension (LLS) for anterior and apical pelvic organ prolapse (POP) repair is a recent approach. Previous studies used various meshes or sutures. The purpose of this study was to evaluate outcomes of a standardized LLS technique. METHODS: From January 2010 until December 2014, we performed POP repair by LLS with mesh on 88 women with anterior and apical POP ≥ stage 2. We used a polypropylene titanized mesh fixed to the vesico-vaginal fascia with absorbable sutures and treated posterior compartment defect by vaginal approach with native tissue repair if required. Between July 2013 and December 2018, all women were assessed by gynecological examination including the pelvic organ prolapse quantification (POP-Q) system. Subjective outcome was evaluated by the patient global impression of improvement (PGI-I) questionnaire. RESULTS: Seventy-nine women (89.8%) were available for follow-up. The mean duration of follow-up was 3.4 years (SD 1.6). Mean age was 59.6 (SD 11.1) years and mean BMI 25.8 (SD 4.0) kg/m2. Ten patients (12.7%) had previous POP surgery. Fifty-two women (65.8%) required posterior colporraphy for associated posterior defect and 21 (26.6%) had associated urinary incontinence (UI) surgery. There were no perioperative complications. The objective cure rate (no prolapse beyond the hymen and no reoperation for POP recurrence) was 87.3%. The reoperation rate for recurrence was 5.1%. The subjective success rate (PGI ≤ 2) was 96.2%. There were no mesh exposures or extrusions. CONCLUSIONS: This standardized LLS is safe and effective with no mesh complications after 3-year follow-up.

Long term outcomes of laparoscopic sacro/colpo-hysteropexy with and without rectopexy for the treatment of prolapse.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrohysteropexy (LSH), sacrocolpopexy (LSC) and ventral rectopexy (LVR) with mesh are advocated for surgical treatment of pelvic and rectal prolapse. Our study aims at showing the feasibility of concomitant laparoscopic prolapse repair by comparing perioperative and long-term outcomes of LSH or LSC with and without LVR. METHODS: This is a retrospective study carried out on 348 women operated on between July 2009 and July 2019. Patients were divided into four groups: (1) LSH only, (2) LSC only, (3) LSH + LVR and (4) LSC + LVR. POP-Q scores and satisfaction questionnaires were recorded at baseline and then annually. Outcomes were defined as subjective failure (vaginal/rectal prolapse symptoms), objective failure (prolapse to/beyond the hymen, full thickness rectal prolapse) or retreatment for prolapse. Complications were collected and graded according to the Clavien-Dindo classification. RESULTS: Three hundred forty-eight women underwent laparoscopic repair for pelvic and rectal prolapse (219, 44, 66 and 19 in group 1, 2, 3 and 4, respectively). Median follow-up was 24 (4-174) months. Success rate for both rectal and pelvic prolapse was 90.2%. Recurrence rates were not significantly different between the groups (12.3%, 6.8%, 9.1% and 10.5% for groups 1, 2, 3 and 4, respectively). Significant improvement was noticed in satisfaction questionnaires in all groups. There was no difference in perioperative and late complications. CONCLUSION: The combined laparoscopic procedure appears to be safe and efficient in treating pelvic and rectal prolapse. Appropriate patient selection and available surgical expertise should determine whether to perform these procedures combined or separately.

Benefit of a nurse-led telephone-based intervention prior to the first urogynecology outpatient visit: a randomized-controlled trial.

INTRODUCTION AND HYPOTHESIS: Triage has become a valid tool to reduce workload during the first consultation in a specialized clinic. A nurse-led telephone intervention prior to the first urogynecologic visit reduces visit duration and increases patients' and physicians' satisfaction. METHODS: All patients scheduled for their very first visit were recruited. They were randomized into an intervention group (prior contact by a specialized urogynecology nurse) and a control group (no contact). The intervention included a questionnaire about history and symptoms. Patients were prompted to complete a bladder diary. Primary outcome was duration of the consultation; secondary outcomes were patients' and physicians' satisfaction with the intervention. RESULTS: Fifty-five patients were allocated to the intervention group and 53 to the control group with no difference regarding age, BMI, parity, menopausal status and primary diagnosis. Mean duration of the telephone call was 10.8 min (SD 4.4). The consultation was significantly shorter in the intervention group than in the control group (mean difference: 4 min and 8 s, p = 0.017). In the intervention group, 79% of the patients found the consultation quality "excellent," 86% would return, and 77% would recommend our clinic to a relative or friend compared with 68%, 67% and 66%, respectively, in the control group. Physicians were "very satisfied" or "satisfied" with the patient preparation. CONCLUSIONS: A nurse-led intervention reduces the duration of the first uroynecologic consultation and is associated with high patient and physician satisfaction. Further research should evaluate whether it also decreases the number of follow-up visits and further referrals.

Is there enough evidence to justify the use of laser and other thermal therapies in female lower urinary tract dysfunction? Report from the ICI-RS 2019.

AIMS: There is increasing evidence to suggest that thermomodulation may have a role in the management of women with lower urinary tract dysfunction (LUTD) and there has been widespread adoption of laser and radiofrequency (RF) therapies within clinical practice. However, in many areas of LUTD, the data are still limited and there remains a need for further evaluation of the safety and efficacy of thermal therapy. The aim of this study proposal is to report the findings of the International Consultation on Incontinence Research Society to clarify our current knowledge regarding the evidence for thermal therapy in LUTD and to set research priorities for the future. METHODS: Literature review based on the search terms: "laser," "radiofrequency," "genitourinary syndrome of the menopause" or "urogenital atrophy," "stress urinary incontinence (SUI)," "pelvic organ prolapse," "OAB" or "overactive bladder," and "urinary tract infection." RESULTS: The current available evidence, though of low or very low quality, appears promising for the use of laser therapy in the management of genitourinary syndrome of the menopause, there are some data to suggest a possible role in SUI although very little evidence for urogenital prolapse. At present, the evidence supporting the use of laser in OAB and recurrent urinary tract infection is limited or lacking, while the available evidence for RF in the management of all forms of LUTD is much less robust. CONCLUSIONS: Laser and RF are being introduced clinically as a minimally invasive, low-risk interventions for women with LUTD although at present, the evidence supporting usage is limited. Consequently, there is an urgent need to demonstrate the safety and efficacy with prospective long-term studies including sham studies and comparative studies with current standard therapy.

Can we harness the placebo effect to improve care in lower urinary tract dysfunction? ICI-RS 2019.

The proposal "Can we harness the placebo effect to improve care in lower urinary tract dysfunction?" was discussed at the International Consultation on Incontinence-Research Society (ICI-RS) 2019 meeting. The placebo effect can change the treatment outcome whether the treatment is an active treatment or placebo. The total active treatment outcome is a combination of the placebo and the active treatment effect which is seen in placebo-controlled trials. The placebo effect plays an important role in the treatment of lower urinary tract dysfunction in overactive bladder, bladder pain syndrome, and stress urinary incontinence. In clinical practice, a number of factors can be employed to use the placebo effect to maximize its effect on patients receiving an active treatment, such as having the same environment for review such as the same appointment time, same room, and same clinician. Clinicians should also be aware of the nocebo effect which is increased with an overemphasis on side effects or negative outcomes.

Is polypropylene mesh material fundamentally safe for use as a reconstructive material in vaginal surgery: ICI-RS 2019?

Polypropylene (PP) mesh has been used as a primary or adjuvant material for vaginal reconstruction for both stress urinary incontinence (SUI) and pelvic organ prolapse (POP) for decades. Whether polypropylene is the optimal material for such indications has been called into question by clinicians, regulatory agencies and the public in several countries around the world. This paper is a report of presentations and subsequent discussion at the annual International Consultation on Incontinence Research Society (ICI-RS) Meeting in June 2019 in Bristol, UK on the proposal "Is polypropylene mesh material fundamentally safe for use as a reconstructive material in vaginal surgery?" in which several of the salient issues were presented and discussed.

Laparoscopic management of pelvic organ prolapse recurrence after open sacrocervicopexy.

In this narrated video we present a case of pelvic organ prolapse (POP) recurrence 12 years after sacrocervicopexy, outline our management and suggest an optimal laparoscopic surgical technique that may reduce the risk of future recurrence. A 71-year-old patient, who had undergone an open sub-total hysterectomy with sacrocervicopexy 12 years previously, complained of a bulging sensation in her vagina, of 12 months' duration. On physical examination, a Pelvic Organ Prolapse Quantification (POP-Q) stage III prolapse was diagnosed, with marked apical, anterior and posterior compartment prolapse. On laparoscopy we identified the old mesh attached to the promontory and to the vaginal apex, without any fixation of the vaginal walls. Complete mesh excision was performed, followed by vaginal dissection to facilitate implantation of two new meshes and performing a new sacrocolpopexy. No postoperative complications occurred. Over 6 weeks of post-operative follow-up, there was no pelvic pain, dysuria or dyschezia. A good anatomical result was noted without any prolapse. Laparoscopy appears to be an effective approach to complete mesh excision. For the treatment of prolapse recurrence, complete excision of the old mesh with new pelvic mesh-augmented reconstruction is recommended. Thorough dissection of the vesico-vaginal and recto-vaginal spaces followed by mesh fixation to the relevant vaginal walls may reduce recurrence.

Rectal injury during laparoscopic mesh removal after sacrocervicopexy.

In this video we present a case of rectal injury, which occurred during laparoscopic mesh removal following sacrocervicopexy. Four years after sub-total hysterectomy with laparoscopic sacrocervicopexy, a 64-year-old patient still suffered from intense proctalgia and pain while sitting. On physical examination, intense pain could be triggered by palpating the left aspect of the levator ani muscle, raising the suspicion of an association with the mesh and leading to the decision for its removal. The left posterior arm of the mesh was removed completely laparoscopically. During this procedure, a rectal lesion was diagnosed and immediately repaired by a double layer of interrupted sutures. There was an immediate and complete resolution of the symptoms after surgery, with no short-term prolapse recurrence or postoperative complications. Laparoscopy appears to be an efficient approach to mesh excision. A high level of alertness to recognize intraoperative injuries is warranted.

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018.

With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.

Burch colposuspension.

AIMS: To evaluate the historic and pathophysiologic issues which led to the development of Burch colposuspension, to describe anatomic and technical aspects of the operation and to provide an update on current evidence. METHODS: We have performed a focused literature review and have searched the current available literature about historic dimension, technical descriptions, and efficacy of Burch colposuspension. RESULTS: Burch colposuspension, performed either by an open or a laparoscopic approach, is an effective surgical treatment for stress urinary incontinence. CONCLUSIONS: In current recommendations, Burch colposuspension remains an option for secondary treatment. Because midurethral slings have recently become under scrutiny, it may return as a first-line treatment procedure. Both open and laparoscopic Burch colposuspension should therefore nowadays be provided in fellowship programs worldwide.

Midurethral slings for treatment of stress urinary incontinence review.

PURPOSE: The midurethral sling (MUS) has largely been regarded as the "gold standard" in treatment of stress urinary incontinence (SUI). Recently the safety and use of the MUS has come under scrutiny following concerns about the use of mesh implants. The aim of this review was to detail the background to SUI which has led to the development of MUS, to highlight the issues surrounding the use of mesh under the current climate of mesh controversies and to provide an update on current evidence on the use of MUS. MATERIALS AND METHODS: We conducted a review of the literature looking at the efficacy and safety of MUS. RESULTS: MUS has good rates of subjective cure in the short and into the longer term. The overall rates of complications are low including those associated with the use of mesh implants. When compared to other continence procedures, MUS is equally effective in regard to cure but has lower rates of complications and more favorable operative outcomes. The use of mesh has been supported by major Urogynaecological Societies along with the reports from government driven enquiries into the use of mesh. CONCLUSIONS: Overall, MUS have been shown to be an effective and safe surgical treatment for management of stress urinary incontinence.

How can we improve the diagnosis and management of bladder pain syndrome? Part 2:ICI-RS 2018.

BACKGROUND: This paper summarises the discussion in a think tank at the International Consultation on Incontinence-Research Society (ICI-RS) 2018 about the treatment of bladder pain syndrome. AIMS: To review the treatments of bladder pain syndrome from behavioural treatments to surgical interventions. MATERIALS AND METHODS: Review the literature in the light of the think tank discussions. RESULTS: All guidelines recommend different levels of treatment starting with conservative behavioral treatments then introducing oral treatments followed by intravesical instillations. If these treatments fail then more invasive treatments such as botulinum toxin injections, neuromodulation, or surgery could be suggested. CONCLUSION: Unfortunately for all treatments, the numbers are limited and, therefore, the evidence base is not strong. Further suggestions for research are suggested.

How can we improve the diagnosis and management of bladder pain syndrome? Part 1: ICI-RS 2018.

BACKGROUND: This paper summarizes the discussion in a think tank at the ICI-RS 2018 about the diagnosis of bladder pain syndrome (BPS). AIMS: To review the guidelines, investigations and subtypes of BPS. MATERIALS AND METHODS: Review of literature in the light of the think tank discussion. RESULTS: All guidelines recommend completing history, physical examination, urine analysis, urine culture, and urine cytology to define the BPS phenotype but there are differences on further investigations. In those guidelines which recommend cystoscopy, the identification of Hunner's lesions (HLs) is recommended as this changes the treatment plan and outcome. CONCLUSION: We propose that the differentiation of Hunner's ulcers is an important step in the assessment of these patients. Further suggestions for research are suggested.

Abnormal vaginal microbiome associated with vaginal mesh complications.

AIMS: To identify differences in the vaginal microbiomes of women after transvaginal mesh (TVM) surgery for pelvic organ prolapse with and without mesh-associated complications. METHODS: Patients with complications were eligible as cases, patients without as controls. DNA was isolated and the V1-2 region of the 16S ribosomal RNA gene was amplified and sequenced. Overall richness was quantified using Chao1. Overall diversity was expressed as Shannon diversity and screened for group differences using analysis of variance. Multivariate differences among groups were evaluated with functions from R. RESULTS: We recruited 14 patients after mesh exposure, 5 after contraction, and 21 as controls. The average number of operational taxonomic unit was 74.79 (SD ± 63.91) for controls, 57.13 (SD ± 58.74) after exposures, and 92.42 (SD ± 50.01) after contractions. Total 89.6% of bacteria in controls, 86.4% in previous exposures, and 81.3% in contractions were classified as either Firmicutes, Proteobacteria, or Actinobacteria (P < .001). Veillonella spp. was more abundant in patients after contraction (P = .045). The individual microbiomes varied, and we did not detect any significant differences in richness but a trend towards higher diversity with complications. CONCLUSIONS: The presence of Veillonella spp. could be associated with mesh contraction. Our study did not identify vaginal microbiotic dysbiosis as a factor associated with exposure. Larger cohort studies would be needed to distinguish the vaginal microbiome of women predisposed to mesh-related complications for targeted phenotyping of patients who could benefit from TVM surgery.

Rouhier's colpocleisis with concomitant vaginal hysterectomy: an instructive video for female pelvic surgeons.

INTRODUCTION AND HYPOTHESIS: The treatment of pelvic organ prolapse (POP) in elderly women can be challenging. The vaginal operation known as colpocleisis, the total occlusion of the urogenital hiatus, with concomitant hysterectomy was described by Rouhier and represents a safe, time-saving, and reproducible procedure in the case of POP associated with uterine pathological conditions. It is suitable for elderly women who do not require preservation of coital function. The objective of this video is to provide anatomical illustrations and a precise description of the surgical steps. METHODS: We present the case of a 62-year-old woman who was referred for hysterectomy in the context of metastatic endometrial cancer. She complained about vaginal bulge and was diagnosed with a POP-Q stage 4 genital prolapse on physical examination. Due to important comorbidities such as arterial hypertension, obesity, and three-site metastatic disease, we suggested a colpocleisis with concomitant vaginal hysterectomy. This approach was intended to treat the prolapse and perform a palliative surgery to alleviate abnormal uterine bleeding. RESULTS: This video illustrates the different surgical steps of a colpohysterectomy according to Rouhier. No intraoperative complications occurred and the postoperative follow-up was uneventful. The patient was fully satisfied and POP has not recurred after a 17-month follow-up. CONCLUSIONS: Colpocleisis should remain an exceptional approach, but could be offered to sexually inactive women of advanced age after thorough discussion and patient consent. If a hysterectomy is necessary, Rouhier's operation offers a time-saving, reproducible, and efficient option for women with symptomatic POP who do not desire future vaginal intercourse.

Uterus preservation is superior to hysterectomy when performing laparoscopic lateral suspension with mesh.

INTRODUCTION AND HYPOTHESIS: We aimed to compare differences between laparoscopic lateral suspension with mesh (LLS) performed with supracervical hysterectomy (LLSHE) and without hysterectomy (LLSUP). METHODS: We retrospectively collected data from women operated by a single surgeon between 2003 and 2011. From a total of 339 women with symptomatic anterior and/or apical pelvic organ prolapse (POP) and an intact uterus, 224 had LLSUP (70.4%) and 94 had LLSHE (29.6%). Three hundred and sixteen patients were examined at 1 year. Primary outcomes were objective and subjective success at 1 year during clinical evaluation. Secondary outcomes were complications (Clavien-Dindo scale) and mesh exposure. Patient satisfaction was evaluated by telephone interview using a 10-point scale and the Patient Global Impression of Improvement Scale (PGI-I). RESULTS: LLSUP and LLSHE did not differ for age (mean 57 and 55 years, respectively), preoperative status, complications, and participation at the interview (52 vs 53%). LLSHE is associated with higher mesh exposure (6.5 vs 1.3%, p = 0.014) and more frequent use of Mersilene. Titanium-coated and noncoated polypropylene was more frequently used in LLSUP. At 1 year, both anatomic success rate for the anterior compartment (98.7 vs 94.6%, p = 0.021) and subjective success rate (83.5 vs 72.8%, p = 0.035) were higher for LLSUP. Without hysterectomy, patients more often improved (90.5 vs 76.5%, p = 0.013) and would more frequently recommend the procedure (94.5 vs 80.4%, p = 0.004). CONCLUSIONS: LLS with or without hysterectomy is a safe technique with high patient satisfaction. The uterus-preserving approach appears to result in better anatomic outcome for the anterior compartment, better subjective outcome, and higher patient satisfaction.

Is the microbiome influencing patient care in lower urinary tract dysfunction? Report from the ICI-RS 2017.

AIMS: This report sets out to consider the role of the microbiome within the bladder to provide clinicians with knowledge on this specific area of research and recommend potential topics for further studies. METHODS: This is a report from the Plenary 6: Is the microbiome influencing patient care in lower urinary tract dysfunction (LUTD)? RESULTS: There appear to be complex associations between microbial presence in the bladder and lower urinary tract symptoms. There appears to be a greater role of bacteria in the development of overactive bladder symptoms than previously thought with bacteria such as Gardnerella highlighted to be more prevalent in women with urgency urinary incontinence. Some species of Lactobacillus have also been found to play a protective role in both overactive bladder syndrome and bladder pain syndrome. CONCLUSIONS: The bladder is a reservoir for bacterial colonization and what was previously thought to be a sterile environment now seems to be a complex interaction of both multiple protective and pathogenic bacterial species than can give rise to lower urinary tract symptoms. While most clinicians use antibacterial agents as part of treatment regimens, and evidence does suggest a role of antibacterial therapies in treatment of LUTS, this remains a far from an ideal solution.

The efficacy of botulinum toxin A and sacral neuromodulation in the management of interstitial cystitis (IC)/bladder pain syndrome (BPS), what do we know? ICI-RS 2017 think thank, Bristol.

AIMS: This manuscript aims to address the evidence availale in the literature on the efficacy of Botulinum Toxin A (BoNT-A) and sacral neuromodulation (SNM) in patients suffering from Interstitial Cystitis (IC)/BPS and propose further research to identify mechanisms of action and establish the clinical efficacy of either therapy. METHODS: At the International Consultation on Incontinence-Research Society (ICI-RS) in 2017, a panel of Functional Urologists and Urogynaecologists participated in a Think Tank (TT) discussing the management of IC/BPS by BoNT-A and SNM, using available data from both PubMed and Medicine literature searches. RESULTS: The role of BoNT-A and SNM in the treatment of IC/BPS are discussed and mechanisms of actions are proposed. Despite the available randomized trial data on the effect of intravesical BoNT-A treatment on symptoms of IC/BPS, a consistent conclusion of a positive effect cannot be drawn at the moment, as the published studies are small and heterogeneous in design. There is substantive evidence for the positive effects of SNM on symptoms of IC/BPS patients however, during patient selection, it is important to distinguish the degree and the location of pain in order to tailor the best therapy to the right patients. CONCLUSIONS: Both intravesical BoNT-A treatment and SNM have been shown to have positive effects in patients with IC/BPS. However, firm conclusions cannot yet be drawn. Patient-reported outcomes and quality of life should be assessed in addition to urinary and pain symptoms. Since current treatments mainly focus on symptomatic relief, future research should also focus on clarifying the pathogenic mechanisms involved in IC/BPS.

The location of pain and urgency sensations during cystometry.

AIMS: The relationship between bladder pain and urinary urgency sensations is poorly understood. We analyzed the relationship between locations and intensities of urgency and pain sensations felt during filling cystometry. METHODS: Participants completed the King's Health Questionnaire (KHQ) to indicate presence of bladder pain or urgency. During cystometry, participants scored the intensity of urgency and pain, both in the suprapubic and the urethral region, on a VAS scale of 0-10 at a baseline, at first desire, normal desire, strong desire to void, and at maximum cystometric capacity during filling. We allocated the participants to six groups; those reporting urgency or not, pain or not, both symptoms and neither. Friedman's Test was used to ascertain if all scores increased significantly, the Wilcoxon Signed Rank Test was used to demonstrate the difference between scores, and agreement for findings during cystometry was tested with Mann-Whitney U. RESULTS: A total of 68 women participated; 38 participants reported pain, 57 reported urgency, and 33 reported both symptoms. Pain and urgency scores significantly increased during cystometry (P < 0.0001). For participants reporting pain, suprapubic pain was rated significantly higher than urethral pain. Participants reporting both symptoms, felt more urgency than pain, and again pain more suprapubically than urethrally. Participants reporting only urgency scored suprapubic and urethral urgency similarly at all desires. CONCLUSIONS: Pain and urgency are well differentiated sensations and are felt at different locations although pain is seemingly easier localized. Neurourol. Urodynam. 36:620-625, 2017. © 2016 Wiley Periodicals, Inc.