Cleveland Clinic

In 2021 the American Urological Association (AUA) and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU) released a joint clinical guideline for comprehensive management of neurogenic lower urinary tract dysfunction (NLUTD) in adults.

There are 60 recommendations in total, but the key highlights focus on leading an initial risk-stratifying assessment to guide care plan strategies, managing autonomic dysreflexia, considerations for urinary tract infection (UTI) management, and treatment options to improve bladder storage function.

A formal guideline and updated terminology

This is the first published guideline about the condition, which has previously been referred to as “neurogenic bladder.” The AUA/SUFU guideline also indicates that neurogenic lower urinary tract dysfunction is the preferred terminology for the condition because it more accurately localizes the voiding issue, which is not solely confined to the bladder.

“It’s not necessarily a bladder problem,” explains 

 a female pelvic medicine and reconstructive surgeon at Cleveland Clinic. “It could be an outlet problem related to the urinary sphincter, or any dysfunction in the lower urinary tract.”

Significant variability in dysfunction and underlying causes

There is significant variability in the dysfunction itself and the underlying causes. While NLUTD is most commonly related to multiple sclerosis and spinal cord injury, it could also be associated with Parkinson’s disease, stroke, or an advanced effect of diabetes—and could also vary based on the effect of any one of these pathologies on a patient’s nervous system.

“Management strategies will vary based on whether the brain and spinal cord are affected, for example, versus nerve involvement in the pelvis. Some people may have a problem with urinary retention, others with urinary incontinence, and some may have both. How the dysfunction is treated really depends on what the problem is,” she says.

Because of this, one of the most notable themes in the guideline is properly evaluating risk.

“Conditions with retention or significant pressure in the bladder can lead to impaired kidney function, so our number one priority is to protect the kidneys,” she notes. “Other sequelae include UTIs, bladder stones and, of course, quality of life.”

About 10% to 20% of Dr. Slopnick’s practice includes treating patients with NLUTD. In an older NLUTD patient population, it can be difficult to decipher whether certain symptoms are associated with the disease or if it’s associated with a natural weakening of lower urinary tract muscles. This underscores the importance of careful evaluation to guide surveillance and treatment approaches.

Formalizing treatment options in patients with NLUTD

The AUA/SUFU guideline is also an opportunity to codify nonsurgical and surgical treatment options and reflect updated approaches, which, in some cases, have expanded in recent years because of new evidence or technology.

For example, indications have only recently included sacral neuromodulation devices as a possible treatment option for patients with NLUTD because the technology was previously not compatible with an MRI, essential to neurologic care.

Collaborating with other specialists — and the takeaway message

Dr. Slopnick says the multidisciplinary nature of care at Cleveland Clinic helps facilitate collaboration with other specialists and subspecialists when issues arise in the management of NLUTD. The team may work with the patient’s neurologist to understand the disease process and whether it’s a progressive or stable pathology. They may also work with colleagues in gastroenterology to manage coexisting neurogenic bowel symptoms, including severe constipation and/or fecal incontinence.

“There’s such huge variability in this patient population, including their functional status – whether or not that they can catheterize themselves, as an example. All of this impacts how we manage their care,” says Dr. Slopnick.

“Someone who has MS with mild symptoms of overactive bladder will be managed very differently from someone who has quadriplegia because of a spinal cord injury, though both patients have NLUTD. The guideline reinforces the diversity and nuance of the dysfunction and helps us individualize care.”

Articles

Cleveland Clinic specialist discusses the implications of the first published guideline for neurogenic lower urinary tract dysfunction

New guideline on neurogenic lower urinary tract dysfunction emphasizes risk management

Androgen deprivation therapy (ADT) and other mainstays of therapy for men with castration-resistant prostate cancer may be effective in the management of Skene’s gland malignancy, a rare paraurethral adenocarcinoma.

The malignancy is exceedingly rare: only 15 cases have been reported in the literature. This is according to recent findings reported by a multidisciplinary team that have led the most comprehensive review of the disease to date.

“Paraurethral and urethra masses are typically unfamiliar even to specialists,” says Emily Slopnick, MD, a female pelvic medicine and reconstructive surgeon at Cleveland Clinic and part of the care team treating a patient with this rare malignancy. “And in this case, the patient didn’t even present with either of these masses; it was an enlarged lymph node,” she explains.

This clinical encounter led Dr. Slopnick and her colleagues to report details from the case and conduct a literature review. They published their findings in 

Presentation, diagnosis – and why PSA evaluation is warranted

A 76-year-old female presented with a left inguinal mass. An excisional biopsy and pathological workup revealed malignant cells consistent with metastatic carcinoma. The patient was referred to gynecologic oncology with suspicion for ovarian germ cell tumor.

Upon physical examination, the gynecological oncology team found a 2 cm mass on the patient’s Skene’s gland, bordering the left distal urethra. The patient was immediately taken to the operating room to undergo bilateral salpingo-oophorectomy, a left obturator lymph node dissection, and a biopsy of the paraurethral mass.

Pathological evaluation confirmed that adenocarcinoma had infiltrated the lymph node and was extending into the surrounding tissue. Interestingly, the cellular composition was similar to that of a Gleason pattern 4 + 4 prostatic adenocarcinoma and even showed expression of NKX3.1 and prostate specific-membrane antigen.

Because the Skene’s glands are the embryologic homologue of the prostate, this is a rare scenario when evaluating PSA levels in a female is helpful in confirming the diagnosis. Laboratory testing revealed significantly elevated PSA levels: 7.91 ng/mL (normal levels are < 0.2 ng/mL in a postmenopausal female).

A true multidisciplinary effort among urology, gynecology, and oncology

“Even getting to the diagnosis was a true multidisciplinary effort,” says Dr. Slopnick. “At a glance, those of us trained in urology may have assume it’s a urethral cancer or from the gynecological perspective, a vaginal cancer; and in this case, she presented with an enlarged lymph node, which can be the result of many things,” Dr. Slopnick explains.

The team moved forward with plans to excise the primary mass, but during the surgery they realized it extended more proximally then was apparent during the physical exam. Complete resection of the tumor would necessitate a total urethrectomy with urinary diversion. The team halted the surgery to allow for additional patient counseling and decision-making.

Her case was presented at a multidisciplinary tumor board conference, which led to a new plan. She was offered a regimen that has demonstrated success in treating men with advanced prostate cancer: androgen deprivation therapy (ADT) with the novel adrenal biosynthesis inhibitor abiraterone acetate and prednisone (AA/P).

The patient opted to stay on the hormonal therapy regimen and declined radiation therapy and surgical treatment. Her results have continued to be positive since beginning treatment. At 24 months, her PSA levels were undetectable; she had no evidence of metastases; and she had a RECIST-defined partial response.

The authors recommend indefinite ADT treatment with ongoing PSA evaluation and imaging, according to the case report.

What is known about Skene’s gland malignancy?

This patient’s outcomes are generally consistent with those reported in the literature, asserts Dr. Slopnick. In the 15 cases identified as true Skene’s gland malignancy, the median patient age was 71 years old, and the most common presentation (N = 5) was an asymptomatic periurethral or urethral lesion. Other symptoms included hematuria or vaginal bleeding, vulvovaginal pain and lower urinary tract symptoms.

In eight cases, PSA levels were measured, and all were found to be elevated. In all eight of these cases, PSA levels regulated in tandem with treatment.

Treatment approaches did vary from patient-to-patient: eight included local excision (with or without pelvic lymphadenectomy), two underwent radical surgical resection, two received radiation therapy, and one, a more recent case, also utilized neoadjuvant ADT along with extensive radical surgery.

There was no incidence of recurrence or disease-related mortality in any of the 15 cases.

Considerations for ADT as a primary modality

In this case, the patient was offered adjuvant radical surgery or whole pelvis radiation therapy, but opted for the ADT treatment alone. This is the first reported case of treatment for this type of malignancy with an antiandrogen.

“Historically, surgical excision has been the preferred approach for managing this rare malignancy; however, hormonal therapy modalities, as in this case, and other regimens that are effective in treating castration-resistant prostate cancer should be considered in the management of Skene’s gland malignancies,” concludes Dr. Slopnick.

1. Slopnick EA, Bagby C, Mahran A, Nagel C, Garcia J, El-Nashar S, Hijaz AK. Skene’s Gland Malignancy: A Case Report and Systematic Review. 

. 2022 Feb 19:S0090-4295(22)00149-2. doi: 10.1016/j.urology.2022.02.004  

ADT and other mainstays of therapy for men with castration-resistant prostate cancer may be effective in the management of Skene’s gland malignancy, a rare paraurethral adenocarcinoma. 

Rare case of Skene’s gland malignancy raises awareness about treatment options

In the transplant community, controversy continues about donation of extrapulmonary organs from deceased donors with COVID-19, despite mounting evidence that transplantation incurs little to no risk for disease transmission or worse outcomes.

Alvin Wee, MD, MBA, Surgical Director of the Kidney Transplant Program in Cleveland Clinic’s Glickman Urological & Kidney Institute, and colleagues published their initial case series in the 

 Here they reported that 10 kidneys from five donors were successfully transplanted, all with good outcomes.

Since then, the research team has gathered additional data from donors and recipients that reinforce the initial findings. Dr. Wee says they’ve completed more than 100 cases to date, all with excellent outcomes and no post-transplant COVID-19-related complications.

At the 2022 American Urological Association (AUA) annual meeting, they presented data collected from February 2021 to October 2021, including 55 patients who underwent kidney transplantation from 34 COVID-19 positive donors.

The transplant team: Evaluating cases collaboratively

Dr. Wee says the selection criterion and guidelines were established collaboratively by a multidisciplinary team of transplant surgeons, nephrologists and infectious disease specialists approved by Cleveland Clinic Transplant Council.

Initially, they evaluated cases more conservatively. In their previously published report, none of the five donors died from COVID-19-related complications. Causes of death included asphyxia, cardiac arrest, drug overdose and drowning.

As the team continued to observe good results, they broadened their criteria selection to better utilize kidneys for transplant, even in deceased donors with more severe disease. In the data presented at the AUA meeting, the physicians report 38.2% (N = 13) died from COVID-19- related causes.

Dr. Wee says these findings show that “generally speaking, as long as kidney function is good, the organ is viable for transplant.”

A summary of donor and recipient characteristics

The median donor age was 35 years (range: 6-57) with a median Kidney Donor Profile Index (KDPI) of 39% (range: 3%-82%). Additionally, all donors had at least one positive COVID-19 test obtained using a nasopharyngeal ribonucleic swab. Prior to death, six of 34 donors underwent ECMO. And median initial and terminal creatinine levels were 0.9 mg/dL (range: 0.3-1.9 mg/dL) and 0.8 mg/dL (range: 0.2-5.7 mg/dL).

Among the recipients, 36 were male and 19 were female. The median age was 55 years (range: 24-70). Two-third of the recipients were receiving dialysis at the time of transplant, and two-thirds of the patients were fully vaccinated at the time of transplantation.

Following transplantation, none of the recipients tested positive for COVID-19. All of the kidneys were functioning, although delayed graft function was found in 19.6% of the recipients, and one kidney was lost due to a vascular complication from infection not related to COVID-19.

Better utilization of organs for transplant

Despite a record-number of kidney transplants completed in 2021 — both at Cleveland Clinic and nationwide — there is still a discrepancy between people on the waitlist and available kidneys for transplant.

Dr. Wee is hopeful that data like these will soon alter industry standards on transplant guidelines for donors with COVID-19 and support better utilization of extrapulmonary organs for transplant.

“Balancing the risk of accepting an organ with dying on the waitlist is always part of the decision when it comes to transplant, and the pandemic has made that even more complicated,” says Dr. Wee.

“But, just think about it, this approach has enabled more than 100 kidney transplants, a lifesaving intervention for patients on the waitlist, which may have otherwise been discounted. It also offers a glimmer of hope and meaning to the family members of these patients who died from this senseless death.”

Kidney transplant surgeon Alvin Wee, MD, MBA, presented findings at the 2022 AUA Annual Meeting

New data show transplanting kidneys from donors with COVID-19 is safe

Benign prostatic hyperplasia (BPH) is ubiquitous in men older than 50 and, with increasing age, causes lower urinary tract symptoms that affect quality of life. In recent years, minimally invasive surgical treatments have joined drug therapy and surgical resection as therapeutic options.

Minimally invasive surgical treatments for BPH have shown promise in terms of efficacy and patient comfort. They cause less tissue damage, can be done in an outpatient setting, are less costly, and allow for quick recovery. The most common side effects include post-procedure urinary frequency and short-lived discomfort.

The prostatic urethral lift, achieved with the UroLift device, is a minimally invasive surgical technique that Cleveland Clinic urologists have been using since 2015. Andrew Altman, MD, of the Glickman Urological & Kidney Institute, uses the UroLift® device for patients in his Twinsburg, Ohio, practice.

The UroLift procedure compresses the enlarged prostate lobes that surround and narrow the urethra, widening the urethra to facilitate urination. Under mild sedation and with the aid of cystoscopy, the urologist inserts a delivery device, or sheath, into the urethra. When the sheath reaches the prostatic urethra, a needle, which houses a small implant, is ejected into the prostatic lobe. The implant consists of a nitinol capsular tab, a retractable PET suture, and a stainless steel urethral end piece. The needle is deployed through the prostatic lobe and capsule. When the needle is retracted, the capsular tab is deposited under tension with a suture. The implant is secured by the urethral end piece and the suture is then cut. The number of implants ranges from two to eight depending on the size of the patient’s prostate.

Generally, a younger man whose prostate weighs 80 grams or less is an ideal candidate for the procedure. The diagnostic and screening workup involves three outpatient tests:

 for real-time analysis of the patient’s average and maximum flow, how much urine remains in the bladder after voiding, and pressure generated by the bladder in the storage and voiding phases.

 to confirm that the problem is prostatic and not caused by urethral stricture, a bladder stone, or a tumor. Cystoscopy defines the type of prostatic growth; ie, whether it is bilobar or trilobar, or whether there is intravesicular extension of prostate tissue growing or pushing into the bladder.

 to determine the prostate size. Treatment for a 40-gram prostate would differ from that needed for an 80- or 180-gram prostate.

“Various treatment options are available to the patient depending on the size and anatomy of his prostate,” says Dr. Altman. “The patient is a candidate for UroLift if bladder contractile function is present, the prostate size is less than 80 grams, and the hyperplasia is bilobar. If there is a large middle lobe, UroLift isn’t an option.”

An advantage of UroLift is that it can be done in the outpatient setting without a general or spinal anesthetic. But ­­UroLift is just one option, notes Dr. Altman. Medication is a good choice for many patients. Some might opt for transurethral resection of the prostate (TURP). Others might prefer laser vaporization of prostate tissue.

UroLift alleviates BPH symptoms, but does not result in the same urine flow rate that patients experience after TURP. The more invasive surgical procedures provide better symptom relief, but they are not appropriate for every patient.

“This is a quality-of-life issue that requires shared decision-making,” says Dr. Altman. “On completion of the workup, we discuss our findings and review the treatment options with the patient, who makes the final decision.”

The procedure takes 10-15 minutes and patients go home the same day, 80% of them without a catheter. Possible aftereffects include short-lived urinary frequency and some discomfort. Because the bladder neck and urethra are left intact, there is little risk of incontinence or retrograde ejaculation— complications of other BPH surgical procedures. Sexual function is preserved.

Because of the lifting and separating effects of the implants, urination improves almost immediately. The improvement in lower urinary tract symptoms associated with BPH is durable for up to 8 years.

Minimally invasive BPH procedures relieve symptoms and can be done in outpatient settings.

Cleveland Clinic

Articles

New guideline on neurogenic lower urinary tract dysfunction emphasizes risk management

Rare case of Skene’s gland malignancy raises awareness about treatment options

New data show transplanting kidneys from donors with COVID-19 is safe

Better options for treating benign prostatic hyperplasia