professor and vice chair of urology at Wake Forest University in Winston-Salem, North Carolina, is a co–editor in chief for 

Gopal H. Badlani, MD

As we look back over the past 5 decades in urology, bladder dysfunction, particularly inadequate contraction, is still a disorder with unmet medical need, for which new treatments are crucial.

“Underactive bladder” (UAB) is a term covering detrusor underactivity as the urodynamic diagnosis, and “UAB syndrome” for its symptomatic manifestations. The acontractile bladder is a urodynamic-based diagnosis wherein the bladder is unable to demonstrate any contraction during a pressure flow study. Although it is often grouped with UAB, acontractile bladder is a unique phenomenon and should be investigated independently.

 The underlying pathology is variable with both neurological and myogenic etiologies. The disorder can have many underlying causes, including aging, prolonged bladder outflow obstruction, diabetes mellitus, and neurogenic disturbances. The term defined by the International Continence Society in 2002 was the urodynamic term, detrusor underactivity (DU) along with detrusor acontractility. The International Continence Society definition provides a framework, considering the urodynamic abnormality of contraction and how this affects voiding;

 however, this is necessarily limited clinically. Detrusor underactivity is present in 9% to 48% of men and 12% to 45% of older women undergoing urodynamic evaluation for non-neurogenic lower urinary tract symptoms.

The condition itself is confusing enough, but over the years, we have seen many different terminologies to describe the syndrome. Furthermore, the coexistent overactive bladder (OAB)-UAB (with or without detrusor overactivity and underactivity)

 is the latest attempt to rename detrusor overactivity with impaired contractility described by Yalla et al.

Although the inability to empty and having a high postvoid residual are easier to understand as a complaint, it is when the UAB presents with frequency urgency (OAB) symptoms that leads to confusion in the diagnosis. The response to OAB drugs is poor and the residual urine increases. A urodynamic study may help in diagnosis but brings one no closer to a solution.

The International Congress of Urologic Research and Education on Aging Underactive Bladder (CURE-UAB) is an initiative partially funded by the National Institute of Diabetes and Digestive and Kidney Diseases,5 and since 2014, 5 CURE-UAB congresses have taken place. “They have brought together diverse stakeholders in the UAB field to identify areas of major scientific challenge and initiated a call to action among the medical community,” write Chancellor et al.

Although several advances have been made to manage urinary bladder overactivity, UAB remains poorly addressed. Treatment is largely tailored for renal preservation and reduction of infection. Future developments may allow for functional restorative treatments; current treatments mainly focus on bladder drainage, largely based on symptoms and presentation. Cellular therapy and neuromodulation may hold promise, but further research is needed into the underlying neuro-urological pathophysiology of this disease so that we can better develop future treatments.

So what is the take-home message? Consider the diagnosis of UAB or detrusor underactivity when an elderly patient, with or without diabetes, presents with frequency, urgency, and a higher-than-normal postvoid residual. If the patient is an older man, do not be too quick to treat his prostate, and if a woman, hesitate before prescribing a medication for OAB.

Bladder training is the best initial management. Need for drainage with clean intermittent catheterization is based on postvoid residual. A multichannel urodynamic study helps clarify the diagnosis. Based on patient choice, neuromodulation may help with OAB symptoms without adding to the postvoid residual, whereas onabotulinumtoxinA (Botox) use requires clean intermittent catheterization. Counseling and setting up expectations are key in managing these patients; that is, until that magic cure arrives.

Gopal H. Badlani, MD, is professor and vice chair of Urology at Wake Forest University in Winston-Salem, North Carolina, and is a co–editor in chief for 

1. Colaco M, Osman NI, Karakeçi A, et al. Current concepts of the acontractile bladder. 

2018;122(2):195-202. doi:10.1111/bju.14236

2. Osman NI, Chapple CR, Abrams P. Detrusor underactivity and the underactive bladder: a new clinical entity? A review of current terminology, definitions, epidemiology, aetiology, and diagnosis. 

2014;65(2):389-398. doi:10.1016/j.eururo.2013.10.015

3. Mancini V, Tarcan T, Serati M, Wyndaele M, Carrieri G, Abrams P. Is coexistent overactive-underactive bladder (with or without detrusor overactivity and underactivity) a real clinical syndrome? ICI-RS 2019. 

2020;39(suppl 3):S50-S59. doi:10.1002/nau.24311

4. Resnick NM, Yalla SV. Detrusor hyperactivity with impaired contractile function. An unrecognized but common cause of incontinence in elderly patients. 

1987;257(22):3076-3081. doi:10.1001/jama.257.22.3076

5. Chancellor MB, Bartolone SN, Lamb LE, Ward E, Zwaans BMM, Diokno A. Underactive bladder; review of progress and impact from the international CURE-UAB initiative. 

2020; 24(1):3-11. doi:10.5213/inj.2040010.005

Articles

"As we look back over the past 5 decades in urology, bladder dysfunction, particularly inadequate contraction, is still a disorder with unmet medical need, for which new treatments are crucial," writes Gopal H. Badlani, MD. 

Call it by any name: Bladder that does not work

“Any knowledge that doesn’t lead to new questions quickly dies out: it fails to maintain the temperature required for sustaining life,” said poet and Nobel Laureate Wislawa Szymborska.

Looking back at the past 50 years, I recounted the achievements and yet-to-be-conquered goals. It is also prudent to think back to what ideas/concepts have withstood the test of time, in the quest for knowledge and the inherent desire to replace old with new.

Females are no longer subjected to urethral dilation, a practice that was popular in the past based on the concept that, what we recognize today as dysfunctional voiding/pelvic floor dysfunction, was caused by the urethra and that overstretching it would fix the problem. Of course, it temporarily helped, but they were back for more.

Credé voiding and use of Bethanechol is another nonphysiologic process that has slowly disappeared—with good reason, because it had no scientific merit in neurologically intact individuals. It has been replaced largely by intermittent catheterization in both neurogenic and nonneurogenic patients with incomplete emptying.

Another diagnosis or myth that should disappear is “prostatitis” and a “boggy prostate” to define it. Chronic pelvic pain syndrome in males is now well recognized, and I wish we could teach primary care and emergency department physicians to stop throwing antibiotics at these young or not-so-young individuals. Despite negative urinalysis, this diagnosis is often made and doing a prostate-specific antigen (PSA) test is one way I have found to convince the patient and a referring physician that the prostate is not inflamed as the PSA level is very low.

The male urethra has seen better days; visual or tactile cannulation of the stricture by a guide wire is much less traumatic than the filiforms, followers, or metal sounds passed by feel. Such devices may have worked in some experienced hands, but many patients paid the price before that experience was gained. We described this technique of trying to avoid trauma/bleeding from the urethra of a patient undergoing cardiac surgery in 

The Urologic Clinics of North America (I. Urologic Pearls)

Similarly, rigid cystoscopy of the male urethra in the office is uncommon practice today, and patients do not have to come off the table during the procedure. I heard from so many of my teachers that it did not hurt the way they did it. I assure you, the patient did not say that.

Monopolar transurethral resection of the prostate is also on its way out. Although still used in many parts of the world due to lower cost, it has been replaced in North America by bipolar and other less invasive procedures.

Urodynamic testing has remained the mainstay of voiding assessment. There are many more components to the machine, and the electronics of the pressure transducers are much more accurate, but the basic concepts have not changed significantly. With International Continence Society terminology, we simply may have changed the terms and added some nomograms.

Since Jack Lapides, MD, made it the norm, intermittent catheterization has served many patients faithfully and improved quality of life. We have made it expensive by discarding the catheter after each use despite many studies showing no difference in the incidence of urinary tract infections with “clean” technique vs reusing the catheters.

The use of lasers has evolved but is now inseparable from urology. We keep learning of new wavelengths and better ways to use lasers for stones, the prostate, and certain urothelial cancers. These uses remain confined to the Western world due to the high cost. This use has allowed smaller, flexible scopes to reach the stone or lesions. The evolution of flexible endoscopy has been a marvel over the past 50 years and made the upper tract so accessible to the urologist regardless of the size of the patient. I fondly recall Demetrius Bagley, MD, who led this path among many others in this field. Bagley said, “Ureter is never fat and if you see fat, you are in the wrong place.”

The innovator F. Brantley Scott, MD, along with his partners Gerald W. Timm, PhD, and William E. Bradley, MD, left us a legacy of the artificial urinary sphincter (AUS) and inflatable penile implants (IPPs). Although there have been improvements, it is amazing that no new device has thus far replaced the AUS and IPP. Surgically, after so many variations of urinary diversion, the suprapubic tube and the ileal conduit remain the leaders.

I have reflected on many of my failed attempts to innovate.

 It is the desire to question, to improve current practice, that keeps me testing the so-called “norm.”

The Urologic Clinics of North America (I. Urologic Pearls).

2. Smith WR, Badlani GH. Are reusable catheters safe? Study provides an answer. 

®. October 30, 2019. Accessed June 2, 2022. https://bit.ly/3t7LH0z

3. Badlani GH. Success is built on a string of failures. 

®. March 6, 2019. Accessed June 2, 2022. https://bit.ly/3za4eNT

"Looking back at the past 50 years, I recounted the achievements and yet-to-be-conquered goals," writes Gopal H. Badlani, MD.

What has stayed and what disappeared in benign urology

In my most recent editorial, I recounted the advances we had made in the last 50 years in benign disease.

 It also provided a good opportunity to reflect on conditions or situations for which we must, still, strive to do better. Although it might be easier to enumerate the cancer conditions, in the benign world, struggles continue to overcome patients challenged with these conditions.

 remains an enigma with no pharmacological or surgical solutions. Although we may understand the multiple pathways that cause the bladder to decompensate, such as aging, prolonged stretching, ischemia, or neuropathy, we still do not know how to predict and/or reverse this change. Mechanical drainage remains the standard treatment. Neuromodulation or bladder stimulation have been attempted, but it is not a current therapy. There is no pharmacological intervention. The advance we have made is in naming the condition differently.

The other aspect of bladder dysfunction affecting a smaller portion of the population is Interstitial cystitis. We now understand that it is not a single entity,

 a segment may not be bladder driven; but the clinical ability to make that decision and apply standard treatment is still elusive, despite strong research support from the National Institute of Diabetes and Digestive and Kidney Diseases.

The evolution of endourology and devices has made the modern management of stones an art form; however, we have not made a significant advance in their prevention or recurrence. Despite guidelines on medical management, such as those from the American Urological Association,

 and improved knowledge of metabolic pathways, there has been no decline in incidence, visits to the emergency department, or the acute pain of renal colic. An increased obesity in the population may be one of causes, but public policy for prevention has been lacking.

 The ever-increasing options to manage the benign prostate have been a technical marvel; however, in the rearview mirror I see all the ones we abandoned after a few years of enthusiastically embracing them as the next big thing. The concern is that we did not learn from the mistakes and continue to accept new treatment options without waiting for durable success. Heating the prostate with low-energy or high-energy microwave; focusing the interstitial laser or radiofrequency current on it; injecting it with agents or dilating it with balloon or stents; and waving certain lasers at it are all in “rest in peace” mode. Yet we are enthusiastically heating, placing devices, or using new lasers, each method promising to let us have our cake and eat it too. Thanks to various investigators and guidelines that have restrained the blaming of the prostate in every older man who complains about getting up at night.

 Despite the advances in tissue engineering and cell therapy, reconstructive urology still relies on the host for providing the graft for replacement or augmentation. The morbidity of harvesting bowel, skin, fascia, muscle, or mucosal flaps remains a challenge to conquer. Off-the-shelf material has made female and male incontinence surgery a new paradigm, but the genitourinary Reconstructive Surgeons, despite advances in surgical techniques, cannot take advantage of minimally invasive surgical techniques due to a lack of constructs. 

 Recurrent UTIs in women continue to fill the schedules at urology clinics. A variety of techniques and rituals has failed to conquer this challenge. The advance in genetic testing for urinary pathogens has led to a decrease in the time to identify the organism responsible. A recent report of a vaccine

 may be groundbreaking if the study results can be replicated in the general population. The ever-growing number of pathogens that are resistant to available antibiotics are a potential threat, as no newer antibiotics class is on the horizon.

I am fortunate to see and review many new research applications to conquer these challenges. The hope is that we see improving quality of life as important as correcting an anatomical defect or curing cancer.

“Energy and persistence conquer all things” – Benjamin Franklin.

1. Badlani GH. Golden jubilee: looking back at 50 years of urology in benign diseases. 

®. January 27, 2022. Accessed March 14, 2022. https://www.urologytimes.com/view/golden-jubilee-looking-back-at-50-years-of-urology-in-benign-diseases

2. Colaco M, Osman NI, Karakeçi A, Artibani W, Andersson KE, Badlani GH. Current concepts of the acontractile bladder. 

3. Overholt T, Evans RJ, Badlani G, Matthews CA, Walker SJ. Functional genomic analyses of IC/BPS patient subgroups: a pilot study. 

4. Pearle MS, Goldfarb DS, Assimos DG, et al; American Urological Association. Medical management of kidney stones: AUA guideline. 

2014;192(2):316-324. doi:10.1016/j.juro.2014.05.006

5. Soloway MS, Weiss JF, Wien AJ. Nocturia. 

2016;17(10):77. doi:10.1007/s11934-016-0632-0

6. Nickel JC, Saz-Leal P, Doiron RC. Could sublingual vaccination be a viable option for the prevention of recurrent urinary tract infection in Canada? A systematic review of the current literature and plans for the future. 

. 2020;14(8):281-287. doi:10.5489/cuaj.6690

"Although it might be easier to enumerate the cancer conditions, in the benign world, struggles continue to overcome patients challenged with these conditions," writes Gopal H. Badlani, MD.

Where can we do better in benign urology?

 professor and vice chair of urology at Wake Forest Baptist Health High Point Medical Center, Winston-Salem, North Carolina, is a coeditor-in-chief for 

Innovation has changed the landscape of how we practice urology today. In every aspect of urological care, minimally invasive approaches with the use of devices prevail. Patients have benefited from the decline in morbidity and need for hospitalization, although one could argue care has become much more expensive.

In 1955, Willard Goodwin, MD, while trying to perform a renal arteriogram, placed a needle into the collecting system of a hydronephrotic kidney and performed the first antegrade nephrostogram. He left a tube to drain the kidney, thereby placing the first nephrostomy tube.

But perhaps the greatest contribution to the field of benign urology was the birth of endourology at the Veterans Administration Hospital in Minneapolis, Minnesota, in the late 1970s under the direction of Arthur D. Smith, MD. Endourology transformed the approach to the upper tract from maximally invasive to minimally invasive.

In 1978, Smith would describe the first antegrade stent placement when he introduced a Gibbons stent through a percutaneous nephrostomy in a patient with a reimplanted ureter. Smith would coin the term endourology to describe closed, controlled manipulation of the genitourinary tract. His collaboration with team of urologists, interventional radiologists, and medical inventors from device companies such as Cook and Boston Scientific, would lead to numerous innovations that would further advance percutaneous nephrolithotomy (PCNL).

In the 1980s, the process of renal access and tract dilation was improved, and the use of a rigid cystoscope was replaced by offset nephroscopes with a large, straight working channel. Radiographic innovations, including improvements in fluoroscopy, would further aid in renal access. The development of various lithotripsy devices and the introduction of the holmium laser improved the efficiency of stone fragmentation and clearance.

 The increased clinical experience and utilization of PCNL would lead to the characterization of stone-free rates and complications for the procedure. Parallel to this effort was the development of the ureteroscope. Enrique Pérez-Castro Ellendt, MD; Edward S. Lyon, MD; and Demetrius H. Bagley, MD, blazed the trail.

Flexible ureteroscopy, initiated in Japan with Yoshio Aso, MD, is currently a standard. Christian G. Chaussy, MD, working with Dornier in Germany, led the evolution of the stone lithotripsy with extracorporeal shock wave lithotripsy, also in the 1970s.

The birth of the Endourological Society in 1984 allowed the expansion of these techniques worldwide and provided a home for the innovators, companies, and the biomedical engineers to come together.

Open prostate surgery evolved to monopolar transurethral resection of the prostate in the early part of the 20th century. Although Marco Caine, MD, in Israel introduced the use of α-blockers, it was not until 1990s when landmark trials on α-blockers

 changed the paradigm of medical management for benign prostate enlargement.

Development of multiple lasers, bipolar energy, and minimally invasive devices for heat therapy to implanted devices reduced morbidity. Today, based on the American Urological Association guideline for male lower urinary tract symptoms due to BPH,

 there are more than 34 options. Treatment can be tailored to the patient’s desire to preserve ejaculation or avoid a catheter at the expense of less improvement in flow, and longevity of the procedure effects when compared with ablative therapies. The spectrum beyond medications include, from a simple removable device such as iTIND, to the automated Aquablation, and the robotic simple prostatectomy.

In the past, care of women with incontinence was largely the domain of the gynecologist, although open surgical correction was a still a procedure I learned in urological training. In 1973, Thomas A. Stamey, MD, modified the Pereyra procedure, adding endoscopic control to put it firmly in the hands of the urologist.

 A plethora of suspension procedures followed with Shlomo Raz, MD, leading the charge. The concept of bladder neck suspension was turned upside down by Ulf Ulmsten, MD, and Peter Petros, MD, with the introduction of the midurethral tension-free tape. It is now the gold standard for the management of stress urinary incontinence. It made the traditional fascial sling almost obsolete until its return with the use of mesh and its subsequent controversy. The concept of bulking the urethra saw a meteoric rise in the 1980s but, despite a promise of many new materials, its use has fallen by the wayside.

Laparoscopy, used largely by gynecologists, saw a dramatic rise in urology for organ extirpation for cancer. The robot also has more or less replaced the use of the laparoscope in urology for reconstructive procedures.

The field that has remained exciting and promising, but yet a step too far, is tissue engineering. The 

 article describing the implanted bladder excited the world.

 Alas, after 20-plus years of continued effort, the bladder and the urinary conduit have not reached a clinical use. Similarly, the use of adult muscle-derived cells for incontinence remains an area of research despite more than 3 decades of effort.

 The field of chemokine therapy holds a promise to replace cell therapy.

The use of implantable devices for erectile dysfunction and urinary sphincter from F. Bradley Scott, MD; Gerald W. Timm, MD; and William E. Bradley, MD, made many men happy. In the past 2 decades, the neuromodulation device pioneered by Richard A. Schmidt, MD; and Emil A. Tanagho, MD, has helped many women and men with refractory bladder overactivity. The use of onabotulinumtoxinA (Botox) in the clinic has made bladder augmentation a historical procedure.

Anatomy and diseases have not changed, yet, except for open surgery in the abdomen, what I learned as a resident in the 1970s has been replaced by the evolving innovation. The devices, telemedicine and remote care, and outpatient surgery risk us losing the human connection we had with the patient, as time spent with them is at a premium today.

“Too often, we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.”—Leo Buscaglia

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9. Chancellor MB, Peters KM, Benson KD, et al. An evaluation of women with persistent or recurrent stress urinary incontinence (SUI) following surgery in a double-blind, randomized, controlled trial comparing safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) with placebo (PBO). Presented at: 2021 American Urological Association Annual Meeting; September 10-13, 2021; virtual. Abstract PD06-02.

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"The devices, telemedicine and remote care, and outpatient surgery risk us losing the human connection we had with the patient, as time spent with them is at a premium today," writes Gopal H. Badlani, MD.

Gopal H. Badlani, MD

Articles

Call it by any name: Bladder that does not work

What has stayed and what disappeared in benign urology

Where can we do better in benign urology?

Golden Jubilee: Looking back at 50 years of urology in benign diseases