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

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. 

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

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

Articles

"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

1. Patel SR, Nakada SY. The modern history and evolution of percutaneous nephrolithotomy. 

2015;29(2):153-157. doi:10.1089/end.2014.0287

2. Rajamahanty S, Grasso M. Flexible ureteroscopy update: indications, instrumentation and technical advances. 

2008;24(4):532-537. doi:10.4103/0970-1591.44263

3. Chaussy CG. ESWL: past, present, and future. 

4. Lepor H, Williford WO, Barry MJ, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. 

1996;335(8):533-540. doi:10.1056/NEJM199608223350801

5. McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. 

1998;338(9):557-563. doi:10.1056/NEJM199802263380901

6. Foster HE, Barry MJ, Dahm P, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. 

 2018;200(3):612-619. doi:10.1016/j.juro.2018.05.048

7. Stamey TA. Endoscopic suspension of the vesical neck for urinary incontinence. 

8. Atala A, Bauer SB, Soker S, Yoo JJ, Retik AB. Tissue-engineered autologous bladders for patients needing cystoplasty. 

2006;367(9518):1241-1246. doi:10.1016/S0140-6736(06)68438-9

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.

10. Williams JK, Dean A, Badra S, et al. Cell versus chemokine therapy in a nonhuman primate model of chronic intrinsic urinary sphincter deficiency. 

 2016;196(6):1809-1815. doi:10.1016/j.juro.2016.05.106

"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.

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

Actress Lorna Luft once said, “I choose not to think of my life as surviving but coping.” I often see patients “living around their bladder.” In a recent paper, Reynolds et al

 studied responses from 5 items from the Overactive Bladder (OAB)-q Quality-of-Life scale asking about OAB symptoms and compensatory coping behaviors to generate a total coping score. They report that higher body mass index, lower education, use of OAB medication, and urgency incontinence as well as urinary symptom severity were all associated with higher coping scores. Furthermore, coping was associated with greater urinary symptom severity and higher anxiety and stress.

Emotions and voiding have an intimate relationship. In an exquisite treatise, 

The Art and Science of Piddling; Voiding Habits of Man and Beast,

 Frank Hinman Jr describes the evolution of defensive voiding by animals so as not to wet their fur and be marked. He further describes the effects of anxiety on frequency, hesitancy, and the effect of voiding in public.

Women carry a significant burden affecting voiding behavior, from genetic/familial effect on the pelvic support mechanism, anatomy of the outlet, childbearing, and hormonal influence to the cultural effects of clothing/posture for voiding. If you add bladder dysfunction or a weak outlet, the problem and fear of being discovered are reflected in coping behavior from knowing where every toilet is to restricting or avoiding activity altogether. The circle is complete with anxiety causing even more defensive frequency, perceived difficulty in voiding because there is hardly any urine in the bladder, and pelvic pain from excessive guarding.

Allowing women to build confidence and assurance that they are not going to leak requires a multimodal approach. A voiding diary and knowing functional capacity at home allows one to assess the scope of a bladder training program. An individual who sleeps 4 to 5 hours at night without leaking but goes frequently during the day in small volumes is an ideal candidate for bladder training, whereas one who leaks with urgency several times around the clock needs more involved assessment and treatment.

Part of coping is making the patient more knowledgeable about their condition and appealing to their logic. It is quicker to write a prescription than to spend time understanding the nuances of their OAB. We have learned that not all OABs are equal. Quality of life improvement is a better goal than perfect dryness. Situational symptoms such as “garage door syndrome” or change of position leaking and increased frequency with lifestyle stress require special education in addition to the fluid management. Use of Kegel exercises before getting up, using support to avoid overt Valsalva pressure are examples of mechanically dealing with situational leaking. Immediate-release sublingual medication that prevents bladder overactivity can be used by the patient when necessary in a situation known to trigger urgency/frequency.

Spend a few extra minutes to learn about emotions and voiding in your patient. Urologyhealth.org is a great patient resource to learn about voiding dysfunction and simple measures to improve the condition.

1. Reynolds WS, Kaufman MR, Bruehl S, Dmochowski RR, McKernan LC. Compensatory bladder behaviors (“coping”) in women with overactive bladder. 

Published online September 15, 2021. doi:10.1002/nau.24788

The Art and Science of Piddling; Voiding Habits of Man and Beast

"Spend a few extra minutes to learn about emotions and voiding in your patient," writes Gopal H. Badlani, MD.

Overactive bladder study explores emotions and voiding

, 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 

Nocturia, or waking up to urinate at night, continues to be a vexing problem for clinicians and patients. In an earlier review

 and in-depth interview of subject matter expert Jeffrey P. Weiss, MD, PhD, a variety of causes of nocturia were discussed.

Writing a prescription for a malady makes the clinician and patient feel better about doing something for the condition. In a study

 reported on in an article in this month’s issue of 

®, the authors suggest that adding medication (non-antidiuretic) to behavioral therapy does not make a difference in veterans studied over a year. In the detailed analysis of their voiding diaries and metabolic characterization, it was shown that all patients did not have significant high nocturnal volume (< 650 for all) and peripheral edema was present in larger proportion of the behavioral therapy-alone group. Obstructive sleep apnea, another common cause of nocturia, was present in a higher percentage of the same group (not statistically significant)

What is difficult to characterize in this retrospective study, or any study for that matter, is how many patients are following the simple instructions of not drinking the last 2 hours before sleep and leg elevation in the evening hours to alleviate some of the volume-induced first instance of waking up at night. Other unexplored reasons of nocturia are restless leg syndrome, painful conditions, anxiety, etc. In this paired analysis, hopefully they do not affect the data analysis.

So what is the take-home message? By all means, educate patients about causes of nocturia, suggest behavior modifications mentioned above, but don’t throw a drug at them unless there are daytime symptoms of urgency (anticholinergics or β-3 agonists), high postvoid residual (α-blockers), or large volume output at night (desmopressin). Complex interactions between the heart, the kidneys, and the bladder warrant a multidisciplinary approach in patients with nocturia. A personalized treatment should be designed, taking into account gender, comorbidities, and identified etiological factors. This is time-consuming and in the future, bladder mobile apps may help obtain logs and be reminders of the bladder training.

As the Dalai Lama said, “Sleep is the best meditation.”

1. Daugherty M, Ginzburg N, Byler T. Prevalence of nocturia in US women: results from NHANES. Paper presented at: American Urological Association annual meeting. May 18-21, 2018. Abstract PD32-03

2. Nocturia: How to define it, and how treat it. 

®. August 25, 2020. Accessed July 27, 2021. https://www.urologytimes.com/view/nocturia-how-to-define-it-and-how-to-treat-it

3. Miller CD, Monaghan TF, Robins DJ, Weiss JP. Does traditional pharmacotherapy augment behavioral modification in the treatment of nocturia? 

. Published online May 11, 2021. doi:10.1002/nau.24692

"By all means, educate patients about causes of nocturia, suggest behavior modifications...but don’t throw a drug at them unless there are daytime symptoms of urgency, high postvoid residual, or large volume output at night," writes Gopal H. Badlani, MD. 

Gopal H. Badlani, MD

Articles

Where can we do better in benign urology?

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

Overactive bladder study explores emotions and voiding

Nocturia: Mind vs medication