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Spotlight

GU Cancers Symposium

1rem

Clinical Focus

® Assistant Editor Janelle Hart spoke with 

, about the presentation, “Feasibility and efficacy of transvaginal onabotulinumtoxinA chemodenervation of the trigone for the third line treatment of refractory overactive bladder,” which was given at the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Winter Meeting. Dobberfuhl is a urologist at Stanford Hospitals and Clinics and an assistant professor of urology at the Stanford University School of Medicine in California.

“This technique is feasible, it is very well tolerated, and there’s not much of a complication rate, so it appears to be very safe,” says Amy D. Dobberfuhl, MD, MS.

Dr. Dobberfuhl discusses novel onabotulinumtoxinA treatment for refractory OAB

 She discusses the stigmas associated with overactive bladder, and how urologists can take the burden off of primary care physicians to educate patients who have this condition. Rogers is a urologist who specializes in incontinence at Sansum Clinic in Santa Barbara, California.

“We need to improve the fact that 75% of these patients are untreated [or] unmanaged and frustrated,” says Alexandra Rogers, MD.

Destigmatizing Urology: Dr. Alexandra Rogers discusses OAB

. He discusses urinary incontinence in male and female patients and how this condition can trigger major anxieties and avoidance behaviors. Seth is a consultant urological surgeon at St. George’s University hospital, London, UK.

“As health care professionals, we've got…an incredibly important role and responsibility with regards to increasing awareness and education, and then really trying to address the barriers and bring down the barriers,” says Jai Seth, MD.

Destigmatizing Urology: Dr. Seth discusses urinary incontinence

® Assistant Editor Janelle Hart spoke with J

. He discusses onabotulinumtoxinA injection programs as a treatment for urinary incontinence and the bleeding risk associated with these injections for patients who also take blood thinners. Seth is a consultant urological surgeon at St. George’s University hospital, London, UK.

“We're not saying a blanket stop for all patients, but I think we do need to be taking each patient as an individual in terms of their backgrounds,” says Jai Seth, MD.

Dr. Seth assesses the bleeding risk of Botox treatments in patients who take blood thinners

"I've worked in 3 different countries, I've seen dozens of people doing robotic radical prostatectomy...so my current practice is kind of a “best of” what I have seen and learned," says Ricardo Soares, MD.

Minimizing incontinence after radical prostatectomy: Lessons learned

"The results of this study demonstrate that peroneal eTNM using the URIS neuromodulation system is safe, well tolerated, and effective, with over 85% of patients experiencing clinically significant improvement in most bothersome OAB symptoms," says Jan Krhut, PhD.

Peroneal electrical transcutaneous neuromodulation is found safe and effective in OAB 

"Until a better option comes along, its low cost (mesh alone) and ease of use allows a standardized approach in an appropriately selected patient," writes Gopal H. Badlani, MD.

What is the future of stress urinary incontinence management?

Yu Zheng, MD, and Eric Rovner, MD, physicans in the Department of Urology, Medical University of South Carolina provided an important apprasial of urethral bulking agents for stress urinary incontience in women in a recently published review.

The evolving landscape of urethral bulking agents: Current practices in review

"We noted in our overall population, which was about 214 women, there was a 40% discontinuation rate for Botox treatments in the office," says Katherine L. Woodburn, MD.

Study finds high rates of discontinuation for overactive bladder treatment

 discusses the EMPOWER study conducted by University Hospitals (UH) to study urinary incontinence. Sheyn was just named the Division Chief of Female Pelvic Medicine at UH, and he is also an assistant professor of urology and reproductive biology at Case Western Reserve University in Cleveland, Ohio.

The EMPOWER study is funded by the Agency for Healthcare Research and Quality (AHRQ), and it's in partnership with the Primary Care Institute at University Hospitals. What we're doing is screening patients coming in for their primary care visits for incontinence, and then ones that are bothered by it, we are either randomizing to standard care and follow-up–which is what people are currently getting, sometimes that's medication, sometimes that's nothing–and to 2 other experimental arms. One arm is a nurse navigator that interacts with the patient at different intervals that are pre-specified by the study to help guide them through treatment, and if they're successful, to discharge them, or if they're not successful to increase their referral to urogynecology or female urology. The other arm is with one of our industry partners Renalis, which has a digital platform for urinary incontinence that is driven by the patient. So, the patient gets signed up for this app on their phone, and then they can interact with this device and it helps them manage their symptoms. If their symptoms are no better, then they also get referred to a urogynecologist.

The overarching goal is to both increase the identification of patients with urinary incontinence as well as shorten the time between diagnosis and appropriate treatment, either at the primary care level or at the specialist level, which currently the average amount of time it takes is around 4 years from diagnosis to treatment.

This transcription has been edited for clarity.

Videos

"The overarching goal is to both increase the identification of patients with urinary incontinence as well as shorten the time between diagnosis and appropriate treatment," says David Sheyn, MD.

Dr. Sheyn highlights University Hospitals’ EMPOWER study for urinary incontinence

discusses how physical therapy and weight loss can improve postprostatectomy incontinence. He also describes elements of his surgical approach. Soares is a urologist at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

There are things that you can do to prepare the patient for when they get to the surgery date. Obviously, weight loss is number 1. With most cases, from the time of diagnosis until the surgery, you're probably going to have maybe 6 weeks to 3 months. That's not a long time to lose a lot of weight, but it still can be significant. I have a patient with a [body mass index] of 49, but his cancer is not too bad. We decided to give him some extra time to become fitter, because this is going to help him in the long run. There are several studies showing that doing aerobic exercise and resistance training can also help with recovery. For me, what is most important is doing pelvic floor muscle therapy. Upon diagnosis, I send all of my patients to see one of our physical therapists here at Northwestern. I have been working here for 3 and a half years, and there was no male pelvic physical therapy program previously. But everyone in back in England, when I was working there, was doing this. You can really see the difference with the patients who go for physical therapy and the ones who don't. This has been studied for over 20 years; there have been randomized controlled trials, initially all [evaluating] postop physical therapy. Then, in 2001, there was the first trial of preop and postop physical therapy, which also showed good results. You can really increase your chances of continence at 3 months by up to 4 times. It's more about quicker recovery. Even at 1 year, it can be 1.2 times compared with someone who doesn't do physical therapy. So I have this in my normal protocol for every single patient.

Then you get to the actual surgery. Since the time of open surgery, there have been multiple maneuvers to try to improve continence. Number 1 is trying to preserve most of the urethra, trying to preserve the bladder neck, nerve sparing as well if the cancer allows you to, some preservation of the puboprostatic ligaments that attach the anterior side of the prostate to the pubic bone. Regarding neurovascular bundle sparing, there are some good data from [Ashutosh K. Tewari, MD], from New York. When he performs grade 1 interfascial nerve sparing, 71% of patients are continent at 3 months, when in general only half of them are. So it's like 50% vs 71. That's a significant improvement. There have some studies trying to link lymph node dissection to incontinence; the results are inconsistent. There's really no proof that one thing affects the other. I think the preservation of puboprostatic ligaments is probably one of the first things that was really done on a regular basis. There are some studies from laparoscopic surgery in Germany from [Jens-Uwe Stolzenberg, MD], back in the early 2000s, showing that if you preserve the puboprostatic ligaments in extraperitoneal laparoscopic prostatectomy, you can really improve continence at 3 months. Usually, there's a lot of preservation anterior to the prostate but also posteriorly. But anteriorly, in regards to the dorsal vascular complex (DVC), I think generally people would put a stitch on the DVC and then cut it. But there are a couple of studies showing that if you cut first, you're able to visualize better where you are cutting and therefore you're probably going to approach the apex in a better place. If you cut and stitch, you can improve continence right there. Also, a study from [Vip Patel, MD], from Florida showed if you suspend that stitch through the pubic periosteum, that is another little gain to get better results. Some of these things by themselves are not going to make a difference, but if you add them all together, they really make a difference for the patient. Posteriorly, the Rocco stitch is very, very widespread. It was actually developed in 2006 for open surgery, and 1 year later, was applied to laparoscopic surgery. I mostly do Retzius sparing, but when I do an anterior approach, I always do a Rocco stitch, because although the data are not very clear if that improves continence or not, some meta analyses show that it may improve continence at 3 months, but doesn't really make a difference at 6 months. But I think it helps achieve a tension-free anastomosis, so when I do an anterior approach, I just do a Rocco stitch.

This transcription was edited for clarity.

“You can really see the difference with the patients who go for physical therapy and the ones who don't,” says Ricardo M. de Oliveira Soares, MD.

Dr. Soares on the effect of weight loss on postprostatectomy incontinence

 discusses patient-specific predictors of post prostatectomy incontinence. Soares is a urologist at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

There is way more than surgery to [predict] why some people get incontinence and others don't. There are different factors that make patients more at risk, and I always discuss them with my patients. For example, patients who are older have higher risk. Patients that have a high [American Society of Anesthesiology] score are going to have worse results. Patients with a higher [body mass index] [are also at higher risk]. Obviously, in the US, obesity is a big problem. Sometimes, it's a little difficult to extrapolate the results from Europe and Asia to the American population, because the bodies are not the same. That's why it's important to know your own results. I know my results over the past 5 years here in the US, and those are what I quote to my patients. Whenever you're talking about the risk of incontinence, you should know your own data and not cite a specialist who has done a [large amount] of cases. That's very important to know. Prostate size is another factor. Patients with larger prostates are going to have a slightly higher risk of incontinence. The bladder neck is going to be bigger, there's more difficulty in sparing the surrounding structures and also having a good view of the apex to spare that membranous urethra. It's easier with small prostates to get a good sparing of the urethra. Patients who have a higher score on questionnaires such as the International Consultation on Incontinence Questionnaire and International Prostate Symptom Score tend to have more problems, particularly [if they have] overactive bladder, because obviously that is not going to be resolved with a prostatectomy. If a patient has had previous surgery such as transurethral resection of the prostate or holmium laser enucleation of the prostate, that also increases their risk of incontinence. Another factor is the stage of the cancer. If the cancer is more advanced, you need to remove more surrounding tissues around the prostate. To get extra safety margin, you remove more nerves and more arteries, and therefore the sphincter innervation and blood supply are going to be compromised, increasing the risk of incontinence. Even if the patient becomes continent, they tend to have a more delayed recovery. In terms of imaging, there's been studies showing either on MRI or the transperineal ultrasound showing that number 1 is obviously the membranous urethra length. For someone who has a very long urethra, the reconstruction is probably going to be easier. It has been shown that for each extra millimeter that you have in the urethra, there is a 5% increase of recovery of continence, and that's predictive at 6 and 12 months. Another parameter is the thickness of the levator ani muscle. That obviously is a surrogate for the patient's fitness, and it has been shown to weave in with other types of cancer surgery. With less muscle mass, the patient's going to have higher risk of complications. For men with bladder cancer, the thickness of the psoas muscle is a surrogate, but in the case of prostate cancer, the thickness of levator ani is a surrogate for fitness, and the thicker it is, the faster recovery the patient is going to have. There have been studies [looking at whether] if the bladder neck shape of the apex is overlapping the urethra makes a difference, but there was nothing conclusive in regards to those parameters.

“Whenever you're talking about the risk of incontinence, you should know your own data and not cite a specialist who has done a [large amount] of cases,” says Ricardo M. de Oliveira Soares, MD.

Patient predictors of postprostatectomy incontinence

 discusses how incontinence develops in patients post prostatectomy. Soares is a urologist at Northwestern University Feinberg School of Medicine, Chicago, Illinois.

When I'm discussing surgery, or any kind of treatment for prostate cancer, with patients, I always talk about the “trifecta”—the 3 factors [patients] want. Number 1 is getting all the cancer out, so having an undetectable [prostate-specific antigen level]. Number 2 is to be continent. And when I say "be continent," I mean being pad free, because [there are] articles out there that say patients are continent, but they're wearing a pad a day, which is not really being continent. Number 3 is keeping their erectile function. In general, I would say 90% of my patients really worry about the first 2. That's why I'm always trying to improve my technique and try to prepare patients better and better to minimize side effects from the surgery. In about 80% of the cases of incontinence after surgery, there is a sphincter insufficiency problem. That's because when you lose the prostate, you lose all the smooth muscle in the prostatic urethra and sometimes the bladder neck. Also, the striated muscle of the sphincter, although it is still saved, it gets impacted by the surgery. It is impacted because of 4 factors. Number one is because by cutting at the apex of the prostate, you're going to have a shortened membranous urethra, and that has been shown to be a factor and a predictor of incontinence. Number 2, the direct trauma of the surgery into the sphincter is great...and takes time to heal. The third factor is obviously the innervation. Particularly with more advanced cancer, you need to remove part of the neurovascular bundle; the innervation of the sphincter is also affected. Number 4 is hypoperfusion for the same reason; if you remove blood vessels that are supplying blood to the sphincter, there's going to be a need for collateral blood supply and until that happens, there's going to be a time of recovery.

“When I'm discussing surgery, or any kind of treatment for prostate cancer, with patients, I always talk about the ‘trifecta,’ “ says Ricardo M. de Oliveira Soares, MD.

Dr. Soares on post-prostatectomy incontinence

 shares notable findings, potential directions, and key takeaways from the recent study, “OnabotulinumtoxinA discontinuation in patients with prior nerve stimulation." Woodburn is an assistant professor of urogynecology at Atrium Health Wake Forest Baptist in High Point and Winston-Salem, North Carolina.

We noted in our overall population, which was about 214 women, there was a 40% discontinuation rate for Botox treatments in the office. This wasn't that surprising. It matches up with a lot of what the other literature suggest. We did find that patients who had recurrent treatment associated urinary tract infections (UTIs) had a higher chance of stopping Botox treatment.

What really surprised us was that 25% of our Botox cohort had previously undergone nerve stimulation, whether that's sacral neuromodulation or peripheral tibial nerve stimulation, and those patients were less likely to stop Botox.

I don't currently have any research going on in this area, but we are looking about how Botox works in a more elderly patient population as well as if factors play into their discontinuation rates of Botox.

I think based on the findings of our study, it would be interesting to look at why patients are stopping Botox. A lot of the patients in our study and other studies previously published are lost to follow-up, and we need more information. Did they stop because it wasn't working? Did they stop for other reasons? I think a great next step would be some patient-centered research, maybe in a qualitative fashion.

I think unfortunately, our study corroborates that there are high Botox discontinuation rates for patients overall. That's probably the biggest take-home, as well as the fact that patients who have recurrent treatment associated infections are more likely to stop. So maybe being a little bit more aggressive in how we treat or prevent those treatment associated UTIs could be helpful for those patients. Overall, we need more information about why women choose to stop Botox treatment and if there are things that we could be helping in that regard.

"What really surprised us was that 25% of our Botox cohort had previously undergone nerve stimulation, and those patients were less likely to stop Botox," says Katherine L. Woodburn, MD. 

Dr. Woodburn discusses discontinuation of Botox treatment for OAB

, discusses his recent studies “Sacral neuromodulation outcomes in male patients with pelvic pain and fecal incontinence” and “Sacral neuromodulation outcomes in male patients with overactive bladder (neurogenic and non-neurogenic),” which were presented at the 74th Annual Meeting of the Northeastern Section of the American Urological Association. Elterman is a urologist at University Urology Associates in Toronto, Ontario.

“The takeaway is that sacral neuromodulation works well for men with overactive bladder and fecal incontinence, but perhaps less well for pelvic pain. We should see it as one of many multimodal treatments that we could offer for men with chronic pelvic pain,” says Dr. Elterman.

Dr. Elterman on the clinical use of sacral neuromodulation in male patients

 shares the take-home message of the recent 

 paper, “An analysis of factors that influence patient preference of third-line therapy for overactive bladder.” Kapur is a urology resident at Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.

“With this study, we gained a better understanding of the features of third line therapy for overactive bladder, that patients find favorable and unfavorable,” says Anjali Kapur, MD.

Dr. Kapur on patient preferences for OAB third-line therapies

 discusses the background and notable findings of the recent 

“We wanted to help provide an understanding of what factors guide patient choice of third line therapy for overactive bladder,” says Anjali Kapur, MD.

Residents Corner

Study measures patient rankings of third-line OAB treatments

 discusses the take-home message from the 

study, “Effect of Vitamin D Supplementation on Overactive Bladder and Urinary Incontinence Symptoms in Older Men: Ancillary Findings from a Randomized Trial.” Markland is an associate professor of medicine in the Division of Gerontology, Geriatrics, and Palliative Care at the University of Alabama at Birmingham.

“Even though this is a really large study, and it appears that vitamin D may not be a sole contributor to improving urinary incontinence or overactive bladder, there may be a subgroup of men who could potentially respond,” says Alayne Markland, DO.

Vitamin D does not appear to improve OAB, incontinence symptoms

 discusses the background and key findings from the recent 

“We did not happen to find that vitamin D compared to placebo lowered the odds of having incontinence at year 2 or year 5. Nor did it lower the odds of having overactive bladder symptoms at year 5,” says Alayne Markland, DO.